Partial Antagonization of Midazolam-Medetomidine-Ketamine in Cats – Atipamezole versus combined Atipamezole and Flumazenil

Ketamine-dexmedetomidine combined with local anesthesia, with or without different doses of atipamezole in the postoperative period, for orchiectomy in cats

OBJECTIVE

To evaluate the anesthetic and cardiopulmonary effects of ketamine-dexmedetomidine combined with local anesthesia, associated or not in the postoperative period with different doses of atipamezole, for orchiectomy in cats.

ANIMALS

24 healthy cats.

PROCEDURES

Cats received ketamine (7 mg/kg) combined with dexmedetomidine (10 µg/kg) IM, and 1 mL of saline (group KDSAL), 25 µg/kg (group KDAT25), or 50 µg/kg (group KDAT50) of atipamezole IV, postoperatively. All cats received local anesthesia (2 mg/kg of lidocaine) intratesticular and SC. Physiologic variables were recorded at baseline and at time points during anesthesia. Ketamine rescue dose (1 mg/kg) was recorded. The quality of recovery, the degree of sedation, and side effects were evaluated postoperatively.

RESULTS

2 cats received a single additional bolus of ketamine to perform local anesthesia. Heart rate was lower in KDSAL, KDAT25, and KDAT50 during anesthesia, compared with baseline. Hypertension was observed intraoperatively in all groups. The time to head up, pedal reflex regained time, time to sternal recumbency, and time to standing were shorter in KDAT25 and KDAT50 compared to KDSAL. Lower sedation scores were assigned sooner to KDAT25 and KDAT50 than KDSAL. All groups resulted in low recovery quality scores and no side effects.

CLINICAL RELEVANCE

At the doses used, ketamine-dexmedetomidine combined with local anesthesia allowed the performance of orchiectomy. Rescue dose of ketamine for performing local anesthesia may be required. This combination can result in hypertension. Both atipamezole doses shortened the anesthetic recovery, without differences among them, and side effects.

Reversal effects of atipamezole, flumazenil, and 4-aminopyridine on bradycardia and increases in blood pressures induced by medetomidine, midazolam, and ketamine in isoflurane-anesthetized cats

OBJECTIVE

To investigate the effects of a fixed dose of atipamezole (AT), flumazenil (FL), and 4-aminopyridine (AP), both alone and in combination, on changes in arterial blood pressure and heart rate induced by medetomidine (ME), midazolam (MI), and ketamine (KE) under isoflurane anesthesia with controlled ventilation in healthy cats.

DESIGN

Prospective experimental study.

SETTING

University animal research facility.

ANIMALS

Healthy adult mixed-breed cats were used for 8 investigation groups (6 cats per group), with ≥2 weeks between interventions.

INTERVENTIONS

Cats were anesthetized with an end-tidal isoflurane concentration of 2% under controlled ventilation. A catheter was inserted into the right or left femoral artery for arterial pressure monitoring and blood gas sampling, and ECG electrodes were placed. Upon completed preparations, cats were administered a mixture of ME (0.05 mg/kg) and MI (0.5 mg/kg), followed 10 minutes later by intramuscular KE (10 mg/kg). Twenty minutes after KE injection, the cats received IV injection with either a physiological saline solution at 0.1 mL/kg (control), or 1 of 7 variations of experimental drugs, alone or in combination: AT (0.2 mg/kg), FL (0.1 mg/kg), AP (0.5 mg/kg), AT+FL, FL+AP, AT+AP, and AT+FL+AP. Arterial blood pressure and heart rate were continuously measured over 120 minutes after administration of potential antagonists.

MEASUREMENTS AND MAIN RESULTS

ME+MI+KE induced an increase in blood pressure and bradycardia. Potential antagonists alone or in combination did not significantly alter the bradycardia. FL, AP alone, and FL+AP did not significantly alter the changes in blood pressures induced by ME+MI+KE. Meanwhile, administration of AT alone or in combination reversed the increase in blood pressure induced by ME+MI+KE but transiently caused excessive hypotension.

CONCLUSION

These results revealed that AT alone or in combination is effective for antagonizing hypertension induced by ME+MI+KE; however, attention should be paid to temporary hypotension in cats anesthetized with isoflurane.

Effects of dissociative anesthesia opioid-free protocols combined with local anesthesia, with or without flumazenil or atipamezole postoperatively, for orchiectomy in cats

OBJECTIVE

To evaluate the anesthetic effects of two drug combinations with local anesthesia, with or without postoperative antagonists, for orchiectomy in cats.

STUDY DESIGN

Prospective, randomized blinded clinical study.

ANIMALS

A total of 64 healthy cats.

METHODS

Cats were assigned to four equal groups: ketamine (5 mg kg^-1) and dexmedetomidine (10 μg kg^-1) were administered intramuscularly (IM), followed postoperatively with intravenous (IV) saline (5 mL; group KDS) or atipamezole (50 μg kg^-1; group KDA); and ketamine (14 mg kg^-1) with midazolam (0.5 mg kg^-1) and acepromazine (0.1 mg kg^-1) IM, with postoperative IV saline (5 mL; group KMAS) or flumazenil (0.1 mg kg^-1; group KMAF). Lidocaine (2 mg kg^-1) was divided between subcutaneous and intratesticular injection. Physiologic variables were recorded at time points during anesthesia. Ketamine rescue dose was recorded. The degree of sedation and the quality of recovery were evaluated postoperatively.

RESULTS

Time to loss of pedal reflex was longer in groups KMAS and KMAF than in groups KDS and KDA (p = 0.010). Total rescue dose of ketamine was higher in KMAS and KMAF than in KDS and KDA (p = 0.003). Heart rate (HR) during anesthesia was higher in KMAS and KMAF than in KDS and KDA (p = 0.001). Times to head up (p = 0.0005) and to sternal recumbency (p = 0.0003) were shorter in KDA than in KDS, KMAS and KMAF. Lower sedation scores were assigned sooner to KDA than KDS, KMAS and KMAF (p < 0.001). Recovery quality scores were good in all groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Both anesthetic protocols allowed the performance of orchiectomy. Groups KMAS and KMAF required higher rescue doses of ketamine before injecting lidocaine. HR and oscillometric systolic pressure were minimally changed in groups KD and tachycardia was recorded in groups KMA. Only atipamezole shortened the anesthetic recovery.

AAFP Feline Anesthesia Guidelines

AIM

The overarching purpose of the AAFP Anesthesia Guidelines (hereafter referred to as the 'Guidelines') is to make anesthesia and sedation safer for the feline patient. Scope and accessibility: It is noteworthy that these are the first exclusively feline anesthesia guidelines authored by an expert panel, making them particularly useful as an extensively referenced, practical resource for veterinary practice teams. Because much of the key content is presented in tabular or visual format, the Guidelines have a high level of accessibility and convenience that invites regular usage. While the recommendations in the Guidelines focus primarily on client-owned cats, the content is also applicable to community-sourced animals with an unknown medical history.

Prolonged Anesthetic Recovery after Continuous Infusion of Midazolam in 2 Domestic Cats (Felis catus)

Two healthy research cats involved in a randomized, blinded prospective pharmacodynamics study evaluating midazolam continuous-rate infusion as a means to decrease sevoflurane concentrations experienced unexpectedly prolonged recoveries. Midazolam loading doses, infusion rates, and the targeted plasma midazolam concentrations at steady-state were determined by pharmacokinetic modeling based on the results of a preliminary pharmacokinetic study using a single dose of midazolam. In the pharmacodynamics study, cats remained oversedated after recovery from anesthesia, and plasma concentrations of midazolam and its primary metabolite (1-hydroxymidazolam) remained elevated. The use of flumazenil was unsuccessful in timely treatment of oversedation. Administration of intravenous lipid emulsion was used in one of the cats to facilitate recovery and appeared to be effective in both reducing the depth of midazolam-induced oversedation and significantly reducing the plasma concentration of 1-hydroxymidazolam. The effects after the administration of both treatment modalities on clinical signs and plasma drug concentrations in cats are discussed. The observations suggest that cats may eliminate 1-hydroxymidazolam more slowly than expected; consequently dose adjustments may be required when continuous infusion of midazolam is intended. In addition, intravenous lipid emulsion may facilitate recovery from midazolam oversedation, particularly in cases unresponsive to traditional treatment modalities. However, further investigations are warranted to delineate the efficacy of this modality in the treatment of midazolam oversedation.

Effects in cats of atipamezole, flumazenil and 4-aminopyridine on stress-related neurohormonal and metabolic responses induced by medetomidine, midazolam and ketamine

This study aimed to investigate the antagonistic effects of a fixed dose of atipamezole (ATI), flumazenil (FLU) and 4-aminopyridine (4AP), both alone and in various combinations, on key stress-related neurohormonal and metabolic changes induced by medetomidine (MED), midazolam (MID) and ketamine (KET) in healthy cats. Seven cats were used consistently in eight investigation groups. Cats were administered a mixture of 0.05 mg/kg MED and 0.5 mg/kg MID followed 10 mins later by 10 mg/kg KET intramuscularly. Twenty minutes after KET injection, the cats were intravenously injected with either a physiological saline solution at 0.1 ml/kg (control) or one of the seven variations of experimental drugs, alone or in combination: ATI, FLU, 4AP, ATI + FLU, FLU + 4AP, ATI + 4AP and ATI + FLU + 4AP. Blood samples were collected 10 times during the 24 h test period. Plasma glucose, insulin, cortisol, epinephrine, norepinephrine and non-esterified fatty acid levels were measured. The administration of MED + MID + KET resulted in hyperglycaemia and decreases in epinephrine, norepinephrine, cortisol and non-esterified fatty acid levels. FLU or 4AP alone or FLU + 4AP did not effectively antagonise the effects induced by MED + MID + KET but enhanced the hyperglycaemia. ATI alone was effective in antagonising these effects. Compared with non-ATI regimens, combinations with ATI were more effective in antagonising the effects induced by MED + MID + KET; however, ATI + FLU + 4AP caused large increases in cortisol, epinephrine and norepinephrine concentrations. ATI, both alone and in combination, is effective in antagonising the neurohormonal and metabolic effects of MED + MID + KET in cats. However, ATI + FLU + 4AP is not suitable because of large stress-related hormonal responses.

Clinical evaluation of alfaxalone to induce and maintain anaesthesia in cats undergoing neutering procedures

This study looked at the use and efficacy of alfaxalone for total intravenous anaesthesia (TIVA) in cats. Following intramuscular medetomidine (20 μg/kg) and morphine (0.3 mg/kg) premedication, anaesthesia was induced and maintained with intravenous alfaxalone. Patients were breathing 100% oxygen. Heart rate (HR), respiratory rate (RR), end-tidal carbon dioxide, oxygen saturation of haemoglobin and indirect arterial blood pressure via Doppler (DAP) were recorded every 5 mins. Thirty-four cats (10 males and 24 females), between the age of 6 and 18 months, and weighing between 1.8 and 5.3 kg, and undergoing neutering procedures were included in this study. The results are presented as median (min, max) values. The time to first spontaneous movement (TS) was >30 mins in 19 cats, of which 12 received atipamezole for reversal of the effects of medetomidine. The TS was 53 (43, 130) mins in these 12 cats and 50 (40, 72) mins in the other seven cats. The body temperature in those 19 cats was significantly lower than the other cats ( P = 0.05). The alfaxalone induction dose and maintenance infusion rate were1.7 (0.7, 3.0) mg/kg and 0.18 (0.06, 0.25) mg/kg/min, respectively. The HR, RR and DAP were 145 (68, 235) beats/min, 17 (5, 40) breaths/min and 110 (58, 210) mmHg, respectively. Apnoea was not observed in any cat. In conclusion, alfaxalone TIVA in combination with medetomidine and morphine premedication was effective in feral and domestic cats for the performance of neutering surgery; low body temperature might have resulted in longer recoveries in some cats.

Sedative effects of three doses of romifidine in comparison with medetomidine in cats

OBJECTIVE

To compare the sedative effects of three doses of romifidine with one dose of medetomidine.

STUDY DESIGN

Prospective blinded experimental cross-over.

ANIMALS

Five adult Domestic Short Hair cats.

METHODS

Cats were administered romifidine at 80, 120 and 160 μg kg(-1) or medetomidine at 20 μg kg(-1) (M20) intramuscularly (IM). Sedative effects were assessed for 3 hours by summing the scores given to posture, auditory response, resistance to positioning, muscular relaxation, and response to noxious stimuli, giving a total sedation score (TS). The area under the curve (AUC) of TS ≥7 (the score considered as clinically useful sedation) was calculated. Times to stages of sedation were determined. Some physiological parameters were measured. Data to compare treatments were analysed by anova or Kruskal-Wallis test as relevant.

RESULTS

All treatments gave a TS considered clinically useful. There were no significant differences between treatments for times to onset of sedation, maximum TS reached, or AUC. Differences between romifidine treatments for other sedation parameters were not significant but the time to maximum TS and to recovery was shortest in M20. Heart rate (HR) fell significantly with all treatments and, although with M20 it recovered at 65 minutes, it remained significantly depressed for 3 hours after all romifidine treatments. Most cats vomited, and/or hypersalivated after all treatments.

CONCLUSIONS

Doses of 80, 120 and 160 μg kg(-1) romifidine IM produce sedation in cats which is similar to that following medetomidine 20 μg kg(-1) . Recovery from sedation and of physiological parameters was quickest after M20.

CLINICAL RELEVANCE

Doses of romifidine considerably lower than those investigated by previous authors give a clinically useful level of sedation, and their use might result in less side effects and a quicker recovery.

AAFP and ISFM Feline-Friendly Handling Guidelines

Background The number of pet cats is increasing in most countries, often outnumbering pet dogs, yet cats receive less veterinary care than their canine counterparts. 1 Clients state the difficulty of getting the cat into a carrier at home, driving to the clinic, and dealing with the fearful cat at the veterinary clinic as reasons for fewer visits. 2 Educating and preparing the client and the veterinary team with regard to respectful feline handling is necessary in order to avoid stress and accomplish the goal of good health care. Without such preparation, feline stress may escalate into fear or fear-associated aggression. The resulting stress may alter results of the physical examination and laboratory tests, leading to incorrect diagnoses (eg, diabetes mellitus) and unnecessary treatments. 3 – 5 Without compassionate and respectful handling by the veterinary team, clients may feel the team lacks skills and compassion, or does not understand cats. Injury may occur to the cat, client and/or veterinary team. 6 Clients who want to avoid stress for their cat may avoid veterinary visits or choose another practice instead.

Goals The use of feline-friendly handling techniques should reduce these problems. Handling is most successful when the veterinary team adapts the approach to each individual cat and situation. The goal of these guidelines is to provide useful information for handling cats that can lead to: Reduced fear and pain for the cat. Reinforced veterinarian—client—cat bond, trust and confidence, and thus better lifelong medical care for the cat. Improved efficiency, productivity and job satisfaction for the veterinary team. Increased client compliance. Timely reporting and early detection of medical and behavioral concerns. Fewer injuries to clients and the veterinary team. Reduced anxiety for the client.