Kim Campbell Thornton Blood draws, chemo, happy vet visits, even training veterinary students: Fear Free makes things work. Here are this month’s success stories.
Chemo for Indy
Indy was a middle-aged mixed-breed dog who developed Stage 3a lymphoma requiring weekly treatment under a CHOP chemo protocol. Only one problem: he was an FAS 4-5 patient who did not like to be touched, let alone restrained. How were we going to treat weekly with IV catheter-administered chemotherapy? Spent a lot of time in the early days fine-tuning a PVP protocol that allowed us to work on touch gradient approach so we could eventually hold his paw and use a regular or butterfly catheter to administer therapy. We always had myself and one specific technician available to work on desensitization with gentle restraint and forelimb holding. Lots of treats. For longer IV treatments, we preemptively sedated Indy. By the end of his treatment cycles, he would walk into the chemo room, sit or lie on a padded mat, and let us treat without incidents. Amazing! It works!
Jeffrey D. Palmer, DVM, Elite Fear Free Certified Professional, Burr Ridge Veterinary Clinic, Darien, Illinois
PVP, Tuna Lead to Successful Cat Exam
A new feline patient with a high level of fear, anxiety, and stress went home with gabapentin as a pre-visit pharmaceutical. The exam we performed two days later was great. He was readily eating tuna and happy to be petted. He did well for a complete exam, including radiographs and blood draw. The Feliway-infused towel was also a great help.
Matthew Hudson, DVM, Elite Fear Free Certified Professional, VCA Blum Animal Hospital, Chicago, Illinois
Cat Can Do
We have seen so many success stories with numerous patients, but the best for me is my personal cat. He is an uncontrolled diabetic, and the first year I owned him he had a lot of blood draws and vet visits. He was a wonderful-tempered cat at home, but at the clinic, while he never bit or scratched, he hissed and struggled every time he came out of the cage and became a difficult patient to handle. He is very food-motivated and after we started Fear Free practices and he got squirt cheese and baby food every time he was handled, he now purrs and rubs on everyone when he comes for treatments and is so much happier and easier to handle. I am overall so much more aware of a patient’s anxiety level the moment they walk in the door now, and it gives us a chance to start finding ways to alleviate their stress before it escalates.
Cheri Crane, Elite Fear Free Certified Professional, Customer Service Representative, Healing Paws Veterinary Clinic, Springfield, Missouri
Culture Change
For most of my practice career, I have been involved in student training. Some students embraced the things I taught them about the importance of minimizing fear, anxiety, and stress in patients, while others felt I was “too soft,” “only cared about giving the animals treats,” or “was crazy or misguided in my efforts.” Fellow faculty members sometimes shared these sentiments and even accused me of not being able to “get the job done” when I would elect to postpone or re-plan a procedure for an animal. The revolution of awareness that Fear Free has helped to create in our profession has changed the way I am viewed by students and colleagues. No longer the “crazy Dr. Griffin,” I am the one they ask to teach them about low-stress handling and Fear Free techniques. The art and science of Fear Free have become valued: this is truly a gift for all of us, our patients, and their owners. I look forward to the day when Fear Free is taught in all veterinary colleges and is fully embraced as an indispensable standard of care in veterinary practice.
Brenda Griffin, DVM, DACVIM, Elite Fear Free Certified Professional, Adjunct Clinical Associate Professor of Shelter Medicine, Maddie’s Shelter Medicine Program, University of Florida College of Veterinary Medicine, Gainesville, Florida
Happy Puppy, Happy Vet Visit
I took a client’s puppy to our veterinary office for a happy visit after the previous appointment did not go well for them. We played on the floor, showed off some of their tricks, ate some really yummy food. I was able to ask for a nose target to get up on the scale all on his own! We were able to leave with a calm, happy puppy and his next vet visit went much better.
Jenn Hauta, Elite Fear Free Certified Professional, Fairy Dogmother Training & Pet Care, Nanaimo, British Columbia, Canada
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Kim Campbell Thornton is content manager for Fear Free Pets and is a Level 3 Fear Free Certified Professional. She has been writing about dogs, cats, wildlife, and marine life since 1985.
Heather E. LewisThe way people interpret color is tied strongly to human culture and language. For example, feeling blue means feeling sad, and seeing red means feeling angry, at least in Western, English-speaking cultures. But how do animals see and respond to color? The answers are few, as there is little research in this field of study. We can say that dogs and cats see a narrower range of colors than we do. This is because they have traded color vision, biologically speaking, for superior vision at night. Indeed, dogs and cats see much better at night than people do.
Cats have trichromatic vision, just like humans, but they do not see the red end of the human visible spectrum. Dogs have dichromatic vision, which means they do not see anything in the orange and red range in the human visible spectrum. Both species see slightly into the ultraviolet range. This is fascinating as it means that any material that has phosphorous in it, or a whitening or brightening agent derived from phosphorous, will fluoresce slightly under their vision. For example, a piece of paper is a glowing white object to a cat.
Fear Free color palettes have three objectives relating to the little we do know about animal preferences for color and stress reduction for people and animals alike.
To avoid anything bright white that may fluoresce. This is the reason behind abandoning a white doctor coat. People often react with stress to laboratory coats, and this is called “white coat syndrome.” If we are trying to create a low-stress medical experience for animals, it is likely best to dress veterinary doctors in colors that do not stand out. Thus, Fear Free practitioners prefer softer colors for coats and scrubs. Architects should also check the building materials we are using in hospital spaces and avoid materials that fluoresce. You can test for this by using a Woods Lamp (a black light used in the veterinary and human healthcare industries for detecting ringworm), in a space with the lights turned off. The lamp will identify materials that fluoresce.
To use colors that animals can see well, particularly in low-light conditions. If you were to paint a dog or cat medical ward dark red, and have dim lighting in that space, the space would appear dark grey and shadowy to the animals. A lighter space, painted in hues and tones that are brighter and more toward the blue end of the spectrum, will be more visually understandable to the animals. There is very little research on this idea, but one example is a study in mice, who see similarly to dogs and cats. The study indicated that mice “showed clear and consistent individual preferences for cages when offered a choice between white, black, green and red cages. Overall, most mice preferred white cages, then black or green, and red was the least preferred.”[i]
To use colors that are relaxing to people. Think of a spa, and the colors that are used in a spa, which are often toward the bluer end of the spectrum, or they are nature based. Spa color palettes tend to be relaxing to people and remind them to slow down and move carefully and gently. The research of color on human behavior is well understood; fast food restaurants use reds and oranges because they are NOT relaxing, and they motivate you to move along and finish your food quickly, so the booth may be occupied by the next customer. We want to encourage the opposite behavior.
Do not worry about hard and fast rules about color, as they don’t exist. Quite simply, use color as a reminder to yourself to be more considerate of how our animal friends see, and to support a gentler way of being around dogs and cats, and all the animals you care for.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Heather E. Lewis, AIA, NCARB, is a principal of Animal Arts, an architectural firm that has exclusively designed animal care facilities, including veterinary hospitals and animal shelters, for more than three decades. She has worked on dozens of projects across the country, both large and small in her 19 years with the firm. Heather is a member of the Fear Free℠ Advisory Board and assisted in creating the Fear Free facility standards for veterinary hospitals. Heather is a regular contributor to various veterinary industry magazines. She has spoken on the design of facilities for the care of animals at dozens of national and regional conferences including Fetch Hospital Design Conferences, the UC Davis Low Stress Animal Handling Conference, and the Humane Society of the United States Animal Care Expo.
We invite you to join us for the third installation of our Fun Webinar series to break up your stressful weeks with something to look forward to! These webinars are for our human clients and intended to give you a mental break, learn something new and fun, or cater to your own emotional and mental wellbeing.
Take an hour to laugh and learn! Join Mark Goldstein, DVM for a fun inside look at the unique challenges encountered around caring for and treating captive wildlife. He will draw upon true stories from his recently published book, “Lions and Tigers and Hamsters: What Animals Large and Small Taught Me About Life, Love, and Humanity,” to keep your interest. He will also share additional cases never published, which will entertain and have you laughing while you wonder how he is still alive to share them.
There will be ample opportunity for Q&A regarding anything in the presentation or related questions regarding working with and caring for captive wildlife or animals in general. During these very challenging times, allow yourself the luxury of sitting back with your beverage of choice, with no responsibility except to pamper yourself and reduce your FAS score!
Rachel Lees, RVT, KPA CTP, VTS (Behavior)Teaching cued behaviors, working through desensitization and classical counterconditioning, and clicker training are the glamorous gowns of training plans or behavioral treatment plans. They’re rewarding because this is where owners and veterinary behavior team members can begin to see improvements in the patient.
But preventing and managing undesirable or unwanted behaviors are the foundation garments beneath the fancy dress of behavior modification. Prevention, safety, and management aren’t glamorous, but they are an important part of the plan. If the patient continues to engage in unwanted behaviors, the behaviors will continue to be reinforced (negatively or positively). To avoid this dynamic, the veterinary behavior team must coach clients as much as possible to set the patient up for success and manage any panic, stress, or anxiety present.
Avoiding Triggers and Controlling the Environment
Learning occurs with every interaction. This can work to our advantage when we can strengthen behaviors we like by adding positive outcomes. The goal with prevention is to control the environment and regulate the patient so we can prevent the patient from learning undesirable behaviors during non-training times. An example might be use of crates and playpens to eliminate urine accidents in the home.
Prevention includes setting each animal up for success and manipulating the environment to promote and reinforce desired behaviors. This can be as general as setting a puppy up for success using crate training for assist with elimination training or working with a puppy or kitten during the socialization period to promote positive experiences for lifelong learning.
Prevention can also be as detailed as using white noise to create a sound buffer for a storm-phobic patient or placing an opaque window treatment on front windows to eliminate displays at passersby. Below is a chart with some common behavioral diagnoses and types of prevention that can be recommended for these conditions until appropriate training and behavior modification have been taught and implemented. Some prevention techniques might be temporary, and others might be long-term.
Behavioral Concern
Types of Prevention
Aggression during Grooming and Husbandry Behaviors (Familiar and Unfamiliar People)
Discontinue all forms of grooming and medical care. If medical or grooming care must be performed (in an emergency) the veterinary team should use sedation to prevent increasing fear, stress, and anxiety during these situations
Inter-Dog Aggression
Keep all patients 100% separated to eliminate practice of aggression in any or all potential situations.
Redirected Aggression to a Canine Housemate
Eliminate and manage all triggers that may create arousal, aggression, and frustration. This may include opaque window treatments to eliminate the display at passersby or may include full separation between patients if triggers are unclear.
Fear-Based Aggression to Unfamiliar People
Discontinue walks and keep the patient away during all guest visits. This may include using a crate in a place where the patient cannot see visitors. This will help keep the patient as safe and comfortable as possible while the guest is in the home.
Coprophagia
Pick up stool immediately after elimination to prevent the patient from ingesting the stool later.
Management: Outlets to Minimize FAS While Practicing Prevention
Providing healthy forms of behavioral management can be helpful in creating a calmer and more confident pet. Providing mental, physical, and environmental enrichment can improve any domesticated animal’s overall wellbeing. Providing enrichment can help pets find appropriate outlets for innate behaviors and physical activity. Enrichment can also help to alleviate tension or any fear, stress, or anxiety the pet may be feeling. Enrichment may be used to eliminate unwanted behaviors such as chewing and destruction by young puppies or to decrease or eliminate barking in the crate during guests’ visits. Below is a short list of different forms of enrichment that can be used together or separately as needed:
Puzzle Toys: Puzzle toys that dispense treats or kibble provide human-approved outlets of stimulation, can double as meal opportunities, and can manage and prevent unwanted behaviors such as barking and other attention-seeking behaviors. This type of enrichment can be more mentally stimulating than a 5-mile walk. Advise clients to give these to patients ideally in anticipation of unwanted behavior or after unwanted behaviors have been interrupted. This can set patients up for success, so they do not continue to perform the undesirable behavior.
Sound Enrichment: Whether clients are away from home or looking to create a sound buffer to help prevent unwanted behaviors, their pets can be enriched through sound in a variety of ways. “Through a Dog’s Ear” CDs or iCalm units provide patients with biorhythmic classical music. Studies have shown that classical music can help to reduce respiration and blood pressure. DOGTV is another form of enrichment that can give dogs visual stimulation while also providing different forms of classical and calming sounds. White noise machines can be another buffer to eliminate sounds happening outside the pet’s home environment.
Enrichment Walks: These walks are an outlet to burn off energy while also allowing the dog to sniff and learn about the environment. In the text “From Fearful to Fear Free,” this type of sniffing is described as a form of social media for your pet. Think “Nosebook” and “Pee Mail.” This same type of enrichment can be used for cats who have learned to walk comfortably in a harness and leash. For patients who have been diagnosed with fear-based aggression issues on walks, enrichment walks can be performed in a space with limited human and dog contact such as industrial parkways.
There are many different forms of prevention and management. This article discusses only a few of the options for some diagnosable behavioral issues. This is something that can be recommended by any veterinary team member if a client and patient are waiting to be seen by a veterinary behaviorist. Suggestions such as using baby gates at doorways to prevent dog fights or keeping a patient leashed to a person can be lifesaving recommendations. Stating some of these more obvious recommendations is essential because not every client or dog trainer understands the importance of management and prevention.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Rachel Lees, an Elite Fear Free Certified Professional, is a veterinary technician specialist in behavior, a KPA certified training partner, and lead veterinary behavior technician at The Behavior Clinic in Olmsted Falls, Ohio. She loves helping people create and maintain a strong human-animal bond.
Mary Ann Vande Linde, DVM, Vande Linde & Associates, Brunswick, GeorgiaOsteoarthritis is the most common joint disease diagnosed in humans and pets. What does this mean to a veterinary team? It means that a high percentage of pets and their owners have some familiarity with the discomfort and pain of joint disease. I’m sure we have all had clients tell us they have noticed a change in their pet’s activity, but they usually pass it off as normal for his/her age or suggest their pet is just “slowing down.” This belief does not mean that they don’t care; they just do not understand that what they are seeing may be due to pain. There are some simple communication tools your team can utilize to add value and increase a client’s understanding and acceptance that osteoarthritis (OA) is not normal, and their pet has options.
One of my mentors once told me “never tell a client what you can show them.” A client may see their pet hiding or not playing, and they will need assistance determining if their pet is painful or fearful. Using the Fear Free Strategies of Considerate Approach (CA) and Gentle Control (GC) allows the pet to be comfortable enough to exhibit OA signs in the client’s presence. With CA, a relaxing atmosphere can be created where the pet can have room to move and be observed. Adding pheromones to help keep them calm and non-slip surfaces both on and off the exam room table enables them to safely explore. In addition, with GC, veterinarians can examine the pet where he or she prefers and is most comfortable. Make sure to plan ahead by having materials easily accessible, and have assistance available in the room so the veterinarian can keep a gentle reassuring hand on the pet. Later during the physical exam, the doctor can communicate how their assessment relates to what the client sees their pet experiencing.
To be efficient and consistent communicators, teams need tools that open clients’ minds to possibilities. The Zoetis Canine and Feline OA Screening Checklists can be a discussion starting point. These checklists have “cartoons” of cats and dogs doing common activities around the home that have been identified through research as top behaviors that can indicate OA pain.1,2
This visual checklist allows the client to see their pet’s behavior changes through the animations. They can see how a healthy cat moves compared to a cat who has unhealthy changes from OA pain. With a checklist a client can tell the veterinarian what they see in comparison to the pictures, or they can review a video of what their pet is doing compared to the cartoon. By reviewing the checklist with a trained technician or veterinarian, the client can offer insight into how they view their pet’s mobility, behavior, and daily comfort. This checklist can be used prior to any exam with an email electric copy, or completed in the room by computer, phone, or as a printed hard copy. This could be a valuable addition to any biannual or annual checkup.
Age is not a disease. And we have tools, strategies and skills that make client discussion interactive, efficient and fun. Clients love to learn about their pets, they want a plan, and they want to feel confident they have made good decisions. Combining the tools of an interactive team checklist, Fear Free strategies of CA and GC and using open questions with active listening create productive discussions, save time, and produce healthier teams and pets. Go ahead talk about OA with these tools: it’s painless.
References
Enomoto, M. (2020). Development of a checklist for the detection of degenerative joint disease-associated pain in cats. Journal of Feline Medicine And Surgery
Wright, A. (2019). PVM1 Diagnosis and treatment rates of OA in dogs using a Health Risk Assessment (HRA) or Health Questionnaire for OA in general veterinary practice Value In Health, 22, S387
Adams, C., & Kurtz, S. (2017). Skills for communicating in veterinary medicine. Oxford: Otmoor Publishing.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Sponsored by our friends at Zoetis Petcare. NA-02335
Tony Johnson, DVM, DACVECC Let’s just get this right out of the way first: animals feel pain.
They have different pain tolerances, just like people do (if I step on my pit bull Gwen’s toe, she never notices, but if I accidentally do the same to my Pomeranian, Turley, she’ll scream, run and hide, and not speak to me for days) but sensing pain comes hand-in-hand with having a complex neurosystem and a big brain.
The challenge for us as veterinarians is how we detect and react to their pain.
To address the complexities of animal pain and its management, the International Veterinary Academy of Pain Management (IVAPM) has declared September to be Animal Pain Awareness Month. (https://ivapm.org/animal-pain-awareness-month/) It’s also Pain Awareness Month for another group of big-brained animals – people.
Treating animal pain will always involve some guesswork until someone develops a way for dogs and cats (and horses and iguanas, etc.) to point to their anatomy and say “It hurts right here, doc.” Until that beautiful day, we have to tease out the sometimes-subtle signals of discomfort and adopt a trial-and-error approach, backed up by science whenever possible.
As an ER clinician, acute pain is what I deal with most. I do see animals with chronic pain, and try to help whenever I can, but for those patients I encourage pet owners to seek the counsel of their family veterinarian, since chronic pain will take a solid partnership spanning weeks or months – things that are impossible in the rushed setting of the ER.
With that as preamble, I’ll share some tips from 25 years of ER pain management.
If a condition is known to be painful, treat for pain. Blocked cats are painful. Pancreatitis is painful. Pyelonephritis hurts. Some diseases have pain baked in, and treating pain should always be part of the initial management plan, yet I very often see pets with diseases such as pancreatitis and urethral obstruction go without pain medication. Until the disease has calmed down, assume pain is present and treat for it.
Recognize the signs of pain. Is that cat sitting at the back of the cage hissing because he is afraid, or is it pain? Is the usually sweet and slap-happy Golden now snapping at the kids because his ears hurt? Recognizing an animal in pain is an important first step in managing pain. A trial of pain medication (perhaps even combined with appropriate sedation) can help tease out the complex web of animal pain responses and decrease the fear, anxiety, and stress of painful conditions and hospitalization. Using a validated pain scale (available at https://ivapm.org/, and many other places) can also help to quantify and track pain during treatment.
Use the right class of medication for the disease. Let’s look again at blocked cats and patients with pancreatitis. A blocked cat who is non-azotemic and going home might benefit from an NSAID used cautiously. A blocked cat with a K+ of 8 and a creatinine of 4? The medical board will be knocking at your door if you give an NSAID.
Same holds true for a dog with raging pancreatitis. If he’s vomiting every time the wind blows, an NSAID will only make matters (way) worse. Opioids have minimal GI effects beyond constipation (which I have not seen as a major problem), and we use tons of opioids in the ER and ICU to manage pain. Our brains (and those of our patients) are hard-wired to receive opioids – it’s a gift from evolution and nature. Use it.
Why do brains have receptors for chemicals produced by a poppy largely grown in the Middle East? I have no idea, but for the sake of my patients I am thrilled that they do, and I make use of it every day I am on the clinic floor.
The opioid crisis has certainly made giving opioids a challenge, with increased regulation and paperwork and changes in the supply chain making some drugs unavailable. Try to keep abreast of what’s on and off the market and do your best to make sure you always have a few options for good pain control on hand. I think every hospital needs to have a full mu agonist such as fentanyl, morphine, or hydromorphone on hand for treating severe pain. Butorphanol is great as an adjunct for sedation for minor procedures like lacerations, but it’s just not potent enough for cases of moderate to severe pain.
Sometime more is more. Treating pain with multiple different approaches can result in better pain control and lower doses of any individual medication. Using a lidocaine sacrococcygeal block to help unblock a cat, combined with a full mu agonist like fentanyl, or an opioid agonist/antagonist like buprenorphine, can treat pain from different angles, as well as make unblocking easier.
Look for creative ways to address pain, using different techniques such as local blocks, epidurals, and topical lidocaine patches. Combining classes of drugs such as NSAIDs and opioids, in carefully selected patients, can achieve results that higher doses of either drug can’t achieve.
I have found that learning new techniques can be a great way to fend off burnout and makes me feel as if I am growing as a clinician. Learning new pain management skills aids me in fulfilling my obligation to alleviate animal suffering. Enrolling in CE classes, attending online seminars, and even brainstorming with colleagues can open new worlds to the clinician who wants to learn and grow. It can also make great financial sense to a practice, as owners now accept and even expect advanced pain-control modalities.
The IVAPM offers consultations in pain management and pathways to become IVAPM-certified as a pain management practitioner. (More info at https://ivapm.org/).
We all want our patients to live long, pain-free lives. Learning about pain and learning new ways to manage pain and recognize it will serve our patients better and help us grow as doctors and people.
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Dr. Tony Johnson, DVM, DACVECC, is a 1996 Washington State University grad and obtained board certification in emergency medicine and critical care in 2003. He is currently Minister of Happiness for VIN, the Veterinary Information Network, an online community of 75,000 worldwide veterinarians, and is a former clinical assistant professor at Purdue University School of Veterinary Medicine in Indiana. He has lectured for several international veterinary conferences (winning the small animal speaker of the year award for the Western Veterinary Conference in 2010) and is an active blogger and writer.
Opening the Door to Lifesaving: How Portals Can Save Shelter Cats
In this webinar, animal welfare strategist Dr. Sara Pizano will be exploring best practices in animal shelters and how implementing portals and the right disinfectant can decrease upper respiratory infections and ultimately increase live release rates.
Pain is not just physically unpleasant for animals. Beyond physiological symptoms such as GI dysfunction, immunosuppression and delayed wound healing, pain also affects animals emotionally and increases FAS. If not controlled, acute pain can lead to central sensitization, chronic pain states, increased morbidity and increased mortality.
If left untreated for too long, pain can become maladaptive and lead to a vicious cycle of reduced activity, weaker muscles, even less exercise, and even more pain. This course will show the importance of treating pain early and why doing so can lessen its overall impact on patients.
This course, approved for 1 RACE CE hour, was written by Ralph Harvey, DVM, MS, DACVA, UTCVM.
We invite you to join us for the second installation of our Fun Webinar series to break up your stressful weeks with something to look forward to! These webinars are for our human clients and intended to give you a mental break, learn something new and fun, or cater to your own emotional and mental wellbeing.
We’ve been told laughter is the best medicine, so we’ve asked comedian Dr. Kevin Fitzgerald to fill our prescriptions. Best known for his 11 seasons on the popular Animal Planet television series “Emergency Vets”, Dr. Kevin Fitzgerald practices small animal medicine at VCA Alameda East Veterinary Hospital in Denver, continues to do research, has authored over a hundred peer-reviewed scientific articles, and is on multiple boards for different Denver-area veterinary and zoo associations. In addition to his veterinary career, Dr. Fitzgerald has been performing stand-up comedy since 1986, opening for and working with performers such as Joan Rivers, Bob Hope, Kevin Nealon, Brian Regan, and Norm McDonald.
Alison Gerken, DVM, Lisa Radosta DVM, DACVB, Tamara Grubb, DVM, PhD, DACVAAHetch-Hetchy is the sweetest, most affectionate cat I have ever known. For the past 12 years, he has seen me through veterinary school, my father’s passing, my marriage, and most recently, a cross-country move to start a veterinary behavior residency. This guy has been the most devoted, loving companion, but he is not the bravest of souls. When Hetch goes in for a veterinary visit, he often leaves with a urethral obstruction (UO). While not fractious at the veterinary hospital, he becomes very stressed and has an impressive ability to wiggle out of any restraint.
The stress of veterinary visits frequently resulted in urethral obstructions for Hetch.
Hetch has had myriad health issues over the last year, necessitating four hospitalizations and at least 10 veterinary visits. Fortunately, pre-medication at home with buprenorphine and trazodone in addition to a quick injection of alfaxalone at the hospital has allowed for almost effortless hospitalizations and has prevented further UOs. Hetch had never needed to be boxed down.
When Hetch recently needed an anesthetic procedure, I researched veterinary specialists in my new area and dropped him off at a trusted specialty hospital. I reminded the staff that Hetch blocks when stressed and attached a note to his carrier requesting that I be called if he became stressed. I thought I was doing everything right to prevent another UO. However, when I picked Hetch up from the hospital after his procedure, I found my normally mellow cat panicking inside his carrier. When I inquired as to why Hetch was so distressed, I was astonished to learn that he had been “boxed down” that day. In other words, rather than being given a fast-acting injectable medication to induce anesthesia, he was stuffed into a box that was then filled with anesthetic gas – a prolonged and stressful way to be anesthetized.
When we returned home, Hetch began vocalizing and walking in and out of his litterbox. I panicked when I realized we might be facing another UO. Fortunately, Hetch wasn’t blocked, but for days after that veterinary visit, my normally social, loving kitty hid beneath the bed and barely ate. He was traumatized, and the only difference in that visit from all of his others was that he was boxed down. Not only was I incredibly saddened to think of my own cat being subjected to the inhalant chamber, I was also deeply troubled to learn that inhalant chamber use is not uncommon in veterinary medicine.
Why “Boxing Down” Animals Isn’t a Good Choice
Most of us who have been practicing for longer than a decade have used inhalant chambers to “box down” feline patients. It seemed to work, and the patient was able to be treated. Why throw away a potentially useful sedation protocol? Because the use of inhalant chambers or masks (also called “boxing” or “masking”) for sedation or induction to anesthesia is not considered standard of care for a number of reasons. (We should note, however, that mask sedation is commonly used for birds.)
Use of inhalant induction can be dangerous to pets.
In a study on anesthetic risk for death, Brodbelt (2009) showed that inducing and maintaining patients on inhalants alone added to the risk of anesthetic fatalities. The risk is secondary to the high dose (high percentage setting on the vaporizer) of inhalants required to achieve induction.
Inhalant anesthetics are appropriate for maintenance of anesthesia but not for induction.
The high dose can cause dangerous physiologic changes, such as hypotension and respiratory depression. In addition, mask or inhalant induction requires a prolonged period with an unprotected airway (i.e., no endotracheal tube) with an increased risk of airway compromise or obstruction. Because of this, inhalant induction can be dangerous in any animal and is contraindicated in brachycephalic animals.
The excitatory phase of anesthesia (Stage II; Table 1) is exaggerated and prolonged with this type of induction, further increasing the dose necessary to achieve induction. The excitement causes a release of catecholamines, which may cause tachycardia, hypertension, and hyperventilation and may increase the risk of arrhythmias and/or cardiopulmonary arrest.
Once the patient is induced, a higher concentration of inhalant is required for the maintenance phase of anesthesia when compared to the dose of inhalants required to maintain anesthesia in patients who also had premedications or injectable induction drugs.
Use of inhalant induction can be dangerous to humans.
The veterinary healthcare team and any pet parents who are present may be potentially exposed unnecessarily to anesthetic inhalants. No matter how tightly the induction chamber is sealed or the mask is fit, it is never totally leak-proof. There will be contamination of the environment with the inhalant gas. Although not consistently linked, health concerns due to exposure to anesthetic gases have been shown to range from reproductive effects such as spontaneous abortion (Shirangi et al. 2008) to genetic damage (Cakmak et al. 2019). OSHA states: “The waste anesthetic gases* and vapors of concern are nitrous oxide and halogenated agents (vapors) such as halothane, enflurane, isoflurane, and desflurane. Some potential effects of exposure to waste anesthetic gases are nausea, dizziness, headaches, fatigue, and irritability, as well as sterility, miscarriages, birth defects, cancer, and liver and kidney disease.” (https://www.osha.gov/SLTC/wasteanestheticgases/index.html)
*Waste anesthetic gas is inhalant anesthetic gas not metabolized by the patient and is exhaled back into the breathing system. It should be evacuated from the anesthetic machine by the scavenging system. Unfortunately, the gas often leaks from the machine or breathing system, causing environmental contamination and human exposure.
The view on dangerous results related to use of chamber inductions in animals is shared by both veterinary and human-health experts:
“Chamber inductions should never be routine but rather a ‘last resort’ and only when other approaches have failed.” (Robertson et al. 2018)
“Mask or chamber inductions can cause stress, delayed airway control, and environmental contamination and are not recommended by the authors.” (Grubb et al. 2020)
“Chamber induction in unpremedicated, agitated cats is the least desirable technique described in these Guidelines, since an agitated cat will require more inhalant anesthetic to achieve the desired endpoint. This increased inhalant anesthetic requirement results in severe depression of the cardiovascular system. Additionally, an increased release of catecholamines predisposes the cat to development of cardiac arrhythmias.” (Robertson et al. 2018)
“The use of an induction chamber with gas anesthetic as a method of restraint may mean less control of the patient’s airway and raises concerns about other safety issues for the cat and the staff.” (Robertson et al. 2018)
“A disadvantage of this technique is the unavoidable release of anesthetic gases and exposure of personnel when the cat is removed from the chamber.” (Rodan et al. 2011)
Stress has many definitions, but according to the National Research Council Committee on Recognition and Alleviation of Distress in Laboratory Animals, it is defined as a real or perceived perturbation that threatens homeostasis.
Inhalant chambers are not considered standard of care. Their use should be avoided for a number of reasons.
The stress response is a normal part of daily life but becomes harmful when triggered too intensely or for too long (Hekman, 2014). Different stressors cause varying levels of activation of these responses, but it has been shown that uncontrollable stressors from which an animal cannot escape and which cannot be mitigated activate the stress response more strongly across species (Dess, 1983).
Activation of the sympatho-adreno-medullary (SAM) axis in response to an acute stressor initiates an immediate response, often known as the “fight or flight” response. SAM axis activation leads to mydriasis, increased heart rate, increased blood pressure, cutaneous vasoconstriction, increased plasma glucose, and increased free fatty acid concentrations (Hekman, 2014).
A slower response to a stressor is mediated by activation of the hypothalamic-pituitary-adrenal (HPA) axis, with effects seen in minutes to hours to days. This response mediates release of glucocorticoids from the adrenal cortex. Glucocorticoids affect a wide range of physiologic functions including, but not limited to, metabolic processes such as protein, glucose, and fatty acid metabolism; immune function; gastrointestinal motility; growth; thyroid function; and reproduction (Hekman, 2014).
The overall effect of these responses is to mobilize energy stores, increase oxygen intake, decrease blood flow to non-critical areas, and inhibit digestion, growth, immune function, reproduction, and pain perception (Tynes, 2014).
Several studies have demonstrated that inhalant chambers are significant stressors. Reiter et al 2017 found that inhalant anesthesia increased concentrations of various hormones, including cortisol, corticosterone, and other glucocorticoids in mice, indicating activation of the HPA axis. The mice in this study appeared agitated and dug in the corners of the induction chamber. Similarly, a study by Flecknell et al 1996 found that induction of anesthesia in an inhalant chamber and an inhalant face mask caused all animals to avoid inhaling anesthetic vapor and to breath-hold, behaviors indicating that the induction was aversive. Another study by Flecknell et al 1999 evaluating the effects of induction of anesthesia with sevoflurane and isoflurane in an inhalant chamber found that most animals struggled violently during induction and breath-held, leading the study authors to conclude that both sevoflurane and isoflurane were aversive and should be avoided.
Furthermore, inhalant chambers cause increased struggling, breath-holding, and excitement because induction times with inhalant anesthetics are generally slower than intravenous agents such as propofol (Lester et al 2012).
Stress increases morbidity and mortality.
The consequences of physiologic and psychogenic stress on health and welfare outcomes have been documented across a range of domestic species.
Stress can increase susceptibility to infection and sepsis, reduce the rate at which wounds
heal, and increase the risk of gastric ulceration development (Hekman, 2014).
Westropp 2006 showed that cats with feline idiopathic cystitis (FIC) had altered bladder permeability, most notably during the initial period of stress.
Some cats may develop marked hyperglycemia secondary to an acute stressor, including struggling, with some cats having glucose concentrations in the diabetic range (> 200 mg/dL) over 90 minutes after exposure to the acute stressor (Rand et al 2002). This may lead some cats to be treated with insulin despite not being diabetic. Furthermore, struggling in an induction chamber may lead to injury of the patient.
Inhalant chambers perpetuate fear.
The animals considered candidates for use of the inhalant chamber or mask are often displaying aggression or fear and restraint is considered difficult or impossible.
Most animals visiting the veterinary hospital display signs of fear. A study by Doring et al 2009
Fear and stress during veterinary care can contribute to illness and injury.
found that 78.5% of clinically healthy dogs visiting a veterinary hospital in Germany showed signs of fear on the examination table. Quimby et al 2011 found that most cats hid more and had elevated physiologic parameters associated with stress (heart rate, respiratory rate, and blood pressure) when in a veterinary clinic compared to their home. In a survey of over 1,100 cat caretakers in Italy, most cats showed signs of fear during all stages of a veterinary visit, including 73% in the reception, 85% on the examination table, 55% during examination, and 58% after returning home. Restraint, pain, and anxiety led to aggression toward veterinarians and caretakers in these cats (Mariti, 2016).
Use of an inhalant chamber or mask will undoubtedly perpetuate underlying fear in patients already displaying fear. Koolhaas 1997 found that a single experience with a major stressor may have long-term consequences ranging from hours to days to weeks. Mariti 2016 showed that 34% of the cats’ stress following a veterinary visit subsequently worsened with handling in other situations. Landsberg 2013 supports that a single exposure to a stressor can be enough to cause a fearful response in the future. Therefore, the trauma of the inhalant chamber or mask is likely to increase the pet’s fear and anxiety at future veterinary visits. This will compromise the veterinarian’s future ability to provide the highest quality of care to these pets.
Increased fear, anxiety, and stress compromise patient care and veterinary staff safety.
Patients subjected to an inhalant chamber may display more fear and aggression. This can make administration of treatments and medications in hospital or at home following the procedure more difficult or unsafe for veterinary staff or clients.
Dog and cat bites as well as cat scratches are the most common cause of injury to veterinary hospital staff (Jeyaretnam, 2000), so increased pet fear and anxiety compromise the safety of staff.
Stressful veterinary visits have economic implications to the practice.
According to the Bayer veterinary care usage study, their pets’ stress is a leading reason pet parents fail to bring their animals to the veterinary hospital (Volk, 2011). Out of more than 1,000 cat caretakers, 58% reported that their cat hates going to the veterinarian and 38% of the cat caretakers reported that they themselves were stressed just thinking about taking their cat to the veterinarian (Volk, 2011). In a survey of 200 cat owners conducted by the International Society of Feline Medicine and Your Cat magazine, 20% of respondents said their most recent visit to a veterinarian had been sufficiently stressful that they would either avoid going back or would change veterinarians (Rodan 2005).
Cats are already underserved veterinary patients. In the Bayer usage study, 40% of cats had not been to a veterinarian in the last year compared to 15% of dogs (Volk, 2011). More than three-quarters of veterinarians in that study reported that care for cats is one of the most significantly missed opportunities in veterinary practice (Volk, 2011).
Stressful veterinary visits are likely to result in a further decline in cat visits, creating a greater obstacle to reaching the feline market.
Overall, the implications of using an inhalant chamber are far-reaching. For all of the above reasons, taking steps to decrease physiological and emotional stress is an essential medical goal, one that is significantly undermined by use of an inhalant chamber or mask.
Why Chemical Restraint Shouldn’t Be a Last Resort
Chemical restraint is often necessary for animals displaying fear and aggression and should not be considered a last resort (Grubb et al. 2020 Lloyd, 2017). According to the American Association of Feline Practitioners/International Society of Feline Medicine Guidelines on Feline Friendly Handling, indications for chemical restraint include the following:
–when an animal shows fear, anxiety, stress, or aggression;
–situations in which pain, discomfort or surgery is anticipated and where analgesia alone will be insufficient;
–when gentle restraint does not provide sufficient safety for the team.
Fortunately, many alternatives to inhalant induction exist to achieve chemical restraint, starting with premedication at home.
Evaluating Patient Fear, Anxiety, and Stress and Determining the Need for Pre-Visit Pharmaceuticals
Premedication at home may reduce the need for the inhalant chamber or mask and may reduce the need for injectable sedation or general anesthesia. It can make handling the patient more pleasant for all. Use of the FAS scale will aid in determining which pets may benefit from pre-visit pharmaceuticals (PVPs).
The FAS scale was created to rate a patient’s level of fear, anxiety, and stress in the veterinary clinic. It is a useful tool to determine if a PVP and/or injectable sedation is indicated.
A pet with FAS scores of 2 or 3 displays some lack of interest in treats, toys, and/or attention. This pet may fidget and have difficulty settling. This is consistent with moderate fear, anxiety, and stress, and a pre-visit pharmaceutical is recommended.
A pet with FAS scores of 4 or 5 displays little to no interest in treats; exhibits a fight, flight, or freeze response, and may display aggression. This is consistent with a high degree of fear, anxiety, and stress, and pre-visit pharmaceuticals combined with injectable sedation if needed is recommended. (Martin K and Martin D, 2007).
When scheduling veterinary appointments or procedures, ask clients about the pet’s behavior in the veterinary hospital. If the pet has a history of being fearful in the hospital, have the pet parent administer oral anxiolytics and/or sedatives such as gabapentin, trazodone, buprenorphine, transmucosal dexmedetomidine, and benzodiazepines prior to arrival.
Using PVPs
All pre-visit pharmaceuticals have variable effects in individual animals and should be tested prior to the veterinary visit to evaluate time to onset, effect, duration of effect, and possible adverse effects. This information will enable the veterinarian to evaluate the pre-visit pharmaceutical plan and make adjustments if warranted to ensure an optimal outcome.
Potential pre-visit pharmaceuticals include gabapentin, trazodone, benzodiazepines, some opioids, and some formulations of alpha-2 agonists. Oral acepromazine and melatonin can also be considered (Costa et al. 2019), keeping in mind, however, that acepromazine should never be used alone, as it is a tranquilizer but not a good anxiolytic. Before prescribing a medication as a pre-visit pharmaceutical, the attending veterinarian should consider the age of the pet, any interactions with other medications or supplements currently being administered, the pet’s overall health status, interactions with the chosen anesthetic protocol, and any other contraindications to administration.
Gabapentin
While not labeled for use for anxiety, gabapentin is increasingly used to reduce anxiety in humans and in veterinary patients. In a study by van Haaften et al 2017, 100 mg of gabapentin per cat prior to a veterinary visit resulted in significantly lower stress during transportation and examination as reported by pet parents, and increased compliance during examination as reported by veterinarians. Gabapentin also reduces neuropathic pain, which may benefit patients in which underlying pain may be contributing to fear and aggression.
Sedation is a possible side effect and may vary depending on cat size, so administer 50 mg to petite or geriatric cats. Large cats may require 200 mg for optimal effect. Other side effects of gabapentin include ataxia, hypersalivation, vomiting, and increased appetite.
Gabapentin should be administered three hours prior to the veterinary visit. The capsule may be opened and the powder sprinkled onto 1 tablespoon or less of wet food, tuna juice, Churu, or other tasty food. The effects of gabapentin may last for 8 to12 hours. When using gabapentin, administering an additional dose the night before the veterinary visit may be helpful.
Trazodone
This serotonin antagonist reuptake inhibitor is an anxiolytic and sedative. The dose of trazodone for cats is 50 to 100 mg per cat (not mg/kg). It should be administered three hours prior to a veterinary visit.
Side effects of trazodone may include drowsiness, variable mild gastrointestinal effects such as vomiting, diarrhea, decreased or increased appetite, and paradoxical excitation. When administering a test dose at home prior to the veterinary appointment, have the pet parent assess the pet’s level of sedation three hours after administration by calling the pet in a happy voice, shaking a treat jar, and/or getting out the pet’s favorite toy. If the pet readily rises and runs over to the pet parent, then the dose should be increased by 25% and another test performed at home. Duration of effect is 4 to 12 hours.
Benzodiazepines
These potent anxiolytics have a rapid onset of action with effects that last a few to several hours. They are reasonable options for patients with severe fear and anxiety, but their use is not recommended in patients with aggression.
Benzodiazepines may cause a paradoxical excitement reaction, so it is necessary that they be tested at home prior to a veterinary visit. Other side effects include ataxia, sedation, muscle relaxation, and increased appetite.
Commonly used benzodiazepines in cats include lorazepam and alprazolam.
Lorazepam has no active metabolites, so it is safer for geriatric patients and patients with hepatic disease. The dose of lorazepam for cats is 0.25 to 0.5 mg per cat (not mg/kg). It should be administered two to three hours prior to a veterinary visit.
Alprazolam has a different pathway for metabolism than diazepam, so it may have reduced risk of liver toxicity in cats. The dose of alprazolam for cats is 0.125 to 0.25 mg per cat (not mg/kg). It also should be administered two hours prior to a veterinary visit.
Injectable diazepam is used frequently in cats for anesthesia. There are a few reports of oral diazepam causing fatal hepatic failure when used at high dosages. Use it with caution in cats with hepatic disease and do not exceed clinical doses.
Buprenorphine
Buprenorphine is a partial mu agonist with analgesic and mild sedative effects. It is commonly administered with other sedatives and anesthetics, making it a reasonable option for balanced sedation or anesthesia in cats and dogs. Side effects may include sedation (which is the goal in this situation), hyperthermia, hypothermia, vomiting, and constipation.
Buprenorphine can be administered transmucosally in cats at a dose of 0.01 to 0.02 mg/kg, although a higher dose may be necessary since oral transmucosal uptake is low and variable (Steagall et al. 2014). Buprenorphine should be administered two to three hours prior to a veterinary visit. Duration of action is four to eight hours. Simbadol provides analgesia for 24 hours but efficacy of this duration has not been proven for OTM administration. (Steagall et al. 2014).
Sileo
Sileo, which is transmucosal dexmedetomidine, is FDA-licensed to treat dogs with noise aversions but is used off-label in a number of situations to reduce anxiety in dogs and cats. Sileo is fast-acting and minimally sedating. At a dose of 0.02 mg/kg, it can be combined with buprenorphine for use in cats with more significant fear and stress. In dogs, the dose is 0.01 to 0.04 mg/kg, and combination with buprenorphine is also an option. Sileo should be administered 60 minutes prior to a veterinary visit.
Not only will an effective pre-visit pharmaceutical plan decrease the animal’s fear, anxiety, and stress, it will also allow for easier and safer administration of intramuscular injections of premedications and anesthetics for all involved.
Transportation and Handling on Arrival
Request that the pet parent transport the patient in a soft, squeezable carrier or a carrier with a top that can be easily removed to facilitate low-stress handling. When the pet arrives at the hospital, immediately place the pet, still in the carrier, in a quiet room. Cover cat carriers with towels sprayed with Feliway.
Proper patient handling skills are paramount to minimizing stress and increasing safety during sedation or anesthesia (Yin 2009, Rodan et al 2011). Low-stress handling techniques are intended to minimize fear and pain experienced by pets during veterinary examination and increase safety of the veterinary team (Rodan 2010, Yin 2009). When handled appropriately with gentle restraint and Fear Free techniques, full anesthesia may not be necessary.
Removal From Carrier
Covering or wrapping a cat with a towel can help to decrease stress and increase a feeling of security.
Use gentle restraint when performing a physical exam and administering intramuscular injections. Do not grab and pull the pet out of the carrier and do not tilt to shake the pet out. For markedly fearful and/or aggressive pets who have arrived in a soft carrier, gently squeeze the sides of the carrier to administer an intramuscular injection through the carrier. For pets who have arrived in a carrier with a removable top, gradually remove the top half of the carrier while simultaneously placing a towel between the two halves of the carrier. Cover the pet with the towel, starting at the rear, and gradually move the towel up the pet’s body while removing the carrier top. This will allow for restraint under the towel for an exam and intramuscular injection.
Additional Sedation
If the pet needs a deeper plane of sedation, balanced sedation can be achieved with intramuscular injections of an opioid, dexmedetomidine or medetomidine, midazolam, alfaxalone, Telazol, and/or ketamine. If IV access is possible, propofol can be added to this list of drugs. When using injectable sedation, be aware that fear, anxiety, and stress may produce a more variable and less efficacious sedative response. The protocol may need to be adjusted. For all drugs, if the patient is deeply sedated or anesthetized, provide supplemental oxygen and initiate monitoring of physiologic parameters and support of normothermia.
For the opioids, mu agonists such as methadone, morphine, and hydromorphone provide the most profound analgesia and should be considered for patients undergoing surgical or other painful procedures. Buprenorphine is a partial agonist and may provide more analgesia than butorphanol but may also be less sedating. As previously stated, buprenorphine is absorbed after OTM administration, as is methadone.
Butorphanol provides mild, short-duration (60 minutes in the dog, 90 minutes in the cat) analgesia so is not optimal for painful procedures. However, butorphanol is a fairly effective sedative in both dogs and cats, especially in sick or aged patients. It is often combined with an alpha-2 agonist to increase the depth and predictability of sedation in healthy dogs and cats, as well as to enhance the alpha-2 mediated analgesia. Nausea and vomiting are the main adverse effects. Pre-treatment with an anti-emetic, such as maropitant, is recommended. Oral maropitant can be administered at home by the pet parent, thereby decreasing the likelihood of vomiting from the car ride to the hospital. Oral maropitant is approved for the dog at 2 mg/kg and used off-label in cats at 1 mg/kg (Quimby 2020). Other adverse effects include those listed above for buprenorphine. Naloxone can be used to reverse the effects of all opioids, although buprenorphine binds tightly to opioid receptors, making full reversal difficult.
Alpha-2 agonists, such as dexmedetomidine and medetomidine, provide fairly rapid analgesia and sedation and their effects can be reversed. There is a ceiling on the degree of analgesia, so further dosing acts to increase the degree of sedation, duration of sedation, and potential adverse effects. Alpha-2 agonists produce an initial hypertension and reflex bradycardia. Avoid using them in patients with most cardiovascular diseases. Alpha-2 agonists may also cause nausea and vomiting. Oral maropitant can be administered by the pet parent at home prior to the visit. Otherwise, administer maropitant SQ prior to the alpha-2 agonist if possible or administer maropitant SQ or IV once the cat is sedate.
Dexmedetomidine will markedly reduce the amount of induction and maintenance drugs required for anesthesia; use half or less of the standard induction drug dose. Wait at least 15 to 20 minutes after administering dexmedetomidine before induction to allow maximum effect to occur. Because level of sedation can be tailored to the patient by adjusting the dose and because the effects of alpha-2 agonists are reversible, this class of drugs is commonly used for sedation of pets admitted for outpatient procedures. The alpha-2 drug effects do not always require reversal, but reversal allows rapid return of a fully conscious pet to the pet parent.
Patients should be calm during both induction and recovery. Excitement should be avoided.
Alfaxalone is an anesthetic drug that can be used at low dosages for sedation or high dosages for anesthesia. It has a short time to onset and rapid duration of action with minimal adverse effects, which include dose-dependent minimal to mild cardiovascular and respiratory depression. It can be safely combined with other premedications such as opioids, dexmedetomidine, medetomidine, midazolam, and acepromazine. Alfaxalone can be administered intramuscularly (IM) and is a good option for cats but its volume makes it impractical for IM injections in larger pets. When used as a sole agent, recovery can be rough so balanced premedication protocols will help to diminish or eliminate this effect.
Ketamine is a dissociative anesthetic that is effective when administered intramuscularly and can be used at lower dosages for sedation and higher dosages for anesthesia. It provides analgesia when used at low doses and administered as an infusion. It is often combined with a benzodiazepine (midazolam or diazepam) for induction. Cardiovascular and respiratory depression are uncommon but could occur if the drug is administered to a severely compromised patient at an anesthetic dose.
Anesthetic dosages may need to be avoided in pets with a history of seizures or suspected intracranial disease, although recent data indicate that the drug may be used with caution in these pets. Anesthetic dosages should be avoided in cats with hypertrophic cardiomyopathy or pets with other cardiac diseases in which tachycardia could be detrimental. Use anesthetic dosages with caution in pets with renal disease. Ketamine is excreted unchanged by the kidneys in cats, and drug accumulation, with subsequent prolonged recoveries, could occur. However, low sedative dosages and the even lower infusion dosages used for analgesia are generally appropriate in all of these patients.
Telazol (tiletamine/zolazepam) is a combination of a dissociative agent (tiletamine) and a benzodiazepine (zolazepam) that can be administered IM and can be used at lower dosages for sedation and at higher dosages for anesthesia. Telazol is an excellent option for FAS-level 5 cats and dogs because the small volume needed to produce sedation or anesthesia can easily and quickly be administered IM. It has a quick onset and longer duration of action than ketamine, and it is not reversible. According to the product label, Telazol is contraindicated in pets with pancreatic disease or severe respiratory and/or cardiovascular disease; however, clinically these are precautions but not contraindications. Follow the same precautions as those listed for ketamine.
Conclusion
Taking steps to increase his comfort and reduce fear, anxiety, and stress have improved Hetch’s veterinary visits.
Overall, the use of inhalant chambers and masks is dangerous and stressful for both pets and anesthesia personnel. Stress causes deleterious effects on health outcomes and compromises mental wellbeing. Given the many alternatives that exist, use of an induction chamber or mask is a poor choice for sedation or induction and should be avoided for all patients. We as a veterinary community must prioritize practices that are both safe and stress-reducing for our patients and colleagues.
Hetch-Hetchy’s comfort for veterinary visits and procedures has increased substantially thanks to an effective protocol of pre-visit pharmaceuticals (0.02 mg/kg buprenorphine OTM and 50 mg trazodone PO 3 hours prior to getting into the car), an intramuscular injection of a sedative (alfaxalone) as needed, and low-stress handling. Having seen how swiftly he responds to this approach has highlighted the recent use of an inhalant chamber to sedate him as an archaic, inhumane practice that needs to be eliminated from our practices.
Table: Stages and Planes of Anesthesia
Stage
Description
Details
1
Disorientation, sedation
Occurs following premedications
2
Delirium, excitation, uncontrolled movement
Occurs during induction and recovery. Anesthetic plans should be designed so the patient spends minimal time in this phase. Induction should be rapid (use injectable drugs) and recovery should include sedatives if excitement/dysphoria occurs.
3
Unconsciousness, surgical plane of anesthesia
Plane 1: Light anesthesia, depth inadequate for moderately-severely painful procedures unless local anesthetic blocks are part of the protocol.Plane 2: Moderate anesthesia, adequate for painful procedures with administration of appropriate analgesia.
Plane 3: Deep anesthesia, required if analgesia is not part of the protocol. More physiologic depression occurs in this plane than in previous planes.
Plane 4: Excessively deep anesthesia, dangerous physiologic depression. Turn the vaporizer off and start ventilating for the patient to speed inhalant elimination.
4
Too deep!
This stage is between respiratory arrest and circulatory collapse. Take the patient off the anesthetic and prepare for CPR.
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This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
Photos of Hetch Hetchy courtesy Alison Gerken, DVM; inhalant photo courtesy Tamara Grubb, DVM, PhD, DACVAA; cat inhalant chamber from Advances in Anesthesia; fearful cat from Napa Valley Holistic Veterinary Services; cat wrapped in towel courtesy Tamara Grubb, DVM, PhD, DACVAA.
A new feline patient with a high level of fear, anxiety, and stress went home with gabapentin as a pre-visit pharmaceutical. The exam we performed two days later was great. He was readily eating tuna and happy to be petted. He did well for a complete exam, including radiographs and blood draw. The Feliway-infused towel was also a great help.
draws and vet visits. He was a wonderful-tempered cat at home, but at the clinic, while he never bit or scratched, he hissed and struggled every time he came out of the cage and became a difficult patient to handle. He is very food-motivated and after we started Fear Free practices and he got squirt cheese and baby food every time he was handled, he now purrs and rubs on everyone when he comes for treatments and is so much happier and easier to handle. I am overall so much more aware of a patient’s anxiety level the moment they walk in the door now, and it gives us a chance to start finding ways to alleviate their stress before it escalates.
in patients, while others felt I was “too soft,” “only cared about giving the animals treats,” or “was crazy or misguided in my efforts.” Fellow faculty members sometimes shared these sentiments and even accused me of not being able to “get the job done” when I would elect to postpone or re-plan a procedure for an animal. The revolution of awareness that Fear Free has helped to create in our profession has changed the way I am viewed by students and colleagues. No longer the “crazy Dr. Griffin,” I am the one they ask to teach them about low-stress handling and Fear Free techniques. The art and science of Fear Free have become valued: this is truly a gift for all of us, our patients, and their owners. I look forward to the day when Fear Free is taught in all veterinary colleges and is fully embraced as an indispensable standard of care in veterinary practice.
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