CLIQUER BOX

A VETERINARY EDUCATIONAL AND SURVEY MAGAZINE

ANAESTHESIOLOGY

SURVEY
USE OF OPIOIDS IN
CLINICAL PRACTICE
p19

MONITORING THE PROTOCOLS:

ANAESTHETIZED QUAD
ANIMAL-PART 1 PROTOCOL
How to minimize adverse Anaesthesia protocol
events during surgical for neutering in
anaesthesia.p01 young cats.p13

TERMINOLOGY ACUTE PAIN

: TIVA MANAGEMENT
anaesthesia induction
IN CATS-
and maintenance OPIOIDS
through intravenous
route.p40 Analgesic effects of
opioids in cats.p06

WHO SAYS A FRESH START HAS

TO BE DIFFICULT?
ISSUE 2  |  VOL 1  | NOVEMBER 2021
 ANAESTHESIOLOGY
NOVEMBER 2021

CONTENT

MONITORING IN ANAESTHETIZED PATIENTS PART-1.......................PAGE 01

ACUTE PAIN MANAGEMENT IN CATS-OPIOIDS.................................PAGE 06

QUAD PROTOCOL-CAT NEUTERING...................................................PAGE 13

SURVEY-OPIOIDS IN CLINICAL PRACTICE.........................................PAGE 19

FAMILIARIZE WITH: ALPHA-2 ADRENERGIC AGONISTS...................PAGE 25

ANAESTHETIC MACHINE PART-1.......................................................PAGE 33

TERMINOLOGY-TIVA.........................................................................PAGE 40

CONTENT WRITERS

Dr.Chris Seymour
Dr.Amish Jain

GUEST EDITOR

Dr.Chris Seymour

DESIGNER AND PROJECT CO-ORDINATOR

Dr.Amish Jain
 Guest Editor

Chris Seymour

About Chris Seymour

Chris graduated from the University of Cambridge in 1982. He was appointed

Whitley Trust Fellow in Veterinary Anaesthesia at the University of LIverpool,
gaining the RCVS Diploma in Veterinary Anaesthesia, and then spent many years
in general practice. In 2006, Chris returned to Cambridge as a Clinical
Anaesthetist, where he gained the Diploma of the European College of Veterinary
Anaesthesia and Analgesia. He was a Lecturer at the Royal Veterinary College
(University of London) from 2009- 2016, after which he has worked as a
consultant in a number of specialist practices in the UK.

Dr.Chris would be happy to help you regarding any queries related to the topics of
Anesthesiology, Feel free to contact him on:

cjs26682@gmail.com
GUEST EDITOR'S PEN

MONITORING IN
ANAESTHETIZED ANIMALS
PART-1

By Chris Seymour Provide all components of a balanced

anaesthetic, as mentioned above
INTRODUCTION
The three main components we want Maintain homeostasis as best as
from a general anaesthetic are: possible (e.g., normothermia, normal
unconsciousness, analgesia and oxygenation, normocapnia, normal
adequate muscle relaxation, but cardiac output). Our aim is to keep
unfortunately all anaesthetic drugs
oxygen delivery to the tissues within
have other unwanted effects,
normal limits
especially on the cardiovascular and
respiratory systems. The main Detect any adverse effects of
responsibility of the anaesthetist is to anaesthesia, especially on the
act as a ‘guardian’ for the cardiovascular and respiratory
anaesthetized patient and systems, as soon as possible and take
consequently all animals should be
corrective measures immediately.
carefully monitored during the whole
perioperative period. Our goals
should be: As well as monitoring the patient, we
should also ‘monitor’ the anaesthetic
machine, breathing system (± ventilator)
ANAESTHESIOLOGY | 01
GUEST EDITOR'S PEN

and any intravenous fluids that are As well as being a useful intra-
being given. Always try to adopt a operative monitor itself (it allows
methodical, structured way of trends in measurements to be seen
monitoring: more easily), it also serves as a
Patient monitoring equipment reference for future anaesthetics for
(and displays) anaesthetic that patient.
machine fluids
A good anaesthetic record should log:
It is vital to continue monitoring into Time, dose and route of drugs
the recovery period: this is the most given
common time for dogs, cats and All intra-operative monitoring
rabbits to die, with most deaths (including blood tests and blood
occurring within 3 hours of the end loss)
of the procedure (Brodbelt et al. IV fluids given (rate and type)
2008). All procedures performed (e.g.,
intubation, invasive monitors)
Not every animal will need every Time of important events, e.g.,
available monitor attached to it. The induction, positioning, start of
level of monitoring will be surgery and extubation
determined by the physical Unusual events or complications
condition of the animal and the Condition of animal at end of
surgical procedure planned. For procedure
example, a dog scheduled for
thoracic surgery where major blood It is worth recording the blood volume
loss is anticipated would benefit of the animal on the record (80ml/kg
from invasive (i.e., direct) monitoring for dogs and 60ml/kg for cats), then
of both arterial and central venous calculating and noting values for
pressures, as well as non-invasive blood loss equal to 10%, 15% and 20%
measurements such as pulse blood volume. This helps decision-
oximetry and capnography. making on whether crystalloids,
colloids or blood will be needed if
THE ANAESTHETIC RECORD blood loss occurs.
Monitoring can only be truly effective
if a proper anaesthetic record is kept.
ANAESTHESIOLOGY | 02
GUEST EDITOR'S PEN

This doesn’t mean that one should MONITORING BY THE

only look at the animal every 5 ANAESTHETIST (HUMAN SENSES)
minutes: monitoring should be Depending on where you anaesthetise
constant. your patient, the monitoring
equipment available will vary – in
MONITORING THE EQUIPMENT amount, quality and type.
Never forget that as well as But one thing that should never vary is
monitoring the patient, we should the presence of a human being
also ‘monitor’ the anaesthetic dedicated to anaesthetic monitoring.
machine and ongoing fluid therapy: Probably the biggest single factor in
Some older machines do not anaesthetic safety is the attentive care
have low oxygen warning alarms of the person monitoring the
fitted and in those it is important anaesthetic. There are things that we
to check cylinder (or pipeline) need monitoring equipment to
pressure and oxygen flowmeters measure, like arterial blood pressure
constantly. and end-tidal carbon dioxide, but in
Vaporizer dial setting and level some situations our own senses can
of volatile anaesthetic in the give us invaluable information more
vaporizer should be checked quickly, more accurately, and in more
regularly. Advanced monitors detail than can be gathered by
(e.g., Datex S/5) display inspired machinery.
volatile anaesthetic By monitoring using our own senses,
concentration – a further we also ensure proximity to our
safeguard against an empty patient. Our undivided attention and
vaporizer concentration promotes the level of
Check breathing system (± vigilance that our patients need and
mechanical ventilator) for deserve.
operation and disconnection The senses we can use for anaesthetic
(e.g., is the reservoir bag properly monitoring are our hearing, sight,
inflated?) touch and smell.
Check rate of fluid
administration and contents of We use our hearing for
fluid bags. Ventilation sounds

ANAESTHESIOLOGY | 03
GUEST EDITOR'S PEN

Detecting leaks around the at induction, and assessment of depth

endotracheal tube or in the of anaesthesia throughout.
breathing system
Low oxygen pressure warning Assessing the ABC is the anaesthetist’s
alarms priority as anaesthesia is induced.
Malfunctioning equipment Information must be gathered and
Communicating with other interpreted quickly. All of this vitally
theatre personnel important first assessment is most
Any music played in theatre should effectively done by using our own
be kept very quiet. senses. As the airway is checked (is the
We are constantly using our endotracheal tube correctly placed,
eyesight, to assess secured, cuff inflated?), we are
Eye position watching the patient’s chest to assess
Chest movements its breathing (is it breathing rapidly,
Colour of mucous membranes slowly, regularly, irregularly – is it
One could argue that touch is the breathing at all?), and at the same
most important sense, bringing the time, we are feeling a pulse (is the
vet into close and immediate pulse strong, regular, weak, absent?).
contact with the patient. Touch will Once we are confident that our
be used to assess patient’s condition is satisfactory, we
Pulses, including quality, rate make a quick assessment of the
and rhythm patient’s depth, by observing eye
Capillary refill time position, palpebral reflex, jaw tone etc.
Jaw tone At this stage we can introduce
Palpebral reflex inhalant anaesthetic agents to effect.
Relaxation of limbs and reflexes Throughout the anaesthetic we are
We use our sense of smell for continually assessing the depth of our
Detecting volatile anaesthetic patient. Various signs help us to do
agent, indicating leaks or this:
disconnections. Palpebral reflex – absent or present,
brisk or sluggish.
Monitoring using our own senses is Eye position.
all we need when we assess the
“ABC” (Airway Breathing Circulation)
ANAESTHESIOLOGY | 04
GUEST EDITOR'S PEN

Muscle relaxation – including jaw

FOR ANY QUERIES,
tone. Tension of muscles and
CLARIFICATION OR FEEDBACK
increased jaw tone are signs of
ON THIS ARTICLE YOU CAN
light anaesthesia. FREELY CONTACT DR.CHRIS
As well as these physical signs, all SEYMOUR AT HIS E-MAIL ID:
the physiological parameters need
to be monitored and interpreted, CJS26682@GMAIL.COM

particularly in response to painful

YOUR FEEDBACK IS VERY
stimuli: heart rate, pulse rate and VALUABLE TO US.
quality, respiratory rate, depth and
quality. All the above information is
effectively gathered by the use of
our own senses.
A very useful, but simple, piece of
equipment can be used in small
animals to augment our own
hearing – the oesophageal
stethoscope. This can be used to
hear heart and respiratory sounds. It
is inexpensive, easy to use, and I
believe has the added advantage of
encouraging close proximity to the
patient, and increased vigilance.

ANAESTHESIOLOGY | 05
 FEATURES

OPIOIDS
ACUTE PAIN
MANAGEMENT IN CATS

By Cliquer Box but also for conversion of certain parent

drugs into their active forms.
Analgesia in cats has often been
ignored in many veterinary facilities
partially due to lack of proper pain Deficient hepatic glucuronidation makes
assessment tools and partially due to cats more susceptible to the toxic effects
limited experimental and clinical data of drugs such as acetaminophen
on safety and efficacy of analgesic (paracetamol). In contrast, conversion of
agents in cats.
morphine into its more active form
However much more information is
(morphine-6-glucuronide) requires this
now available on use and toxicity of
common analgesics in cats. pathway and this may be one reason why
it is less effective in cats compared to
Cats are deficient in hepatic UDP- dogs.
glucuroninosyltransferase (UGT) which
is required for hepatic glucuronidation
Opioids are often the preferred drugs for
of glycosidic bonds in drugs. This
process is not only crucial for pain management in cats because of
detoxification of drugs, pollutants and their efficacy, better safety profile and
other phenolic compounds, but also possible routes of administration.

ANAESTHESIOLOGY| 06
FEATURES

Mechanism of action: Hydromorphone can also cause

Opioids act through G-protein histamine release but to a much lesser
coupled receptors present in the extent and is safer drug for
peripheral and central nervous intravenous use. No histamine release
systems. is caused by oxymorphone, fentanyl,
Opioid agonists bind to these methadone and butorphanol, so these
receptors on presynaptic nerve drugs are considered safe for
terminals, producing intravenous use.
hyperpolarization and analgesic
effects. Euphoria and dysphoria: Changes
Various types of opioid receptor in behavior, usually ‘euphoric’ (e.g.
have been identified, including purring, kneading, rolling, rubbing
delta, kappa, and mu opioid on objects) may be observed with
receptors. administration of opioids in cats.
Opioids are classified according Dysphoria and hyper-excitability
to their affinity for mu receptors have been observed with
and include full agonists, partial butorphanol in cats.
agonists, antagonists, and Hyperthermia: Hydromorphone is
agonist-antagonists (agonist at frequently associated with
kappa receptors and antagonist hyperthermia in cats and all
at mu receptors. animals receiving hydromorphone
should have their body
Side Effects and Toxicity: temperature monitored. Morphine
Histamine release: Morphine and > 1.0 mg/kg, meperidine at higher
meperidine (pethidine) may cause doses and fentanyl may also cause
histamine release on intravenous hyperthermia.
administration. Thus their use is not Mydriasis: Opioids may cause
recommended in cases of mydriasis in cats, and animals
hypotension and shock. Meperidine should be kept in a quiet
should not be given by the environment with low light.
intravenous route in dogs and Vomiting and salivation: Opioid-
cats.·Morphine, if given IV, should be induced nausea and vomiting are
injected slowly. incompletely understood and

ANAESTHESIOLOGY | 07
FEATURES

involve both central and peripheral Butorphanol alone or in combination

sites including the vomiting centre, with other drugs are generally
chemoreceptor trigger zone (CTZ), preferred for endoscopic procedures
the cerebral cortex, and the involving the gastrointestinal system
vestibular apparatus. These drugs because of lesser effects on
given via the subcutaneous route gastrointestinal motility and sphincter
may cause an increased incidence activity. Gastrointestinal motility
of vomiting compared to the effects of opioids may be dose and
intravenous route. Combining duration dependent.
opioids with acepromazine in pre-
medication may reduce the Urine retention: Urine retention is
incidence of vomiting in cats. most commonly observed with
Vomiting is less commonly noted epidural morphine administration.
with methadone, buprenorphine
and butorphanol. Constriction of biliary smooth
muscle: Some opioids like
Constipation and Anorexia: morphine, fentanyl,
Long term use of opioids meperidine(pethidine) and
decreases bowel motility and pentazocine may cause
can lead to constipation and constriction of smooth muscle in
anorexia in some patients. This the common biliary and pancreatic
effect is more profound with full ducts, increasing intraluminal
mu-agonists.Gastric and pressure; these drugs should
intestinal smooth muscle tone therefore be avoided in cats with
may increase, leading to “ropy biliary and/or pancreatic disease.
gut” which is more evident in Butorphanol and buprenorphine
kittens. Systemic treatment with may be better opioids for pain
buprenorphine may cause management of pancreatitis in
inappetence in some cats after cats.
2-3 days. Fentanyl and
buprenorphine patches did not
affect food intake or frequency
of bowel movement in an
experimental group of cats.
ANAESTHESIOLOGY | 08
FEATURES

Analgesic effects of opioids in morphine in dogs but are better

cats: analgesics in cats, with shorter
Morphine is the most widely used duration of action. These drugs are
opioid in veterinary practice globally considered safe for IV use because of
and considered to be the ‘gold lack of histamine release.
standard’. In cats, however,
morphine is less effective than in Hydromorphone is less expensive and
dogs and the onset of action is produces less sedation with a similar
slower because of limited analgesic effect to oxymorphone.
production of morphine-6- However oxymorphone has a longer
glucuronide - an active metabolite duration of action.
of morphine. This may be attributed
to deficient hepatic glucuronidation Methadone is a synthetic opioid with
in cats. long duration of action. It has an
analgesic efficiency similar to
Hydromorphone and Oxymorphone morphine in dogs. The
are semisynthetic opioids which are pharmacokinetics of this drug have
equally effective analgesics as
ANAESTHESIOLOGY | 09
FEATURES

not been reported in cats. Buprenorphine is partial mu agonist. It

Methadone is also an antagonist at has lower analgesic effect than
NMDA receptors – thus possessing morphine but is an effective analgesic
an additional mechanism of in cats undergoing various procedures,
analgesic action. It rarely causes such as ovariohysterectomy,
vomiting. onychectomy andorthopaedic surgery.

Meperidine(Pethidine) is a weak Oral transmucosal absorption of this

synthetic opioid with a short drug is almost 100% in cats due to it
duration of action of less than an pH similarity with the oral pH of cats.
hour in cats. This drug has limited Drug applied to the gums and oral
use in cats. mucosa is readily absorbed, and this is
a major advantage in animals that are
Fentanyl is a synthetic opioid with a difficult to handle.
very short plasma half-life and is
often administered as a constant Vomiting and dysphoria is rarely
rate infusion (CRI). This drug has associated with this drug and together
gained popularity due to its with its good efficacy and duration of
availability in patches, so that the action, buprenorphine is a good
drug can be given via the analgesic for cats.
transdermal route. Transdermal
fentanyl patches (TDF) are available Butorphanol is a mu antagonist and
for use in acute peri-operative pain kappa receptor agonist. It is a
management in cats. These patches relatively weak analgesic compared to
give steady and reliable analgesia in pure mu agonists and more suitable
healthy cats, although body for mild pain. Duration of action is 2-6
temperature, skin permeability and hours in cats.
skin perfusion will influence uptake
of the drug via the transdermal Tramadol has both opioid and non-
route. Most cats achieve steady state opioid mechanisms of action and has
plasma concentrations within 6-12 been used for management of acute
hours of patch placement. Other perioperative pain in continental
opioids can be given during this Europe, where a preparation for
uptake phase. intravenous use is available.

ANAESTHESIOLOGY | 10
FEATURES

IN MANY COUNTRIES, ONLY THE ITS MAIN USE, HOWEVER, HAS BEEN
ORAL FORM IS AVAILABLE AND IT FOR TREATMENT OF CHRONIC PAIN,
IS FINDING
INCREASING USE IN ESPECIALLY THAT ASSOCIATED WITH
THE MANAGEMENT OF MODERATE OSTEOARTHRITIS.
PERIOPERATIVE PAIN.

ANAESTHESIOLOGY | 11
FEATURES

References and Further readings:

Anti-inflammatory therapy: Shauna Blois, Karol A.Mathews

Overview of Drugs Administered to Treat Pain: William W. Muir III ,Handbook of
veterinary pain management.
A review of opioid use in cats: Robertson S. ,Recent advances in veterinary
anaesthesia and analgesia.
Treatment of acute (adaptive) pain: Paulo Steagall and Polly Taylor. ,Feline
anaesthesia and pain management.

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ANAESTHESIOLOGY | 12
 IDEAL
ANAESTHETICS

PROTOCOLS

THE QUAD PROTOCOL

By Cliquer Box in some cases, early neutering reduce

that risk.
Cats have limited ability to metabolize
many drugs thus extra care is needed
to choose drugs for induction and Although early neutering has its
maintenance of anaesthesia in cats. advantages but anaesthesia at early age
Anaesthesia protocols and drug carries a greater risk than healthy adults.
dosage meant for small dogs cannot Many paediatric factors should be taken
be applied to cats.
into consideration and proper safety and
anaesthetic protocols should be followed
Neutering in cats at young age below
4 months are now adopted in most for risk free and event free neutering in
part of world. It has been shown that young kittens.
cats neutered at young age had
reduced risk of getting diseases like Patient consideration:
FIV and FeLV, reduced risk of
Kitten should be healthy and have
mammary carcinoma (in female
cats).Moreover queens can get healthy body weight according to age.
pregnant as early as 4 months of age Most kitten presented are around 1 kg or
less in weight.

ANAESTHESIOLOGY | 13
IDEAL ANAESTHETICS

Proper weight of kitten should Hypothermia: Limited ability to

be noted and compared with regulate temperature, high body-
weight according to its breed at surface-area to mass ratio and low
that age. subcutaneous fat reserve make
It is good practice to ensure that young kittens more susceptible to
kitten is properly vaccinated and hypothermia during anaesthesia.
have completed its vaccination Animal should be constantly
shots before undergoing monitored for body temperature
neutering. throughout procedure and should
For male kitten ensure that both be kept above 36 degree
testicles are hanging and animal centigrade to avoid adverse events
is not Cryptorchid. In case of due to low body temperature.
cryptorchidism surgery may be High tissue oxygen consumption:
delayed until animal is at least 6 Oxygen should be provided
months of age. throughout the surgery due to high
tissue oxygen consumption rate in
Potential Problems of anaesthesia paediatric patients. For male kitten
in young kittens: oxygen mask may be sufficient for
delivering oxygen while
Limited cardiovascular endotracheal intubation shall be
compensation: Cardiac output in considered in female kitten where
young kittens predominantly duration of surgery is expected to
depends on heart rate rather than increase more than 10-15 minutes.
depth of stroke volume due limited Limited drug metabolism and
proportion of contractile cardiac excretion: Hypoalbuminaemia and
tissue hence a there is immature hepatic enzyme system
predetermined stroke volume. may reduce young kitten ability to
Moreover kittens have immature metabolize anaesthetic drugs and
sympathetic nervous system. may prolong recovery time in these
Anaesthesia protocol in kitten animals. Reduced renal blood flow
should have minimal effect on and glomerular filtration rate may
cardiovascular system. decrease clearance and excretion
of certain drugs in urine.

· ANAESTHESIOLOGY | 14
IDEAL ANAESTHETICS

Hypoglycaemia: Kittens are Animal should be handled in quiet

susceptible to hypoglycaemia environment and should be
which may lead to prolonged subjected to minimal stress.
recovery and other adverse Handling of animal should be firm
events. Animal blood glucose and gentle.
should be monitored in case of Measure accurate weight and
prolonged recovery and shall be calculate dose accordingly.
given 5% Dextrose in isotonic Consider using body surface area to
crystalloid solution. calculate anaesthesia requirement
Dehydration and Hypovolemia: if using quad protocol.
Due to limited ability to Hairs should be clipped (not
concentrate urine kittens are shaved) on limited portion, scrub
susceptible to dehydration. should be kept dried as much as
Circulating blood volume is possible and limit use of alcoholic
small, and haemorrhage must be solutions due to limited
prevented, as loss of more than a thermoregulatory ability of young
few millilitres can be harmful. animals.

Pre-anaesthetic considerations: Anaesthetic Considerations:

Due to difficulty in accessing IV
Animal should have full clinical route in kittens, anaesthetic
check-up before administration induction through intramuscular
of sedation or anaesthetics. A route is preferable in most cases.
complete blood count (CBC) test Benzodiazepines, opioids,
may be helpful. ketamine, alpha-2 adrenergic
Hypoglycaemia is a major agonists in different combinations
concern in kittens, food in are considered for induction of
kittens should be withheld for no anaesthesia in kittens.
more than 3-5 hours before ·
surgery.
To prevent dehydration water
should be available to kitten not
less than 1 hour before of
anaesthetic administration.
ANAESTHESIOLOGY | 15
IDEAL ANAESTHETICS

Procedure like castration where Quad Protocol:

duration of surgery is less than The quad protocol was devised by
10-15 minutes may not require David Yates of the RSPCA Greater
maintenance anaesthesia and Manchester Animal Hospital, is
oxygen mask may be sufficient, promoted by RSPCA and Cat
whereas in female spaying Protection.
endotracheal intubation is It is considered to give safe, reliable
required and attach to non- and effective anaesthesia for short
rebreathing circuit and procedures.
maintenance with inhalant The quad protocol comprise of
anaesthesia mixed with oxygen equal volume of medetomidine (1
is usually used. mg/ml solution), ketamine (100
Intubation in kittens should be mg/ml solution), midazolam (5
performed carefully due to mg/ml solution), buprenorphine
possibility of tissue damage, 2% (0.3 mg/ml solution) given
lidocain spray may be helpful in intramuscularly in single injection.
smooth intubation in some cats, Methadone (10 mg/ml) can be used
lidocain dose should not exceed in place of buprenorphine.
10 mg/kg. Body surface area is better method
to calculate volume of anaesthesia
Anaesthesia Protocols for for quad protocol.
induction in kitten: Quad protocol effects can be
reversed using atipamezole
Some Anaesthetic combinations (5mg/ml) however its use is usually
used for induction in kittens are: not recommended until at least
half an hour after anaesthetic
Medetomidine + Ketamine injection to avoid excitement.
Medetomidine + Ketamine +
Butorphanol ·
Tiletimine and zolazepam

ANAESTHESIOLOGY | 16
IDEAL ANAESTHETICS

ANAESTHESIOLOGY | 17
IDEAL ANAESTHETICS Refrences and further readings:

Post-Operative Monitoring: Faggella A M & Aronshon M G (1993).

Animal should be monitored till it
is able to maintain sternal
recumbency without difficulty.
Temperature should be
maintained regularly and kitten
should be wrapped in bubble
wrap or given active warmth if
temperature fall below 36 degree
centigrade.
If recovery is prolonged blood
glucose level should be checked
and in case of hypoglycaemia
animal should be given 5 %
dextrose in isotonic colloidal
solution (10 ml/kg/hr.).
Buprenorphine or methadone in quad
protocol give sufficient analgesia for
postoperative pain for a period of 6
hours. Carpofen before surgery may
give analgesic effect for 24 hours in
cats.
Anaesthetic techniques for neutering
6- to 14-week-old kittens. Journal of
the American Veterinary Medical
Association.
Hall L W and Taylor P M Eds. (1994)
Anaesthesia of the cat. Bailliere
Tindall, London
Hird J E F (200 1) General anaesthesia
for the early neutering of kittens.
Cats Protection Newsletter.
Feline relinquishment: how can the
veterinary profession help reduce
this? Vanessa Bourne MVB
CertAVP(SAM-F) PGCertVetEd FHEA
MRCVS
Neutering pet cats at four months of
age (or less) Philippa Welsh BVSc
(Hons) MRCVS Pfizer Feline Fellow.

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OUR ARTICLES AND WHAT YOU WOULD LIKE TO INCLUDE OR REMOVE FROM NEXT ISSUE.
PLEASE MAIL US ON:

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ANAESTHESIOLOGY | 18
 SURVEY

SURVEY

OPIOIDS IN CLINICAL
PRACTICE

By Cliquer Box Opioids

Alpha-2 adrenergic agonists
This is a short survey on opioids use in
Ketamine
clinical practices around the world.
We asked 6 basic question about use Corticosteroids
of opioid drugs for analgesic and pre- Local anaesthetics
anaesthetic use in dogs and cats. Gabapentin
Survey form was sent to 1000
veterinarians, 480 responded, more
Q2.Which of the following drugs do
responses are expected and we will
you prefer for analgesia in cats?
update the data and information in
subsequent issues. Options:
NSAIDS
Questions asked: Opioids
Alpha-2 adrenergic agonists
Q1.Which of the following drugs do
Ketamine
you prefer for analgesia in dogs?
Options: Corticosteroids
NSAIDS Local anaesthetics
Gabapentin

ANAESTHESIOLOGY | 19
SURVEY

Q3.Which opioid drugs you Synergistic effects with other

commonly use in your practice? sedatives
Anxiolysis
Short Answer....................................................
Participant Country and Number of
Q4.Which of the following is participants:
primary indication for opioids in

your practice? 1000 vets from 18 different countries

Options: were asked question mentioned above
Analgesia 242 responded till this issue was
Sedation published.
Both
USA ..................58
Q5.Which of the following drug India..................49
effects is reason for preference of UK.......................32
opioids in dogs? Australia..........29
Options: Philippines.....21
Gastrointestinal safety South Africa...11
Reliable analgesia Egypt.................09
Safe sedation Sweden............08
Better cardiovascular safety Croatia..............06
Synergistic effects with other Zimbabwe......05
sedatives Canada.............04
Anxiolysis Saudi Arabia..04
Botswana........02
Q6.Which of the following drug Netherlands...01

effects is reason for preference of Russia.................01

opioids in cats? China..................01

Rwanda ...........01
Options:
Gastrointestinal safety
Reliable analgesia
Safe sedation
Better cardiovascular safety

ANAESTHESIOLOGY | 20
SURVEY
Q1.Which of the following drugs do
you prefer for analgesia in dogs?
NSAID were clearly the most preferred
class of drugs for pain management in
dogs followed by opioids. Most
veterinary practitioners use
multimodal analgesia in their patients.
Almost 22.9% veterinarians do not use
opioids for pain management in dogs.
Majority of respondents who do not
use opioids were from Zimbabwe,
Croatia, South Africa, Rwanda, Egypt
and Russia.
This may be due to non-avalabilty of
opioid drugs for veterinary practice in
these countries.
Only 2.90% respondents use
corticosteroids in pain management in
dogs.
Gabapentin a GABA analogue is relatively
new drug, Limited data is available for its
analgesic effects in dogs and cats. 18%
respondents use Gabapentin in their
practice. Most respondents who use
gabapentin were from USA, UK, Australia,
Russia. One respondent from India use
gabapentin in their patient.
Local anaesthetics and alpha-2 adrenergic
agonists are used mostly in multimodal
analgesic approach. 14.3% vets use Local
anaesthetics and 14.3% use alpha-
adrenergic agonists.
ANAESTHESIOLOGY | 21
SURVEY
Q2.Which of the following drugs do
you prefer for analgesia in cats?
Opioids are primary drugs for pain
management in cats. 52.9% vets use
opioids for pain management,
however majority use multimodal
analgesia approach in cats.
Although cats are deficient is enzymes
that metabolize certain NSAID drugs,
some NSAIDS like meloxicam is
considered to be safe for short term
use in therapeutic dose. Thus NSAIDS
are second favorite of veterinarians
around the world for acute pain
management in cats.
Gabapentin is another popular drug for
pain management in cats specially in
USA,UK, Australia.
Alpha-2 adrenergic agonists, ketamine
and local anaesthetics are used in
multimodal approach and relatively
less number of vets use them in their
practice compared to other three
drugs.
Below are the results of survey so far.
Proper analysis and conclusion of the
survey will be published in next issue as
survey is still open and more responses
are awaited.
ANAESTHESIOLOGY | 22
SURVEY
Q3.WHICH OPIOID DRUGS YOU COMMONLY USE IN YOUR PRACTICE?

Q4.WHICH OF THE FOLLOWING IS PRIMARY INDICATION FOR OPIOIDS IN YOUR

PRACTICE?

ANAESTHESIOLOGY | 23
SURVEY

Q5.WHICH OF THE FOLLOWING DRUG EFFECTS IS REASON FOR PREFERENCE

OF OPIOIDS IN DOGS?

Q6.WHICH OF THE FOLLOWING DRUG EFFECTS IS REASON FOR PREFERENCE

OF OPIOIDS IN CATS?

ANAESTHESIOLOGY | 24
 FAMILIARIZE WITH
PRE-ANAESTHETICS
ALPHA-2 ADRENERGIC
AGONISTS
By Cliquer Box
This article on α 2 adrenergic agonists
is divided into three parts: this part
describes general properties, systemic
effects and dose ranges. In the second
part we will discuss combinations of
explain why they are the most widely used
α 2 adrenergic agonists with other
sedatives and anxiolytics like opioids
and benzodiazepines and their effects
on various parameters; we will also
look at the effect of co-administration
anticholinergic drugs. In the third part,
we will focus on the use of α 2
adrenergic agonists for pre-
medication and as adjuncts to
balanced anaesthesia with various
injectable and inhalant anaesthetics.
We will also discuss reversibility of
their effects with α 2 adrenergic
antagonists.
ANAESTHESIOLOGY | 25
Alpha-2 adrenergic agonists possess reliable
sedative effects, as well as providing
anxiolysis, analgesia and muscle relaxation.
These properties make them unique and
sedatives and pre-anaesthetics in veterinary
medicine. Reversibility of effects of these
drugs is another added advantage.
Currently xylazine, medetomidine and
dexmedetomidine are used in dog and cats,
whereas xylazine, detomidine and
romifidine are approved for use in horses.
Drug combinations and anaesthetic
sparing effects:
All alpha-2 agonists are primarily used alone
or in combination with benzodiazepines or
opioids as sedatives for animal handling,
and for minor diagnostic or surgical
procedures.
FAMILIARIZE WITH

As pre-anaesthetics, alpha-2 receptors located in the pons (locus

agonists have been used with ceruleus) produces sedative and
injectable anaesthetics like anxiolytic effects, whereas stimulation
thiopental, propofol, ketamine, and of those receptors present in the
inhalational anaesthetics like dorsal horn of the spinal cord
halothane and isoflurane. produces analgesic effects.
A major advantage of using alpha-2 Stimulation of pre-synaptic alpha-2
agonists is their anaesthetic sparing receptors causes hyperpolarization of
property. Medetomidine has been neurons and blocks release of
found to decrease the dose norepinephrine from nerve terminals
requirement of propofol and in the CNS. Norepinephrine is a
thiopental by up to 75% depending neurotransmitter for arousal in the
on the dose administered for CNS.
premedication Alpha-2 adrenergic receptors have
The mean alveolar concentration further subtypes A, B, C, D, which are
(MAC) of both halothane and important to mention here. see Table2
isoflurane is reduced by xylazine Most α 2 adrenergic agonists can also
and medetomidine. see Table 1. activate α 1 adrenergic receptors to
some degree; each of them has
Mechanism of action: different specificity and selectivity and
Adrenergic receptors are G-protein this greatly influences their effects.
coupled receptors that are the Drugs which have a greater selectivity
target for catecholamines like for α 2 adrenergic receptors are more
epinephrine and norepinephrine. potent and produce more profound
Alpha-adrenergic receptors are a sedation at lower doses.
group of adrenergic receptors α 2 / α 1 selectivity has been reported in
present in the central nervous following manner:
system (CNS) and virtually in every Xylazine = 160:1
tissue of the body, and are further Clonidine =220:1
divided into alpha-1 and alpha-2 Detomidine = 260:1
adrenergic receptors. Medetomidine = 1620:1
Stimulation of alpha-2 adrenergic Alpha-1 adrenergic receptors are
activated mostly at high doses of these

· ANAESTHESIOLOGY | 26
FAMILIARIZE WITH

drugs and seldom is cause of receptors results in more profound

concern at therapeutic doses. and longer lasting vasoconstriction
systemic vascular resistance and
Toxicity and side effects: sympathetic tone. Medetomidine has
Cardiovascular depression: more profound cardiovascular effects
Initially, stimulation of peripheral α 2 than xylazine, but is less likely to
adrenergic receptors causes produce ventricular arrhythmias
vasoconstriction (increased systemic (which may be α1 mediated).
vascular resistance), with arterial Arrhythmogenicity of a drug refers to
hypertension and consequent reflex its ability to induce myocardial
bradycardia and reduced cardiac sensitivity to epinephrine and promote
output. There can also be 1st and ventricular arrhythmias.
2nd degree atrio-ventricular block Arrhythmogenicity of α 2 adrenergic
caused by the increased vagal agonists is dependent on dose, route
activity. Duration of these effects is of administration and α2
dose-dependent, but is adrenoreceptor selectivity, with more
approximately 30 minutes. selective α 2 adrenergic agonists like
Decreased release of medetomidine less likely to cause
norepinephrine from nerve arrhythmias.Xylazine can produce
terminals in the CNS reduces ventricular arrhythmias in halothane
sympathetic vascular tone. and isoflurane anaesthetized animals.
Therefore, the cardiovascular effects
consist of an initial vasoconstrictor ·The dose and route of
phase where an increase in arterial administration also affects the
blood pressure causes bradycardia degree of vasoconstriction: xylazine
via a baroreceptor-mediated reflex, and medetomidine given IV have
followed by diminished sympathetic more profound and long lasting
tone which also leads to a reduced effects when compared to the
heart rate and decrease in cardiac intramuscular (IM) route of
output. administration. However, one study
Alpha-2 adrenergic receptor showed that in when medetomidine
selectivity plays an important role in was given IV at doses ranging from 1 –
the cardiovascular effects. Greater 20 µg/kg, only the 2 lowest doses used
selectivity for α 2 adrenergic seemed to induce

ANAESTHESIOLOGY |27
FAMILIARIZE WITH

drugs less pronounced effects than Thus, oxygen supplementation is

the higher doses. This could recommended whenever α2
indicate that near-maximal adrenergic agonists are combined
cardiovascular effects produced by with other sedatives or anaesthetics.
the medetomidine are present with
doses as low as 5 µg/kg and that Gastrointestinal Effects: α2
increasing the dose over this value adrenergic agonists have inhibitory
only minimally further influences effects on gastric motility and
cardiovascular function, but secretions. There is also increased
prolongs drug effects. This also gastric sphincter tone through
implies that, in a clinical setting, if activation of visceral α 2 adrenergic
medetomidine has to be used, a receptors and inhibition of
reduction of the recommended acetylcholine release. These effects
dose up to 6 times does not can be completely reversed by the α 2
significantly influence the degree of adrenergic antagonist atipamezole.
cardiovascular effects and will not
reduce the undesirable effects of Endocrine and Hormonal Effects:
the alpha-2 adrenoceptor agonist. Both xylazine and medetomidine
cause hyperglycemia through
Respiratory Effects: There are suppression of insulin release.
minimal respiratory effects when α 2 However, xylazine causes more
adrenergic agonists are used alone. profound hyperglycemia than
Xylazine and medetomidine do not medetomidine, which might be due to
produce significant changes in the lesser selectivity of xylazine and is
respiratory rate, nor in PaCO2 or attributed to action at both α 1 and α 2
PaO2 . However respiratory adrenoreceptors.
depression is observed when Both xylazine and medetomidine have
xylazine and medetomidine are been associated with increased urine
combined with other sedatives or production with low specific gravity.
anaesthetics. Hypoxemia, acidosis This diuretic effect of α 2 adrenergic
and respiratory depression is agonist can be attributed to decreased
observed when xylazine and
medetomidine are combined with
opioids, ketamine or propofol.

ANAESTHESIOLOGY | 28
FAMILIARIZE WITH

production and release of Clinical use of alpha-2 agonists:

antidiuretic hormone (ADH) and Apart from their reliable sedative,
suppression of the renin- anxiolytic, analgesic and muscle
angiotensin system. relaxant effects, the anaesthetic dose-
α 2 adrenergic agonists also inhibit sparing effect is major advantage of α 2
the release of stress-related adrenergic agonists. The vasodilatory
hormones, which might effects of isoflurane can therefore be
havepositive effects on early attenuated and arterial blood pressure
recovery in surgical patients. is generally improved by the
concurrent administration of alpha-2
Muscle twitching has been agonists. Some clinicians believe that
observed with both xylazine and their inhibitory effect on the release of
medetomidine after intravenous stress hormones may promote early
administration. A noisy environment recovery in surgical patients.
and the route of administration are
believed to be factors in muscle As stated above, the sedative effects of
twitching incidences in dogs. α2 adrenergic agonists are due
inhibition of release of norepinephrine
Vomiting is often observed with in pons and brainstem.
both xylazine and medetomidine in Norepinephrine is catecholamine
dogs and cats. Vomiting is observed required for arousal. Stress, fear,
as sedation develops; about 90% anxiety or trauma can induce
cats and 50% dogs vomit after endogenous catecholamine release,
xylazine, and in about 20% dogs which may interfere with the sedative
and up to 90% cats after effects of α 2 adrenergic agonists. Thus,
medetomidine. a quiet, calm and stress-free
Vomiting with and lower head environment is important for
posture can increase both consistent sedative effects. Sedated
intraocular and intracrainial dogs can become aroused and
pressures in dogs and cats and α 2 become aggressive with noise and
adrenergic agonists should be used tactile stimulation.
cautiously in patients with ocular
problems.

ANAESTHESIOLOGY | 29
FAMILIARIZE WITH

The analgesic properties of α2 PLEASE GIVE YOUR FEEDBACK ON

adrenergic agonists are mediated THIS ARTICLE, ALSO TELL US HOW
WE CAN IMPROVE OUR ARTICLES
by α 2 adrenoreceptors present in
AND WHAT YOU WOULD LIKE TO
dorsal horn of spinal cord. When
INCLUDE OR REMOVE FROM NEXT
combined with opioids, the ISSUE. PLEASE MAIL US ON:
analgesic effects are synergistic.

Xylazine and medetomidine have

been used with butorphanol, OR

morphine, methadone,
IF YOU WANT TO WRITE AN ARTICLE
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medetomidine produces an
TO US.
analgesic effect for 30-45 minutes
(although this is dose dependent).

Table 1:

Table 2:

ANAESTHESIOLOGY | 30
FAMILIARIZE WITH

Medetomidine Doses in Dogs and Cats:

Ideally, medetomidine dose is calculated according to body surface area (in m2) rather
than body weight

ANAESTHESIOLOGY | 31
FAMILIARIZE WITH

Dosage based on body surface area (m2):

750 µg – 1000 µg /m2 body surface area IM is dose recommended in dogs for sedation
and analgesia.

Dosage based on body weight (kg):

A dosing table provided by manufacturer of medetomidine (Domitor with
concentration of medetomidine hydrochloride of 1mg/ml) may be used:

ANAESTHESIOLOGY | 32
 VET TECH

ANAESTHTIC APPARATUS

ANAESTHETIC MACHINE
PART-1

By Cliquer Box

The range of anaesthetic equipment

can be quite bewildering. It is
especially important that you
understand the working principles
behind all equipment used for
delivering anaesthetic gases.

GAS SUPPLIES

Cylinders
Manufactured in different sizes.
Cylinders attached to an
anaesthetic machine are usually
size E, whereas those used for
manifolds (for supplying pipelines)
are usually size J

ANAESTHESIOLOGY | 33
VET TECH
Should be stored under cover
and not subjected to extremes of
heat or cold
Handle with respect – although
they are strong they can be lethal
if dropped onto a hard surface.
Don’t leave them propped up
against a wall. And never be
tempted to use WD40 on a stiff
valve unless you want to die
young!
Identified not only by labels but
also by colour coding
Oxygen is stored at a pressure of
13700kPa (137bar).
pressure indicates the
volume left inside the cylinder
Nitrous oxide is stored in a liquid
phase with gas on the top at a
pressure of 4400kPa (4.4bar).
Gauge pressure stays constant as
long as there is some liquid left
in the cylinder and does not
indicate gas volume remaining –
the cylinder needs to be weighed
to know this.
On one side of the valve block
are holes that correspond with
pins on the yoke of
anaesthetic machine (the pin-
index system). Each medical gas
has its own specific pin-index
configuration, which prevents
connection of the wrong cylinder
to a yoke
A sealing washer (called a Bodok
seal) must be placed between the
cylinder and anaesthetic machine
to make a gas-tight joint. Always
check that this seal is present
when changing cylinders – if it is
missing there will be a very loud
Gauge noise when the cylinder is turned
gas on!
·When turning cylinders on, open
the valve by two full turns – a
partially open valve may restrict gas
flow as cylinder pressure falls
Pipelines
Some practices now have medical
gases supplied by pipeline from a
central supply outside the building
(for reasons of economy and safety)
All piped supplies end in special
terminal units called Schrader
the valves. These valves are non-
interchangeable, i.e. an oxygen line
can’t be plugged into the Schrader
valve for nitrous oxide
· ANAESTHESIOLOGY | 34
VET TECH
The Anaesthetic Machine

Schrader valves are also labelled

and colour-coded like cylinders
Hoses connecting Schrader
valves with the anaesthetic
machine are also colour-coded

Oxygen Concentrators:
This is necessary to deliver oxygen
and other anaesthetic gases
accurately. The main components are:
Gas supply (oxygen ± nitrous oxide
± air)
Pressure gauges measure gas
pressures in cylinders or pipelines.
They may be mounted either on
top of the cylinder or on the front
panel of the anaesthetic machine
Extract oxygen from air (using
zeolite molecular sieves)
Need a source of electrical power
(which is their main drawback)
Maximum oxygen concentration
achievable is 95%
Now being marketed for veterinary
use

ANAESTHESIOLOGY | 35
VET TECH

Pressure Regulator(reducing valve) These valves are opened by knobs

on the front of the flowmeter
block and are labelled and colour-
coded for each gas. The oxygen
control knob is often larger and
more prominent than those for
nitrous oxide and air (a safety
feature).
A bobbin (or ballbearing) is
supported in the middle of a
Reduces cylinder pressure to a
tapered glass or plastic tube by
safer operating pressure of about
the gas flow. The higher the flow,
400kPa (4 bar).
the higher the bobbin rises in the
As well as reducing pressure, it
tube. Small slots are placed
also helps to keep the operating
around the top of bobbins,
pressure constant. Without a
causing them to rotate in the gas
regulator, flowmeters would
flow. A dot on the bobbin shows
need constant adjustment as
that the bobbin is rotating and
cylinder pressure fell.
functioning properly.
Positioned between cylinders
Read flow from the top of a
and the anaesthetic machine.
bobbin, and from the centre of a
Flowmeters and needle valve: ballbearing.

Vaporizers:

Flowmeters (rotameters) measure

flow rates of gases passing through
them and are calibrated for a
single gas.
Flow of gases to the flowmeters is
controlled manually by means of
needle valves (or flow control
valves).
ANAESTHESIOLOGY | 36

VET TECH

Designed to vaporize liquid

(volatile) anaesthetics
Deliver clinically safe
concentrations of anaesthetic
vapour to the patient
Calibrated for a single volatile
agent
As the liquid anaesthetic
Contain a ‘vaporization chamber’
vaporizes, it cools, and as a result
containing fully saturated
its saturated vapour pressure falls.
anaesthetic vapour (for isoflurane
All modern vaporizers are fully
the saturated vapour pressure is
temperature compensated (this is
240mmHg, or 32%). Full
why some of them are called ‘Tec’
saturation is achieved by
vaporizers!) so that output remains
increasing the surface area
constant over a wide range of
between liquid anaesthetic and
temperatures (and gas flows).
carrier gas, using some form of
Temperature compensation is
wick
achieved by making the vaporizer
Fresh gas flowing through the
from materials with high specific
vaporizer is ‘split’: it can either
heat capacity material (e.g.
flow through a bypass channel, or
copper) and/or having some form
pass through the vaporization
of temperature-sensitive valve that
chamber. It therefore mixes gas
can alter the proportion of gas
containing no vapour with gas
flowing through the vaporization
containing fully saturated
chamber
anaesthetic vapour to produce a
Always keep vaporizers upright
final mixture with appropriate
(otherwise the bypass channel
vapour concentration. The
may flood with anaesthetic and
‘splitting ratio’ (i.e. the proportion
dramatically increase output) and
of gas passing through the
don’t overfill them
vaporization chamber) is
Newer vaporizers have some form
adjusted by the control dial on
of key-indexed filling system,
the vaporizer
preventing them being filled with
the wrong agent.

ANAESTHESIOLOGY | 37
VET TECH

Emergency oxygen flush:

Oxygen is delivered to the

Some vaporizers are designed to be common gas outlet of the
positioned within the anaesthetic anaesthetic machine at a pressure
circuit (rather than the normal of 400kPa, directly from the
position on the anaesthetic cylinder or pipeline
machine). These are called ‘low The button is usually found next to
resistance’ or ‘draw-over’ vaporizers, the common gas outlet (where the
because gas flow through them is circuit is attached)
generated by the patient’s Bypasses flowmeters and
respiratory efforts. Exact vapour vaporizers
output is not known. These are Delivered at a flow of 30-70
found in the Komesaroff and litres/minute
Stephens’ machines, which are really It can dilute anaesthetic gases e.g.
circle systems with one or two draw- if used to fill an empty reservoir
over vaporizers ‘in-circuit’. The theory bag during anaesthesia
is that if anaesthesia is too light,
patient minute volume will increase, Compressed oxygen outlets:
vaporize more anaesthetic, and Some machines have auxiliary
increase depth (the reverse is also oxygen outlets (at a pressure of
true). They are not easy to use, but 400kPa) to drive ventilators
some practices have them.

ANAESTHESIOLOGY | 38
VET TECH

FOR ANY QUERIES,

CLARIFICATION OR FEEDBACK
ON THIS ARTICLE YOU CAN
FREELY CONTACT DR.CHRIS
SEYMOUR AT HIS E-MAIL ID:

CJS26682@GMAIL.COM

YOUR FEEDBACK IS VERY

VALUABLE TO US.

Oxygen Alarms

Operation should depend on low

oxygen pressure and not need
any other source of power
Ideally should cut off nitrous
oxide supply
Give an audible signal

ANAESTHESIOLOGY | 39
 TERMINOLOGY

TIVA-TOTAL INTRAVENOUS
ANAESTHESIA

By Cliquer Box 1. Easy to measure and administer drugs

The term TIVA is most commonly
encountered in books and articles on
hypnotic, sedative and analgesic drugs
like propofol, ketamine, fentanyl etc. It
is an abbreviation of “Total Intravenous
Anaesthesia.”It simply means
induction and maintenance of general
anaesthesia through intravenous
route.
TIVA interests many clinicians because
it does not require specialized
equipment like inhalant anaesthesia.
There are some advantages of TIVA in
veterinary anaesthesia that include:
without use of specialized equipment.
Thus can be used in any clinical setup
and field surgeries.
2. Surgical procedures in upper
respiratory tract where intubation can
interfere with procedure.
3. Better regulation in cranial surgeries
where reduced intracranial pressure is
required. Most inhalant drugs increase
intracranial pressure.
4. Reduced postoperative nausea and
vomiting.
5. Better cardiovascular and respiratory
stability

ANAESTHESIOLOGY | 40
TERMINOLOGY

Principle of TIVA: Mode of administration:

Basic principle of TIVA is to reach Injection of calculated dose of
desired therapeutic plasma anaesthetic is given as intravenous
concentration and maintain it over bolus to achieve desired level of
a period of time for surgical plasma concentration. Maintenance of
procedure. anaesthesia after induction can be
The drug administered in form of achieved by simple intermittent
bolus result in peak plasma boluses (commonly called “Top Ups”),
concentration (central Constant Rate Infusion or Target-
compartment) which is the Controlled Infusion.
redistributed to peripheral Intermittent Boluses: This is the
compartments (tissues and organs) simplest method of maintenance of
reperesented by Volume of intravenous anaesthesia and only
distribution or Vd , since site of require syringe and cannula.
action of anaesthetic drugs is CNS Calculated maintenance dose of
and not plasma Vd is an important anaesthetic is administered at regular
parameter to determine loading interval (according to clearance
dose, it is determined by rate).Dose and interval can be
pharmacokinetic studies in animals. adjusted according to physical
Lipophilic drugs are more easily parameters and depth of anaesthesia
redistributed and thus have more required.
rapid onset of action. Disadvantage: Plasma concentration
Drug is metabolized and eliminated oscillates between peaks and troughs.
from body at a constant rate called There is potential risk of overdosing
as clearance rate. Therefore in order due to accumulation in repeated
to maintain a steady state plasma administration and at troughs there is
concentration over a period of time possibility of awareness to painful
more drug needs to be procedures.
administered. Constant Rate Infusion (CRI): Drug
Drugs with rapid clearance and used for maintenance is given at a
shorted elimination half-life is constant rate intravenously.
desirable in TIVA due to rapid
recovery and better safety to
overdose and adverse drug effects. ·
ANAESTHESIOLOGY | 41
TERMINOLOGY Refrences and further readings:

Total intravenous anaesthesia in dogs:

A steady state of plasma
T.Waelber, P.Vermoere, I.polis.
concentration is maintained
throughout the procedure this Total intravenous anaesthesia (TIVA)
eliminates the risk of peak and in veterinary practice: Rukmani
troughs observed in intermittent Dewangan, S.K.Tiwari.

boluses. CRI can be given by simple

Total intravenous anaeastesia (TIVA)
infusion set where rate of infusion and partial intravenous anaesthesia:
can be adjusted by regulating K.W.Clarke,
clamp or with more sophistication
with specific volume pump. We will Pharmacokinetics of TIVA/TCI: Dr
Graeme Wilson Division of Paediatric
discuss CRI in detail in subsequent
Anaesthesia UCT Department of
issues of this magazine.
Anaesthesia & Perioperative
Target Controlled Infusion (TCI): It Medicine.
is computer controlled infusion of
anaesthetics, rate of infusion is
calculated based of
pharmacokinetics of the drug and
physical description of the animal.
Devices for TCI is available for
human anaesthesia. There is still no
reliable TCI equipment and software
for use in animal anesthesia.

PLEASE GIVE YOUR FEEDBACK ON THIS ARTICLE, ALSO TELL US HOW WE CAN IMPROVE OUR
ARTICLES AND WHAT YOU WOULD LIKE TO INCLUDE OR REMOVE FROM NEXT ISSUE. PLEASE
MAIL US ON:

OR

IF YOU WANT TO WRITE AN ARTICLE FOR THE MAGAZINE. PLEASE MAIL US ON:

AMISHRV55@GMAIL.COM

YOUR FEEDBACK IS VERY VALUABLE TO US.

ANAESTHESIOLOGY | 42