This article was downloaded by: [New York University]

On: 14 May 2015, At: 03:17

Publisher: Taylor & Francis
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41
Mortimer Street, London W1T 3JH, UK

New Zealand Veterinary Journal

Publication details, including instructions for authors and subscription information:
http://www.tandfonline.com/loi/tnzv20

A comparison of two different ketamine and diazepam

combinations with an alphaxalone and medetomidine
combination for induction of anaesthesia in sheep
a a a a a
VP Walsh , M Gieseg , PM Singh , SL Mitchinson & JP Chambers
a
Institute of Veterinary, Animal and Biomedical Sciences , Massey University , Private Bag 11222,
Palmerston North , New Zealand
Accepted author version posted online: 05 Dec 2011.Published online: 21 Feb 2012.

To cite this article: VP Walsh , M Gieseg , PM Singh , SL Mitchinson & JP Chambers (2012) A comparison of two different ketamine
and diazepam combinations with an alphaxalone and medetomidine combination for induction of anaesthesia in sheep, New Zealand
Veterinary Journal, 60:2, 136-141, DOI: 10.1080/00480169.2011.645769

To link to this article: http://dx.doi.org/10.1080/00480169.2011.645769

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the
publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or
warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions
and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed
by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with
primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings,
demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly
in connection with, in relation to or arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any substantial or systematic
reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is
expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/terms-
and-conditions
 136 New Zealand Veterinary Journal 60(2), 136–141, 2012
Scientific Article
A comparison of two different ketamine and diazepam combinations with
an alphaxalone and medetomidine combination for induction of
anaesthesia in sheep
VP Walsh*, M Gieseg*, PM Singh*, SL Mitchinson* and JP Chambers*x
Abstract
AIMS: To investigate the perceived adverse effects of a
particular batch of ketamine during induction of anaesthesia
in sheep and to assess if any adverse effects would make
intubation more difficult for the veterinary students.
Downloaded by [New York University] at 03:17 14 May 2015
METHODS: Thirty adult sheep (mean bodyweight 74.5 (SD
9.4) kg) were randomly assigned to one of six groups of five
sheep. Sheep in Groups A and B received I/V 0.5 mg/kg
diazepam and 10 mg/kg ketamine (Ketamine Injection; Parnell
Laboratories NZ Ltd, of the suspect batch); those in Groups C
and D received I/V 0.5 mg/kg diazepam and 10 mg/kg
ketamine (Ketalar; Hospira NZ Ltd.), and those in Groups E
and F received I/V 2 mg/kg medetomidine and 2 mg/kg
alphaxalone. In Groups A, C and E, intubation was by an
experienced anaesthetist, and in Groups B, D and F intubation
was by a veterinary student. Time from injection to successful
intubation, the ease of intubation, saturation of haemoglobin
with oxygen (SpO2) and partial pressure of oxygen in arterial
blood (PaO2) were measured before the sheep were connected
to an anaesthetic machine and allowed to breath oxygen. Times
to extubation, holding its head up and standing, maximum and
minimum heart rates, respiratory rates, maximal end tidal CO2,
and the quality of recovery were then recorded.
RESULTS: There were no measurable differences in outcomes
between sheep in Groups A and B compared with C and D.
Time to intubation was slightly shorter for the experienced
anaesthetist than the student, but the difference was not
significant. The sheep in Groups E and F took less time to
recover than those in Groups AD (p50.05), but there were no
significant differences between the groups in either the ease of
induction or quality of recovery. Most sheep in Groups E and F
showed minor excitatory effects, mainly at induction, which did
not interfere with induction. Respiratory rates were lower in
Groups E and F than Groups AD (p50.01), but SpO2 was
higher in Groups E and F than A and B (p50.05).
CONCLUSIONS: The clinical impression that the batch of
Parnell ketamine produced unexpected effects was shown to be
incorrect. All the combinations produced anaesthesia that
allowed intubation by the veterinary student.
CLINICAL RELEVANCE: All the drug combinations
produced satisfactory anaesthesia in sheep, but the alpha-
* Institute of Veterinary, Animal and Biomedical Sciences, Massey University,
Private Bag 11222, Palmerston North, New Zealand.
x
Author for correspondence. Email: j.p.chambers@massey.ac.nz
xalone and medetomidine combination resulted in faster
recovery.
KEY WORDS: Anaesthesia, ketamine, diazepam, alphaxalone,
medetomidine, sheep
Introduction
Although sheep are rarely anaesthetised in general practice, they
are commonly anaesthetised by veterinary students to gain expe-
rience in all aspects of general anaesthesia as part of their training
programme. The requirements for an anaesthetic induction drug
in these circumstances are that it reliably induces anaesthesia with
good muscle relaxation for long enough to allow a student with little
or no experience to intubate the trachea. At Massey University,
combinations of diazepam and ketamine mixed in the same syringe
are traditionally used. This combination is well established in other
species, however there are few references to its use in sheep, even
though its use was first described in sheep 30 years ago (Green et al.
1981). Recently, there have been perceived problems associated
with the use of one batch of ketamine (Ketamine Injection; Parnell
Laboratories NZ Ltd, Auckland, NZ) at Massey University. This
product in combination with diazepam appeared to require a
higher dose to induce anaesthesia, be longer acting than the
ketamine from other batches and produce a greater incidence of
excitatory effects. The higher doses required for anaesthesia may
have depressed the respiratory and cardiovascular systems more
than would be expected. In the interests of animal welfare and
veterinary students’ education, it is important that the most reliable
and safe anaesthetic drugs be used.
Alphaxalone is a steroid anaesthetic drug that has been used for
many years for induction of anaesthesia in a variety of species,
including ruminants (Hall 1972 (preliminary report); Waterman
1981; Camburn 1982). The original formulation of alphaxalone
and alphadolone in polyethoxylated castor oil (Saffan) was
withdrawn and alphaxalone is now formulated in 2-hydroxypro-
pyl-beta-cyclodextrin as Alfaxan CD (Jurox New Zealand Ltd.,
Auckland, NZ). It is currently registered for use in cats and dogs in
New Zealand. Since the registration of Alfaxan CD in 2000 there
have been reports of its use in a number of species including pigs
(Keates 2003), and rabbits (Grint et al. 2008; Marsh et al. 2009)
and most recently, sheep (Andaluz et al. 2011).
GABA A Gamma aminobutyric acid type A
NMDA N-methyl D-aspartate
PaO2 Partial pressure of oxygen in arterial blood
SpO2 Saturation of haemoglobin with oxygen
 Walsh et al. New Zealand Veterinary Journal 60(2), 2012
This study was designed to compare, in a blinded, randomised
controlled trial, the quality of anaesthesia and range of side effects
produced by the suspect batch of Parnell ketamine with two
positive controls: ketamine sold for human use and a combina-
tion of drugs (alphaxalone and medetomidine) which act by a
different mechanism and are routinely used in ruminants by one
of us (PC).
Materials and methods
All procedures were approved by Massey University Animal
Ethics Committee. A total of 30 Romney cross 4-year-old
wethers (mean bodyweight 74.5 (SD 9.4) kg) were grazed on
pasture and groups of six brought into the yards approximately
12 h before they were anaesthetised, where they were given water
but no food. On the day of the study they were randomised into
six treatment groups, so that each group contained five sheep.
Downloaded by [New York University] at 03:17 14 May 2015
Anaesthesia
For sheep in Groups A and B, 0.5 mg/kg diazepam (Pamlin;
Parnell Laboratories NZ Ltd.) and 10mg/kg ketamine (Ketamine
Injection; Parnell Laboratories NZ Ltd.) of the suspect batch
were drawn up into a 20 mL syringe by one researcher. For
groups C and D, 10 mg/kg ketamine (Ketalar; Hospira NZ Ltd.,
Wellington, NZ) replaced the Parnell ketamine. For sheep in
groups E and F, 2 mg/kg medetomidine (Domitor, Pfizer Animal
Health, Auckland, NZ) and 2 mg/kg alphaxalone (Alfaxan CD;
Jurox New Zealand Ltd.) was combined in one syringe. The full
calculated dose of all the combinations occupied the same
volume. In addition, each syringe had 0.5 mL of a mixture of 100
mg/mL vitamin B1 and 1.0 mg/mL B12 (Duoject-B; Bomac
Laboratories Ltd., Auckland, NZ) added to hide the distinctive
colour of the diazepam formulation.
For induction, half the calculated dose was injected over 30
seconds into a cephalic vein through a catheter. After a further 15
seconds the depth of anaesthesia was assessed to determine if the
jaw was relaxed and the palpebral and gag reflexes were absent
and another half of the remaining dose administered if necessary.
This process was repeated until the sheep was judged ready to
intubate. If additional anaesthetic drug was required this was also
given in half primary dose increments. Induction was recorded on
video for subsequent behavioural analysis.
The sheep were placed in sternal recumbency with the neck
extended, the larynx sprayed with 1 mL of 2% lignocaine
(Bomacaine; Bomac Laboratories Ltd.) and the sheep intubated
with a 9 mm cuffed endotracheal tube by either a veterinary
anaesthetist with 15 years’ experience (Groups A, C and E) or a
competent fourth-year student who had already participated in
one sheep anaesthesia practical (Groups B, D and F). The persons
injecting the drugs and intubating the sheep were blinded to the
drugs they were administering.
Cardiorespiratory and anaesthetic effects
After intubation, sheep were placed in left lateral recumbency, a
pulse oximeter (Mindray 9200 anaesthetic monitor; Mindray,
137
Shenzhen, China) was attached to the tongue of each sheep to
measure saturation of haemoglobin with oxygen (SpO2) and
pulse rate, and an arterial blood sample taken from either the
auricular or carpal artery for blood gas analysis (iSTAT; Abbott
Laboratories, USA, using CG4þ cartridges). The endotracheal
tube was then connected to a circle anaesthetic system and the
sheep was allowed to breathe 100% oxygen. Expired gases and
respiratory rate were monitored using the Mindray 9200
anaesthetic monitor and recorded every 5 minutes. When the
sheep started to swallow, the tube was removed and the head
supported until the sheep was able to hold its head up.
Subjective ease of intubation was scored on a visual analogue scale
by the person intubating, with 0 indicating intubation could not
be completed, and 100 indicating intubation was as easy as
possible. The interval from injection to intubation, extubation,
holding the head up and standing were recorded. The initial
SpO2 and partial pressure of oxygen in arterial blood (PaO2) after
intubation were measured before the sheep was given oxygen.
End tidal CO2, respiratory rate and heart rate were monitored
until the sheep was extubated.
The quality of recovery was also scored on a visual analogue scale
by an observer blinded to the anaesthetic agents used. The scale
ranged from 0 indicating an excitable recovery with numerous
unsuccessful attempts to stand and obvious distress, to 100
indicating a fast, smooth recovery with rapid return to normal
behaviour. Other clinical signs relating to the quality of induction
including muscle twitching of the face, neck and whole body
along with the presence or absence of nystagmus, leg movement
and paddling and obvious central nervous system excitation were
recorded.
Statistical analyses
The experience level of the anaesthetist and its effect on
intubation were assessed by comparing time to intubation and
ease of intubation within Groups A and B, C and D, and E and F
using an unpaired, two-tailed t-test. Ease of intubation and the
other parameters were then compared by drug combination (i.e.
Groups A and B, C and D, and E and F were combined) using a
one-way ANOVA with Tukey’s test (Prism 4, GraphPad
Software, CA, USA). Results were considered significant at
p50.05.
Results
All the combinations produced satisfactory anaesthesia and no
major adverse events were seen during any phase of the
anaesthetic induction or recovery.
The mean dose of diazepam and ketamine required to induce
anaesthesia was the same for sheep in Groups A and B (0.28 (SD
0.06) mg/kg diazepam, 5.66 (SD 1.11) mg/kg ketamine) as
Groups C and D (0.29 (SD 0.06) mg/kg diazepam, 5.71 (SD
1.16) mg/kg ketamine). The mean dose for sheep in Groups E
and F was 1.57 (SD 0.3) mg/kg medetomidine and 1.57 (SD 0.3)
mg/kg alphaxalone.
Three of the 10 sheep in Groups A and B and 3/10 sheep in
Groups C and D required an additional (top-up) dose to reach a
suitable depth of anaesthesia for intubation, whereas 9/10 sheep
 138 New Zealand Veterinary Journal 60(2), 2012 Walsh et al.

in Groups E and F required at least one, and three sheep required
two additional doses.
The experienced anaesthetist consistently took less time (about
20 seconds) to intubate the sheep than the student (Figure 1),
but this difference was not statistically significant for any
comparison. Similarly, there was no difference in time to
intubation of sheep receiving the different drug combinations.
The experienced anaesthetist scored intubation as significantly
easier than the student for sheep receiving Parnell ketamine and

a d
3 25

20

Time (mins)
Time (mins)

15

10
1

5
Downloaded by [New York University] at 03:17 14 May 2015

0 0
A B C D E F A&B C&D E&F
Group Group
b e
good

100 25

20
75
Time (mins)

15
score

50
10

25
5
bad

0 0
A B C D E F A&B C&D E&F
Group Group

c f
good

100 50

40
75
Time (mins)

30
Score

50
20

25
10
bad

0 0
A B C D E F A&B C&D E&F
Group Group

Figure 1. Individual results for 30 sheep (n¼5 per group) anaesthetised using I/V 0.5 mg/kg ketamine (Ketamine Injection; Parnell Laboratories NZ
Ltd.) and 10 mg/kg diazepam (Groups A and B), or 0.5 mg/kg ketamine (Ketalar; Hospira NZ Ltd.) and 10 mg/kg diazepam (Groups C and D), or 2 mg/
kg medetomidine and 2 mg/kg alphaxalone (Groups E and F), for (a) interval from I/V injection to intubation, (b) score for the ease of intubation, (c)
score for ease of recovery, (d) time from injection to extubation, (e) time from injection to animal holding head upright and (f) time from injection to
animal standing. Intubation was carried out by an experienced anaesthetist in Groups A, C and E, and by a veterinary student in Groups B, D and F.
Horizontal lines are group means.
 Walsh et al. New Zealand Veterinary Journal 60(2), 2012 139

diazepam (Group A vs. B; p¼0.03), otherwise there were no
significant differences in ease of intubation (Figure 1).
Muscle twitching of the face (nine sheep), neck (eight sheep) or
whole body (five sheep) occurred in the Groups E and F, mainly
at induction, with five individuals displaying twitching of all
three areas. In two sheep nystagmus accompanied twitching and
both of these sheep also had obvious leg movements or paddling.
These effects were not seen in the Groups AD.
All recovery parameters were significantly shorter in Groups E
and F compared with the other Groups (Table 1, Figure 1).
There was no difference in recovery scores.
Arterial blood samples were not obtained from all individuals and
there was no significant difference between any of the Groups in
mean PaO2. SpO2 was higher in Groups E and F than A and B
(p50.05) and respiratory rate was lower in these Groups than in
either A and B, or C and D (p50.01), but there was no difference
between Groups in mean end tidal CO2, despite large differences
in respiratory rate (Table 1).
Downloaded by [New York University] at 03:17 14 May 2015
The problems previously experienced with use of Parnell
ketamine were not seen during the study and the quality of
induction along with the dose rates required were similar for both
ketamine formulations. A combination of ketamine and
diazepam or medetomidine and alphaxalone produced suffi-
ciently deep anaesthesia in all cases to allow intubation of adult
sheep by both an experienced anaesthetist and a student with
minimal experience.
Recovery was significantly faster in the alphaxalone and
medetomidine than the ketamine and diazepam groups. While
rapid recovery is generally considered desirable, if it is
accompanied by a shorter period of anaesthesia, it may not be
suitable for teaching students to intubate the trachea. Although
there are no published pharmacokinetic data for alphaxalone in
sheep, the fast recovery was probably caused by rapid clearance, as
occurs in dogs (Ferre et al. 2006). Pharmacokinetic studies in
other species (Sewell and Sear 2002; Visser et al. 2002) have
indicated a plasma concentration of about 4–5 mg/mL is required
for anaesthesia: assuming similar pharmacokinetics in sheep, this
would be maintained for a very short time. However,

pharmacokinetic-pharmacodynamic modelling of alphaxalone in

Discussion
This experiment was designed to test the hypothesis that one
particular batch of ketamine required a higher dose to induce
anaesthesia and produced a greater incidence of side effects, and
to assess if these would cause students to have difficulty
intubating the trachea. While it would have been interesting to
compare this batch with another from the same manufacturer,
sporadic reports of a similar nature concerning all the brands of
veterinary ketamine available in New Zealand suggested that
ketamine from a completely different source would be a better
control group. At the same time, the effects seen could have been
associated with ketamine itself, so another control group, using
drugs which produced anaesthesia by a different mechanism, was
used.
rats has shown a complex biphasic response with hysteresis
(Visser et al. 2002).
The use of diazepam-ketamine mixtures in sheep dates back to
1981, but there is no consensus on the most suitable dose rates.
They range from I/V 2 mg/kg diazepam and 4 mg/kg ketamine
(Green et al. 1981) to the dose currently used at Massey, 0.5 mg/
kg diazepam and 10 mg/kg ketamine, with many variations in
between. This lack of consistency makes comparison of effects of
any type difficult.
Alphaxalone and alphadolone mixtures (alphaxalone 9 mg/mL
and alphadolone 3 mg/mL) were first used at 2.2 mg/kg total
steroids (1.65 mg/kg alphaxalone) for induction of anaesthesia in
sheep (Copland 1977), and 4.4 mg/kg total steroids (3.3 mg/kg
alphaxalone) was considered equivalent to 22 mg/kg ketamine in

Table 1. Overall mean (+SD) outcomes for sheep anaesthetised using I/V 0.5 mg/kg ketamine (Ketamine Injection; Parnell Laboratories NZ Ltd.) and
10 mg/kg diazepam (Groups A and B), or 0.5 mg/kg ketamine (Ketalar; Hospira NZ Ltd.) and 10 mg/kg diazepam (Groups B and C), or 2 mg/kg
medetomidine and 2 mg/kg alphaxalone (Groups E and F) (n¼5 per Group). Intubation was carried out by an experienced anaesthetist in Groups A, C
and E, and by a veterinary student in Groups B, D and F.

Groups Significance of difference

Parameter A and B C and D E and F A and B vs. C and D C and D vs. E and F A and B vs. E and F

Time to intubation (min) 1.57+0.57 1.74+0.38 1.92+0.52 ns ns ns

Ease of intubation scorea 85.4+9.3 76+12.5 81.9+16 ns ns ns
Time to extubation (min) 10.26+3.88 11.44+4.47 5.38+1.92 ns p50.01 p50.05
Time to holding head up (min) 11.89+4.37 12.27+4.51 5.90+2.03 ns p50.01 p50.01
Time to standing (min) 21.95+9.34 16.37+4.92 8.56+3.59 ns p50.05 p50.001
Recovery scorea 83.5+10 78.3+16.6 79.8+11.4 ns ns ns
SpO2 (%) 82.6+9.5 83.5+10.3 92.7+6.8 ns ns p50.05
Maximum heart rate (bpm) 107+14.5 100.9+8.6 115+18.9 ns ns ns
Minimum heart rate (bpm) 86+13.8 86+15.1 104+19.9 ns ns ns
Respiratory rate (bpm) 50+17.3 47+20.7 19+12.4 ns p50.01 p50.01
End-tidal CO2 (mmHg) 46+8 40+4.1 41+4.2 ns ns ns
Arterial PaO2 (mmHg)b 48 55.4+15.6 65.6+9 ns ns ns

a
Scores assessed on a scale of 0 to 100, with 0 being bad and 100 being excellent
b
Samples not obtained from all animals; for combined Groups A and B n¼2, C and D n¼9, E and F n¼5
bpm ¼ beats per minute; ns ¼ not significant; PaO2 ¼ Partial pressure of oxygen in arterial blood; SpO2 ¼ Saturation of haemoglobin with oxygen
 140 New Zealand Veterinary Journal 60(2), 2012
sheep (Waterman and Livingston 1978). This dose produced
small changes in arterial blood gas values. Cardiopulmonary
parameters were stable when 2 mg/kg alphaxalone was
administered as an induction agent in sheep (Andaluz et al.
2011), and a double induction dose caused minimal cardiovas-
cular depression in people (Campbell et al. 1971), it is reasonable
to assume that the dose rate of alphaxalone could easily be
increased without significant adverse effect. All of the sheep in
Groups E and F required top-up doses for induction, so we
recommend that the entire dose (2 mg/kg alphaxalone with 2 mg/
kg medetomidine) be given as a slow bolus before intubation is
attempted. This is our current practice in the clinic, but for this
study a different method of administration would have voided the
blinding. Giving additional top up doses was inconvenient, but
did not cause any other problems, apart from prolongation of the
intubation time.
The more rapid recoveries seen in the sheep in Groups E and F
than AD may have been caused by relatively less anaesthetic
being administered compared with the ketamine groups i.e. the
dose rates chosen may not have been equipotent. The endpoint
Downloaded by [New York University] at 03:17 14 May 2015
of induction was chosen as intubation, but this depends to some
extent on the skill of the anaesthetist, as well as the depth of
anaesthesia. Because the induction drug was administered using a
fixed protocol of half the calculated dose followed by assessment
of the effects and then additional doses given, there was no
correlation between dose and ease of intubation. Ideally, to find
the effective dose, all drugs would have been given slowly and
continuously to effect, with each animal receiving a fixed dose
(Powell et al. 1992) but this does not reflect clinical practice, or
the situation where the reported adverse effects had occurred. As
the sheep in Groups E and F usually required additional
anaesthetic the hypothesis that the drug combinations were not
equipotent is possible, although the intubation scores were not
different between the groups. In retrospect, it may have been
better to give the full dose and then to have measured or recorded
the effects.
For a combination of drugs to produce maximal effect, they
should reach the site of action at the same time, and ideally have a
synergistic effect. The rate at which these drugs cross the blood
brain barrier is not known in sheep, but clinical experience
suggests that none of them exert as fast an effect as thiopentone,
for instance. Medetomidine has been shown to produce sedation
in lambs within one to 2 minutes of intravenous administration
(Ko and McGrath 1995) while adult sheep took 7 minutes to
become recumbent (Raheim et al. 2000).
Mixtures of drugs may also be chemically incompatible, which
could reduce their effects. There is no information on the stability
of any of the mixtures used in the current study. However, only
the ketamine and diazepam mixtures showed any sign of
interactions in the syringe; the mixture became transiently turbid
before clearing again. This was attributed to an interaction
between the high proportion of propylene glycol in the diazepam
formulation mixing with the water in the ketamine solution. All
the other drugs, including the vitamin B solution, were in simple
aqueous solutions, except alphaxalone which was bound to the
water soluble cyclodextrin. All drugs were mixed in a syringe
immediately before use to minimise any interactions.
There is evidence from humans that endotracheal intubation can
be painful (Hohlrieder et al. 2007) and the addition of analgesics
can reduce the dose of induction anaesthetic required to allow
Walsh et al.
intubation in dogs (Chambers 1989). Low-dose medetomidine is
analgesic in sheep (Muge et al. 1994) and may therefore reduce
the dose of alphaxalone required.
Alphaxalone and diazepam bind to different sites on the g
aminobutyric acid type A (GABA A) receptor (Franks 2008) and
ketamine probably exerts its main effects as a blocker of N-
methyl D-aspartate (NMDA) receptor channels, although other
effects are likely as other NMDA blockers are not anaesthetics
(Kelland et al. 1993). Medetomidine probably has sedative effects
through an action at the locus coeruleus (Scheinin and Schwinn
1992) and analgesic effects at the spinal cord, the thalamus, and
probably several other sites (Murrell and Hellebrekers 2005).
Thus the interactions are likely to be complex. The argument for
using the fixed ratios chosen in this experiment is purely
empirical; other ratios may be more rational. This is an area that
needs more research.
Arterial oxygen saturation was higher in sheep in the alphaxalone
and medetomidine than those receiving ketamine and diazepam,
although differences were only significant compared with Groups
A and B. Medetomidine causes intense peripheral vasoconstric-
tion, thus although the saturation is maintained, the reduced
blood flow may lead to greatly reduced oxygen delivery to
peripheral tissues (Lawrence et al. 1996). PaO2, measured by
arterial blood gas analysis, was also numerically highest in the
alphaxalone and medetomidine groups but blood gases were not
analysed in all sheep therefore a definitive comparison was not
possible. Mean PaO2 in Groups E and F (65.6 mmHg) were
lower than those reported in sheep given 4.4 mg/kg alphaxalone
and alphadolone (about 80 mmHg at 12 minutes of anaesthesia
(Waterman and Livingston 1978). This may reflect the influence
of medetomidine as alpha-2 adrenergic agonists have been shown
to cause hypoxaemia in sheep (Celly et al. 1997, 1999; Kastner
et al. 2007).
There were no differences in objective measures between groups
but there were qualitative differences to the point where the
anaesthetist could tell which combination was being given.
Parnell ketamine produced satisfactory anaesthesia, but the depth
of anaesthesia appeared greater with Hospira ketamine, even
though this was not reflected in the dose required for intubation.
The reasons for this difference are not obvious, as both
formulations contain ketamine hydrochloride in aqueous solu-
tion. Both also contain 0.1 mg/mL benzethonium chloride as a
preservative but this is unlikely to exert any anaesthetic effects on
the sheep, although it has been shown to interact with
acetylcholine receptors (Coates and Flood 2001). Commercial
ketamine is a racemic mixture: S-ketamine is thought to exert
most of the anaesthetic effect, but R-ketamine also binds to other
receptors in the brain. Differences in the proportions of S and R-
ketamine in the two brands of ketamine could possibly account
for the different effects perceived in the sheep.
Sheep recovering from alphaxalone and medetomidine may have
been under-dosed relative to those recovering from ketamine and
diazepam induced anaesthesia, resulting in unexpected excitatory
side effects. Our usual practice with this mixture is to inject the
whole calculated dose over one minute, rather than half, as was
done in this study to maintain blinding. These excitatory effects
were mainly muscle twitching, seen at both induction and
recovery. These effects have also been reported in people (Clarke
et al. 1971) and dogs (Maddern et al. 2010) after injection of
alphaxalone. It is possible that these side-effects could have been
reduced by giving the medetomidine first, rather than mixing the
 Walsh et al. New Zealand Veterinary Journal 60(2), 2012
drugs in the same syringe. These different subjective effects
meant that this combination may not have been the best choice
as a control treatment. Alphaxalone and medetomidine was the
regimen of choice for sheep of one of the anaesthesia staff
members, and as it acts at different receptors, it could control for
effects inherently associated with ketamine.
In conclusion, the subjective impression that a particular batch of
ketamine produced unsatisfactory anaesthesia was shown to be
incorrect when a randomised controlled comparison with other
anaesthetic combinations was made. Alphaxalone and medeto-
midine produced a shorter period of anaesthesia and a faster
recovery than ketamine and diazepam mixtures, although they
may have been under-dosed. There was less respiratory
depression with the alphaxalone and medetomidine combination,
but a greater incidence of excitatory side effects, particularly on
recovery.
Acknowledgements
Downloaded by [New York University] at 03:17 14 May 2015
This study was partly funded by the Lewis Fitch Veterinary
Research Fund.
References
Andaluz A, Felez-Ocaña N, Santos L, Fresno L, Garcı́a F. The effects on cardio-
respiratory and acid-base variables of the anaesthetic alfaxalone in a 2-
hydroxypropyl-b-cyclodextrin (HPCD) formulation in sheep. The Veterinary
Journal doi:10.1016/j.tvjl.2011.03.017, 2011
Camburn MA. Use of alphaxalone-alphadolone in ruminants. Veterinary Record
111, 166–7, 1982
Campbell D, Forrester AC, Miller DC, Hutton I, Kennedy JA, Lawrie TD,
Lorimer AR, McCall D. A preliminary clinical study of CT1341-a steroid
anaesthetic agent. British Journal of Anaesthesia 43, 314–24, 1971.
Celly CS, McDonell WN, Black WD, Young SS. Cardiopulmonary effects of
clonidine, diazepam and the peripheral alpha 2 adrenoceptor agonist ST-91 in
conscious sheep. Journal of Veterinary Pharmacology and Therapeutics 20, 472–
8, 1997
Celly CS, McDonell WN, Black WD. Cardiopulmonary effects of the alpha2-
adrenoceptor agonists medetomidine and ST-91 in anesthetized sheep. Journal
of Pharmacology and Experimental Therapeutics 289, 712–20, 1999
Chambers JP. Induction of anaesthesia in dogs with alfentanil and propofol.
Journal of the Association of Veterinary Anaesthetists 16, 14–7, 1989
Clarke RS, Montgomery SJ, Dundee JW, Bovill JG. Clinical studies of
induction agents. XXXIX: CT1341, a new steroid anaesthetic. British Journal
of Anaesthesia 43, 947–52, 1971
Coates KM, Flood P. Ketamine and its preservative, benzethonium chloride,
both inhibit human recombinant alpha7 and alpha4beta2 neuronal nicotinic
acetylcholine receptors in Xenopus oocytes. British Journal of Pharmacology
134, 871–9, 2001
Copland MD. The effects of CT1341, thiopentone and induction- delivery time
on the blood gas and acid-base status of lambs delivered by casesarean
operation and on the onset of respiration. Australian Veterinary Journal 53,
436–9, 1977
Ferre PJ, Pasloske K, Whittem T, Ranasinghe MG, Li Q, Lefebvre HP. Plasma
pharmacokinetics of alfaxalone in dogs after an intravenous bolus of Alfaxan-
CD RTU. Veterinary Anaesthesia and Analgesia 33, 229–36, 2006
141
Franks NP. General anaesthesia: from molecular targets to neuronal pathways of
sleep and arousal. Nature Reviews Neuroscience 9, 370–86, 2008
Green C J, Knight J, Precious S, Simpkin S. Ketamine alone and combined
with diazepam or xylazine in laboratory animals: a 10 year experience.
Laboratory Animals 15, 163–70, 1981
Grint NJ, Smith HE, Senior JM. Clinical evaluation of alfaxalone in cyclodextrin
for the induction of anaesthesia in rabbits. Veterinary Record 163, 395–6, 2008
Hall LW. Althesin in the larger animal. Postgraduate Medical Journal 48
(Supplement 2), 55–8, 1972
Hohlrieder M, Brimacombe J, Eschertzhuber S, Ulmer H, Keller C. A study of
airway management using the ProSeal LMA laryngeal mask airway compared
with the tracheal tube on postoperative analgesia requirements following
gynaecological laparoscopic surgery. Anaesthesia 62, 913–8, 2007
Kastner SBR, Ohlerth S, Pospischil A, Boller J, Huhtinen MK. Dexmedeto-
midine-induced pulmonary alterations in sheep. Research in Veterinary Science
83, 217–26, 2007
Keates H. Induction of anaesthesia in pigs using a new alphaxalone formulation.
Veterinary Record 153, 627–8, 2003
Kelland MD, Soltis RP, Boldry RC, Walters JR. Behavioral and electro-
physiological comparison of ketamine with dizocilpine in the rat. Physiology
and Behavior 54, 547–54, 1993
Ko JCH, McGrath CJ. Effects of atipamezole and yohimbine on medetomidine-
induced central nervous system depression and cardiorespiratory changes in
lambs. American Journal of Veterinary Research 56, 629–32, 1995
Lawrence C, Prinzen F, de Lange S. The effect of dexmedetomidine on nutrient
organ blood flow. Anesthesia and Analgesia 83, 1160–5, 1996
Maddern K, Adams VJ, Hill NA, Leece EA. Alfaxalone induction dose following
administration of medetomidine and butorphanol in the dog. Veterinary
Anaesthesia and Analgesia 37, 7–13, 2010
Marsh MK, McLeod SR, Hansen A, Maloney SK. Induction of anaesthesia in
wild rabbits using a new alfaxalone formulation. Veterinary Record 164, 122–3,
2009
Muge DK, Chambers JP, Livingston A, Waterman AE. Analgesic effects of
medetomidine in sheep. Veterinary Record 135, 43–4, 1994
Murrell JC, Hellebrekers LJ. Medetomidine and dexmedetomidine: a review of
cardiovascular effects and antinociceptive properties in the dog. Veterinary
Anaesthesia and Analgesia 32, 117–27, 2005
Powell H, Morgan M, Sear JW. Pregnanolone: a new steroid intravenous
anaesthetic. Dose-finding study. Anaesthesia 47, 287–90, 1992
Raheim B, Amemo JM, Stuen S. Medetomidine and atipamezole in sheep:
disposition and clinical effects. Journal of Veterinary Pharmacology and
Therapeutics 23, 401–4, 2000
Scheinin M, Schwinn D. The locus coeruleus: site of hypnotic actions of alpha2-
adrenoreceptor agonists? Anaesthesiology 76, 873–5, 1992
Sewell JC, Sear JW. Can molecular similarity-activity models for intravenous
general anaesthetics help explain their mechanism of action? British Journal of
Anaesthesia 88, 166–74, 2002
Visser SA, Smulders CJ, Reijers BP, Van der Graaf PH, Peletier LA, Danhof
M. Mechanism-based pharmacokinetic-pharmacodynamic modeling of con-
centration-dependent hysteresis and biphasic electroencephalogram effects of
alphaxalone in rats. Journal of Pharmacology and Experimental Therapeutics
302, 1158–67, 2002
Waterman AE. Evaluation of the actions and use of alphaxolone/alphadolone
(CT1341) in sheep. Research in Veterinary Science 30, 114–9, 1981
Waterman A, Livingston A. Some physiological effects of ketamine in sheep.
Research in Veterinary Science 25, 225–33, 1978
Submitted 06 July 2011
Accepted for publication 11 November 2011
First published online 05 December 2011