Determining the best anesthetic protocol

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Are you relying on a standardized anesthetic protocol for every case? Or are you individualizing protocols for each patient dependent on their American Society of Anesthesiologists (ASA) status, personality/temperament, and medical history? If you answered yes to the first question I implore you to keep reading. If you answered yes to the second question, I still ask you to keep reading.

For most of us in general practice or even specialty hospitals, spending time to make an individualized protocol can add stress and time to our already busy day. So let’s simplify the process a bit and reduce the mental load but also elevate the quality of anesthesia you provide. Better yet, develop a strong and trusting rapport with a few of your senior credentialed veterinary technicians to do that heavy lifting for you.

What’s the issue with cookie-cutter, one-size-fits-all protocols? Depending on the patient’s physiological status based on acute or chronic medical conditions (anesthetic risk; see ASA status definitions below), present pain score or anticipated pain score after a procedure, and mental well-being of the animal—potentially a lot. Using a cookie-cutter protocol may only partially or not at all cover one of these 3 areas, leaving your animal in a more compromised physiological status, poorly managed pain state, or psychological crisis. Twenty years ago, many of us were used to giving a sedative (or maybe not even that), a splash of pain medication, and then inducing the patient. Wake-ups were interesting and pain was considered acceptable.

Today we are more informed on the detrimental impacts that had on our patients’ physiological and mental well-being. It also mentally broke some of us who assumed we could be doing better but didn’t know how or were told not to worry about it. How do we get away from the one-size-fits-all mentality? We try, and by that I mean we can find that happy medium of not flipping the things we’ve always done on their head, although that is called for at times, but creating a thoughtful way to introduce new ways of thinking while using efficient strategies for busy practices that the staff is already used to. Instead of using 1 protocol for all patients all the time, consider making protocols to use based on the ASA status of the animal and even the species we most commonly see.¹

While there are technically 6 ASA statuses used in human medicine, we use only 5 in veterinary medicine. Does that mean we need 5 protocols? Not necessarily. Given the seriousness of ASA statuses IV and V, we can often use the same protocol for both classifications, leaving us with 4 protocols to create but still consider individualized patients’ needs. One of the emerging areas regarding patient comfort is not only appropriate pain management but also their psychological status. Recent research is showing us how sentient our patients really are and how our misunderstanding of their mental well-being impacts them acutely and chronically, particularly as it relates to stress and anxiety.² Mental well-being is only just now being looked at more seriously for humans and the stigma of medicating for psychological disorders is still prevalent.³ Research is discovering that our patients, though evolved to be stoic and resilient, are also suffering. This is one of the major areas I hope we can start to focus on in addition to pain management and relying on multimodal protocols.

More specifically, studies have found that more extroverted dogs require more analgesics than their counterparts.⁴ Animals with traumatic experiences or poorly managed pain early in life also require more pain medications. Animals that are particularly anxious have more heightened pain experiences than those that are cool, calm, and collected in their daily affect.^5,6 These personality traits should not be ignored but instead listened to as a cue to adjust protocols for each patient. Anxiolytic medications should be used in a majority or our patients and event anti-depressants are worth consideration for animals that seem to have a dull affect vs how the owner may describe their pet’s personality at home.^7-9 A drug many hospitals already have is tramadol, which has been shown to be a poor pain medication in dogs but does have selective serotonin reuptake inhibitor and serotonin and norepinephrine reuptake inhibitor effects, reviving, in a sense, its relevance in daily practice.^10,11

As more cognitive science is available, it demonstrates the intricate interactions and crossover between physical pain and emotion. Just because we don’t understand animal emotion in its entirety, this should not be an excuse to not treat and consider more for our patients that enriches our lives as much as we enrich theirs. We know better now, so let’s do better.

For current trends in anesthesia and pain management care please consider these free resources:

• 2022 AAHA Pain Management Guidelines for Dogs and Cats
• 2022 ISFM Consensus Guidelines on the Management of Acute Pain in Cats
• 2020 WSAVA Guidelines for Recognition, Assessment and Treatment of Pain
• 2020 AAHA Anesthesia and Monitoring Guidelines for Dogs and Cats

The ASA created a physical status scale that is often used in veterinary medicine to rate patients for potential anesthetic risk. The scale is as follows:

• ASA status I is a healthy patient.
• ASA status II is a patient with mild systemic disease with no functional limitations.
• ASA status III is a patient with severe systemic disease with functional limitations.
• ASA status IV is a patient with severe systemic disease that is a constant threat to life.
• ASA status V is a moribund patient that is not expected to survive 24 hours with or without surgery.
• E denotes an emergency.

References

1. Keefe J. Special considerations in anesthesia (proceedings). dvm360. April 1, 2010. Accessed April 18, 2022. https://www.dvm360.com/view/special-considerations-anesthesia-proceedings
2. Alleviating pain and distress in laboratory animals. American Association for Laboratory Animal Science. Accessed April 18, 2022. https://www.aalas.org/about-aalas/position-papers/alleviating-pain-and-distress
3. Stigma, prejudice and discrimination against people with mental illness. American Psychiatric Association. August 2020. Accessed April 18, 2022. https://www.psychiatry.org/patients-families/stigma-and-discrimination
4. Lush J, Ijichi C. A preliminary investigation into personality and pain in dogs. J Vet Behav. 2018;24:62-68. doi:10.1016/j.jveb.2018.01.005
5. Walker SM. Long-term effects of neonatal pain. Semin Fetal Neonatal Med. 2019;24(4):101005. doi:10.1016/j.siny.2019.04.005
6. Walker SM. Translational studies identify long-term impact of prior neonatal pain experience. Pain. 2017;158(suppl 1):S29-S42. doi:10.1097/j.pain.0000000000000784
7. Ijichi C, Collins LM, Elwood RW. Pain expression is linked to personality in horses. Appl Anim Behav Sci. 2014;152:38-43. doi:10.1016/j.applanim.2013.12.007
8. Litchfield CA, Quinton G, Tindle H, Chiera B, Kikillus KH, Roetman P. The ‘Feline Five’: an exploration of personality in pet cats (Felis catus). PLoS One. 2017;12(8):e0183455. doi:10.1371/journal.pone
9. Ley JM, McGreevy P, Bennett PC. Inter-rater and test-retest reliability of the Monash Canine Personality Questionnaire-Revised (MCPQ-R). 2009;119(1-2):85-90. doi:10.1016/j.applanim.2009.02.027
10. Beakley BD, Kaye AM, Kaye AD. Tramadol, pharmacology, side effects, and serotonin syndrome: a review. Pain Physician. 2015;18(4):395-400
11. Osman M, Mustafa M. Tramadol-induced mood elevation in a patient with no previous psychiatric history. Case Rep Psychiatry. 2018;2018:9574395. doi:10.1155/2018/9574395