Restoration of arterial oxygen tension in horses recovering from general anaesthesia

Successful management of two horses with suspected pulmonary haemorrhage in recovery from general anaesthesia

A 24 year old warmblood mare (case 1) and a 12 year old Holsteiner gelding (case 2) were anaesthetized for bursoscopy and phacoemulsification, respectively. Both were premedicated with intramuscular acepromazine (30 μg kg-1). The horses were sedated with intravenous (IV) medetomidine (7-9 μg kg-1 to effect), before anaesthetic induction with ketamine-diazepam. Anaesthesia was maintained with isoflurane in a mixture of oxygen and medical air, alongside a medetomidine constant rate infusion at 3.5 μg kg-1 hour-1. In recovery, 3 and 5 μg kg-1 of medetomidine were administered IV to cases 1 and 2, respectively. After tracheal extubation, both patients developed haemoptysis exceeding an estimated 5% loss of total blood volume. This gradually ceased after IV injection of tranexamic acid (2 mg kg-1, both cases) and acepromazine (case 1, 15 μg kg-1; case 2, 20 μg kg-1), administered while the horses were recumbent. Oxygen insufflation was commenced on entry to the recovery box, initially via the trachea, and then the nasopharynx postextubation, until the horses stood. Both cases survived to discharge. Postanaesthetic pulmonary haemorrhage was suspected; multiple causative factors have been proposed for this rare complication. These include increased pulmonary vascular resistance secondary to α2 adrenoceptor agonist use, hypoxaemia and high catecholamine levels, increased intrathoracic pressures owing to respiratory obstruction and coughing, and underlying, often subclinical, respiratory disease. Particular to case 1 and 2 was the rapid injection of higher than usual doses of medetomidine in recovery owing to persistent nystagmus. Resultant pulmonary hypertension may have caused the haemorrhage observed.

Evaluation of Recovery Time and Quality After Two Different Post-Operative Doses of Medetomidine in Spanish Purebred Horses Anaesthetized with Medetomidine-Isoflurane Partial Intravenous Anaesthesia

Recovery from general anaesthesia is risky in horses. Alpha2-agonist administration after anaesthesia enhances the quality of recovery but may prolong this phase. Recovery time and quality were investigated after medetomidine administration at the end of general anaesthesia in a prospective, randomised, masked and clinical study. Horses underwent medetomidine-isoflurane partial intravenous anaesthesia. Medetomidine (0.5 or 1 µg/kg) IV was administered just after isoflurane was discontinued. The duration of different recovery phases and the number of attempts were recorded. A composite scale (from 1-excellent to 6-accident) was used for quality assessment. Mann-Whitney U-test was performed (p < 0.05). Twenty-seven horses per group were included. Results for 0.5 and 1 µg/kg groups were as follows: lateral recumbency time: 35 (24-45) and 43 (35-55) minutes; sternal recumbency time: 6 (3-15) and 5 (2-15) minutes; total recovery time: 47 (40-59) and 49 (42-62) minutes; number of attempts to sternal: 1 (1-1) and 1 (1-2) and to standing: 1 (1-3) and 1 (1-2); and, quality: 2 (1-2) and 2 (1-2), respectively. No significant differences between the groups were found. Medetomidine 0.5 µg/kg dose did not decrease the recovery time but maintained the recovery quality.

Arterial blood gas tensions during recovery in horses anesthetized with apneustic anesthesia ventilation compared with conventional mechanical ventilation

OBJECTIVE

To compare PaO₂ and PaCO₂ in horses recovering from general anesthesia maintained with either apneustic anesthesia ventilation (AAV) or conventional mechanical ventilation (CMV).

STUDY DESIGN

Randomized, crossover design.

ANIMALS

A total of 10 healthy adult horses from a university-owned herd.

METHODS

Dorsally recumbent horses were anesthetized with isoflurane in oxygen [inspired oxygen fraction = 0.3 initially, with subsequent titration to maintain PaO₂ ≥ 85 mmHg (11.3 kPa)] and ventilated with AAV or CMV according to predefined criteria [10 mL kg^-1 tidal volume, PaCO₂ 40-45 mmHg (5.3-6.0 kPa) during CMV and < 60 mmHg (8.0 kPa) during AAV]. Horses were weaned from ventilation using a predefined protocol and transferred to a stall for unassisted recovery. Arterial blood samples were collected and analyzed at predefined time points. Tracheal oxygen insufflation at 15 L minute^-1 was provided if PaO₂ < 60 mmHg (8.0 kPa) on any analysis. Time to oxygen insufflation, first movement, sternal recumbency and standing were recorded. Data were analyzed using repeated measures anova, paired t tests and Fisher's exact test with significance defined as p < 0.05.

RESULTS

Data from 10 horses were analyzed. Between modes, PaO₂ was significantly higher immediately after weaning from ventilation and lower at sternal recumbency for AAV than for CMV. No PaCO₂ differences were noted between ventilation modes. All horses ventilated with CMV required supplemental oxygen, whereas three horses ventilated with AAV did not. Time to first movement was shorter with AAV. Time to oxygen insufflation was not different between ventilation modes.

CONCLUSIONS

Although horses ventilated with AAV entered the recovery period with higher PaO₂, this advantage was not sustained during recovery. Whereas fewer horses required supplemental oxygen after AAV, the use of AAV does not preclude the need for routine supplemental oxygen administration in horses recovering from general anesthesia.

Recovery after General Anaesthesia in Adult Horses: A Structured Summary of the Literature

Simple Summary

Recovery is the most dangerous phase of general anaesthesia in horses. Numerous publications have reported about this phase, but structured reviews that try to reduce the risk of bias of narrative reviews/expert opinions, focussing on the topic are missing. Therefore, the aim of the present article was to publish the first structured review as a summary of the literature focussing on the recovery phase after general anaesthesia in horses. The objective was to summarise the available literature, taking into account the scientific evidence of the individual studies. A structured approach was followed with two experts in the field independently deciding on article inclusion and its level of scientific evidence. A total number of 444 articles, sorted by topics and classified based on their levels of evidence, were finally included into the present summary. The most important findings were summarised and discussed. The present structured review can be used as a compilation of the publications that, to date, focus on the recovery phase after general anaesthesia in adult horses. This type of review tries to minimise the risk of bias inherent to narrative reviews/expert opinions.

Abstract

Recovery remains the most dangerous phase of general anaesthesia in horses. The objective of this publication was to perform a structured literature review including levels of evidence (LoE) of each study with the keywords “recovery anaesthesia horse”, entered at once, in the search browsers PubMed and Web of Science. The two authors independently evaluated each candidate article. A final list with 444 articles was obtained on 5 April 2021, classified as: 41 “narrative reviews/expert opinions”, 16 “retrospective outcome studies”, 5 “surveys”, 59 “premedication/sedation and induction drugs”, 27 “maintenance with inhalant agents”, 55 “maintenance with total intravenous anaesthesia (TIVA)”, 3 “TIVA versus inhalants”, 56 “maintenance with partial intravenous anaesthesia (PIVA)”, 27 “other drugs used during maintenance”, 18 “drugs before/during recovery”, 18 “recovery systems”, 21 “respiratory system in recovery”, 41 “other factors”, 51 “case series/reports” and 6 “systems to score recoveries”. Of them, 167 were LoE 1, 36 LoE 2, 33 LoE 3, 110 LoE 4, 90 LoE 5 and 8 could not be classified based on the available abstract. This review can be used as an up-to-date compilation of the literature about recovery after general anaesthesia in adult horses that tried to minimise the bias inherent to narrative reviews.

Changes in Arterial Blood Pressure and Oxygen Tension as a Result of Hoisting in Isoflurane Anesthetized Healthy Adult Horses

Background: In anesthetized adult horses, changes in recumbency can influence the cardiovascular system but how arterial blood pressures and oxygen tension change in isoflurane anesthetized animals as a direct result of hoisting has not been investigated. Objective: To evaluate effects of hoisting on hemodynamic function and pulmonary gas exchange in isoflurane-anesthetized horses. Study Design: Prospective, experimental study. Methods: Six adult horses were anesthetized three times using isoflurane in pure oxygen (inspired fraction 0.9-1.0), and allowed breathing spontaneously in lateral recumbency. After 45 min horses were hoisted using a single hoist-hobble system for 5 min and returned into left lateral recumbency. Heart rate (HR), respiratory rate (RR), and systolic (SAP), diastolic (DAP), and mean arterial blood pressures (MAP) were measured every minute starting from 5 min before to 5 min after hoisting. Arterial blood gas samples were collected before, during, and after hoisting. Results: Significant changes in hemodynamic parameters and PaO₂ but not PaCO₂ were found between baseline recordings and measurements obtained during and early after hoisting. The MAP decreased within the 1st min of hoisting from a mean of 74 ± 17 mmHg at baseline to 57 ± 20 mmHg (p < 0.05). Thereafter, it rapidly recovered to baseline before continuing to rise to higher than baseline values and then remaining elevated for 5 min after horses were returned into lateral recumbency. Simultaneously, the HR increased by 6-9 beats per min during the initial 3 min of hoisting before returning close to baseline values (p < 0.05). The PaO₂ decreased significantly from a mean of 324.9 ±137.0 mmHg at baseline to a mean of 141.3 ± 104.2 mmHg during hoisting (p < 0.001) without recovering any more to baseline values. Clinical significance: Hoisting an adult horse during or at the end of isoflurane anesthesia carries the risk of a precipitous, though short-lived (1-2 min), drop in arterial blood pressures and a persistent decrease in arterial oxygenation. While in systemically healthy animals the observed functional impairments were not life-threatening, they may be more severe in systemically compromised horses.Therefore, arterial blood pressures and oxygenation must be carefully monitored when hoisting sick equine patients during or at the end of inhalant anesthesia.