Vet School 101 Understanding “adverse anesthetic events” in pets (Part 1: The numbers)

November 16th, 2008  

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I actually have no idea whether your practice extends beyond cats and dogs, but I've heard conflicting information about the risks of anesthesia for rabbits, and I'd be interested if you had anything to say!

Sarah November 16th, 2008 12:35:18 PM

Like Sarah, I too am curious about other animals - there's lots of anecdotal evidence among birds that they do not do well with anesthesia.  Of course, anecdotes are NOT data, and it sounds like it might not be well-studied enough to draw conclusions. 

Also, I'm really curious as to what factors increase or decrease the risk of "adverse anesthetic events" - for example, years of experience of the vet, weight of the animal, health of the animal, cost of the procedure, personality of the owner, etc.

zandperl November 16th, 2008 12:40:18 PM

As you know, I maintain a website about what happened to my cat. Sometimes I hear from other people who have lost pets due to what they believe is veterinary malpractice. In the 3 1/2 years or so since I've maintained this site, I've only once heard about the same vet twice, and it was anesthetic deaths of pets being seen by a local dentistry specialist.

The owners of one dog testified locally for some legislation, and said that their 11 year old dog had been kept under over 3 hours by these people. They didn't really communicate apparently about the number of extractions the planned to do. By the time the dogs heart gave out at over 3 hours (according to them), the vet had pulled all the teeth on one level of one side of the dogs mouth.

Later, I heard from an owner whose dog died at the same place pretty much immediately after induction.

What kind of anesthetic protocol are these people using, I want to know?

I now advise people to discuss exactly what anesthetic agents will be used and try to get a review from someone. Also, specify exactly how long their pets are to be under. From what I've seen, it's better to come back in 6 months for more work than to allow them to be kept under HOURS AND HOURS at a time.

Is that correct?

Stefani November 16th, 2008 01:20:58 PM

Maybe I'm a rare bird, but I honestly am not all that frightened of anesthesia. I have a healthy amount of concern, but I wouldn't put off something reasonably important, simply for fear of a potential adverse reaction, in an otherwise healthy, uncompromised pet (or myself). I'm just not the kind of person who allows fear to make my decisions. It's a factor, but rarely is it the deciding factor. Let's take lipomas, for example. Yep...they're unsightly. Typically benign. Most dog owners live with 'em, if their dogs got 'em. I'm well known as saying I'd have them removed, if they became too large or impeded my dog's abilities too much. (knock wood, I haven't had that problem yet, though) My good friend, a veterinarian herself, sticks to her mantra against anesthesia at (virtually) all costs. Her Doberman had several large lipomas for the last few years of her life. The largest one was directly behind the elbow, and rubbed with every step. When I'd admit that I'd've had them removed from my own dog, my friend would just smile a rather condescending smile, and look at me as though I was frivolous and unconcerned about my dog's welfare. "You'd risk anesthesia to remove something that doesn't bother the dog anyway?" Well...er...all things being equal..."Yes." I'm either that confident, that naive, or that "centered," depending on how you want to look at it. ;-) Because of that stance, though, I'd often wonder why any less-than-life-and-death procedures are EVER done, if anesthesia really is as dangerous as my friend makes it seem. Friends recently put down their Dane after a short bout with osteosarcoma. After the dog was diagnosed, I was asked what I would do, if I were in their shoes. I replied that the affected leg would be off in no time (assuming it hadn't already metastasized). But their veterinarian told them that "at her age" (about 9 1/2) they shouldn't risk the anesthesia, etc., etc. So they just managed her pain until "it was time," a few months later. Let's just say that vet's answer wouldn't fly very well with me and my 10-year-old, very active and puppy-like Dane, if I found myself in similar circumstances. For me, anesthesia for important medical procedures is a no-brainer. But for even moderately important procedures, I'm not fearful to the point I'd automatically say no. I'd weigh the pros and cons objectively. Then again, contrary to the opening line, "Sadly, everyone knows someone whose pet has died mysteriously under anesthesia," I don't actually personally know anyone to whom this has happened. (And I've been involved with animal welfare, dog training, and the dog community, for decades.) I suppose puts my views in perspective, though. ;-)

Marjorie November 16th, 2008 02:03:57 PM

Sorry about the lost paragraph formatting, again. I know it's hard to read a big block of text. :-)

Marjorie November 16th, 2008 02:04:48 PM

Therein sometimes lies the rub, though, especially with dentistry. Put a simple cleaning off year after year out of fear of anesthesia, and ultimately, it's no longer a simple cleaning that's necessary...we're talking dental radiographs and extractions, etc., which increases length of anesthesia. As a member of the staff that's responsible for the bulk of dentistries, I cringe when I see the elderly pets on the board whose owners have neglected their dental care, for whatever reason. It seems the pets tend to have a little more difficulty under anesthesia despite their clean bloodwork and our use of i.v. fluids, propofol, and sevo, and I know there's no way to make it a quick procedure and still do a good job. Same goes for older dog spays (not neuters so much, it seems). Especially big, fat dogs. I've seen my docs cringe, too, when they see such a pet on the board. I can understand an owner's fear of anesthesia - I don't like having my own pets go under. In fact, my coworkers and I kind of have an understood pact that no one be the anesthetic nurse for their own pets...although we do tend to hover and drive each other crazy.

anna November 16th, 2008 02:07:42 PM

I have been practicing for a little over six years - I succumbed to the statistic of losing a pet under anesthesia this past year. There is nothing like it when it is a young animal in for a 'routine' procedure. It only takes one of these adverse reaction type deaths to snap you back to reality - and for me was so upsetting I had some thoughts of whether or not to keep practicing. We had done pre-op bloodwork, placed IV cath and administer fluids during procedure, has ECG and pulse ox monitoring during procedure and was down all told about 30 - 45 min. The patient did fine during the procedure - no problems noted but died until the 'recovery' phase. No obvious reason for it - I can only guess Cardiomyopathy - no necropsy was done. I can say I would do things different but I can't say what I had initially done that was so wrong. I did everything that I would do (and have!) done for my own pets. It was devestating......I hope that is my one for life; I am not sure I could go through it again. We, as vets, know it can happen but I do think it is important to know and acknowledge as owners that it can happen. There is no routine anesthetic procedure --- I think a healthy amount of respect is needed each time you approach something like anesthesia. It doesn't mean you have to be afraid but be involved in the process. Discuss with your vet what is going to be done and how. Maybe some owner's just don't want to know but I think that is important for everyone to be on the same page.

JC November 16th, 2008 05:57:26 PM

Fortunately I've never lost any of my pets during an elective procedure - but I know lots and lots of people who have, usually during or especially after spays. Most of the dogs made it fine (apparently so) during the surgery but died during recovery. This has been reported so often that the Great Dane Club of America actually commissioned a study about it and came up with specific surgical guidelines - you can read them here: http://www.gdca.org/health/surgery.htm There isn't anything there that most vets don't recommend anyway - except maybe the emphasis on keeping the patient warm during surgery and recovery. In my experience some clinics are better at that than others. I know there are human studies linking post surgical hypothermia to the development of DIC, but I don't know if any similar studies have been done in dogs or not. But of the post-spay deaths I've heard of, most seemed to involve some sort of clotting problem.

Barb November 16th, 2008 07:15:57 PM

If you want to go to that link I posted, trim off the word "There" - it got attached to the link somehow.

Barb November 16th, 2008 07:17:30 PM

I have seen too many cats with adverse reactions not to the actual gas,(isoflourine) or even the propofol, but to ketamine. So I simply do not allow my vet to use ketamine with any of my cats.

since I have insisted on that change, none of my cats old or young have had any trouble. But I've almost lost cats to the use of ketamine.

I don't worry about anesthesia without the ketamine, but I do just simply worry about my pets during any procedure.

LorriM November 16th, 2008 07:42:27 PM

JC, I appreciate your candidness and feel very badly that happened to you. For years a chest x-ray was always recommended pre-anesthesia, would that have helped on a cardiomyopathy? When I went to a new clinic, chest x-rays were not protocol, as blood screen was, and an optional ECG. I was a bit nervous about that. Here again, tomorrows post will be enlightening on what expectations are within reason. Having a dog anesthetized for a 4 hour duration, I was extremely nervous! After all, I witnessed family members post-surgery and mental confusion happens. We were explained the protocol and I am happy to say, I observed NO adverse reactions at all! No mental or personality changes. But are all these safeguards in place everywhere? I have had to risk anesthesia more than once on an elderly pet, with infected, cracked molars---there I felt it was a no-brainer quality of life issue. But removing a lipoma or mammary lump on a 15 year old?? Nope, not me, not to mention the after healing that has to take place. Barb, funny-odd that you should say about the lipoma. A woman told me the other day about losing her 7 yr. old Dobie post-sugical wounds and infection for a lipoma removal. And how about surgical rapid & volumous blood loss, happens with humans...

Barbara "Pocket's Story from NH" November 16th, 2008 07:49:04 PM

Lori, (or Dr. K), what are alternatives to ketamine?

My vet uses that on my cats.

Stefani November 16th, 2008 08:13:45 PM

ketamine is an extremely safe drug. it supports both heart rate and blood pressure - as opposed to propofol which is a potent, potent respiratory depressant and actually often causes a brief period of apnea (not breathing) after induction.

ketamine does induce muscle rigidity, cats keep their eyes open while under anesthesia (if nothing else is used), and they often have rough (read: thrashing around and hallucinating) recoveries - but i have NEVER seen a cat die from ketamine. EVER.

ketamine and valium is a GOLD standard induction agent because it is very cardio-vascularly stable and supports the body's system, while propofol and thiopental cause respiratory depression.

as an emergency doctor - in ANY unstable patient - ket/val is my combination of choice for induction, bar none.

lorriM: i'm interested in what you mean about having nearly lost cats to ketamine? i find this extremely hard to believe. they may have had rough recoveries that were disturbing to witness, but actually dangerous? i highly doubt it.

homeless parrot November 16th, 2008 08:30:07 PM

sorry homeless parrot, I completely disagree ketamine is dangerous to cats ( and even more so in some specific breeds) and some even develop further medical problems. Hardly a "gold " standard. and too much valium will fry the cats liver.

There are many articles citing it's dangers.

Propofol is only dangerous if it is given too quickly, and supportive respiratory care is all that can be required in those few cases. The danger of propofol is with the giver, not the drug.

ketamine is easy, which is why it is so popular. I certainly wouldn't recommend it for an unstable patient as it can significantly raise blood pressure as well.

No ketamine ever for my  animals. Cats or even my dachshunds.

LorriM November 16th, 2008 08:58:54 PM

Barbara - A chest xray would probably not have helped in my case. There was no heart murmur on auscultation and the ECG during surgery was normal. Maybe an Echo would have shown a problem but (and I am sure I am not alone) that is not usually something that I routinely recommend in an otherwise normal healthy 16 week old animal with no family history or risk factors.

JC November 16th, 2008 09:17:26 PM

Barbara-

I may be wrong, but I don't think radiography is a particularly reliable means of detecting cardiomyopathy (except maybe in severely affected animals).

One of my cats received an incidental chest x-ray two years ago when he injured a forelimb. The ER doc thought there was a possibility that his heart might be slightly enlarged. Specialists reviewed the films, and felt everything checked out within normal limits.

Less than a year later, he received a steroid injection and wound up in congestive heart failure. At the time, the only appreciable anomaly on his x-rays was the fluid, which initially led the ER doc to suspect asthma. (Although he, too, gave me the 'there is a possibility this might be ever so slightly enlarged' spiel.) The next morning, the radiologist reviewed his films, and I received the 'So.. we have more information.. and, um, you need to call us. Now.' message. He was diagnosed with HCM via echocardiogram the next morning.

Because his enlargement is relatively mild, I doubt he'd have been pegged as an anesthetic risk via x-ray. If I had any preanesthetic concerns regarding the possibility of a heart condition, personally, I'd just shell out the extra cash and opt for the echo. The cost might be prohibitive in some cases, but I don't know how much assurance you'd really buy with the x-rays.

Ramen Connoisseur November 16th, 2008 09:37:52 PM

JC-

Even as a client who has recently had one pet experience an unexpected cardiac event and lost another during the post-surgical recovery period (to the vet's credit, this was an emergency procedure and the outcome was not entirely unexpected).. I can't see myself ever opting for an echo on an animal of that age with no apparent risk factors. I would imagine that even if the option were made available, the owner probably would not have taken it. Heck, I've gone under three times, and nobody's ever subjected me to one.

Ramen Connoisseur November 16th, 2008 09:52:06 PM

The only animals my vet had to put in anesthesia for me are rodents: fancy mice, some gerbil species, jerboas and some others. It almost always worked out fine, of about 300 hundred mice I had neutered (for a private rescue organisation) only about five died. So I'm not really afraid of anesthesia. My vet uses Isoflurane, inhalational anesthesia. I wouldn't trust an injection anesthesia that uses only one drug (ketamine or others), but I've heard good things about a combination of several drugs both for putting the animal to sleep and for waking it up again.

As far as I know, rabbits can be a problem when you use inhalational anesthesia because they can hold their breath for a really long time.

Jennifer November 17th, 2008 02:29:58 AM

I have seen plenty of anesthetic procedures done, and participated in a few. Even our class of sophomore vet students got all 90 of our spay/neuter patients through their operations successfully (and some of them were under for three or four hours, since it was our first surgery). I've seen only one death after a rough anesthetic experience, and that animal was shown to have underlying heart disease on necropsy that wasn't apparent on EKG or pre-op bloodwork.

That said, I still turn in to a nervous mess when my girl needs to go under anesthesia. I just have to hand over her leash and try not to think about it, or I drive myself crazy with what-if's.

Megan November 17th, 2008 08:23:02 AM

As to the questions on rabbit, ferret, reptile and bird anesthetics. Yes, the risks seem much higher. I personally believe that's because there's been much less research done...and because it seems easier to extrapolate from human medicine to canine and feline medicine. But I'm no exotics vet. I practiced some exotics for two years right out of school. It's been a loooong time.

Dr. Patty Khuly November 17th, 2008 08:35:19 AM

I lost a greyhound to anesthesia-caused hyperthermia (heatstroke/brain seizures), which can be a problem in sighthounds and other dogs with little body fat. Dr. K., can you explain the how and why of body fat and amounts/types of anesthesia? Btw, birds generally have little body fat, and their lungs are really big in relation to their body size, so their risks are higher. Reptiles also can be 'skinny beasts' and their respiration rates can often be both shallow and slow, which really causes trouble inducing and clearing anything they're given.

Kate November 17th, 2008 10:02:15 AM

Interesting, in all the years I've scheduled some older dogs for teeth cleaning, I've only had ONE cancelled by the clinic---yes, that was my dear Pocket, http://clik.to/scotty and the reason cited was grade 2/6 heart murmur...I can only suspect in "retrospect" that a lot more was suspicious at the time and not disclosed. Particularly, since I have had several others go under at the same or older ages. This is a real tough dilemma...does anyone pull teeth with novacaine in the veterinary field??

Barbara "Pocket's Story from NH" November 17th, 2008 11:13:39 AM

You know Barbara, I recently was told that my 2 y/o cat has a grade 2 heart murmur. I wonder if he won't be able to have dentals? He made it through linear foreign body surgery, but I don't want to push it.

Poor lil guy. I will eventually probably do a cardiac follow up but right now, someone else is next in line for a long overdue dental.

Stefani November 17th, 2008 03:27:29 PM

Kate brings up an excellent point... I think that animals (especially dogs) with low amounts of body fat tend to be overdosed on anesthesia. When you think about it, there is a HUGE difference in fat:muscle ratio in, say a 120 lb. Lab or Rottie, and a 120 lb. Dane or Wolfhound. Yet since the dosage is figured by weight, both animals might be given the same dose of anesthetic.

Barb November 17th, 2008 08:13:29 PM

Stefani, I suspect that Pocket had a grade 2 heart murmur for years ---have you ever read the chart on murmurs? Perhaps, we may learn of what anesthetic risk that really poses? And for a dog to live in a cage for a week with no nourishment or sustenance, her heart must have been pretty strong to have not given out, particularly when she was receiving 60+ ml/hr. fluid rate (10 lb. dog) to cause jugular vein distended (I still feel sick over that--) details: http://walnut-hill.bravehost.com

Barbara "Pocket's Story from NH" November 17th, 2008 10:13:20 PM

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I think the problems with exotic anaesthesia are probably more to do with the lack of research in that area, and the lack of experience the average vet has in anaesthesising these species, than something fundamental about rabbits etc.  When I get my rabbits neutered I have always made sure that I have a vet who is reasonably experienced in rabbit anaesthesia and I ask the questions suggested on the House Rabbit Society website (http://rabbit.org/).

Sian November 18th, 2008 09:18:23 AM

Jennifer: "only" 5 out of 300 died?!  That's 1 in 60!  The rate of death in dogs and cats of 1 in 1,000 is so high that if that happened in humans we wouldn't see anesthesia used except in life-threatening situations.  If it were 1 in 60, I don't think we'd even be using it then!  Those sorts of risks are entirely unacceptable in humans, why do we let our pets face them?  The pet industry should be putting more money into researching causes and helping to reduce the risk.

zandperl November 18th, 2008 09:26:35 AM

I looked it up in my records and I got the numbers a bit wrong (too many mice...): there were three dead fancy mice in over 400 that the vet neutered and one dead bushy-tailed jird. Two of the three mice died from complications, not during the operation itself. With mice, even 5 of 300 would be an excellent ratio, though, many vets admit that they have a success ratio of only about 50%. Mice are delicate and overdosing them is easy, especially with lack of experience. The thing is that male fancy mice more or less only have the option of neing neutered or living alone for the rest of their life, which is nothing but torture for such a social animal. Male mice will fight (with rare exceptions, usually in small cages), but neutered males are perfectly fine with each other.

I couldn't agree more about doing more research on small animal health care in general, it's really hard to find a vet who is willing to even treat a mouse, not to mention operate on it. Many think it's a waste of money.

Jennifer November 20th, 2008 03:12:31 AM

I found your site while trying to find answers to the death of a cat I was trying to rescue last Sunday. We heard him days before we rescued him, but couldn't find out where his meow was coming from. Finally we tracked it down to the inside of an abandoned building, about 20 feet in the rafters. He had wandered in a side window and climbed up there probably trying to find a way out. We called the fire department before we knew where he was, and they did a quick half assed search of the building and told us we were just hearing things.

After they left, I searched the building myself and found the cat in the rafters, but I couldn't get him to come down. Someone saw us and called the cops, and the stupid cops who came tried to scare the poor cat down by trying to smack the rafters with a metal pole. I finally got the jerks to stop and leave, and I called animal control. An animal control officer came and tried to get him down but couldn't, so he had to tranquilize him. When they got him down we could tell he was dehydrated and malnutrished, so I was very happy that we did something to save him.

After they took him I called and fought for days to get animal control to let us adopt him, and they wouldn't because they said he was aggressive. I made many calls and plead my case with every authority I could, and finally the director of the animal control center gave us the okay to adopt him, but first he would have to be neutered. I was so relieved and after days without sleep, I drove over and signed the adoption papers. About 4 hours later I get a call that he was dead, and died due to complications of the anesthesia.

I am so angry and heart broken right now. I was trying to save the poor cat, not cause his death. I really need answers. I need to understand what happened and how this happened. I blame myself because Animal Control would have never captured him if I didn't call with the hopes to try to save him. What happened? Why would he live through being tranquilized on Sunday, then die while going under anesthesia on Thursday? I just wanted to help him. I wanted to save his life. :(

Jonathan November 21st, 2008 06:34:36 AM

One thing that needs to happen more in the veterinary field: M&Ms.

Morbidity and mortality reviews aren't terribly commonplace (in my experience) and are SO SO SO invaluable when trying to advance the quality of medicine we practice.

I also think that every unexplained death should be followed up with a full necropsy.

We do make mistakes (great example mentioned above-overdosing sight hounds!!!), but the real crime would be to not learn from the mistakes.

Morgan November 23rd, 2008 08:34:14 PM

Jonathan: What a sad story. I'm sorry this happened. I can honetly say I've never seen a cat die during a neuter. But sometimes these stray/feral cats have a lot of underlying issues. I also know that many shelters don't  (can't?) offer the kind of careful anesthetic monitoring most of our pets would get in private practice. I can't speak to this individual cat's issues but I can say that you did a wonderful thing--regardless of the outcome. Please don't let it keep you from adopting another needy one. Sometimes things just happen...

Dr. Patty Khuly November 24th, 2008 11:54:25 AM

I would never again allow any future dog I may own to go under anethesia for teeth cleaning. I purchased him at age 3 for protection. My 8 yr. old German Shepherd died on Monday, January 19, 2008 from overdose of anethesia. My dog had his teeth cleaned with this same vet before. Fargo had all the pre-bloodwork that morning and last week when we took him in for consultation our vet commented his heart beat was slow, although he was excited showing he was in great heart health. Here is the story the vet told us. He gave him the minimal amount of pre-meds and since he was not groggy enough, he put the mask on him for a few seconds. Immediately, he saw his chest pound once, then his heart stop, this happened again, then he went into cardic arrest-meaning his heart rate accelerated, then stopped for good. He then gave Fargo ephinephrine and some other injection into his iv. He did this again, as there was no response. He then did palpations working on him for a total of 20 minutes. He was gone. I am heartbroken and angry at the vet and will never put another pet through that at such great risk of death. There are alternatives to surgery that I am now aware of just by doing a couple searches on the internet. I only wish I would have known of them prior to this. The number of dogs dying from overdose of anethesia is 1 in 400 and can be as high as 1 in 200. For all of you who were 'lucky' enough your dog survived anethesia, I would hope alternatives to anethesia for teeth cleaning is something you would look into. Good oral health is extremely important. As for me, as I stated earlier, I will never put any future dog I may own at such high risk of death for teeth cleaning. Life or death situations for dogs=anethesia and nothing else. Thank you for taking time to read my story as I continue to grieve losing my absolute best friend.

Sharon January 21st, 2009 07:12:18 AM

My healthy, 1.5 year old cat went in for spaying yesterday.  We came to pick her up, and were told they almost lost her on the table.  I was told she had a severe reaction to anesthesia, and her heart stopped for TWO MINUTES!  But they brought her back with epinephrine and chest compressions in the nick of time.  She seems to be doing okay now (she has enough energy to try to get her ecollar off).  I guess they didn't call me because they didn't want me to freak out.  I have been looking for info about these kinds of reactions in cats, but it seems more likely that they overdosed her.  She is light for her size if you know what I mean--she is very lean and muscular, but long.  So she looks like she should weigh more than she does.  Astonishingly, once she was back out of it, they did the procedure under light gas instead of calling me to see if I wanted her to go ahead with the surgery.

Amanda February 3rd, 2009 08:27:03 AM

Ann May 10th, 2009 09:19:38 PM

Hi,

 

Can someone answer a question. I took my 16 year old cat to the Vet for a senior exam. the vet used the isoflurane anesthesia to examine him because he was aggressive, and she was afraid of getting scratched/bitten. She gave him a rabies shot before examining. She then felt a mass in his intestinal area and did a needle aspiration but accidentally got some bacteria/feces mixed in with the tissue.  She gave him two different antibiotic injections to ward off any possible infection and gave me some amoxicillin to take home.  Now when I took my cat in he was feeling fine and showed no symptoms.  When I got him home, he was not the same cat and was deathly sick.  I was heartsick as I trusted this Vet.  I questioned and questioned this Vet, and she said she did not know what caused him to be so sick.  Any answers?  I eventually got him to a different Vet where he survived seven more months.  but I am haunted over what could have happened during that Vet visit.

 

 

 

Ann May 10th, 2009 09:31:30 PM

I recently lost my english bulldog during neuter surgery.  We believe it was due to an error made by the vet and are currectly proceeding with a lawsuit.  Unfortunately, some states do NOT consider pets as part of the family.  So the laws are horrible.  Investigate your vet before allowing them to preform surgery on them!

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