Clinical evaluation of romifidine/ketamine/halothane anaesthesia in horses

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.

Sedative and cardiorespiratory effects of three doses of romifidine in comparison with medetomidine in five cats

This study was designed to compare the effects of three doses of romifidine (200, 400 and 600 microg/kg) with medetomidine (80 microg/kg) administered intramuscularly to five cats. The quality of sedation and the cardiovascular and respiratory effects of each treatment were evaluated, and the onset and duration of the sedation, and the cats' recovery times, were measured. Cardiorespiratory variables were also analysed. The dose of 200 microg/kg romifidine was clinically superior to the other doses of romifidine, providing moderate sedation, with minor cardiorespiratory and other adverse effects. However none of the doses of romifidine induced as deep and reliable sedation as the dose of medetomidine.

Clinical comparison of xylazine and medetomidine for premedication of horses

OBJECTIVE

To compare the analgesic and cardiopulmonary effects of medetomidine and xylazine when used for premedication of horses undergoing general anesthesia.

DESIGN

Randomized clinical trial.

ANIMALS

40 horses.

PROCEDURE

Twenty horses were premedicated with medetomidine (10 microg/kg [4.5 microg/lb], i.m.) and the other 20 were premedicated with xylazine (2 mg/kg [0.9 mg/kg], i.m.). Horses were then anesthetized with a combination of guaifenesin and ketamine; anesthesia was maintained with halothane. Additional doses of medetomidine or xylazine were given if horses were not sufficiently sedated at the time of anesthetic induction. After induction of anesthesia, sodium pentothal was administered as necessary to prevent limb movements. Hypotension was treated with dobutamine; hypoventilation and hypoxemia were treated with intermittent positive-pressure ventilation. The quality of anesthetic induction, maintenance, and recovery and the quality of the transition to inhalation anesthesia were scored.

RESULTS

Scores for the quality of the transition to inhalation anesthesia were significantly higher for horses premedicated with medetomidine than for horses premedicated with xylazine. However, other scores, recovery times, and numbers of attempts needed to achieve sternal recumbency and to stand were not significantly different between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that medetomidine is suitable for premedication of horses undergoing general anesthesia. Analgesic and cardiopulmonary effects of medetomidine were similar to those of xylazine, except that the transition to inhalation anesthesia was smoother when horses were premedicated with medetomidine, rather than xylazine.

Comparison of detomidine and romifidine as premedicants before ketamine and halothane anesthesia in horses undergoing elective surgery

OBJECTIVE

To compare detomidine hydrochloride and romifidine as premedicants in horses undergoing elective surgery.

ANIMALS

100 client-owned horses.

PROCEDURE

After administration of acepromazine (0.03 mg/kg, IV), 50 horses received detomidine hydrochloride (0.02 mg/kg of body weight, IV) and 50 received romifidine (0.1 mg/kg, IV) before induction and maintenance of anesthesia with ketamine hydrochloride (2 mg/kg) and halothane, respectively. Arterial blood pressure and blood gases, ECG, and heart and respiratory rates were recorded. Induction and recovery were timed and graded.

RESULTS

Mean (+/- SD) duration of anesthesia for all horses was 104 +/- 28 minutes. Significant differences in induction and recovery times or grades were not detected between groups. Mean arterial blood pressure (MABP) decreased in both groups 30 minutes after induction, compared with values at 10 minutes. From 40 to 70 minutes after induction, MABP was significantly higher in detomidine-treated horses, compared with romifidine-treated horses, although more romifidine-treated horses received dobutamine infusions. In all horses, mean respiratory rate ranged from 9 to 11 breaths/min, PaO2 from 200 to 300 mm Hg, PaCO2 from 59 to 67 mm Hg, arterial pH from 7.33 to 7.29, and heart rate from 30 to 33 beats/min, with no significant differences between groups.

CONCLUSIONS AND CLINICAL RELEVANCE

Detomidine and romifidine were both satisfactory premedicants. Romifidine led to more severe hypotension than detomidine, despite administration of dobutamine to more romifidine-treated horses. Both detomidine and romifidine are acceptable alpha2-adrenoceptor agonists for use as premedicants before general anesthesia in horses; however, detomidine may be preferable when maintenance of blood pressure is particularly important.

Cardiopulmonary effects of romifidine and detomidine used as premedicants for ketamine/halothane anaesthesia in ponies

The cardiopulmonary effects of romifidine at 80 microg/kg (R80) or 120 pg/kg (R120), and detomidine at 20 pg/kg (D20) when used as premedicants for ketamine/halothane anaesthesia were investigated in six ponies. Using a blinded crossover design, acepromazine (0-04 mg/kg) was administered followed by the alpha-2 agonist. Anaesthesia was induced with ketamine at 2.2 mg/kg and maintained with halothane (expired concentration 1.0 per cent) in oxygen for three hours. During anaesthesia, arterial blood pressure, cardiac index, PaO2 and PmvO2 decreased, and systemic vascular resistance and PaCO2 increased. The cardiac indices for R80, R120 and D20 were, respectively, 39, 39 and 32 ml/kg/minute at 30 minutes and 29, 29 and 26 ml/kg/minute at 180 minutes. The alpha-2 agonists had similar cardiovascular effects, but PaO2 was significantly lower with R120. The quality of anaesthesia was similar in all three groups.

Alpha 2 adrenoceptor agonists in the horse--a review

In recent years the usefulness of the alpha 2 adrenoceptor agonist drugs has been recognized in equine practice. Several agents have become available and are now licensed for use in a number of countries. The principle actions of all alpha 2 adrenoceptor agonists are similar, in that they produce a reduction in heart rate and alteration of heart rhythm, an initial hypertension followed by a prolonged hypotension, a decrease in the cardiac output and respiratory depression. For clinical purposes, these agents produce sedation and analgesia, they are useful for premedication and markedly potentiate the effects of other sedative/analgesic agents. Differences in receptor specificity between the alpha 2 adrenoceptor agonists results in the distinguishing characteristics of the individual agents, particularly with respect to their duration of action, sedative effect and analgesic properties; their cardiopulmonary effects are however similar, when equipotent sedative doses are administered. When used in combination with other agents, the alpha 2 adrenoceptor agonists all appear to act in a similar manner, with the greatest difference being related to their duration of action.

Romifidine as a premedicant to propofol induction and infusion anaesthesia in the dog

The effects of premedication with four different intravenous doses of romifidine (20, 40, 80 and 120 micrograms/kg bodyweight) and a saline placebo were compared in a group of 20 adult beagles of both sexes, undergoing anaesthesia with propofol for a clinical dental procedure. Anaesthesia was induced 10 minutes after premedication and maintained by intravenous infusion of propofol for a period of 30 minutes. Romifidine had a marked synergistic effect with propofol and reduced the required induction and infusion doses by more than 60 per cent for a standard level of anaesthesia; the synergistic effect was dose related. Following premedication, propofol produced no significant alteration of respiratory rate, heart rate or rectal temperature. Anaesthesia was found to be more stable following romifidine premedication at all doses studied. The quality of induction was unaltered by the dose of the romifidine. Recovery from anaesthesia was smooth and of a similar quality in all cases. There were no differences in the recovery times between the unpremedicated group and the dogs premedicated with any dose of romifidine studied. There were no adverse effects noted following this anaesthetic regimen. The marked dose-related synergism with propofol induction and infusion anaesthesia is relevant should romifidine be used in the dog in clinical veterinary practice.

Sedative effects of romifidine in the dog

The sedative and physiological effects of intravenous romifidine at 0, 20, 40, 80 and 120 micrograms/kg were investigated in five clinically normal adult male beagle dogs in a blind study using a Latin square design. Following the injection of romifidine, the dogs became ataxic and stood with a wide-based stance, they exhibited signs of skeletal muscle relaxation and their heads were lowered. All the dogs became recumbent and there was a reduction in the heart and respiratory rates. Increasing the dose from 20 to 40 micrograms/kg, or higher, produced a significant reduction in heart rate. There was am increase in the sedation score following even low doses of romifidine, and although measures of sedation showed no differences among romifidine doses, subjectively, the higher doses produced a more consistent effect. Dogs given lower doses of romifidine regained a standing position more rapidly than following the higher doses, although this effect was not significantly different. A second blind study compared the sedative effects of intravenous romifidine, at 40 and 80 micrograms/kg, with medetomidine at 10 micrograms/kg in six adult beagles. The cardiopulmonary and sedative effects were not significantly different between all regimens, although medetomidine at 10 micrograms/kg appeared to be intermediate in effect between romifidine at 40 and 80 micrograms/kg. The sedative and physiological effects of romifidine in dogs appear to be similar to other alpha2-adrenoceptor agonists. Intravenous administration provided sedation which might be clinically useful.