Guidelines for safer anaesthesia

The AVA guidelines for safer anaesthesia are designed to make it easier for veterinary practices and pet owners alike to understand what best practice in veterinary anaesthesia should involve.

For veterinary practices we hope it can promote evaluation and where necessary changes, as well as providing a framework for discussion of services with owners.

For pet owners, we hope this can allow appreciation of the necessary steps required for a pet to receive a safer anaesthetic, and the time, skills and money involved with providing this.

The Association of Veterinary Anaesthetists have compiled a list of pointers that we believe should be incorporated in to every pet’s anaesthetic to improve patient safety.

We want you, as an owner, to be able to understand these points so you can discuss them with your vet before the anaesthetic. We also want you to be able to appreciate the depth of care your vet is providing your pet when they work within these guidelines.

‘AVA recommended procedures and safety checklist’ incorporated in to every case.

Anaesthesia plan considered for each individual patient, covering patient risk factors, procedure risk factors, suitable anaesthesia drugs, fluids and monitoring aids.

Consideration given to the limits of anaesthesia care that can be provided, and outside assistance sought or case referral to specialist anaesthesia facilities arranged when required.

Analgesia should be a top priority of care.

A range of analgesic therapies should be available and utilised including full opioid agonists, local anaesthetics, NSAIDs, adjunctive drug therapies and non-drug therapies.

An analgesic plan should be made for each case recognising the expected level and modality of pain.

Patients should be actively assessed using validated pain scores and results responded to appropriately.

 Patients with known or expected pain should be prescribed ongoing analgesia at discharge and the owners should be informed of pain related behavioural signs.

Qualified veterinary staff, who have received anaesthesia training, to monitor every anaesthetic.

Veterinary Students to be supervised by a qualified member of veterinary staff when monitoring an anaesthetic.

Use of advanced anaesthesia trained staff whenever available or required.

Dedicated Anaesthetist monitoring each case.

Additional monitoring equipment of pulse oximetry, capnography and blood pressure monitors available and utilised.

Active temperature monitoring and temperature support, including preventative measures and active warming devices available and utilised.

 Fluid therapy considered for every anaesthetic and goal directed administration provided where indicated. Availability of fluid pumps and/or syringe drivers to ensure accuracy.

Blood Pressure support considered from outset and managed where appropriate through anaesthetic drug selection, fluid therapy and appropriate drug administration.

Requirement of ventilation support considered from outset. Availability of manual or mechanical means of positive pressure ventilation utilised when necessary.

 

All staff to have received CPR training, and CPR simulations to be practiced in house during each year. All patients to have IV access during anaesthesia via an IV catheter. Emergency equipment to be available at all times.

Patients recovery from anaesthesia to be adequately monitored and recorded. Recovery to take place in a suitable location.

All clinical staff involved with anaesthesia to receive regular CPD on anaesthesia and analgesia. A dedicated member of staff to oversee practice policies and standards of care.

Professional records of anaesthesia kept, including; patient details, procedure details, staff involved, drugs, monitoring and recovery. Records should be reviewed for morbidity and mortality issues.

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‘AVA recommended procedures and safety checklist’ incorporated in to every case.

Discussion: Anaesthesia is a complex process involving many critical steps that need to be performed in a correct and timely manner. Within a busy veterinary clinic there can be a tendency to try and over-simplify this complexity which can lead to steps being missed and vital components of a “safe” anaesthetic process being overlooked.

The use of checklists ensure safety critical steps are performed, as well as improving teamwork and communication (McMillan 2014).

More information: The AVA has designed veterinary-specific safety procedures and checklists.

Anaesthesia plan considered for each individual patient, covering patient risk factors, procedure risk factors, suitable anaesthesia drugs, fluids and monitoring aids.

Consideration given to the limits of anaesthesia care that can be provided, and outside assistance sought or case referral to specialist anaesthesia facilities arranged when required.

Discussion:

Every patient undergoing anaesthesia should be treated as an individual.
Although previously devised protocols may be suitable for the bulk of routine procedures on healthy patients, thought must be given to ensure an individual patient meets these criteria.

Anaesthesia plans must be made to meet specific needs and risk factors of unhealthy patients or patients undergoing non-routine procedures.

More information: Visit the AVA website.

Analgesia should be a top priority of care.

A range of analgesic therapies should be available and utilised including full opioid agonists, local anaesthetics, NSAIDs, adjunctive drug therapies and non-drug therapies.

An analgesic plan should be made for each case recognising the expected level and modality of pain. Patients should be actively assessed using validated pain scores and results responded to appropriately.

Patients with known or expected pain should be prescribed ongoing analgesia at discharge and the owners should be informed of pain related behavioural signs.

Discussion:

The ability to experience pain is universally shared by all mammals, including companion animals, and as members of the veterinary healthcare team it is our moral and ethical duty to mitigate this suffering to the best of our ability. This begins by evaluating for pain at every patient contact (Mathews et al. 2014).

Analgesic drugs all have the potential to cause side effects. When pain is moderate or severe, the veterinarian should consider combining drugs that act at different sites in the pain pathway to provide optimal analgesia; multimodal analgesia (sometimes referred to as balanced analgesia) is the name given to this approach to treating pain.

Combining different classes of analgesic drugs allows the veterinarian to optimize the management of pain, while limiting the occurrence of side effects. Drugs most commonly used in multimodal analgesia include opioids, NSAIDs, local anaesthetics, NMDA antagonists and alpha2 adrenoceptor agonists (Mathews et al. 2014).

Access to full agonist opioids is recommended as partial and agonist/antagonist opioids are not suitable for treatment of moderate–severe pain, which can be commonly expected to be seen in general practice from either surgery, trauma or disease.

More information: Global Pain Council Guidelines.

Qualified veterinary staff, who have received anaesthesia training, to monitor every anaesthetic.

Veterinary Students to be supervised by a qualified member of veterinary staff when monitoring an anaesthetic.

Use of advanced anaesthesia trained staff whenever available or required.

Discussion:

The AVA believes that veterinary anaesthesia is a complicated enough subject that its management should only be entrusted to staff that have received a rounded veterinary education and have documented this through industry respected qualifications. Examples of this include graduates of EAEVE accredited veterinary institutions, British RVNs, US CVTs/RVTs.

The AVA actively supports the progression of veterinary professionals through specialist and advanced training, such as DipECVAA, DipACVAA, VTS (Anesthesia & Analgesia) .

More information:

The European Association of Establishments for Veterinary Education
European College of Veterinary Anaesthesia and Analgesia
The American College of Veterinary Anesthesia and Analgesia
Academy of Veterinary Technicians in Anesthesia and Analgesia.

Dedicated Anaesthetist monitoring each case.

Additional monitoring equipment of pulse oximetry, capnography and blood pressure monitors available and utilised.

Discussion:

The AVA believes that a suitably trained and focused anaesthetist is the most vital instrument for safely monitoring an anaesthetic, and cannot be replaced by a machine.

The additional information gained by pulse oximetry, capnography and blood pressure cannot be objectively gained by a person alone and the interpretation of this information will regularly improve case management. Additional monitoring such as ECG may be required in some cases.

Active temperature monitoring and temperature support, including preventative measures and active warming devices available and utilised.

Fluid therapy considered for every anaesthetic and goal directed administration provided where indicated. Availability of fluid pumps and/or syringe drivers to ensure accuracy.

Blood Pressure support considered from outset and managed where appropriate through anaesthetic drug selection, fluid therapy and appropriate drug administration.

Requirement of ventilation support considered from outset. Availability of manual or mechanical means of positive pressure ventilation utilised when necessary.

Discussion:

Two large-scale studies have reported a high incidence of post-operative hypothermia (83.6% in dogs and 96.7% in cats) (Redondo, Suesta, Gil, et al. 2012; Redondo, Suesta, Serra, et al. 2012).

Hypothermia disrupts homeostasis and has several detrimental effect on a patients wellbeing, preventative measures such as blankets and active warming therapies such as warm air blowers should be utilised (Armstrong et al. 2005).

Administration of fluid therapy has advantages for all anaesthetised patients. Consideration should be given to type and dose or whether it is appropriate to withhold. Careful administration using calibrated administration equipment and continued monitoring will minimise risks of adverse effects (Davis et al. 2013).

Blood pressure should be kept within normal ranges to protect vital organs and promote adequate tissue perfusion. Fluid therapy should not be solely relied upon to correct anaesthetic related hypotension – initial drug selection and dosage should be used preventively (i.e. reducing dependency on vasodilating drugs such as isoflurane), and appropriate supportive drugs should also be available as a treatment option.

Consideration of patient signalment and procedure can highlight risk of hypoventilation or apnoea during anaesthesia – plans for positive pressure ventilation of high risk patients should be made. Equipment should be available to allow endotracheal intubation and to apply positive pressure ventilation in all cases.

More Information: AAHA Fluid therapy guidelines.

All staff to have received CPR training, and CPR simulations to be practiced in house every 6 months. All patients to have an IV access during anaesthesia via a IV catheter. Emergency equipment to be available at all times.

Discussion:

Adherence to CPR guidelines can only be accomplished if personnel receive effective, standardized training and regular opportunities to refresh their skills.

The use of a pre-stocked, organized and functional arrest station is a key element in the efficient operation of CPR.

Maintaining IV access throughout an anaesthetic allows the quick administration of emergency drugs or fluids, and prevents wasted time in emergency situations. An IV catheter provides safe and secure IV access.

More Information: RECOVER Guidelines, ECC small talk podcasts.

Patients recovery from anaesthesia to be adequately monitored and recorded and to take place in a suitable location.

Discussion:

Recovery is a high risk period of anaesthesia accounting for over 60% of cats and rabbits and nearly 50% of dog anaesthetic related deaths (Brodbelt et al. 2008). Patients should be receiving one-to-one care until extubation and should be under constant observation until they are alert and have a core body temperature of above 37°C.

Recovery areas should ideally be quiet and calm, have access to pulse oximetry and temperature measurement devices and have close access to emergency equipment.

Close attention should be paid to analgesia and nursing care of the patient.

More Information: AVA anaesthetic record forms, AVA safety checklists.

All clinical staff involved with anaesthesia to receive regular CPD on anaesthesia and analgesia. A dedicated member of staff to oversee practice policies and standards of care.

Discussion:

Veterinary staff that have an involvement in anaesthesia should keep up to date with current practices of anaesthesia through the reading of journals, attendance at CPD events, conferences and private study. This should be supported and encouraged by employers.

As veterinary surgeons often work independently, the appointment of a single member of staff to oversee broad anaesthesia policies can ensure a uniform high level of care.

More Information: AVA membership benefits.

Professional records of anaesthesia kept, including patient details, procedure details, staff involved, drugs, monitoring and recovery. Records should be reviewed for morbidity and mortality issues.

Discussion:

The practice of keeping anaesthetic records has many benefits including: improved monitoring, patient details to hand, accurate record of timings, legal protection, data for future use.

Records should be clear and legible with all required information provided; they should clearly document a case from start to finish.

Morbidity and mortality should be reported and recorded, and can be discussed and reflected upon within formal M&M rounds.

More Information: AVA checklists.

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The “AVA recommended procedures and safety checklist” has been designed to allow your vet to quickly ensure everything is ready for your pet to be anaesthetised in the safest possible manner. We recommend this is used for every anaesthetic.

Every anaesthetic, surgery and patient is individual and carries with it its own unique risks. Your vet should design an anaesthetic protocol tailored to what your pet needs. Just like with surgery some anaesthetics require specialist equipment and expertise; if required your vet should offer referral to a specialist centre or seek advice from a specialist veterinary anaesthetist.

Pain management is a top priority and there are different drugs and pain assessment techniques available to assess and manage pain effectively . Following surgery pain relief should be continued, with most animals requiring pain relief when they come home. We recommend vets stock a wide range of pain relief medications and use them to meet each pets specific needs through thorough pain assessments.

Having a dedicated anaesthetist reduces the risks of anaesthesia and we recommend your pet should be monitored continuously and exclusively by either a registered veterinary nurse or a veterinarian. In the UK, the RCVS website can be consulted to check the status of practicing vets and registered veterinary nurses; Other countries have different systems in place and we suggest you investigate through the veterinary regulating body.

Special monitors are available to make sure your pet’s blood pressure, heart and breathing are ok during the anaesthetic. This is important to ensure that vital organs such as the kidneys and brain receive the nutrients they require during the anaesthetic. We recommend a dedicated anaesthetist routinely uses of pulse oximeters, capnographs and blood pressure monitors.

Your vet should have equipment available to make sure that they can treat any minor problems that may happen during the anaesthetic. This includes warming devices to maintain body temperature and intravenous access through an IV cannula so that fluids or other medication can be given quickly and effectively.

Sadly, sometimes things don’t go as planned. We recommend every pet has an IV cannula even for sedation or routine surgery. This means that emergency drugs and treatment can be given quickly and easily. We also recommend that staff have regular CPR training

Once your pet has woken up after surgery they should continue to be monitored until back to normal, this includes within the kennel area.

There are many courses available to vets and nurses to allow them to provide the best possible care for your pet. We recommend that practice staff regularly attend anaesthesia training, and share the information they have learnt to their colleagues

A record of your pet’s anaesthetic should be kept for at least five years. If your pet needs another anaesthetic at the same vets or another practice, the previous record can be made available beforehand.

Evidence Base Statement

Information provided here is based on best available evidence where possible, as referenced. Where sufficient data is not available to support the information provided, a team of AVA endorsed veterinary anaesthesia professionals have verified the information as best practice. The team members are as follows: 

Susanna Taylor RVN, VTS(Anesthesia/Analgesia), NCert A&CC, PGCert (Vet Ed), FHEA (Project Chair) 

Helen Benney RVN, Dip HE CVN, Dip AVN, VTS(Anesthesia/Analgesia) 

Georgina Beaumont BVSc(Hons), MANZCVS(VA&CC), Dip.ECVAA, MRCVS 

Elisa Bortolami DVM, PhD, Dip.ECVAA, MRCVS 

Vicky Ford-Fennah BSc(Hons), RVN, VTS(Anesthesia/Analgesia), A1, VPAC 

William Mcfadzean BVetMed, CertAVP(VA), MRCVS 

Evidence Base Statement

Information provided here is based on best available evidence where possible, as referenced. Where sufficient data is not available to support the information provided, a team of AVA endorsed veterinary anaesthesia professionals have verified the information as best practice. The team members are as follows: 

Susanna Taylor RVN, VTS(Anesthesia/Analgesia), NCert A&CC, PGCert (Vet Ed), FHEA (Project Chair) 

Helen Benney RVN, Dip HE CVN, Dip AVN, VTS(Anesthesia/Analgesia) 

Georgina Beaumont BVSc(Hons), MANZCVS(VA&CC), Dip.ECVAA, MRCVS 

Elisa Bortolami DVM, PhD, Dip.ECVAA, MRCVS 

Vicky Ford-Fennah BSc(Hons), RVN, VTS(Anesthesia/Analgesia), A1, VPAC 

William Mcfadzean BVetMed, CertAVP(VA), MRCVS 

References

  • Armstrong, S.R., Roberts, B.K. & Aronsohn, M., 2005. Perioperative hypothermia.
    Journal of Veterinary Emergency and Critical Care, 15(1), pp.32–37.
    Available at: <Go to ISI>://WOS:000227351000006.
  • Brodbelt, D.C. et al., 2008. The risk of death: The confidential enquiry into perioperative small
    animal fatalities. Veterinary Anaesthesia and Analgesia, 35(5), pp.365–373. Davis, H. et al., 2013. 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats. Journal of the American Animal Hospital Association, 49, pp.149–159. Available at: http://www.ncbi.nlm.nih.gov/pubmed/23645543.
  • Mathews, K. et al., 2014. Guidelines for Recognition, Assessment and Treatment of Pain. Journal of Small Animal Practice, (June), p.10.1111/jsap.12200. Available at: http://www.wsava.org/sites/default/files/jsap_0.pdf.
  • McMillan, M., 2014. Checklists in veterinary anaesthesia: why bother? The Veterinary Record, 175(22), pp.556–9. Available at: http://veterinaryrecord.bmj.com/content/175/22/556.full.
  • Redondo, J.I., Suesta, P., Gil, L., et al., 2012. Retrospective study of the prevalence of postanaesthetic hypothermia in cats. Veterinary Record, 170(8), pp.206–206.
  • Redondo, J.I., Suesta, P., Serra, I., et al., 2012. Retrospective study of the prevalence of
    postanaesthetic hypothermia in dogs. Veterinary Record, 171(15), pp.374–374.

Evidence Base Statement

Information provided here is based on best available evidence where possible, as referenced. Where sufficient data is not available to support the information provided, a team of AVA endorsed veterinary anaesthesia professionals have verified the information as best practice. The team members are as follows: 

Susanna Taylor RVN, VTS(Anesthesia/Analgesia), NCert A&CC, PGCert (Vet Ed), FHEA (Project Chair) 

Helen Benney RVN, Dip HE CVN, Dip AVN, VTS(Anesthesia/Analgesia) 

Georgina Beaumont BVSc(Hons), MANZCVS(VA&CC), Dip.ECVAA, MRCVS 

Elisa Bortolami DVM, PhD, Dip.ECVAA, MRCVS 

Vicky Ford-Fennah BSc(Hons), RVN, VTS(Anesthesia/Analgesia), A1, VPAC 

William Mcfadzean BVetMed, CertAVP(VA), MRCVS