Originally published in the October 2014 issue of Veterinary Practice News
When she wanted to offer one crystal-clear message to veterinarians about anesthesia best practices, Christina Braun, Dr. Med. Vet, Dipl. ACVAA, offered one of her favorite quotes from J.W. von Goethe: “You only see what you know.”
It’s unlikely the German writer and statesman was referring to anesthesia, but Dr. Braun thinks it’s a good point nonetheless.
“Monitoring is the first step to improve anesthetic outcome,” said Braun, a professor in anesthesiology and perioperative intensive care medicine at the University of Veterinary Medicine in Vienna, Austria.
She encourages general practice veterinarians to reach out to the American College of Veterinary Anesthesia and Analgesia (ACVAA) if they have questions or concerns, and pet owners may be referred to the group’s website for more information.
“For example, I know of old cats and dogs that had such terrible teeth that they wouldn’t eat anymore,” Braun said. “Because they were old, the fear of anesthesia was so high that the owner didn’t want the general veterinarian to perform a dental cleaning —which, in pets, absolutely [requires] general anesthesia.
“Contacting a diplomate of the ACVAA can help in learning about good ways to anesthetize these animals or allow the DVM to find a referral center where anesthesia can be applied appropriately to the old or sick patient.”
Khursheed Mama, DVM, president of ACVAA, also is a proponent of monitoring.
“Appropriate monitoring of animals during anesthesia can reduce morbidity and mortality,” said Dr. Mama, a professor of anesthesiology in the department of clinical sciences at Colorado State University.
One thing Jennifer Carter, DVM, Dipl. ACVAA, wants all veterinarians to be aware of is “that there is no such thing as a safe anesthesia drug.
“Nearly every drug we use has the potential to kill an animal if it is used inappropriately,” added Dr. Carter, a professor at Ross University School of Veterinary Medicine and at the University of Melbourne.
Knowledge about a drug’s mechanisms of action, its expected effects and any anticipated side effects can improve the safety of veterinary anesthesia by enabling a practitioner to make informed choices of agents and to predict complications, Carter emphasized.
“Thorough monitoring in the perioperative period also significantly reduces the risk of morbidity or mortality from veterinary anesthesia,” she said.
How to Use Protocols
Protocols hold a great deal of importance in medicine, but some practitioners have come to rely too heavily on them, said Bonnie Wright, DVM, Dipl. ACVAA, the president-elect of the International Veterinary Academy of Pain Management .
In fact, Dr. Wright, who works at the Fort Collins Veterinary Emergency and Rehabilitation Hospital in Colorado, said protocols have now become “almost an obsession.”
“There’s this great sense of wanting protocols,” Wright said, adding that while they help give practitioners a strong familiarity with particular drugs, “protocols don’t meet the needs of every patient.”
Protocols aren’t necessarily a bad thing in Wright’s eyes, but she believes the biggest issue is that some practitioners have a limited number of them.
She suggests having a greater number of protocols from which to draw, which she believes adds needed flexibility.
“It’s that lack of flexibility I hate about protocols,” Wright said. “People want to stick to the same premeds, the same induction drugs—regardless of age, heart and lung function. They become very attached to a certain way of doing things.”
The Human Touch
It’s human habit to skip steps, which in the case of applying anesthesia may lead to disastrous results, experts say.
“Taking shortcuts is not addressing the needs of each patient as an individual,” Wright said.
Mama expressed concerns that steps might be skipped when workloads grow heavy.
“Given time and financial pressures, monitoring and support of animals during anesthesia isn’t consistently appropriate,” she said. “Often the individual being asked to care for the animal is also asked to do other tasks and cannot focus exclusively on the animal.”
Relying too heavily on equipment is a widespread shortcut being taken by too many veterinarians, Braun said.
“It’s easy to either mistrust the equipment if the values displayed are not looking good or falsely trust it if it does look good,” she said. “While new technologies are greatly improving everyday practice, the person behind it is the most valuable part of anesthetic monitoring and in administering the safest possible anesthesia.”
A skipped step that gets Carter’s goat is the failure to place an IV catheter.
“This, in my opinion, should be mandatory in any animal undergoing sedation or anesthesia,” Carter said. “IV catheters assure correct administration of IV drugs and provide venous access should an emergency occur. The overall cost of a catheter and injection cap is quite small in the scheme of the cost of the procedure itself.”
Carter also feels someone should be dedicated to monitoring anesthesia.
“In most practices, the technician who is monitoring the patient’s anesthesia is also the surgical technician,” Carter said. “This is fine in most routine cases but can result in suboptimal monitoring and delayed time to recognize and correct abnormalities in more complex cases.”
Despite the broad warning from experts about overreliance on protocols and technology, there was certainly no absence of enthusiasm for either.
“Nowadays most monitors measure and display many different parameters at the same time,” Braun said. “Considering the impact on the well-being of the patient, measuring blood pressure and the level of carbon dioxide in the patient’s expired air are two important ones for the majority of patients.”
Mama, ACVAA’s president, is encouraged by the fact that much more emphasis is placed today on the use of regional anesthesia techniques, such as nerve blocks, for peri-operative pain management in a wide variety of procedures.
“Use of both nerve-locator devices and ultrasound technology has improved the accuracy, efficacy and safety of these techniques,” Mama said.
Anesthesia itself is evolving as more and more veterinary anesthesiologists enter private practice, research and industry compared with the broad number of specialists previously found primarily in academia, Braun said.
“Considering that veterinary medicine in general is becoming more and more complex and specialized, I imagine that more anesthesiologists will be needed to perform anesthesia and analgesia in a growing population of older and sicker pets,” Braun said.
“That said, I believe that the bar is being set higher the more we know,” she said. “[Allowing an animal to wake] up alone after anesthesia will not be good enough anymore. Our goal will be to find ways of administering anesthesia to our patients that minimize any negative impact on them, including often times overlooked behavioral changes or rather transient changes in their well-being.”
As newer anesthetic drugs become available, Wright said, practitioners will begin to expand their thinking about approaches to anesthesia and pain management.
“People used to gauge the quality of anesthesia by, ‘Well, no one died,’” she said.
She hopes to see the anesthesia practice expand beyond merely ensuring survival to also giving strong considerations to good pain management, good recovery and preventing organ damage.
Mama believes that there is an increasing public demand for veterinarians with expertise in anesthesia and pain management.
“Through ongoing training of both experts and veterinary practitioners, one anticipates that the veterinary community will be able to continue provide these services at a high level to a broader based clientele within the next five to 10 years,” Mama said. “This reflects a response to increasing consumer expectations for animal well-being.”
Carter agreed that the growing presence of specialists in private practice will serve to further the level of anesthesia and analgesia care in the profession.
“In addition, as new graduates join the profession, I see them pushing the bar on the current standards of care, which will benefit the animals and the profession as a whole,” Carter said.