Safe, Modern Anesthesia
Every step in our protocol is to minimize risks and keep your pet safeOne of the hardest decisions to make for some concerned pet owners is the decision to have their pet anesthetized for a necessary procedure. Some of these procedures are preventative, such as a spay or neuter as well as an early stage dental cleaning, which can make the decision to incur some amount of risk with anesthesia seem like a tough call to make.
We have all heard of stories of animals or people going in for routine procedures and have a major complication or die under anesthesia. You may know families or have experienced this with one of your own pets. It is a horrible tragedy and still happening more commonly than it should. However, the reason is because anesthesia is not performed adequately at a large number of veterinary practices.
This is one of the most important services we offer which truly sets us apart from most veterinary hospitals.
Knowing what goes on behind closed doors and the technical aspects of safe anesthesia make it difficult for the average consumer to compare apples to apples when considering where to have a procedure performed. We admittedly do not have the cheapest dental, neuter, or other basic procedure because we feel doing anesthesia right is more important to our patients than cutting corners to decrease cost. Our goal is to make these “routine” procedures as absolutely routine and safe as possible.
Below is a list of ways that we minimize “morbidity and mortality” (pain, suffering, poor outcomes, death) associated with anesthesia. If you are wondering if your vet is performing anesthesia at a high level, you can ask if they follow each of these steps every time.
How anesthesia is performed at Coastal Animal Hospital (while each step is critical, we placed * next to the items that even other high quality practices may not be doing):
1. Complete examination prior to anesthesia
We perform a complete physical examination the morning of every procedure to ensure there are no new findings which would complicate the procedure.
2. Pre-operative blood work, echocardiogram, etc.
We require blood work prior to anesthetic procedures to ensure the organs are functioning the way we expect them to so they can process the drugs we use to induce anesthesia. This also helps us to customize each drug protocol for the individual patient based on their needs. Just because your pet has elevated liver values or is in kidney failure doesn’t mean they can’t have anesthesia, it just means we need to choose the right combination of drugs and treatments that will minimize further damage to those organs. Also, we have a cardiologist who can perform echocardiograms in our clinic if your pet has a heart murmur to help us know their overall risk and best drug therapy to safely get them through the procedure. We also can perform coagulation testing for at-risk patients.
3. Pre-anesthesia injectable sedation
This is one of the key steps in decreasing the overall risk of anesthesia. Pre-anesthesia sedation lowers the need for the inhaled anesthesia gases which are the most potent destabilizers of our cardiovascular system at high doses. This is the first step in what is known as “balanced anesthesia”.
4. Anti-nausea medication*
This is included in our “pre-anesthesia cocktail”, but is not commonly included in most veterinary clinics. Anti-nausea medications have been shown to reduce gastric reflux during anesthesia (which can lead to esophagitis and esophageal strictures), reduce anesthetic gas requirements (see item 3), and get pets eating again faster post-operatively. Also, preventing vomiting and regurgitation is important because this can lead to pneumonia since pets cannot protect their airway while anesthetized (see item 7).
5. Injectable induction
The safest way to induce anesthesia (going from awake to anesthetized) is with injectable medications. There are lots of combinations of medications and some are better than others in terms of how smooth their induction process is as well as the smoothness of their recovery. For most healthy patients, we use a combination of propofol and midazolam to induce anesthesia. We may choose different medications (Etomidate) if your pet has severe heart disease, for example.
6. NEVER “mask (or box) down"
“Masking down” a patient is the act of restraining them and holding a gas mask over their face until they are anesthetized. This is a very old school way of inducing anesthesia and a recent paper found that it was associated with a SIX fold greater risk of anesthetic death. This is also a much more stressful process for the animal as they are typically struggling through the whole procedure while the mask is held on their face pumping stinky anesthetic gasses. Another procedure in this same vein is called “boxing down” where a cat is placed in a box which is then filled with gas until they pass out. While these animals don’t require restraint, it can still be very stressful, is terrible for their cardiovascular stability, and there is no way to monitor them while they are being “induced”. Plus, this technique exposes the veterinary staff to a high concentration of the anesthetic gases.
7. Endotracheal intubation
Amazingly, there are still hospitals out there that do not place endotracheal tubes during anesthesia. Without putting a tube to protect their airway, if they regurgitate, the stomach contents can go directly in to their lungs, causing pneumonia or death. Also, the tube allows us to control their breathing should they not be breathing well on their own. While most hospitals intubate every anesthetized patient, some older generation clinics do not.
8. Modern inhaled anesthetic gases*
We have 2 different anesthesia gases available based on the patient: Isoflurane or Sevoflurane. Both are safe and effective, but Sevoflurane allows the anesthetist to more rapidly change the depth of anesthesia and if needed, stop the anesthesia and have all of the gas leave the body as quickly as possible. We use this gas on older and at-risk patients to ensure we are doing absolutely everything we can to minimize their risks. The downside of Sevoflurane is the expense as it is significantly more expensive than Isoflurane. We continue to use Isoflurane for our young, healthy pets as it is still a very safe anesthetic gas, but is significantly less expensive and we can pass that savings on to our clients for routine procedures.
9. Technician dedicated to monitoring anesthesia*
This is a very important point. People often ask why our dentals are more expensive than another hospital who is doing it for less than what we charge. This is a great example of difficulty comparing apples to apples. A large majority of veterinary practices have dental cleanings performed by a single technician who is performing the dental cleaning AND monitoring anesthesia at the same time. How effective and safe would you imagine this process is? Even if they are a highly qualified technician, there is no way to safely monitor a patient under anesthesia and do ANYTHING else. We have a technician dedicated to monitoring anesthesia during the entire procedure. We also employ multiple Registered Veterinary Technicians who are specially trained in anesthesia because it is not simply enough to have someone in front of an anesthesia machine, but someone who is qualified to monitor and react when things go wrong.
10. IV catheter and fluid therapy
Putting an animal under anesthesia alters the body’s ability to maintain normal homeostasis and cardiovascular stability. The most important variable that we monitor when they are under anesthesia is blood pressure (see item 18) and IV fluids help to control and maintain that variable. Without it, your pet may experience low blood pressure for the entire procedure which can lead to chronic kidney damage and at worse, death. Also having a patent IV catheter is essential if there is sudden cardiac collapse and they need injectable medications to support their heart.
11. Constant rate infusion
This is an example of a modern anesthesia skill that is rarely employed by the average veterinary practice. While we do not use constant rate infusions of pain and anesthetic combinations for routine procedures, we will employ them when we have an especially painful procedure to help “balance the anesthesia” and keep them from feeling pain during and after the surgery.
12. Pain medications
Pain is not helpful in any way during or after surgery. It causes the anesthetist to use more gas anesthesia (see item 3), delays healing, and makes your pet miserable. We use injectable pain medications (including item 11) for every surgery to decrease the morbidity associated with the procedure.
13. Local blocks/anesthetics
Another way we “balance anesthesia” is with locoregional anesthesia using nerve and local blocks. This decreases the pain right at the source and minimizes gas anesthesia as well as post-operative pain, making anesthesia safer and your pet more comfortable.
14. Judicious use of antibiotics
Part of being a modern practitioner is not knowing what to give, but also know what not to give. There are many practices still giving antibiotics to routine surgeries such as spays, neuters, and routine dental cleanings for healthy patients. This is completely unnecessary (unless they are concerned about the sterility of their equipment, which is another topic) and an example of not practicing high quality medicine.
15. Pre-calculated emergency drugs and doses
While sudden cardiovascular collapse is rare, when it does happen you do not have a moment to lose. Our anesthesia monitoring sheets have drug doses pre-calculated so if there is a sudden emergency, we can react at a moment’s notice.
16. Hetastarch, blood pressure support
When monitoring anesthesia, standard adjustments don’t always work to maintain parameters such as blood pressure. We have multiple methods of maintaining this critical parameter through different types of fluids and constant rate infusions of blood pressure support medications.
17. Temperature support
One of biggest obstacles for our smallest patients is how rapidly they lose body heat and how low it can go. This can be a real danger to them during anesthesia as well as prevent them from recovering well. We have multiple effective warming strategies that we employ on each patient as well as close monitoring to ensure their temperature stays in an optimal range.
18. Multi-parameter monitoring*
One of the most well known ways we keep patients safe while under anesthesia is with multi-parameter monitoring. Many vet clinics will only monitor their patients with 3 values – heart rate, respiratory rate, and SpO2. This is completely insufficient, however, not uncommon. We monitor these parameters on every patient:
- Blood pressure
- EtCO2
- ECG
- Temperature
- Heart Rate
- Respiratory rate
- SpO2
19. Technician dedicated to monitoring post-op*
This is a KEY difference between us and almost any other general practice. After every procedure, we have a technician who is dedicated to sit with that patient until they are fully recovered. What happens at most hospitals is there is a technician who will be with the patient until they are extubated (if they were intubated in the first place), then everyone will continue to “keep an eye” on that patient. When everyone is responsible it means that no one is responsible. What happens is the technician starts cleaning up from the procedure, helping with the next appointment, etc, then 5 minutes later will look over and see if the patient is doing ok. A lot can happen in those 5 minutes when they were doing other things. A large study of anesthetic deaths found that nearly 50% of deaths took place AFTER anesthesia was discontinued and within the first 3 hours. This is the critical time to watch these patients and why in human hospitals, universities, etc, they have a team (post-anesthetic recovery or PAR) dedicated to watching and monitoring their recovery.
20. Post-op monitoring equipment*
It is also not enough to have someone staring at the patient and wondering if they are actually oxygenating well, etc. We have extra monitoring equipment that is specifically used to let us know if internally they are not recovering well and is kept on them until they are fully recovered. Most practices do not have enough units and will take the monitoring device to use for the next procedure.
(* – indicate key differentiators of how anesthesia is performed at Coastal)
Each of these steps is important to decrease the risks and complications of anesthesia. While we can never 100% eliminate risk, we rest easier knowing we are doing as much as we can to minimize it.
To read about the large study which goes in to detail about how common anesthetic deaths are and how you can decrease risk for your pet – read our post about it here.
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