CURRENT CONCEPTS IN PHARMACOLOGY OF ANAESTHETIC AGENTS

IN RELATION TO DIAGNOSTIC PROCEDURES IN ANIMALS

K.ADILAXMAMMA*, E.MADAN MOHAN AND M.ALPHA RAJ,
DEPARTMENT OF PHARMACOLOGY & TOXICOLOGY, COLLEGE OF VETERINARY SCIENCE, TIRUPATI

Anaesthesia is used for a wider range of circumstances in animals than in

humans due to unwillingness of animals to co-operate with certain diagnostic /
therapeutic procedures.

The diagnostic procedures requiring anaesthetic procedures are

• Endoscopy
• Bone marrow aspiration
• Ultrasonography
• Magnetic resonance imaging
• X-Ray imaging
• Aggressive animals
• Exotic and wild animals

Differences between surgery and diagnostic procedures

Diagnostic procedures differ from classical surgery in the following aspects

i. Elective
ii. Minimally invasive
iii. Short duration
iv. General anaesthesia or sedation is usually required to assure patient
immobility during these procedures.
v. Anaesthetic should provide rapid recovery
vi. Not life saving

Principles of anaesthesia for diagnostic procedures

i. Identification and correction of underlying patient problem to minimize

anaesthetic risk.
ii. Formulation of an anaesthetic protocol feasible with existing environment
and that can be readily adapted to individual patient and its disease
process.
iii. Application of effective and adequate monitoring provision of appropriate
supportive therapy.
iv.

*
Presenting author

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 Anaesthetics commonly used in large animals include – Alpha – 2 receptor
agonists like xylazine, romifidine, detomidine, medetomidine. Propofol is rarely used
in large animals due to cost factors. Butorphanol is used in all species. Ketamine is
used in many species. Etomidate and desflurane are used only in university
hospitals.

Patient Preparation

Pre-anaesthetic patient assessment including physical examination and

laboratory evaluation (complete blood count, chemistry panel and urine analysis) is
essential for successful outcome. For marrow and organ biopsy, a coagulation
profile should also be evaluated. System specific diseases and interactions should
be considered.

Protocol Selection
When formulating an anesthetic plan, reversibility, familiarity and maintenance of
homeostasis by provision of adequate supportive care and monitoring should be
addressed. The plan should meet majority of patients and should be compatible with
the facility.
• The drugs should be short acting and or reversible
• For premedication, an opioid alone or with a benzodiazepine has relatively
mild cardiopulmonary effects and will provide sedation and reduce induction
and maintenance requirements. The opioid can be reversed with naloxone
and benzodiazepine with flumazenil, if necessary.
• Acepromazine premedication may be beneficial for healthy animals that are
difficult to restrain or aggressive, if there are no patient contraindications.
Acepromazine facilitates a smooth but prolonged recovery, so the benefits
should be weighed against the disadvantage.
• Ketamine with an opioid–benzodiazepine combination may be beneficial in
fractious cats to provide sedation and immobilization. Induction options
include propofol, etomidate, ketamine and inhalant agents. Propofol is
probably the most frequent used because of its short duration of action, but
can be detrimental in animals with underlying hypotension that remains
uncorrected prior to induction. Etomidate may provide a better alternative in
cardiovascular –compromised patients.
• Ketamine with benzodiazepine represents an alternative method for induction
but recovery may be prolonged. Contraindications for ketamine use such as a
history of seizures and the presence of increased intracranial pressure are
particularly dangerous to patients undergoing MRI and CT. Induction with an
inhalant agent via facemask may be used if other options present

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 unacceptable patient risk. A major disadvantage with mask induction is waste
gas pollution and subsequent exposure of personnel.

Monitoring

One or more monitoring devices should be applied to every individual patient

to help assure its well-being. Monitoring techniques could be

Continuous ECG
Pulse oximetry
Capnography
Blood pressure monitoring
Measurement of end – tidal anaesthetic gas concentration

The use of montoring should be tailored to individual procedure. Pulse

oximetery is especially important for assessing patients at risk for developing
hypoxemia such as during bronchoscopy and thoracostomy. Capnography is useful
for intubated patients at risk of hypoventilating (thorocostomy tube placementa).
Availability of mechanical ventilation to provide intermittent positive pressure
ventilation (IPPV) is important during diagnostic imaging. IPPV in combination with
capnography will enhance patient management by assuring ventilatory homeostasis.
Increased intracranial pressure caused by trauma or brain tumor is a common sign
in patients undergoing CT or MRI imaging. Maintain these patients in a mildly
hypocapneic state (PaCO2 = 30 mm Hg) will improve anesthetic out come by
minimizing the detrimental effects of increased CO2 on intra-cranial pressure.

Anaesthesia in different diagnostic procedures

Endoscopy

The visual examination of internal organs with out invasive surgery and
performed with a rigid / flexible fiberoptic instrument is termed as endoscopy.

a. Respiratory Endoscopy: This is one of the most valuable diagnostic

procedure to evaluate air way diseases in dogs and cats. Respiratory
endoscopy includes rhinoscopy, laryngoscopy, bronchoscopy. General
anaesthesia is required. Generally, gas anaesthetics are used for rhinoscopy
and injectible anaesthetics are used for laryngoscopy and bronchoscopy.

i. Rhinoscopy : It is the visual assessment of nasal cavity , nasopharynx

and in some cases paranasal sinus. A complete examination requires
general anesthesia, due to strong airway protective reflexes (sneezing and

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 gagging). Rhinoscopy requires a deep plane anaesthesia especially for
posterior rhinoscopy. Topical lidocaine sprayed on mucosa may blunt
some of the reflexes.
ii. Laryngoscopy: It is a gold standard for assessing laryngeal diseases
and it allows for evaluation of both anatomical as well as disorders of
intrinsic laryngeal function / motion, specifically, laryngeal paralysis. Light
plane of anaesthesia is required so that animal maintains gagging reflex.
Sedation is required to facilitate relaxation of the jaw, but anaesthetic
should be carefully selected to have a minimal effect on laryngeal function.
It can be challenging to keep patients adequately sedated without
affecting laryngeal function. A neuroleptanalgesic combination of an opioid
and benzodiazepine is adequate for most patients. These drugs have the
advantage of preserving laryngeal function and being reversible if
respiratory distress develops. Challenge with doxaparam 1mg/kg i.v to
increase respiratory activity may be used if evaluation is hindered by drug
induced respiratory depression.

iii. Bronchoscopy : It is the gold standard for diagnosis of lower respiratory

tract diseases in small animals. It may be used for diagnosis, therapeutic
and prognostic purposes. General anaesthesia is necessary to control the
reflexes during bronchoscopy there by preventing trauma to airways and
protecting the endoscope. The ideal anaesthetic should provide good
patient restraint, minimal effects on cardio-pulmonary effects, reversible or
short duration of action and should facilitate smooth recovery. The general
anaesthetic propofol is used with either atropine or glycopyrrolate or either
acepromazine or butorphanol. This anesthetic is adequate and allows
rapid patient recovery. Bronchoscopy is performed in dogs and cats for
evaluation of airway disease and to perform bronchoalveolar lavage. Many
of the patients presented for laryngoscopy and bronchoscopy are at
increased risk for development of hypoxemia. Preoxygenation should
accompany both the procedures and the anaesthetist should always be
prepared to take control of the airway by intubation and application of
ventilatory support. During the bronchoscopy, oxygen may be delivered to
smaller patients via an endoscope-working channel. Larger patients may
be intubated and connected to oxygen by a breathing system: a Y-piece
aperture may be used to pass the endoscope into the trachea. An opiod-
benzodiazepine combination for sedation, followed by administration of
low-dose propofol to effect, is commonly used to facilitate bronchoscopy.

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 b. Gastrointestinal Endoscopy

Gastroduodenoscopy and proctoscopy may be performed in relatively

healthy dogs or in dogs with a history of chronic weight loss. The decreased
serum protein concentration may result in decreased anaesthetic requirement
for thiopental or propofol and serious loss of fat and muscle will result in
prolonged recovery from thiopental. Premedication with atropine and
morphine is reported to enhance the chances of passing of the endoscope.

Bone Marrow Aspiration

This is performed to evaluate bone marrow disease and to stage certain

cancer patients. Protocol selection should be based on the individual patient;
depending on the level of an animal’s activity, bone marrow aspiration may be
performed in dogs with local infiltration alone or in combination with sedation.
Uncooperative dogs and the majority of cats may require general anaesthesia.
Reversible agents with mild cardiopulmonary effects, such as combination of a
benzodiazepine with butorphanol or puprenorphine provide adequate sedation in
most patients. Propofol, benzodiazepine–ketamine combination or etomidate are
good induction choices, providing for relatively rapid recoveries.

Laproscopy

This is an operative procedure designed for the visual inspection and biopsy
of peritoneal cavity and its organs. General anesthesia with gaseous agents like
isoflurane and sevoflurane are preferred. Propofol is commonly used for the
induction of anesthesia. In depressed patients, local anesthetic agents may be
sufficient used either alone or in conjecture with a combination of diazepam and
butorphanol or propofol. Oxymorphine or butorphanol provides analgesia, which is
often beneficial to the patient during recovery.

Ultrasonography

It is a routine diagnostic procedure for animals. Most animals tolerate us

evaluation without sedation or anaesthesia, but sedation may be necessary in
fractious, aggressive or painful animals. Ultrasonography guided organ or tissue
biopsy is becoming a common method for collecting samples less invasively. Small
animals usually tolerate the procedure well with sedation and local anaesthetic
infiltration, but general anaesthesia may be more effective in some individuals. Local
anaesthetic infiltration alone or with mild sedation, combined with proper restraint is
effective for collecting biopsy samples in standing horses, cows and other large
animal species.

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X-Ray Imaging

Patient must remain motion less and be precisely positioned for x-ray. A
profound sedation or general anaesthetic protocol should be used that is easily
administered and has a quick recovery time. During x-ray, personnel cannot be
present in the X-ray room to directly monitor the animal because of radiation safety.
Remote monitors or cameras focused on the patient and in-room monitors should be
used to assess the patient.

Computed Tomography And Magnetic Resonance Imaging

Anaesthetic management for CT and MRI presents unique challenges

• There is no painful stimulation during the anaesthetic period. Thus,
response to a noxious stimulus does not provide a method for
assessing anaesthetic depth.
• The majority of the patients of scans are performed with dorsal
recumbency, which has the most significant detrimental effects on
ventilation and perfusion matching.
• Access to the patient is limited during CT and MRI. Hence subjective
evaluation such as assessment of pulse quality and mucous
membrane colour may not be feasible. With CT although patient
access is not problematic, exposure of the anaesthetist to radiation is
an issue and direct patient assessment during scan is discouraged.
• Reaction to contrast media administration in animals is relatively
uncommon but potential complications can arise.
• Traditional anaesthetic equipment and monitors may be unsafe, may
be damaged, may malfunction or may interfere with the image
generation when used in MRI suite.

Anaesthesia for CT and MRI is most commonly maintained with an inhalant

agent. Isoflurane and sevoflurane both facilitate a rapid recovery. If Anaesthesia
machines and ventilators, which are not MRI compatible, are present, anaesthesia
can be maintained by propofol by using a constant rate infusion or intermittent bolus
technique. Maintenance with propofol should always include intubation,
supplemented with oxygen and a method for ventilatory support. Patients
anesthetized for MRI and CT require i.v. fluid administration to maintain adequate
perfusion and application of monitoring devices to identify and address alterations in
homeostasis proactively.

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 Premedication : Opiod – benzodiazepine combination
Opioids (IV, IM or SC; IV administration of morphine is not
recommended)
Butorphanol 0.2 – 0.4 mg/kg
Buprenorphine 0.01 – 0.04 mg/kg
Morphine 0.4 – 1.0 mg/kg
Hydromorphine 0.1 – 0.2 mg/kg
Oxymorphone 0.05 – 0.1 mg/kg
Benzodiazepines (Diazepam: IV only; Midazolam : IV, IM or SC)
Diazepam 0.1 – 0.4 mg/kg
Midazolam 0.1 – 0.3 mg/kg
Antagonists
Naloxone (opioid) 0.001 mg/kg
Flumazenil 0.01 – 0.02 mg/kg
(Benzodiazepine)
Induction
Propofol 2-6 mg/kg, IV.
Etomidate 0.5-2.0 mg/kg, IV.
Ketamine 2-5 mg/kg, IV, IM.
Maintenance
Inhalation anaesthesia : Isoflurane or Sevoflurane
Propofol, CRI 0.4 mg/kg/min
Propofol, IB 0.5 – 2.0 mg/kg
CRI = Continuous rate infusion; IB = Intermittent bolus

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