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Veterinary Anaesthesia
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Veterinary
Anaesthesia
Eleventh Edition
K. W. Clarke MA, VetMB, DVA, DVetMed, DipECVAA, FHEA, MRCA, FRCVS

Hon Professor of Veterinary Anaesthesia, Royal Veterinary College, University of London, UK
C. M. Trim BVSc, DVA, DipACVAA, DipECVAA, MRCVS

Professor Emeritus of Anesthesiology, Josiah Meigs Distinguished Teaching Professor, College of
Veterinary Medicine, University of Georgia, Athens, Georgia, USA
L. W. Hall MA, BSc, PhD, DVA, Dr (Hons Causa) Utrecht, DipECVAA, DipACVA (Hon), FRCA, FRCVS
(deceased)
Reader in Comparative Anaesthesia, University of Cambridge, UK
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2014
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First edition 1941
Second edition 1947
Third edition 1948
Fourth edition 1957
Fifth edition 1961
Sixth edition 1966
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Tenth edition 2001
Eleventh edition 2014
ISBN: 9780702027932
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Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden our
understanding, changes in research methods, professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any
information, methods, compounds, or experiments described herein. In using such information or methods they
should be mindful of their own safety and the safety of others, including parties for whom they have a professional
responsibility.
With respect to any drug or pharmaceutical products identified, readers are advised to check the most current infor-
mation provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify
the recommended dose or formula, the method and duration of administration, and contraindications. It is the
responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses,
to determine dosages and the best treatment for each individual patient, and to take all appropriate safety
precautions.
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Contributors
Jennifer G. Adams DVM, DipACVIM, DipACVAA Leslie W. Hall MA, BSc, PhD, DVA, Dr (Hons Causa)
Hull, Georgia, USA Utrecht, DipECVAA, DipACVA (Hon), FRCA, FRCVS
(deceased)
Kate Borer-Weir BVSc, PhD, DVA, DipECVAA, FHEA, Reader in Comparative Anaesthesia,
MRCVS University of Cambridge, UK
Lecturer in Anaesthesia
Royal Veterinary College Sonia M. Hernandez DVM, PhD, DipACZM
Hatfield, Hertfordshire, UK Assistant Professor of Wildlife Disease
Daniel B. Warnell School of Forestry and Natural Resources and
K. W. Clarke MA, VetMB, DVA, DVetMed, DipECVAA, Southeastern Cooperative Wildlife Disease Study
FHEA, MRCA, FRCVS College of Veterinary Medicine
Hon Professor of Veterinary Anaesthesia University of Georgia
Royal Veterinary College Athens, Georgia, USA
University of London, UK
Cynthia M. Trim BVSc, DVA, DipACVAA,
Stephen J. Divers BVetMed, DZooMed, DipACZM, DipECVAA, MRCVS
DipECZM (Herpetology), MRCVS Professor Emeritus of Anesthesiology
Professor of Zoological Medicine Josiah Meigs Distinguished Teaching Professor
Department of Small Animal Medicine & Surgery College of Veterinary Medicine
College of Veterinary Medicine University of Georgia
University of Georgia Athens, Georgia, USA
Athens, Georgia, USA
vii
Preface
In this eleventh edition of Veterinary Anaesthesia we have attempted to continue Dr Leslie Hall’s
tradition of providing ‘how to’ advice on anaesthetizing animals. In addition, our goal has been to
expand the evidence-based theme and provide published justification for most of our conclusions,
particularly in relation to clinical advice, while also including information based on our own experi-
ences. There are now hundreds of relevant published papers, and we have to acknowledge that in
the space available we cannot cite all.
The aim of the book has always been to provide a text for veterinary students, a reference work
for veterinarians in practice or working with laboratory animals, and a stimulating introduction to
the subject for those wishing to specialize in veterinary anaesthesia. While following the format of
previous editions, we have made several major changes in this edition. We have invited other
authors to contribute chapters, and are grateful for their excellent reviews which provide added
dimensions to the book. A chapter specifically devoted to analgesia recognizes the importance of
pain relief and the major advances in the physiology and practice in this area. A new chapter is
devoted to wild animal anaesthesia and another discusses anaesthetic management of small
mammals, exotic pets and small wildlife. A chapter has been added to provide current information
on cardiopulmonary cerebral resuscitation. We would also like to acknowledge valuable contribu-
tions to Chapter 1 by Craig Johnson (electroencephalography) and Daniel Pang (mechanisms of
action of general anaesthetic agents) to ensure accuracy in these specialized and fast advancing
areas.
We would wish to express our appreciation to David Gunn (AIIP) and to Charlotte Hall for many
of the figures re-used from previous editions, and to those who have provided new figures for this
edition and are acknowledged in the text. We also thank Kim Stevens and Flint Buchanan for their
expert assistance with some of the figures. Our warmest thanks are due to the publishers for their
patience, and in particular to Nicola Lally and Alison McMurdo for their constant encouragement.
Finally, we must thank our families, who tolerated our constant ‘absence’, and carried out our day-
to-day duties for us enabling us to concentrate on writing. Without them, the book would never
have been completed.
K. W. Clarke
C. M. Trim
ix
In memoriam
Leslie W. Hall (1927–2010)

MA, BSc, PhD, DVA, Dr (Hons Causa) Utrecht, DipECVAA, DipACVA (Hon),
FRCA, FRCVS
Dr Leslie Hall’s foresight and drive led to the development of veterinary anaesthesia as a speciality.
His contributions to the veterinary profession as a scientist, clinician, teacher and author have been
matched by very few.
Dr Hall qualified as a veterinary surgeon at the Royal Veterinary College, London in 1950, remain-
ing there to obtain his PhD. At that time, anaesthesia was produced in most animals by administer-
ing large doses of the few drugs available, with no specific perianaesthetic care. He recognized that
animals needed better care under anaesthesia and set out to address their most pressing needs.
xi
In memoriam
Dr Hall developed suitable dosage regimens, promoted the use of endotracheal intubation, oxygen
administration, and artificial ventilation. He also instituted the practice of monitoring the animals
during and after anaesthesia and, importantly, began administering analgesics postoperatively, an
approach that was not considered necessary for animals at that time.
Dr Hall then moved to Cambridge where he excelled as a scientist, a clinician and as a teacher
and worked tirelessly to promote veterinary anaesthesia as a speciality. He developed liaisons with
the human medical (physician) anaesthetists, and became an active member of their national and
local associations. In 1977, he was honoured with the Faculty Medal of the Faculty of Anaesthesia
of the Royal College of Surgeons and, in 2001, was awarded an Honorary Fellowship of the Royal
College of Anaesthetists.
Of the many highlights in Dr Hall’s career, we believe the following deserve specific mention. In
1964, with six of his colleagues, Dr Hall founded the Association of Veterinary Anaesthetists (AVA).
This association now has members world-wide, and is the ‘base society’ for the European College
of Veterinary Anaesthesia and Analgesia (ECVAA). On his retirement, Dr Hall was made an Honor-
ary Fellow of AVA. Working with his colleague, Dr Barbara Weaver, Dr Hall helped develop the
Diploma of Veterinary Anaesthesia (DVA) of the Royal College of Veterinary Surgeons, the first
‘specialist’ veterinary qualification in anaesthesia. For the first examination in 1968, they organized
a syllabus, created a robust examination, and included a medical (physician) anaesthetist on the
examination panel. The DVA provided the foundation for the current Diploma of the ECVAA and
served as a model for the Diploma of the American College of Veterinary Anesthesia and Analgesia
(ACVAA). Dr Hall was awarded an Honorary Diploma from the ACVAA in 1985.
While teaching at Cambridge, Dr Hall provided postgraduate training in veterinary anaesthesia
through research scholarships and through a clinical position of University Assistant Anaesthetist,
a post equivalent to what is now termed a ‘Residency’. He also used his influence to establish a
career structure for those who entered the speciality. For example, he convinced surgeons that their
clinical practice and the outcomes of their patients would be improved by including a trained
anaesthetist. He also promoted the concept to veterinary school administrators that future veteri-
nary surgeons needed a high standard of anaesthesia training before venturing into practice. As a
result, university positions of Lecturer (and later, Professorships) in Veterinary and Comparative
Anaesthesia started to appear.
In 1982, under Dr Hall’s guidance, the first International (now World) Congress of Veterinary
Anaesthesia was held at Cambridge. Due to the overwhelming success of that meeting, Congresses
have been held, in several continents, every three years since that time. In the mid-1990s, Dr Hall
served as one of the founding members of the ECVAA, the authority that grants certification for the
speciality of veterinary anaesthesia and analgesia in Europe.
Leslie Hall was not just a clinician – but a brilliant scientist – indeed, he believed strongly in
what is now called ‘evidence-based medicine’. He authored more than 80 papers now cited in
PubMed, and many more in other veterinary journals. Much of his work focused on the physiologi-
cal responses to anaesthesia, particularly in horses and many of his publications are now considered
‘classics’. Examples of the latter include an investigation of muscle relaxants in dogs (1953), recogni-
tion of malignant hyperthermia in pigs (1966), and the first demonstration of ventilation/perfusion
mismatch in the anaesthetized horse (1968). Many anaesthetic agents were introduced into veteri-
nary practice as a direct result of his experimental work and clinical trials. Classical examples include
the introduction of halothane (1957), xylazine (1969), alphaxalone (as Saffan) (1972, 1975), and
propofol (1985, 1987). Dr Hall’s vision was far-reaching and involved research students from all
over the world.
In addition to his scientific publications, Leslie was author/joint author of many review articles
and several books. For more than 50 years he served as the primary author of this book. However,
he also published a small book ‘Fluid balance in canine surgery’ in 1967, which includes informa-
tion from some otherwise unpublished research studies, and ‘Anaesthesia of the cat’ in 1994 in
collaboration with Dr Polly Taylor.
Leslie Hall was a knowledgeable and enthusiastic teacher of anaesthesia to veterinary and post-
graduate clinical and research students. His enthusiasm for his subject was infectious, and post-
graduate students were impressed by his unique ability to link clinical care with evidence-based
research, and with his integrity within his research, always looking for the reason for an unexpected
result. He was a superb clinician, a self-confessed workaholic, a hard taskmaster but a loyal mentor.
xii
In memoriam
He imparted knowledge regardless of the venue, whether it was the surgery theatre or the local pub.
Furthermore, he did all this with loving support of his family.
Although Leslie Hall had many opportunities to move elsewhere and upwards in rank, he pre-
ferred to remain Reader in Comparative Anaesthesia at Cambridge. Despite this reticence, he
received many honours in the UK and elsewhere, including honorary degrees from Utrecht and the
RCVS, the Francis Hogg Prize for advancing small animal practice, the Livesey Medal for alleviating
pain and fear in animals, the Blaine award from the British Small Animal Veterinary Association,
and Fellowship from the RCVS by election.
A fitting summation of his influence and impact comes from a note from one of his previous
postgraduate students, now a Professor:
‘Leslie was responsible for setting clinical standards that were rigorous and science-based and
those of us lucky enough to be taught by him were the fortunate beneficiaries. Of course, Leslie’s
home-made beer was also legendary!’
K. W. Clarke
Cynthia Trim
Parts of this Eulogy, and the picture, were published as an ‘Obituary to Dr L.W. Hall’, in Veterinary
Anaesthesia and Analgesia 2010 (37): 387–389, published by Wiley-Blackwell.
xiii
Chapter 1
An introduction to anaesthesia and
general considerations
Introduction 3 Influence of pre-existing drug therapy 16

Veterinary anaesthesia 4 Pharmacogenetics 17
General anaesthesia 4
Mechanisms of action of general
anaesthetic agents 4 INTRODUCTION
Depth of anaesthesia 6
Electroencephalography (EEG) 6 Anaesthesia is one of the greatest ‘discoveries’ there has
ever been – there are few scientific advances which have
The ‘classic’ signs of anaesthesia 7
reduced pain and suffering in so many people and animals.
Computer control in anaesthesia 8 It is difficult to remember that the first anaesthetic was
Minimum Alveolar Concentration administered only in the 1840s (there is argument as to
(MAC) and Minimum Infusion who was first to administer it clinically), although analge-
Rate (MIR) 9 sics (for example opiates) have been available for many
Anaesthetic risk 10 centuries. The term anaesthesia was coined by Oliver
Wendell Holmes in 1846 to describe using ether to
General considerations in the selection
produce insensibility in a single word and it comes from
of the anaesthetic method 11
the Greek ‘without feeling’. The term ‘analgesia’ is Greek
Evaluation of the patient before for ‘without pain’.
anaesthesia 11 While anaesthesia has precisely the same meaning as
Biochemical tests prior to anaesthesia 12 when it was first coined, i.e. the state in which an animal
Significance of conditions found by is insensible to pain resulting from the trauma of surgery,
preanaesthetic examination 13 it is now used much more widely. Starting with the premise
that ‘pain is the conscious perception of a noxious stimu-
Cardiovascular and respiratory disease 13
lus’, two conditions may be envisaged: general anaesthesia
Drug metabolism and disease states 13 where the animal is unconscious and apparently unaware
Factors affecting transport of drugs in of its surroundings, and analgesia or local anaesthesia where
the body 14 the animal, although seemingly aware of its surroundings,
Renal disease 14 shows diminished or no perception of pain. Perioperative
Preparation of the patient 15 analgesia, a subject once much neglected by veterinarians,
is now recognized as an essential component of the
Food and water 15
process, and the physiology of pain and mechanisms of
Fluid and electrolytes 15 how it can be controlled and treated are discussed in
Haemoglobin level 15 Chapter 5, Analgesia.
©2014 Elsevier Ltd 3

Section 1 Principles and procedures
in which the patient neither perceives nor recalls noxious

VETERINARY ANAESTHESIA or painful stimuli’. Professors Rees and Grey (1950) intro-
duced the concept that the requirements from general
The clinical discipline of veterinary anaesthesia is essen- anaesthesia were analgesia, muscle relaxation and ‘narco-
tially a practical subject based on science. In addition to sis’, these being known as the ‘Liverpool Triad’. This idea
the scientific base for human anaesthesia, the veterinarian has been expanded to add suppression of reflexes (motor
has to contend with species differences, particularly in and autonomic) and unconsciousness or at least amnesia
anatomy and in metabolism that effects the actions and and, most importantly, that these requirements should be
elimination of drugs. achieved without causing harm to the patient. For over 100
In clinical veterinary anaesthesia, the major require- years anaesthesia was achieved mainly with a single drug,
ments of the anaesthetist are: most commonly ether. Now, as well as a number of anaes-
thetic drugs which are administered by inhalation as is
• Humane treatment of the animal
ether (see Chapter 7), single-agent drugs that are given by
■ This includes prevention of awareness of pain,
injection (see Chapter 6) are also employed. However, in
relief of anxiety and sympathetic animal handling
clinical practice, it is now usual to use many different
• Provision of adequate conditions for the procedure
agents, which act at multiple receptors, in the CNS and
■ This includes adequate immobility and relaxation
peripherally, in order to achieve the goals required to
■ Ensuring neither the animal, nor the personnel
provide good anaesthesia.
are injured in any way.
Currently, when considering single-agent anaesthetics,
All patients require an adequate standard of monitoring many authorities now believe that the state of general
(Chapter 2), and of general care throughout the anaes- anaesthesia requires only two features: immobility in
thetic process. However, other than this, there is a myriad response to noxious stimulation and amnesia (the latter
of acceptable methods from which the anaesthetist can often taken as unconsciousness) (Eger et al., 1997; Urban
choose to satisfy the above aims. Certain drugs and/or & Bleckwenn, 2002). The argument is that the immobility
systems may be put forward as ‘best practice’ but, in vet- is required for surgery; if the patient is unconscious they
erinary anaesthesia, there is rarely the ‘evidence base’ to cannot perceive pain (although the autonomic system may
prove that they are so. Choice of methods used may be still react to noxious stimuli), and if they don’t remember
limited by a number of factors. Legal requirements, which the pain, it is similar to lack of perception. This theory
will depend on the country concerned, need to be ignores evidence and theories relating to pain and hyper-
observed. Examples include laws involving the control of sensitization as described in Chapter 5. However, it con-
dangerous drugs, or the choice of drugs in animals des- siders that analgesia is desirable but is not an essential
tined for human consumption. In the European Union, feature of the state of ‘general anaesthesia’. Thus the ‘defi-
currently, the ‘cascade’ is a major barrier to anaesthetists’ nition’ of a single-agent anaesthetic drug, such as the
choice. This law implies that if there is a drug licensed for injectable agent, propofol or the volatile anaesthetic
a species, it is criminal to use another unlicensed agent for agents is that they have these two actions of preventing
the same purpose, unless the veterinary surgeon can prove movement and causing amnesia (Franks, 2006). Some
that their alternative choice was justified for welfare of the compounds which from structure and lipophility might
specific individual animal concerned. Facilities may be be expected to be anaesthetics can cause amnesia without
limited, and while expense should not be the governing immobility; these are sometimes termed ‘non-anaesthetics’
factor, it does need to be considered; animals throughout (Johansson & Zou, 2001), their major interest being
the world require anaesthesia and if the owners cannot related to studies of mechanism of anaesthetic action.
afford the cost, the animal will be denied treatment. The
objective of this book is to give the reader the information Mechanisms of action of general
enabling them to make an informed choice of the best
method of anaesthesia and care for their patient in their anaesthetic agents
circumstances. The central nervous system control of the functions altered
by anaesthesia and related drugs is incredibly complex.
Sherrington in 1906 pointed out the importance of the
synapse in the CNS in providing connections between
GENERAL ANAESTHESIA multiple neuronal systems (Fig. 1.1). At synapses, trans-
mission involves release of transmitter that will ‘trigger’
General anaesthesia is and has been given many different the action of the next neuron. Receptors sensitive to the
definitions (reviewed by Urban & Bleckwenn, 2002), but transmitter may be postsynaptic, or presynaptic feeding
a simple practical one that has been used in the previous back on the original nerve terminal and modulating
editions of this book is ‘the reversible controlled drug further action. Transmitters act through two main types of
induced intoxication of the central nervous system (CNS) receptor: ionotropic and metabotropic. With inotropic or
4
An introduction to anaesthesia and general considerations Chapter 1
Presynaptic changing the lipid bilayer of nerve cells. There are excep-
inhibitory axon tions which disprove the hypothesis but, nevertheless, for
Afferent axon most the correlation is amazing, and this theory, with
modifications, held sway until Franks and Lieb (1984)
showed that inhalational general anaesthetics inhibited
protein activity in the absence of lipids. This finding led
Terminal
arborization Excitatory to the explosion of studies on (a) where in the CNS anaes-
synapses thetics act, (b) differences between motor and amnesic
actions and, finally, (c) the molecular targets for action.
Dendritic tree Inhibitory (Franks (2006) quotes a review that cites 30 possible such
synapse targets.) All these three points are inextricably interlinked.
Inhibitory A full discussion is beyond the remit of this book, but the
interneurone following very simplified summary is based on reviews by
Cell body Urban & Bleckwenn (2002), Sonner et al. (2003), Rudolph
& Antikowiak (2004), Franks (2006) and Perouansky
et al. (2012).
All anaesthetic agents do not act in the same way or in
the same place. Classified by their mode and place of
actions, there appear to be four main types of anaesthetic
agent: (1) injectable agents such as propofol, etomidate
and alfaxalone; (2) volatile anaesthetic agents such as
Axon colateral halothane, isoflurane and sevoflurane; (3) the injectable
Figure 1.1 Schematic diagram of the organization of a dissociative agents such as ketamine; and (4) the gaseous
synaptic relay within the CNS. agents, nitrous oxide and xenon.
It is now considered that the inhibition of motor actions
occurs at the spinal cord, at least for the volatile anaes-
thetic agents, while amnesia and unconsciousness are
‘ligand-gated’ receptors, the transmitter binds directly with the remit of the higher centres in the brain (Eger et al.,
the ion-channel proteins, allowing the channel to open 1997) – these two aspects of anaesthesia being separate.
and the ions to pass. Binding of a transmitter to metabo- Most anaesthetics can cause amnesia at subhypnotic
tropic receptors involves G-proteins as secondary messen- doses, although the relative dose for amnesia in relation-
gers. Recent roles for voltage-gated channels, where ship to that required for unconsciousness varies between
changes in cellular membrane potential triggers a response, drugs. The area of brain critical for amnesia appears to be
such as two-pore potassium channels have also been the hippocampus and basal nucleus of the amygdala.
identified. Other centres are involved in the production of sedation
In the CNS, three major transmitters are considered and unconsciousness. For example, functional neuroimag-
most directly relevant to general anaesthesia. Gamma- ing demonstrated that when propofol was administered at
amino-butyric acid (GABA) is inhibitory and decreases the sedative doses and a noxious stimulus applied, evoked
excitability of neurons. Glycine is inhibitory in most cir- responses were attenuated only in the somatosensory
cumstances and is the most important inhibitory transmit- cortex, but once doses reached hypnotic levels, thalamic
ter at the spinal cord. The main excitatory transmitter in and cortical responses ceased. Ketamine, a dissociative
the CNS is glutamate. Anaesthetic drugs that are thought anaesthetic, however, did not depress sensory inflow
to act at the N-methyl d-aspartate (NMDA) receptor, one through the thalamus. Perouansky et al. (2012) summa-
of at least three types of ligand-gated glutamate receptor, rize by pointing out that anaesthesia is a very complex
inhibit the effect of glutamate, thus again inhibiting the state, and that current evidence shows that general anaes-
CNS. However, there are many other relevant transmitters, thetics produce separate ‘agent specific’ substates, proba-
for example acetylcholine, dopamine, norepinephrine, bly at different areas of the CNS.
endogenous opioids and others (Sonner et al., 2003) and Three very differing molecular targets have been sug-
their resultant actions may influence (modulate) the gested as the major sites of anaesthetic actions: GABAA
actions, directly or indirectly, of the GABA, glycine and receptors, NMDA receptors and glycine receptors. Anaes-
glutamate pathways. thetic drugs that act at the GABAA receptors are the classi-
In the 1900s, for the inhalation agents (no injectable cal IV anaesthetics; these potentiate the action of GABA,
had been discovered), Meyer and Overton independently hence increase overall CNS inhibition. The volatile anaes-
noted the correlation between anaesthetic potency and thetic agents have similar actions at GABAA receptors in
solubility in oil, which led to the ‘lipid theory’ that general addition to actions at other targets, and their mode of
anaesthetics acted through a non-specific mechanism by action is more complex. Dissociative anaesthetics such as
5
ketamine and the gaseous anaesthetic agents are thought

to be antagonistic at the NMDA receptor, thus blocking DEPTH OF ANAESTHESIA
the action of the excitatory glutamate, but again, this does
not explain all their actions. Many authorities consider that ‘depth of anaesthesia’ is
A great deal is known about the GABAA receptor (there impossible to define, but anaesthesiologists need some
are also GABAB and GABAC). It is a polymeric receptor guidelines to ensure that the patient comes to no harm.
with five subunits; there have been at least 30 types of Only two years after the first demonstration of general
subunit cloned so the potential for heterogenicity is enor- anaesthesia, John Snow (1847) stated, quite emphatically,
mous. Different arrangements of subunits are sensitive to that the point requiring most skill in the administration
different anaesthetic agents. For example, genetically engi- of anaesthetics is to determine when it has been carried
neered ‘knock-out mice’ in which one particular subunit far enough. Snow described five stages of anaesthesia pro-
was missing were insensitive to the anaesthetic effects of duced by diethyl ether, the last stage in his experiments
the steroid anaesthetic, alfaxalone, but not to propofol with animals being characterized by feeble and irregular
suggesting that these two apparently similar IV anaesthet- respiratory movements heralding death – clearly a stage
ics were working through different configurations of too far. A major problem faced by all anaesthetists since
GABAA receptor. The mode of action of the volatile anaes- that time is to avoid both ‘too light’ anaesthesia with the
thetic agents, in particular in the brain, is less proven (and risk of sudden violent movement, and the dangerous ‘too
more complex) than for the IV agents; the volatile anaes- deep’ stage. Snow suggested guidelines whereby anaesthet-
thetic agents do have some actions at the GABAA receptor ists could reduce the risk of either too light or too deep
but at a much lower potency. Subunits of GABAA essential ether anaesthesia. Guedel, in 1918, devised a scheme
for efficacy differ between the volatile and IV agents. It is involving observation of changes in respiratory rate, limb
thought that glycine receptors are involved in the actions movement and eye signs which formed the basis of his
of the volatile agents, in particular those in the spinal cord celebrated ‘Signs and Stages of Ether Anaesthesia’ which
which inhibit movement. The reason for giving these has been included until very recently in all text books
examples (there are very many more) of differing modes of anaesthesia, and is the basis for that described in
of actions between apparently similar types of anaesthetics Chapter 2.
is to point out that to say ‘an anaesthetic acts at the GABAA The introduction of neuromuscular blocking drugs,
receptor’ is certainly not the whole story. which remove all the somatic responses on which Guedel’s
Knowledge of the mode of action of the anaesthetics scheme is based, completely changed the picture and the
that work at the NMDA receptor is less well developed. emphasis swung from the danger of too deep anaesthesia
The anaesthetics (ketamine and the gaseous agents) are to that of too light anaesthesia with the risk of conscious
thought to cause their effects on memory and conscious- awareness and perception of pain. Cullen et al. (1972), in
ness at least partly through these receptors. Sonner et al. an attempt to produce new guidelines indicating depth of
(2003) consider that NMDA receptors in the spinal cord anaesthesia, were forced to conclude that it was difficult
might be a target for all inhalation anaesthetic agents (not to categorize the clinical signs of anaesthesia for any one
just those those termed ‘gaseous’) in the production of inhalation anaesthetic let alone for inhalation agents in
immobility. However, once again, action at the NMDA general. The signs also differed markedly when the dis-
receptor does not explain all the actions seen. sociative anaesthetic agents such as ketamine were used.
The methods of investigation used to study anaesthetic Today a very much broader range of different drugs are
actions are multiple, and readers are referred to the reviews employed during anaesthesia. These include agents to give
cited above. All reviews point out the number of other analgesia, amnesia, unconsciousness and relaxation of
potential molecular, ion or voltage-gated possible sites skeletal muscles as well as suppression of somatic, cardio-
which might be the target for anaesthetic action. Other vascular, respiratory and hormonal responses to surgical
routes of investigation have examined the modulating stimulation. All may influence the classical signs of ‘depth’
influence of alternative CNS pathways. Following the find- of anaesthesia.
ings of Franks and Lieb (1984), it was anticipated that a
(relatively) simple pharmacological pathway for anaes-
Electroencephalography (EEG)
thetic action might be found to explain anaesthetic actions,
as has been for many other systems (e.g. opioids, see It is only possible to describe the EEG changes related to
Chapter 5, α2-adrenoceptor agonists, see Chapter 4). This anaesthesia in the most general terms. The responsive
has not happened, although our knowledge is greatly alpha rhythm associated with awareness changes on
expanded. However, we have yet really to know how induction of anaesthesia in terms of frequency and ampli-
general anaesthetics work, and indeed Sonner et al. (2003) tude. The most common pattern seen with light general
raise a question that, at least for volatile agents, some anaesthesia has low amplitude and is dominated by high
variant of the Overton–Meyer lipid theory may yet play a frequency activity; it is often referred to as desynchronized.
partial role. Increasing concentrations of anaesthetics tend to produce
6
increasing amplitude and decreasing frequency, a phe- Evoked responses

nomenon known as synchronization. In addition, some
Evoked responses are changes in the EEG produced by
anaesthetics produce periods of burst suppression where
external stimuli, surgical or otherwise. Anaesthetic depth
the EEG is isoelectric, repetitive high amplitude spikes and
is a balance between cerebral depression and surgical (or
complexes or even the epileptoid activity characteristic of
other) stimulation. Thus, cerebral function during anaes-
the anaesthetic ethers.
thesia is most easily assessed by putting in a stimulus –
The majority of attempts to monitor the depth of anaes-
auditory or somatic or visual – and observing the EEG
thesia objectively have focused on the EEG, but the raw
response. That response can then be compared for ampli-
data are of limited practical value to the clinical anaesthet-
tude and latency with the response to the same stimulus
ist. To simplify the extraction of useful information from
in the presence of differing brain concentrations of any
complex waveforms, a number of methods of compress-
anaesthetic. Evoked responses can be used as monitors of
ing, processing and displaying EEG signals have been
anaesthetic depth when agents acting at the NMDA recep-
developed and these techniques have, in many cases, been
tor are being employed.
applied to a limited number of channels of EEG rather
than the 16 channels normally studied.
The ‘classic’ signs of anaesthesia
Power spectrum analysis
Use of the term ‘depth of anaesthesia’ is now so ingrained
In this technique, the EEG signal, after being digitalized,
in common usage that it must be accepted since it prob-
is subjected to Fast Fourier Transformation (FFT) in which
ably cannot be eradicated. It is important, however, to
it is separated into a series of sine waves. The sum of these
realize that it commonly refers to depression of brain
sine waves represents the original integrated signal. Break-
function beyond that necessary for the production of
ing up the original waveform in this way makes it possible
‘general anaesthesia’.
to compare one non-standard wave form with another
The so-called ‘classic signs’ of anaesthesia, such as
and, in particular, to extract the distribution of compo-
described in Chapter 2 for convenience of newcomers to
nents of different frequency within the EEG signal. The
the subject, were provided by the presence or absence of
power in each frequency band is derived from the sum of
response of the anaesthetized subject to stimuli provided
the squares of the amplitude of the sine waves into which
by the anaesthetist or surgeon. Particular signs of anaes-
the FFT has separated the original signal. Power spectrum
thesia were, therefore, equated with particular anatomical
analysis has been used in a number of experimental situ-
levels or ‘planes’ of depression of the central nervous
ations related to veterinary anaesthesia (e.g. Otto & Short,
system. These signs were often likened to a series of land-
1991; Murrell et al., 2003; Johnson et al., 2005, 2009).
marks used to assess the progress made on a journey. Such
empirical, traditional methods of assessing the progress of
Cerebral function monitors anaesthesia and the anatomical implications that went
A number of monitors, including the Bispectral Index with these methods incorporated a fallacy, because they
(BIS), the Cerebral Function Monitor (CFM) and the took no account of the fact that the changing function of
Patient State Index (PSI) feed the EEG signals from a any biological system can only be made in terms of mag-
limited number of leads into a ‘black box’ which, on the nitude and time. A depth of unconsciousness is really a
basis of an algorithm derived from analysis of EEGs from particular moment in a continuous temporal stream of
a large number of human patients, produces a number biological or neurological phenomena to be interpreted
which is related to depth of anaesthesia. All these moni- by the magnitude and quality of these phenomena obtain-
tors have a number of limitations in clinical use. They may ing to that moment.
be influenced by other electrical ‘noise’ such as the elec- In general, the volatile anaesthetic agents halothane,
tromyogram (EMG). The algorithms are based mainly on enflurane, isoflurane, sevoflurane and desflurane produce
anaesthetic drugs that have their hypnotic effect through a dose-dependent decrease in arterial blood pressure and
actions at the GABAA receptors. The monitors are ineffec- many veterinary anaesthetists use this depression to assess
tive for the anaesthetic agents that act at the NMDA recep- the depth of anaesthesia. The effect is not so marked
tors such as nitrous oxide, xenon or ketamine. Of great during anaesthetic techniques involving the administra-
concern is the fact that when neuromuscular blocking tion of opioid analgesics and nitrous oxide. If the depth
drugs were given to conscious human volunteers, BIS of unconsciousness is adequate, surgical stimulation does
reduced to values suggestive of very deep anaesthesia not cause any change in arterial blood pressure. There are,
(Messner et al., 2003). The use of these monitors may however, many other factors which influence the arterial
reduce the incidence of awareness under anaesthesia but blood pressure during surgery such as the circulating
has not eliminated it. The most common of these moni- blood volume, cardiac output and the influence of drug
tors is the BIS; its use and limitations in veterinary anaes- therapy given before anaesthesia. If ketamine or high
thesia are described in Chapter 2. doses of opioids are given, arterial blood pressure may
7
change very little if the depth of unconsciousness is should be smooth although its rate and depth may alter
increased by the administration of higher concentrations depending on the prevailing severity of the surgical stimu-
of inhalation anaesthetics. lation. Rapid nystagmus is usually a sign that anaesthesia
Changes in heart rate alone are a poor guide to changes is light but it is a common feature of ketamine anaesthesia
in the depth of unconsciousness. The heart rate may and it also seen sometimes seen in horses just before
increase under isoflurane and desflurane anaesthesia due death. Absence of the lash or palpebral reflex (closure of
to the agents’ effects. Arrhythmias are common during the eyelids in response to light stroking of the eyelashes)
light levels of unconsciousness induced by halothane, is another reasonably reliable guide to satisfactory anaes-
when they are usually due to increased sympathetic activ- thesia. In dogs and cats, it is safe to assume that if the
ity. In general, however, tachycardia in the absence of any mouth can be opened without provoking yawning or
other cause may be taken to represent inadequate anaes- curling of the tongue, central depression is adequate. In
thesia for the procedure being undertaken. all animals, salivation and excessive lacrimation usually
Anaesthetic agents affect respiration in a dose-dependent indicate a returning awareness.
manner and this was responsible for the original classifica- Disappearance of head shaking or whisker twitching in
tion of the ‘depth of anaesthesia’. In deeply anaesthetized response to gentle scratching of the inside of the ear pinna
animals, tidal and minute volumes are decreased but, is a good sign of unawareness in pigs, cats, rabbits and
depending on the species of animal and on the anaesthetic guinea pigs. Pupil size is a most unreliable guide to anaes-
agents used, respiratory rate may increase before breathing thetic depth as various ancillary agents (e.g. opioids, atro-
eventually ceases once the animal is close to death. As pine) may influence it. The pupils do, however, dilate
inadequate anaesthesia also is often indicated by an when an overdose of an anaesthetic has been given or
increase in the rate and/or depth of breathing the unwary when awareness is imminent.
may be tempted to administer more anaesthetic agent to The experienced anaesthetist relies most of the time on
the deeply anaesthetized animal in the mistaken impres- an animal’s response to stimuli produced by the surgeon or
sion that awareness is imminent. Laryngospasm, coughing procedure to indicate adequate depth of unconsciousness.
or breath-holding can indicate excessive airway stimula- The most effective depth is taken to be that which oblit-
tion or inadequate depth of unconsciousness. erates the animal’s response to pain and/or discomfort
All anaesthetic agents, other than the dissociative drugs without depressing respiratory and circulatory function.
such as ketamine, cause a dose-related reduction in
muscle tone and overdosage produces complete respira-
tory muscle paralysis. In the absence of complete neu-
Computer control in anaesthesia
romuscular block produced by neuromuscular blocking
drugs, the degree of muscle relaxation may, therefore, With the current sophistication of computers, there have
usually be used as a measure of the depth of anaesthetic- been many attempts to obtain a method of anaesthesia
induced unconsciousness. However, even in the presence totally controlled by the computer; various parameters
of muscular paralysis due to clinically effective doses of being monitored, results fed back into the system, and the
neuromuscular blockers, it is not uncommon to observe system then altering the dose of anaesthetic administered
movements of facial muscles, swallowing or chewing accordingly – i.e. a closed-loop system.
movements in response to surgical stimulation if the The use of computers (including microprocessors) has
depth of unconsciousness becomes inadequate. improved many aspects of anaesthesia. Monitoring can
When animals are breathing spontaneously, there are be more sophisticated, and give more accurate results.
several signs which are generally recognized as indicating Ventilators can be programmed to provide very specific
that the depth of unconsciousness is adequate for the requirements of, for example, tidal volume, or respiratory
performance of painful procedures, i.e. the animal is pressures. Constant infusion pumps provide a very accu-
unaware of the environment and of the infliction of rate flow rate which is useful for fluid administration, but
pain – it is anaesthetized. also can be utilized to provide targeted plasma levels of
Unfortunately, there are many differences between the intravenous anaesthetic agents (this is known as Target
various species of animal in the signs which are usually Controlled Infusion or TCI). The most validated versions
used to estimate the depth of unconsciousness. One fairly of this are the Propofusor® and the Remifusor®, which
reliable sign is that of eyeball movement, especially in will deliver infusions to achieve set plasma levels of pro-
horses and cattle, although even this may be modified in pofol and remifentanil respectively. Their programming is
the presence of certain other drugs, such as the α2- based on a very accurate knowledge of the pharmacokinet-
adrenoceptor agents (see Chapter 11). Unless neuromus- ics in humans of these drugs so their algorithms are not
cular blocking drugs are in use, very slow nystagmus in necessarily correct for other animals, although the Propo-
both horses and cattle and downward inclination of the fusor has been modified successfully for use in dogs (Beths
eyeballs in pigs and dogs usually indicates a satisfactory et al., 2001; Musk et al., 2006). There is computer-software
level of unconsciousness and, at this level, breathing available to use with other agents (RugloopII); it can be
8
used for research projects (Ribeiro et al., 2009) but, as it in animals and is usually measured in triplicate, concen-
classifies as a ‘medical device’, there may be legal limita- tration of anaesthetic being lowered until there is a
tions (country specific) to its clinical use in humans. It is response, then raised again until the response is lost. In
also possible to have target controlled inhalation anaes- humans, the most common stimulus is a single surgical
thesia; the volatile anaesthetic is injected into the circuit incision; if the patient responds the next patient gets a
so as to maintain a targeted end-tidal anaesthetic concen- higher dose and so on, until the ED50 is found. A single
tration. The anaesthetic machine named ‘Zeus’ from stimulus of this type is certainly not supramaximal, and
Draeger has this facility as well as programmable infusion the difference in measurement techniques may explain
syringes and the advertisement talks of target controlled why MAC in humans usually is less than in experimental
anaesthesia. However, neither of these systems involves a animals. End-tidal anaesthetic gas concentration is taken
feedback loop within the computer; the feedback loop is as an approximation of alveolar gas. With a forced expira-
the anaesthetist who asks it for a different target, ‘up or tion (as is requested when similar technology is used for
down’ according to the patient requirements. the alcohol ‘breathalyser’), this is reasonable, but under
In order to have a feedback loop, there have to be anaesthesia a forced breath cannot be obtained. For really
patient data measured and returned to the computer. To accurate experimental results, sampling should be via a
date, the most common parameter used for this purpose catheter passed down the trachea but, in the clinical situ-
is the ‘anaesthetic depth monitor’, BIS (see Electroen- ation, sampling at the ET tube suffices.
cephalography). As has been discussed, this is a monitor A number of factors affect MAC. It is not affected by the
based on the ‘hypnosis’ resulting from the anaesthetic duration of anaesthesia, hyperkalaemia, hypokalaemia,
agents that act primarily on the GABAA receptor, and there- hypercarbia or metabolic acid–base changes, but is reduced
fore is most accurate with propofol anaesthesia. Not sur- by hyponatraemia. MAC is reduced by 8% for every °C
prisingly, computer-controlled anaesthesia has been most reduction in body temperature, and similarly, raised by
effective with systems involving propofol infusions hyperthermia. Young animals have high MAC values, but
(Hemmerling et al., 2010). Recently, Liu et al. (2011) used MAC decreases with age (Mapleson, 1996; Eger, 2001).
computer-controlled infusion of propofol together with MAC is measured as vol%, and so is dependent on atmos-
remifentanil, and found it more effective in maintaining pheric pressure, thus explaining the increased doses of vola-
a steady BIS target than was manual control. However, as tile agents required to maintain anaesthesia at high altitudes
discussed previously, in any one individual, steady BIS (Quasha et al., 1980). MAC is reduced by many other
does not always represent the ideal ‘depth’ of anaesthesia anaesthetic related agents which add to neuronal depres-
so the anaesthetist is still needed to assess the patient’s sion. The MACs of two volatile and/or inhalation agents are
overall response, in particular cardiopulmonary changes themselves additive (Eger et al., 2003), hence the use of
and autonomic responses to stimulation. Absalom et al. nitrous oxide as part of the carrier gas for volatile agents.
(2011) have reviewed the current status of computer- It is now considered that MAC is a measurement that
controlled anaesthesia and consider that the limitations relates to the spinal cord, and not to the brain (Eger et al.,
are such that it is a goal not yet achieved. 1997). Its end-point is movement and, as discussed above
(mode of action), it is movement that is considered to be
prevented by the actions at the spinal cord. Interestingly,
Minimum Alveolar Concentration in relation to analgesia, volatile anaesthetic agents do
(MAC) and Minimum Infusion prevent ‘wind-up’ of nociceptive neurons in the cord, and
Rate (MIR) it is suggested that this may play a part in preventing
movement.
Minimum alveolar concentration Despite its limitations, however, the concept of MAC
In 1963, Merkel & Eger proposed the concept of MAC, and has now been used for more than five decades to enable
Eger et al. (1965) expanded the idea further, suggesting the relative potencies of anaesthetics to be compared
that it would be useful as a measurement of volatile anaes- (Antognini & Carstens, 2005). This reproducible method
thetic potency. MAC is defined as the alveolar concentra- may be contrasted with the difficulty in using physiologi-
tion of an anaesthetic that prevents muscular movement cal parameters as an indication of anaesthetic depth, or
in response to a painful stimulus in 50% of the test sub- the EEG, which varies according to the agent used.
jects. It is therefore what is known in pharmacology as the Although the MAC value represents the anaesthetizing
ED50 (effective dose). If adequate time is allowed for the dose for only 50% of subjects, the anaesthetist can be
anaesthetic in the brain to equilibrate with the anaesthetic reasonably certain that increasing the alveolar concentra-
agent in the blood, the alveolar partial pressure of the tion to between 1.1 or 1.2 times MAC will ensure satisfac-
anaesthetic (which can be measured) is a reasonably accu- tory anaesthesia in the vast majority of individuals because
rate expression of the anaesthetic state. The stimulus, the dose–response curve is relatively steep. In veterinary
standardized as far as possible to be ‘supramaximal’, practice, it is also important to note that, according to
usually consists of tail clamping or an electrical stimulus Eger, the variability of MAC is remarkably low between
9
mammalian species and, as long as conditions remain the

Table 1.1 American Society of Anesthesiologists’
same, is quite constant in any one animal. Finally, it is
physical status classification system
important to remember that MAC is determined in healthy
animals under laboratory conditions in the absence of Category 1 Normal healthy patient
other drugs and circumstances encountered during
clinical anaesthesia which may alter the requirement for Category 2 A patient with mild systemic disease
anaesthesia. Category 3 A patient with severe systemic disease
Category 4 A patient with severe systemic disease

Minimum infusion rate
that is a constant threat to life
The accurate control of depth of unconsciousness is more
difficult to achieve with intravenous anaesthetic agents. To Category 5 A moribund patient who is not expected
to survive without the operation
obtain unconsciousness, they must be administered at a
rate which produces a concentration of drug in the blood- American Society of Anesthesiologists (2010).
stream sufficient to result in the required depth of depres-
sion of the central nervous system. The concept of
minimum infusion rate (MIR) was introduced by Sears
in 1970 to define the median ED50 of an intravenous
anaesthetic agent which would prevent movement in immediate attention for obstetrical crises, intractable
response to surgical incision (or in experimental animals, haemorrhage or thoracic injuries. In the USA, the
a supramaximal stimulus). Unlike MAC, in which alveolar American Society of Anesthesiologists (ASA) has
concentrations can be considered to equate to arterial, adopted a classification of physical status into
blood cannot be analysed rapidly for injectable anaes- categories, ‘E’ being added after the number when
thetic concentrations. MIR is therefore measured similarly the case is presented as an emergency (Table 1.1).
to MAC using movement as an end-point. However, MIR This is a useful classification but, most importantly,
may change with time if the drug is cumulative; a lower it refers only to the physical status of the patient
infusion rate being required as the tissues become satu- and is not necessarily a classification of risk
rated. The term ‘context sensitive MIR’ is used to describe because additional factors such as its species,
these changes with duration of infusion. As changes with breed and temperament contribute to the risk
context depend on pharmacokinetic parameters, MIR may involved for any particular animal. Moreover, the
differ markedly between species depending on rate of drug assessment of a patient’s ‘correct’ ASA classification
metabolism and elimination. In veterinary anaesthesia, to varies between different anaesthetists (Haynes &
date, the greatest knowledge of MIRs in anaesthesia has Lawler, 1995; Wolters et al., 1996; McMillan &
been with propofol infusions (Beths et al., 2001; Bettschart- Brearley, 2013).
Wolfensberger et al., 2001; Oku et al., 2005; Boscan et al., 2. The influence of the surgeon. Inexperienced
2010; Rezende et al., 2010), but the same concept (using surgeons may take much longer to perform an
different end-points) has been employed for choosing operation and by rough technique produce intense
suitable infusion rates of sedative drugs (see Chapter 4). and extensive trauma to tissues, thereby causing
a greater metabolic disturbance (and increased
postoperative pain). Increased danger can also arise
when the surgeon is working in the mouth or
ANAESTHETIC RISK pharynx in such a way as to make the maintenance
of a clear airway difficult, or is working on structures
such as the eye or larynx and provoking autonomic
General anaesthesia and local analgesia do not occur natu- reflexes.
rally and their induction with drugs that even today are 3. The influence of available facilities. Crises arising
never completely devoid of toxicity must constitute a during anaesthesia are usually more easily overcome
threat to the life of the patient. This can be a major or in a well-equipped veterinary hospital than under
trivial threat depending on the circumstances, but no the primitive conditions which may be encountered
owner must ever be assured that anaesthesia does not on farms.
constitute a risk. When an animal owner raises the ques- 4. The influence of the anaesthetist. The competence,
tion of risk involved in any anaesthetic procedure the experience and judgement of the anaesthetist have a
veterinarian needs, before replying, to consider: profound bearing on the degree of risk to which the
1. The state of health of the animal. Animals presented patient is exposed. Familiarity with anaesthetic
for anaesthesia may be fit and healthy or suffering techniques leads to greater efficiency and the art of
from disease; they may be presented for elective anaesthetic administration is only developed by
(‘cold’) surgery or as emergency cases needing experience.
10
General considerations in the anaesthetists will also influence the choice of anaesthetic
technique. In addition, factors causing increased suscepti-
selection of the anaesthetic method
bility to the toxic actions of anaesthetic agents must be
The first consideration will be the nature of the operation borne in mind. These include:
to be performed, its magnitude, site and duration. In 1. Prolonged fasting. This, by depleting the glycogen
general, the use of local infiltration analgesia may suffice reserves of the liver, greatly reduces its detoxicating
for simple operations such as the incision of superficial power and when using parenterally administered
abscesses, the excision of small neoplasms, biopsies and agents in computed doses, allowance must be made
the castration of immature animals. Nevertheless, what for increased susceptibility to them.
seems to be a simple interference may have special anaes- 2. Diseased conditions. Toxaemia causes degenerative
thetic requirements. Subdermal fibrosis may make local changes in parenchymatous organs, particularly the
infiltration impossible to effect. Again, the site of the liver and the heart, and great care must be taken in
operation in relation to the complexity of the structures giving computed doses of agents to toxaemic
in its vicinity may render operation under local analgesia subjects. Quite often it is found that a toxaemic
dangerous because of possible movement by the con- animal requires very much less than the ‘normal’
scious animal, e.g. operations in the vicinity of the eyes. dose. Toxaemia may also be associated with a
When adopting general anaesthesia, the likely duration slowing of the circulation and unless this is
of the procedure to be performed will influence the selec- recognized it may lead to gross overdosing of IV
tion of the anaesthetic. Minor, very short operations may anaesthetics.
be performed after IV administration of a small dose of an
agent such as propofol or thiopental sodium. For longer
operations, anaesthesia may be induced with an ultra-
short acting agent and maintained with an inhalation
EVALUATION OF THE PATIENT
agent with or without endotracheal intubation. However,
the ability to perform endotracheal intubation, to admin- BEFORE ANAESTHESIA
ister oxygen and to apply some form of ventilation must
always be available and to hand for use should an emer- It is probable that most veterinary operations are per-
gency arise. Similarly, the fact that anaesthesia is brief does formed on normal, healthy animals. The subjects are
not remove the need for minimal monitoring. For most generally young and represent good ‘anaesthetic risks’.
operations under general anaesthesia, preanaesthetic med- Nevertheless, enquiry should be made to ensure that they
ication (‘premedication’) will need to be considered, par- are normal and healthy – bright, vigorous and of hearty
ticularly when they are of long duration and the animal appetite. Should there be any doubt, operations are best
must remain quiet and pain-free for several hours after the delayed until there is assurance on this point. Many a
operation. Undesirable effects of certain agents (e.g. keta- reputation has been damaged by performing simple oper-
mine) may need to be countered by the administration of ations on young animals which are in the early stages of
‘correcting’ agents (e.g. α2-adrenoceptor agonists, atro- some acute infectious disease or which possess some con-
pine). Although sedative premedication may significantly genital abnormality.
reduce the amount of general anaesthetic required, it may When an operation is to be performed for the relief of
also increase the duration of recovery from anaesthesia. disease, considerable care must be exercised in assessing
The species of animal involved is a pre-eminent consid- the factors which may influence the choice or course of
eration in the selection of the anaesthetic method (see the anaesthetic. Once these are recognized, the appropri-
later chapters). The anaesthetist will be influenced not ate type of anaesthesia can be chosen and preoperative
only by size and temperament but also by any anatomical measures adopted to diminish or, where possible, prevent
or physiological features peculiar to a particular species or complications. The commonest conditions affecting the
breed. Experience indicates that the larger the animal, the course of anaesthesia are those involving the cardiovascu-
greater are the difficulties and dangers associated with the lar and respiratory systems, but the state of the liver and
induction and maintenance of general anaesthesia. kidneys cannot be ignored.
Methods which are safe and satisfactory for the dog and The owner or attendant should always be asked
cat may be quite unsuitable for horses and cattle. In vigor- whether the animal has a cough. A soft, moist cough is
ous and heavy creatures the mere upset of locomotor associated with airway secretions that may give rise to
coordination may entail risks, as also may prolonged respiratory obstruction and lung collapse when the cough
recumbency. reflex is suppressed by general anaesthesia. Severe cardio-
vascular disease may be almost unnoticed by the owner
Individual animals and enquiry should be made to determine whether the
The variable reaction of the different species of animals, animal appears to suffer from respiratory distress after
and of individuals, to the various agents administered by exertion, or indeed appears unwilling to take exercise,
11
since these signs may precede other signs of cardiac and Pulmonary disorders provide particular hazards for an
respiratory failure by many months or even years. Dysp- animal undergoing operation and any examination, no
noea is generally the first sign of left ventricular failure and matter how brief, must be designed to disclose their pres-
a history of excessive thirst may indicate the existence of ence or absence. On auscultation, attention should be
advanced renal disease, diabetes mellitus or diabetes directed towards the length of the expiratory sounds and
insipidus. the discovery of any rhonchi or crepitations. If rhonchi or
The actual examination may be restricted to one which crepitations are heard, excessive sputum is present, and the
is informative yet will not consume too much time nor animal is either suffering from, or has recently suffered,
unduly disturb the animal. While a more complete exami- a pulmonary infection. Prolongation of the expiratory
nation may sometimes be necessary, attention should sounds, especially when accompanied by high-pitched
always be paid to the pulse, the position of the apex beat rhonchi, indicate narrowing of the airways or broncho
of the heart, the presence of cardiac thrills, the heart spasm. Respiratory sounds may be absent in animals with
sounds and the jugular venous pressure. Examination of pneumothorax, extensive lung consolidation, or severe
the urine for the presence of albumin and reducing sub- emphysema; they are usually faint in moribund animals.
stances may also be useful. Uneven movement between the two sides of the chest
Tachycardia is to be expected in all febrile and in many is a reliable sign of pulmonary disease and one which is
wasting diseases and, under these circumstances, is indica- easily and quickly observed. The animal should be posi-
tive of some myocardial weakness. It can, however, also be tioned squarely while the examiner stands directly in front
due to nervousness and where this is so it is often associ- of it and then directly behind it. In small animals, uneven
ated with rather cold ears and/or feet. Bradycardia may be movement of the two sides of the chest is often better
physiological or it may indicate complete atrioventricular appreciated by palpation rather than by inspection.
block. In horses, atrioventricular block that disappears The mouth should be examined for the presence of
with exercise is probably of no clinical significance. In all loose teeth which might become dislodged during general
animals, the electrocardiogram may be the only way of anaesthesia and enter the tracheobronchial tree. Other
determining whether bradycardia is physiological or is due mucous membranes should be inspected for evidence of
to conduction block in the heart. anaemia, denoted by paleness.
The jugular venous pressure is also important. When the
animal is standing and the head is held so that the neck
is at an angle of about 45° to the horizontal, distension Biochemical tests prior to anaesthesia
of the jugular veins should, in normal animals, be just The question as to whether preanaesthetic urine and
visible at the base of the neck. When the distension rises blood analysis should be performed routinely before every
above this level, even in the absence of other signs, it elective anaesthetic is, and has always been, controversial.
indicates an obstruction to the cranial vena cava or a rise While targeted tests are essential to confirm or exclude
in right atrial or ventricular pressures. The commonest disease conditions suspected as a result of clinical history
cause of a rise in pressure in these chambers is probably and examination, the cost/benefit of their use in animals
right ventricular hypertrophy associated with chronic lung which appear perfectly healthy can be argued on the basis
disease, although congenital conditions such as atrial that the results rarely would alter the anaesthetic protocol
septal defects may also be indicated by this sign and it to be employed. Urine testing is simple, inexpensive and
should be remembered that cattle suffering from constric- is particularly important in dogs for, in these animals,
tive pericarditis, or bacterial endocarditis, may have a renal disease and previously undiagnosed diabetes melli-
marked increase in venous pressure. tus are common. Urine samples may be less readily
The presence of a thrill over the heart is always a sign of obtainable from other species of animal. The Association
cardiovascular disease and suggests an increased risk of of Veterinary Anaesthetists (AVA) debated (Spring Meeting,
complications arising during anaesthesia. More detailed 1998) the question as to the need for routine preanaes-
cardiological examination is warranted when a cardiac thetic checks on haematological and biochemical profiles,
thrill is detected during the preoperative examination. and voted that they were unnecessary if the clinical exami-
Auscultation of the heart should never be omitted, par- nation was adequate. In a more recent AVA debate led by
ticularly when the animal’s owner is present because medical anaesthetists, they pointed out that a major dis-
owners expect this to be carried out. Accurate location of advantage of non-targeted screening was ‘over-diagnosis’
the apex beat is an important observation in assessing the when an apparent abnormality of no significance was
state of the cardiovascular and respiratory systems. It is found. An advantage of prescreening, however, is that
displaced in many abnormal conditions of the lungs (e.g. abnormalities occurring early in the course of a disease
pleural effusion, pneumothorax, lung collapse) and in the without current clinical symptoms may be identified.
presence of enlargement of the left ventricle. In the absence These values then become the baseline for comparison if
of any pulmonary disorder, a displaced apex beat indicates abnormalities occur following anaesthesia and surgery.
cardiac hypertrophy or dilatation. There may well be a place for routine screening older
12
animals. Although in a very occasional case (e.g. the detec- body tissues. If all three variables are reduced the effect is,
tion of a partial hepato-portal shunt in a young dog) of course, even more dramatic.
biochemical tests may detect an unsuspected disease state,
in the vast majority of young apparently fit healthy
Drug metabolism and disease states
animals, they constitute an unnecessary expense and,
indeed, the extra cost involved may prevent an owner from Drugs are usually metabolized through several pathways
agreeing to continuation of treatment necessary for the so that they are changed from fat-soluble, active, unexcret-
well-being of the patient. able drugs into water-soluble, inactive drugs that can be
Provided a brief examination such as that described excreted by the kidneys and in the bile. Since the mam-
is carried out thoroughly, and that the examiner has malian body metabolizes many thousands of compounds
sufficient skill and experience to recognize the significance every day and has far fewer enzymes, each enzyme metab-
or lack of significance of the findings, most of the condi- olizes many substrates. Only very rarely, if ever, will one
tions that have a bearing on the well-being of an animal enzyme metabolize only one substrate. Many things
in the perioperative period will be brought to light so change enzyme function. Mechanisms for enzyme induc-
that appropriate measures can be taken to protect it tion are poorly understood, unlike inhibition, which has
from harm. been much more extensively studied. Enzyme induction
is a slow process involving an increased amount of enzyme
in the cell over about 24 to 48 hours, whereas inhibition
is quick and sometimes occurs after only one dose of
an inhibitor. Since enzymes are proteins their concentra-
SIGNIFICANCE OF CONDITIONS tions inside cells may be changed by a variety of factors
FOUND BY PREANAESTHETIC (Fig. 1.2).
EXAMINATION There is now an increasing amount of information
about how enzymes change in response to one stressful
stimulus but it is important to recognize that usually
Cardiovascular and respiratory disease several stimuli exist at the same time in each critically ill
The cardiovascular and respiratory systems are those which animal. Most chemical reactions are sensitive to tempera-
govern the rate at which oxygen can be made available to ture, speeding up as the temperature increases and slowing
the tissues of the body. Oxygen supply is equal to the
product of the cardiac output and the oxygen content of
the arterial blood. Since the arterial oxygen content
Lack of co-factors
approximates to the product of the oxygen saturation and
(e.g. oxygen)
the quantity of oxygen which can be carried by the hae-
moglobin (about 1.34 mL/g of haemoglobin when fully
saturated), the oxygen made available to the body can be
expressed by a simple equation:
Environmental
Available oxygen (mL/min) = cardiac output (mL/min) changes
Inducers (e.g. hypoxia,
× arterial saturation (%) × haemoglobin (g/mL) × 1.34 (e.g. phenobarbitone) inflammation)
This equation makes no allowance for the small quan-
tity of oxygen which is carried in physical solution in the
plasma, but it serves to illustrate the way in which three Enzyme
variables combine to produce an effect which is often
greater than is commonly supposed. If any one of the three
determining variables on the right-hand side of the equa-
tion is changed, the rate at which oxygen is made available
to the tissues of the body is altered proportionately. Thus, Inhibitors
if the cardiac output is halved, the available oxygen is also
halved. If two determinants are lowered simultaneously
while the third remains constant, the effect on the avail-
able oxygen is the product of the individual changes. For Direct effect on Substrate
example, if the cardiac output and the haemoglobin con- the enzyme competition
centration are both halved while the arterial oxygen satu- (e.g. propofol) (e.g. midazolam)
ration remains at about the normal 95%, only one-quarter
of the normal amount of oxygen is made available to the Figure 1.2 Factors which may change enzyme function.
13
with a decrease in temperature but, in spite of this, all needed. A rapid intravenous injection of an albumin-
fevers do not increase the rate of metabolism of drugs: the bound drug may also lead to increased pharmacological
cause of the fever is important. Infections and pyrogens activity because the binding capacity of the albumin in the
cause the release of inflammatory mediators which reduce limited volume of blood with which the drug initially
the expression and activity of many enzymes. Non- mixes is exceeded and more free (active) drug is presented
traumatic stress has been shown to reduce enzyme func- to the receptor sites. Plasma protein binding enhances
tion, possibly by decreased hepatic blood flow resulting in alimentary absorption of drugs by lowering the free
hypoxaemic-induced reduction in metabolizing enzymes. plasma concentration, thereby increasing the concentra-
Endogenous corticosteroid secretion as part of the stress tion gradient for diffusion from the gut lumen.
response or exogenous steroid given to treat disease will Not surprisingly, for a protein with a molecular weight
change the expression of drug metabolizing enymes, and of about 65 000, there are several genetically acquired vari-
metabolic activity also varies with age. The anaesthetist ants of albumin. Furthermore, the configuration of the
must be aware of these factors so that any increase or albumin molecule also changes during illness and, for
decrease in the duration of drug action may be example, in renal failure. These changes can be demon-
anticipated. strated by electrophoresis but their significance for the
binding of drugs in vivo is not known.
Factors affecting transport
of drugs in the body Renal disease
Most drugs are carried in the bloodstream partly bound, Chronic renal disease is common in dogs and cats, and
usually by electrostatic bonds, to the proteins of the affected animals cannot produce concentrated urine.
plasma, albumin being far the most important for the Dehydration from any cause deprives the kidneys of suf-
majority of agents. Light or moderate protein binding has ficient water for excretory purposes. To ensure that these
relatively little effect on drug pharmacokinetics or phar- animals receive an adequate fluid intake over the anaes-
macodynamics. Heavy protein binding with drugs such as thetic period, it is usually necessary to administer fluid by
thiopental results in a low free plasma concentration of intravenous infusion. A uraemic circle can also be set up
the drug, which may become progressively augmented as in animals suffering from chronic renal disease if the arte-
the available binding sites become saturated. The bound rial blood pressure is allowed to decrease because of anaes-
drug is, of course, in dynamic equilibrium with free thetic overdose or haemorrhage and renal ischaemia
(active) drug in the plasma water. The bonds are generally ensues. The maintenance of the circulating fluid volume
reversible and conform to the law of mass action: is most important in all animals with chronic renal disease
The association and dissociation processes take place and it is important that adequate venous access is assured
very quickly, and can generally be taken to be instantane- before anaesthesia and operation.
ous. The equilibrium association constant KA is defined as Acute renal failure can be defined as an abrupt decline
the ratio of rate constants, and of bound to the product of in renal function with a decrease in glomerular filtration
unbound concentrations. rate (GFR) resulting in the retention of nitrogenous waste
This simple relationship is often obscured by the fact products. Acute renal failure is classified into:
that one protein molecule may possess several binding 1. Pre-renal failure, denoting a disorder in the systemic
sites for any particular drug, which may or may not have circulation that causes renal hypoperfusion. Implicit
the same association constant. It can generally be assumed, here is that correction of the underlying circulatory
however, that so long as the plasma proteins remain disturbance (e.g. by improvement in cardiac function
unchanged, the ratio of ‘free’ to ‘bound’ drug will remain or repletion of volume) restores the GFR. However,
constant. This ratio depends on the nature of the drug pre-renal failure is often followed by transition to:
molecule. Small, neutral, water-soluble drugs will not 2. Intrinsic renal failure, where correction of the
bind to protein at all but larger lipophilic molecules may underlying circulatory impairment does not restore
exhibit very high binding ratios. the GFR to normal levels. Intrinsic renal failure
Anaemia is often associated with hypoproteinaemia and generally includes tubular necrosis or the blocking of
this can have marked effects in anaesthesia. In conditions tubules by cell debris or precipitated proteins and
where there is anaemia and hypoalbuminaemia, a greater there is no question of unaffected nephrons
fraction of a given dose of a drug will be unbound and compensating for failing nephrons as there is in
this will be even greater if other bound drugs have already chronic renal failure. Instead, all are involved in a
occupied many of the binding sites. This can result in an massive disturbance of renal function with diversion
increased peak activity of the drug. Liver disease giving rise of blood flow away from the renal cortex towards the
to hypoalbuminaemia can result in reduced binding of medulla and an overall reduction in renal perfusion.
drugs such as morphine so that smaller than normal doses There is, however, a potential for complete recovery,
of this analgesic will be effective when pain relief is whereas chronic renal failure invariably progresses
14
over a variable period of time with no hope of not result in an appreciable reduction in the volume of
recovery of renal function. the fluid content of the rumen but it seems to reduce the
3. Post-renal failure (obstructive) is a third possibility rate of fermentation within this organ, thus delaying the
and urethral obstruction is not uncommon in some development of tympany when eructation is prevented by
species, becoming a cause for emergency anaesthesia recumbency.
and surgery. Excessive fasting exposes the patient to risks almost as
Excessive reliance on blood pressure maintenance to great as those associated with lack of preparation and
between the ‘autoregulatory range’ by infusion or the use of should not be adopted. Any fasting of birds and small
vasoactive drugs overlooks the fact that renal blood flow is mammals is actually life threatening. Many clinicians are
labile since the kidneys contribute to the regulation of of the opinion that prolonged fasting in horses predis-
blood pressure. The incidence of acute renal failure is high poses to postanaesthetic colic by encouraging gut stasis. In
after the use of intravenous contrast radiological media, or horses, it is now usual practice to allow free access to water
of nephrotoxic drugs (e.g. non-steroidal anti-inflammatory until right up to the time premedication is given.
drugs, gentamycin, amphotericin).
Fluid and electrolytes
The water and electrolyte balance of an animal is a most
PREPARATION OF THE PATIENT important factor in determining uncomplicated recovery
or otherwise after operation. The repair of existing deficits
Certain operations are performed as emergencies when it of body fluid, or of one of its components, is complex
is imperative that there shall be no delay and little prepara- because of the interrelations between the different electro-
tion of the patient is possible. Among these operations are lytes and the difficulties imposed by the effects of severe
repair of thoracic injuries, the control of severe, persistent sodium depletion on the circulation and renal function.
haemorrhage, and certain obstetrical interferences where An anaesthetic should not be administered to an animal
the delivery of a live, healthy neonate is of paramount which has a depleted circulating blood volume for the
importance. For all other operations, time and care spent vasodilatation caused by anaesthetic agents may lead to
in preoperative preparation are well worthwhile since acute circulatory failure, and every effort should be made
proper preparation not only improves the patient’s chances to repair this deficit by the infusion of crystalloid or
of survival, but also prevents the complications which colloid solutions, blood, or plasma, as appropriate, before
might otherwise occur during and after operation. When anaesthesia is induced. In many instances, anaesthesia and
operations are to be performed on normal, healthy surgery may be safely postponed until the total fluid deficit
animals, only the minimum of preparation is required is made good and an adequate renal output is achieved
before the administration of a general anaesthetic, but but, in cases of intestinal obstruction, operation should be
operations on dehydrated, anaemic, hypovolaemic or carried out as soon as the blood volume has been restored.
toxic patients should only be undertaken after careful Attempts to restore the complete extracellular deficit
preoperative assessment and preparation. before the intestinal obstruction is relieved result in further
loss of fluid into the lumen of the obstructed bowel and,
especially in horses, make subsequent operation more dif-
Food and water ficult. When in doubt about the nature and volume of
The time for which food should be withheld from the fluid to be administered, it is as well to remember that,
animal on the day it is to undergo an elective operation with the exception of toxic conditions and where severe
under general anaesthesia is species dependent. A dis- hypotension due to hypovolaemia is present, an animal’s
tended stomach may interfere with the free movement of condition should not deteriorate further if sufficient fluid
the diaphragm and hinder breathing. In dogs, cats and is given to cover current losses. These current losses include
pigs, a full stomach predisposes to vomiting under anaes- the inevitable loss of water through the skin and respira-
thesia but, in dogs, it has now been shown that prolonged tory tract (approximately 20–60mL/kg/day depending on
starvation increases the incidence of gastro-oesophageal the age and species of the animal), the urinary and faecal
reflux (Savvas et al., 2009) so it might be time to recon- loss, and any abnormal loss such as vomit.
sider the teaching of many years to starve for at least 12
hours. In horses, a full stomach may rupture when the
horse falls to the ground as unconsciousness is induced;
Haemoglobin level
except in cases of colic this is unlikely with current As already mentioned earlier (cardiovascular and respira-
methods of anaesthetic induction, but a full stomach will tory disease), anaemia reduces oxygen content and also
exert pressure on the diaphragm, in particular in dorsal makes injectable anaesthetic drugs more potent by reduc-
recumbency, resulting in hypoventilation and bloat in ing overall blood protein. Where surgery is not an emer-
some cases. In ruminants, a few hours of starvation will gency and there is a medical cause that can be treated, then
15
this should be done. For more immediate surgical needs, 3. Allergy. Allergic responses are, in general, not dose
in human anaesthesia, it used to be routine to transfuse related and the allergy may be due to the drug itself
red blood cells, but the potential disadvantages (Shander or to the vehicle in which it is presented. The
et al., 2012; Theusinger et al., 2012) now mean that where reaction may take a number of forms: shock,
blood volume is adequate, low levels of haemoglobin are asthma or bronchospasm, hepatic congestion from
tolerated unless extreme. There is no equivalent evidence hepatic vein constriction, blood disorders, rashes
relating to blood transfusions in animals but it is probable or pyrexia. Terms such as ‘allergic’, ‘anaphylactic’,
that this is also a reasonable approach to veterinary ‘anaphylactoid’ or ‘hypersensitive’ have specific
anaesthesia. meanings to immunologists but, unfortunately, they
are often used interchangeably. Strictly speaking, it is
inaccurate to use any of these terms until evidence of
the immunological basis of a reaction has been
INFLUENCE OF PRE-EXISTING established. Many of these reactions are histamine
DRUG THERAPY related but other mediators such as prostaglandins,
leucotrienes or kinins may be involved. Some
immunologists consider that where either the
Modern therapeutic agents are often of considerable phar- mediator or the mechanism involved is uncertain,
macological potency and animals presented for anaesthe- reactions are best described as ‘histaminoid’ or
sia may have been exposed to one or more of these. Some ‘anaphylactoid’ (Armitage-Chan, 2010).
may have been given as part of the preoperative manage- 4. Drug interactions. Despite the importance of drug
ment of the animal but, whatever the reason for their interactions, there is little information in the
administration, they may modify the animal’s response to veterinary literature on this subject. Drug interaction
anaesthetic agents, to surgery and to drugs given before, can occur outside the body, as when two drugs are
during and after operation. In some cases, drug interac- mixed in a syringe before they are administered, or
tions are predictable and these may form the basis of many inside the body after administration by the same
of the combinations used in modern anaesthesia, but or different routes. It is generally unwise to mix
effects which are unexpected may be dangerous. products or vehicles in the same syringe (although
In an ideal situation, a drug action would occur only at frequently done). If drugs are to be administered
a desired site to produce the sought-after effect. In practice, into an IV infusion, it must be certain that some
drugs are much less selective and are prone to produce combination is compatible and, for example, does
‘side effects’ which have to be anticipated and taken into not result in precipitation of one or both drugs
account whenever the drug is administered. (A ‘side effect’ (Kanji et al., 2010). The result of the interaction
may be defined as a response not required clinically, but between two drugs inside the body may be an
which occurs when a drug is used within its therapeutic increased or decreased action of one or both or even
range.) Apart from these unavoidable side effects which an effect completely different from the normal
are inherent, adverse reactions to drugs may occur in many action of either drug. The result of interaction may
different ways which are of importance to the anaesthetist. be simply the sum of the actions of the two drugs
These include: (1 + 1 = 2), or greater (1 + 1 > 2), when it is known
1. Overdosage. For some drugs, exact dosing may be as synergism. When one agent has no appreciable
difficult. Overdosage may be absolute as when an effect but enhances the response to the other (0 + 1
amount greater than the intended dose is given in > 1), the term ‘potentiation’ is used to describe the
error, or a drug is given by an inappropriate route, effect of the first on the action of the second. An
e.g. a normal intramuscular dose may constitute a agent may also antagonize the effects of another and
serious overdose if given intravenously. Relative the antagonism may be ‘chemical’ if they form an
overdose may be due to an intrinsic difference in the inactive complex, ‘physiological’ if they have directly
animal, for example, newborn animals are sensitive opposing actions although at different sites, or
to non-depolarizing neuromuscular blocking drugs. ‘competitive’ if they compete for the same receptors.
The use in dogs and cats of flea collars containing Non-competitive antagonism may result from
organophosphorus compounds may reduce the modification by one drug of the transport,
plasma cholinesterase. Overdose manifestations may biotransformation or excretion of the other. In the
also be due to side effects (e.g. morphine producing liver, the non-specific metabolic degradation of many
respiratory depression). drugs occurs and many different agents have the
2. Intolerance. This is exhibiting a qualitatively normal ability to cause an ‘enzyme induction’ while a few
response but to an abnormally low or high dose. It decrease the activity – ‘enzyme inhibition’. Analgesics
is usually simply explained by the Gaussian such as phenylbutazone cause enzyme induction
distribution of variation in the animal population. and can produce a great increase in the rate of
16
metabolism of substrates. Barbiturate treatment of pseudocholine-esterase. Aside from these more general-
epilepsy may almost halve the half-life of ized species/breed differences, some individual animals
dexamethasone with a consequent marked may respond to a drug in an unexpected manner that is
deterioration in the therapeutic effect of this qualitatively different to that of normal individuals. Many
steroidal substance. Competition for binding sites such reactions are genetically determined. Examples
and the displacement of one drug from the bound related to veterinary anaesthesia include malignant hyper-
(inactive) form may lead to increased toxicity. thermia in pigs and horses, hyperkalaemia in quarter
horses and the response to surgery and anaesthesia of dogs
suffering from von Willebrands’s disease.
Since the knowledge of the human genome, the genetics
PHARMACOGENETICS of many such problems in humans has been clarified,
enabling tests to be carried out prior to anaesthesia.
Throughout this chapter there has been reference made Although knowledge of animal genomes is not as com-
to the existence of species differences, both anatomical plete, there are now genetic tests for the most common of
and physiological. However, within a species, and even these disorders in animals. For non-emergency surgery, in
within a breed, there are also differences. Many of these the future preanaesthetic testing in potentially susceptible
result in different metabolism of drugs; for example the animals (from breed or family history) may allow the
cat’s inability to conjugate many agents; rabbits’ rapid anaesthetist to be prepared for the previously termed ‘idi-
metabolism of atropine, differences between species in osyncratic reaction’.
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18
Chapter 2
Patient monitoring and clinical measurement
Introduction 19 Monitoring body temperature 56

General considerations relating Hypothermia 56
to monitoring 20 Hyperthermia 57
Clinical assessment of the patient 21 Malignant hyperthermia 57
Monitoring the central nervous system 21 Monitoring urine volume 58
Eye position and reflexes 23 Monitoring blood glucose 58
Anaesthetic gas analysers 24 Monitoring neuromuscular blockade 58
EEG and Bispectral index 25
Monitoring the circulation 26
Pulse rate and rhythm 26
Heart rate monitors 27 INTRODUCTION
Tissue perfusion 29
Arterial blood pressure 30 From the earliest days of anaesthesia, the anaesthetist has
Central venous pressure 38 monitored the patient’s pulse rate, pattern of breathing
Left atrial pressure (pulmonary artery and general condition. Advances in electronic technology
wedge pressure) 39 have made reasonably reliable, easily attached, non-
invasive monitoring devices available for clinical practice.
Cardiac output 39
Observations and measurements of certain parameters
Blood loss 42 before, during, and after anaesthesia provide important
Monitoring the respiratory system 42 data to support the clinical assessment of the animal’s
Rate monitors and apnoea alarms 42 condition and improve the chances of survival of the very
Tidal and minute volume monitors 43
ill by indicating what treatment is needed, as well as the
response to treatment already given.
Blood gas analysis 43
It is necessary to know what to measure as well as how
Pulse oximetry 47 to measure it and not all anaesthetists may agree on the
Capnography 49 priority ranking of the monitoring devices available.
Transcutaneous CO2 analysis 53 However, for major surgery, for anaesthesia and surgery of
poor-risk patients, and for equine anaesthesia, it would be
Acid–base analysis 53
difficult to defend the failure to use monitoring equip-
Blood gas and acid base values 53 ment, especially if it were available. Recommendations for
Interpretation of acid base abnormalities 55 monitoring of anaesthetized patients are available on the
©2014 Elsevier Ltd 19

web sites for the Association of Veterinary Anaesthetists, hypoxaemia. In any animal, evaluation of the degree of
American College of Veterinary Anesthesia and Analgesia, sedation produced by premedicant drugs may indicate
and the American Animal Hospital Association. that the anaesthetic plan should be reassessed and either
drug doses reduced or additional agents included.
Careful observation of the patient during induction of
anaesthesia may allow precise titration of drugs to achieve
GENERAL CONSIDERATIONS
the desired depth of anaesthesia and ensure early recogni-
RELATING TO MONITORING tion of a complication that requires immediate specific
treatment, such as cyanosis, anaphylaxis, or cardiac arrest.
Complications, including death, may occur in healthy Where possible, patients at risk for complications may be
patients at all stages of anaesthesia and monitors provide attached to specific monitoring equipment before induc-
early warning of life-threatening developments. Anaes- tion of anaesthesia. Appropriate equipment for this would
thetic mishaps may be caused by mechanical malfunction, be the electrocardiograph (ECG), a device for measure-
disconnection of equipment, or human error. Judgemen- ment of blood pressure, or a pulse oximeter.
tal error frequently occurs when the anaesthetist is in a Recording drugs, dosages and responses for each patient
hurry and circumvents basic practices and procedures, or is essential and provides valuable information for any
when a decision must be made in an emergency. The subsequent time that anaesthesia may be needed. Noting
prevalence of complications may also be associated with all measurements on an anaesthetic record provides a pic-
inadequate training or experience of the anaesthetist. torial description of changes that can be used to predict
Knowledge and experience are a function of the nature complications and plan treatment (Fig. 2.1). Retrospective
of the training received and the years of practice, but evaluation of difficult cases and of series of records,
proper vigilance at all times can only be generated by perhaps of patients with similar surgical procedures, or to
self-motivation. compare different anaesthetic protocols, can be used to
Routines should be developed to ensure that each aspect monitor the anaesthetist’s performance and identify dif-
of apparatus function is checked before use. Failure to ficult situations that require further thought and improved
follow a simple checklist in every case features high on the management. For research purposes, data can be acquired
list of causes of anaesthetic disasters. All anaesthetic equip- into a computer for accurate data summaries.
ment, including monitoring devices, should be main- Monitoring animals during anaesthesia must include
tained in good functioning order. It should be a matter of observation of behaviour and reflexes and measurement
course to maintain monitors with a battery back up fully of various physiological parameters at regular intervals to
charged in case of need in an area without a convenient accomplish two objectives. The first objective is to ensure
electricity outlet nearby, failure of electricity supply, or the that the animal survives anaesthesia and surgery. The
need to disconnect from the main supply to minimize second objective is to obtain information that can be used
electrical interference with other monitoring equipment. to adjust anaesthetic administration and management to
Proficiency with methods of electronic surveillance minimize physiological abnormalities, which is especially
must be acquired during minor procedures so that they important for animals that have already compromised
can be applied properly in circumstances where their use organ systems. The goal is to prevent development of pre-
is mandatory (e.g. during major surgery or a cardiovascular ventable adverse consequences 1 hour, 12 hours, or even
crisis). Routine use ensures that probes, sensors, elec- 3 days after anaesthesia.
trodes, etc. can be applied quickly to the animal and Monitoring should continue into the recovery period to
increases the likelihood that the information obtained is determine the need for additional analgesic drugs, ade-
reliable. quacy of ventilation, and to record serious deviations in
Although current practice is to establish monitoring body temperature. Mucous membrane colour should be
only after the animal has been anaesthetized, it must checked for at least 20 minutes after the animal has been
be recognized that many complications occur during disconnected from oxygen as it may take that long for
induction of anaesthesia. Ideally, especially for poor-risk hypoxaemia to develop in animals that are moderately
patients, monitoring should begin when the drugs for hypoventilating and breathing air.
premedication are administered. Dogs and cats may vomit A variety of methods using inexpensive or expensive
after administration of an opioid and the quantity and equipment can be used to monitor parameters determined
content of the vomit may warn that the animal was fed by the species of animal to be anaesthetized and by the
recently and so may be at risk for regurgitation and pul- abnormalities already present in the patient. Not all moni-
monary aspiration of gastric material. Brachycephalic toring techniques need to be applied to every patient. A
breeds and animals with respiratory problems should recommendation for three levels of monitoring is pre-
always be observed after administration of preanaesthetic sented in Table 2.1; level 1 monitoring information should
drugs because sedation may cause partial or complete be obtained from all anaesthetized animals, level 2 moni-
airway obstruction or serious respiratory depression and tors are affordable and recommended for routine use in
20
Patient monitoring and clinical measurement Chapter 2
Abbreviations AG 1 2 3 4 AE
TIME 0 15 30 45 0 15 30 45 0 15 30
O2 flow L/min 2
End tidal CO2 37 32 38 38 38
Vaporizer % 2 1.75 2 1.5
HR
180 180
Arterial pressure:
160 160
V
V Systolic
Diastolic 140 V V 140
X Mean V V V
120 V V V 120
Ventilation: V V V V
V V V V
VV V V V V V V V V V V V
Spontaneous 100 100
S
V VV V V XX X
V X X X
80 80
X XX V V V V XXXXX XX
Controlled XXX V
XXX V V X V V V V V
60 V
C VV V V V V V V V V V V 60
V
40 40
AI Anes. induction S S
AG Begin inhalant 20 S 20
AE End anes.
SS Surgery start 10 10
SE Surgery end
E Extubation 0 0
Temperature 103.1 101.6 101.6 99.9 98.8 98.6 98.1 97.5 97.2 96.6 96.1 96.5
Fluids (ml) LRS 175 350 550 850 1050 1430 2050 2200 2530 2650 2725
Other
DETAILED COMMENTS:
1. Oxymorphone 4.5mg slowly IV
2. Move to O.R. 1200mg Cefotetan IV
3. Change from indirect to direct arterial BP monitoring
4. Morphine 30mg IM
Figure 2.1 Anaesthetic record of a 61 kg, 6-year-old female Great Dane anaesthetized for exploratory laparotomy because of
torsion of the spleen. Anaesthesia was induced by intravenous administration of ketamine, 200 mg, and diazepam, 10 mg,
and maintained with isoflurane. Heart rate, blood pressure and respiratory rate were recorded at regular intervals to facilitate
early recognition of adverse trends.
some groups of patients, and level 3 monitors individually CLINICAL ASSESSMENT

offer improved monitoring for patients with specific
problems. OF THE PATIENT
This chapter will describe the techniques of monitor-
ing using a systems approach, and offer guidelines for Monitoring the central
interpretation of the information obtained. Further
nervous system
recommendations are given in the chapters devoted to
species anaesthesia and the chapter on management of Monitoring the depth of anaesthesia is not easy (see
complications. Chapter 1). An early attempt at definition through
21
Table 2.1 Prioritization of monitoring
Monitor Information obtained Specific use
Level 1 (Basic monitoring)

Palpebral and pedal reflexes, eye position Depth of anaesthesia All anaesthetized animals
Respiratory rate and depth of chest or bag Adequacy of ventilation All anaesthetized animals
excursion
Oral mucous membrane colour Oxygenation All anaesthetized animals
Heart rate, rhythm, pulse strength, capillary Assessment of circulation All anaesthetized animals
refill time
Temperature Temperature Dogs and cats anaesthesia greater than

30 min; all inhalation anaesthesia
Level 2 (Routine use recommended for some patients)

Arterial blood pressure measurement Blood pressure; pulse pressure variation All inhalation anaesthesia; cardiovascular
(indirect or direct methods) disease or depression
Blood glucose Blood glucose Paediatric patients; diabetics; septicaemia;

insulinoma
Electrocardiography Cardiac rate and rhythm; diagnosis of All inhalation anaesthesia; thoracic
arrhythmia or cardiac arrest trauma or cardiac disease
Pulse oximetry Haemoglobin oxygen saturation; pulse rate Animals breathing air during anaesthesia;
recovery from anaesthesia; thoracic
trauma or pulmonary disease;
septicaemia/endotoxaemia
Capnography End-tidal carbon dioxide concentration; estimate All inhalation anaesthesia; patients at risk
of adequacy of ventilation; warning of circuit for complications
disconnect/malfunction or cardiac arrest
Urine output, either by expression of urinary Urine volume produced during anaesthesia Dogs and cats; renal disease; some
bladder or by urethral catheterization urinary tract surgery; multiorgan failure
Level 3 (Use for specific patients or problems)

Anaesthetic gas analyser Inspired and end-tidal anaesthetic agent Any patient on inhalation anaesthesia
concentration; evaluation of depth of
inhalation anaesthesia
Blood gases and pH PaCO2, PaO2, pH, HCO3, base excess/deficit Suspected hypoventilation or hypoxaemia;
measurement of metabolic status
Cardiac output measurement Cardiac output Sick animals with decreased perfusion;
complicated surgeries
Central venous pressure Indicator of central blood volume Dehydrated/hypovolaemic patients
Packed cell volume and total protein Haemodilution and protein concentration Haemorrhage; large volume infusion of
crystalloid solution
Peripheral nerve stimulator Neuromuscular transmission Use of neuromuscular blocking agents
observation of changes in reflexes, muscle tone, and respi- excitement might be observed), Stage II (when the animal
ration with administration of increased concentration of appeared to be unconscious but exhibited involuntary
ether resulted in classification of anaesthesia into four muscle movement, such as limb paddling, and vocaliza-
stages (Fig. 2.2). The animal was said to make the transition), Stage III (surgical anaesthesia), and Stage IV (anaes-
tion from consciousness to deep anaesthesia by passing thetic overdose immediately prior to death). Stage III was
sequentially through Stage I (in which voluntary further divided into Plane 1 (light anaesthesia sufficient
22
VENTILATION
Intercostal Diaphragm Pattern Pupil Eyeball Eye Lacrimation Response to

position reflexes surgical stim.
Irregular
Awake panting
Irregular
Stage II breath- Palpebral
holding
Stage III
LIGHT Regular
Plane 1
MEDIUM Regular
Plane 2 shallow
DEEP Jerky
Plane 3
Corneal
Stage IV
Figure 2.2 Changes in ventilation and eye signs follow recognized patterns with different stages of inhalation anaesthesia.
The progression of these changes will be influenced by inclusion of injectable anaesthetic agents.
Adapted from Soma, 1971.
only for non-painful procedures), Plane 2 (medium depth

anaesthesia employed for most surgical procedures), Plane
3 (deep anaesthesia), and Plane 4 (excessively deep anaes-
thesia). Although the progression of changes described in
Fig. 2.2 are generally accurate representations of the transi-
tion from light to deep anaesthesia, the rate of changes are
altered by concurrent administration of injectable drugs.
Thus, in clinical practice, depth of anaesthesia is judged
by a number of methods, including altered somatic and
autonomic reflexes in response to nociceptive stimulation
and by knowledge of the amount of anaesthetic and anal-
gesic agents administered.
Eye position and reflexes

Eye movements are similar with thiopental, propofol, eto-
midate, alfaxalone, and inhalant anaesthetics in that the
eyeball rotates rostroventrally during light and moderate
depths of surgical anaesthesia, returning to a central posi-
tion during deep anaesthesia (Fig. 2.3). Muscle tone is Figure 2.3 The rostroventral rotation of the eye in this dog
retained during ketamine anaesthesia and the eye remains is consistent with light and medium planes of isoflurane or
centrally placed in the orbit in dogs and cats (Fig. 2.4), sevoflurane anaesthesia.
23
Table 2.2 Approximate MAC* values for isoflurane

and sevoflurane in several species
Anaesthetic agent Dogs Cats Horses
Isoflurane 1.4 1.6 1.3
Sevoflurane 2.4 2.6 2.3
*MAC: minimum alveolar concentration of anaesthetic agent

required to prevent purposeful movement in 50% of animals in
response to a standard painful stimulus; see species chapters for
ranges of values.
rates, heart rates, and blood pressure are not reliable

Figure 2.4 The central position of the eye, with a brisk
guides to depth of anaesthesia. It is not uncommon for an
palpebral reflex and pupillary dilation, is observed typically
during ketamine anaesthesia in cats.
unstimulated dog or horse anaesthetized with an inhala-
tion agent to have a low arterial blood pressure and yet in
the next minute start moving its legs in response to a skin
incision, all accompanied by a dramatic increase in blood
and only slightly rotated in horses and ruminants. Fine pressure. Nevertheless, significant increases in heart rate
nystagmus may be present in horses anaesthetized with and/or arterial blood pressure in response to surgical stim-
ketamine (see Chapter 11). The palpebral reflex, which is ulation are an indication of inadequate analgesia. In
partial or complete closure of the eyelids (a blink) elicited certain circumstances, surgical pain can induce a vaso-
by a gentle tap at the lateral canthus of the eye or gentle vagal response resulting in bradycardia, decreased periph-
stroking of the eyelashes, is frequently a useful guide to eral perfusion and pale mucous membranes. An example
depth of anaesthesia. At a plane of anaesthesia satisfactory is traction on the ovarian ligament during ovariohysterec-
for surgery, the palpebral reflex is present but weak and tomy in a bitch. Preanaesthetic administration of an anti-
nystagmus is absent. A brisk palpebral reflex develops cholinergic may prevent bradycardia but may also obscure
when anaesthesia lightens. Ketamine anaesthesia is associ- heart rate responses to painful stimuli.
ated with a brisk palpebral reflex.
A corneal reflex is a similar lid response elicited by
gentle pressure on the cornea. The presence of a corneal Anaesthetic gas analysers
reflex is no indicator of depth of anaesthesia and may The anaesthetic gas analyser measures the concentration
still be present for a short time after cardiac arrest has of inhalation anaesthetic agent in inspired and expired
occurred. gases (Fig. 2.5). The gases are sampled at the junction of
The pedal reflex is frequently tested in dogs, cats and the endotracheal tube and breathing circuit by continuous
small laboratory animals to determine if depth of anaes- aspiration of gases at a rate of 150 mL/min to a monitor
thesia is adequate for the start of surgery. Pinching the web placed at some distance from the patient. To assess the
between the toes or firm pressure applied to a nail bed will depth of anaesthesia, the end-tidal concentration of inha-
be followed by withdrawal of the limb if analgesia is inad- lation agent is measured (alveolar concentration is meas-
equate. Other species-specific reflexes that have been ured at the end of exhalation) and compared with the
found useful include the whisker reflex in cats, where Minimum Alveolar Concentration (MAC) value for that
pinching of the pinna elicits a twitch of the whiskers, and inhalant anaesthetic and species (Table 2.2). Using MAC
tickling the inside of a pig’s ear, where a shake of the for monitoring depth of anaesthesia is not precise as MAC
head indicates inadequate anaesthesia for surgery. It must is only an approximation of the predicted response in 50%
be remembered that administration of neuromuscular of a population and MAC is decreased in very young and
blocking agents blocks somatic reflexes and respiratory in old patients. Higher than MAC values will be required
responses, and that the eye position will be central. to prevent movement in all patients, and to block auto-
Increasing the depth of anaesthesia by increasing nomic responses and increases in cortical electrical activity
administration of an anaesthetic agent in most cases pro- in response to a painful stimulus (March & Muir, 2003a),
duces increased respiratory and cardiovascular depression. usually 1.2–1.5 times MAC, when anaesthesia is main-
However, more than one anaesthetic or preanaesthetic tained almost entirely by inhalation agent. Less than MAC
agent is generally administered and the cardiopulmonary value may be sufficient when the patient is receiving con-
effects are determined by the combination of agents used tinuous or intermittent administration of an adjunct
and their dose rates. Thus measurements of respiratory agent(s) such as an opioid, lidocaine, ketamine, propofol,
24
Figure 2.5 This gas analyser (Capnomac UltimaTM, Datex-Engstrom Inc., Tewksbury, Maryland, USA) is monitoring a 27 kg
female English Bulldog that was premedicated with glycopyrrolate and butorphanol and anaesthesia induced with propofol.
She has been breathing oxygen and isoflurane at a vaporizer setting of 2.5% for 5 minutes. The monitor indicates that the
inspired (Fi) isoflurane concentration is less than the vaporizer setting and that the end-tidal (ET) isoflurane concentration is
less than MAC value.
or medetomidine/dexmedetomidine. For these animals, EEG and Bispectral index

the anaesthetic administration must be adjusted according The subject of encephalogram (EEG) guidance to depth of
to observation of reflexes and lack of significant cardiovas- anaesthesia has been discussed in Chapter 1 and Murrell
cular response to surgical stimulus. and Johnson (2006) have published a review of the tech-
It should be noted that the gas analyser also accurately niques using bispectral index and somatosensory evoked
measures inspired anaesthetic concentration, which may potentials for assessment of pain in animals.
be substantially lower than the vaporizer setting in Intraoperative awareness occurs when a patient becomes
rebreathing systems during anaesthesia in large dogs, conscious during general anaesthesia. Significant psycho-
horses and ruminants (see Fig. 2.5). A situation may arise logical effects have been identified in humans after epi-
where administration of an anaesthetic agent may be inad- sodes of awareness that later are associated with changed
equate despite an apparently adequate vaporizer setting. behaviour (Apfelbaum et al., 2006). The American Society
In a retrospective study of equine anaesthesia, it was found of Anesthesiologists (ASA) task force identified certain
that horses were four times more likely to move during procedures and anaesthetic techniques during anaesthesia
anaesthesia when an anaesthetic agent analyser was not of human patients that may be associated with intraopera-
used (Parviainen & Trim, 2000). tive awareness and these included caesarian section,
Some monitors using the principles of infrared absorp- cardiac surgery, trauma surgery, rapid-sequence induction,
tion spectrometry cannot be used for horses or ruminants total intravenous anaesthesia, and use of reduced anaes-
as they will measure exhaled methane and record the con- thetic drug dosages with or without neuromuscular paraly-
centration as halothane, for example the Datex Capnomac/ sis. Awareness has been reported in the absence of
Normac (Taylor, 1990). There may be minimal effect with tachycardia or hypertension. Nonetheless, clinical tech-
isoflurane but negligible with sevoflurane and desflurane. niques such as observation for lack of movement, the
Analysers that use higher wavelengths of infrared light palpebral reflex, and other monitors are useful to assess
should be unaffected by methane (Moens et al., 1991). anaesthetic unconsciousness.
25
Monitoring of brain electrical activity has clinical appli- in anaesthetized cats in response to a noxious stimulus
cation and a number of monitors have been developed. (March & Muir, 2003a). The relationship between BIS
Various signal processing algorithms can be applied to the and clinically evaluated anaesthetic depth in dogs was
frequency, amplitude, and latency of the EEG to generate found to be unsatisfactory (Bleijenberg et al., 2011).
a number. This number, or ‘index’, is scaled 0 to 100 with Although BIS decreased significantly between sedation
a value of 100 associated with wakefulness and 0 referring and anaesthesia, BIS values overlapped significantly
to an isoelectric EEG. One monitor, the Bispectral Index between light and deep anaesthesia. Similarly, in horses
(BIS) has become the one most used. BIS is a proprietary anaesthetized with isoflurane, BIS monitoring was not
algorithm based on a large number of EEG recordings found to be a useful predictor of depth of anaesthesia
taken during human anaesthesia that converts a single or warning of patient movement (Haga & Dolvik, 2002).
channel frontal EEG to an index 0 to 100, of which a range In another investigation in horses anaesthetized with
of 40 to 60 is reported to be associated with anaesthesia sevoflurane and undergoing a variety of surgical proce-
without awareness or decreased incidence of awareness dures, the mean BIS value was >60 and changes in BIS
when compared with anaesthesia monitored by other values were not detected in all horses that moved during
means. It has also been proposed that targeting a specific anaesthesia (Belda et al., 2010). Further investigations are
BIS index range may avoid excessive depth of anaesthesia needed to define the recommendations for BIS monitor-
such that the patients enter recovery at a lighter plane of ing in veterinary medicine.
anaesthesia with less respiratory depression and experi- Another monitor used in human anaesthesia is the
ence shorter recovery times. Concerns are that the numeric cerebral state index (CSI) monitor. The CSI is not depend-
value may be influenced by other factors such as bolus ent on algorithms derived from human patients (see
administration of anaesthetic drugs, electrocautery, or cer- Chapter 1) and, consequently, was hoped to be more reli-
ebral hypoxia, and may not accurately reflect the depth of able in domestic species. However, Ribeiro et al. (2009)
anaesthesia and initiate an inappropriate change in anaes- investigating induction of anaesthesia with propofol in
thetic administration. Further, that use of a brain function dogs concluded that CSI monitoring was not consistent
monitor may result in excessively deep anaesthesia to the with the clinical observations observed in different stages
detriment of organ blood flow and function. Several pro- of depth of anaesthesia.
spective multicentre controlled trials involving human
patients have evaluated the role of BIS monitoring in
determining depth of anaesthesia and reliability for pre-
vention of awareness during intravenous or inhalant Monitoring the circulation
general anaesthesia (Bruhn et al., 2005; Avidan et al., The heart rate, pulse rate and rhythm, tissue perfusion, and
2008; Ellerkmann et al., 2010; Kertai et al., 2011). The blood pressure of all anaesthetized animals should be
results thus far have not supported a unified view, however, assessed at frequent regular intervals (Table 2.3).
it appears that BIS monitoring may have an impact on
incidence of awareness but not influence the amount of
anaesthetic agents administered or influence postoperative
mortality.
Pulse rate and rhythm
The use of BIS monitoring is being investigated in The peripheral pulse rate and rhythm may be counted by
animals. Electrodes manufactured for human patients palpation of a peripheral arterial pulse, such as the femoral
may require modification and reconfiguration to adjust artery in dogs and cats, lingual artery in dogs (Fig. 2.6),
to the differences in shape and nature of animals’ facial, median or metatarsal arteries in horses (Fig. 2.7),
heads. Decreasing BIS values have been recorded with and femoral, median, or auricular arteries in ruminants
increasing concentrations of isoflurane and sevoflurane and pigs. The pulse rate and rhythm can also be deter-
in dogs and cats (March & Muir, 2003b; Lamont et al., mined from the audible sound of blood flow from a
2004; Campagnol et al., 2007). Burst suppression of the Doppler ultrasound probe (see later) and as a digital
EEG, characterized by periods of low amplitude waves number and waveform generated by a pulse oximeter. The
interspersed with bursts of high amplitude waves, occurs physiological relationship between the heart sounds, ECG,
during deep anaesthesia (2.0 MAC) resulting in paradoxi- and arterial pulse is depicted in Figure 2.8. Pulse deficits
cal increases in BIS values (Lamont et al., 2004; Henao- are identified by palpation of a peripheral pulse that has
Guerrero et al., 2009). Concern has been expressed that an irregular rhythm, pauses, or a pulse rate that is less than
the BIS range for animals may not be the same as the the heart rate determined by auscultation of the heart
accepted range for anaesthesia in humans. A study in using a stethoscope. Pulse deficits may be associated with
experimental cats found that pedal and palpebral reflexes any of several cardiac dysrhythmias, such as sinoatrial
were lost at BIS values 66 to 67, however, these values heart block, atrioventricular heart block, premature ven-
may not be associated with a surgical depth of anaesthesia tricular depolarizations, or atrial fibrillation, and will
(March & Muir, 2003b). BIS values increased significantly require an ECG for diagnosis.
26
Table 2.3 Methods of assessing cardiovascular

function in anaesthetized clinical patients
Heart rate and rhythm

Transverse
Palpation of arterial pulse
Oesophageal stethoscope
facial artery
Electrocardiogram
Blood pressure monitor
Pulse oximeter
Tissue perfusion
Mucous membrane colour
Capillary refill time
Blood pressure
Bleeding at operative site
Observation of intestine colour
Urine output
Arterial blood pressure

Palpation of arterial pulse
Facial artery
Doppler ultrasound method
Oscillometric method
Arterial catheterization Lateral
nasal artery
Blood volume
Figure 2.7 Sites for palpation of arterial pulse or catheter
Pulse pressure variation placement for blood pressure measurement in horses.
Central venous pressure
Assess blood loss
Aortic Aortic
valve valve
opens closes
AA
Aortic Aortic
valve valve
closes R opens
P T
BB
Q
S
1st 2nd 3rd
CC
Systole Diastole Systole

Figure 2.8 Relationship between aortic pulse (A), ECG (B),
and heart sounds as auscultated with a stethoscope (C).
Modified from Guyton, 1986.
Heart rate monitors

Heart rates measured before anaesthesia are greatly influ-
enced by the environment. Means (standard deviations,
range) of heart rates obtained by palpation from healthy
cats at home were 118 mean (SD 11, range 80–160) beats
Figure 2.6 The lingual artery is easily palpated in dogs per minute compared with mean 182 (SD 20, range 142–
midline on the ventral surface of the tongue, adjacent to the 222) when obtained by electrocardiography in the veteri-
nerve and between the lingual veins. The arrow in the nary hospital (Sawyer et al., 1991).
photograph points to a line drawn adjacent to the lingual The lowest acceptable heart rates during anaesthesia are
artery. controversial, but reasonable guidelines are 55 beats/min
27
Figure 2.9 The oesophageal stethoscope. It may be used with a single earpiece or with a conventional stethoscope
headpiece. This is a simple and inexpensive monitoring device for heart beat and respiratory activity.
for large dogs, 65 beats/min for adult cats, 26 beats/min Electrocardiography

for horses, and 50 beats/min for cattle. Heart rates should
Heart rate and rhythm can be obtained from an ECG using
be higher in small breed dogs and much higher in imma-
standard limb leads in small animals, clip electrodes and
ture animals. Heart rates may be less than these values
ECG paste or gel, and selecting ECG Lead II on the oscil-
when medetomidine/dexmedetomidine has been admin-
loscope (Fig. 2.10A). Poor contact of the electrodes to the
istered. It should be remembered that heart rate is a major
skin from hair bunched in the clips, or close proximity to
determinant of cardiac output, consequently, bradycardia
another electrical apparatus, such as the hot water circulat-
should be treated if blood pressure and peripheral per-
ing pad, can result in electrical interference that obscures
fusion are also decreased.
the ECG. The leads should not be placed over the thorax
as breathing will move the electrodes and result in a wan-
Oesophageal stethoscope dering ECG baseline (Fig. 2.10B).
The oesophageal stethoscope (Fig. 2.9) is a simple method A frequently used monitor lead in equine anaesthesia is
of monitoring heart rate in dogs and cats. This monitor the ‘base-apex’ lead. The right arm electrode is clipped on
consists of a tube with a balloon on the end which is the neck in the right jugular furrow and the left arm elec-
passed dorsal to the endotracheal tube and into the trode is passed between the forelimbs and clipped at the
oesophagus until the tip is level with the heart. The open apex of the heart over the left fifth intercostal space several
end of the tube is connected to an ordinary stethoscope inches from the midline. The left leg electrode is clipped
headpiece, to a single earpiece that can be worn by the on the neck or on the shoulder. Good electrical contact is
anaesthetist or surgeon, or connected to an amplifier that achieved with alcohol or electrode paste. Lead I is selected
makes the heart sounds audible throughout the room. on the electrocardiograph and the normal configuration
This monitor provides only information about heart rate includes a negative R wave (see Fig. 2.10C). A bifid P wave
and rhythm; the intensity of sound is not reliably associ- is frequently observed in the normal equine ECG. Sinus
ated with changes in blood pressure or cardiac output. arrhythmia in dogs and cats is abolished when atropine
Other electronic oesophageal probes are available to or glycopyrrolate has been administered. Other arrhyth-
provide heart rate, and some also may produce an ECG mias, for example second degree atrioventricular heart
and oesophageal temperature. block and ventricular premature depolarizations (VPD) or
28
Figure 2.10 (A) Normal lead II ECG from a Labrador during inhalation anaesthesia. (B) ECG with a wandering baseline
induced by movement of leads as the dog breathes. The bottom trace is arterial blood pressure. This dog has a heart rate of
114 beats per minute, systolic arterial pressure of 96 mmHg, diastolic pressure of 46 mmHg, and mean pressure of 61 mmHg.
(C) Normal base apex ECG and blood pressure recorded from a horse anaesthetized with isoflurane.
premature ventricular complexes (PVC), may or may not

require specific treatment (see Chapter 21). Tissue perfusion
There is a high incidence of sinus arrhythmia and first Evaluation of tissue perfusion can be done by considering
and second degree atrioventricular (AV) heart block in gum or lip mucous membrane colour, the capillary refill
conscious unsedated horses (Robertson, 1990). In con- time, and the blood pressure. High mean arterial pressure
trast, AV block during anaesthesia is uncommon except does not guarantee adequate tissue perfusion. For example,
when the horse has been premedicated with detomidine, when blood pressure increases during anaesthesia in
or supplemental intravenous injections of xylazine are response to a surgical stimulus, cardiac output may be
given during anaesthesia. The appearance of this arrhyth- decreased due to increased afterload from peripheral
mia during anaesthesia on any other occasion is cause for vasoconstriction.
concern as this rhythm may progress within a few minutes Tissue perfusion is usually decreased when the gums are
to advanced heart block (P waves only, no ventricular pale, rather than pink, sometimes when very pink, and the
complexes) and cardiac arrest. Atrial fibrillation and PVCs capillary refill time (CRT) exceeds 1.5 seconds, or the
occur rarely in horses but may require specific treatment mean arterial pressure (MAP) is less than 60 mmHg.
if associated with hypotension. When MAP is above 60 mmHg, palpation of the strength
29
Abbreviations Myths about blood pressure in anaesthetized

animals
NIBP Non-invasive blood pressure
IBP Invasive blood pressure If you can feel a strong pulse the blood pressure is
SAP Systolic arterial pressure adequate
DAP Diastolic blood pressure Heart rate will increase during hypotension
MAP Mean arterial pressure
CVP Central venous pressure
CO Cardiac output
An approximate estimate of blood pressure can be made
from palpation of a peripheral artery. However, strength
of a palpated pulse is determined by the pulse pressure
of the peripheral pulse and observation of oral membrane
(difference between systolic and diastolic pressures) and,
colour and CRT should be used to assess adequacy of
in states associated with vasodilatation, a peripheral pulse
peripheral perfusion and cardiac output. During laparot-
can be palpated at MAP as low as 40 mmHg so that, in
omy, intestinal colour should be bright pink and intestines
some cases, palpation alone does not suggest the urgency
that are pale pink, white, or grey may be an indicator of
for treatment. The turgidity of the artery will provide
inadequate tissue perfusion. Measurement of central
further information because pressure is likely to be low if
venous O2 saturation may provide further information in
the artery is soft or collapsible rather than solid like a
sick patients, as described later.
pencil. Bear in mind that it is not uncommon for heart
rates to be within an accepted normal range while blood
Arterial blood pressure pressure is low or decreasing (Fig. 2.11).
Systolic (SAP), mean (MAP), and diastolic (DAP) arterial Measurement of blood pressure can be made easily;
pressures in awake healthy animals are approximately equipment cost varies. The investment in time and money
125–160 mmHg, 90–110 mmHg, and 75–95 mmHg, is worthwhile in animals at risk for hypotension, such as
respectively. Excepting when premedication has included small animals and horses anaesthetized with inhalation
detomidine or medetomidine or when anaesthesia was agents, and in animals with abnormalities likely to give
induced with ketamine or tiletamine, arterial blood pres- rise to complications during anaesthesia. The least expen-
sure is decreased from the awake value during anaesthesia. sive techniques are the Doppler ultrasound technique in
Arterial blood pressure is lower in paediatric patients than dogs and cats, and direct blood pressure measurement
in mature animals. For example, healthy 5- or 6-day-old using an anaeroid manometer in horses, however, pur-
foals anaesthetized with isoflurane had an average MAP of chase of a unit that monitors more than one parameter,
58 mmHg. When the same foals were reanaesthetized 4–5 for example, ECG, blood pressure, and temperature, is
weeks later, the average MAP had increased to 80 mmHg, more economical than acquiring monitors individually.
with a corresponding decrease in cardiac index (Hodgson
et al., 1990).
Doppler ultrasound for indirect measurement
Hypotension may be defined as MAP less than 65 mmHg of blood pressure
in mature animals. A MAP as low as 60 mmHg may be Hair is first clipped from the skin on the palmar surface
allowed in dogs and cats provided that the mucous mem- of the paw of dogs and cats (Fig. 2.12). A probe covered
brane colour is pink and CRT is 1 second. This combina- with contact gel is placed over the artery and taped in place
tion of values may occur during inhalation anaesthesia at with the electrical lead pointing down towards the toes
the time of minimal stimulation during preparation of the (Fig. 2.13). Ultrasound waves emitted from one of the two
operative site and before the onset of surgery. MAP is piezoelectric crystals embedded in the probe pass through
not usually allowed to fall below 65–70 mmHg for any the skin and deeper tissues. A structure that is stationary
length of time in anaesthetized horses because of the will reflect sound back to the second crystal without any
increased risk for postanaesthetic myopathy. When hypo- frequency change (Stegall et al., 1968). Moving objects,
tension is documented, appropriate treatment can be such as erythrocytes and the artery wall, will reflect some
instituted, such as decreasing anaesthetic depth or com- of the sound at a different frequency (Doppler-shift). The
mencing or increasing the intravenous administration of change in frequency can be heard through a loudspeaker
fluids or administration of a vasoactive drug such as as an audible swooshing sound with each pulse.
dopamine, dobutamine, or ephedrine. The outcome of A cuff is wrapped snugly around the extremity proximal
untreated severe or prolonged hypotension may be unex- to the probe, in dogs and cats with the centre of the inflat-
pected cardiac arrest during anaesthesia or neurological able part of the cuff, or an arrow or dot, on the medial
deficits, blindness or renal failure after recovery from aspect of the limb and the air tube positioned on the distal
anaesthesia. end of the cuff. The cuff is connected to an anaeroid
30
TIME 135 150 165 180 195 210 225

O2 L/min 1
Vaporizer 2.2 0 1.5 1
Inspired Iso
End tidal Iso 1.6 1.0
End tidal CO2 28
32
SpO2 98
140
120 1
100
80
60
Systolic
40
Heart rate 2
20
C C S
Resp rate
10
Figure 2.11 Blood pressure (Doppler systolic) decreased without a change in heart rate after this hound was turned over
(Arrow 1) during anaesthesia. Blood pressure continued to decrease after isoflurane was discontinued. Infusion of dobutamine
(Arrow 2) produced a rise in blood pressure.
A B
3
1 Figure 2.13 Doppler-shift pulse detector. One piezoelectric
4
2 crystal emits incident ultrasound signal while the other
5 receives the reflected signal from cells in flowing blood. The
6 frequency shift between the incident and reflected sound is
converted to audible sound.
manometer and a bulb for manual inflation of the cuff

Figure 2.12 Sites for application of the Doppler probe for with air (Fig. 2.14). In horses, the cuff is wrapped around
indirect measurement of arterial blood pressure in dogs. 1 & 2:
the base of the tail with the cuff air bladder centred over
Ulnar artery on the caudal surface of the forelimb, above
and below the carpal pad; 3: cranial tibial artery on the the ventral surface of the tail. The probe is taped distal
craniolateral surface of the hindlimb; 4 & 5: saphenous artery to the cuff over the coccygeal artery in the ventral midline
on the medial surface of the flexor tendons and on the plantar groove. The coccygeal artery can be used for this technique
surface of the paw proximal to the foot pad; 6: dorsal pedal in adult cattle but the results are not reliable. In foals, the
artery; 7: coccygeal artery on the ventral surface of the tail. probe and cuff are commonly attached to the tail. In foals
31
that the cuff is level with the manubrium. Furthermore, a

cuff that is attached too loosely or slips down the extrem-
ity and becomes loose, or situated over a joint such as the
carpus will result in an erroneously high value.
To measure blood pressure, the cuff is inflated to above
systolic pressure to occlude the artery and no sound is
heard. The pressure in the cuff is gradually released until
the first sounds of blood flow are detected at systolic pres-
sure. As additional pressure is released from the cuff,
diastolic pressure is heard as a change in character of
sound from a one or two beat sound to a multiple beat
sound, to a muffling of sound, or to a growl. This will
occur 15–40 mmHg below systolic pressure. The sounds
associated with diastolic pressure are well defined in some
animals but not at all clear in others. In some animals, a
first muffling of beat signals may occur 10–15 mmHg
above the true diastolic pressure. In this event, the second
change in beat signal will be more abrupt or distinct. Mean
pressure can be calculated as one third of the pulse pres-
sure (systolic−diastolic) plus diastolic pressure.
A decrease in intensity of the pulsing sound, when the
attachment and setting have been unchanged, is a reliable
indication of decreased blood flow. Furthermore, changes
in cardiac rhythm are easily detected by listening to this
monitor.
The Doppler ultrasonic method was observed to provide
both overestimated and underestimated values over a wide
range of systolic pressures in conscious and anaesthetized
dogs, with a tendency for overestimation when MAP
<80 mmHg and underestimation at high pressures
(Haberman et al., 2006; Bosiack et al., 2010). An investiga-
Figure 2.14 Measurement of arterial pressure in a dog by tion in cats comparing the Doppler ultrasonic method,
taping a Doppler probe over an artery distal to the carpal using a cuff placed halfway between the carpus and the
pad so that audible sounds of arterial pulses are emitted elbow, with measurements obtained from a femoral artery
from the box. A blood pressure cuff is applied higher up the catheter revealed that the indirect method consistently
limb and the anaeroid manometer attached to the cuff is underestimated systolic pressure by an average of
used to identify systolic and diastolic pressures. 14 mmHg (Grandy et al., 1992). Caulkett et al. (1998)
also determined that the Doppler method both overesti-
mated and underestimated systolic blood pressure in
and small ruminants in lateral recumbency, the probe can anaesthetized cats but that it proved to be an accurate
be taped over the metatarsal artery on the lateral surface predictor of MAP. Using this technique of measuring
of the hind limb or the common digital artery on the blood pressure in mature horses using a cuff width 48%
medial side of the forelimb distal to the carpus. The cuff of the circumference of the tail (bladder width 10.4 cm)
is secured around the limb above the hock or carpus and systolic pressure was underestimated and diastolic pres-
positioned level with the sternum. In pigs, the probe is sure overestimated by approximately 9% (Parry et al.,
most reliable when taped over the common digital artery 1982). In another investigation, measurements of systolic
on the caudomedial aspect of the forelimb. The cuff arterial pressure in horses anaesthetized in dorsal recum-
should be placed between the carpus and the elbow but, bency with halothane using a cuff 41% of the tail circum-
because of the triangular shape of the forearm, it may be ference was reasonably accurate but, in 5% of the horses,
unable to occlude blood flow when inflation of the cuff this technique had an error range of ±20 mmHg (Bailey
causes it to slip down over the carpus. For all animals, the et al., 1994).
width of the air bladder within the cuff is important for
accuracy; a bladder that is too narrow will overestimate
Oscillometry for indirect measurement
blood pressure and one that is too wide will underesti- of blood pressure
mate it. The cuff (air bladder) width should be 40% of the Devices that non-invasively measure peripheral blood
circumference of the extremity and the leg positioned so pressure using the oscillometric method operate by
32
Figure 2.15 Non-invasive measurement of blood pressure by oscillometry. The cuff should be positioned level with the
manubrium or sternum, and for big dogs it may be necessary to hold the limb elevated during measurement to achieve
alignment. A Doppler ultrasound probe is also attached to the limb of this dog for audible recognition of blood flow.
automatically inflating a cuff placed around an extremity, (Haberman et al., 2006; Bosiack et al., 2010). Closest cor-
either above or below the carpus, above or below the hock, relations between direct and indirect measurements have
or the tail (Fig 2.15). The monitor measures and records been measured using cuff widths of 40% of the circumfer-
the amplitude of pressure changes in the cuff caused by ence of the animal’s leg or tail.
pulses in underlying arteries. The cuff is inflated to above By far the highest number of published articles compar-
systolic pressure and deflated slowly. The pressure oscilla- ing NIBP and IBP measurements have been in dogs. Not
tions in the cuff start small and increase to a maximum all investigations have produced similar results, in part
value (corresponding with MAP) and then decrease. Each influenced by use of different models from several manu-
monitor uses fixed or variable parameter identification facturers, measurement in awake versus anaesthetized
points based on the MAP value to calculate electronically animals, increased variability attributed to haemodynamic
systolic and diastolic pressures. The algorithm determin- alterations imposed by disease, differences in size and
ing systolic and diastolic pressures varies between models gender, sites of measurement, patient body position, phar-
and thus measurement results are not the same for all macological methods used to alter blood pressure, and the
models. There is a also small difference in the recorded investigators varied definitions of hypotension or hyper-
MAP and MAP calculated from the systolic and diastolic tension. The ‘take home’ message is that NIBP does not
pressures using the formula MAP = diastolic pressure + accurately predict IBP all of the time and that no treatment
0.33 (systolic − diastolic) and this value is dependent on decision should be made based solely on one measure-
the measurement device (Kiers et al., 2008). Values for ment. Investigations of specific models have employed
SAP, DAP, MAP, and heart rate are digitally displayed and the average of three to six consecutive readings taken
the monitor can be programmed to measure automatically 30–60 seconds apart to increase accuracy. Frequently
at a specified time interval. The cuff should be situated during anaesthesia, the site of surgery and accessibility
approximately level with the heart (manubrium or dictates the site for application of the cuff. Different sites
sternum if in lateral recumbency) for accurate measure- have been investigated with the result that the forelimb
ment. Artefactual pressure changes induced in the cuff by in dogs was determined to be more accurate when com-
movement of the extremity, for example, during prepara- pared with lingual artery pressure and the hind limb
tion of the surgical site, will either induce abnormal read- more accurate when compared with dorsal pedal artery
ings or prevent the monitor from obtaining a measurement pressure (McMurphy et al., 2006), no difference between
33
measurements was recorded between the fore and hind isoflurane and high pressures MAP >140 mmHg were
limbs (Sawyer et al., 1991), or that the tibial or coccygeal created by administration of medetomidine. Mean differ-
arteries provided better correlation than the metacarpal ences between NIBP and IBP were <5 mmHg for MAP and
artery when compared with aortic or anterior tibial artery DAP in all pressure ranges; SAP differences increased
pressure (Sawyer et al., 2004; Haberman et al., 2006). as pressure increased from hypotension to hypertension
Most oscillometric monitors provide a reasonable approx- resulting in underestimation of SAP. The DINAMAP had
imation of MAP in normotensive animals. good correlation with IBP systolic pressure in anaesthe-
The greatest concern during most anaesthetic episodes tized cats (Caulkett et al., 1998), however, the Datascope
is the accurate identification of hypotension to avoid Passport did not accurately estimate direct blood pressure
cardiac arrest or postoperative organ malfunction. The in cats (Branson et al., 1997).
Surgivet V60046, with the cuff placed distal to the hock, In horses, the oscillometric method of blood pressure
provided accurate information for MAP in normotensive measurement is used when direct measurement of arterial
and hypotensive dogs, with 90.6% of the dogs with MAP pressure is not possible, for total intravenous anaesthesia,
<70 mmHg being accurately diagnosed as hypotensive and for awake animals. The cuff is wrapped around the tail
(Deflandre & Hellebrekers, 2007). The monitor was less of mature horses and foals or around the hind limb near the
accurate at high pressures. The Cardell 9401, DINAMAP metatarsal artery in foals. The cuff should not be wrapped
(Device for Indirect Noninvasive Automatic Mean Arterial tightly. Some investigators have recommended that the tail
Pressure) 8100, DINAMAP 8300 and PetMAP overesti- cuff be placed close to the base of the tail but, in this
mated pressures during hypotension (Sawyer et al., 1991; author’s opinion, more accurate readings are obtained with
Meurs et al., 1996; Bosiack et al., 2010; Shih et al., 2010), the cuff applied approximately 10 cm from the base of the
and did not reliably predict the severity of hypotension in tail, where the tail diameter is constant for the length of the
animals with acute haemorrhage or in critically-ill patients cuff. In standing horses, cuff placement may be higher than
in the ICU. Wernick et al. (2010) compared measurements the atrium, resulting in a measurement that is lower than
in anaesthetized dogs between pressures recorded from the actual pressure. Early investigations of the DINAMAP
the dorsal pedal artery and from a cuff around the ante- confirmed accurate and clinically useful values for arterial
brachium using the DINAMAP 8300. The DINAMAP pressure using a cuff width 24% of the tail circumference in
slightly underestimated SAP and DAP and overestimated ponies (Geddes et al., 1977) and 25–35% in horses
MAP; comparisons that fell just short of the validation (Latshaw et al., 1979; Muir et al., 1983). However, meas-
requirement proposed by the American College of Veteri- urements were inaccurate at heart rates of less than 25
nary Internal Medicine (Brown et al., 2007). In contrast, beats/minute. Our experience using a Model 8300
the DINAMAP 8300 underestimated all BP parameters in DINAMAP and a cuff width 35–40% of the tail circumfer-
awake experimental Beagles, and to a greater extent at high ence ratio (child or small adult cuff for a mature horse
pressures generated by administration of phenylephrine depending on tail thickness and the amount of hair) has
(Haberman et al., 2006). Comparisons with the Cardio- been that MAP value obtained from this monitor is usually
cap II in clinical canine patients using premedication to the same as that obtained by direct blood pressure measure-
alter blood pressure (acepromazine or medetomidine) ment. Occasionally, the DINAMAP recorded pressures
generated a smaller bias than previously reported (Sawyer 10–20 mmHg higher than the true MAP. An evaluation of
et al., 2004; McMurphy et al., 2006) but greater limits of the Cardell Model 9402 and the DINAMAP Pro 100 in
agreement (variability) that was attributed to variation in anaesthetized foals of less than 7 days of age using cuff sizes
clinical population (MacFarlane et al., 2010). recommended by the manufacturers revealed that both
In clinical practice, it may be necessary to identify hyper- monitors had similar performance (Giguère et al., 2005b).
tension before anaesthesia and to measure accurately high Analysis of MAP values confirmed acceptable accuracy with
pressures during anaesthesia in patients at risk, such as the cuffs on the tail or metatarsus for conditions of normo-
phaeochromocytoma, renal or endocrine disease. Oscil- tension and hypotension, although the Cardell was most
lometric methods tend to underestimate systolic blood accurate over the coccygeal artery and the DINAMAP over
pressures during hypertension (Haberman et al., 2006; the metatarsal artery. Cuffs placed over the median artery
McMurphy et al., 2006; Deflandre & Hellebrekers, 2007; produced less accurate values and wider variability. This
Bosiack et al., 2010), consistently underestimate MAP or study also confirmed that blood pressure did not correlate
DAP (Haberman et al., 2006), overestimated MAP or DAP well with cardiac output, i.e. a good MAP does not guaran-
(Bosiack et al., 2010), or underestimated SAP and DAP tee that cardiac output is also acceptable. In summary,
with close agreement with MAP (McMurphy et al., 2006). indirect method of measurement of blood pressure pro-
The Cardell 9301V with 2.5 cm-wide neonatal pressure vides useful information in most horses, but may produce
cuff placed around the forelimb above the carpus, with the erroneous values in a small number. Consequently, blood
monitor set at ‘small cuff’ mode has been evaluated in cats pressure should be measured by direct means whenever
(Pedersen et al., 2002). Low pressure MAP <60 mmHg possible in horses at risk of developing low blood pressure,
was achieved by increasing depth of anaesthesia with for example, during inhalation anaesthesia.
34
Standards have been set for automated sphygmoma- paralleled the telemetered pressures (Meyer et al., 2010).
nometers in human medicine by several organizations, The standards set by AAMI were not met in this study. The
including the British Hypertension Society, the Associa- authors noted that the mean standard deviations were
tion for the Advancement of Medical Instrumentation substantially decreased by use of six averaged measure-
(AAMI) and the American National Standards Institute, ments at any time point compared with a single
Inc. (ANSI). Devices validated for use in humans must measurement.
have a correlation of ≥0.9 across a range of measurements
with specific % of readings to be within 5, 10, or 15 mmHg Direct measurement of blood pressure
of the standard measurement. Requirements for validation Measurement of arterial blood pressure directly is accom-
were tightened in 2011. These standards have been met for plished by insertion of a 20 gauge, 22 gauge or, in very
MAP at low and normal pressures in dogs with the Surgivet small animals, a 24 gauge catheter aseptically into a
V60046 (Deflandre & Hellebrekers, 2007), for MAP and peripheral artery; the dorsal pedal, anterior tibial, femoral,
DAP in cats with the Cardell 9301V (Pedersen et al., 2002), coccygeal, metacarpal, auricular or lingual artery in dogs
and for MAP in foals using the Cardell 9402 and DINAMAP (Fig. 2.16), the dorsal pedal, femoral or coccygeal artery
Pro 100 (Giguère et al., 2005b). For the most part, oscil- in cats, the lateral nasal, facial, transverse facial, or meta-
lometric blood pressure monitors provide useful informa- tarsal artery in horses (see Fig. 2.7), or an auricular artery
tion for management of the clinical patient. Trends in in ruminants, pigs and rabbits (Fig. 2.17). Placement of a
pressures can be used to direct management of anaesthesia catheter in an artery in most animals is not difficult with
and, although hypotension may not be accurately diag- experience. Complications are rare provided there is strict
nosed, a decrease in measurements to low values should attention to asepsis during insertion, wrapping to main-
be a warning that action should be taken. A single abnor- tain cleanliness, use of sterile solutions for flushing, and
mal measurement should be confirmed by taking two appropriate pressure on the artery when the catheter is
more readings. Failure of the monitor to achieve a reading removed to avoid a haematoma. The cap or extension
(‘timed out’) when it had just previously been recording must be secured firmly to the arterial catheter to prevent
may indicate a change in peripheral blood flow. It must accidental disconnection and blood loss. The catheter is
be remembered that although on average there is reason- connected by saline-filled tubing to either an anaeroid
able correlation between direct and indirect pressure manometer (Fig. 2.18) or an electrical pressure transducer
measurements, in individual patients the difference in (Fig. 2.19) for measurement of arterial pressure. Either an
readings can be up to 20 mmHg and a patient may not be air gap or a connector containing a latex diaphragm
identified as having a MAP outside an accepted range.
Therefore, NIBP readings must be assessed together with
other observations of cardiovascular performance and
depth of anaesthesia.
High-definition oscillometry
In contrast to previously described oscillometric tech-
niques, high-definition oscillometric (HDO) technology
discriminates between pressure waveform changes that are Cranial
characteristic for systolic, mean, and diastolic pressures. tibial artery
The technology allows much more rapid assessments that
minimize the impact of outside factors, and is able to
accommodate fast heart rates and weak pulse signals. The
expectation is for increased accuracy at high and low
blood pressures and increased reliability for use in ill
patients. In anaesthetized dogs, comparison between IBP Dorsal
measured at the dorsal pedal artery and a high-definition pedal artery
oscillometric device, Memodiagnostic MD_15/90 Pro,
revealed that values for SAP, MAP, and DAP were all over-
estimated by HDO and the overestimation increased for
SAP and DAP with increasing pressures (Wernick et al.,
2010). The precision exceeded the 15 mmHg limit required
for validation and only 50–60% of readings were within
10 mmHg. In a group of conscious experimental Beagles
with implanted aortic devices for telemetry of blood pres-
sures, measurement of pressures from a cuff around the Figure 2.16 Sites for insertion of arterial catheters on the
base of the tail using HDO revealed that MAP most closely cranial aspect of the right hind limb of a dog.
35
should be maintained next to the anaeroid manometer to

prevent saline entering the manometer and to maintain Fine nylon
sterility. An optional addition to the electrical transducer Anaeroid catheter or
is a continuous flushing device (Fig. 2.20) that can be manometer needle in artery
inserted between the transducer and the artery. This device
is connected to a bag of saline that has been pressurized
to 200 mmHg and will deliver 2–4 mL saline/hour to help Three-way tap
prevent clotting of blood in the catheter. Extension tubing
Plastic tube
6-8 cm long
Drip extension tube

Male Luer
conection
Three-way
taps
20 ml syringe
Drip extension tube

Figure 2.18 Inexpensive apparatus for the direct
Figure 2.17 Ink lines have been drawn over the auricular measurement of mean arterial blood pressure.
arteries in this goat.
Figure 2.19 Direct measurement of blood pressure in a horse using a catheter in the facial artery connected by saline-filled
tubing to an electrical transducer.
36
Figure 2.20 Continuous infusion valve (c) for attachment to a pressure transducer (b). A pressurized bag of intravenous fluid
(d) is connected to the device to give a continuous infusion of 3 mL per hour. With this particular version, rapid flushing of
the saline-filled tubing (a) to the arterial catheter is achieved by squeezing the tabs (arrow) around the valve.
sold specifically for arterial pressure measurement is non- mmHg

distensible to preserve an accurate waveform. 120
For accurate measurement, the electrical transducer, or
the air–saline junction in the tubing connected to the
manometer, are zero reference points and should be
placed level with the right atrium that approximately cor- 80
responds to the manubrium; the point of the shoulder or A B
thoracic inlet when the animal is in dorsal recumbency
or level with the sternum or spine when in lateral
mmHg dP/dt
recumbency.
The anaeroid manometer costs very little but provides 120
only MAP. The needle of the anaeroid manometer deflects
slightly with each beat and the value at the upper deflec-
tion of the needle is slightly less than the MAP value
80
obtained by direct measurement (Riebold & Evans, 1985).
The electrical transducer provides values for SAP, MAP and C D
DAP, heart rate, and a waveform that can be observed on Figure 2.21 Waveforms from direct measurement of the
the oscilloscope or paper printout (Fig. 2.21). Values may arterial pressure. (A) Good trace. (B) Recording of the same
be slightly different when recorded from different sites, for pressure but with excessive damping, systolic pressure low,
example comparison of lingual artery and dorsal pedal diastolic pressure high, mean arterial pressure unchanged.
artery pressures in dogs revealed that systolic pressure was (C) Recording of same pressures but with resonance, systolic
higher and the diastolic pressure was lower in the pedal pressure apparently increased while diastolic pressure
artery (McMurphy et al., 2006). Mean pressures should be reduced, mean pressure unchanged. (D) Illustration of how
left ventricular contractility may be estimated from the rate
similar in most arteries but systolic pressure increases by
of rise of pressure during early systole (dP/dt) while the
up to 30% and diastolic pressure decreases by 10–15%
shaded area gives an index of stroke volume.
with increasing distance of measurement site from the
heart due to enhancement of the peripheral pulse pressure
(Guyton, 1986). significant relationship has been documented between
Important advantages of direct measurement of blood pulse pressure variation and volume loss and measure-
pressure are the reliability of measurement compared with ment of pulse pressure variation has been used to predict
NIBP, independence from observer error, and the ability responsiveness of a patient by increased cardiac output to
continuously to observe the pressure and immediately volume loading with IV crystalloid and/or colloid fluid
detect an abnormality (Fig. 2.22). Systolic pressure varia- (Durga et al., 2008; Pizov et al., 2010; Cannesson et al.,
tion (pulse pressure variation, ‘cycling’) caused by control- 2011). One multicentre study of human patients noted
led ventilation is an indication of decreased cardiovascular that approximately 25% of patients with small pulse pres-
function (Fig. 2.23). Artificial ventilation is key to induc- sure variation still experienced a clinically significant
ing cycling in that the increase in thoracic pressure during increase in cardiac output in response to fluid loading
inspiration causes a significant decrease in stroke volume (Cannesson et al., 2011). Pulse pressure variation has been
in situations of decreased venous return to the heart. A determined to be better than measurement of central
37
1 second 1 minute 1 second

Arterial B.P.
150 mmHg 150 mmHg
0 0
ECG
Figure 2.22 Top: pressure trace from a dog’s femoral artery. Bottom: Lead II electrocardiogram. Circulatory failure from an
overdose of pentobarbital. Note that while the pressure trace shows the circulation to be ineffective, the ECG trace is little
different from normal – heart rate monitors relying on the QRS complex for detection of the heart beat would, under these
circumstances, show an unchanged heart rate and, in the absence of a blood pressure record, encourage the erroneous belief
that all was well with the circulatory system.
A B
Figure 2.23 (A) Variations in the height of systolic arterial pressure and pulse pressures corresponding to positive pressure
ventilation as seen in this arterial waveform of a dog anaesthetized with isoflurane are predictive of decreased preload or
hypovolaemia. Note that hypovolaemia was present even when the arterial pressures were within accepted ranges. (B)
Expansion of blood volume using an IV fluid bolus resulted in improvement in cardiovascular function as demonstrated by
disappearance of systolic pressure and pulse pressure variations increased blood pressure, and decreased heart rate.
venous pressure for optimizing fluid therapy. Not all manometer set or be constructed from venous extension
animals with hypovolaemia may show systolic pressure or tubes and a centimetre ruler (Fig. 2.24). A catheter of suf-
pulse pressure variations. Each patient with obvious pulse ficient length is introduced into the jugular vein and
pressure variation should be evaluated for the potential advanced until its tip lies in the cranial vena cava. The
adverse effect of volume loading before administration of distance the catheter tip has to be introduced is, initially,
IV fluids. It must be remembered that cycling will not be estimated by measurement of length from the jugular vein
observed in animals that are spontaneously breathing or to the third rib and, once the catheter is connected to the
are ventilated with small (6 mL/kg) tidal volumes. manometer, its position may be adjusted until the level of
fluid in the manometer tube moves in time with the ani-
mal’s respiratory movements. In dogs and cats, the intro-
Central venous pressure duction of a catheter into the jugular vein is often greatly
The apparatus for measurement of central venous pressure facilitated by laying the animal on its side and extending
(CVP) can include a commercially available plastic venous its head and neck over a rolled up towel or sandbag. Care
38
and manometer in close proximity or by using a spirit level

to ensure accuracy. The ideal reference point is the mean
Balanced electrolyte pressure in the right atrium but, for practical purposes, the
solution with most appropriate is the sternal manubrium which is easily
administration set located and is related to the position of the right atrium
in all animals, irrespective of body position. Measure-
ments of CVP are not significantly affected by positioning
the animal in right or left recumbency or by catheter size,
although oscillations are more easily observed with a 16
gauge catheter (Oakley et al., 1997).
CVP is used in the evaluation of adequacy of blood
Fluid-filled volume, with the normal range being 0–5 cmH2O or
manometer 0–4 mmHg in small animals. Hypovolaemia is indicated
calibrated when the CVP is less than 0 cmH2O. An increase in pres-
in cm sure above 12 cmH2O or 9 mmHg may be caused by fluid
overload or cardiac failure. A recent study measured mean
CVP of 9.4 ± 3.6 cmH2O in standing horses with their
heads in a neutral position (Norton et al., 2011). Head
height exerted a significant effect on CVP in that the CVP
decreased by 2.0 ± 6.5 cmH2O when the horses’ heads
were elevated and increased by 3.7 ± 5.5 cmH2O when the
heads were lowered to the ground. The authors suggested
to increase accuracy of comparison of measurements to be
3–way stopcock made over several hours that the zero reference point be
identified by a small line of clipped hair.
Manometer connected Zero on scale
to jugular catheter corresponds with Left atrial pressure (pulmonary arterial
(covered by bandage thoracic inlet occlusion pressure)
around neck)
Left heart failure may precede that of the right side and
Figure 2.24 Schematic diagram of the apparatus for precipitate pulmonary oedema without a rise in central
measurement of central venous pressure. venous pressure. The pulmonary arterial occlusion pres-
sure (PAOP) is used as a measure of the left atrial filling
pressure. A balloon-tip catheter is introduced into the
must be taken to avoid entrainment of air during insertion jugular vein and its tip advanced into the heart. Inflation
of the catheter. Air embolism will occur through an open- of the balloon with 0.5 mL air facilitates floating the cath-
ended catheter that is inserted with the animal in sternal eter in the bloodstream into the pulmonary artery and
or standing position or during inspiration in a recumbent then the catheter can be advanced until the tip is wedged
animal. If the catheter is to be left in position for a long in a small pulmonary vessel. The measurement is made
time, it is kept patent with a drip infusion or the catheter using the same apparatus as is used for the measurement
is kept filled with heparin–saline solution (10 units/mL) of central venous pressure or using an electrical pressure
between measurements. Readings may be taken at any transducer. Care must be taken to ensure that vessel occlu-
time. If an intravenous drip is used, it is turned full on and sion is not maintained between measurements or pulmo-
the stopcock manipulated first to fill the manometer tube nary infarction may occur. If a balloon catheter is used,
from the bag or bottle and then to connect the manometer the balloon should only be inflated while measurements
tube to the catheter. The fall of fluid in the manometer is are made and, if a simple catheter is used, it should be
observed and should be ‘step-like’ in response to respira- slightly withdrawn from the wedged position between
tory pressure changes. The CVP is read off when fluid fall measurements.
ceases.
Central venous pressure may also be measured by
attaching an electrical transducer to the jugular catheter. Cardiac output
Venous pressures being low, the margin of error intro- The measurement of cardiac output is not one that has
duced by inaccuracies in obtaining a suitable reference been routinely carried out in clinical veterinary anaesthe-
point to represent zero pressure may be clinically signifi- sia. Invasive methods are commonly employed in research
cant. Whatever apparatus is used, the zero of the scale and there are minimally invasive and non-invasive
should be carefully located, either by placing the patient methods available for use in research and clinical patients.
39
The cost of the equipment, as always, is a limiting factor. the patient’s PaCO2 increases up to 5 mmHg during
Various sources of inaccuracy are likely to influence results rebreathing. Concurrent input from the pulse oximeter
of cardiac output measurements and personnel using allows the NICO to calculate stroke volume and manual
these techniques should first read relevant literature. entry of the patient’s weight produces CO in mL/kg. Accu-
racy of the NICO is unsatisfactory in patients <18 kg
Fick method bodyweight (Yamashita et al., 2007). This technique is
The Fick method was one of the earliest methods to be contraindicated in any animal for which a small increase
used to calculate cardiac output (CO) and utilized oxygen in PaCO2 would be deleterious, such as conditions at risk
as the indicator. The method used the formula CO = O2 for increased intracranial pressure. Cardiac output meas-
consumption per minute/(arterial O2 content − mixed urements obtained by NICO are useful to assess trends but
venous O2 content) × 100 because the size of a fluid stream should not be considered as absolute values (Giguère
can be calculated when the amount of a substance enter- et al., 2005a).
ing the stream and the concentration difference between
entry and removal are known (Lake, 1990). This method Indicator dilution method
has a number of technical difficulties and, more recently, The principle involves injection of an indicator substance
a non-invasive technique using CO2 has been used in into a central or peripheral vein and blood is withdrawn
clinical patients. The non-invasive cardiac output (NICO) from an artery continuously with a pump and directed
method employs a differential Fick partial rebreathing through an electrical cuvette densitometer where the con-
technique that eliminates the need to measure mixed centration of the indicator is measured. This blood is then
venous CO2 by assuming that the value remains constant delivered back to the patient. The electrical input from the
(Jaffe, 1999). A combined mainstream capnometer and densitometer is proportional to the indicator concentra-
fixed orifice differential pressure pneumotachometer (to tion and the monitor generates an indicator–dilution
measure flow) adapter is inserted next to the endotracheal curve that is plotted against time. The area under the curve,
tube adapter (Fig. 2.25). An adjustable (rebreathing) loop with some modifications, is proportional to the cardiac
of tubing with an automatic valve is then attached before output. The original technique used indocyanine green, a
connecting the patient to the circle anaesthesia system. non-toxic dye, but this technique is complicated by a
The animal must be on controlled ventilation and the gradual increase in baseline due to recycling. Thermodilu-
rebreathing loop is expanded or contracted so that the tion cardiac output measurement (TDCO) is an indicator
volume of the loop matches 35–70% of the ventilator’s dilution method that has replaced dye dilution and is the
tidal volume setting. The NICO has a 3-minute cycle technique that is used for comparing all new methods of
within which the rebreathing valve is activated for 35 cardiac output measurement. A multilumen catheter with
seconds so that the animal’s breathing is rerouted from a thermistor approximately 4 cm from the tip (Swan–
the anaesthesia circle into the rebreathing loop. Typically, Ganz catheter) is inserted into the jugular vein and
A B
Figure 2.25 (A) Rebreathing circuit of the NICO™ (Novametrix Medical Systems, Inc. Wallingford, CT, USA). (B) NICO™
monitor measuring cardiac output in an anaesthetized dog.
40
advanced through the heart until the tip lies in the pul- cardiac outputs but have a closer agreement at higher
monary artery. Correct placement of the catheter is con- values.
firmed by connecting a pressure transducer to the lumen
that exits at the tip of the catheter and observation of the Pulse contour method
distinctive pressures and waveforms as the catheter passes Monitors have been developed for assessing changes in
through the atrium, ventricle and pulmonary artery. The cardiac output by analysis of the arterial pulse waveform.
catheter is designed such that one lumen of the catheter The LiDCO™plus monitor includes the PulseCO™ system
exits in the right atrium and that port is used for injection that analyses the arterial waveform following initial calibra-
of cooled saline or 5% dextrose. The time of injection and tion by measuring cardiac output by lithium dilution and
temperature of injectate is recorded by the monitor, the calculates stroke volume and CO. The PiCCO™ system’s
temperature changes in the pulmonary artery are detected, initial calibration uses transpulmonary thermal dilution
and the time lapse from injection to measured tempera- and requires cardiac catheterization. The FloTrac™/Vigileo™
ture change allow calculation of cardiac output. Different is ‘self-calibrated’ based on an algorithm derived from
lengths of catheter and varying volumes of injectate are measurements in humans. These systems have been increas-
chosen to accommodate various sizes of animals, from ingly used for tracking the haemodynamic status of human
cats to horses. Either the ventilator is temporarily shut off patients in the ICU or postoperative recovery areas. Studies
or each injection is made at the same time in the respira- in human patients have determined that the monitors lose
tory cycle and two to three measurements are performed accuracy with time and require recalibration, particularly
in quick succession and averaged to improve accuracy. when major changes in cardiovascular status have occurred,
Problems associated with insertion of a Swan–Ganz cath- and that values obtained by one monitor differ from
eter include prolongation of anaesthesia time, initiation values obtained from a monitor from a different manufac-
of premature ventricular depolarizations, and potential turer. Although good agreement was obtained between
complications of laceration of a blood vessel, knotting of LiDCO™ and PulseCO™, cardiac output measurements in
the catheter, and infection. dogs anaesthetized with fentanyl and pentobarbital, the
Lithium dilution cardiac output (LiDCO™) technique PulseCO™ was unable to measure accurately the decrease
mimics the dye dilution technique by injection of lithium in CO after severe haemorrhage and the authors concluded
chloride into a central or peripheral vein and a pump that recalibration was necessary after any major alteration
withdraws blood from an artery pulling it through a in haemodynamic status (Cooper & Muir, 2007). Investiga-
lithium sensor to measure blood concentration. Advan- tions of the PulseCO™ in dogs with systemic inflammatory
tages of this system include no major invasive catheteriza- response syndrome (SIRS) (Duffy et al., 2009) and in
tion and a small volume of injectate that is easily injected horses using inotropes to change cardiovascular dynamics
by hand and which causes minimal haemodynamic effect. (Schauvliege et al., 2009) revealed failure of accuracy when
The patient’s haemoglobin and sodium concentrations compared with LiDCO™ and the need for frequent recali-
must be entered into the monitor because lithium is dis- bration. In anaesthetized neonatal foals, values for CO
tributed only in plasma. Some blood loss may occur even recorded using PulseCO™ agreed significantly better
though the sampled blood is returned to the patient. A with values from LiDCO™ than measurements using the
close correlation between the LiDCO and thermodilution PiCCO™ method (Shih et al., 2009). Comparison of the
techniques has been verified in several animal species FloTrac™/Vigileo™ with TDCO in experimental dogs docu-
(Linton et al., 2000; Mason et al., 2001; Beaulieu et al., mented overestimations, sometimes excessive, influenced
2005). One experimental study in anaesthetized neonatal by MAP which led to the conclusion that FloTrac™/Vigileo™
foals discovered that the LiDCO technique overestimated was not suitable for CO measurement in dogs (Bektas
TDCO measurements when CO <10 L/min and that the et al., 2012).
correlations changed over time, however, the authors con-
cluded that LiDCO was an acceptable alternative to TDCO Flow method
(Corley et al., 2002). Transoesophageal Doppler echocardiography cardiac
In anaesthetized healthy experimental dogs weighing output (TEECO) is increasingly used as a cardiovascular
22–25.4 kg ventilated with tidal volumes of 10–15 mL/kg, monitor in anaesthetized human patients. The technique
cardiac outputs ranged from 50 to 303 mL/kg/min and the involves insertion of a probe into the oesophagus to the
average difference between the LiDCO and NICO was level of the left ventricular outflow tract. The pulsed-wave
9.3 mL/kg/min, indicating that NICO would be accepta- Doppler crystal emits an ultrasound wave and moving
ble for clinical use (Gunkel et al., 2004). Comparison of objects (red blood cells) change the frequency resulting in
the NICO and LiDCO techniques in foals 1–6 days old a curved waveform. Cardiac output is calculated from the
and weighing 32–61 kg identified a good correlation for velocity-time integral (VTI, area under the curve) of the
CO measurements between the two techniques over a ascending aorta × aortic cross-sectional area × heart rate.
wide range of values (Valverde et al., 2007). The NICO Comparison with TDCO measurements has identified
technique tended to overestimate the LiDCO values at low no significant differences between measurements from
41
both techniques in horses and dogs (Young et al., 1996; Haemorrhage % of blood volume
Yamashita et al., 2007). Probe size has been a problem,
10% 20% 30%
and the technique requires operator training. 0
Impedance cardiography -10
Percent decrease
Transthoracic bioimpedance (BICO) involves placement
of electrodes, continuous output of high-frequency, low -20
magnitude current, measurement of electrical resistance,
and a monitor that calculates CO using an algorithm. -30
BICO did not produce acceptable values in Beagle dogs
-40 Heart rate
(Yamashita et al., 2007).
Mean arterial pressure
-50 Cardiac output
Blood loss
Figure 2.26 Cardiovascular responses to graded
Monitoring blood loss should include measuring the haemorrhage in five splenectomized isoflurane-anaesthetized
volume of blood aspirated into a suction bottle, estimating dogs. Results are presented as percent change from values
free blood on drapes around the surgical site, and counting measured before blood loss
blood-soaked gauze squares. Placing a bucket under the Adapted from Weiskopf et al., 1981.
surgical site to catch free-flowing blood, for example during
rhinotomy in large animals, will assist assessment of blood Blood volume of paediatric patients may be 50% greater
loss. Gauze squares of different sizes absorb varying than the blood volume of the mature animal. The percent-
amounts of blood from 5–8 mL to 12–14 mL. The volume age of this volume that the animal can lose before circula-
of blood lost on the gauze squares may be estimated or the tory shock ensues depends to a large extent on the physical
gauzes weighed and, after the weight of the same number status of the patient, the preanaesthetic PCV, the depth of
of dry gauzes has been subtracted, applying the formula anaesthesia, and the support treatment provided. Signifi-
that 1 g weight equals 1 mL blood. Measurement of packed cant cardiovascular changes occur after loss of 15% of the
cell volume is not useful during acute blood loss as this blood volume. The maximum blood loss allowed before
value will not change initially. Once an increased volume giving a blood transfusion is usually 20% of the estimated
of balanced electrolyte solution with or without colloid blood volume, however, in some animals up to 30% of
has been infused, the packed cell volume and total protein the total blood volume may be lost without onset of hypo-
concentrations will decrease to a value of use during assess- tension or hypoxia if the patient has no major preanaes-
ment. When evaluating packed cell volume changes, it is thetic illness, is ventilated with oxygen, the depth of
important to consider that anaesthesia per se will result in anaesthesia is lightened, balanced electrolyte and colloid
sequestration of red blood cells in the spleen and decrease solutions are infused intravenously, and vasoactive drugs
the packed cell volume by up to 20%. are administered as needed.
In the conscious animal, loss of blood volume is ini-
tially compensated for by increased heart rate and cardiac Monitoring the respiratory system
contractility, together with peripheral vasoconstriction.
Visual observation of respiratory rate and depth of breath-
These physiological responses are blunted or abolished
ing is a basic estimate of adequacy of breathing. The res-
during anaesthesia. Consequently, the significance of the
piratory rate may be counted by observation of chest
blood loss may not be appreciated owing to maintenance
movement or movement of the reservoir bag on the anaes-
of a normal heart rate. Furthermore, it should be remem-
thesia machine. The excursion of the chest, abdomen, or
bered that when MAP is decreasing in response to
bag should be observed to gain an impression of the depth
haemorrhage, cardiac output decreases to a greater extent
of breathing. In general, except possibly in horses, a spon-
(Fig. 2.26) (Weiskopf et al., 1981).
taneous rate of 6 breaths/min or less is likely indicative of
Measurement of arterial pressure is an important step
hypoventilation. Respiratory rates of 10 breaths/min or
in the management of blood loss as oxygen delivery to
greater may provide adequate ventilation or be associated
tissues is impaired when mean arterial pressure decreases
with hypoventilation when the breaths are shallow. Chest
below 60 mmHg. The potential impact of blood loss on
wall movement with no corresponding movement of the
the patient may be evaluated better by assessing the
reservoir bag is indicative of airway obstruction or tension
volume of blood loss against the total blood volume.
pneumothorax.
The blood volume varies between species and is usually
assessed in mature animals as 86 mL/kg body weight in
dogs, 56 mL/kg in cats, 72 mL/kg in draught horses and Rate monitors and apnoea alarms
ponies, 100 mL/kg in Thoroughbreds and Arabians, Rate monitors and apnoea alarms may use a thermistor
60 mL/kg in sheep. either connected to the endotracheal tube or placed in
42
front of a dog’s nose. The thermistor detects temperature the tip of the needle into a rubber stopper. Leaving an air
differences between inspired and exhaled gases to produce bubble in the syringe for any length of time allows diffu-
a signal that drives a digital rate meter to make a noise sion of gases between the blood and bubble such that
which varies in intensity or pitch in time with the animal’s PCO2 will decrease and PO2 will decrease if the animal is
breathing. An alarm sounds if a constant gas temperature breathing O2 and increase if the animal is breathing air.
is detected. Like the oesophageal stethoscope that counts The syringe should be inverted several times over 20
only heart rate, the respiratory rate monitor registers rate seconds to mix the blood with the heparin. The tempera-
only and not adequacy of ventilation. ture of the animal should be measured at the time of
sampling. Firm pressure should be applied to the artery
Tidal and minute volume monitors for 3 minutes after percutaneous needle puncture to avoid
haematoma formation.
The volume of each breath (tidal volume) and the volume
Ideally, blood gas analysis should be performed imme-
of gas inhaled or exhaled per minute (minute volume) can
diately after blood collection into plastic syringes because
be measured in small animals by attaching a gas meter
there is a significant change in PO2, an increase if PO2 is
such as a Wright’s respirometer within the circle circuit or
12 kPa (90 mmHg) and a decrease when the PO2 is
to the endotracheal tube. The respirometer has a low
>33.3 kPa (>250 mmHg), due to diffusion of O2 into or
resistance to breathing and is reasonably accurate over
out of the syringe and metabolism in white blood cells
volumes ranging from 4 L/min to 15 L/min but under
and platelets that consumes O2 and produces CO2
reads below 4 L/min.
(Beaulieu et al., 1999). Not all plastic syringes are the
same, even those marketed specifically for blood gas analy-
Blood gas analysis sis, and the magnitude of PO2 change depends on the
Measurement of the partial pressure of carbon dioxide in manufacturer and characteristics of the syringe (Wu et al.,
a sample of arterial blood (PaCO2) using blood gas analy- 1997). Investigations have discovered that the change in
sis is the best monitor of ventilation. Arterial blood may PO2 over time is greater with a 3 mL syringe than a 5 mL
be collected from any peripheral artery used for invasive syringe (Wu et al., 1997) and inaccuracy is greater when
blood pressure measurement. Commonly for clinical <1.8 mL is collected into a 3 mL syringe compared with
patients, a small amount of 1 : 1000 heparin is drawn into >2 mL (Hedberg et al., 2009). Furthermore, accuracy of
a 3 mL plastic syringe using a 25 gauge needle and the PO2 measurement is related to the method of storage of
plunger withdrawn to wash the inside of the syringe with the syringe before analysis, in iced water at 0°C or at
heparin. Excess heparin is then squirted from the syringe ambient temperature of 20–25°C, and the time lapse
leaving only syringe dead space filled with heparin and no between collection and analysis (Pretto & Rochford, 1994;
bubbles. A larger volume of heparin will increase the Deane et al., 2004, Picandet et al., 2007). Iced water
acidity of the sample. A 2 mL sample of blood is collected decreases the rate of metabolism in blood and the lower
from most dogs and 2–3 mL from horses (collecting the temperature promotes increased PO2 by facilitating diffu-
same volume for sequential samples). Individually pack- sion of O2 from water into the plastic syringe through
aged 1 mL syringes containing a dry lithium heparin pellet increased gas solubility and increased haemoglobin O2
(to decrease dilution) can also be used (for example, affinity (Wu et al., 1997). A significant change in PO2 has
Portex® Line Draw Arterial Blood Sampling Kit, Smiths been measured by 10 minutes after blood collection
Medical ASD, Inc., Keene, NH, USA). After removing the (Pretto & Rochford, 1994; Picandet et al., 2007). PCO2
cap from the nozzle of the syringe, the plunger should be undergoes a clinically insignificant but statistically signifi-
pushed fully forward before allowing the syringe to fill cant change. Picandet et al. (2007) suggested that although
with blood. Larger plastic syringes containing lyophilized the PCO2 appeared to be stable, the value may have been
heparin are also commercially available. a balance between leakage of CO2 out of the blood and
Blood may be collected by percutaneous puncture or increased CO2 from metabolism. Values other than PO2
from a catheter. The contents of the catheter should be may be relied upon from plastic syringes stored at room
aspirated using a separate syringe before a sample of blood temperature up to 60 minutes. It has been suggested that
is collected for analysis. This mixture of saline and blood blood from different species may require different han-
may be discarded or, if collected into a syringe containing dling but published data reveal differences in results even
some heparinized saline, can be returned into the animal within the same species. Despite differences in findings
through a venous catheter. The blood sample should be between investigations, it appears that with an expected
collected anaerobically slowly over several respiratory PO2 of about 13.3 kPa (100 mmHg), the increase may be
cycles and without aspirating any air bubbles. Excessive less if the plastic syringe is kept at room temperature until
negative pressure should be avoided as oxygen can be analysis (Deane et al., 2004; Picandet et al., 2007) whereas
extracted from the blood sample. After expressing a drop the decrease may be less in blood with a high PO2 when
of blood and any bubbles from the needle, the syringe the syringe is stored in a slurry of ice and water (Pretto &
should be sealed either with a special cap or by inserting Rochford, 1994). Plastic syringes for blood gas analysis
43
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PLATE XX.
PAIR OF COTTAGES.
Variation of Former Plan.—This plate shows the development and

variation of the inside houses of the block of four shown on Plate
xiv., with a superior arrangement of larder, and with projecting coals.
The long sloping roof has been hipped back to give a pleasing line,
especially in perspective.
The Long Sloping Roof.—The long sloping roof, a feature frequently
introduced at Bournville, has several advantages. If it were not
employed, and the front walls were carried up level with the ceiling
line of the bedroom, the proportions of the elevation would not be
so happy, while an additional expense would be incurred by the
extra brickwork. Such a height, moreover, would be wholly
unnecessary. In the case of cottages with the long sloping roof the
height of bedrooms to the point of intersection of roof and wall need
only be 5 ft. 6 ins. Ample ventilation is obtained by the simple
insertion of a 9 in. by 7 in. air-brick on the outside wall, and a
Sheringham ventilator or Tobin tube within, about 5 ft. 6 ins. from
the floor, the cost of the latter being about 3s., and of the former a
little more. The long sloping roof can rarely be treated tastefully
without boldly projecting the eaves. The projection gives a verandah
in front of the house which affords a pleasant shelter. Wooden posts
may be used as supports, and by training climbing plants up them,
and allowing them to festoon, a really delightful summer bower may
be formed. As the roof is broad, pantiles may be used with safety so
far as good taste is concerned: bold roof, bold covering. By omitting
the gutters at the dormer eaves a pleasing effect is gained, and
gutters are quite unnecessary with an eaves projection. The cheeks
of the dormers should be dressed with lead. The cottages in
question are whitewashed, and have a tarred plinth of about 2 ft. to
prevent the unsightliness of mud splashes.
FRONT ELEVATION
GROUND PLAN
BEDROOM PLAN
PLATE XX.
PAIR OF COTTAGES.
SEE PAGE 30.
The Large Living Room.—In view of the gain to health of one

spacious living room over the parlour plan, a number of these
cottages has been built in varying design at Bournville, and no
difficulty has been found in letting them. There has been, however,
considerable discussion with regard to their convenience to the
artisan in other districts where they have been introduced. Although
cottages in the past had no third room, there having been, as here,
one large comfortable room (often with the ingle nook) and a small
kitchen at the back—all the accommodation really required—yet at
the present time many artisans are not content without the useless
parlour, which they appear to think adds dignity to the house, but
which is used by them chiefly as a store-room for gim-cracks. There
is, perhaps, a reasonable objection to a single large living room on
the part of a particular class who let the front room to a lodger.
Nevertheless, for a model village or a garden city it is strongly
recommended that the plan should be adopted freely, and the
preference for the useless front room in small cottages discouraged.
Total cost of the example given, including all extras, £268 per
cottage.
Laying out of gardens, £10 each.
Cubical contents, 28,587 ft., at 4½d. per foot cube, £536, or £268
per cottage.
Instances of the last two types of cottages dealt with appear in
the view given on Plate iv.
PLATE XXI.
PAIR OF COTTAGES.
PLATE XXI.
PAIR OF COTTAGES.
SEE PAGE 32.
The smaller cottage shown here is planned on similar lines to the

foregoing, but with the additional accommodation of an attic, and bay
windows to the two storeys. This is an instance of how a smaller
cottage may be joined to a larger one in treating a corner site, the
larger one on the corner giving importance to each road.
PLATES XXII., XXIII., I. (FRONTISPIECE), XXIV., XXV., AND XXVI.
BLOCKS OF FOUR.
PLATE XXII.
BLOCK OF FOUR COTTAGES.
SEE PAGE 32.
PLATE XXIII.
SEE PAGE 32.
PLATE XXIV.
SEE PAGE 32.
These plates show examples of cottages in blocks of four rather

larger in size than the last type, and treated in different materials.
Plate xxvi. shows the details of the cottages on Plate xxv.
PLATE XXV.
SEE PAGE 32.
PLATE XXVI.
DETAIL VIEW.
SEE PAGE 32.
PLATE XXVII.
PAIR OF COTTAGES.
FRONT ELEVATION
GROUND PLAN
BEDROOM PLAN
PLATE XXVII.
PAIR OF COTTAGES.
SEE PAGE 33.
Plate xxvii. gives the plan and elevation of a pair of cottages also
having similar accommodation to those with the long sloping roofs
shown on Plate xx. The cost, however, is here considerably reduced
by each house having a side entrance, and by the omission of the
ingle nook, verandah and bay, while the living room, though smaller,
is not a passage room. By approaching the stairs from the lobby, not
only is more privacy secured, but the space beneath is made
available in the kitchen for a “Cabinet” bath, which is so placed as to
occupy it when in use instead of projecting into the kitchen. The
planning is simple and square, which, with the omission of bays and
the introduction of plain casements, all helps to reduce the cost.
The accommodation is:—
Ground Floor.
Living Room, 12 ft. 4 ins. × 16 ft. Kitchen, 10 ft. 3 ins. × 11 ft. 6 ins. Lobby.
Larder, w.c. and Coals.
Bedroom Floor.
First Bedroom, 12 ft. 4 ins. × 16 ft. Second Bedroom, 7 ft. 8 ins. × 11 ft. 6
ins. Third Bedroom, 8 ft. × 8 ft. 3 ins. Linen Closet.
Total cost, including all extras, £250 per cottage.
Laying out of gardens, £10 each.
Cubical contents, 24,000 ft., at 5d. per foot cube, £500, or £250
per cottage.
PLATE XXVIII.
PAIR OF COTTAGES.
FRONT ELEVATION
GROUND PLAN
BEDROOM PLAN
PLATE XXVIII.
PAIR OF COTTAGES.
SEE PAGE 34.
This plate shows the plan and elevation of a pair of cottages

having the parlour in addition to the living room and scullery. The
living room, which should always be the larger, is here the full width
of the house. The measurements are:—
Ground Floor.
Living Room, 11 ft. 5 ins. × 16 ft. 6 ins. Parlour, 11 ft. 4 ins. × 13 ft. 3 ins.
Scullery, Outside Larder, w.c. and Coals.
Bedroom Floor.
First Bedroom, 11 ft. 4 ins. × 13 ft. 3 ins. Second Bedroom, 8 ft. 6 ins. × 11
ft. 5 ins. Third Bedroom, 7 ft. 8 ins. × 8 ft. 6 ins. Linen Closet.
Total cost, including all extras, £230 per cottage. Cubical contents,
33,918 ft. at 3¼d. per ft. cube. £460, or £230 each. (Built in 1899.)
The stairs in this instance descend to the entrance lobby, but they
may be planned the other way about in order to avoid the necessity
of traversing the parlour to get to the bedrooms, and to insure
children crying upstairs being heard in the living room or the
scullery. This, however, would necessitate the cutting of 3 ft. off the
large front bedroom, while the respective spaces for the larder and
the lobby below would be reversed, the position of the former being
undesirable.
Ordinary roofing tiles and common bricks have been used. The
living room is boarded, and the scullery quarried.
It might be pointed out that there is but little scope for variety of
plan in these smaller cottages. The variations must be obtained in
the treatment of elevations. As already stated, to build cheaply the
main point is to get the walls as long and straight as possible.
FRONT ELEVATION
BLOCK OF THREE COTTAGES.
PLATES XXIX. AND XXX.

GROUND PLAN
BEDROOM PLAN
PLATE XXIX.
SEE PAGE 35.
Plate xxix. and the accompanying scale-drawing give the plan and
elevation of a block of three cottages, a sketch of which appears in
Plate xxx. The inner one occupies an exact third of the land, and is
double fronted. By putting the inner one with its axis to the front, an
equal garden-space is given to all the houses without incurring a re-
division of the land.
PLATE XXX.
SEE PAGE 35.
The inner and left-hand houses have practically the same

accommodation, but the right-hand has several advantages: there is a
wider hall, the living room is not a passage room, while the kitchen is
reached from the hall, and the wash-house is entered from the yard.
Accommodation of left-hand and inner houses.
Ground Floor.
Parlour, 11 ft. 4 ins. × 15 ft. 3 ins. Living Room, 10 ft. × 14 ft. 6 ins. and bay.
Scullery, 10 ft. × 6 ft. and recess for Bath. Coals, Tools, and w.c.
Bedroom Floor.
First Bedroom, 11 ft. 4 ins. × 15 ft. 3 ins. Second Bedroom, 7 ft. 6 ins. × 14 ft.
6 ins., and bay. Third Bedroom, 7 ft. 5 ins. × 11 ft. 6 ins. Fourth Bedroom, 9 ft.
6 ins. × 6 ft. (middle house only). Linen Closet.
Cost of left-hand and inner houses, including all extras, £293 per
cottage. (Built in 1904.)
The right-hand house, owing to the extra conveniences, works out
at rather more.
In the middle house the recess between the range and small
window makes a very convenient space for a writing table, especially
if curtains are dropped from a rod to screen it off, its proximity to the
range making it a warm and cosy retreat in winter. There is a bay
window to the living room of the outside houses.
Two of the houses in this block are fitted with Cornes’ Patent
Combined Scullery-Bath-Range and Boiler, described on page 52, and
the third with the “Cabinet” bath.
The elevation, with the forecourt formed by the projection of the
two outside houses, may be made very pleasing. From the perspective
it will be seen that the inner house is covered with rough-cast, making
an agreeable contrast with the outer ones of plain brickwork. Rough-
cast, while fairly economical, is very effective, and helps to brighten
the forecourt. The projection of the outer houses affords a break, the
abruptness of which does not attract attention, but which gives an
opportunity of stopping the rough-cast, which would otherwise have
to be carried round to the back of the whole block.
It is not advisable to introduce a variety of colour upon exteriors.
Colour is best disposed in masses—that is, it should be treated
broadly, not distributed in isolated portions, or in sharply contrasting
tints. (See page 59.)
The roof of this block is of green slates of varying sizes, diminishing
towards the ridge.
Aspect in the placing of the house is here studied as well as the
site. The axis runs south-west and north-east, and the front
commands a pleasing perspective of one of the principal Bournville
roads, and an admirable view of the Lickey Hills in the distance.
D E S C R I P T I O N S O F P LAT E S
X X X I .-X X X I I I .
PLATE XXXI.
PAIR OF COTTAGES (SHALLOW SITE).
PLATE XXXI.
PAIR OF COTTAGES.
SEE PAGE 38.
The view shown in this plate illustrates the treatment of a shallow

corner site, the block being a pair of semi-detached, double-fronted
cottages. The plan is similar to the middle house of the foregoing
block.
PLATE XXXII.
PAIR OF COTTAGES.
PLATE XXXII.
PAIR OF COTTAGES.
SEE PAGE 38.
A pair of cottages also planned on the same lines as the middle

house shown in Plate xxix. and the foregoing shallow-site pair, but
placed at right angles instead of lengthwise, and occupying a corner
position.
PLATE XXXIII.
PAIR OF COTTAGES.
PLATE XXXIII.
PAIR OF COTTAGES.
SEE PAGE 38.
An example of a pair of cottages treated in the Dutch style.

D E S C R I P T I O N O F P LAT E S
X X X I V. A N D X X X V.
PLATE XXXIV.
PAIR OF COTTAGES.
FRONT ELEVATION
GROUND PLAN
BEDROOM PLAN
PLATE XXXIV.
PAIR OF COTTAGES.
SEE PAGE 40.
The accommodation of the pair of cottages shown in this plate is as

follows:—
Ground Floor.
Parlour, 11 ft. 4 ins. × 13 ft. 6 ins., and bay. Living room, 11 ft. 6 ins. × 14 ft. 5
ins. (French Windows). Kitchen, 10 ft. 8 ins. × 12 ft. 3 ins. Larder. Porch, Hall,
and Clock Space under stairs. Tools, w.c., and Coals (Enclosed yard).
Bedroom Floor.
5 ins. Third Bedroom, 8 ft. 6 ins. × 10 ft. 8 ins. Bath Room (hot and cold
water).
Height of rooms: Ground floor, 8 ft. 9 ins.; first floor, 8 ft. 6 ins.
Total cost, including all extras, £375 per cottage.
Laying out of gardens, £12 10s. each.
Cubical contents, 34,285 ft., at 5¼d. per foot cube = £375 per
cottage. (Built in 1903.)
Materials.—Whitewashed common bricks are here used. Whitewash
is cheap and may be used very effectively, especially where there are
trees in the background. The roofs and dormers are hipped, and
covered with Welsh green slates and blue half-round ridges; the
chimney pots are buff-colour.
Sills.—The sills, as in many of the other houses, are formed of calf-
nosed bricks set on edge in cement, with two courses of tiles beneath,
which form a drip under the sill, and with a backing of slate in
cement. By bringing the window-frame forward to reduce the size of
the top of the sill, damp and the driving in of rain are prevented. This
makes an inexpensive sill, and adds to the homely appearance of the
cottage.
Interior Wall Decoration.—The interior wall decoration is Duresco
throughout. Plain ingrain paper, of which there is a number of very
cheap kinds now on the market, might be used with a frieze. A good
effect is obtained by bringing down the white from the ceiling as far
as the picture rail, which gives light to the room and improves its
proportions.
The exterior woodwork is painted a Verona green.
Fireplaces.—Fireplaces suitable for this or any of the six-roomed
cottages are as follows:—
Front Room: interior grate, slabbed surrounds, tiled hearth, and white wood
chimney piece. Living Room: iron tiled mantel-sham. Kitchen: 3 ft. range with
white tiled coves and York stone shelf and trusses. Front Bedroom: 30 in.
mantel-sham and tiled hearth. Back Bedrooms: 24 in. mantel-sham and tiled
hearth.
The total cost of the whole should not amount to more than £12.
The scullery is lengthened by a projection in the nature of a bay.
The outbuildings, which are carried to right and left of the pair, give
privacy to the garden near to the houses.
PLATE XXXV.
PAIR OF COTTAGES.
This plate illustrates one of several different treatments of the last

plan.
PLATE XXXV.
PAIR OF COTTAGES.
SEE PAGE 41.
PLATES XXXVI., XXXVII., AND XXXVIII.
SINGLE COTTAGE.
FRONT ELEVATION
SIDE ELEVATION
GROUND PLAN
BEDROOM PLAN
PLATE XXXVI.
SINGLE COTTAGE.
SEE PAGE 42.
Plate xxxvi. gives the plan of a single cottage occupying a corner

site. It contains:—
Ground Floor.
Drawing Room, 12 ft. 6 ins. × 13 ft. 6 ins., and bay. Dining Room, 13 ft. × 13
ft., and bay (French casements). Kitchen, 10 ft. × 11 ft. Scullery, 8 ft. × 10 ft.
Larder. Porch and Hall, with Cloak Space under stairs. Coals, Tools, and w.c.
Bedroom Floor.
Third Bedroom, 10 ft. × 13 ft. Dressing Room. Cupboards. Bathroom, with w.c.
and Lavatory (hot and cold water).
As will be seen, there is very little space wasted in the planning of
the rooms.
The whole of the exterior is rough-cast. The front bedroom is
enlarged and projects over the ground floor, giving a pleasant shade
to the lower portion of the elevation, while the roof is continued over
one side and carried down to form the porch. The gable is of half-
timber framing.
The roof is covered with Hartshill hand-made tiles, which, while
richly toning and colouring, have admirably stood the test of several
years’ hard weather, and have proved much more durable than the
pressed tile used for some of the other cottages at Bournville.
The plan of the cottage might be simplified by gabling back and
front, the roof thus covering the whole building, and having no
valleys. The bedroom accommodation could be then increased by the
addition of attics.
Two views of the actual example appear in Plates xxxvii. and xxxviii.
PLATE XXXVII.
SINGLE COTTAGE.
SEE PAGE 42.
PLATE XXXVIII.
SINGLE COTTAGE.
SEE PAGE 42.

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Introduction 3 Influence of pre-existing drug therapy 16

©2014 Elsevier Ltd 3

in which the patient neither perceives nor recalls noxious

ketamine and the gaseous anaesthetic agents are thought

increasing amplitude and decreasing frequency, a phe- Evoked responses

mammalian species and, as long as conditions remain the

Category 4 A patient with severe systemic disease

Introduction 19 Monitoring body temperature 56

©2014 Elsevier Ltd 19

some groups of patients, and level 3 monitors individually CLINICAL ASSESSMENT

Table 2.1 Prioritization of monitoring

Monitor Information obtained Specific use

Level 1 (Basic monitoring)

Oral mucous membrane colour Oxygenation All anaesthetized animals

Temperature Temperature Dogs and cats anaesthesia greater than

Level 2 (Routine use recommended for some patients)

Blood glucose Blood glucose Paediatric patients; diabetics; septicaemia;

Level 3 (Use for specific patients or problems)

Central venous pressure Indicator of central blood volume Dehydrated/hypovolaemic patients

Peripheral nerve stimulator Neuromuscular transmission Use of neuromuscular blocking agents

Intercostal Diaphragm Pattern Pupil Eyeball Eye Lacrimation Response to

only for non-painful procedures), Plane 2 (medium depth

Eye position and reflexes

Table 2.2 Approximate MAC* values for isoflurane

Anaesthetic agent Dogs Cats Horses

Isoflurane 1.4 1.6 1.3

Sevoflurane 2.4 2.6 2.3

*MAC: minimum alveolar concentration of anaesthetic agent

rates, heart rates, and blood pressure are not reliable

or medetomidine/dexmedetomidine. For these animals, EEG and Bispectral index

Table 2.3 Methods of assessing cardiovascular

Heart rate and rhythm

Arterial blood pressure

Systole Diastole Systole

Heart rate monitors

for large dogs, 65 beats/min for adult cats, 26 beats/min Electrocardiography

premature ventricular complexes (PVC), may or may not

Abbreviations Myths about blood pressure in anaesthetized

TIME 135 150 165 180 195 210 225

manometer and a bulb for manual inflation of the cuff

that the cuff is level with the manubrium. Furthermore, a

should be maintained next to the anaeroid manometer to