# Sticky  Reducing Anesthesia Risk - What to Ask What to Know



## Rose n Poos

When I decided that it was time to neuter my boys, I had to consider the risks of anesthesia. It isn't optional so what could be done to reduce risks associated with it?

It turns out that medical science has been looking at this too. There are similarities between human and canine risks for anesthesia so what are factors to consider?

You have some factors that are out of personal control in the short term such as being overweight, unknown underlying conditions, things like that. With time to plan, weight might be managed, underlying conditions may be identified and addressed but this isn't always possible.

Factors that can be addressed are learned from procedures used in human anesthesia.

There's a quote I ran across frequently in researching, “There are no safe anesthetic agents, there are no safe anesthetic procedures. There are only safe anesthetists.” (Robert Smith, MD)

Information below is taken from the linked sources further below.


_Among the factors that increase the odds of anesthetic-related death in individual dogs and cats are being in worse health, urgent procedures, age, long procedures, use of injectable anesthesia rather than inhalant anesthesia, obesity, and brachycephaly.

*Factors that decrease the odds of anesthetic-related death* are an equipment check with a protocol and checklist, direct availability of an anesthesiologist and a trained nurse, no change of anesthetics during the procedure, two people available for emergencies, post-operative pain management, epidural or local analgesia rather than systemic analgesia, pulse oximetry, *and monitoring in general.*

Dr. da Cunha said all the studies—on horses, rabbits, cats, dogs, or humans—agree that *monitoring is key to reducing mortality rates.* He also recommended following an anesthesia checklist to prevent mistakes, as he does.

*Anesthesia is more like a coma than simply being unconscious.* Automatic functions are slowed down, reversibly, and this is why the monitoring is so important. _


So, what needs to be monitored or in place before, during and after, and who does all that?


*What:

Before:*

Ask your vet if there are relevant breed-specific anesthesia concerns

Make sure your vet knows of all the medications, supplements and nutraceuticals that your dog is taking. Vaccine history and lifestyle can be relevant.

Follow the pre op instructions at home carefully. Fasting is important to limit the incidence of vomiting, regurgitation, or gastroesophageal reflux during anesthesia
Pre op bloodwork is done to ensure that there are no imbalances or underlying conditions that could complicate surgery

*During:*

IV catheter in place (see below)

Preoxygenating the patients – providing supplemental oxygen prior to inducing anesthesia

Pre-anesthetic - a mild sedative to calm a dog so he can be more easily handled and prepped for surgery. Acepromazine is commonly used

Induction anesthetic - this anesthesia agent kicks off the anesthesia process. Propofol is the name that most owners will be familiar with. Induction anesthesia is administered intravenously; the idea is to administer a fast-acting anesthetic to pave the way for the more powerful inhalant anesthesia.
Because propofol can cause significant hypoventilation (low breathing rate) or apnea (absence of breathing), it is recommended that a patient be intubated, or have a breathing tube placed, and a supplemental oxygen source available
The catheter that dispenses the induction agent also gives the veterinarian a conduit to provide supportive fluids – and immediate access to the bloodstream should other drugs need to be administered in response to the patient’s condition.

Inhalant anesthetic - requires a breathing tube, which is placed in the trachea to ensure that the dog gets the proper levels of anesthetic, as well as oxygen, during the surgery.

*In place or to monitor - during and afte*r

Temperature - Hypothermia is a risk, especially smaller breeds
O2 levels/CO2 levels
Respiratory rate
Heart rate/ECG
Blood pressure

_For an idea of just how important monitoring is in avoiding complications, Dr. Clark-Price points to the four main monitors used during human surgeries: 
electrocardiogram (which measures the electrical activity of the heart), 
pulse oximetry (how much oxygen is in the blood),
blood pressure, 
and end tidal gas monitoring (how well a patient is breathing during anesthesia). 
When those four monitors are used in human medicine, “it reduces the chances of avoidable anesthetic complications by 96 percent!” he says. “Many veterinary practices have one or more of these monitoring devices, and clients should ask their veterinarians if they are using any of them.”_

*Recovery*

Monitoring should continue thru the recovery period.

*Who:*

A second trained tech to support the vet, with primary focus on monitoring.

_Sometimes, an experienced eye can be even more critical than a high-tech approach. Most veterinary practices do not have a board-certified anesthesiologist on staff; instead, anesthesia monitoring typically falls to a veterinary technician, who is supervised by the veterinarian. Vet techs can be certified in anesthesia management. 
Make sure to ask your veterinarian about who will be assisting with surgery, and if that person is board certified (in cases where the anesthetist is a veterinarian) or has received any specialized training in anesthesia administration (in cases where the anesthetist is a veterinary technician).

If your dog is at risk for anesthesia-related complications, consider asking your veterinarian to consult with a veterinary-anesthesia specialist who has been certified by the American College of Veterinary Anesthesia and Analgesia._


*Pain management*

Make sure you have post operative instructions and a clear description of what to expect during immediate and extended recovery.
Ask the vet or tech to advise you what issues might require immediate medical care and what can wait til the office opens.
Have pain medication ready and have enough to get you thru several days and be sure to contact the vet if you have any concerns before going into a weekend.


_Age is not a disease, and the anesthetic risk is not much greater for a geriatric patient than a patient who is younger, as long as they are healthy with no co-existing disease,” says Dr. Berit Fischer, head of the Anesthesia and Pain Management Service at New York City (NYC)'s Animal Medical Center. A board-certified veterinary anesthesiologist, Dr. Fischer is one of approximately 220 currently in North America._


*Educating Ourselves*

Important questions to ask:

_Will there be a dedicated person monitoring the anesthesia while the vet is performing the procedure?
What are his credentials or training?
What type of monitoring is performed, and will there be someone watching my dog’s vitals (i.e. heart rate and rhythm, blood pressure, temperature, oxygen saturation)?
Will blood work be checked before anesthesia?
Is my dog on oxygen during surgery?
Will he be on fluids? Will there be an intravenous catheter placed?
Is there someone present to help him ventilate (breathe), and do you intubate your patients?
Where does the dog go for recovery, and who will be with him during this period?
How do you plan to control any possible pain—both during surgery and after my pet comes home?_


I'd welcome additions or corrections from our medically inclined members.


Sources

<What You Should Know About Anesthesia Before You Schedule Your Dog's Veterinary Procedure - Whole Dog Journal>

<‘There are only safe anesthetists’>









Anesthesia for Dogs | VCA Animal Hospital


Anesthesia is accomplished by administering drugs that depress nerve function. It is important that you fully understand what will happen to your pet, and that you acknowledge that you understand the risks. Anesthetic monitoring in a veterinary hospital is similar to that found in any human...




vcahospitals.com













What Every Dog Owner Should Know When It Comes to Anesthesia – American Kennel Club


Every day, pets across the country are undergoing some sort of procedure; whether it’s routine or an emergency that requires anesthesia, owners know




www.akc.org


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## fjm

Thank you. I think this should be a sticky!


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## EVpoodle

Thank you Rose. I agree with fjm that this should be a sticky!


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## 94Magna_Tom

Very good info. Thank you.


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## DogtorDoctor

This is a fantastic resource, Rose! I don't have anything succinct to add (I think I'm incapable of brevity), but I put some of my thoughts down for funsies in no particular order of importance. I definitely agree that this would make a great sticky. 



Rose n Poos said:


> *Before:*
> Ask your vet if there are relevant breed-specific anesthesia concerns
> 
> ...
> 
> Follow the pre op instructions at home carefully. Fasting is important to limit the incidence of vomiting, regurgitation, or gastroesophageal reflux during anesthesia.


For Poodles, one breed-related concern prior to *surgery*, not anesthesia, would be von Willebrand factor deficiency (vWD, Type 1) testing. This can either be performed as a DNA test (either on your pet or performed by reputable breeders on the parents, and you can be "clear by parentage" for one generation) or as a buccal mucosal bleeding time (BMBT) the day of surgery. Not all hospitals will have the supplies for this test, so it would be something to ask about prior to surgery if necessary. Poodles are not as commonly affected as other breeds (looking at you, Dobermans), but this is something to keep in mind. 

Special note about fasting prior to anesthesia/sedation: if you forget, please tell your vet prior to surgery. If it's something routine, like a spay/neuter, and my schedule isn't booked months out, I may recommend rescheduling. Other procedures may not be able to wait that long. For instance, I would wager that most of the C-sections we perform are on non-fasted dogs (that are also brachycephalic, so increased risk of aspiration pneumonia right there). We simply take extra precautions during pre-medication, induction, and recovery. However, I can only do this if owners are honest and let me know what's going on. My current dog has bilious vomiting syndrome (AKA: the hunger pukes), and I knowingly fed him exactly 10 pieces of kibble at 6 AM prior to his 11 AM induction. I also brought his food up to the hospital for after his recovery. I'm sure many vets would be willing to work with similar situations; all you have to do is ask. 



Rose n Poos said:


> _Age is not a disease, and the anesthetic risk is not much greater for a geriatric patient than a patient who is younger, as long as they are healthy with no co-existing disease,” says Dr. Berit Fischer, head of the Anesthesia and Pain Management Service at New York City (NYC)'s Animal Medical Center. A board-certified veterinary anesthesiologist, Dr. Fischer is one of approximately 220 currently in North America. _


"Age is not a disease" is one of my favorite quotes! Never refuse anesthesia *only* because your pup is getting up in years. We have plenty of 10+ year old dogs who are anesthetized for yearly dental cleanings without issue. It's the hidden/undiagnosed co-existing diseases that cause problems, but there are additional tests that can be performed to find these and decrease anesthetic risk. For instance, at the specialty teaching hospital I was at during vet school, we "strongly recommended" (read: required) chest x-rays for all pets over 7 years of age. This is a check for any lung diseases, most notably cancer, which can often be asymptomatic. I will say that such requirements are not very common outside of specialty hospitals. 

You can also ask for more in-depth bloodwork, as standard pre-op tests will vary between hospitals. The full gamut may include a serum chemistry panel, urinalysis, and complete blood count (with blood smear). These may need to be sent out, so blood and urine may have to be collected at a prior appointment. 

For dogs that have diagnosed heart disease, a fresh echocardiogram would be recommended within a short time frame prior to anesthesia. I'd be hard pressed to recommend this very expensive test for an animal that doesn't have any physical exam findings of cardiac disease, however. 



Rose n Poos said:


> *Educating Ourselves*
> Important questions to ask:
> 
> _Will there be a dedicated person monitoring the anesthesia while the vet is performing the procedure?
> What are his credentials or training?
> What type of monitoring is performed, and will there be someone watching my dog’s vitals (i.e. heart rate and rhythm, blood pressure, temperature, oxygen saturation)?
> Will blood work be checked before anesthesia?
> Is my dog on oxygen during surgery?
> Will he be on fluids? Will there be an intravenous catheter placed?
> Is there someone present to help him ventilate (breathe), and do you intubate your patients?
> Where does the dog go for recovery, and who will be with him during this period?
> How do you plan to control any possible pain—both during surgery and after my pet comes home? _


This is a great summary of concerns to think about prior to any anesthetic event/surgery! One thing I thought of as I read down the list was $, $$, $$$. Each extra step you take will add on to your bill, and you have to be prepared for that. I would love to have an anesthesiologist any time my dog goes under, but they are exceptionally well-compensated for their expertise. You can have your dog spayed by a boarded veterinary surgeon under an anesthesiologist, but it will cost you thousands. Each additional test you ask for adds up. The technician monitoring vitals, recorded on expensive machines, has to be trained and paid. The best drugs are (generally) more expensive. My favorite pain medication is the opioid methadone. It can be prohibitively expensive in large dogs for most owners, and many hospitals will not carry more than the weakest opioids (butorphanol, buprenorphine, and maybe hydromorphone) due to red tape and human drug abuse. For the best pain management, you often have to go to larger hospitals.

Anecdote time: when I was a student, my dog was neutered by a very experienced general practitioner in less than 10 minutes for less than $100. He did not have a catheter in or any monitoring equipment other than myself making sure he breathed once every 30 or so seconds. When his upper fourth premolar was pulled, I went to a different hospital and pulled out all the stops (dental radiographs, osteopromotive agent post-extraction, and more in-depth monitoring). The cost was between two and three times what I would've paid at the first hospital, and I paid it gladly. Were my dog to need any kind of surgical oncologic procedure, I'd be going to the nearest specialty hospital with pet insurance in hand. 

Many times vets will recommend the "gold standard," which is everything performed to the highest/best option. This can be very expensive depending on what's going on. If you cannot afford the gold standard, *that is okay*. You have to do what is right for you pet in your situation. Talk it over with your vet, ask for a consult with an anesthesiologist (as mentioned above), and find a solution that works for you. Everyone wants the best for you and your dog.


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## Rose n Poos

DogtorDoctor said:


> I don't have anything succinct to add (I think I'm incapable of brevity), but I put some of my thoughts down for funsies in no particular order of importance.


Thank you so much for adding your expertise! 

Until not so many years ago, I don't know how much of this would have even been available in a typical privately owned small clinic. I completely understand trusting the experienced GP (my dad was one, on the human side), but medicine on the canine and human side both has changed significantly. 

When it was time to consider neutering my boys our vet's office gave us a detailed breakdown of the services that would be provided, basically the "gold standard" you mention, and the cost (barring unforeseens). I chose to forego only one thing, the IV cath, after discussing it all thoroughly with the vet, but will not skip that in the future. It wasn't a significant cost, maybe that one thing just made me uncomfortable actually planning for the what-ifs, rather than pre-empting. 

The odds are still low that anything would go wrong, especially with taking additional precautions, but from that procedure on, so long as I can, I will. 

Not everyone will be able to, I know, but having this information along with a good vet, I hope that best _possible_ decisions can be made together.


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## DogtorDoctor

Rose n Poos said:


> ... medicine on the canine and human side both has changed significantly.


I agree with you 100%! I don't think I made my timeline very clear, but the longer I've had my dog (and the longer I've been in the profession), the *more *risk-adverse I've become. Like for his tooth extraction, he'll have a catheter for any surgery in the future. For my new puppy, I will also be placing a catheter (and having some fancy monitoring equipment on him) for his eventual neuter, no matter how short the surgery time will be. If we have these advances is technology, we might as well use them, right?  



Rose n Poos said:


> It wasn't a significant cost, maybe that one thing just made me uncomfortable actually planning for the what-ifs, rather than pre-empting.


This made me think of one more consideration that should be discussed while you're filling out paperwork prior to anesthesia/surgery: code status. This is normally broken into two categories: either green code or red code. A dog who is a green code will receive CPR in the (hopefully very unlikely) event that they become unresponsive, their heart stops, or another adverse event occurs during or around the procedure. A dog who is a red code would not receive CPR. This is a very personal decision for an owner to make and your vet should be more than happy to discuss the differences between the two code statuses. However, it's a good idea to at least have this on your mind prior to the day of anesthesia so you're not too overwhelmed when you're dropping your pup off.


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## Vita

Excellent and needed, helpful discussion, thank you Rose for starting this thread. It's now joined the Sticky Hall of Fame. 😀


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## Fenris-wolf

Thank you, Rose!


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## Sylvia K

DogtorDoctor said:


> This is a fantastic resource, Rose! I don't have anything succinct to add (I think I'm incapable of brevity), but I put some of my thoughts down for funsies in no particular order of importance. I definitely agree that this would make a great sticky.
> 
> 
> 
> For Poodles, one breed-related concern prior to *surgery*, not anesthesia, would be von Willebrand factor deficiency (vWD, Type 1) testing. This can either be performed as a DNA test (either on your pet or performed by reputable breeders on the parents, and you can be "clear by parentage" for one generation) or as a buccal mucosal bleeding time (BMBT) the day of surgery. Not all hospitals will have the supplies for this test, so it would be something to ask about prior to surgery if necessary. Poodles are not as commonly affected as other breeds (looking at you, Dobermans), but this is something to keep in mind.
> 
> Special note about fasting prior to anesthesia/sedation: if you forget, please tell your vet prior to surgery. If it's something routine, like a spay/neuter, and my schedule isn't booked months out, I may recommend rescheduling. Other procedures may not be able to wait that long. For instance, I would wager that most of the C-sections we perform are on non-fasted dogs (that are also brachycephalic, so increased risk of aspiration pneumonia right there). We simply take extra precautions during pre-medication, induction, and recovery. However, I can only do this if owners are honest and let me know what's going on. My current dog has bilious vomiting syndrome (AKA: the hunger pukes), and I knowingly fed him exactly 10 pieces of kibble at 6 AM prior to his 11 AM induction. I also brought his food up to the hospital for after his recovery. I'm sure many vets would be willing to work with similar situations; all you have to do is ask.
> 
> 
> 
> "Age is not a disease" is one of my favorite quotes! Never refuse anesthesia *only* because your pup is getting up in years. We have plenty of 10+ year old dogs who are anesthetized for yearly dental cleanings without issue. It's the hidden/undiagnosed co-existing diseases that cause problems, but there are additional tests that can be performed to find these and decrease anesthetic risk. For instance, at the specialty teaching hospital I was at during vet school, we "strongly recommended" (read: required) chest x-rays for all pets over 7 years of age. This is a check for any lung diseases, most notably cancer, which can often be asymptomatic. I will say that such requirements are not very common outside of specialty hospitals.
> 
> You can also ask for more in-depth bloodwork, as standard pre-op tests will vary between hospitals. The full gamut may include a serum chemistry panel, urinalysis, and complete blood count (with blood smear). These may need to be sent out, so blood and urine may have to be collected at a prior appointment.
> 
> For dogs that have diagnosed heart disease, a fresh echocardiogram would be recommended within a short time frame prior to anesthesia. I'd be hard pressed to recommend this very expensive test for an animal that doesn't have any physical exam findings of cardiac disease, however.
> 
> 
> 
> This is a great summary of concerns to think about prior to any anesthetic event/surgery! One thing I thought of as I read down the list was $, $$, $$$. Each extra step you take will add on to your bill, and you have to be prepared for that. I would love to have an anesthesiologist any time my dog goes under, but they are exceptionally well-compensated for their expertise. You can have your dog spayed by a boarded veterinary surgeon under an anesthesiologist, but it will cost you thousands. Each additional test you ask for adds up. The technician monitoring vitals, recorded on expensive machines, has to be trained and paid. The best drugs are (generally) more expensive. My favorite pain medication is the opioid methadone. It can be prohibitively expensive in large dogs for most owners, and many hospitals will not carry more than the weakest opioids (butorphanol, buprenorphine, and maybe hydromorphone) due to red tape and human drug abuse. For the best pain management, you often have to go to larger hospitals.
> 
> Anecdote time: when I was a student, my dog was neutered by a very experienced general practitioner in less than 10 minutes for less than $100. He did not have a catheter in or any monitoring equipment other than myself making sure he breathed once every 30 or so seconds. When his upper fourth premolar was pulled, I went to a different hospital and pulled out all the stops (dental radiographs, osteopromotive agent post-extraction, and more in-depth monitoring). The cost was between two and three times what I would've paid at the first hospital, and I paid it gladly. Were my dog to need any kind of surgical oncologic procedure, I'd be going to the nearest specialty hospital with pet insurance in hand.
> 
> Many times vets will recommend the "gold standard," which is everything performed to the highest/best option. This can be very expensive depending on what's going on. If you cannot afford the gold standard, *that is okay*. You have to do what is right for you pet in your situation. Talk it over with your vet, ask for a consult with an anesthesiologist (as mentioned above), and find a solution that works for you. Everyone wants the best for you and your dog.


Just to add my (limited) experience. My toy poodle developed pancreatitis and hepatitis around last Christmas and had an xray as part of the diagnostic procedures. The vet advised that the xray indicated lung cancer may be present and sent the xrays to a much larger diagnostic clinic for review. The advice from this source also suggested a likelihood of cancer. My vet gave advice on follow up procedures which I could never have afforded but he told me there was another much lower cost option that could reveal a lot. I opted for that procedure and the results showed no cancer cells in the lungs at all. Just recently, my dog has developed more lung issues and I have been considering whether or not to arrange another xray to see what is happening. I have been reluctant owing to his age (14 years old and a bit frail these days) but reading through this thread has given me hope that an xray may be helpful so long as correct monitoring etc is done. The vet I went to initially is great and has a really good reputation, but unfortunately he is nearly 700 kilometres away from my home. However, if I can organise a visit to my daughter in the vet's town, I think I will take my little dog back to him for a review and follow up xray to see if the original mass that was noted has cleared or ??? Either way, I will probably get some really good advice from this vet. Many thanks for making this a 'sticky'. It contains much invaluable advice for poodle owners.


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## Rose n Poos

A member has also written of a secondary issue, probably due to the intubation, not the anesthetic, but since these are hand in glove, it's added here.

She reported permanent vocal change of one dog after a procedure, and a longer term (approx 6 wks as of this writing) vocal change of another poodle.

This is not common beyond a few days, so ask your vet about what to expect for vocal recovery from intubation. There are rare situations where medical intervention would be advised.


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