The importance of using an individualized approach when integrating an anesthesia protocol
Do you rely on a standardized anesthesia protocol for each case? Or do you individualize protocols for each patient based on status, personality/temperament, and American Society of Anesthesiologists (ASA) medical history? If you answered yes to the first question, I implore you to keep reading. If you answered yes to the second question, I still urge you to continue reading.
For most of us in general practice or even specialty hospitals, spending time developing an individualized protocol can add stress and time to our already busy day. So let’s simplify the process a bit and reduce the mental load, but also improve the quality of the anesthesia you provide. Better yet, develop a strong, trusting relationship with a few of your qualified vet techs to do the heavy lifting for you.
What’s wrong with cookie-cutter and one-size-fits-all protocols? Depending on the patient’s physiological status based on acute or chronic medical conditions (anesthetic risk; see ASA status definitions below), the current pain score or anticipated pain score after a procedure, and the well -mental being of the animal – potentially a lot. Using a cookie-cutter protocol may only partially or not cover any of these 3 areas, leaving your pet in a more compromised physiological state, a poorly managed state of pain, or a psychological crisis. . Twenty years ago many of us used to sedate (or maybe not even that), a dose of painkiller, and then induce the patient. The awakenings were interesting and the pain was considered acceptable.
Today, we are better informed about the harmful impacts that have had on the physiological and mental well-being of our patients. It also mentally broke some of us who thought we could do better but didn’t know how or were told not to worry about it. How do you get out of the one-size-fits-all mentality? We try, and by that I mean we can find that happy medium of not overturning the things that we’ve always done, although that’s sometimes necessary, but creating a thoughtful way of introducing new ways of thinking while using strategies for busy practices that staff are already used to. Instead of using 1 protocol for all patients all the time, consider creating protocols to use based on the animal’s ASA status and even the species we see most often.1
While there are technically 6 ASA statuses used in human medicine, we only use 5 in veterinary medicine. Does that mean we need 5 protocols? Not necessarily. Given the severity of ASA IV and V status, we can often use the same protocol for both classifications, leaving us with 4 protocols to create while considering individualized patient needs. One of the emerging areas regarding patient comfort is not only appropriate pain management, but also their psychological state. Recent research shows us how sensitive our patients truly are and how our misunderstanding of their mental well-being affects them acutely and chronically, especially when it comes to stress and anxiety.2 Mental well-being is only now being looked at more seriously for humans and the stigma of medication for psychological disorders is still prevalent.3 Research finds that our patients, though evolved to be stoic and resilient, also suffer. This is one of the main areas that I hope we can start to focus on, in addition to pain management and the use of multimodal protocols.
Specifically, studies have shown that more outgoing dogs need more painkillers than their counterparts.4 Animals that have had traumatic experiences or poorly managed pain early in life also need more painkillers. Animals that are particularly anxious have more intense experiences of pain than those that are calm, calm, and collected in their everyday affect.5.6 These personality traits should not be ignored but rather listened to as a cue to adjust protocols for each patient. Anti-anxiety medications should be used in the majority or our patients and antidepressants are worth considering for pets that seem to have a dull effect on how the owner can describe their pet’s personality at home .7-9 One drug that many hospitals already have is tramadol, which has been shown to be a poor pain reliever in dogs, but has selective serotonin reuptake inhibitor and serotonin and noradrenaline effects, reviving, in a meaning, its relevance in daily practice.10.11
As cognitive science becomes available, it demonstrates the complex interactions and intersection between physical pain and emotion. Just because we don’t understand animal emotion in its entirety doesn’t mean it shouldn’t be an excuse not to treat and consider more for our patients, which enriches our lives as much as we enrich theirs. We know better now, so do better.
For current trends in anesthesia and pain management, please see these free resources:
- AAHA’s 2022 Guidelines for Pain Management in Dogs and Cats
- 2022 ISFM consensus guidelines on the management of acute pain in cats
- 2020 WSAVA guidelines for the recognition, assessment and treatment of pain
- 2020 AAHA Guidelines for Anesthesia and Monitoring of Dogs and Cats
The ASA created a body condition scale that is often used in veterinary medicine to assess patients for potential anesthetic risk. The scale is as follows:
- ASA I status is a healthy patient.
- ASA II status corresponds to a patient with mild systemic disease without functional limitations.
- ASA III status is a patient with severe systemic disease with functional limitations.
- ASA IV status is a patient with a serious systemic disease that constantly threatens his life.
- ASA V status is a moribund patient who is not expected to survive 24 hours with or without surgery.
- E indicates an emergency.
- Keefe J. Special considerations in anesthesia (procedures). dvm360. April 1, 2010. Accessed April 18, 2022. https://www.dvm360.com/view/special-considerations-anesthesia-proceedings
- Relief of pain and distress in laboratory animals. American Association for Laboratory Animal Science. Accessed April 18, 2022. https://www.aalas.org/about-aalas/position-papers/alleviating-pain-and-distress
- Stigma, prejudice and discrimination against people with mental illness. American Psychiatric Association. August 2020. Accessed April 18, 2022. https://www.psychiatry.org/patients-families/stigma-and-discrimination
- Lush J, Ijichi C. A preliminary investigation of personality and pain in dogs. J Vet Behavior. 2018;24:62-68. doi:10.1016/j.jveb.2018.01.005
- Walker SM. Long-term effects of neonatal pain. Semin Fetal Neonatal Med. 2019;24(4):101005. doi:10.1016/j.siny.2019.04.005
- Walker SM. Translational studies identify the long-term impact of prior neonatal pain experience. Pain. 2017;158(supplement 1):S29-S42. doi:10.1097/j.pain.0000000000000784
- Ijichi C, Collins LM, Elwood RW. The expression of pain is linked to the personality of horses. Appl Anim Behav Sci. 2014;152:38-43. doi:10.1016/j.appplanim.2013.12.007
- Litchfield CA, Quinton G, Tindle H, Chiera B, Kikillus KH, Roetman P. The ‘Feline Five’: an exploration of personality in companion cats (Felis catus). PLoS One. 2017;12(8):e0183455. doi:10.1371/journal.pone
- Ley JM, McGreevy P, Bennett PC. Inter-rater and test-retest reliability of the Monash Canine Personality Questionnaire Revised (MCPQ-R). 2009;119(1-2):85-90. doi:10.1016/j.appplanim.2009.02.027
- Beakley BD, Kaye AM, Kaye AD. Tramadol, pharmacology, side effects and serotonin syndrome: a review. pain doctor. 2015;18(4):395-400
- Osman M, Mustafa M. Tramadol-induced mood elevation in a patient with no psychiatric history. Psychiatry Case Representative. 2018;2018:9574395. doi:10.1155/2018/9574395