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3-Protocols, CPR Guidelines, & Appendix

This document provides clinical guidelines for anesthesia and analgesia in veterinary practice, specifically for canine and feline patients. It includes ASA classification for patient status, emergency drug dosing, and protocols for various surgical procedures, emphasizing the need for individualized anesthetic plans based on patient health and specific conditions. Additionally, it outlines the importance of compliance with state regulations and the responsibilities of veterinary practitioners in ensuring safe anesthesia practices.

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0% found this document useful (0 votes)

199 views220 pages

3-Protocols, CPR Guidelines, & Appendix

Uploaded by

wcvet3579

We take content rights seriously. If you suspect this is your content, claim it here.

Available Formats

Download as PDF, TXT or read online on Scribd

Book 3 | 2nd Edition

Protocols
CPR Clinical Guidelines
Anesthesia and
Analgesia
for the Veterinary Practitioner: Canine and Feline

Appendix
©Banfield 2022.04
Asa status
Emergency drug dosing
Status ASA classification Examples
I Healthy pet, no disease Elective OVH or castration Drug Low dose High dose

II Mild systemic disease or Healthy geriatric pet, mild Atropine

0.02 mg/kg 0.04 mg/kg
localized disease anemia or obesity 0.54 mg/mL

III (fair) Moderate systemic Mitral valve insufficiency, Dexamethasone SP

1 mg/kg 4 mg/kg
disease limiting activity collapsing trachea, poorly 4 mg/mL
but not life-threatening controlled diabetes Diphenhydramine
2.2 mg/kg N/A
50 mg/mL
IV (poor) Severe systemic disease; Hemoabdomen from
incapacitating; life- splenic rupture, severe Dopamine 40 mg/mL 2.5 mcg/kg/min 10 mcg/kg/min
threatening; not expected traumatic pneumothorax,
to live without surgery organ failure Epinephrine 0.2 mg/kg
0.01 mg/kg
1 mg/mL intratracheal (IT)
V (grave) Moribund; not expected to Multi-organ failure,
live >24 hours, with or severe shock, terminal Glycopyrrolate
without surgery malignancy 0.005 mg/kg 0.01 mg/kg
0.2 mg/mL

Lidocaine Canine 2 mg/kg 4 mg/kg

bolus
Determine the pet ASA status 20 mg/mL Feline 0.2 mg/kg N/A

■ History Amiodarone
5 mg/kg N/A
■ Clinical Pathology Data 50 mg/mL
■ Physical Exam Reversal agents
CLINICAL Equal to amount of
ESSENTIAL dexmedetomidine
Atipamezole
I -II 100 mcg/kg administered if dose
The attending 5 mg/mL
■ There is little to no increase in risk was higher than 10
veterinarian mcg/kg
chooses protocols Butorphanol
0.05 mg/kg 0.1 mg/kg
and determines 10 mg/mL
specific drug Flumazenil Repeat every hour if
III - V 0.01 mg/kg
■ Discuss increased risk with the client dosages 0.1 mg/mL needed
■ Maximize preanesthetic
Naloxone
medical management 0.04 mg/kg N/A
0.4 mg/mL
■ Cancel or refer procedure as
clinically indicated

Reversal agents may also reverse

analgesic properties. Ensure patient
analgesic needs are met
Anesthesia and
Analgesia
for the Veterinary Practitioner: Canine and Feline

Book 3 | 2nd Edition

© 2022 Banfield Pet Hospital

ISBN # 978-0-9743262-8-3
All rights reserved. Reproduction in whole or in part without the express written permission
of Banfield Pet Hospital, is prohibited.
Preface
■ Individual state practice act requirements and DEA regulations must be
met or exceeded in all instances.
■ Review Medical Quality Standards. Meet or exceed all Clinical Essentials.

State regulations

■ At all times, every medical team must comply with individual state
practice acts.
■ It is each doctor’s responsibility to know and understand the
requirements of his/her specific state, as well as Banfield policies
and procedures.
■ The doctor must ensure compliance with state regulations regarding:
● Handling and administration of controlled substances
● Intubation of pets
● Anesthetic monitoring
● Drug administration documentation
● Which hospital associates can legally perform dental prophylaxis and
all other medical procedures
● Off-label usage of medications

This publication may contain information that is not within the current FDA-
approved labeling for several products for companion animals.
Contributing authors

Nora S. Matthews, DVM, DACVAA

Professor Emeritus, Texas A & M University
Anesthesiologist in various clinics and working with residents in practice.

David D. Martin DVM, DACVAA

Senior Veterinary Specialist
Zoetis

Jo Ann Morrison, DVM, MS, DACVIM

Director, Veterinary Science
Banfield Pet Hospital

Major editorial author

Tricia Beal, DVM, MS

Program Manager, Clinical Excellence
Banfield Pet Hospital
Dr. Beal received her DVM degree from Oregon State University in 2005. After a
short time working with non-human primates, she transitioned to a small animal
practice in Salem, Oregon. During her 12 years in practice she accepted the role of
Medical Director and helped grow the general practice to eventually include a 24
hour emergency and urgent care facility. Dr. Beal earned her master’s in veterinary
forensic toxicology in 2021 and currently works at Banfield as a Program Manager
on the Veterinary Affairs team promoting medical quality and standards.
Contents
Protocols

Introduction 2
Protocols 4
Abdominal/hepatic 4
Brachycephalic 12
Caesarean section 21
Cardiac 29
Dental prophylaxis 39
Diabetic (stable) 47
Emergency 55
Geriatric 63
Hands-free radiology 73
Obese (stable) 79
Orthopedic 87
Pediatric 95
Renal/post-renal 103
Sighthounds 121
Soft tissue (elective) 127
Stressed/fractious 134
Addendum 144
CPR clinical guidelines

Preparedness and Prevention 148

Equipment 148
Resuscitation aids 148
Training 148
Basic Life Support 150
Definition 150
Recognition 150
Chest compressions 151
Ventilation 152
Advanced Life Support 153
Monitoring 155
Post-cardiac Arrest Care 157

Appendix

Medication Dilution and Combination 164

Advanced Analgesic Techniques 166
Constant rate infusions 167
Wound infusion catheters 174
Dosage Charts 179
Protocols

Abbreviations

ABCB1 updated name for GI gastrointestinal

MDR gene GDV gastric dilatation volvulus
ACVIM American College of MAP mean arterial pressure
Veterinary Internal MDR multi-drug resistant
Medicine NRB non-rebreathing
ALP alkaline phosphatase NSAID nonsteroidal
ALT alanine aminotransferase anti-inflammatory
ASA American Society of OVH ovariohysterectomy
Anesthesiologists SpO2 peripheral capillary
bpm beats per minute or oxygen saturation
breaths per minute, TPR temperature, pulse,
depending on context respiration
BUN blood urea nitrogen
CNS central nervous system
CRI constant rate infusion

DKT dexmedetomidine,
ketamine, torbutrol
ECG electrocardiogram
EtCO2 end-tidal carbon dioxide

1 Book 3
Protocols

Introduction
Protocols have been developed from an evaluation of the current
literature and the consensus of board-certified veterinary specialists
(anesthesiology and internal medicine). Protocols are never meant to
be followed blindly and the anesthesia team remains responsible for
making decisions in the best interest of the patient.
Examples:
■ If a protocol calls for cefazolin but the patient is allergic to
cephalosporins, administer a different antibiotic
■ If a protocol utilizes acepromazine, but the patient is undergoing
medical therapy for a portosystemic shunt, administer a
different premedication

Protocols 2
Protocols

Why do we need different protocols for different patients

if the goals of anesthesia (analgesia, unconsciousness
and muscle relaxation) are the same for all?
Healthy patients have the highest requirements (in mg/kg) for drugs
especially if they are very nervous or very active. These patients usually
have increased physiologic reserve in organ and cardiac function.
Remember that an unremarkable physical examination does not
preclude the presence of underlying pathology. The Medial Quality
Standards chapter includes examples of potential genetic or breed-
associated conditions, which may impact anesthetic decision making.
Generally, consider the need to reduce drugs or drug dosages for older,
sicker patients or substitute a drug with fewer side effects depending on
disease and American Society of Anesthesiologists (ASA) status.

Considerations for all patients

■ Premedication should be appropriate for the patient (see specific
protocols) and given 30 minutes before induction (route dependent
on medication).
■ Wait 30 minutes to allow premedications to take full effect before
induction, unless patient status dictates otherwise.
■ Premedications are generally administered to provide anxiolysis
(e.g., tranquilizers and sedatives) and preemptive analgesia.
■ Repeat physical exam and temperature, pulse, respiration (TPR) prior
to induction. If any part of TPR has changed significantly and raises
concern, stop and reevaluate the patient.
■ Complete Anesthetic Machine Checklist prior to each anesthetic procedure.
■ Plan analgesic protocol and implement as appropriate for each patient.
■ Use of reversal agents should be made on an individual patient basis.
See Induction, Monitoring and Recovery chapter for details.

3 Book 3
Abdominal/Hepatic

Abdominal

What is different about this patient?

There are multiple clinical scenarios where abdominal surgery may be
performed with a variety of comorbidities:
■ Abdominal mass removal
■ Cystic calculi
■ Gastric dilatation volvulus (GDV)
■ Gastrointestinal (GI) foreign body
■ Hepatic biopsy
■ Pyometra

Depending on the underlying etiology, patients may require a large

number of stabilizing procedures before becoming anesthetic candidates
(e.g., GDV), or may be hemodynamically stable with a relatively
unremarkable physical examination (e.g., cystic calculi removal).
A range of analgesic requirements may exist and analgesic plans
should be individualized to each patient. Certain conditions may be
associated with nausea or vomiting, so the addition of antiemetics
(e.g., maropitant) should be considered when medically indicated.
Elevated hepatic enzymes (ALT and ALP) may be seen in many of these
patients, so close attention should be paid to potential indicators of
hepatic dysfunction and supportive measures be proactively prepared.

Examples
Hepatic dysfunction Intervention
Hypoglycemia Dextrose CRI
Hypoalbuminemia Colloid support
Coagulopathy Vitamin K or transfusion therapy

Protocols 4
Abdominal/Hepatic

Premedication
Drug Dose Route
Canine 0.05–0.2 mg/kg
Hydromorphone
Feline 0.05–0.1 mg/kg IM, SC
Midazolam 0.1–0.3 mg/kg
OR
Methadone 0.25 mg/kg
IV
+/- Midazolam 0.05 mg/kg
OR
if there is a history of vomiting:
Midazolam 0.1–0.3 mg/kg IM, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV

■ Provide antiemetic support (maropitant) if vomiting

■ Consider if additional analgesic therapy is warranted based on:
● Signalment ● Anesthetic indication
● Physical examination ● Surgical intervention planned

Additional analgesic therapy

Drug Dose Route
Hydromorphone 0.05–0.1 mg/kg IM, IV, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV
Buprenorphine –
Feline 0.24 mg/kg SC only
long acting
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine –
Feline 1 tube Transdermal
Transdermal

5 Book 3
Abdominal/Hepatic

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Preoxegenate based on patient tolerance and clinical stability

■ Induce with lowest possible dose of propofol

● May cause apnea if given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

50–100 mL/kg/minute
(rebreathing) For first 15 minutes
Oxygen
150–300 mL/kg/minute after induction
(non-rebreathing (NRB))
Large dogs may
Sevoflurane 3% for 3 minutes
need higher rates
■ Monitor anesthetic depth and oxygenation closely

Protocols 6
Abdominal/Hepatic

Anesthetic maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen
■ Prevent/treat hypothermia associated with a large, open abdomen
(see Induction, Monitoring and Recovery chapter for details)
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

7 Book 3
Abdominal/Hepatic

Perioperative anesthetic support

Intravenous
Rate Miscellaneous
Fluids
Canine 5 mL/kg/hour Consider avoiding
Crystalloids lactate in patients
Feline 3 mL/kg/hour with hepatic disease
20 mL/kg/day
Canine OR
Bolus of 5 mL/kg If medically
Colloids
20 mL/kg/day indicated
Feline OR
Bolus of 2.5 mL/kg

Anticholinergics

Drug Dose Route

Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Depending on preanesthetic blood glucose (BG) readings, BG may

need to be checked intraoperatively and postoperatively
■ IV dextrose infusion at 2.5–5% may be utilized to support BG in the
hypoglycemic patient
■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Protocols 8
Abdominal/Hepatic

Local blocks and antibiotics

Local Block
Lidocaine (2 mg/kg) OR
Line block for abdominal incision
Bupivacaine (1.5 mg/kg)
Antibiotics
See Medical Quality
As medically indicated
Standards chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
● Pay attention to maximum cumulative doses
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

9 Book 3
Abdominal/Hepatic

Postoperative care and pain management

Drug Dose Route
OPIOID
Canine 0.005–0.02 mg/kg IM
Buprenorphine
Feline 0.01–0.02 mg/kg IM, Transmucosal
0.24 mg/kg
Buprenorphine –
Feline (dose on lean body SC only
long acting
weight)
0.01–0.2 mg/kg SC, IM
Canine
0.005 mg/kg IV every 2–4 hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline
0.05 mg/kg IV every 2–6 hours
See Appendix chapter
Fentanyl IV as CRI
for details
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on
Feline Transdermal
Transdermal lean body weight)

■ Opioids are most commonly used

● Avoid NSAIDs with all gastrointestinal surgeries
■ Adequate pain management must follow through postoperative
period and facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with analgesic medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria, refer to Induction, Monitoring
and Recovery chapter for details

Protocols 10
Abdominal/Hepatic

Analgesia to go home

Drug Dosage Route

Canine 5 mg/kg PO, every
Tramadol*
Feline 2–4 mg/kg 6 hours
OR
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours
* Oral tramadol has not been shown to be effective postoperatively in dogs.

■ Use opioid as appropriate for health status

■ Avoid NSAIDs when possible

Notes
_______________________________________________________________

_______________________________________________________________

11 Book 3
Brachycephalic

Brachycephalic

What is different about this patient?

Most brachycephalic patients, either canine or feline, have difficulty
breathing when awake. Small nares, elongated soft palates and
hypoplastic tracheas create a very abnormal upper airway.
Some breeds (e.g., Pugs and Bulldogs) are more likely to be obese,
which further exacerbates breathing problems
■ Stress increases respiratory rate and can cause serious
complications such as hyperthermia or respiratory collapse
Brachycephalic patients (Bulldogs in particular) may not be good
candidates for procedures using sedation; general anesthesia may
be safer for them. See Sedation and Immobilization chapter for more
information.

Anticipated problems
■ Preoperative airway obstruction after premedication
■ Difficulty visualizing the larynx during intubation

■ Prolonged and difficult intubation

■ Hypoplastic trachea - smaller ET tube than expected

■ Airway obstruction during recovery

■ Passive gastric reflux (regurgitation) at any point during sedation/

anesthesia/recovery
■ Bulldogs have a higher incidence of vomiting and aspiration within
24 hours of anesthesia
All sedatives and anesthetic drugs impair respiratory function
by central (neurologic) depression and relaxation of muscles
needed for maintaining an airway. Patients must be carefully
monitored from premedication through recovery.

Protocols 12
Brachycephalic

Examples
ANY pet with a shortened snout
Boston Terrier Boxers
Bulldogs Himalayan
Lhasa Apso Persian
Pugs Shih Tzu

ANY pet with a functional or anatomic abnormality of the

larynx, pharynx, esophagus or trachea
Labrador Retriever with
Shar Pei
laryngeal paralysis

Home administered anxiolytics

Drug Dose Route
Trazodone Canine 5–15 mg/kg PO 1hr prior to travel
PO 2–3 hrs
Gabapentin Feline 50–100 mg/cat
prior to travel

■ Consider giving the first dose the night before along with another
dose the morning of the procedure
■ Trazodone can cause paradoxical excitement. Trial doses
are recommended.

13 Book 3
Brachycephalic

Premedication
Drug Dose Route
Butorphanol 0.2–0.4 mg/kg IM
Midazolam 0.1–0.3 mg/kg IM

■ For procedures that need analgesia, avoid opioids that induce vomiting
in the premedication. Supplement with another opioid once the patient
is intubated and asleep (45-60minutes after the butorphanol).
■ Consider pre-operative thoracic radiographs to evaluate the lungs and
heart. These patients can be difficult to auscultate and are prone to
aspiration pneumonia. Identifying underlying conditions early increases
anesthetic safety.
■ Never muzzle or restrict the airway in any brachycephalic patient and
use minimum physical restraint necessary
■ Anxiolytics may be helpful but should not be used in place of safe
patient handling practices
● Cautious use of acepromazine at low-dose (0.01 mg/kg) may be
considered if patients are significantly anxious
● Patient analgesic needs should be considered
■ Use maropitant to reduce the risk of vomiting.
■ Other perianesthetic protocols to decrease post-operative GI complications:
● Famotidine 1mg/kg IV or SQ
● Metoclopramide 0.5mg/kg SQ
● Omeprazole 1mg/kg PO
● If history of regurgitation: 1 week of PPI and metoclopramide
■ Pre-oxygenation for at least 3-5 minutes is very important for
these patients if they will tolerate it, but stress should be kept to
a minimum.
■ Once premedicated, these patients should be kept under
observation at ALL times

Protocols 14
Brachycephalic

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Preoxygenate based on patient tolerance and clinical stability

■ Continue to provide oxygen between intubation attempts if applicable

■ Induce with lowest possible dose of propofol or alfaxalone

● May cause apnea if given rapidly
■ Bradycardia, hypotension and respiratory depression may develop
after rapid administration
■ It is important to have a range of endotracheal tube sizes available
in the case of a hypoplastic trachea
■ The average Bulldog may take a 6.5 mm tube (approximate size), instead
of the 9 mm tube one might anticipate based on body size
■ The DVM should evaluate the soft palate, saccules and search for other
abnormalities (tonsilar hypertrophy) just prior to intubation

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

50–100 mL/kg/minute
(rebreathing) For first 15 minutes
Oxygen
150–300 mL/kg/minute after induction
(NRB)
Large dogs may
Sevoflurane 3% for 3 minutes
need higher rates
■ Monitor anesthetic depth and oxygenation closely

15 Book 3
Brachycephalic

Anesthetic maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen
■ Once intubated these patients usually do well due to upper airway
bypass (until extubation)
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details
■ Inspect the pharynx frequently for reflux

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 16
Brachycephalic

Perioperative anesthetic support

Intravenous
Rate Miscellaneous
fluids
Higher fluid rates may
Canine 5 mL/kg/hour be needed if patient
Crystalloids is not adequately
Feline 3 mL/kg/hour hydrated when
anesthesia begins
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV
■ Brachycephalic patients may have high vagal tone with
profound respiratory sinus arrhythmias and may benefit from
anticholinergic therapy
■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter
for details

Local blocks and antibiotics

Local block
Pay attention to maximum
As medically indicated
cumulative doses
Antibiotics
See Medical Quality Standards
As medically indicated
chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

17 Book 3
Brachycephalic

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

■ Extubation should be as late as possible and oxygen

should be provided until the patient can maintain normal SpO2
without assistance
● It is not unusual to allow the patient to sit in sternal, moving
his/her head around with the endotracheal tube still in place

■ Extubate when the patient starts chewing on the tube; continue to

monitor closely after extubation (and provide oxygen as necessary)
until normal SpO2 readings are sustained
■ Since the airway is so compromised, even a small amount of edema
caused by intubation can be catastrophic
● Neosynephrine nasal drops (one drop per nostril and one on the
soft palate) may help with swollen, edematous nasal and soft
palate mucosae
■ Reintubation may be necessary if serious respiratory distress
occurs after extubation
● Have propofol, a laryngoscope, and clean endotrachel tubes
available
■ Consider supplemental O2 via mask/flow-by/oxygen cage/nasal
oxygen tubes
● An example procedure for placement of nasal oxygen is provided in
the Respiratory Compromise protocol
● Flow-by O2 support is inefficient and should only be utilized if the
patient will not calmly tolerate the mask
■ Do not rush recovery
● Can provide butorphanol 0.1 mg/kg IV, 10 minutes prior to
discontinuing anesthesia to promote a quiet recovery and
reduce coughing

Protocols 18
Brachycephalic

Postoperative care and pain management

Drug Dose Route
NSAID
Carprofen Canine 4 mg/kg SC (initial dose)
Meloxicam Canine 0.2 mg/kg SC (initial dose)
Robenacoxib Feline 2 mg/kg SC (initial dose)
OPIOID
Butorphanol 0.2–0.4 mg/kg IM
Canine 0.005–0.02 mg/kg IM
Buprenorphine
Feline 0.01–0.02 mg/kg IM, Transmucosal
0.24 mg/kg
Buprenorphine –
Feline (dose on lean body SC only
long acting
weight)
0.01–0.2 mg/kg SC, IM
Canine
0.005 mg/kg IV every 2–4 hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline
0.05 mg/kg IV every 2–6 hours
Fentanyl See Appendix chapter for details IV as CRI
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine –
Feline 1 tube Transdermal
Transdermal

■ NSAIDs and/or opioids are most commonly used as indicated for

patient analgesia
■ Adequate pain management must follow through postoperative period
and facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with analgesic
medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

Note: For dogs already on an NSAID, do not change to a different NSAID

19 Book 3
Brachycephalic

■ Only use NSAID if patient is well-hydrated, has received intraoperative

fluids and is not hypotensive or bleeding

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily or divided into
Carprofen Canine 4 mg/kg
2 doses for 3–5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
PO once daily for a
maximum of 3 total doses
Robenacoxib Feline 1 mg/kg over 3 days.
Do not exceed
1 dose per day.
OPIOID
Canine 5 mg/kg
Tramadol* PO, every 6 hours
Feline 2–4 mg/kg
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours
*Oral tramadol has not been shown to be effective postoperatively in dogs.

■ NSAID and/or opioid as appropriate for health status

■ Dispense the same NSAID that was utilized postoperatively

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 20
Caesarean section

Caesarean section
What is different about this patient?
Patients that require a caesarean section (C-section) may be
hemodynamically stable and have a relatively unremarkable
physical examination. Conversely, patients may be critically ill with
complications of pregnancy/delivery and may require significant
medical stabilization before proceeding to general anesthesia.
Respiratory compromise may occur when patients with a large,
gravid uterus are placed in dorsal recumbency. It is recommended,
when possible, to perform abdominal imaging preoperatively to help
determine treatment plan and management. This may also allow a
determination of fetal number and viability.
Large volumes of fluid and/or blood may potentially be lost with a
C-section and replacement needs should be anticipated. Additionally,
the use of certain drugs should be avoided in a pregnant patient:
■ Acepromazine
■ Ketamine
■ Benzodiazepines (midazolam, zolazepam)
■ Alpha-2 agonists (dexmedetomidine)

Additional considerations:
■ It is important to minimize fetal exposure to inhalant anesthetic
agents. However, the surgeon should wait 10 - 15 minutes post-
induction to remove fetuses from the uterus, to allow for metabolism
and redistribution of injectable agents.
■ Preloading with a fluid bolus may help avoid hypotension, which
occurs when puppies/kittens are delivered. Begin fluid bolus as
indicated per patient when abdomen is incised.
■ Prevent/treat hypothermia associated with a large, open abdomen
(see Induction, Monitoring and Recovery chapter for details).

21 Book 3
Caesarean section

Premedication
Drug Dose Route
Butorphanol 0.2–0.4 mg/kg IM, SC
OR
Methadone 0.2 mg/kg IM, IV

■ Premedication analgesia may not be required for very quiet or

depressed patients
● May be given IV after puppies/kittens are removed if medically
indicated based on stability and response to anesthesia and surgery
■ As much patient preparation as possible should occur before
induction and may include:
● Gathering all drugs and supplies needed for resuscitation
● Calculating and filling syringes for line blocks
● Collecting supplies and medications anticipated for CRIs
(e.g., dobutamine, etc.)
● Clipping and initial cleaning of surgical fields
■ Preoxygenate based on patient tolerance, to help avoid maternal
and fetal hypoxia
■ Consider the use of maropitant for visceral pain, nausea and faster
return to eating post-operatively.

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 22
Caesarean section

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over IV
15 seconds until intubation
OR
1–4 mg/kg incrementally over
Alfaxalone 60 seconds until intubation can IV
be achieved

■ Alfaxalone may be associated with better neonatal vitality upon

delivery and in the immediate post-operative period
■ Induce with lowest possible dose of induction agent
● Both propofol and alfaxalone may cause apnea if
given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Transition phase
Post-induction inhalant rates
Inhalant Rates Miscellaneous
50–100 mL/kg/minute
(rebreathing) For first 15 minutes
Oxygen
150–300 mL/kg/minute after induction
(NRB)
Large dogs may
Sevoflurane 3% for 3 minutes
need higher rates
■ Be prepared to perform manual ventilation
■ Monitor anesthetic depth and oxygenation closely

23 Book 3
Caesarean section

Anesthetic maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ Be prepared to adjust oxygen flow rates in response to patient

clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details
■ Inspect the caudal pharynx frequently for reflux
● To decrease chances of passive gastric reflux, do not position the
patient head down during surgery

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 24
Caesarean section

Perioperative anesthetic support

Intravenous
Rate Miscellaneous
Fluids
Higher fluid rates
Canine 5 mL/kg/hour may be needed
if patient is not
Crystalloids
adequately
Feline 3 mL/kg/hour hydrated when
anesthesia begins
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV
■ Watch for significant changes in heart rate throughout the
procedure, beginning with premedication administration
■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Notes
_______________________________________________________________

_______________________________________________________________

25 Book 3
Caesarean section

Local blocks and antibiotics

Local Block

PF Morphine 0.1 mg/kg

Awake, sedated, epidural block of
PF Lidocaine 3 mg/kg
morphine and lidocaine
Max Volume 6 mL

OR
Reduced dose of lidocaine
Line blocks for
OR
abdominal incision
bupivacaine (see below)
Antibiotics
If medically indicated, See Medical Quality
cefazolin is recommended Standards chapter

■ Reduce lidocaine/bupivacaine dosage by 50–75%

■ Dilute local anesthetic as needed to obtain adequate volume
for administration
● Pay attention to maximum cumulative doses — decrease
as described
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed
■ If unable to perform an awake epidural block, perform presurgical line
blocks once anesthetized and a postsurgical epidural opioid block.

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 26
Caesarean section

Anesthetic recovery

Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

Resuscitation of pups/kits:
■ Provide warmth and gentle stimulation
■ Provide supplemental oxygen
■ If spontaneous respiration is not occurring:
● Consider intubation, depending on size
● Administer oxygen
● If dam was given opioid prior to delivery, apply one drop of
naloxone sublingually to each pup or kit
● DO NOT administer doxapram
● DO NOT swing/sling pups or kits
● Gentle suction of nose, mouth and airways may be performed
■ Place pups/kits with dam as soon as complete recovery is attained
● Ensure patient is fully recovered before leaving pups/kits unattended

27 Book 3
Caesarean section

Postoperative care and pain management

Drug Dose Route
Canine 0.005–0.02 mg/kg IM
Buprenorphine IM,
Feline 0.01–0.02 mg/kg
Transmucosal
■ Opioids are most commonly used
● Avoid NSAIDs when possible
■ Adequate pain management must follow through postoperative
period and facilitates anesthetic recovery
■ Consider premedication utilized when choosing
postoperative analgesics
■ Pain scores of 2 and greater should be treated with
analgesic medications
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

Analgesia to go home
Drug Dosage Route
Canine 5 mg/kg PO, every
Tramadol*
Feline 2–4 mg/kg 6 hours
OR
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours
*Oral tramadol has not been shown to be effective postoperatively in dogs.

■ Use opioid as appropriate for health status

■ Avoid NSAIDs when possible

Protocols 28
Cardiac

Cardiac
What is different about this patient?
Patients with cardiac disease are at an increased risk for clinical
decompensation, fluid overload and potentially cardiac arrhythmias
with anesthesia. Remember that the presence or absence of a murmur
does not equate to clinical cardiac disease.
Patients with known or suspected congenital cardiac disease (e.g.,
patent ductus arteriosus, ventricular septal defect, pulmonic stenosis)
that has not been corrected should not undergo general anesthesia
due to high potential risks. If anesthesia cannot be avoided and
referral is not an option, consider the Cardiac protocol.
Patients with known but stable cardiac disease should be thoroughly
assessed prior to anesthesia (e.g., thoracic radiographs, blood
pressure, ECG, minimum data base) to ensure disease is clinically
stable. See the 2009 American College of Veterinary Internal Medicine
(ACVIM) Consensus Statement on Chronic Valvular Disease for a
discussion on the classification of heart disease and heart failure for
details.
Additional considerations:
■ Blood pressure may be affected by comorbid conditions (e.g., renal
or endocrine disease) so ensure complete clinical picture is obtained
prior to anesthesia
■ If patients have evidence of clinical decompensation, stabilize
medically and reschedule anesthesia. If anesthesia cannot be
avoided and referral is not an option, consider the Cardiac protocol.
■ Complete cardiac work-ups are recommended for all patients with
cardiac disease prior to anesthesia:
● ECG
● Echocardiogram
● BP
■ Minimum Data Base (MDB) for these patients should include 2 view
thoracic radiographs, labwork and urine prior to the procedure

29 Book 3
Cardiac

Canine examples
Breeds with known risk of Doberman Pinscher
cardiac arrhythmias ECG Boxer
Breeds with increased
incidence
King Charles Cavalier Spaniel
of mitral valve disease
Thoracic radiographs
Feline considerations
Potential presence of subclinical See Physiology chapter
cardiac disease (HCM) for details

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg IM, SC
Butorphanol 0.2– 0.4 mg/kg IM, SC
OR
Midazolam 0.1–0.2 mg/kg IM, SC
Canine 0.05–0.2 mg/kg IM
Hydromorphone
Feline 0.05–0.1 mg/kg SC
■ Consider if additional analgesic therapy is warranted based on:

● Signalment ● Anesthetic indication

● Physical examination ● Surgical intervention planned
■ If analgesic therapy is warranted, replace butorphanol in
the premedication with another opioid listed in Additional
Analgesic Therapy

Protocols 30
Cardiac

■ Pay attention to heart rate after premedication administration

● It is expected that heart rate will decrease as the onset of
action of premedication is reached
■ Anesthetic drug choices should be based on the type of
cardiac disease
● Ketamine should be avoided in cats with HCM
● Lower dosed opioids and benzodiazepines are usually safe
for patients with cardiac disease

Additional analgesic therapy

Drug Dose Route
Buprenorphine 0.01–0.02 mg/kg IM, IV
0.24 mg/kg
Buprenorphine –
Feline (dose on lean body SC only
long acting
weight)
Buprenorphine –
Feline 1 tube Transdermal
Transdermal
■ Thoroughly evaluate cardiovascular parameters after premedication
administration
■ Any worsening or refractory parameter warrants aborting
elective procedures

31 Book 3
Cardiac

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

■ Both propofol and alfaxalone may cuase apnea if given
rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Protocols 32
Cardiac

Anesthetic maintenance
Inhalant Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ If lidocaine CRI is utilized for control of arrhythmias, remember

to decrease sevoflurane to 0.5–1% when CRI is started
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

Notes
_______________________________________________________________

_______________________________________________________________

33 Book 3
Cardiac

Perioperative anesthetic support

Intravenous
Rate Miscellaneous
Fluids
Canine 4 mL/kg/hour Monitor closely
Crystalloids for signs of fluid
Feline 2 mL/kg/hour overload
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Fluid rates for patients with cardiac disease are decreased due to
concerns of possible fluid overload
● Monitor patient cardiovascular parameters closely and change
fluid rate as indicated
■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension
● Use with caution in patients with cardiac disease
● If anticholinergics are administered, continuous ECG monitoring
for cardiac arrhythmias is critical

Protocols 34
Cardiac

Local blocks and antibiotics

Local Block
Pay attention to maximum
As medically indicated
cumulative doses
Antibiotics
See Medical Quality
As medically indicated
Standards chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
■ Perform blocks once patient is under general anesthesia and the
first of 3 sterile skin preps has been performed

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

35 Book 3
Cardiac

Postoperative care and pain management

■ NSAIDs and/or opioids are most commonly used as indicated for

patient analgesia
■ Adequate pain management must follow through postoperative period
and facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with
analgesic medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

Protocols 36
Cardiac

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action (e.g.,
opioid or tramadol). See The Individualized Anesthesia and Analgesia Plan
chapter for details.
■ Only use NSAIDs if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily or
Carprofen Canine 4 mg/kg divided into 2 doses
for 3–5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
PO once daily for a
maximum of 3 total
Robenacoxib Feline 1 mg/kg doses over 3 days.
Do not exceed 1
dose per day.
OPIOID
Canine 5 mg/kg
Tramadol* PO, every 6 hours
Feline 2–4 mg/kg
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours
*Oral tramadol has not been shown to be effective postoperatively in dogs.

■ NSAID and/or opioid as appropriate for health status

■ Dispense the same NSAID that was utilized postoperatively

37 Book 3
Cardiac

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 38
Dental prophylaxis

Dental prophylaxis
What is different about this patient?
This same protocol for anesthesia and recovery can be used for
healthy, elective soft tissue surgery. However, it is important to
evaluate the patient for dental prophylaxis very carefully; patients with
significant tooth disease may be geriatric or have concurrent disease,
which must be taken into account (see other protocols depending
on the nature of the concurrent disease). Use the dental prophylaxis
protocol in those healthy pets when no concurrent diseases or patient-
specific factors impacting anesthesia are present. Healthy geriatric
patients undergoing routine dental prophylaxis should be anesthetized
using the Geriatric protocol.
Dental prophylaxis is considered a non-sterile procedure. It has
been shown that bacteremia occurs with routine dental prophylaxis,
independent of the severity of dental disease. Performing sterile
procedures under the same anesthesia as a dental prophylaxis is
not recommended due to concerns of contamination.
Unique risks to the patient undergoing a dental prophylaxis include:
■ Hypothermia
● Length of time of procedure
● Potential for fur to become soaked with flushing solution
■ Aspiration
● Potentially large volume of oral flushing solutions
● Incorrect or incomplete ET cuff inflation
■ Thermal burns
● Potentially saturated fur and prolonged recumbency on
warming devices
● Be especially cautious in older patients/patients with thin
body condition

39 Book 3
Dental prophylaxis

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg IM, SC
Butorphanol 0.2–0.4 mg/kg IM, SC
OR
Acepromazine 0.02–0.05 mg/kg IM, SC
Butorphanol 0.2–0.4 mg/kg IM, SC

■ Maximum acepromazine dose of 2 mg in dogs and 1 mg in cats.

Dose should be reduced for Boxers, sighthounds and dogs positive
for ABCB1 (MDR1) gene (Collies and others)
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Midazolam commonly causes excitation in younger, healthy patients

Note: Routine dental prophylaxis (with no extractions and with

minimal periodontal disease) is not anticipated to require additional
analgesic therapy

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 40
Dental prophylaxis

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if
given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

■ Ensure appropriate seal on endotracheal cuff due to high volumes of

oral flush solution

41 Book 3
Dental prophylaxis

Anesthetic maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ High volumes of water may be used to rinse and flush the oral cavity
during dental prophylaxis
● Ensure patient fur does not become saturated with water
● This may predispose to hypothermia and potentially thermal burns
(especially if thin body condition)
□ Keep patients as dry as possible
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

Protocols 42
Dental prophylaxis

Perioperative anesthetic support

Intravenous Fluids Rate Miscellaneous
Higher fluid rates
Canine 5 mL/kg/hour
may be needed
if patient is not
Crystalloids
adequately
Feline 3 mL/kg/hour hydrated when
anesthesia begins
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Local blocks and antibiotics

Local block
Dental nerve block(s) Bupivacaine Canine 2 mg/kg
Feline 1.5 mg/kg
+/- Buprenorphine 3-5 mcg/kg
Antibiotics
As medically indicated See Medical Quality Standards chapter

■ Dilute local anesthetic as needed to obtain adequate volume

for administration
● Pay attention to maximum cumulative doses

43 Book 3
Dental prophylaxis

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 44
Dental prophylaxis

Postoperative care and pain management

■ Adequate pain management must follow through postoperative period

and facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with analgesic
medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action
(e.g., opioid or tramadol). See The Individualized Anesthesia and Analgesia
Plan chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

45 Book 3
Dental prophylaxis

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily or
Carprofen Canine 4 mg/kg divided into 2 doses
for 3–5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
PO once daily for a
maximum of 3 total
Robenacoxib Feline 1 mg/kg doses over 3 days.
Do not exceed 1
dose per day.
OPIOID
Canine 5 mg/kg
Tramadol* PO, every 6 hours
Feline 2–4 mg/kg
0.01–0.02 Transmucosal,
Buprenorphine Feline
mg/kg every 8 hours
*Oral tramadol has not been shown to be effective postoperatively in dogs.

■ NSAIDs and/or opioids are most commonly used as indicated for

patient analgesia
● Analgesic therapy is not anticipated to be necessary for routine
dental prophylaxis
● Extractions may require additional analgesic medication
■ NSAID and/or opioid as appropriate for health status
■ Dispense the same NSAID that was utilized postoperatively

Protocols 46
Diabetic (stable)

Diabetic (stable)

What is different about this patient?

Stable may be a relative term for a diabetic as changes in routine and
stress can cause the patient to destabilize. It is important to try to fit
the anesthesia and procedure into the patient’s “normal” pattern as
much as possible. Goals are to have the patient awake and eating as
soon as possible and able to leave the hospital.
This patient should have the normal evening meal and insulin dose at
the regular time the night before anesthesia, then proceed with the
following recommendations.
■ Give half morning feeding and half morning insulin two to three
hours prior to anesthesia.
■ Schedule anesthesia as early in the day as possible.
■ Ensure preoperative bloodwork is relatively normal (BG should be
between 150 - 250 mg/dL).
● If BG is less than 50 or greater than 600 mg/dL do not proceed
with anesthesia and institute measures to control BG.
● IV infusions of 2.5 or 5% dextrose may be used to support BG when
levels are less than 100 mg/dL.
● If BG levels are greater than 300 mg/dL, IV dextrose support is
not indicated.
■ Consider antiemetic administration prior to premedication to help
prevent nausea and vomiting with the shorter than normal fast.

Stable diabetic patients should be discharged from the hospital as

quickly as possible after complete recovery. These patients should
be able to eat a normal evening meal with a full insulin dose after
anesthesia if the procedure was performed early in the day.

47 Book 3
Diabetic (stable)

Home administered anxiolytics

Drug Dose Route
Trazodone Canine 5–15 mg/kg PO 1 hr prior to travel
PO 2–3 hrs
Gabapentin Feline 50–100 mg/cat
prior to travel

■ Consider giving the first dose the night before along with another
dose the morning of the procedure
■ Trazodone can cause paradoxical excitement. Trial doses
are recommended.

Premedication
Drug Dose Route
Acepromazine 0.02–0.05 mg/kg IM, SC
Butorphanol 0.2–0.4 mg/kg IM, SC
OR
Midazolam 0.1–0.3 mg/kg IM, SC
Butorphanol 0.2–0.4 mg/kg IM, SC

■ Pre-treatment with maropitant is recommended to improve early return to

eating post-operatively
■ If patient is very relaxed or elderly, butorphanol alone may be appropriate
■ Maximum acepromazine dose of 2 mg in dogs and 1 mg in cats.
Dose should be reduced for Boxers, sighthounds and dogs positive for
ABCB1 (MDR1) gene (Collies and others)
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Consider if additional analgesic therapy is warranted, based on:
● Signalment ● Anesthetic indication
● Physical examination ● Surgical intervention planned
■ If analgesic therapy is warranted, replace butorphanol in the
premedication with another opioid listed in Additional Analgesic Therapy

Protocols 48
Diabetic (stable)

Additional analgesic therapy

Drug Dose Route
Hydromorphone 0.05–0.1 mg/kg IM, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV
Buprenorphine – 0.24 mg/kg
Feline SC only
long acting (dose on lean body weight)
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on lean body
Feline Transdermal
Transdermal weight)

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

● Both propofol and alfxalone my cause apnea if given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

49 Book 3
Diabetic (stable)

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

Anesthetic maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ BG should be measured after induction and at 30-minute intervals

or more frequently if medically indicated. If glucose is under
100 mg/dL, IV fluids should be supplemented with dextrose at
calculated fluid rate. Dextrose administration should be discontinued
if BG is greater than 300 mg/dL.
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

Protocols 50
Diabetic (stable)

Perioperative anesthetic support

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Notes
_______________________________________________________________

_______________________________________________________________

51 Book 3
Diabetic (stable)

Local blocks and antibiotics

Local block
Pay attention to maximum
As medically indicated
cumulative doses
Antibiotics
See Medical Quality
As medically indicated
Standards chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
■ Perform blocks once patient is under general anesthesia and the
first of 3 sterile skin preps has been performed

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on
SpO2 95–100%
room air
Sternal recumbency
Pain controlled Pain score <2
■ Patient should be offered a small amount of food as early as possible
when fully awake and able to eat without risk of aspiration

Protocols 52
Diabetic (stable)

Postoperative care and pain management

■ NSAIDs and/or opioids are most commonly used as indicated for

patient analgesia
■ Adequate pain management must follow through postoperative period
and facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with
analgesic medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action (e.g.,
opioid or tramadol). See The Individualized Anesthesia and Analgesia Plan
chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

53 Book 3
Diabetic (stable)

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily or
Carprofen Canine 4 mg/kg divided into 2 doses
for 3–5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
PO once daily for a
maximum of 3 total
Robenacoxib Feline 1 mg/kg doses over 3 days.
Do not exceed 1 dose
per day.
OPIOID
Canine 5 mg/kg
Tramadol* PO, every 6 hours
Feline 2–4 mg/kg
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours
* Oral tramadol has not been shown to be effective postoperatively in dogs.

■ NSAID and/or opioid as appropriate for health status

■ Dispense the same NSAID that was utilized postoperatively

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 54
Emergency

Emergency
What is different about this patient?
True emergencies are surgical cases that require immediate
anesthesia (within 15 minutes) to save the patient’s life.
These situations are rare and thus this protocol should be
infrequently used

These patients may require intensive preparation to become as stable

as possible for anesthesia. Surgical preparation can occur while
stabilization is being performed, prior to induction.
■ Calculate emergency drug doses and draw up medication.
■ Prepare other equipment that may be necessary – chest tubes,
tourniquets, etc.
■ Place a second IV catheter.
■ Prepare anticipated CRIs – dopamine, fentanyl, lidocaine, etc.

If preanesthetic clinical pathology data cannot be obtained due to the

urgency of the situation, perform it as the patient is being examined
and stabilized. Address life-threatening abnormalities
(e.g., hypoglycemia, hyperkalemia).
Some patients may present on emergency with a life-threatening illness
(e.g., urethral obstruction, pyometra). It is important to differentiate
patients that require emergency surgery from patients with critical
illness that will need anesthesia at some point but require medical
intervention first. Proceed to anesthesia when these patients have
medically stabilized and anesthesia risks have been reduced.

Examples
Airway obstruction, Life-threatening
bilateral pneumothorax acute hemorrhage

55 Book 3
Emergency

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg IM, SC
Butorphanol 0.2–0.4 mg/kg IM, SC
■ Consider if additional analgesic therapy is warranted, based on:
● Signalment ● Anesthetic indication
● Physical examination ● Surgical intervention planned
■ If analgesic therapy is warranted, replace butorphanol in
the premedication with another opioid listed in Additional
Analgesic Therapy

Additional analgesic therapy

Drug Dose Route
Hydromorphone 0.05–0.1 mg/kg IM, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV
0.24 mg/kg
Buprenorphine –
Feline (dose on lean body SC only
long acting
weight)
Methadone 0.1–0.4 mg/kg IM, IV

Protocols 56
Emergency

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Preoxygenate if possible, based on patient tolerance and

clinical stability
■ Induce with lowest possible dose of induction agent
● Both propofol and alfaxalone may cuase apnea if given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

57 Book 3
Emergency

Anesthetic maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ Be prepared to adjust oxygen flow rates in response to patient

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 58
Emergency

Perioperative anesthetic support

Intravenous
Rate Miscellaneous
Fluids
Canine 5 mL/kg/hour Higher fluid rates
may be needed
if patient is not
Crystalloids adequately
Feline 3 mL/kg/hour hydrated when
anesthesia
begins
20 mL/kg/day
Canine OR
Bolus of 5 mL/kg If medically
Colloids
20 mL/kg/day indicated
Feline OR
Bolus of 2.5 mL/kg
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Treat hypotension and prevent/treat hypothermia as aggressively as

possible in the critical patient
■ See Induction, Monitoring and Recovery chapter for details regarding
colloid and transfusion support
■ Depending on preanesthetic BG readings, BG may need to be
checked intraoperatively and postoperatively. IV dextrose infusion at
2.5–5% may be utilized to support BG in the hypoglycemic patient.
■ If a lidocaine CRI is utilized during surgery, turn the vaporizer
down to 0.5–1%
■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

59 Book 3
Emergency

Local blocks and antibiotics

Local block
Pay attention to maximum
As medically indicated
cumulative doses
Antibiotics
See Medical Quality Standards
As medically indicated
chapter

■ Dilute local anesthetic as needed to obtain adequate volume

for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed
■ Line blocks may be performed at end of surgery at the time of
incision closure

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

Protocols 60
Emergency

Postoperative care and pain management

Drug Dose Route
OPIOIDS
Canine 0.005–0.02 mg/kg IM
Buprenorphine IM,
Feline 0.01–0.02 mg/kg
Transmucosal
0.24 mg/kg
Buprenorphine –
Feline (dose on lean body SC only
long acting
weight)
0.01–0.2 mg/kg SC, IM
Canine IV every
0.005 mg/kg
2–4 hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline IV every
0.05 mg/kg
2–6 hours
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on lean
Feline Transdermal
Transdermal body weight)

■ Critical or unstable patients, or patients that require

continuous monitoring, should be referred to an overnight/24-
hour facility for continued care
■ Opioids are most commonly used
● Avoid NSAIDs depending on the emergency, blood pressure
stabilization and underlying risks
■ Adequate pain management must follow through postoperative
period and facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative
analgesics
■ Pain scores of 2 and greater should be treated with analgesic
medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

61 Book 3
Emergency

■ Use opioid as appropriate for health status

■ Avoid NSAIDs when possible
■ Tailor to the individual patient as clinically indicated

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 62
Geriatric

Geriatric
What is different about this patient?
Geriatric patients are usually considered to be those that have
reached 75–80 percent of breed-specific lifespan. An age of 8 years
for dogs and 12 years for cats may be a good estimate.
It is important to review the medical history of these patients closely
as they may be receiving medications for concurrent diseases or
analgesic medication (including NSAIDs) for known or presumptive
arthritis. These patients should be scrutinized for concurrent diseases
with careful physical examination, clinical pathology evaluation and
additional testing if medically indicated.
■ Use the Geriatric protocol in those pets where no concurrent
disease conditions are identified or suspected.
● Geriatric patients undergoing a routine dental prophylaxis should
be anesthetized using the Geriatric protocol.
■ If concurrent disease is identified in a geriatric patient, then the
protocol specific to that disease should be utilized.
● The most common conditions include cardiac, renal and hepatic
disease (see specific protocols for details).
■ Thoracic radiographs are recommended within 6 months prior to
any anesthesia

63 Book 3
Geriatric

Complications to consider:
■ Increased anxiety
■ Arthritis - patients may need additional padding during the
procedure, low-stress handling techniques and more support when
moving/carrying
■ Decreased dose adjustments
■ Use of the saphenous vein for IV catheter to decrease stress and handling

Geriatric patients often have significant physiologic decline in most

organ functions as well as a decline in neurologic function, leading
to less reserve in all vital organs. This means that the patient is less
tolerant of anesthesia; all drug dosages (including inhalant anesthesia)
must be carefully titrated based on the patient’s response.

Examples
Reasonable Canine: > 8 years
(adjust for size/breed) No concurrent
estimates for
disease
geriatric ages Feline: >12 years

Protocols 64
Geriatric

Premedication
Drug Dose Route
Low dose
0.01 mg/kg IM
Acepromazine
Butorphanol 0.2 mg/kg IM
OR
Midazolam 0.1 mg/kg IM
Butorphanol 0.2–0.4 mg/kg IM
OR
IM (volume limits to
Alfaxalone 2 mg/kg
small patients only)
Butorphanol 0.2-0.4 mg/kg IM
OR

Alfaxalone IM (volume limits to

2 mg/kg
small patients only)
Methadone 0.2 mg/kg IM

■ If the patient is very stressed by the hospital environment or the

procedure warrants additional analgesic needs, hydromorphone
may replace butorphanol (see dosing below)
● Alternatively, the opioid may be used alone
■ Maximum acepromazine dose of 2 mg in dogs and 1 mg in cats
● Dose should be reduced for Boxers, sighthounds and dogs positive
for ABCB1 (MDR1) gene (Collies and others)
□ See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ If analgesic therapy is warranted, replace butorphanol in the
premedication with another opioid listed in Additional
Analgesic Therapy

65 Book 3
Geriatric

Additional analgesic therapy

Drug Dose Route
Hydromorphone 0.05–0.1 mg/kg IM, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV
Buprenorphine – 0.24 mg/kg (done on lean
Feline SC only
long acting body weight)
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on lean
Feline Transdermal
Transdermal body weight)

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of propofol

● May cause apnea if given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration

Protocols 66
Geriatric

Anesthetic maintenance
Inhalant Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ Hypotension should not be tolerated (i.e., two consecutive low

readings should prompt notification of the veterinarian and
treatment as directed)
● A fluid bolus, usually the first treatment for hypotension, should
be used with caution if there is concurrent
heart disease
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic therapy
and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

67 Book 3
Geriatric

Perioperative anesthetic support

■ Avoid anticholinergics unless extremely bradycardic,

accompanied by hypotension, as geriatric patients may be
hypersensitive to anticholinergics
■ Remember that fluid rates and the use of anticholinergics may need
to be altered for concurrent disease conditions. See specific
protocols for guidelines.
■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter
for details

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 68
Geriatric

Local blocks and antibiotics

Local block
Use whenever possible to lower Pay attention to maximum
vaporizer setting required cumulative doses
Antibiotics
See Medical Quality
As medically indicated
Standards chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

Notes
_______________________________________________________________

_______________________________________________________________

69 Book 3
Geriatric

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

■ Careful auscultation of lungs for evidence of pulmonary edema

should be performed if additional fluids were required at any time
during or after the procedure
■ Patients with preexisting arthritis may have difficulty moving around
after surgery and may benefit from additional padding and pillows
■ Patients with chronic respiratory disease may have SpO2 levels below
and EtCO2 levels above the normal range
● Upon recovery, SpO2 levels should return to preoperative levels
■ Supplemental oxygen may be of benefit to these patients in the
recovery phase and can be provided by mask/flow by/oxygen cage
(where available)/instillation of nasal oxygen tubes
● Note that there are multiple methods described to place nasal
oxygen catheters
● The medical record should contain accurate documentation of the
step-by-step procedure utilized
□ An example procedure is provided in the Respiratory
Compromise protocol
■ Recovery may be delayed. Closely monitor for hypothermia and comfort.

Protocols 70
Geriatric

Postoperative care and pain management

■ NSAIDs and/or opioids are most commonly used as indicated for

patient analgesia
■ Consider potential drug interactions
■ Pain management can be the same as for healthy (nongeriatric) patients if
renal function (as investigated by preanesthetic minimum data base) is normal
● If abnormal renal function is present, NSAIDs should not be used
■ Adequate pain management must follow through postoperative period and
facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with analgesic medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

71 Book 3
Geriatric

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action
(e.g., opioid or tramadol). See The Individualized Anesthesia and Analgesia
Plan chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

■ Dispense the same NSAID that was utilized postoperatively

Protocols 72
Geriatric

Notes
_______________________________________________________________

_______________________________________________________________

73 Book 3
Hands-free radiology

Hands-free radiology

What is different about this patient

and procedure?
This protocol should be utilized to help minimize exposure to radiation
for hospital associates. The ALARA (as low as reasonably achievable)
principles for radiation exposure should be consistently followed and
be followed throughout this protocol.
Many drugs and combinations may be used for sedation to get
diagnostic radiographs and should be individualized for each patient.
Additionally, it is important to preplan radiographic studies to enable
maximal utilization of chemical restraint in conjunction with patient
positioning tools.
Additional considerations:
■ Always consider the safest anesthetic procedure (sedation,
immobilization or general anesthesia) for the patient.
■ Ensure appropriate monitoring and airway support is provided for
every anesthetic procedure.
■ Follow all Medical Quality Standards for patient monitoring and
recovery during sedation and immobilization procedures.

Examples
Coxofemoral joint
Orthopedic injury Neoplasia staging
assessment

Protocols 74
Hands-free radiology

Home administered anxiolytics

Drug Dose Route
PO 1hr prior
Trazodone Canine 5–15 mg/kg
to travel
PO 2–3 hrs prior
Gabapentin Feline 50–100 mg/cat
to travel

■ Consider giving the first dose the night before along with another
dose the morning of the procedure
■ Trazodone can cause paradoxical excitement. Trial doses
are recommended.

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg
IM, SC
Butorphanol 0.2–0.4 mg/kg
OR
Acepromazine 0.02–0.05 mg/kg
IM, SC
Butorphanol 0.2–0.4 mg/kg
OR
Dexmedetomidine 2–5 mcg/kg
Canine IM
Butorphanol 0.2–0.4 mg/kg
OR
DKT mixture.
See Appendix
Feline 0.035 mL/kg IM
chapter for mixing
instructions.

■ If patient is immobilized, procedures must be converted to general

anesthesia if lasting more than 10 minutes
■ Consider a different opioid if patient is painful for any reason.

75 Book 3
Hands-free radiology

■ As a general rule, try using normal premedication for patients that

are not fractious
■ Fractious patients may require premedication from the Stressed/
Fractious Patient protocol
● See Stressed/Fractious Patient protocol for details and dosages
■ Maximum acepromazine dose of 2 mg in dogs and 1 mg in cats
● Dose should be reduced for Boxers, sighthounds and dogs positive
for ABCB1 (MDR1) gene (Collies and others)
□ See The Individualized Anesthesia and Analgesia Plan chapter for
details
■ If patient is immobilized, procedures must be converted to general
anesthesia if lasting more than 10 minutes
■ Consider a different opioid if patient is painful for any reason

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant
■ Propofol can provide an ultra-short (<5–10 minutes) duration of
deeper sedation if additional sedation is needed
● An IV catheter is required to administer propofol or IV alfaxalone
■ Hospital teams should be prepared to intubate and administer
supplemental oxygen when medically indicated

■ Bradycardia, hypotension and respiratory depression may

develop after rapid administration
● May cause apnea if given rapidly

■ Intubation and inhalant anesthesia are required for immobilization

procedures lasting longer than 10 minutes

Protocols 76
Hands-free radiology

Maintenance/monitoring

■ Monitoring equipment should always be available and used as

much as possible
■ Almost all animals will tolerate a blood pressure cuff and pulse
oximeter while sedated
■ Oxygen, laryngoscopes and endotracheal tubes should also
be available
■ Use of dexmedetomidine requires flow-by oxygen and pulse
oximeter monitoring

Caution: Dexmedetomidine may cause significant bradycardia

(heart rate below 50 bpm). The severity is related to dose (the higher the
dose, the higher MAP and the lower the heart rate) and tends to be more
severe in dogs than cats. This is a REFLEX bradycardia in response to
peripheral vasoconstriction and baroreceptor-mediated decrease in heart
rate and SHOULD NOT be treated with an anticholinergic drug. However,
at lower doses of dexmedetomidine (less than 5 mcg/kg) and also when
the vasoconstrictor response starts to diminish (approximately 30 minutes
to one hour post-administration), the central sympatholytic effect is in
effect, resulting in bradycardia AND hypotension. When bradycardia is
associated with hypotension in patients administered dexmedetomidine,
it is appropriate to administer an anticholinergic drug.

Support

■ IV fluids should not be required for radiographic studies in

healthy patients
■ Fluid therapy (type and rate) should be individualized to each
patient based on physical examination, hydration status and clinical
pathology evaluation

77 Book 3
Hands-free radiology

Local block and antibiotic

■ Not applicable to hands-free radiology

Anesthetic recovery

Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

■ Monitoring requirements for sedation/immobilization/general

anesthesia procedures as described
● See Medical Quality Standards chapter for details

Postoperative care and pain management

■ As medically indicated

Protocols 78
Hands-free radiology

Notes
_______________________________________________________________

_______________________________________________________________

79 Book 3
Obese (stable)

Obese (stable)
What is different about this patient?
Obese patients are those with a body weight 20 – 30 percent or more above
ideal. For optimal patient safety in elective procedures, postpone general
anesthesia and institute a directed weight loss program. General anesthesia
should be then pursued when ideal body weight has been reached.
If there is a need to proceed to anesthesia with an obese patient, drug
doses and IV fluid rates should be calculated on lean body weight. Body
fat stores do not add to the metabolic fate of medications. This involves
a degree of estimating as to what lean body weight should be. Previous
medical history with body weight and body condition score may be helpful
in determining accurate estimates. If in doubt, underestimate what the
patient’s weight should be — additional drugs can always be given if
administered doses appear ineffective.
Additional considerations:
■ Intramuscular and IV injections should be considered. Larger amounts
of SC fat lead to variable drug absorption with SC injections. Lumbar
injections are likely to only reach the SC space in obese animals.
■ Estimated lean body weight should be used to determine endotracheal
tube size, size of the rebreathing circuit and bag, tidal volume to be
delivered and may influence the size of IV catheter chosen for the patient.
● Premedication, induction agents, maintenance and analgesic
medications should have doses calculated on estimated lean
body weight.
■ Obesity will have a major impact on the patient’s ability to ventilate
adequately, especially when placed in dorsal recumbency. Monitor
oxygenation closely and be ready to assist ventilation.
■ Complications to consider:
● Passive gastric reflux/regurgitation
● Hypoxemia
● Hyperthermia
● Upper airway obstruction when not intubated
● Difficulty identifying landmarks and placing IV catheters
● Hypoventilation especially when the head is tilted lower

Protocols 80
Obese (stable)

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg
IM, SC
Butorphanol 0.2–0.4 mg/kg
OR
Acepromazine 0.02–0.05 mg/kg
IM, SC
Butorphanol 0.2–0.4 mg/kg

■ Provide flow-by oxygen prior to induction (preoxygenate for 5

minutes prior if patient will tolerate)
■ Maximum acepromazine dose of 2 mg in dogs and 1 mg in cats
● Dose should be reduced for Boxers, sighthounds and dogs positive
for ABCB1 (MDR1) gene (Collies and others)
□ See The Individualized Anesthesia and Analgesia Plan chapter for
details
■ Consider if additional analgesic therapy is warranted, based on:
● Signalment ● Anesthetic indication
● Physical examination ● Surgical intervention planned
■ If analgesic therapy is warranted, replace butorphanol in
the premedication with another opioid listed in Additional
Analgesic Therapy

Additional analgesic therapy

Drug Dose Route
Hydromorphone 0.05–0.1 mg/kg IM, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV
0.24 mg/kg
Buprenorphine –
Feline (dose on lean SC only
long acting
body weight)
Buprenorphine – 1 tube (dose on lean
Feline Transdermal
Transdermal body weight)
Methadone 0.1–0.4 mg/kg IM, IV

81 Book 3
Obese (stable)

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

Protocols 82
Obese (stable)

Anesthetic maintenance
Inhalant Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ Remember that obesity will have a major impact on the patient’s ability
to ventilate adequately, especially when placed in dorsal recumbency
● Monitor oxygenation closely and be ready to assist ventilation
■ Obese patients may have ineffective cooling mechanisms and
may be prone to hyperthermia
● Monitor temperatures closely
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

83 Book 3
Obese (stable)

Perioperative anesthetic support

■ Calculate fluid rates based on lean body weight

■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 84
Obese (stable)

Local blocks and antibiotics

Local block
As medically indicated Pay attention to maximum cumulative doses
Antibiotics
As medically indicated See Medical Quality Standards chapter

■ Dilute local anesthetic as needed to obtain adequate volume

for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2
■ If drugs have been carefully administered in minimal dosages,
recovery of the obese patient should be fairly rapid
■ Obese patients may not ventilate well; place them in sternal
recumbency and give oxygen by facemask until they are able
to maintain saturation (SpO2 above 95%) by themselves and
temperature is above 100 ° F
■ Extremely obese patients might have difficulty righting themselves if
they fall into lateral recumbency
● Ensure complete visual observation until patient is mobile

85 Book 3
Obese (stable)

Postoperative care and pain management

Drug Dose Route
NSAID
Carprofen Canine 4 mg/kg SC (initial dose)
Meloxicam Canine 0.2 mg/kg SC (initial dose)
Robenacoxib Feline 2 mg/kg SC (initial dose)
OPIOID
Canine 0.005–0.02 mg/kg IM
Buprenorphine
Feline 0.01–0.02 mg/kg IM, Transmucosal
0.24 mg/kg
Buprenorphine –
Feline (dose on lean body SC only
long acting
weight)
0.01–0.2 mg/kg SC, IM
Canine
0.005 mg/kg IV every 2–4 hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline
0.05 mg/kg IV every 2–6 hours
Fentanyl See Appendix chapter for details IV as CRI
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on lean
Feline Transdermal
Transdermal body weight)
■ NSAIDs and/or opioids are most commonly used as indicated for
patient analgesia
■ Adequate pain management must follow through postoperative period and
facilitates anesthetic recovery
■ Consider premedication when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with analgesic medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action (e.g.,
opioid or tramadol). See The Individualized Anesthesia and Analgesia Plan
chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative fluids
and is not hypotensive or bleeding

Protocols 86
Obese (stable)

Notes
_______________________________________________________________

_______________________________________________________________

87 Book 3
Orthopedic

Orthopedic

What is different about this patient?

The unique aspects of orthopedic surgery include the use of
perioperative antibiotics and the anticipation of more significant
analgesic requirements. Anesthesia teams should pay close attention
to signs of pain (see The Individualized Anesthesia and Analgesia Plan
chapter for details) throughout hospitalization and be prepared to
intervene when medically indicated.
Additional considerations:
■ Ensure patient has not received corticosteroids prior to the
procedure as these could impact postoperative NSAID therapy.
■ Ensure that if NSAIDs have been given preoperatively, type, dose and
duration of therapy are known.
● Do not combine different NSAIDs and wait appropriate half-life if
changing NSAIDs.

Protocols 88
Orthopedic

Premedication
Drug Dose Route
Acepromazine 0.02–0.05 mg/kg
Canine 0.05–0.2 mg/kg IM, SC
Hydromorphone
Feline 0.05–0.1 mg/kg
OR
Midazolam 0.1–0.3 mg/kg
Canine 0.05–0.2 mg/kg IM, SC
Hydromorphone
Feline 0.05–0.1 mg/kg

■ See The Individualized Anesthesia and Analgesia Plan chapter

for details
■ Consider if additional analgesic therapy is warranted based on:
● Signalment ● Anesthetic indication
● Physical examination ● Surgical intervention planned
■ If additional analgesic therapy is warranted, consider one of
the listed options

Additional analgesic therapy

89 Book 3
Orthopedic

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if
given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

Protocols 90
Orthopedic

Anesthetic maintenance

Anesthetic Rates
maintenance
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ Be prepared to adjust oxygen flow rates in response to patient

Notes
_______________________________________________________________

_______________________________________________________________

91 Book 3
Orthopedic

Perioperative anesthetic support

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 92
Orthopedic

Local blocks and antibiotics

Local block and/or epidurals
Pay attention to maximum
As medically indicated
cumulative doses
FDA approved for canine
Liposomal bupivacaine (Nocita)
CCL surgery
Antibiotics
IV
Cefazolin 22 mg/kg
Repeat every 90 minutes until
over 3–5 minutes at induction
skin closure is complete
■ For more local and regional analgesia options see The Individualized
Anesthesia and Analgesia Plan chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

93 Book 3
Orthopedic

Postoperative care and pain management

Drug Dose Route
NSAID
Carprofen Canine 4 mg/kg SC (initial dose)
Meloxicam Canine 0.2 mg/kg SC (initial dose)
Robenacoxib Feline 2 mg/kg SC (initial dose)
OPIOID
0.01–0.2 mg/kg SC, IM
Canine
0.005 mg/kg IV every 2–4 hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline
0.05 mg/kg IV every 2–6 hours
Fentanyl See Appendix chapter for details IV as CRI
HLK See Appendix chapter for details IV as CRI
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine - 1 tube (dose on lean
Feline Transdermal
Transdermal body weight)

■ NSAIDs and/or opioids are most commonly used as indicated for

patient analgesia
■ Adequate pain management must follow through postoperative period
and facilitates anesthetic recovery
■ Consider premedication utilized when choosing postoperative analgesics
■ Pain scores of 2 and greater should be treated with analgesic
medications
■ Watch for potential hyperthermia in cats with opioid therapy
■ Do not confuse pain with dysphoria.
● Refer to Induction, Monitoring and Recovery chapter for details

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action
(e.g., opioid or tramadol). See The Individualized Anesthesia and Analgesia
Plan chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

Protocols 94
Orthopedic

Analgesia to Go Home
Drug Dosage Route
NSAID
PO once daily or
Carprofen Canine 4 mg/kg divided into 2 doses
for 3–5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
PO once daily for a
maximum of 3 total
Robenacoxib Feline 1 mg/kg doses over 3 days.
Do not exceed
1 dose per day.
OPIOID
Canine 5 mg/kg
Tramadol PO, every 6 hours
Feline 2–4 mg/kg
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours
Fentanyl patch Follow dosing chart Transdermal

■ Hospital teams are reminded that if analgesic needs cannot be met

with multimodal analgesia, referral to an overnight (24-hour) facility
for additional care is warranted and should be recommended
■ NSAID and/or opioid as appropriate for health status
■ Dispense the same NSAID that was utilized postoperatively

95 Book 3
Pediatric

Pediatric (under 16 weeks of age)

What is different about this patient?

Pediatric patients are those less than 16 weeks of age. These patients
may pose several additional risks associated with anesthesia, and
their size, physiology and ability to thermoregulate should always be
considered prior to, during and after any anesthetic procedure.
Additional considerations for pediatric patients:
■ May not be as competent to metabolize drugs as adults
■ May not thermoregulate well and have little body fat
■ Are dependent on higher heart rates to maintain cardiac output
■ May be smaller, making changes in anesthetic depth happen faster
■ May be harder to monitor, place catheters, intubate, etc.

Ideally, postpone any elective procedure until a patient is over

16 weeks of age and the risks of anesthetizing a pediatric patient can
be avoided. If anesthesia cannot be postponed and referral is not an
option, consider the Pediatric protocol. Do not fast weaned puppies
and kittens for longer than two to three hours before anesthesia.

Protocols 96
Pediatric

General puppy and kitten information

(compared to adult animals):
Pediatric value/comparison
Physical parameter
to adult value
Heart rate 200 + bpm
Respiratory rate 15–35 bpm
Blood pressure
BUN
Cardiac stroke volume Decreased
Peripheral vascular resistance
Urine specific gravity
Cardiac output
Risk of:
■ Dehydration Increased
■ Hypoglycemia
■ Hypothermia

Normal puppy/kitten
Age Physical Parameter
value
<2 weeks Temperature 96–97° F
Total white blood Decreased compared
3 weeks
cell count to adults
Decreased compared
<4 weeks Albumin*
to adults
4 weeks Temperature 100° F
<6 weeks Urine color Colorless
<7 weeks Packed cell volume 27%
8 weeks Albumin Normal adult value

*Puppies and kittens may have greater sensitivity to highly protein-bound medications

97 Book 3
Pediatric

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg
IM
Butorphanol 0.2–0.4 mg/kg
PLUS
Glycopyrrolate 0.01 mg/kg IM
OR
May be used in place
Atropine 0.02–0.04 mg/kg of glycopyrrolate in
case of back orders
■ Remember that cardiac output depends primarily on cardiac
rate in pediatric patients because of decreased stroke volume
■ Consider preemptive warming post premedication due to increased
risk for hypothermia

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 98
Pediatric

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Intubation may be difficult in small patients

● Extreme care must be taken to avoid laryngeal trauma,
which may induce swelling

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cause apnea if
given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

99 Book 3
Pediatric

Anesthetic maintenance
Inhalant Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ Bradycardia is defined as a heart rate under 150 bpm and should

be addressed immediately as cardiac output depends primarily on
heart rate in pediatric patients
■ Hypothermia may be of particular concern in pediatric patients
■ High respiratory rates, which are normal to meet the higher oxygen demand
of puppies and kittens, will result in rapid changes in anesthetic depth
● Extra care in continuous monitoring must be taken to keep the
patient at the appropriate depth of anesthesia
■ High metabolic rates also mean that pediatric patients are frequently
hypercapnic
● Intermittent positive pressure ventilation may be needed to prevent
hypoventilation and atelectasis
□ Airway pressures should not exceed 15 cm H20 since lung
compliance should be very good in young patients
■ Hypoglycemia can occur in young patients especially if
inadvertently fasted for longer than one to two hours
● BG should be checked after induction (so that dextrose can be
added to IV fluids if needed) and at 30-minute intervals during the
procedure and at recovery
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

Protocols 100
Pediatric

Perioperative anesthetic support

Intravenous
Rate Miscellaneous
Fluids
Puppies 5 mL/kg/hour Higher fluid rates
may be needed
if patient is not
Crystalloids
Kittens 3 mL/kg/hour adequately
hydrated when
anesthesia begins
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Local blocks and antibiotics

Local Block
As medically indicated Pay attention to maximum
cumulative doses
Antibiotics
As medically indicated See Medical Quality Standards
chapter

■ Dilute local anesthetic as needed to obtain adequate volume

for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

101 Book 3
Pediatric

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

■ Pediatric patients should recover fairly quickly if proper

attention has been paid to prevent hypothermia, hypoglycemia
and hypoventilation
■ It is also important to feed pediatric patients as early as possible,
once they are able to eat without risk of regurgitation or aspiration

Postoperative care and pain management

Drug Dose Route
OPIOID
Puppies 0.005–0.02 mg/kg IM
Buprenorphine
Kittens 0.01–0.02 mg/kg Transmucosal

■ Opioids are most commonly used

■ Adequate pain management must follow through postoperative
period and facilitates anesthetic recovery
■ Consider premedication utilized when choosing
postoperative analgesics
■ Pain scores of 2 and greater should be treated with
analgesic medications
■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details

Protocols 102
Pediatric

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily
or divided into
Carprofen Puppies 4 mg/kg
2 doses for
3 - 5 days
OPIOID
Transmucosal,
Buprenorphine Kittens 0.01–0.02 mg/kg
every 8 hours

■ NSAID and/or opioid as appropriate for health status

● Carprofen label indicates approved for use on puppies >6 weeks
of age
● Use NSAID only if patient is well-hydrated, has received
intraoperative fluids and is not hypotensive or bleeding

Notes
_______________________________________________________________

_______________________________________________________________

103 Book 3
Renal/post-renal

Renal/post-renal
(urinary/urethral obstruction)

What is different about this patient?

Acid-base and electrolyte status in these patients may be severely
abnormal, which can result in cardiac arrest. Additionally, neurologic
status may be markedly depressed from abnormal acid-base status and
uremia. Most medication dosages should be on the lower end of the
dosage range due to concerns regarding drug metabolism and excretion.
Preanesthetic assessment is essential and potassium should be
less than 6.0 mEql/L before it is considered safe to anesthetize
the patient. Preanesthetic ECG is also important. If abnormal ECG
tracing is observed, hyperkalemia may be present and pose a great
risk for proceeding with anesthesia. Normal ECG and sinus rhythm
do NOT equate to normokalemia. Evaluation of potassium should still
be performed to guide the administration of IV fluids as medically
indicated before proceeding.
Considerations for initial stabilization:
■ Determine physical status and address fluid, acid-base and
electrolyte imbalances.
■ Address patient analgesic requirements.
■ Place sterile urinary catheter with minimal urethral trauma.
■ Decompressive cystocentesis may facilitate urinary catheterization:
● Decreases intravesicular, intrarenal and urethral pressures
● Improves patient comfort
● Allows collection of unadultered urine sample
● Sterile urinary catheterization should follow cystocentesis.

Examples
Urethral obstruction Chronic renal disease
Acute renal injury Presence of ureteroliths

Protocols 104
Renal/post-renal

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg IM, SC
Butorphanol 0.2–0.4 mg/kg IM, SC
OR (if chemical restraint required for obstructed cats)
Alfaxalone 2 mg/kg IM (wait 10 minutes
Butorphanol 0.2 mg/kg before attempting
Atropine 0.02 mg/kg IV catheter)

■ Consider giving atropine (0.2–0.4 mg/kg) IM if HR is under

120 bpm (feline).
■ Consider if additional analgesic therapy is warranted, based on:
● Signalment ● Anesthetic indication
● Physical examination ● Surgical intervention planned
■ If analgesic therapy is warranted, replace butorphanol in
the premedication with another opioid listed in Additional
Analgesic Therapy
■ Recommend maropitant SQ to promote rapid return to eating
after recovery.

Additional Analgesic Therapy

105 Book 3
Renal/post-renal

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if
given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

Protocols 106
Renal/post-renal

Anesthetic maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen

■ Be cautious with vaporizer settings

● Sick patients may require a vaporizer setting of 1% or less for
maintenance
● If the patient is hypothermic prior to anesthesia, anesthetic
requirements will be decreased
● Pay close attention to the ECG and heart rate in these patients
■ Hypotension cannot be tolerated and must be treated promptly
and aggressively as hypotension will exacerbate renal function
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

107 Book 3
Renal/post-renal

Perioperative Anesthetic Support

Intravenous
Rate Miscellaneous
Fluids
Canine 5 mL/kg/hour Higher fluid rates
may be needed
if patient is not
Crystalloids
Feline 3 mL/kg/hour adequately
hydrated when
anesthesia begins
20 mL/kg/day
Canine OR
Bolus of 5 mL/kg If medically
Colloids
20 mL/kg/day indicated
Feline OR
Bolus of 2.5 mL/kg
Perfusion Support
Drug Dose Route
1–10 mcg/kg/
Canine
minute IV CRI if medically
Dobutamine
1–10 mcg/kg/ indicated
Feline
minute
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Monitor fluid input and urine output closely and evaluate frequently
for signs of over hydration
● Consider measuring patient ins and outs to best individualize
fluid therapy
■ Additional support to assist and maintain renal perfusion with
colloids and dobutamine CRIs may be indicated
■ Intraoperative analgesia as indicated by patient clinical status
● See The Individualized Anesthesia and Analgesia Plan chapter for details

Protocols 108
Renal/post-renal

Local blocks and antibiotics

Local Block
Consider caudal epidural block
for patients with Use bupivacaine or PF lidocaine
urethral obstruction
Antibiotics
See Medical Quality
As medically indicated
Standards chapter

■ See The Individualized Anesthesia and Analgesia Plan chapter

for details
■ Pay attention to maximum cumulative dosages of local anesthetics
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

Notes
_______________________________________________________________

_______________________________________________________________

109 Book 3
Renal/post-renal

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

■ Throughout recovery, continue to monitor fluid input and urine output

■ Frequently assess hydration and blood pressure to determine needs
for ongoing fluid therapy
■ Patients may be slow to recover and good support is essential
■ Supportive measures include:
● Provide heat as necessary
● Monitor temperature and ECG continuously
● Administer IV fluids as medically indicated and recheck electrolytes
every 2 hours until normal
● Supplement with SQ fluids before discharge. Consider
administration of SQ fluids the next day for continued fluid support

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 110
Renal/post-renal

Postoperative care and pain management

Drug Dose Route
OPIOID
Canine 0.005–0.02 mg/kg IM
Buprenorphine IM,
Feline 0.01–0.02 mg/kg
Transmucosal
0.24 mg/kg
Buprenorphine –
Feline (dose on lean SC only
long acting
body weight)
0.01–0.2 mg/kg SC, IM
Canine IV, every
0.005 mg/kg
2–4 hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline IV, every
0.05 mg/kg
2–6 hours
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on lean
Feline Transdermal
Transdermal body weight)

■ Avoid NSAIDs in patients with renal disease

■ Adequate pain management must follow through postoperative
period and facilitates anesthetic recovery
■ Opioids are most commonly used
■ Consider premedication utilized when choosing
postoperative analgesics
■ Watch for potential hyperthermia in cats with opioid therapy
■ Pain scores of 2 and greater should be treated with
analgesic medications

111 Book 3
Renal/post-renal

Analgesia to go home
Drug Dosage Route
OPIOID
Canine 5 mg/kg
Tramadol* PO, every 6 hours
Feline 2–4 mg/kg
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours

*Oral tramadol has not been shown to be effective postoperatively in dogs

■ Opioid as appropriate for health status

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 112
Respiratory compromise

Respiratory compromise
What is different about this patient?
Patients with respiratory compromise may decompensate rapidly and
quickly become critically hypoxemic. Stabilize as much as possible
prior to any procedure and continually monitor patient oxygenation.
Control and manage the airway not only under anesthesia but
throughout the recovery phase.
Additional considerations:
■ Anesthetic and analgesic agents tend to depress respiration and
administration of these agents could result in worsening of patient
status and potentially be fatal.
■ Be aware of risks and monitor closely — always be ready to
intervene with assisted ventilation.
● See Induction, Monitoring and Recovery chapter for details on
hypoventilation/hypoxemia.

Examples
Chronic Conditions Acute Respiratory Distress
Collapsing trachea Pleural effusion
Asthma Diaphragmatic hernia

113 Book 3
Respiratory compromise

Home administered anxiolytics

Drug Dose Route
PO 1hr prior
Trazodone Canine 5–15 mg/kg
to travel
PO 2-3 hrs prior
Gabapentin Feline 50–100 mg/cat
to travel
■ Consider giving the first dose the night before along with another
dose the morning of the procedure
■ Trazodone can cause paradoxical excitement. Trial doses are
recommended.

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg
IM, SC
Butorphanol 0.2–0.4 mg/kg

■ Preoxygenate based on patient tolerance and

clinical stability
■ Consider if additional analgesic therapy is warranted, based on:
● Signalment ● Anesthetic indication
● Physical examination ● Surgical intervention planned
■ If analgesic therapy is warranted, replace butorphanol in
the premedication with another opioid listed in Additional
Analgesic Therapy

Additional analgesic therapy

Protocols 114
Respiratory compromise

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant
■ Take extra caution with intubation in patients with preexisting
tracheal disease
● The presence of an ET tube may irritate tracheal mucosa, causing
coughing and inflammation, exacerbating clinical signs
● Intubate as quickly and as gently as possible

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

115 Book 3
Respiratory compromise

Anesthetic maintenance
Inhalant Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 116
Respiratory compromise

Perioperative anesthetic support

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension
● Patients with respiratory disease may have increased vagal
tone, resulting in bradycardia and may benefit from
anticholinergic administration

Notes
_______________________________________________________________

_______________________________________________________________

117 Book 3
Respiratory compromise

Local blocks and antibiotics

Local Block
Pay attention to maximum
As medically indicated
cumulative doses
Antibiotics
As medically indicated See Medical Quality Standards chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally
SpO2 95–100%
on room air
Sternal recumbency
Pain controlled Pain score <2

■ Patients with chronic respiratory disease may have SpO2 levels below
and EtCO2 levels above the normal range
● Upon recovery, SpO2 levels should return to preoperative levels
■ Supplemental oxygen may be of benefit to these patients in the
recovery phase and can be provided by flow by/mask/oxygen cage
(where available)/instillation of nasal oxygen tubes
● Flow-by O2 support is inefficient and should only be utilized if the
patient will not calmly tolerate the mask

Protocols 118
Respiratory compromise

■ There are multiple methods described to place nasal oxygen catheters

● One optional method for placement is provided on the following page
● The medical record should contain accurate documentation of the
step-by-step procedure utilized
For Collapsing Trachea:
■ Administer butorphanol 0.2 mg/kg IM 10 minutes before
discontinuing anesthesia to prevent coughing
● Allow slow return to consciousness
● Extubate early, at first sign of swallow
● If urgent reintubation is required, next attempt should take place over
20–30 minutes, moving 1–2 cm at a time
● Deliver oxygen by face mask until the patient can hold their head up

Method for nasal oxygen tube placement

1. Instill one to two drops of lidocaine into each nostril if needed,

based on patient level of consciousness and tolerance.
2. Premeasure and mark an appropriately sized red rubber catheter
from the end of the nose to the medial canthus. A tape butterfly
may be placed at the mark to assist with securing the tube.
3. Coat the end of the catheter with a small amount of water
soluble lubricant.
4. Aiming medially and dorsally, advance the tube into the nose to
the level of the mark on the tube.
5. Secure the tube under the alar fold (when possible, based on
patient anatomy).
6. Using suture, staple or tissue glue, secure the tube as close as
possible to end of nostril.
7. Provide additional attachments on midline of muzzle and at top
of head.
8. Attach end of red rubber tube to oxygen line.
9. Administering oxygen at 100 mL/kg/min unilaterally should
increase FiO2 to 37%.
10. If needed, place an Elizabethan collar or similar device to prevent
patient dislodgement of tube.

119 Book 3
Respiratory compromise

Postoperative care and pain management

Drug Dose Route
NSAID
Carprofen Canine 4 mg/kg SC (initial dose)
Meloxicam Canine 0.2 mg/kg SC (initial dose)
Robenacoxib Feline 2 mg/kg SC (initial dose)
OPIOID
Butorphanol 0.2–0.4 mg/kg IM
Canine 0.005–0.02 mg/kg IM
Buprenorphine
Feline 0.01–0.02 mg/kg IM, Transmucosal
0.24 mg/kg
Buprenorphine
Feline (dose on lean body SC only
– long acting
weight)
0.01–0.2 mg/kg SC, IM
Canine IV every 2–4
0.005 mg/kg
hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline IV every 2–6
0.05 mg/kg
hours
Fentanyl See Appendix chapter for details IV as CRI
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine - 1 tube (dose on lean
Feline Transdermal
Transdermal body weight)

■ NSAIDs and/or opioids are most commonly used as indicated for

Protocols 120
Respiratory compromise

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action (e.g.,
opioid or tramadol). See The Individualized Anesthesia and Analgesia Plan
chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

*Oral tramadol has not been shown to be effective postoperatively in dogs

■ NSAID and/or opioid as appropriate for health status
■ Dispense the same NSAID that was utilized postoperatively

121 Book 3
Sighthounds

Sighthounds
What is different about this patient?
Sighthounds have unique behavioral and physical characteristics that
will influence anesthetic and monitoring choices.
■ Higher PCV% and lower protein levels which can result in effects of
drugs that are highly protein bound
■ Low body fat increasing the risk for hypothermia under anesthesia
■ Deep chested with a larger chest capacity than other breeds of
similar weights
■ Greyhounds specifically can appear quiet but can be nervous and
develop stress hypertension, hyperthermia and colitis
■ Decreased activity in liver metabolism slowing the clearance of some
drugs such as propofol
■ Pressure injuries occur easily from improper positioning or padding
■ Skin is easily lacerated or damaged

To help minimize stress in these patients:

■ Schedule procedures early in the day
■ Administer premedications upon arrival
■ Consider keeping the patient with the owner until medications have
taken effect
■ Minimize the stay in the hospital

Protocols 122
Sighthounds

Premedication
Drug Dose Route
Butorphanol 0.2 mg/kg
IM
Acepromazine 0.05 mg/kg
OR
Butorphanol 0.2 mg/kg IM
IM
Dexmedetomidine 2.5 mcg/kg
■ Reduce acepromazine or dexmedetomidine doses in older or
quiet patients
■ Only using opioids may predispose to dysphoria in recovery
■ If analgesic therapy is warranted, replace butorphanol in
the premedication with another opioid listed in Additional
Analgesic Therapy

Additional analgesic therapy

Drug Dose Route
Hydromorphone 0.05–0.1 mg/kg IM, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV
Methadone 0.1–0.4 mg/kg IM, IV

Notes
_______________________________________________________________

_______________________________________________________________

123 Book 3
Sighthounds

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if
given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Protocols 124
Sighthounds

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

Anesthetic Maintenance
Drugs Rates
20–30 mL/kg/minute (rebreathing)
Oxygen
200 mL/kg/minute (average rate, NRB)
Sevoflurane 1–4% to effect with oxygen
■ Be prepared to adjust oxygen flow rates in response to patient
clinical parameters
■ Amount of sevoflurane will vary with patient health, analgesic
therapy and local blocks used
■ If 4% or more sevoflurane is required:
● Check the anesthesia system for leaks
● Ensure appropriate analgesia
● Consider:
□ Inadequate premedication
□ Improper endotracheal intubation, etc.
○ See Equipment chapter for more details

125 Book 3
Sighthounds

Perioperative Anesthetic Support

Fluids Rate Miscellaneous
Higher fluid rates
may be needed
if patient is not
Crystalloids Canine 5 mL/kg/hour
adequately
hydrated when
anesthesia begins
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

Anesthetic recovery
Anesthetic Recovery Parameter
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

■ Anxious and rough recoveries are not uncommon with sighthounds

● Premedication of acepromazine or dexmedetomidine helps prevent
these incidents
● Can repeat dose of (0.5–1 mcg/kg dexmedetomidine if
hypertension and bradycardia have resolved

Protocols 126
Sighthounds

Postoperative Care and Pain Management

Drug Dose Route
NSAID
Carprofen Canine 4 mg/kg SC (initial dose)
Meloxicam Canine 0.2 mg/kg SC (initial dose)
OPIOID
Buprenorphine Canine 0.005–0.02 mg/kg IM
0.01–0.2 mg/kg SC, IM
Hydromorphone Canine
0.005 mg/kg IV every 2–4 hours
Methadone 0.1–0.4 mg/kg IM, IV

■ NSAIDs and/or opioids are most commonly used as indicated for

127 Book 3
Sighthounds

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily
Carprofen Canine 4 mg/kg or divided into 2
doses for 3–5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
OPIOID
Tramadol* Canine 5 mg/kg PO, every 6 hours
*Oral tramadol has not been shown to be effective postoperatively in dogs
■ NSAID and/or opioid as appropriate for health status
■ Dispense the same NSAID that was utilized postoperatively

Notes
_______________________________________________________________

_______________________________________________________________

Protocols 128
Sighthounds

Notes
_______________________________________________________________

_______________________________________________________________

129 Book 3
Soft tissue (elective)

Soft tissue (elective)

What is different about this patient?
Elective soft tissue surgery patients would include those with normal
organ function as determined by clinical pathology data and
unremarkable physical examination results, undergoing planned
anesthesia. These patients should have an ASA status of I – II. An age-
specific protocol (Geriatric or Pediatric) should be utilized if applicable.
Premedication and additional analgesic choices should reflect patient
requirements and anticipated surgical interventions. As such, a routine
ovariohysterectomy with elective gastropexy might be expected to
require more analgesic therapy than a routine OVH alone. Always
consider the use of multimodal therapy for analgesic needs, including
the use of local and regional analgesia. See The Individualized
Analgesia and Anesthesia Plan chapter for details.
Additional considerations:
■ Due to concerns of potential surgical site contamination with
bacteremia associated with dental prophylaxis, sterile soft tissue
procedures should not be combined with elective dental
prophylaxis.
■ All sterile soft tissue surgeries are to be performed in the surgical
suite.

Examples
Castration Ovariohysterectomy
Mass removal Laceration repair

Protocols 130
Soft tissue (elective)

Premedication
Drug Dose Route
Midazolam 0.1–0.3 mg/kg
IM, SC
Butorphanol 0.2–0.4 mg/kg
OR
Acepromazine 0.02–0.05 mg/kg
IM, SC
Butorphanol 0.2–0.4 mg/kg

■ Maximum acepromazine dose of 2 mg in dogs and 1 mg in cats

● Dose should be reduced for Boxers, sighthounds and dogs positive
for ABCB1 (MDR1) gene (Collies and others)
● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Consider if additional analgesic therapy is warranted, based on:

● Signalment ● Anesthetic indication

● Physical examination ● Surgical intervention planned
■ Additional analgesia is warranted. Replace butorphanol with
another opioid or provide an additional opioid 30-60 minutes
after administration of butorphanol (route dependent).

Additional Analgesic Therapy

Drug Dose Route
Hydromorphone 0.05–0.1 mg/kg IM, SC
Buprenorphine 0.01–0.02 mg/kg IM, IV
Buprenorphine – 0.24 mg/kg
Feline SC only
long acting (dose on leanbody weight)
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on lean body
Feline Transdermal
Transdermal weight)

131 Book 3
Soft tissue (elective)

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if given
rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

Protocols 132
Soft tissue (elective)

Perioperative Anesthetic Support

Fluids Rate Miscellaneous
Canine 5 mL/kg/hour Higher fluid rates
may be needed
if patient is not
Crystalloids
Feline 3 mL/kg/hour adequately
hydrated when
anesthesia begins
Anticholinergics
Drug Dose Route
Atropine 0.02–0.04 mg/kg IV
Glycopyrrolate 0.005–0.01 mg/kg IV

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension

133 Book 3
Soft tissue (elective)

Local blocks and antibiotics

Local block
Required: Intratesticular
(castration) and line block (OVH) Lidocaine (2 mg/kg) OR
Strongly Recommended: bupivacaine (1.5 mg/kg)
Field/regional blocks
Antibiotics
Not applicable to healthy
See Medical Quality Standards
patient, elective soft tissue
chapter
procedures
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
● Pay attention to maximum cumulative doses
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

Protocols 134
Soft tissue (elective)

Postoperative care and pain management

■ NSAIDs and/or opioids are most commonly used as indicated for

135 Book 3
Soft tissue (elective)

Note: For dogs already on an NSAID, do not change to a different NSAID

without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action
(e.g., opioid). See The Individualized Anesthesia and Analgesia Plan
chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily or
Carprofen Canine 4 mg/kg divided into 2 doses
for 3 - 5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
PO once daily for a
maximum of 3 total
Robenacoxib Feline 1 mg/kg doses over 3 days.
Do not exceed 1
dose per day.
OPIOID
Canine 5 mg/kg
Tramadol* PO, every 6 hours
Feline 2–4 mg/kg
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours
* Oral tramadol has not been shown to be effective postoperatively in dogs

■ NSAID and/or opioid as appropriate for health status

■ Dispense the same NSAID that was utilized postoperatively

Protocols 136
Stressed/fractious

Stressed/fractious
What is different about this patient?
This patient will have extremely high levels of circulating
catecholamines (epinephrine, norepinephrine), which can make the
patient prone to sudden cardiovascular collapse (hypotension, cardiac
arrhythmias, shock, organ dysfunction), especially when sedatives and
anesthetics are added. This is sometimes referred to as a “crash.”
Additionally, stressed/fractious patients may be impossible to handle
for a physical exam. The presence of serious disease may be masked
by this physiologic “fight or flight” state, making these patients prone
to crash after sedation or induction when the full extent of underlying
disease becomes known.
Always be prepared for this crash.
Considerations before proceeding to chemical restraint:
■ Most aggressive behavior is a result of underlying fear or pain.
● Provide analgesic therapy as medically indicated.
● It may be in the best interest of the fearful patient to reschedule
the procedure and introduce a counterconditioning program.
■ If the patient struggles for more than three seconds, release and
reposition.
● If struggling for more than three seconds occurs two to three times,
consider chemical restraint or abort the procedure.
● Remember that less may be more in regards to handling and restraint.

DO NOT USE THE STRESSED/FRACTIOUS PET PROTOCOL IF

ACEPROMAZINE HAS ALREADY BEEN ADMINISTERED

137 Book 3
Stressed/fractious

WHEN POSSIBLE, DO NOT PROCEED WITH THE PROCEDURE AND

RESCHEDULE TO HELP MITIGATE STRESS
Mitigation Strategies
■ Institute a counterconditioning plan
■ Plan ahead for minimal patient handling and utilize rapidly acting
medications
■ Consider oral sedative administration at home prior to next visit
(be cautious of emesis if given with food or treat)

Drug Dose
5–15 mg/kg PO 1hr prior to travel

Trazodone Canine If more anxiolytic needed add:

Gabapentin 5–20 mg/kg
PO 2–3 hrs prior to travel
Gabapentin 50–100 mg/cat
150 mg/large cats 1hr prior to travel
OR Feline OR
Buprenorphine – 0.03 mg/kg transmucosal,
injectable 60–90 minutes prior to travel
■ Can give a dose at bedtime and an additional dose in the morning
■ Prepare owners for ataxia/sedation in cats
■ Paradoxical excitation is uncommon with Trazodone, trial doses are
still recommended
■ Decrease doses of Trazodone in larger dogs
■ These medications are not to replace the pre-anesthetic protocol.
Low-stress handling, minimizing stress and further analgesia +/-
sedation are required.

DO NOT WAIT FOR THE STRESSED/FRACTIOUS PET TO BECOME

UNMANAGEABLE BEFORE CHANGING YOUR PLAN
See physical examination of the stressed patient (Medical Quality
Standards chapter) and stressed/fractious patient physiology (Physiology
chapter) for additional information.
SPECIAL CONSIDERATIONS FOR THE STRESSED/FRACTIOUS
BRACHYCEPHALIC PET
■ Stressed/fractious brachycephalic patients provide a unique challenge
for both patient and associate safety
■ If it is determined that the procedure cannot be completed safely,
abort the procedure, stabilize and recover the patient and reschedule
the procedure

Protocols 138
Stressed/fractious

■ Oxygenation and a protected airway are critical to patient safety

■ Provision of oxygen and tracheal intubation should be provided as
quickly as possible and whenever medically indicated

Premedication
Drug Dose Route
CANINE
Tiletamine,
2–4 mg/kg
Zolazepam IM
Butorphanol 0.2–0.4 mg/kg
OR
Dexmedetomidine 2–5 mcg/kg
Ketamine 1–2 mg/kg IM
Butorphanol 0.2–0.4 mg/kg
OR
Dexmedetomidine 5–7 mcg/kg IM
Butorphanol 0.2–0.4 mg/kg
OR
Alfaxalone 2 mg/kg IM (volume will limit to
Butorphanol 0.2–0.4 mg/kg small dogs)

139 Book 3
Stressed/fractious

Premedication (continued from previous page)

Drug Dose Route
FELINE
See Appendix
DKT chapter for dosing IM
charts
OR
Administer orally as
the cat is hissing and
0.2 mL of each drug
the mouth is open
DKT mixture for oral for a 5 kg cat
administration Consider using
Allow 10–15 minutes
open-ended tom cat
for effect
catheter to assist with
administration
OR
Dexmedetomidine 7–10 mcg/kg
IM
Methadone 0.3–0.5 mg/kg

Dexmedetomidine 7–10 mcg/kg

IM
Hydromorphone 0.05–0.1 mg/kg

Dexmedetomidine 7–10 mcg/kg IM

IM
Buprenorphine 0.01–0.02 mg/kg

Dexmedetomidine 7–10 mcg/kg IM

IM
Butorphanol 0.2–0.4 mg/kg
OR
(for geriatric or ill cats)
Alfaxalone 1–2 mg/kg
IM
Methadone 0.3–0.5 mg/kg

Protocols 140
Stressed/fractious

Premedication (continued from previous page)

OR
2 mg/kg IM
Alfaxalone
(max 10 mg/cat) IM
Butorphanol 0.2–0.4 mg/kg

Note: Unique DKT dosing and directions for use in both canines and felines
■ lfaxalone 2 mg/kg IM can be added to above feline protocols to
achieve more sedation or as an additional IM injection if sedation is not
adequate after 15 minutes
■ Perform physical examination if not able to be completed prior
to premedication
■ Place IV catheter if medically indicated or length of procedure is
anticipated to be longer than 10 minutes
■ Obtain necessary clinical pathology samples

Induction and intubation

Drug Dose Route
1.0 mg/kg slowly over 15 seconds
Propofol Increments of 0.5 mg/kg over 15 IV
seconds until intubation
OR
0.5 mg/kg slowly over 30 seconds

Alfaxalone Increments of 0.5 mg/kg until IV

smooth transition to intubation
and inhalant
■ Propofol: Anticipate need for lower dose and may not be needed
for intubation
■ Preoxygenate if possible, based on patient tolerance and clinical stability

■ Induce with lowest possible dose of induction agent

● Both propofol and alfaxalone may cuase apnea if
given rapidly
■ Bradycardia, hypotension and respiratory depression may
develop after rapid administration of propofol or alfaxalone

141 Book 3
Stressed/fractious

Transition phase
Post-induction inhalant rates

Inhalant Rates Miscellaneous

50–100 mL/kg/minute
(rebreathing) For first 15 minutes
Oxygen
150–300 mL/kg/minute after induction
(NRB)
Large dogs may
Sevoflurane 1–2% for 3 minutes
need higher rates
■ Monitor anesthetic depth and oxygenation closely

Protocols 142
Stressed/fractious

Perioperative anesthetic support

Caution: Dexmedetomidine may cause significant bradycardia

(heart rate below 50 bpm). The severity is related to dose (the
higher the dose, the higher MAP and the lower the heart rate)
and tends to be more severe in dogs than cats. This is a REFLEX
bradycardia in response to peripheral vasoconstriction and
baroreceptor-mediated decrease in heart rate and SHOULD
NOT be treated with an anticholinergic drug. However, at lower
doses of dexmedetomidine (less than 5 mcg/kg) and also when
the vasoconstrictor response starts to diminish (approximately
30 minutes to one hour post-administration), the central
sympatholytic effect is in effect, resulting in bradycardia AND
hypotension. When bradycardia is associated with hypotension
in patients administered dexmedetomidine, it is appropriate to
administer an anticholinergic drug.

■ Intraoperative analgesia as indicated by patient clinical status

● See The Individualized Anesthesia and Analgesia Plan chapter
for details
■ Anticholinergics as clinically indicated for bradycardia accompanied
by hypotension (see Caution above)

143 Book 3
Stressed/fractious

Local blocks and antibiotics

Local Block
Pay attention to maximum
As medically indicated
cumulative doses
Antibiotics
See Medical Quality Standards
As medically indicated
chapter
■ Dilute local anesthetic as needed to obtain adequate volume
for administration
■ Perform blocks once patient is under general anesthesia and the first
of 3 sterile skin preps has been performed

Anesthetic recovery
Parameter Range
Normothermic Temp 100–102.5° F
Normotensive MAP 80–100 mm Hg
Oxygenating normally on room air SpO2 95–100%
Sternal recumbency
Pain controlled Pain score <2

■ The addition of butorphanol or midazolam may assist with recovery

from tiletamine, zolazepam in dogs
● See The Individualized Anesthesia and Analgesia Plan chapter for
additional details

Protocols 144
Stressed/fractious

Postoperative care and pain management

Drug Dose Route

NSAID
Carprofen Canine 4 mg/kg SC (initial dose)
Meloxicam Canine 0.2 mg/kg SC (initial dose)
Robenacoxib Feline 2 mg/kg SC (initial dose)
OPIOID
Canine 0.005–0.02 mg/kg IM
Buprenorphine
Feline 0.01–0.02 mg/kg IM, Transmucosal
0.24 mg/kg
Buprenorphine –
Feline (dose on lean SC only
long acting
body weight)
0.01–0.2 mg/kg SC, IM
Canine IV every
0.005 mg/kg
2–4 hours
Hydromorphone
0.05–0.1 mg/kg SC, IM
Feline IV every
0.05 mg/kg
2–6 hours
Fentanyl See Appendix chapter for details IV as CRI
Methadone 0.1–0.4 mg/kg IM, IV
Buprenorphine – 1 tube (dose on
Feline Transdermal
Transdermal lean body weight)

■ NSAIDs and/or opioids are most commonly used as indicated for

145 Book 3
Stressed/fractious

■ Watch for potential hyperthermia in cats with opioid therapy

■ Do not confuse pain with dysphoria
● Refer to Induction, Monitoring and Recovery chapter for details
Note: For dogs already on an NSAID, do not change to a different NSAID
without observing the recommended number of half-lives. Maintain on the
same NSAID or use an analgesic with a different mechanism of action
(e.g., opioid or tramadol). See The Individualized Anesthesia and Analgesia
Plan chapter for details.
■ Use NSAIDs only if patient is well-hydrated, has received intraoperative
fluids and is not hypotensive or bleeding

Analgesia to go home
Drug Dosage Route
NSAID
PO once daily
Carprofen Canine 4 mg/kg or divided into 2
doses for 3–5 days
Meloxicam Canine 0.1 mg/kg PO, every 24 hours
PO once daily for a
maximum of 3 total
Robenacoxib Feline 1 mg/kg doses over 3 days.
Do not exceed 1
dose per day.
OPIOID
Canine 5 mg/kg
Tramadol PO, every 6 hours
Feline 2–4 mg/kg
Transmucosal,
Buprenorphine Feline 0.01–0.02 mg/kg
every 8 hours

■ NSAID and/or opioid as appropriate for health status

■ Dispense the same NSAID that was utilized postoperatively

Protocols 146
Stressed/fractious

Addendum:
Special considerations for surgery:
Ear/Aural Tissue
Induce healthy patients for aural surgery with tiletamine, zolazepam
1–2 mg/kg IV, rather than propofol. Dilute with sterile water to a volume
of 1–3 mL and give slowly to effect for intubation. Watch closely for
signs of patient readiness for intubation as described in the Induction,
Monitoring and Recovery chapter.
Tiletamine might be helpful with neuropathic pain, which may be
present with aural surgery.
These patients may be expected to have more significant analgesic
requirements. Consider:
■ Wound infusion catheters
■ Constant rate infusions (CRIs)
■ See Appendix chapter for details of advanced analgesic techniques

CNS and Eye/Globe

Carefully consider anesthesia in patients with neurologic disease or
head/ocular trauma.
■ Intensive stabilization, continuous monitoring and nursing care
are likely to be required
■ Serial neurologic examinations must be performed
■ Consider referral for specialty care

Avoid acepromazine
Maintain EtCO2 between 28–35 for patients with head trauma.
Avoid increasing intracranial pressure:
■ Vomiting
■ Coughing
■ Jugular vein occlusion
■ Recumbent position with head lowered
■ Medications (e.g., ketamine)

147 Book 3
Stressed/fractious

Precalculate doses for mannitol and hypertonic saline for administration

in cases of increased intracranial pressure.

Monitor heart rate and blood pressure extremely closely. Bradycardia

in conjunction with hypertension may indicate brain herniation
(Cushing reflex).

Hyperthyroidism
ECG and echocardiogram are recommended prior to elective anesthesia.
If unable to pursue, assume the patient has ventricular hypertrophy when
choosing your anesthetic drug and monitoring protocol.
Possible Complications:
■ Bradycardia
■ Hypotension
■ Heart failure
■ Hypoglycemia (higher risk if hyperthyoridism is uncontrolled)

Recommend avoiding the use of ketamine, tiletamine/zolazepam, and

dexmedetomidine.

Use caution with NSAID administration as renal function is commonly

reduced in these patients.

References and suggested reading for Protocols:

1. Krein S, Wetmore LA. Breed-specific anesthesia. NAVC Clinician’s Brief., March
2012;17-20.
2. Neiger-Aeschbacher G. Geriatric patients. In: BSAVA Manual of Canine and
Feline Anaesthesia and Analgesia. 2nd edition. British Small Animal Veterinary
Association. Gloucester, U.K. 2007;303-309.
3. Holden D. Paediatric patients. In: BSAVA Manual of Canine and Feline
Anaesthesia and Analgesia. 2nd edition. British Small Animal Veterinary
Association. Gloucester, U.K. 2007;296-302.
4. Fortney W (ed). Geriatrics. Vet Clin North Am Small Anim Pract. July
2012;42(4):11-12.
5. Landsberg GM, Nichol J, Arauio J. Cognitive dysfunction syndrome. Vet Clin
North Am Small Anim Pract. 2012;42(4):749-768.
6. Alhelail M, Al-Salamah M, Al-Mulhim M, et al. Comparison of bupivacaine
and lidocaine with epinephrine for digital nerve blocks. Emerg Med J. May
2009;26(5):347-350.

Protocols 148
Stressed/fractious

7. Tranquilli WJ, Thurman JC, Grimm KA. Lumb and Jones’ Veterinary Anesthesia
and Analgesia. 4th edition. Oxford, England. Wiley-Blackwell. 2007;933.
8. Hoskins JD. Veterinary Pediatrics: Dogs and Cats from Birth to Six Months. 3rd
edition. Philadelphia, Pa. Saunders. 2001;525-547.
9. Atkins C, Bonagura J, Ettinger S, et al. Guidelines for the diagnosis and
treatment of canine chronic valvular heart disease. J Vet Intern Med. Nov-Dec
2009;23(6):1142-1150.
10. Hall J, Hall K, Powell LL, etal. Outcome of male cats managed for urethral
obstruction with decompressive cystocentesis and urinary catheterization: 47
cats (2009-2012). J Vet Emerg Crit Care. 2015 Mar-Apr;25(2):256-262.
11. Cooper ES. Controversies in the management of feline urethral obstruction. J
Vet Emerg Crit Care (San Antonio). Jan-Feb 2015;25(1):130-137.
12. Stevens BJ , Frantz EM, Orlando JM, et al. Efficacy of a single dose of
trazadone hydrochloride given to cats prior to veterinary visits to reduce
signs of transport- and examination-related anxiety. J Am Vet Med Assoc. July
2016;249(2):202-207.
13. Neilson J. Drug Therapy for Behavioral Problems. Proceedings: 2010 Western
Veterinary Conference. Las Vegas, Nev.
14. Nieves MA, Hartwig P, Kinyon JM et al. Bacterial isolates from plaque and from
blood during and after routine dental procedures in dogs. Vet Surg. 1997 Jan-
Feb 1997;26(1):26-32.
15. Gruen ME, X.Lascelles BD, Colleran E, et al. 2022 AAHA Pain management
Guidelines for Dogs and Cats. J Am Anim Hosp Assoc. 2022; 58:55-76.
16. 16. Brock N. Veterinary Anesthesia Update: Guidelines and Protocols for Small
Animal Anesthesia. 3rd Edition. Nancey Brock. 2000.
17. 17. Greene SA. Veterinary Anesthesia and Pain Management Secrets.
Philadelphia, PA: Haley & Belfus; 2001.
18. 18. Lerche P, Thomas JA. Anesthesia and Analgesia for Veterinary Technicians.
4th Edition. St Louis, MO. Elsevier; 2011.
19. 19. Grubb T, Sager J, Gaynor Jet al. 2020 AAHA Anesthesia and Monitoring
Guidelines for Dogs and Cats. J AM Anim Hosp Assoc. 2020;56.

Notes
_______________________________________________________________

_______________________________________________________________

149 Book 3
CPR Clinical
Guidelines
This chapter is comprised of excerpts taken from the Reassessment
Campaign on Veterinary Resuscitation (RECOVER) guidelines,
published in the Journal of Veterinary Emergency and Critical Care,
and used with permission from John Wiley and Sons, Inc., publisher.
Note: Information regarding defibrillation therapy and open chest
cardiopulmonary resuscitation (CPR) is not included in this text

Abbreviations

ABC airway, breathing, PaO2 partial pressure of

circulation arterial oxygen
ALS advanced life support PCA post cardiac arrest
BLS basic life support RECOVER Reassessment
C:V compression ventilation Campaign
ratio on Veterinary
CPA cardiopulmonary arrest Resuscitation
CPR cardiopulmonary ROSC return of spontaneous
resuscitation circulation
ET endotracheal SpO2 peripheral capillary
EtCO2 end-tidal carbon dioxide oxygen saturation
ECG electrocardiogram TPR temperature, pulse,
FiO2 fraction of inspired oxygen
MAP mean arterial pressure respiration
PaCO2 partial pressure of arterial VF ventricular fibrillation
carbon dioxide VT ventricular
tachycardia

CPR 150
Preparedness and prevention
Equipment
■ Equipment and supply inaccessibility or failure has been implicated
in delays in initiation of CPR in up to 18 percent of cardiopulmonary
arrest (CPA) cases.
■ The location, storage and content of resuscitation equipment
should be standardized and regularly audited (see Medical Quality
Standards chapter for essential equipment and medications).

Resuscitation aids
■ The presence of cognitive aids (checklists, algorithm charts and
dosing charts) has been shown to improve compliance with CPR
guidelines.
■ Formal training of team members in the use of these aids is crucial
for effective utilization during a crisis.
■ Availability and clear visibility of charts and other resuscitation aids
in areas where CPA may occur (procedure areas, surgery suites) is
recommended.

Training
■ Adherence to CPR guidelines can only be accomplished if team
members receive effective, standardized training and regular
opportunities to refresh skills.
■ Regardless of the type of technology used for initial training,
refresher training at least every six months is recommended to
reduce the risk of skill decay.
■ Improved learning outcomes have been documented when CPR
training culminates in performance testing.
■ Regardless of the methods used for initial and refresher training,
structured assessment after CPR training is recommended.

Clinical essential
A CPR team is available during
normal hours of operation

151 Book 3
■ In addition to assessment after didactic and psychomotor skills training,
structured debriefing after a real resuscitation effort or simulated CPR,
allowing participants to review and critique their performance and the
performance of the team as a whole, is recommended.
■ Open, honest discussion about opportunities for improvement
immediately after a CPR attempt can lead to significant
enhancement in CPR performance.
■ Regardless of the status of the CPR team leader (veterinarian or
technician), there is strong evidence that communication and team
skills training can improve the effectiveness of a CPR attempt.
■ Specific leadership training is recommended for team members who
may lead a CPR attempt.
● Crucial roles of the CPR team leader include:
□ Distributing tasks to other team members
□ Enforcing rules and procedures
■ Important leadership behaviors that can improve CPR team
performance include:
● Intermittently summarizing the code to ensure a shared mental
model among team members
● Actively soliciting input from team members to encourage situation
awareness and identify issues and ideas from all team members
● Assigning individual tasks to team members rather than performing
them personally to allow better attention to the global status of the
code
■ Team performance can be enhanced by using focused, clear
communication directed at individuals when tasks are assigned and
utilization of closed loop communication.
● Closed loop communication is accomplished by a clear, directed
order being given to one team member by another, after which the
receiving team member repeats the order back to the requestor to
verify the accuracy of the receiver’s perception.
■ There is high-level and high-quality supportive evidence
in veterinary medicine that anesthesia-related CPAs are
associated with increased survival compared to arrests from
other causes.

CPR 152
Basic Life Support (BLS)
It is imperative that BLS is provided immediately upon diagnosis or
suspicion of CPA.

Definition
■ Recognition of CPA
■ Administration of chest compressions
■ Airway management and provision of ventilation

Recognition
■ It is reasonable to utilize continuous electrocardiogram (ECG) and
arterial blood flow monitoring in at-risk pets.
■ Continuous end-tidal carbon dioxide (EtCO2) monitoring is
recommended in intubated and ventilated at-risk pets.
■ Monitored pulse sounds are not a reliable tool for the diagnosis
of cardiac arrest, although their disappearance may indicate
impending arrest in pets in which the probe was placed prior to CPA.
● In anesthetized pets, the loss of pulse sounds may be a reasonable
indicator of profound hemodynamic deterioration or CPA.
■ In anesthetized pets (monitored with an ECG prior to CPA) where
physical signs of CPA (unconsciousness, apnea) are not available,
ECG alterations may prove helpful as a supporting diagnostic tool
for confirmation of CPA.
■ Since CPA is a clinical diagnosis, it is essential that the ECG is not
regarded as the sole indicator of life or perfusing cardiac rhythm.
■ Aggressive administration of CPR in pets suspected of being in CPA is
recommended, as the risk of injury due to CPR in pets not in CPA is low.
■ When assessing pets that are apneic and unresponsive, a rapid
airway, breathing, circulation (ABC) assessment lasting no more
than five to 10 seconds is recommended.

153 Book 3
Chest compressions
■ Chest compressions should be initiated as soon as possible upon
recognition of CPA. If multiple rescuers are present, airway and
ventilation management should not delay commencement of
chest compressions.
● Ideal chest compressions may achieve a cardiac output of, at
most, approximately 25–30 percent of normal.
■ The immediate provision of chest compressions should be
the priority.
■ Intubation and ventilation should be attempted as soon as possible,
while compressions are being performed.
■ Chest compressions should be done in lateral recumbency
(either left or right) in both dogs and cat.
■ There is strong evidence supporting a recommendation for
compression rates of 100–120/minute in cats and dogs

Delivering chest compressions:

› In most large and giant breed dogs: Deliver chest compressions with
the hands placed over the widest portion of the chest.
› In narrow, deep chested dogs, such as Greyhounds: Deliver chest
compressions with the hands positioned directly over the heart.
› In dogs with barrel-chested conformations, such as English Bulldogs:
Consider sternal compressions in dorsal recumbency.
› Cats and small dogs tend to have higher thoracic wall compliance
and effective chest compressions can likely be achieved with a one-
hand technique with the compressor’s fingers wrapped around the
sternum at the level of the heart.
● Consider circumferential compressions rather than lateral
compressions.
● A two-handed technique can also be used.

■ There is good evidence to support deep chest compressions of

one-third to one-half the width of the thorax in most pets
■ It is recommended that full chest wall recoil is allowed
between compressions

CPR 154
Ventilation
■ Early endotracheal (ET) intubation and provision of ventilation in
CPR is likely to be beneficial.
■ If equipment and team members are available, rapid intubation of
dogs and cats in CPA is recommended.
● This should be accomplished with the pet in lateral recumbency so
chest compressions may be continued during the procedure.
● Once the ET tube is in place, inflate the cuff so that ventilation and
chest compressions can occur simultaneously.

Ventilation rate:
› A ventilation rate of 10 breaths/minute with a tidal volume of 10 mL/kg
and a short inspiratory time of one second are recommended.
› For single-rescuer CPR, a compression:ventilation (C:V) ratio of 30:2
in non-intubated dogs is recommended.
● Perform a series of 30 chest compressions at a rate of 100–120
compressions/minute.
● Deliver two breaths quickly using the mouth-to-snout technique.
● Perform another series of 30 chest compressions.
› Chest compressions should be performed in two-minute cycles without
interruption in intubated pets when several rescuers are present.

■ Rotate the compressor role after each two-minute cycle of

compressions to reduce compressor lean, which may impact chest
wall recoil and avoid compromise of compression efficacy due to
team member fatigue.
■ The use of interposed abdominal compressions in dogs and cats with
CPA is reasonable when sufficient team members trained in its use
are available.

155 Book 3
Advanced life support (ALS)
ALS includes:
› Administration of: › Correction of:
● Vasopressors ● Electrolyte disturbances
● Positive inotropes ● Volume deficits
● Anticholinergic drugs ● Severe anemia

■ If BLS and ALS are performed promptly, initial return of

spontaneous circulation (ROSC) rates may be as high as 50
percent in dogs and cats.
■ The use of low-dose (0.01 mg/kg intravenously (IV) epinephrine
administered every three to five minutes early in CPR is
recommended.
● High-dose (0.1 mg/kg IV) epinephrine may be considered after
prolonged CPR.
● In order to minimize underdosing or overdosing during CPR,
epinephrine should be administered during every other cycle
of BLS.
■ Routine use of atropine (0.04 mg/kg IV) during CPR in dogs and cats
may be considered.
■ A precordial thump may have some efficacy for treatment of
ventricular fibrillation and/or pulseless ventricular tachycardia.
● To perform a precordial thump:
□ Ensure the pet is in lateral recumbency.
□ Use a closed fist to sharply strike (“thump”) the ribcage over the
area of the heart.
■ In dogs and cats that have received reversible anesthetic/sedative
drugs, administering reversal agents during CPR may be considered.
■ Potential risks associated with administration of these drugs are low.

CPR 156
■ In refractory ventricular fibrillation/pulseless ventricular
tachycardia, consider:
● Amiodarone (5 mg/kg IV)
● Lidocaine (2 mg/kg IV)
■ IV calcium may be considered in dogs and cats with documented
moderate to severe hypocalcemia during CPR.
■ Documented hyperkalemia should be treated during CPR.
■ Treatment of documented hypokalemia during CPR may
be considered.
■ The routine use of corticosteroids during CPR is not recommended.
■ Administration of 1 mEq/kg of sodium bicarbonate may be
considered after prolonged CPA of more than 10–15 minutes.
■ For pets in which IV or intraosseous access is not possible, consider
the use of the intratracheal route for epinephrine or atropine.
● Drugs should be diluted with saline or sterile water and
administered via a catheter longer than the ET tube.
■ Use of a fraction of inspired oxygen (FiO2) of 21 percent (room air)
may be considered.
● In the absence of arterial blood gas data, the risks of hypoxemia
likely outweigh the risks of hyperoxemia and the use of a FiO2 of
100 percent is reasonable.
■ In euvolemic or hypervolemic dogs and cats, routine administration
of IV fluids is not recommended.
● Pets with pre-existing hypovolemia are likely to benefit from
increased circulating volume during CPR and administration of IV
fluids in these pets is reasonable.

Pets that experience CPA while under general

anesthesia should be aggressively resuscitated,
as a much higher percentage should be
anticipated to survive to discharge compared
to the general population

157 Book 3
Monitoring
End-tidal carbon dioxide (EtCO2)
■ Immediate post-intubation EtCO2 value should not be used for
diagnosis of CPA in dogs and cats.
● Initial values may not be representative of pulmonary perfusion.
□ Subsequent values may be associated with pulmonary perfusion.
● Multiple high-quality studies support the conclusion that sudden
increases in EtCO2 occur rapidly with ROSC (due to increased
pulmonary blood flow).
■ EtCO2 monitoring is likely a valuable adjunct for verification of
correct ET tube placement, in conjunction with:
● Direct visualization
● Auscultation
● Observation of chest excursions
■ EtCO2 should not be used as a sole measure of correct ET tube placement.
■ Evaluation of the ECG (though susceptible to artifact) during
intercycle pauses is recommended to obtain an accurate rhythm
diagnosis and guide ALS therapy.
● Chest compressions should not be stopped during a complete
two-minute cycle of CPR to allow ECG interpretation.
● Pauses in chest compressions to evaluate the ECG rhythm should
be minimized.
■ There is strong evidence supporting the use of EtCO2 monitoring
during CPR as an early indicator of ROSC and as a measure of
efficacy of CPR.
● Potentially allows rescuers to adjust treatment to maximize perfusion

Pulse
■ Interruption of chest compressions during CPR specifically to
palpate the pulse is not recommended.
■ Palpation of the pulse to identify ROSC during intercycle pauses in CPR
is reasonable as long as it does not delay resumption of compressions.

CPR 158
Electrolytes
■ Routine monitoring of electrolytes, especially during prolonged CPR,
may be considered.
■ In cases of CPA that are known or suspected to be due to electrolyte
derangements, monitoring of electrolytes will help guide therapy and
is recommended.

Additional
■ Central or mixed venous blood gas analysis to evaluate the
effectiveness of CPR may be considered but arterial blood gas
analysis during CPR is not recommended.
■ Due to the high risk of recurrence, post-resuscitation monitoring should
be sufficient to detect impending reoccurrence of CPA and should be
sufficient to guide therapy appropriate for the pet’s condition.
■ There is no clear evidence to delineate between recommendations for
continuous monitoring versus intermittent monitoring.
● Monitoring should be tailored to the individual pet and its
circumstances and underlying diseases, especially when
determining the intervals for intermittent monitoring.
■ There is evidence in support of serial monitoring following ROSC of:
● Continuous ECG
● Arterial oxygenation
● Ventilation
● Body temperature
● Blood glucose
● Systemic (arterial) blood pressure
● Serial physical exams and neurologic monitoring
■ Serial body temperature measurements are recommended to avoid
high rewarming rates and hyperthermia.
■ In one veterinary study, 54 percent of pets that achieved
ROSC succumbed to another episode of CPA, highlighting the
importance of post-cardiac care and monitoring.

159 Book 3
Post-cardiac arrest (PCA) care

Goals of PCA Care

› Target:
● Normocapnia
● Normotension to hypertension
● Avoid hypoxemia and hyperoxemia
● Normal temperature/mild hypothermia
› Glucocorticoids if refractory hypotension
› Hypertonic saline or mannitol if cerebral edema
› Referral for advanced or 24-hour care to facility with intensive
monitoring and advanced therapeutics

■ Routine use of large volumes of IV fluids post-arrest is not

recommended, except in strongly suspected or confirmed
hypovolemia cases.
■ Fluid therapy should be adjusted according to criteria customary to
veterinary small animal emergency and critical care.
■ Fluid therapy should be avoided in pets with evidence of congestive
heart failure.
■ Use of vasopressor and/or positive inotropic support to reach
hemodynamic goals in dogs and cats with persistent hypotension
and/or cardiovascular instability is reasonable.
■ It is reasonable to assume that hypertension in the immediate PCA
period in dogs and cats is beneficial.
■ It is reasonable to target normocapnia (arterial carbon dioxide
partial pressure (PaCO2) of 32–43 mm Hg in dogs and 26–26 mm Hg
in cats) in the PCA period.
● Serial monitoring of EtCO2 or arterial blood gases is necessary to
assure adequacy of ventilation.
■ Routine mechanical ventilation in all PCA pets is not recommended.

CPR 160
■ It is reasonable to employ manual or mechanical ventilation in the
PCA period in pets that:
● Are hypoventilating
● Are hypoxemic
● Require high inspiratory oxygen concentration (FiO2 equal to or
greater than 60 percent) to maintain normoxemia
● Are at risk of respiratory arrest
■ Both hypoxemia and hyperoxemia should be avoided.
■ If mild accidental hypothermia is present in the PCA period, it is
reasonable to not rapidly rewarm these pets.
● Mild therapeutic hypothermia should not be initiated if advanced
critical care capabilities, including mechanical ventilation, are
not available.
■ Routine administration of corticosteroids during PCA care is
not recommended.
● Administration of hydrocortisone (1 mg/kg followed by either
1 mg/kg every six hours or an infusion of 0.15 mg/kg/hour and
then tapered as the pet’s condition allows) to cats or dogs that
remain hemodynamically unstable despite administration of fluids
and inotropes/pressors during PCA care may be considered.
Equivalent dexamethasone sodium phosphate dosing is roughly
0.5 mg/kg IV.
■ Use of hypertonic saline and mannitol in dogs and cats with neurologic
signs consistent with cerebral edema (e.g., coma, cranial nerve deficits,
decerebrate postures, abnormal mentation) may be considered.
■ Referral of critically ill dogs and cats to facilities with intensive
monitoring and advanced therapeutics for PCA care is reasonable.

Clinical essential
Offer referral of critical or unstable
pets to owners when appropriate and
in the best interest of the pet

161 Book 3
Figure 3.1

Cardiopulmonary Resuscitation
Cardiopulmonary Arrest
(CPA)

INITIATE BASIC LIFE SUPPORT (BLS)

1 Cycle = 2 Minutes

Chest compressions Ventilation

10 breaths/minute
100 – 120/minute
Tidal volume = 10 mL/kg
Compress 1/3–1/2 of chest width Inspiratory time = 1 second
Do not lean
OR
Allow full recoil of chest in between compressions Mouth to snout ventilation at
C:V of 30:2

2-handed compressions 1-handed compressions Resuscitation bag used to

Suitable for large dogs Suitable for small dogs and cats provide ventilation

Evaluate Patient

Return of Spontaneous
Circulation
Change Compressor
every 2 minutes

Advanced Life Support

Post-CPA Care

For additional information see RECOVER guidelines, CPR chapter and supporting materials.

CPR 162
Figure 3.2

Advanced Life Support (ALS)

INITIATE
1 ECG MONITORING
2 EtCO2 MONITORING (where equipment exists)
3 ENSURE PATENT VASCULAR ACCESS
4 ADMINISTER REVERSAL AGENTS (if appropriate)

DRUG DOSE NOTES

Atipamezole (5 mg/mL) 50 mcg/kg Reverses alpha-2 agonists
Flumazenil (0.1 mg/mL) 0.01 mg/kg Reverses benzodiazepines
Naloxone (0.4 mg/mL) 0.04 mg/kg Reverses opioids

5 ADMINISTER PRECORDIAL THUMP

BEGIN TIMING 2 MINUTE CYCLE

AVOID DISRUPTION TO COMPRESSION/VENTILATION

VASOPRESSOR DRUGS
DRUG DOSE NOTES
Epinephrine Administer every other cycle
0.01 mg/kg
(1 mg/mL) Consider 0.1 mg/kg with CPA >10 min
Atropine Administer every other cycle with
0.05 mg/kg
(0.54 mg/mL) asystole or pulseless electrical activity
ANTI-ARRHYTHMIC DRUGS
Amiodarone Used for ventricular fibrillation and
5 mg/kg
(50 mg/mL) ventricular tachycardia
Lidocaine
(20 mg/mL) Canine: 2–8 mg/kg Canine: 8 mg/kg
Maximum doses:
if amiodarone Feline: 0.2 mg/kg Feline: 1 mg/kg
is not available

163 Book 3
MONITOR

PARAMETER NOTES
Continuous ECG Normal sinus rhythm; assess for ROSC
EtCO2 >15 mm Hg indicates good compressions
SpO2 >90 % breathing room air or 100% O2
Ensure monitoring does not impede
TPR
compressions and ventilation
Blood pressure MAP >80 mm Hg
Blood glucose >100 mg/dL
Serial physical and neurologic examinations

ASSESS

PARAMETER NOTES
Calcium Correct if needed
Potassium Correct if needed
Volume status Administer fluids if hypovolemic
Inhalant rates of 21 - 100%;
FiO2
adjust based on SpO2
Consider sodium bicarbonate therapy
Acid base status
(1 mEq/kg) if CPA >10 min

Book 3 CPR 164

Post-Cardiopulmonary Arrest (CPA)
Care and Monitoring

PARAMETER GOAL NOTES

Canine: PaCO2 = 32–43 Manual ventilation

for hypoventilating
Ventilation
patients; avoid
Feline: PaCO2 = 26–36 hypercapnia
Normotension to mild
Blood pressure
hypertension
PaO2 = 80–100 mm Hg Avoid hypoxemia and
Oxygenation
SpO2 = 94–98% hyperoxemia
Normothermia to
Temperature Warm patients slowly
mild hypothermia
Additional Therapies
Hydrocortisone If refractory
Glucocorticoids
(1 mg/kg initial dose) hypotension
Hypertonic 2–4 mL/kg of For neurologic signs
saline 7% solution consistent with
OR cerebral edema;
0.5 g/kg IV over monitor volume status
Mannitol and urine output
15–20 minutes
24-hour care center with advanced critical
Referral
care capabilities

Clinical essential
Crash cart containing emergency
drugs and equipment is readily available,
in a designated place, portable, clearly
labeled and appropriately stocked at
all times

165 Book 3
References and suggested reading for CPR:
1. McMichael M, Herring J, Fletcher DJ, et al. RECOVER evidence and
knowledge gap analysis on veterinary CPR. Part 2: Preparedness and
prevention. J Vet Emerg Crit Care (San Antonio). 2012;22(S1):13-25.
2. Hopper K, Epstein SE, Fletcher DJ, et al. RECOVER evidence and knowledge
gap analysis on veterinary CPR. Part 3: Basic life support. J Vet Emerg Crit
Care. 2012;22(S1):26-43.
3. Rozanski EA, Rush JE, Buckley GJ, et al. RECOVER evidence and knowledge
gap analysis on veterinary CPR. Part 4: Advanced life support. J Vet Emerg
Crit Care. 2012;22(S1):44-64.
4. Brainard BM, Boller M, Flectcher DJ, et al. RECOVER evidence and
knowledge gap analysis on veterinary CPR. Part 5: Monitoring. J Vet Emerg
Crit Care. 2012;22(S1):65-84.
5. Smarick SD, Haskins SC, Boller M, et al. RECOVER evidence and knowledge
gap analysis on veterinary CPR. Part 6: Post-cardiac arrest care. J Vet
Emerg Crit Care 2012;22(S1):85-101.
6. Scott-Moncrieff JC. Hypoadrenocorticism in dogs and cats: Update on
diagnosis and treatment. Proceedings ACVIM Forum 2010, Anaheim, Calif.

Full RECOVER articles are available online with open access at:
www.onlinelibrary.wiley.com/doi/10.1111/vec.2012.22.issue-s1/issuetoc
Job aids, posters and charts are available at the Veterinary Emergency
and Critical Care Society (VECCS) website:
www.veccs.org/product-category/posters/

CPR 166
APPENDIX

Abbreviations

CRI constant rate infusion IPPV intermittent positive

ECG electrocardiography pressure ventilation
EtCO2 end-tidal carbon dioxide IM intramuscular
HLK hydromorphone, IV intravenous
lidocaine, ketamine MAP mean arterial pressure
HR heart rate SpO2 saturation of
peripheral oxygen

Medication dilution
and combination
■ Completely label and date all medication dilutions and combinations
with the appropriate labels

Figure 3.3: Mixed medication label

■ Follow local, state and/or federal law for the mixing, storage and
disposal of all medications and controlled drugs

167 Book 3
■ All CRIs:
● Prepared directly at the time of use
■ Dedicated to one patient
● Discarded immediately when no longer in use
■ Completely label and date all syringes with the appropriate label.

For dilution of acepromazine or preparation of DKT:

Figure 3.4: Syringe label

Resultant
Medication Dilution
Solution
Sterile Mix 27mL sterile water
Acepromazine 1 mg/mL
vial 3 mL (30 mg) acepromazine
1 mL dexmedetomidine
Sterile (0.5 mg)
DKT
vial 1 mL ketamine (100 mg)
1 mL butorphanol (10 mg)
● Stability and length of efficacy of diluted or combination
medications have only been determined in a limited number of
animal species and for a minimal amount of medications1,2,3
● Follow the intravenous access requirements for multi-dose vial usage:
□ Use amber-colored glass vials to protect contents from light.
□ Use aseptic technique every time, with every instance of
handling.
□ Discard immediately if any signs of gross contamination.
□ Obtain a new, sterile syringe and needle for each use.
□ Discard syringe and needle after each use.

Appendix 168
■ Except where prohibited by law, it is recommended to:
● Check all medication vials prior to use to ensure medications are
not expired prior to diluting or mixing and to ensure expiration
dates will not be exceeded with storage.
● Keep medications that have been diluted or mixed at room
temperature and protect from light.
● Discard any unused medications (following appropriate laws for
disposal) after 28 days.

Advanced analgesic techniques

Introduction
This section provides information on advanced analgesic techniques.
Identification and treatment for immediate and post-operative pain are
clinical essentials. The decision to utilize advanced techniques should
be individualized and only considered when medically indicated in
those uncommon situations where pain cannot be controlled.
Hospital teams should recognize that these techniques may require
additional supplies (e.g., syringe pump, wound infusion catheters),
personnel, and training to perform effectively and safely.
Side effects and complications may occur and intensive monitoring is
warranted for all patients that are deemed severely painful. Referral
to 24-hour care facilities with advanced capabilities for critical patient
care should be considered and offered when medically indicated.

Notes
_______________________________________________________________

_______________________________________________________________

169 Book 3
Constant Rate Infusions (CRIs)
Dexmedetomidine CRI
■ Post-operative/recovery/sedative/anxiety treatment if analgesics
have been administered and pet is showing signs of stress or anxiety
■ Has synergistic effects with opioid analgesics and decreases
perioperative stress in dogs
■ Provides analgesia through both central and peripheral mechanisms
■ Should not be considered a “standalone” analgesic
● Should be used in conjunction with opioid analgesics to take
advantage of synergistic effects
■ May be used as a treatment option for opioid dysphoria
■ May help with neuropathic pain
■ Should be administered via syringe or fluid pump

Dose:
› Recommended dose range is 0.5–2.0 mcg/kg/hour (canine and feline)
● 1.0 mcg/kg/hour is most commonly used

Intra-operative Dexmedetomidine CRI:

0.25 mL (0.125mg) dexmedetomidine in 1.0 L of crystalloid fluids:
Infusion at 10 mL/kg/hour = 1.25 mcg/kg/hour
Infusion at 5 mL/kg/hour = 0.63 mcg/kg/hour
› Empty the urinary bladder at the end of surgery
› Use additional analgesics (e.g., opioids) since dexmedetomidine is
not a standalone analgesic
› Have post-op sedation available and ready since patients can be
noise sensitive and suddenly rousable

Post-operative Dexmedetomidine CRI:

1.0 mL (0.5 mg) dexmedetomidine in 1.0 L of crystalloid fluids
Infusion at 2.0 mL/kg/hour = 1.0 mcg/kg/hour*
2.0 mL (1.0 mg) dexmedetomidine in 1.0 L of crystalloid fluids
Infusion at 2.0 mL/kg/hour = 2.0 mcg/kg/hour*

*Patients should be monitored for level of sedation and rousability and infusion
rate decreased accordingly

Appendix 170
Fentanyl CRI
■ Fentanyl is very short acting (approximately 15 minutes) and
therefore requires CRI administration.
■ Major advantage of a fentanyl CRI is that it allows titration of opioid
dosing to pet needs.
■ Fentanyl may decrease the inhalant requirements up to
approximately 65 percent depending on dose.
● It is very important that the inhalant be titrated accordingly
to avoid the pet being too deep.
■ Fentanyl should be administered via syringe pump.
■ If hydromorphone premedication dose was administered within
2 hours, a fentanyl loading dose is not required.
● If not, then administer a fentanyl loading dose of 3–5 mcg/kg
slowly over 2 minutes while monitoring pulse/HR via ECG and
respiration to rapidly achieve analgesic plasma levels

Heart rate:
■ If significant bradycardia is associated with hypotension
(MAP <60 mm Hg) then administer an anticholinergic (glycopyrrolate
0.005 mg/kg IV or 0.01 mg/kg IM).
● Significant bradycardia; less than 50 bpm in medium to large
dogs, less than 70–80 bpm in small dogs and cats.

Respiration:
■ Monitor saturation of peripheral oxygen (SpO2) at transition
from 100% oxygen to room air at recovery.
● Provide supplemental O2 (100 mLs/kg/min) until able to maintain
SpO2 >93–95%.
■ End-tidal carbon dioxide (EtCO2) should be monitored and manual or
mechanical intermittent positive pressure ventilation (IPPV) provided
if EtCO2 is greater than 55 mm Hg, despite titration of inhalant.

171 Book 3
Level of sedation:
■ Ensure that patient is ‘rousable’ and can respond to his/her name.
If not:
● May be prone to hypoventilation/hypoxemia, regurgitation/
aspiration
□ Lower/stop CRI, assess pulse/HR, respiration, SpO2
(provide supplemental O2 if <93%).
□ Partial reversal with butorphanol 0.1 mL (1.0 mg) diluted in
0.9 mLs IV fluid, given in 0.2 mL increments IV

Body temperature:
■ If hypothermic, provide active heating

Assessment of pain:
■ Adjust CRI based on pain level

Dose:
Loading dose:
3.0 - 5.0 mcg/kg IV slowly over 2 minutes, monitor pulse/heart rate
(HR) via electrocardiography (ECG) and respiration

CRI:
Intra-op: 5.0–10 mcg/kg/hr*
Post-op: 2.0–10 mcg/kg/hr*

*The reported analgesic plasma levels of fentanyl in dogs are 1.0 -2.0 ng/mL.

■ There may be considerable inter-individual variation in plasma levels

and pain threshold for different patients.
■ It is imperative that patients be regularly assessed for pain and level
of sedation (rousability) in order to titrate the fentanyl CRI to the
patient’s analgesic needs.

Appendix 172
Hydromorphone, Lidocaine, Ketamine (HLK) CRI
■ Intra-operative constant rate infusion (CRI) for multimodal analgesia
■ Administer via a fluid or syringe pump:
● Ensure accurate dosing
● Decrease the chance of inadvertent bolus administration

Intra-operative Dose:
› Infuse at 10 mLs/kg/hour for the first hour then reduce to 5.0 mLs/kg/hr

■ DO NOT BOLUS!

■ Add to 1.0 liter bag of crystalloid fluids (all drug volumes and
milligrams can be halved if adding to a 500 mL bag of crystalloids):

Volume to Infusion dose Infusion dose

Drug
add (mg) (1st hour) (2nd hour)
Hydromorphone 0.2 mLs
0.02 mg/kg/hr 0.01 mg/kg/hr*
(10 mg/mL) (2.0mg)
3.0 mg/kg/hr
Lidocaine 15 mLs 1.5 mg/kg/hr
(50 mcg/kg/
(20 mg/mL) (300mg) (25 mcg/kg/min)
min)
1.2 mg/kg/hr
Ketamine 1.2 mLs 0.6 mg/kg/hr
(20 mcg/kg/
(100 mg/mL) (120mg) (10 mcg/kg/min)
min)
* Dose of hydromorphone over 4 hours = 0.04 mg/kg

Note: Some patients may require supplemental doses of

hydromorphone intra-operatively. It is important to monitor patients for
anesthetic requirement (i.e., level of gas anesthetic required and signs of
inadequate analgesia such as increased heart rate and blood pressure.

173 Book 3
Post-operative Dose:
› Infuse at 2.0 mLs/kg/hour

■ DO NOT BOLUS!

■ Add to 1.0 liter bag of crystalloid fluids:

Volume to
Drug Infusion dose
add (mg)
Hydromorphone
0.5 mLs (5.0 mg) 0.01 mg/kg/hr
(10 mg/mL)
Lidocaine 1.5 mg/kg/hr
37.5 mLs (750 mg)
(20 mg/mL) (25 mcg/kg/min)
Ketamine 0.12 mg/kg/hr
0.6 mLs (60 mg)
(100 mg/mL) (2.0 mcg/kg/min)

Supplemental Information:
■ When patients have significant analgesic requirements, and an HLK
CRI is planned, loading doses of medications may be considered
prior to induction.
■ Remember the caveats for these patients.
■ Lidocaine
● Provide loading dose for intra-operative CRI
□ 2.0 mg/kg slowly IV over 2 minutes prior to induction
■ Ketamine
● Can be administered after lidocaine and prior to propofol to
provide a loading dose for intra-operative CRI
□ 0.5 mg/kg slowly IV
■ Note that the use of these medications may impact (reduce)
the amount of induction agent needed to achieve intubation.

Note: There are multiple formulas that may be used for calculations of
CRIs. Examples using a syringe pump or a 250 mL fluid bag for infusion
are provided here. See individual chapters and additional content in the
Appendix for details. It is the attending veterinarian's responsibility to
correctly calculate and administer CRIs. Concentrations may need to
vary based upon patient size. Pay close attention to fluid administration
rates and the potential for fluid overload.

Appendix 174
Table 3.1

Resultant
Medication Infusion
Solution
Dexmedetomidine Syringe Mix 30 mL sterile 5 mcg/mL
(0.5 mg/mL) pump 0.9% NaCl with
0.3 mL (0.15 mg)
dexmedetomidine
250 mL Add 2.5 mL (1.25 mg)
bag dexmedetomidine to
0.9% NaCl new, sterile bag
Dobutamine Syringe Mix 30 mL sterile 12.5
(12.5 mg/mL) pump 0.9% NaCl with mcg/mL
0.03 mL (0.375 mg)
dobutamine
250 mL Add 0.25 mL (3.125
bag mg) dobutamine to
0.9% NaCl new, sterile bag
Dopamine Syringe Mix 30 mL sterile 0.9% 40 mcg/mL
(40 mg/mL) pump NaCl with 0.03 mL (1.2
mg) dopamine
250 mL Add 0.25 mL (10 mg)
bag dopamine to new,
0.9% NaCl sterile bag
Fentanyl Syringe Mix 30 mL sterile 0.9% 2.5 mcg/
(0.5 mg/mL) pump NaCl with 0.15 mL mL
(0.075 mg) fentanyl
250 mL Add 1 mL (0.5 mg) 2 mcg/mL
bag fentanyl to new,
0.9% NaCl sterile bag
Lidocaine Syringe Mix 30 mL sterile 0.9% 2 mg/mL
(20 mg/mL) pump NaCl with 3 mL (60
CRI mg) lidocaine
250 mL Add 12.5 mL (250 mg) 1 mg/mL
bag 0.9% lidocaine to new,
NaCl sterile bag

175 Book 3
Fentanyl Patch
■ Recommended dose is 4 mcg/kg/hour (canine)
■ In cats, a 25 mcg/hour patch is applied resulting in doses ranging
from 4–8 mcg/kg.
■ Analgesia has been associated with plasma concentrations of
~0.6–1.2 ng/mL in dogs and 1.5–1.7 ng/mL in cats which can take up
to 24 hours in dogs and 7 hours in cats.5
● There is significant inter-individual variability in plasma
concentrations achieved with fentanyl patches, therefore, patients
should be assessed for adequate analgesia using the Colorado
Acute Pain Scale.
■ Plans for alternative mu-opioid analgesia should be made until the
expected onset of adequate analgesic plasma levels.
● Buprenorphine (partial mu agonist) and butorphanol
(mu antagonist) will antagonize the effects of fentanyl and
should not be used concurrently.
● Hydromorphone or fentanyl CRI are recommended.
■ Fentanyl patches should be placed at recovery from general
anesthesia to avoid excessive absorption due to external pet warming
devices.
■ Apply to dorsal/lateral thorax.
● Consider patient access to licking or ingesting patch when
planning site of application.
■ Clip hair, wipe excess hair (rolled self-adherent wraps work well),
warm with hands, apply.
■ Fentanyl patches are typically removed by ~72 hours post application.
■ Patches that lift off of the skin should be replaced on a newly
prepared area of skin.
■ If an animal ingests a patch, it should be monitored for signs
of opioid overdosage and naloxone (mu antagonist) should be
administered.
■ Proper disposal is imperative.

CAUTION! A significant amount of residual fentanyl may still reside

in the patch after removal. There is potential for abuse or diversion
and inadvertent ingestion has led to fatalities in children. Consider
these prior to sending a pet home with a fentanyl patch. In the home
environment, proper disposal is imperative. Gloves should be worn
while handling.

Appendix 176
Wound Infusion Catheters
■ Flexible, polypropylene, perforated, indwelling catheters imbedded in
or near surgical sites and used to deliver intermittent injections of
local anesthetics
■ Major advantages:
● Provide local pain relief
● Reduce the need for systemic analgesics
● Faster return of appetite
● Ambulatory the evening of or morning after surgery
□ Require less nursing care as patients are able to walk outside for
elimination needs
■ Less parenteral analgesic requirement reduces side effects:
● Sedation
● Risk of regurgitation/aspiration
● Urinary retention
■ Clinical investigations of this technique in human medicine
have demonstrated:
● Improved pain control at rest and with activity
● Decreased opioid requirement
● Increased patient satisfaction
● Shorter hospital stay following a variety of surgical procedures
■ Studies in animals describe uses for:
● Ear canal ablation
● Median sternotomy
● Lateral thoracotomy
● Limb amputation
● Major soft tissue tumor excision:
□ Mastectomy
□ Fibrosarcoma resection in cats

177 Book 3
Equipment:
■ Butterfly connectors
■ Wound infusion catheter (Figures 3.5 and 3.6)
● The distal tip of the wound infusion catheter is sealed so that liquid
exits only from the micropores.
● The catheters are available with different lengths of micropores to
allow for use in a variety of anatomical sites and sizes of pets.
● A black depth indicator marks a point located ½ inch (1.25 cm)
from the first micropore to insure that all micropores are located
below the skin.
■ Line filter
■ Waterproof dressing
■ Suture

Positioning and anatomic landmarks:

■ Dependent upon site and type of wound

Figure 3.5: Wound infusion catheter

Used with permission from Bonnie L. Hay Kraus, DVM, DACVS, DACVAA

Figure 3.6: Catheter showing micropore locations

Used with permission from Bonnie L. Hay Kraus, DVM, DACVS, DACVAA

Appendix 178
Technique:
■ Plan for the location of the catheter end/filter/cap.
■ Make a stab incision in the skin, insert the catheter tip and pull the
catheter tip into the wound bed normograde.
■ Insert the catheter with the distal tip in the deepest layer of the
closure and then suture in place.
■ It is essential that all perforations are below the skin.
■ Perform routine wound closure over the catheter.
■ Place a purse string suture and finger trap to secure the catheter.
■ Suture both butterfly connectors to the skin. One should be adjusted
to be located close to the exit of the catheter from the skin to help
keep it from backing out. Cover with sterile, waterproof dressing and
seal the catheter end with a 0.2 micron filter and an injection cap.
Add a clear label to the soaker catheter site to avoid confusion with
an IV injection cap.

Drugs Figure 3.7

■ Bupivacaine dosing
is 1.5 mg/kg and
should be injected
10 - 15 minutes prior
to the end of surgery
and continued every
Catheter loaded with calculated bupivacaine
four to six hours dose and priming volume of catheter and filter
post-operatively. Used with permission from Bonnie L. Hay Kraus, DVM, DACVS, DACVAA
(Figure 3.7)
■ Be sure to add the priming volume and the filter volume to the
calculated dose. The priming volume for all sizes of catheters is
0.8 mLs and the filter volume is 1 mLs so this volume needs to be
added to the first intra-operative dose.
■ For small dogs or cats, the bupivacaine may need to be diluted,
otherwise the volume may not be sufficient to reach the entire
tissue bed.

179 Book 3
Figure 3.8

Examples of Bupivacaine Dosing Calculations

For patients <10 kg For patients >10 kg

2.5 kg feline 5 kg feline

x 1.5 mg/kg x 1.5 mg/kg
= 3.75 mg = 7.5 mg
÷ 5 mg/mL ÷ 5 mg/mL
= 0.75 mL. Add 0.75 mL = 1.5 mLs (feline dose)
sterile water (do not use + 0.8 mLs (priming volume)
saline-containing fluids) + 1 mL filter volume
= Final volume of 1.5 mL, = 3.3 mLs bupivacaine for
which is more likely to first dose only. Thereafter,
be a sufficient volume to each subsequent dose
adequately bathe the wound should be the regular
bed without going above the calculated dose.
recommended dose.

Notes
_______________________________________________________________

_______________________________________________________________

Appendix 180
Points to Remember:
› Bury the catheter in deepest part of wound/incision
› Ensure that all micropores are below the skin
› Secure the catheter with a purse string and finger trap and both
plastic tabs
› Administer bupivacaine every four to six hours
› The priming volume for all wound infusion catheters is 0.8 mL and
filters are 1 mL
› Maintain catheter for minimum of 24 - 72 hours and up to three to
five days
› Infuse with bupivacaine 1.5 mg/kg prior to catheter removal to
extend the duration of analgesia
› Assess individual pet for:
● Fluid accumulation. Decrease infusion volume or increase
dosing interval
● Pain assessment of the pet at regular intervals
● Tenderness to palpation. Dose more frequently (reaction to
injection can be seen when dosing interval is every six hours).
● Lower opioid doses. Use of wound infusion catheters will lower
opioid dose requirements. More signs of opioid dysphoria
(or other opioid side effects such as sedation) may be observed
if full opioid doses are used.

181 Book 3
Dosage Charts
The charts are meant to provide a guideline to dosing calculations and
typically list the minimum and maximum dosages for a given medication.
It is the responsibility of the providing veterinarian to decide drug
dosages for an individual patient and perform accurate calculations.

Acepromazine 1 mg/mL
CANINE FELINE
mLs to administer mLs to administer
Weight
(kg) Low end High end Low end High end
0.005 mg/kg 0.05 mg/kg 0.01 mg/kg 0.1 mg/kg
0.5 0.00 0.03 0.01 0.05
1 0.01 0.05 0.01 0.10
2 0.01 0.10 0.02 0.20
3 0.02 0.15 0.03 0.30
4 0.02 0.20 0.04 0.40
5 0.03 0.25 0.05 0.50
6 0.03 0.30 0.06 0.60
7 0.04 0.35 0.07 0.70
8 0.04 0.40 0.08 0.80
9 0.05 0.45 0.09 0.90
10 0.05 0.50 0.10 1.00
11 0.06 0.55
12 0.06 0.60
13 0.07 0.65
14 0.07 0.70
15 0.08 0.75
16 0.08 0.80
17 0.09 0.85 MAXIMUM DOSAGE
18 0.09 0.90
19 0.10 0.95 Canine:
20 0.10 1.00
21 0.11 1.05 2 mg/dog
22 0.11 1.10
23 0.12 1.15 Feline:
24 0.12 1.20
25 0.13 1.25 1 mg/cat
26 0.13 1.30
27 0.14 1.35
28 0.14 1.40
29 0.15 1.45
30 0.15 1.50
31 0.16 1.55
32 0.16 1.60
33 0.17 1.65
34 0.17 1.70
35 0.18 1.75
36 0.18 1.80
37 0.19 1.85
38 0.19 1.90
39 0.20 1.95
40 0.20 2.00
40 + 0.20 2.00

Appendix 182
Alfaxalone 10 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
1 mg/kg 4 mg/kg
0.5 0.05 0.2
1 0.1 0.4
2 0.2 0.8
3 0.3 1.2
4 0.4 1.6
5 0.5 2.0
6 0.6 2.4
7 0.7 2.8
8 0.8 3.2
9 0.9 3.6
10 1.0 4.0
11 1.1 4.4
12 1.2 4.8
13 1.3 5.2
14 1.4 5.6
15 1.5 6.0
16 1.6 6.4 SEE DOSING
17 1.7 6.8
18 1.8 7.2 INSTRUCTIONS
19 1.9 7.6 IN TEXT
20 2.0 8.0
21 2.1 8.4 Administer only
22 2.2 8.8 to effect
23 2.3 9.2
24 2.4 9.6
25 2.5 10.0
26 2.6 10.4
27 2.7 10.8
28 2.8 11.2
29 2.9 11.6
30 3.0 12.0
31 3.1 12.4
32 3.2 12.8
33 3.3 13.2
34 3.4 13.6
35 3.5 14.0
36 3.6 14.4
37 3.7 14.8
38 3.8 15.2
39 3.9 15.6
40 4.0 16.0
41 4.1 16.4
42 4.2 16.8
43 4.3 17.2
44 4.4 17.6
45 4.5 18.0
46 4.6 18.4
47 4.7 18.8
48 4.8 19.2
49 4.9 19.6
50 5.0 20.0

183 Book 3
Atipamezole 5 mg/mL

FELINE
mLs to administer
Weight
(kg) Compromised Healthy
0.012 mL/kg 0.021 mL/kg
0.5 0.01 0.01
1 0.01 0.02
2 0.02 0.04
3 0.04 0.06
4 0.05 0.08
5 0.06 0.11
6 0.07 0.13
7 0.08 0.15
8 0.10 0.17
9 0.11 0.19
10 0.12 0.21
11 0.13 0.23
12 0.14 0.25
13 0.16 0.27

PACKAGE INSERT CONTAINS

DETAILED DOSING INSTRUCTIONS

Feline:
Reversal for DKT

Canine:
Reversal of dexmedetomidine

Administer atipamezole IM
at equal mL volume to
dexmedetomidine administered

Appendix 184
Atropine 0.4 mg/mL (For cardiac support)

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
0.02 mg/kg 0.04 mg/kg
0.5 0.025 0.05
1 0.05 0.1
2 0.10 0.2
3 0.15 0.3
4 0.20 0.4
5 0.25 0.5
6 0.30 0.6
7 0.35 0.7
8 0.40 0.8
9 0.45 0.9
10 0.50 1.0
11 0.55 1.1
12 0.60 1.2
13 0.65 1.3
14 0.70 1.4
15 0.75 1.5
16 0.80 1.6
17 0.85 1.7
18 0.90 1.8
19 0.95 1.9
20 1.00 2.0
21 1.05 2.1
22 1.10 2.2
23 1.15 2.3
24 1.20 2.4
25 1.25 2.5
26 1.30 2.6
27 1.35 2.7
28 1.40 2.8
29 1.45 2.9
30 1.50 3.0
31 1.55 3.1
32 1.60 3.2
33 1.65 3.3
34 1.70 3.4
35 1.75 3.5
36 1.80 3.6
37 1.85 3.7
38 1.90 3.8
39 1.95 3.9
40 2.00 4.0
41 2.05 4.1
42 2.10 4.2
43 2.15 4.3
44 2.20 4.4
45 2.25 4.5
46 2.30 4.6
47 2.35 4.7
48 2.40 4.8
49 2.45 4.9
50 2.50 5.0

185 Book 3
Bupivacaine 5 mg/mL (For local anesthesia)

CANINE FELINE
mLs to administer mLs to administer
Weight Maximum Maximum
(kg) Low end Low end
Dose Dose
1 mg/kg 1 mg/kg
2 mg/kg 1.5 mg/kg
0.5 0.10 0.20 0.10 0.15
1 0.20 0.40 0.20 0.30
2 0.40 0.80 0.40 0.60
3 0.60 1.20 0.60 0.90
4 0.80 1.60 0.80 1.20
5 1.00 2.00 1.00 1.50
6 1.20 2.40 1.20 1.80
7 1.40 2.80 1.40 2.10
8 1.60 3.20 1.60 2.40
9 1.80 3.60 1.80 2.70
10 2.00 4.00 2.00 3.00
11 2.20 4.40 2.20 3.30
12 2.40 4.80 2.40 3.60
13 2.60 5.20 2.60 3.90
14 2.80 5.60
15 3.00 6.00
16 3.20 6.40
17 3.40 6.80
18 3.60 7.20
19 3.80 7.60
20 4.00 8.00
21 4.20 8.40 LOCAL INJECTION
22 4.40 8.80
23 4.60 9.20 GUIDELINES
24 4.80 9.60
25 5.00 10.00 Canine:
26 5.20 10.40
27 5.40 10.80 0.5 - 1.0 mL per site
28 5.60 11.20
29 5.80 11.60 Feline:
30 6.00 12.00 0.2 - 0.3 mL per site
31 6.20 12.40
32 6.40 12.80
33 6.60 13.20 Dilute with sterile water if
34 6.80 13.60
35 7.00 14.00 more volume
36 7.20 14.40 is needed
37 7.40 14.80
38 7.60 15.20
39 7.80 15.60
40 8.00 16.00
41 8.20 16.40
42 8.40 16.80
43 8.60 17.20
44 8.80 17.60
45 9.00 18.00
46 9.20 18.40
47 9.40 18.80
48 9.60 19.20
49 9.80 19.60
50 10.00 20.00

Appendix 186
Buprenorphine 0.3 mg/mL

CANINE FELINE
mLs to administer mLs to administer
Weight Low end
(kg) 0.005 mg/ High end Low end High end Acute pain
0.02 mg/kg 0.01 mg/kg 0.02 mg/kg 0.04 mg/kg
kg
0.5 0.01 0.03 0.02 0.03 0.07
1 0.02 0.07 0.03 0.07 0.13
2 0.03 0.13 0.07 0.13 0.27
3 0.05 0.20 0.10 0.20 0.40
4 0.07 0.27 0.13 0.27 0.53
5 0.08 0.33 0.17 0.33 0.67
6 0.10 0.40 0.20 0.40 0.80
7 0.12 0.47 0.23 0.47 0.93
8 0.13 0.53 0.27 0.53 1.07
9 0.15 0.60 0.30 0.60 1.20
10 0.17 0.67 0.33 0.67 1.33
11 0.18 0.73 0.37 0.73 1.47
12 0.20 0.80 0.40 0.80 1.60
13 0.22 0.87 0.43 0.87 1.73
14 0.23 0.93
15 0.25 1.00
16 0.27 1.07
17 0.28 1.13
18 0.30 1.20
19 0.32 1.27
20 0.33 1.33
21 0.35 1.40
22 0.37 1.47
23 0.38 1.53
24 0.40 1.60
25 0.42 1.67
26 0.43 1.73
27 0.45 1.80
28 0.47 1.87
29 0.48 1.93
30 0.50 2.00
31 0.52 2.07
32 0.53 2.13
33 0.55 2.20
34 0.57 2.27
35 0.58 2.33
36 0.60 2.40
37 0.62 2.47
38 0.63 2.53
39 0.65 2.60
40 0.67 2.67
41 0.68 2.73
42 0.70 2.80
43 0.72 2.87
44 0.73 2.93
45 0.75 3.00
46 0.77 3.07
47 0.78 3.13
48 0.80 3.20
49 0.82 3.27
50 0.83 3.33

187 Book 3
Buprenorphine – long acting 1.8 mg/mL

FELINE

Weight mLs to administer

(kg) 0.24 mg/kg
0.5 0.07
1 0.13
2 0.27
3 0.40
4 0.53
5 0.67 DOSAGE
6 0.80 Dose on lean
7 0.93 body weight
8 1.07
9 1.20
10 1.33
11 1.47
12 1.60
13 1.73

Appendix 188
Butorphanol 10 mg/mL (For analgesia)

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
0.2 mg/kg 0.4 mg/kg
0.5 0.01 0.02
1 0.02 0.04
2 0.04 0.08
3 0.06 0.12
4 0.08 0.16
5 0.10 0.20
6 0.12 0.24
7 0.14 0.28
8 0.16 0.32
9 0.18 0.36
10 0.20 0.40
11 0.22 0.44
12 0.24 0.48
13 0.26 0.52
14 0.28 0.56
15 0.30 0.60
16 0.32 0.64
17 0.34 0.68
18 0.36 0.72
19 0.38 0.76
20 0.40 0.80
21 0.42 0.84
22 0.44 0.88
23 0.46 0.92
24 0.48 0.96
25 0.50 1.00
26 0.52 1.04
27 0.54 1.08
28 0.56 1.12
29 0.58 1.16
30 0.60 1.20
31 0.62 1.24
32 0.64 1.28
33 0.66 1.32
34 0.68 1.36
35 0.70 1.40
36 0.72 1.44
37 0.74 1.48
38 0.76 1.52
39 0.78 1.56
40 0.80 1.60
41 0.82 1.64
42 0.84 1.68
43 0.86 1.72
44 0.88 1.76
45 0.90 1.80
46 0.92 1.84
47 0.94 1.88
48 0.96 1.92
49 0.98 1.96
50 1.00 2.00

189 Book 3
Carprofen 50 mg/mL

CANINE
mLs to administer
Weight
(kg) Low end High end
4 mg/kg 4.4 mg/kg
0.5 0.04 0.04
1 0.08 0.09
2 0.16 0.18
3 0.24 0.26
4 0.32 0.35
5 0.40 0.44
6 0.48 0.53
7 0.56 0.62
8 0.64 0.70
9 0.72 0.79
10 0.80 0.88
11 0.88 0.97
12 0.96 1.06
13 1.04 1.14
14 1.12 1.23
15 1.20 1.32
16 1.28 1.41
17 1.36 1.50
18 1.44 1.58
19 1.52 1.67
20 1.60 1.76
21 1.68 1.85
22 1.76 1.94
23 1.84 2.02
24 1.92 2.11
25 2.00 2.20
26 2.08 2.29
27 2.16 2.38
28 2.24 2.46
29 2.32 2.55
30 2.40 2.64
31 2.48 2.73
32 2.56 2.82
33 2.64 2.90
34 2.72 2.99
35 2.80 3.08
36 2.88 3.17
37 2.96 3.26
38 3.04 3.34
39 3.12 3.43
40 3.20 3.52
41 3.28 3.61
42 3.36 3.70
43 3.44 3.78
44 3.52 3.87
45 3.60 3.96
46 3.68 4.05
47 3.76 4.14
48 3.84 4.22
49 3.92 4.31
50 4.00 4.40

Appendix 190
Dexamethasone SP 4 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
0.1 mg/kg 0.4 mg/kg
0.5 0.013 0.05
1 0.025 0.10
2 0.050 0.20
3 0.075 0.30
4 0.100 0.40
5 0.125 0.50
6 0.150 0.60
7 0.175 0.70
8 0.200 0.80
9 0.225 0.90
10 0.250 0.10
11 0.275 0.11
12 0.300 0.12
13 0.325 0.13
14 0.350 0.14
15 0.375 0.15
16 0.400 0.16
17 0.425 0.17
18 0.450 0.18
19 0.475 0.19
20 0.500 0.20
21 0.525 0.21
22 0.550 0.22
23 0.575 0.23
24 0.600 0.24
25 0.625 0.25
26 0.650 0.26
27 0.675 0.27
28 0.700 0.28
29 0.725 0.29
30 0.750 0.30
31 0.775 0.31
32 0.800 0.32
33 0.825 0.33
34 0.850 0.34
35 0.875 0.35
36 0.900 0.36
37 0.925 0.37
38 0.950 0.38
39 0.975 0.39
40 1.000 0.40
41 1.025 0.41
42 1.050 0.42
43 1.075 0.43
44 1.100 0.44
45 1.125 0.45
46 1.150 0.46
47 1.175 0.47
48 1.200 0.48
49 1.225 0.49
50 1.250 0.50

191 Book 3
Dexmedetomidine 0.5 mg/mL

CANINE FELINE
mLs to administer mLs to administer
Weight
(kg) Low end High end Low end High end
2 mcg/kg 5 mcg/kg 5 mcg/kg 10 mcg/kg
0.5 0.00 0.01 0.01 0.01
1 0.00 0.01 0.01 0.02
2 0.01 0.02 0.02 0.04
3 0.01 0.03 0.03 0.06
4 0.02 0.04 0.04 0.08
5 0.02 0.05 0.05 0.10
6 0.02 0.06 0.06 0.12
7 0.03 0.07 0.07 0.14
8 0.03 0.08 0.08 0.16
9 0.04 0.09 0.09 0.18
10 0.04 0.10 0.10 0.20
11 0.04 0.11 0.11 0.22
12 0.05 0.12 0.12 0.24
13 0.05 0.13 0.13 0.26
14 0.06 0.14
15 0.06 0.15
16 0.06 0.16
17 0.07 0.17
18 0.07 0.18
19 0.08 0.19
20 0.08 0.20
21 0.08 0.21
22 0.09 0.22 Package insert
23 0.09 0.23
24 0.10 0.24 contains detailed
25 0.10 0.25 dosing instructions
26 0.10 0.26
27 0.11 0.27
28 0.11 0.28 For reversal, administer
29 0.12 0.29 atipamezole IM at
30 0.12 0.30
31 0.12 0.31 equal mL volume to
32 0.13 0.32 dexmedetomidine
33 0.13 0.33
34 0.14 0.34 administered
35 0.14 0.35
36 0.14 0.36
37 0.15 0.37
38 0.15 0.38
39 0.16 0.39
40 0.16 0.40 Usage limited to
41 0.16 0.41 pets with
42 0.17 0.42
43 0.17 0.43 ASA status I - II
44 0.18 0.44
45 0.18 0.45
46 0.18 0.46
47 0.19 0.47
48 0.19 0.48
49 0.20 0.49
50 0.20 0.50

Appendix 192
Diphenhydramine 50 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
1mg/kg 2.2 mg/kg
0.5 0.01 0.02
1 0.02 0.04
2 0.04 0.09
3 0.06 0.13
4 0.08 0.18
5 0.10 0.22
6 0.12 0.26
7 0.14 0.31
8 0.16 0.35
9 0.18 0.40
10 0.20 0.44
11 0.22 0.48
12 0.24 0.53
13 0.26 0.57
14 0.28 0.62
15 0.30 0.66
16 0.32 0.7
17 0.34 0.75
18 0.36 0.79
19 0.38 0.84
20 0.40 0.88
21 0.42 0.92
22 0.44 0.97
23 0.46 1.00
24 0.48 1.00
25 0.50
26 0.52
27 0.54
28 0.56
29 0.58
30 0.60
31 0.62
32 0.64
33 0.66
34 0.68
35 0.70 MAXIMUM DOSE
36 0.72 1 ML (50 MG)
37 0.74
38 0.76
39 0.78
40 0.80
41 0.82
42 0.84
43 0.86
44 0.88
45 0.90
46 0.92
47 0.94
48 0.96
49 0.98
50 1.00

193 Book 3
DKT Dexmedetomidine, Ketamine, Butorphanol

FELINE
mLs DKT mL mLs DKT mL
Weight administered atipamezole administered atipamezole
(kg) Compromised Reversal Healthy Reversal
0.035 mL/kg 0.012 mL/kg 0.065 mL/kg 0.021 mL/kg
0.5 0.02 0.01 0.03 0.01
1 0.04 0.01 0.07 0.02
2 0.07 0.02 0.13 0.04
3 0.11 0.04 0.20 0.06
4 0.14 0.05 0.26 0.08
5 0.18 0.06 0.33 0.11
6 0.21 0.07 0.39 0.13
7 0.25 0.08 0.46 0.15
8 0.28 0.10 0.52 0.17
9 0.32 0.11 0.59 0.19
10 0.35 0.12 0.65 0.21
11 0.39 0.13 0.72 0.23
12 0.42 0.14 0.78 0.25
13 0.46 0.16 0.85 0.27

ATIPAMEZOLE REVERSAL:
REPEAT IN 10 MINUTES
IF NEEDED

Appendix 194
Epinephrine 1 mg/mL

CANINE/FELINE
mLs to administer
Weight High end
(kg) Low end
0.2 mg/kg
0.01 mg/kg
(intra-tracheal)
0.5 0.01 0.10
1 0.01 0.20
2 0.02 0.40
3 0.03 0.60
4 0.04 0.80
5 0.05 1.00
6 0.06 1.20
7 0.07 1.40
8 0.08 1.60
9 0.09 1.80
10 0.10 2.00
11 0.11 2.20
12 0.12 2.40
13 0.13 2.60
14 0.14 2.80
15 0.15 3.00
16 0.16 3.20
17 0.17 3.40
18 0.18 3.60
19 0.19 3.80
20 0.20 4.00
21 0.21 4.20
22 0.22 4.40
23 0.23 4.60
24 0.24 4.80
25 0.25 5.00
26 0.26 5.20
27 0.27 5.40
28 0.28 5.60
29 0.29 5.80
30 0.30 6.00
31 0.31 6.20
32 0.32 6.40
33 0.33 6.60
34 0.34 6.80
35 0.35 7.00
36 0.36 7.20
37 0.37 7.40
38 0.38 7.60
39 0.39 7.80
40 0.40 8.00
41 0.41 8.20
42 0.42 8.40
43 0.43 8.60
44 0.44 8.80
45 0.45 9.00
46 0.46 9.20
47 0.47 9.40
48 0.48 9.60
49 0.49 9.80
50 0.50 10.00

195 Book 3
Fentanyl 0.05 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
3 mcg/kg 5 mcg/kg
0.5 0.03 0.05
1 0.06 0.10
2 0.12 0.20
3 0.18 0.30
4 0.24 0.40
5 0.30 0.50
6 0.36 0.60
7 0.42 0.70
8 0.48 0.80
9 0.54 0.90
10 0.60 1.00
11 0.66 1.10
12 0.72 1.20
13 0.78 1.30
14 0.84 1.40
15 0.90 1.50
16 0.96 1.60
17 1.02 1.70
18 1.08 1.80
19 1.14 1.90
20 1.20 2.00
21 1.26 2.10
22 1.32 2.20
23 1.38 2.30
24 1.44 2.40
25 1.50 2.50
26 1.56 2.60
27 1.62 2.70
28 1.68 2.80
29 1.74 2.90
30 1.80 3.00
31 1.86 3.10
32 1.92 3.20
33 1.98 3.30
34 2.04 3.40
35 2.10 3.50
36 2.16 3.60
37 2.22 3.70
38 2.28 3.80
39 2.34 3.90
40 2.40 4.00
41 2.46 4.10
42 2.52 4.20
43 2.58 4.30
44 2.64 4.40
45 2.70 4.50
46 2.76 4.60
47 2.82 4.70
48 2.88 4.80
49 2.94 4.90
50 3.00 5.00

Appendix 196
Flumazenil 0.1 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) 0.01 mg/kg
Repeat every hour if needed
0.5 0.05
1 0.1
2 0.2
3 0.3
4 0.4
5 0.5
6 0.6
7 0.7
8 0.8
9 0.9
10 1.0
11 1.1
12 1.2
13 1.3
14 1.4
15 1.5
16 1.6
17 1.7
18 1.8
19 1.9
20 2.0
21 2.1
22 2.2
23 2.3
24 2.4
25 2.5
26 2.6
27 2.7
28 2.8
29 2.9
30 3.0
31 3.1
32 3.2
33 3.3
34 3.4
35 3.5
36 3.6
37 3.7
38 3.8
39 3.9
40 4.0
41 4.1
42 4.2
43 4.3
44 4.4
45 4.5
46 4.6
47 4.7
48 4.8
49 4.9
50 5.0

197 Book 3
Glycopyrrolate 0.2 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
0.005 mg/kg 0.01 mg/kg
0.5 0.01 0.03
1 0.03 0.05
2 0.05 0.10
3 0.08 0.15
4 0.10 0.20
5 0.13 0.25
6 0.15 0.30
7 0.18 0.35
8 0.20 0.40
9 0.23 0.45
10 0.25 0.50
11 0.28 0.55
12 0.30 0.60
13 0.33 0.65
14 0.35 0.70
15 0.38 0.75
16 0.40 0.80
17 0.43 0.85
18 0.45 0.90
19 0.48 0.95
20 0.50 1.00
21 0.53 1.05
22 0.55 1.10
23 0.58 1.15
24 0.60 1.20
25 0.63 1.25
26 0.65 1.30
27 0.68 1.35
28 0.70 1.40
29 0.73 1.45
30 0.75 1.50
31 0.78 1.55
32 0.80 1.60
33 0.83 1.65
34 0.85 1.70
35 0.88 1.75
36 0.90 1.80
37 0.93 1.85
38 0.95 1.90
39 0.98 1.95
40 1.00 2.00
41 1.03 2.05
42 1.05 2.10
43 1.08 2.15
44 1.10 2.20
45 1.13 2.25
46 1.15 2.30
47 1.18 2.35
48 1.20 2.40
49 1.23 2.45
50 1.25 2.50

Appendix 198
Hydromorphone 2 mg/mL

CANINE FELINE
mLs to administer mLs to administer
Weight
(kg) Low end High end Low end High end
0.05 mg/kg 0.2 mg/kg 0.05 mg/kg 0.1 mg/kg
0.5 0.01 0.05 0.01 0.03
1 0.03 0.10 0.03 0.05
2 0.05 0.20 0.05 0.10
3 0.08 0.30 0.08 0.15
4 0.10 0.40 0.10 0.20
5 0.13 0.50 0.13 0.25
6 0.15 0.60 0.15 0.30
7 0.18 0.70 0.18 0.35
8 0.20 0.80 0.20 0.40
9 0.23 0.90 0.23 0.45
10 0.25 1.00 0.25 0.50
11 0.28 1.10 0.28 0.55
12 0.30 1.20 0.30 0.60
13 0.33 1.30 0.33 0.65
14 0.35 1.40
15 0.38 1.50
16 0.40 1.60
17 0.43 1.70
18 0.45 1.80
19 0.48 1.90
20 0.50 2.00
21 0.53 2.10
22 0.55 2.20
23 0.58 2.30
24 0.60 2.40
25 0.63 2.50
26 0.65 2.60
27 0.68 2.70
28 0.70 2.80
29 0.73 2.90
30 0.75 3.00
31 0.78 3.10
32 0.80 3.20
33 0.83 3.30
34 0.85 3.40
35 0.88 3.50
36 0.90 3.60
37 0.93 3.70
38 0.95 3.80
39 0.98 3.90
40 1.00 4.00
41 1.03 4.10
42 1.05 4.20
43 1.08 4.30
44 1.10 4.40
45 1.13 4.50
46 1.15 4.60
47 1.18 4.70
48 1.20 4.80
49 1.23 4.90
50 1.25 5.00

199 Book 3
100 mg/mL
Ketamine (For stressed/fractious canines)
CANINE

Weight mLs to administer

(kg) 1 mg/kg 2 mg/kg
0.5 0.005 0.01
1 0.01 0.02
2 0.02 0.04
3 0.03 0.06
4 0.04 0.08
5 0.05 0.10
6 0.06 0.12
7 0.07 0.14
8 0.08 0.16
9 0.09 0.18
10 0.10 0.20
11 0.11 0.22
12 0.12 0.24
13 0.13 0.26
14 0.14 0.28
15 0.15 0.30
16 0.16 0.32
17 0.17 0.34
18 0.18 0.36
19 0.19 0.38
20 0.20 0.40
21 0.21 0.42
22 0.22 0.44
23 0.23 0.46 In combination with
24 0.24 0.48
25 0.25 0.50 dexmedetomidine
26 0.26 0.52 and butorphanol
27 0.27 0.54
28 0.28 0.56
29 0.29 0.58
30 0.30 0.60
31 0.31 0.62
32 0.32 0.64
33 0.33 0.66
34 0.34 0.68
35 0.35 0.70
36 0.36 0.72
37 0.37 0.74
38 0.38 0.76
39 0.39 0.78
40 0.40 0.80
41 0.41 0.82
42 0.42 0.84
43 0.43 0.86
44 0.44 0.88
45 0.45 0.90
46 0.46 0.92
47 0.47 0.94
48 0.48 0.96
49 0.49 0.98
50 0.50 1.00

Appendix 200
20 mg/mL
Lidocaine Bolus (For cardiac arrhythmias)

CANINE FELINE
mLs to administer mLs to administer
Weight
(kg) Low end High end High end
2 mg/kg 4 mg/kg 0.2 mg/kg
0.5 0.05 0.10 0.01
1 0.10 0.20 0.01
2 0.20 0.40 0.02
3 0.30 0.60 0.03
4 0.40 0.80 0.04
5 0.50 1.00 0.05
6 0.60 1.20 0.06
7 0.70 1.40 0.07
8 0.80 1.60 0.08
9 0.90 1.80 0.09
10 1.00 2.00 0.10
11 1.10 2.20 0.11
12 1.20 2.40 0.12
13 1.30 2.60 0.13
14 1.40 2.80
15 1.50 3.00
16 1.60 3.20
17 1.70 3.40
18 1.80 3.60
19 1.90 3.80
20 2.00 4.00
21 2.10 4.20
22 2.20 4.40 MAXIMUM
23 2.30 4.60
24 2.40 4.80 DOSAGE
25 2.50 5.00
26 2.60 5.20 Canine:
27 2.70 5.40 8 mg/kg
28 2.80 5.60
29 2.90 5.80 Feline:
30 3.00 6.00
31 3.10 6.20 1 mg/kg
32 3.20 6.40
33 3.30 6.60 Administer
34 3.40 6.80
35 3.50 7.00 slowly over
36 3.60 7.20 1 - 2 minutes
37 3.70 7.40
38 3.80 7.60
39 3.90 7.80
40 4.00 8.00
41 4.10 8.20
42 4.20 8.40
43 4.30 8.60
44 4.40 8.80
45 4.50 9.00
46 4.60 9.20
47 4.70 9.40
48 4.80 9.60
49 4.90 9.80
50 5.00 10.00

201 Book 3
Lidocaine 20 mg/mL (For local anesthesia)

CANINE FELINE
mLs to administer mLs to administer
Weight
(kg) Low end High end Low end High end
1 mg/kg 4 mg/kg 1 mg/kg 2 mg/kg
0.5 0.03 0.10 0.03 0.05
1 0.05 0.20 0.05 0.10
2 0.10 0.40 0.10 0.20
3 0.15 0.60 0.15 0.30
4 0.20 0.80 0.20 0.40
5 0.25 1.00 0.25 0.50
6 0.30 1.20 0.30 0.60
7 0.35 1.40 0.35 0.70
8 0.40 1.60 0.40 0.80
9 0.45 1.80 0.45 0.90
10 0.50 2.00 0.50 1.00
11 0.55 2.20 0.55 1.10
12 0.60 2.40 0.60 1.20
13 0.65 2.60 0.65 1.30
14 0.70 2.80
15 0.75 3.00
16 0.80 3.20
17 0.85 3.40
18 0.90 3.60 MAXIMUM DOSAGE
19 0.95 3.80
20 1.00 4.00 Canine:
21 1.05 4.20
22 1.10 4.40 10 mg/kg
23 1.15 4.60
24 1.20 4.80 Feline:
25 1.25 5.00
26 1.30 5.20 5 mg/kg
27 1.35 5.40
28 1.40 5.60
29 1.45 5.80
30 1.50 6.00
31 1.55 6.20
32 1.60 6.40 LOCAL INJECTION
33 1.65 6.60 GUIDELINES
34 1.70 6.80
35 1.75 7.00 Canine:
36 1.80 7.20
37 1.85 7.40 0.5 - 1.0 mL per site
38 1.90 7.60
39 1.95 7.80 Feline:
40 2.00 8.00
41 2.05 8.20 0.2 - 0.3 mL per site
42 2.10 8.40
43 2.15 8.60 Dilute with sterile
44 2.20 8.80 water if more
45 2.25 9.00
46 2.30 9.20 volume is needed
47 2.35 9.40
48 2.40 9.60
49 2.45 9.80
50 2.50 10.00

Appendix 202
Meloxicam 5 mg/mL

CANINE FELINE

Weight mLs to administer mLs to administer

(kg) 0.2 mg/kg 0.3 mg/kg
0.5 0.005 0.025
1 0.01 0.05
2 0.02 0.1
3 0.03 0.15
4 0.04 0.2
5 0.05 0.25
6 0.06 0.3
7 0.07 0.35
8 0.08 0.4
9 0.09 0.45
10 0.01 0.5
11 0.11 0.55
12 0.12 0.6
13 0.13 0.65
14 0.14 0.7
15 0.15 0.75
16 0.16 0.8
17 0.17 0.85
18 0.18 0.9
19 0.19 0.95
20 0.2 1
21 0.21 1.05
22 0.22 1.1
23 0.23 1.15
24 0.24 1.2
25 0.25 1.25
26 0.26 1.3
27 0.27 1.35
28 0.28 1.4
29 0.29 1.45
30 0.3 1.5
31 0.31 1.55
32 0.32 1.6
33 0.33 1.65
34 0.34 1.7
35 0.35 1.75
36 0.36 1.8
37 0.37 1.85
38 0.38 1.9
39 0.39 1.95
40 0.4 2
41 0.41 2.05
42 0.42 2.1
43 0.43 2.15
44 0.44 2.2
45 0.45 2.25
46 0.46 2.3
47 0.47 2.35
48 0.48 2.4
49 0.49 2.45
50 0.5 2.5

203 Book 3
Methadone 10mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
(0.1 mg/kg) (0.5 mg/kg)
0.5 0.005 0.025
1 0.01 0.05
2 0.02 0.10
3 0.03 0.15
4 0.04 0.20
5 0.05 0.25
6 0.06 0.30
7 0.07 0.35
8 0.08 0.40
9 0.09 0.45
10 0.10 0.50
11 0.11 0.55
12 0.12 0.60
13 0.13 0.65
14 0.14 0.70
15 0.15 0.75
16 0.16 0.80
17 0.17 0.85
18 0.18 0.90
19 0.19 0.95
20 0.20 1.00
21 0.21 1.05
22 0.22 1.10
23 0.23 1.15
24 0.24 1.20
25 0.25 1.25
26 0.26 1.30
27 0.27 1.35
28 0.28 1.40
29 0.29 1.45
30 0.30 1.50
31 0.31 1.55
32 0.32 1.60
33 0.33 1.65
34 0.34 1.70
35 0.35 1.75
36 0.36 1.80
37 0.37 1.85
38 0.38 1.90
39 0.39 1.95
40 0.40 2.00
41 0.41 2.05
42 0.42 2.10
43 0.43 2.15
44 0.44 2.20
45 0.45 2.25
46 0.46 2.30
47 0.47 2.35
48 0.48 2.40
49 0.49 2.45
50 0.50 2.50

Appendix 204
Midazolam 1 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
0.1 mg/kg 0.3 mg/kg
0.5 0.05 0.15
1 0.10 0.30
2 0.20 0.60
3 0.30 0.90
4 0.40 1.20
5 0.50 1.50
6 0.60 1.80
7 0.70 2.10
8 0.80 2.40
9 0.90 2.70
10 1.00 3.00
11 1.10 3.30
12 1.20 3.60
13 1.30 3.90
14 1.40 4.20
15 1.50 4.50
16 1.60 4.80
17 1.70 5.10
18 1.80 5.40
19 1.90 5.70
20 2.00 6.00
21 2.10 6.30
22 2.20 6.60
23 2.30 6.90
24 2.40 7.20
25 2.50 7.50
26 2.60 7.80
27 2.70 8.10
28 2.80 8.40
29 2.90 8.70
30 3.00 9.00
31 3.10 9.30
32 3.20 9.60
33 3.30 9.90
34 3.40 10.20
35 3.50 10.50
36 3.60 10.80
37 3.70 11.10
38 3.80 11.40
39 3.90 11.70
40 4.00 12.00
41 4.10 12.30
42 4.20 12.60
43 4.30 12.90
44 4.40 13.20
45 4.50 13.50
46 4.60 13.80
47 4.70 14.10
48 4.80 14.40
49 4.90 14.70
50 5.00 15.00

205 Book 3
Midazolam 5 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
0.1 mg/kg 0.3 mg/kg
0.5 0.01 0.03
1 0.02 0.06
2 0.04 0.12
3 0.06 0.18
4 0.08 0.24
5 0.10 0.30
6 0.12 0.36
7 0.14 0.42
8 0.16 0.48
9 0.18 0.54
10 0.20 0.60
11 0.22 0.66
12 0.24 0.72
13 0.26 0.78
14 0.28 0.84
15 0.30 0.90
16 0.32 0.96
17 0.34 1.02
18 0.36 1.08
19 0.38 1.14
20 0.40 1.20
21 0.42 1.26
22 0.44 1.32
23 0.46 1.38
24 0.48 1.44
25 0.50 1.50
26 0.52 1.56
27 0.54 1.62
28 0.56 1.68
29 0.58 1.74
30 0.60 1.80
31 0.62 1.86
32 0.64 1.92
33 0.66 1.98
34 0.68 2.04
35 0.70 2.10
36 0.72 2.16
37 0.74 2.22
38 0.76 2.28
39 0.78 2.34
40 0.80 2.40
41 0.82 2.46
42 0.84 2.52
43 0.86 2.58
44 0.88 2.64
45 0.90 2.70
46 0.92 2.76
47 0.94 2.82
48 0.96 2.88
49 0.98 2.94
50 1.00 3.00

Appendix 206
Naloxone 0.4 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) 0.04 mg/kg
Repeat every hour if needed
0.5 0.05
1 0.1
2 0.2
3 0.3
4 0.4
5 0.5
6 0.6
7 0.7
8 0.8
9 0.9
10 1.0
11 1.1
12 1.2
13 1.3
14 1.4
15 1.5
16 1.6
17 1.7
18 1.8
19 1.9
20 2.0
21 2.1
22 2.2
23 2.3
24 2.4
25 2.5
26 2.6
27 2.7
28 2.8
29 2.9
30 3.0
31 3.1
32 3.2
33 3.3
34 3.4
35 3.5
36 3.6
37 3.7
38 3.8
39 3.9
40 4.0
41 4.1
42 4.2
43 4.3
44 4.4
45 4.5
46 4.6
47 4.7
48 4.8
49 4.9
50 5.0

207 Book 3
Propofol 10 mg/mL

CANINE/FELINE
mLs to administer
Weight
(kg) Low end High end
1 mg/kg 8 mg/kg
0.5 0.05 0.40
1 0.10 0.80
2 0.20 1.60
3 0.30 2.40
4 0.40 3.20
5 0.50 4.00
6 0.60 4.80
7 0.70 5.60
8 0.80 6.40
9 0.90 7.20
10 1.00 8.00
11 1.10 8.80
12 1.20 9.60
13 1.30 10.40
14 1.40 11.20
15 1.50 12.00
16 1.60 12.80 SEE DOSING
17 1.70 13.60
18 1.80 14.40 INSTRUCTIONS
19 1.90 15.20
20 2.00 16.00 IN TEXT
21 2.10 16.80 Administer only
22 2.20 17.60
23 2.30 18.40 to effect
24 2.40 19.20
25 2.50 20.00
26 2.60 20.80
27 2.70 21.60
28 2.80 22.40
29 2.90 23.20
30 3.00 24.00
31 3.10 24.80
32 3.20 25.60
33 3.30 26.40
34 3.40 27.20
35 3.50 28.00
36 3.60 28.80
37 3.70 29.60
38 3.80 30.40
39 3.90 31.20
40 4.00 32.00
41 4.10 32.80
42 4.20 33.60
43 4.30 34.40
44 4.40 35.20
45 4.50 36.00
46 4.60 36.80
47 4.70 37.60
48 4.80 38.40
49 4.90 39.20
50 5.00 40.00

Appendix 208
Robenacoxib 20 mg/mL

FELINE

Weight mLs to administer

(kg) 2 mg/kg
0.5 0.05
1 0.10
2 0.20
3 0.30
4 0.40
5 0.50
6 0.60
7 0.70
8 0.80
9 0.90
10 1.00
11 1.10
12 1.20
13 1.30

209 Book 3
Tiletamine/Zolazepan 100 mg/mL

CANINE/FELINE

Weight mLs to administer

(kg) 1 mg/kg 2 mg/kg 4 mg/kg
0.5 0.01 0.01 0.02
1 0.01 0.02 0.04
2 0.02 0.04 0.08
3 0.03 0.06 0.12
4 0.04 0.08 0.16
5 0.05 0.10 0.20
6 0.06 0.12 0.24
7 0.07 0.14 0.28
8 0.08 0.16 0.32
9 0.09 0.18 0.36
10 0.10 0.20 0.40 DOSAGE
11 0.11 0.22 0.44 1-4 mg/kg
12 0.12 0.24 0.48
13 0.13 0.26 0.52 IM for
14 0.14 0.28 0.56 stressed/
15 0.15 0.30 0.60
16 0.16 0.32 0.64 fractious
17 0.17 0.34 0.68 canines
18 0.18 0.36 0.72
19 0.19 0.38 0.76
20 0.20 0.40 0.80
21 0.21 0.42 0.84
22 0.22 0.44 0.88
23 0.23 0.46 0.92 DOSAGE
24 0.24 0.48 0.96
25 0.25 0.50 1.00 1-2 mg/kg
26 0.26 0.52 1.04 IV for
27 0.27 0.54 1.08
28 0.28 0.56 1.12 surgical
29 0.29 0.58 1.16 induction
30 0.30 0.60 1.20
31 0.31 0.62 1.24
32 0.32 0.64 1.28
33 0.33 0.66 1.32
34 0.34 0.68 1.36
35 0.35 0.70 1.40
36 0.36 0.72 1.44
37 0.37 0.74 1.48
38 0.38 0.76 1.52
39 0.39 0.78 1.56
40 0.40 0.80 1.60
41 0.41 0.82 1.64
42 0.42 0.84 1.68
43 0.43 0.86 1.72
44 0.44 0.88 1.76
45 0.45 0.90 1.80
46 0.46 0.92 1.84
47 0.47 0.94 1.88
48 0.48 0.96 1.92
49 0.49 0.98 1.96
50 0.50 1.00 2.00

Appendix 210
References and suggested reading for Appendix:
1. Dodelet-Devillers et al. Assessment of stability of ketamine-xylazine
preparations with or without acepromazine using high performance liquid
chromatography-mass spectrometry. Can J Vet Res. Jan 2016;80(1):
86-89.
2. Taylor BJ, Orr SA, Chapman JL, et al. Beyond-use dating of
extemporaneously compounded ketamine, acepromazine,and xylazine:
safety, stability, and efficacy over time. J Am Assoc Lab Anim Sci. Nov
2009:48(6)718-726.
3. Kwiatkowski JL, Johnson CE, Wagner DS. Extended stability of intravenous
acetaminophen in syringes and opened vials. Am J Health Syst Pharm. 2012
Nov 2012;69(22):1999-2001.
4. U.S. Pharmacopeial Convention (USP). General Chapter 797. www.usp.org/.
Accessed February 15, 2017.
5. Hofmeister EH, Egger CM. Transdermal fentanyl patches in small animals. J
Am Anim Hosp Assoc. 2004;40(6):468-478.

211 Book 3

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