UPDATE: AAHA released its anesthesia guidelines in early November.
The American Animal Hospital Association is poised to release the first-of-its-kind small animal anesthesia guidelines. A task force comprising six board-certified veterinary anesthesiologists and a certified technician specializing in anesthesia created the approximately 10-page document in an 11-month timeframe.
The AAHA guidelines is an all-inclusive, easily digestible document created for use by the entire veterinary team. With expanding anesthesia capabilities for the profession, Jason Merrihew, associate public relations manager at AAHA, says the association recognized the need to develop guidelines for veterinary professionals.
He attributes the multitude of factors to consider when sedating or anesthetizing a healthy dog or cat, as well as the pet with one or more medical conditions a leading incentive.
“AAHA’s guidelines include information on pre-anesthesia bloodwork, examination, equipment, staffing recommendations, monitoring from induction through recovery, pain management, drug choices, drug combinations, what drugs to use according to patients’ age, body type and temperament,” says Richard Bednarski, DVM, Dipl. ACVA, associate professor (anesthesia) at The Ohio State University in Columbus and chair for AAHA anesthesia guidelines. “These guidelines differ from the American College of Veterinary Anesthesiologists’ (ACVA) anesthesia monitoring guidelines because their guide is specific only to monitoring.”
Dr. Bednarski says these guidelines are applicable to most of the profession and will offer uniformity for those who choose to utilize them. The guidelines give rationale to drug selection and assists practitioners when customizing anesthesia plans for each patient.
“These are not standards, so AAHA-accredited hospitals will not be required to follow the guidelines to obtain or retain AAHA accreditation,” Bednarski says. “These guidelines will hopefully minimize morbidity and mortality of veterinary patients. Keeping updated on techniques and drug choices means that primary care practices will be able to handle quality anesthesia just as well as in specialty settings.”
According to Lysa P. Posner, DVM, Dipl. ACVA, associate professor of anesthesiology and anesthesiology section chief at North Carolina State University in Raleigh, N.C., anesthesia mortality rates for small animals is 1:1,000, while that number is 1:10,000 for humans.
“I believe a major reason for this difference is the quality of anesthesia and monitoring,” Dr. Posner says. “I realize this comes at a financial cost. Similarly, veterinarians are likely OK with a death rate of 1:1,000 patients. That would be a loss of one every few years for most practices. I’ve had veterinarians proudly tell me that they haven’t lost a dog or cat in five years. That may be par with what is expected, but if it were 1:10,000 as in human medicine, they might lose one in a whole career.”
| AAHA Task Force Members
• Richard Bednarski, DVM, MSc; Dipl. ACVA, professor, The Ohio State University in Columbus, Ohio
• Kurt Grimm, DVM, MS, PhD, Dipl. ACVA, Dipl. ACVCP; Veterinary Specialist Services PC in Conifer, Colo.
• Ralph Harvey, MS, DVM, Dipl. ACVA; University of Tennessee College of Veterinary Medicine in Knoxville, Tenn.
• Victoria Lukasik, DVM, Dipl. ACVA; Southern Arizona Veterinary Specialty & Emergency Center in Tucson, Ariz.
• Wm Sean Penn, DVM, Dipl. ABVP (Canine/Feline); Alta Vista Veterinary Hospital in Phoenix, Ariz.
• Brett Sargent, DVM, Dipl. ABVP (Canine/Feline); Front Range Veterinary Clinic in Lakewood, Colo.
• Kim Spelts, CVT, VTS (Anesthesia); Peak Performance Veterinary Group in Colorado Springs, Colo.
The ACVA was founded in 1975 to promote the advancement of veterinary anesthesiology and to assist the veterinary profession in providing exceptional service to all animals, according to the college. Considering the availability of specialists in this modality, specialists ask why they aren’t called on more for expert advice.
“It has been interesting to me to see the general veterinary practitioner refer patients for (among others) complex surgical or cardiac procedures, and yet it seems that there is not a willingness to refer a patient who may require complex anesthetic management,” says Khursheed Mama, DVM, Dipl. ACVA, professor and anesthesiology departmental representative for the anesthesia Section department of clinical sciences at Colorado State University in Fort Collins, Colo. “It is more common that someone would call an expert to ask for a plan that is ‘safe’ – the drug plan is sometimes the easiest part, it’s the other support and monitoring that often can make the difference and it may not available in the general practice environment or individuals may be unfamiliar with how to use this, but yet this seems to be the trend.”
Peter Pascoe, DVM, Dipl. ACVA, professor (anesthesia), University of California, Davis, School of Veterinary Medicine says better guidelines for human anesthesia were formed when liability of anesthesiologists made for extremely high insurance rates.
“The guidelines adoption was very successful and minimized death under anesthesia,” Dr. Pascoe says. “While veterinarians don’t have the same liability rate as in human medicine, the guideline can promote overall better care.”
Specialists say experience is a must when considering who is authorized to monitor animals under and recovering from anesthesia.
“I believe licensed veterinary technicians are qualified to monitor anesthetized animals,” Posner says. “However, many states do not require veterinary technicians to be licensed, which introduces the concern that an untrained staff member might be entrusted with anesthesia monitoring. This is one of many reasons I believe all states should require licensed technicians and all veterinarians should insist on trained and licensed people working in their hospitals.”
Some specialists say they would like to see practices monitor anesthesia more closely and effectively.
“I think some hospitals could do a better job of maintaining the anesthesia record to include recordings of the vital signs,” says Emily McCobb, DVM, MS, Dipl. ACVA, clinical assistant professor at Cummings School of Veterinary Medicine at Tufts University in North Grafton, Mass. “It is important to educate staff as how to appropriately respond to audible monitors and alarms as well as to check the patient whenever there is an alarm detected.”
| Zoo Vet on Guidelines
Zoo veterinarians frequently use comparative medicine and apply it to a variety of animals when documentation doesn’t exist for the specific patient’s species. Having a more detailed anesthesia guide is welcomed according to Andrea Goodnight, DVM, and associate veterinarian at the Oakland Zoo in Oakland, Calif.
“We use a zoo animal anesthesia book for many of our cases, but sometimes no information exists for that animal,” Dr. Goodnight says. “We are generalists, so having a small animal anesthesia guide will be a good additional source to pull from.”
Goodnight says in a week’s time, she may have a fruit bat, an alligator and a baboon under anesthesia. Special safety precautions must be taken for both the animal and veterinary staff.
“Not all equipment works for some of our exotic species,” Goodnight says. “Guidelines can help us check if we are doing everything we can for our patients through the entire anesthesia process and recovery.”
Goodnight says zoo keepers act like animal owners for a primary care practice, telling veterinarians of irregular behavior that needs to be investigated.
“We have to put almost all of our patients under a form of sedation or anesthesia to even examine them,” Goodnight says. “Anesthesia is an area we are always very careful using. We sometimes call on the specialists at U.C. Davis for certain cases.”
Goodnight says the Oakland Zoo has approximately 600 inhabitants, so although anesthesia isn’t used unless an animal is ill or is receiving a life-stage exam, there’s always “someone in need of anesthesia.”
Specialists warn that a common mistake in anesthesia monitoring is simply readjusting probes when an irregular reading or alarm occurs instead of examining the patient.
“The person in charge of monitoring the anesthetized patient needs to lay hands on the animal if the equipment is indicating there is a problem,” Pascoe says. “Use a stethoscope – listen to the heart. Look at the patient’s mucous membranes. This is a job for a person capable of understanding how the machine obtained the reading and knowing what a correct reading should be. ”
Specialists say that although equipment is beneficial in the surgical environment, it isn’t the main ingredient to a smooth anesthetic experience.
“The most important part of monitoring is that no piece of fancy equipment can substitute for a well-trained and attentive technician,” Dr. McCobb says. “Technicians’ information in conjunction with electronic monitors is what provides the greatest margin of safety for the patient.”
Bloodwork and Pain Management
Pascoe says pre-anesthesia bloodwork might be performed too frequently.
“If a significant medical history is available on the dog or cat and the physical exam doesn’t reveal anything, bloodwork is often not going to benefit the patient,” Pascoe says. “Statistics show this bloodwork – (on healthy patients) often doesn’t change the course of the anesthesia plan.”
Patient pain management has been a growing interest and concern for the veterinary profession over the past decade, specialists say. This means using more drugs that assist pain control in different ways during differing points of anesthesia, tailored for the severity of pain control needed.
“While unconsciousness provided by many anesthetic drugs blocks conscious perception of nociceptive input during the period in which the patient is unconscious, it is now known that neural pathways that transmit nociceptive impulses are activated during noxious (e.g., surgical) intervention and that if these are not addressed during the anesthetic period, then the potential for post-operative pain may be greater,” Dr. Mama says. “This of course must be balanced with knowledge of the side effects that pain medications used in the perioperative period have.”
“Recovery seems to be an area where awry,” Pascoe says. “The veterinary team gets the animal through the procedure and no one monitors it during recovery. Studies have shown that this is an area where many deaths take place. At the university, we keep patients in a post-op recovery room with a dedicated staff that monitors animals anywhere from a half hour to four hours depending on each patient’s need.”
Although specialists say there’s room for improvement, they’re also optimistic about increased education, vigilance and monitoring techniques surrounding small animal anesthesia protocols.
“There is a huge spectrum of interest and compliance by veterinarians’ interest in monitoring devices,” Posner says. “In the almost 10 years I have been giving CE talks the number of veterinarians who attend lectures in anesthesia monitoring have been increasing. I’d like to think this is a good sign of increased compliance.”