Medication errors in veterinary anesthesia: a literature review.

OBJECTIVE: To provide an overview of medication errors (MEs) in veterinary medicine, with a focus on the perianesthetic period; to compare MEs in veterinary medicine with human anesthesia practice, and to describe factors contributing to the risk of MEs and strategies for error reduction. DATABASES USED: PubMed and CAB abstracts; search terms: [("patient safety" or "medication error∗") AND veterin∗]. CONCLUSIONS: Human anesthesia is recognized as having a relatively high risk of MEs. In veterinary medicine, MEs were among the most commonly reported medical error. Predisposing factors for MEs in human and veterinary anesthesia include general (e.g. distraction, fatigue, workload, supervision) and specific factors (e.g. requirement for dose calculations when dosing for body mass, using several medications within a short time period and preparing syringes ahead of time). Data on MEs are most commonly collected in self-reporting systems, which very likely underestimate the true incidence, a problem acknowledged in human medicine. Case reports have described a variety of MEs in the perianesthetic period, including prescription, preparation and administration errors. Dogs and cats were the most frequently reported species, with MEs in cats more commonly associated with harmful outcomes compared with dogs. In addition to education and raising awareness, other strategies described for reducing the risk of MEs include behavioral, communication, identification, organizational, engineering and cognitive aids.

Nerve stimulator-guided mandibular block in an alpaca undergoing dental extraction.

General anesthesia of a 2-year-old castrated male alpaca undergoing mandibular tooth extraction was successfully managed via a mandibular nerve block with bupivacaine, using nerve stimulation to confirm correct needle placement. The local block was effective, with no cardiovascular or respiratory responses to surgical stimulation observed. Key clinical message: Use of a locoregional technique in dentistry confers anesthetic stability, blocks nociceptive responses to surgery, and promotes a smooth recovery and comfortable postoperative period.

Bloc du nerf mandibulaire confirmé en utilisant la stimulation nerveuse chez un alpaga subissant une extraction dentaire. L'anesthésie générale d'un alpaga mâle castré de 2 ans subissant une extraction de dent mandibulaire a été gérée avec succès par un bloc du nerf mandibulaire avec de la bupivacaïne en utilisant la stimulation nerveuse. Aucune réaction contre la stimulation chirurgicale, y compris une augmentation de la fréquence cardiaque et de la pression artérielle, n'a été observée pendant l'opération.Message clinique clé :L'utilisation d'une technique locorégionale en dentisterie confère une stabilité anesthésique, bloque les réactions nociceptives à la chirurgie et favorise un rétablissement en douceur et une période postopératoire confortable.(Traduit par les auteurs).

A prospective survey of veterinary anesthesia equipment in Alberta, Canada, using a standardized checkout procedure.

Background: In both human and veterinary medicine, it is recommended that an anesthetic machine checkout procedure (preuse check) be performed daily, with some items tested before each case, to confirm safe function and the check results recorded. Objective: The objective of this prospective study was to evaluate anesthetic machines in private veterinary clinics in Alberta (Canada) using a standardized checkout procedure. Animals and procedures: One-hundred consecutive anesthetic machines were assessed. For each item of the checkout procedure, a "pass," "fail," or "not applicable" score was awarded. "Not applicable" indicated an item that could not be evaluated. Results: Few machines (10%) evaluated had a secondary oxygen supply, no machines had an oxygen supply pressure alarm, and leaks were identified in 31 and 17% of rebreathing and non-rebreathing systems, respectively. Thirty-nine percent of machines did not have a high-pressure circuit alarm, 86% of machines were attached to an active scavenging system, although it was improperly connected in 56% of cases, and only 2% of machines were accompanied by a checkout log. Conclusion and clinical relevance: There was widespread variation in anesthetic machine standards and function, highlighting the value of performing a regular machine checkout procedure in creating a foundation for safe anesthetic practice.

Une enquête prospective sur l'équipement d'anesthésie vétérinaire en Alberta, au Canada, à l'aide d'une procédure de vérification normalisée. Historique: En médecine humaine et vétérinaire, il est recommandé qu'une procédure de vérification de la machine d'anesthésie (vérification avant utilisation) soit effectuée quotidiennement, avec certains éléments testés avant chaque cas, pour confirmer le fonctionnement sécuritaire et les résultats de la vérification enregistrés. Objectif: L'objectif de cette étude prospective était d'évaluer les machines d'anesthésie dans les cliniques vétérinaires privées de l'Alberta (Canada) en utilisant une procédure de contrôle standardisée. Animaux et procédures: Cent machines d'anesthésie consécutives ont été évaluées. Pour chaque élément de la procédure de vérification, une note « réussite ¼, « échec ¼ ou « non applicable ¼ a été attribuée. « Sans objet ¼ indique un élément qui n'a pas pu être évalué. Résultats: Peu de machines (10 %) évaluées avaient une alimentation secondaire en oxygène, aucune machine n'avait d'alarme de pression d'alimentation en oxygène, et des fuites ont été identifiées dans 31 et 17 % des systèmes de ré-inhalation et sans ré-inhalation, respectivement. Trente-neuf pourcents des machines n'avaient pas d'alarme de circuit haute pression, 86 % des machines étaient rattachées à un système de balayage actif, bien qu'il soit mal raccordé dans 56 % des cas, et seulement 2 % des machines étaient accompagnées d'un journal de sortie. Conclusion et pertinence clinique: Il y avait une grande variation dans les normes et le fonctionnement des machines d'anesthésie, soulignant l'importance d'effectuer une procédure de vérification régulière de la machine pour créer une base pour une pratique anesthésique sûre.(Traduit par Dr Serge Messier).

Successful blood transfusion in a Holstein cow experiencing hemorrhagic shock under general anesthesia.

A 2-year-old Holstein cow weighing 530 kg at 2 mo gestation was scheduled for a paracostal laparotomy and abomasotomy following diagnosis of a reticular foreign body causing obstruction and abomasal impaction. Hemorrhagic shock occurred during surgery, with a rapid, approximately 60% decrease in arterial blood pressure, and reflex tachycardia with a 2-fold increase in heart rate. Following identification of hemorrhagic shock, arterial blood pressure was supported by reducing the inhalant anesthetic requirement, positive inotropic support (IV dobutamine infusion), and IV fluid therapy. Hypertonic saline was administered IV for initial resuscitation of arterial blood pressure, followed by a whole blood transfusion to replenish red blood cells, support oxygencarrying capacity, and provide intravascular volume to maintain cardiac output and tissue perfusion. A gradual increase in arterial blood pressure and a decrease in heart rate were observed in response to treatment. This case report demonstrates the physiologic compensatory response to hemorrhagic shock and the treatment to stabilize cardiovascular parameters in an anesthetized cow. Key clinical message: This case illustrates the physiological reponses to acute hemorrhage under general anesthesia and the effects of various treatment interventions.

Transfusion sanguine réussie chez une vache Holstein en état de choc hémorragique sous anesthésie générale. Une vache Holstein de 2 ans pesant 530 kg à 2 mois de gestation devait subir une laparotomie paracostale et une abomasotomie à la suite du diagnostic d'un corps étranger réticulaire provoquant une obstruction et une impaction abomasale. Un choc hémorragique est survenu pendant la chirurgie, avec une diminution rapide d'environ 60 % de la pression artérielle et une tachycardie réflexe avec une augmentation du double de la fréquence cardiaque. À la suite de l'identification d'un choc hémorragique, la pression artérielle a été soutenue en réduisant le besoin d'anesthésique inhalé, un soutien inotrope positif (perfusion de dobutamine IV) et une thérapie avec des fluides IV. Une solution saline hypertonique a été administrée par voie intraveineuse pour la restauration initiale de la pression artérielle, suivie d'une transfusion de sang total pour rétablir la quantité de globules rouges, soutenir la capacité de transport d'oxygène et fournir un volume intravasculaire pour maintenir le débit cardiaque et la perfusion tissulaire. Une augmentation progressive de la pression artérielle et une diminution de la fréquence cardiaque ont été observées en réponse au traitement. Ce rapport de cas démontre la réponse physiologique compensatoire au choc hémorragique et le traitement pour stabiliser les paramètres cardiovasculaires chez une vache anesthésiée.Message clinique clé :Ce cas illustre les réponses physiologiques à une hémorragie aiguë sous anesthésie générale et les effets de diverses interventions thérapeutiques.(Traduit par Dr Serge Messier).

A practical guide to implementing clinical audit.

Clinical audit is a quality improvement tool for evaluating and improving patient care and outcomes. This is achieved by systematically reviewing current practices against explicit criteria and measuring the impact of change(s) introduced to generate improvement. The clinical audit process can be described by "Plan," "Do," "Study," "Act" phases that comprise an audit cycle. The phases are moved through in turn to attempt quality improvement. Clinical audits are widely used in human medicine at both local (individual clinic or hospital) and national (to achieve nationwide improvements in care) levels. Substantial and sustained improvements in patient care have been attributed to the use of clinical audits. Clinical audits have been described in the veterinary literature since the 1990s, but their adoption does not appear widespread. This paper is intended as a practical, "how to" guide to applying clinical audit in veterinary practice.

Un guide pratique pour la mise en place d'un audit clinique. Un audit clinique est un outil d'amélioration de la qualité pour évaluer et améliorer les soins aux patients et les résultats. Ceci est obtenu en révisant systématiquement les pratiques actuelles envers des critères spécifiques et en mesurant l'impact des changements introduits pour générer une amélioration. Le processus d'audit clinique peut être décrit par les phases « Planifier ¼, « Exécuter ¼, « Examiner ¼ et « Agir ¼ qu'incluent un cycle d'audit. Le passage en séquence des phases vise une amélioration de la qualité. Les audits cliniques sont utilisés extensivement en médecine humaine à l'échelle locale (clinique individuelle ou hôpital) et nationale (pour atteindre des améliorations des soins à la grandeur du pays). Des améliorations substantielles et soutenues dans les soins aux patients ont été attribuées à l'utilisation des audits cliniques. Les audits cliniques ont été décrits dans la littérature vétérinaire depuis le début des années 1990, mais l'adhésion ne semble pas être répandue. Cet article se veut un guide pratique sur le « comment faire ¼ pour mettre en application un audit clinique en pratique vétérinaire.(Traduit par Dr Serge Messier).

Predicting the duration of surgery and procedures in a veterinary referral center.

OBJECTIVE: To evaluate the ability of veterinary personnel to predict the duration of surgery and associated procedures in a referral center. STUDY DESIGN: Prospective observational study. SAMPLE POPULATION: Experienced surgeons (ES; n = 2, board certified for 10+ years), inexperienced surgeons (IS; n = 2, residency completed, not board certified), anesthesia animal health technicians (AAHT; n = 3) and surgery animal health technicians (SAHT; n = 2). METHODS: Surgeons and technicians predicted surgery duration (skin incision to final stitch/staple) and total procedure duration (TPD; from induction of anesthesia to extubation). Predictions were compared to actual durations with Bland-Altman plots to assess agreement (accuracy) as indicated by bias (mean of observed differences) and limits of agreement (LOA; bias ±1.96 SD). RESULTS: All groups underestimated TPD. Experienced surgeons predicted their own TPD more accurately (bias -20.1 ± 30.4 minutes [±SD]) and more consistently (narrower LOA) than IS for their own TPD (-40.1 ± 41.0 minutes). Experienced surgeon TPD predictions by AAHT were more accurate than those by ES (bias -16.0 ± 28.9 minutes, LOA 5% narrower). Inexperienced surgeon TPD predictions by AAHT were less consistent (wider LOA) than those by IS. Own surgery duration predictions by surgeons were similar in magnitude (ES surgery duration [ESSD] 8.3 ± 18.3, IS surgery duration [ISSD] surgery duration -7.9 ± 27.2 minutes), with greater consistency by ES (LOA 30% narrower). Anesthesia animal health technician predictions were similar to those of surgeons (ESSD 3.0 ± 19.3, ISSD -9.0 ± 28.7 minutes). Surgery animal health technician predictions were similar to those of AAHT for ESSD but were less accurate for ISSD. CONCLUSION: Surgery duration was more accurately predicted than TPD, which was most accurately predicted by anesthesia technicians. CLINICAL SIGNIFICANCE: Surgical procedure planning should involve personnel best able to predict total procedure durations; in this case, anesthesia technicians. Accurate planning will promote efficient operating room and personnel use.

Impact of preanaesthetic echocardiography on the planned anaesthetic management of cats.

OBJECTIVE: To assess the impact of preanaesthetic echocardiography on the subsequent intended anaesthetic management plan in cats with incidental clinical findings that may indicate cardiac disease. STUDY DESIGN: Clinical study involving cats undergoing echocardiography and subsequent anaesthesia. ANIMALS: A total of 40 client-owned cats. METHODS: Echocardiography was performed in conscious cats and the information was used to plan anaesthesia or sedation. An information sheet including relevant history, temperament, body condition score, clinical examination findings, current medication and results of any relevant tests such as haematology, biochemistry or Doppler blood pressure measurement was sent to three specialist anaesthetists and virtual case management plans were designed for each cat in two steps: step 1) anaesthetists were unaware of echocardiography results; and step 2) anaesthetists were aware of echocardiography results. In the second step the anaesthetists documented any changes to their original management plan, as either 'step-up' or 'step-down'. RESULTS: Of the 40 cats, 26 had murmurs, four had a gallop rhythm, four had both findings and six had other findings. Pathology of potential haemodynamic significance was found on echocardiography in 23 cats, 17 of which anaesthetists had correctly identified as having disease before echocardiography. A proportion of cats with murmurs were subsequently deemed to have no significant pathology after echocardiography. Echocardiography findings in these cases were: dynamic left ventricular outflow tract obstruction (DLVOTO) without hypertrophy; DLVOTO without hypertrophy + dynamic right ventricular outflow tract obstruction (DRVOTO); DRVOTO; valvular dysplasia; normal. In a median of 26/40 (range 16-38) of cases, the anaesthetic plan was changed after provision of further information; in 15/40 (8-20) cases, this was a 'step-up' in care and in eight/40 (6-23) it was a 'step-down' in care. In cases with atrial enlargement (left atrium to aortic ratio of >1.6) and deemed at risk of cardiac failure, alpha-2 agonist use changed considerably with availability of echocardiography findings. CONCLUSION: and clinical relevance Where there are abnormal cardiac findings on clinical examination in cats, echocardiography is required to accurately assess anaesthetic risk . The availability of echocardiographic information positively influences anaesthetic management.

Management of a severe peripartum hemorrhage following cesarean section in a dog.

This report describes the intensive blood pressure management and transfusion of a peripartum intrauterine hemorrhage following a cesarean section in a dog. The impact of pregnancy-associated physiologic changes and anesthesia on hemodynamic parameters along with potential alternate management techniques are discussed.

Gestion d'une hémorragie péri-partum sévère à la suite d'une césarienne chez une chienne. Ce rapport décrit la gestion intensive de la pression sanguine et des transfusions lors d'une hémorragie intra-utérine péri-partum à la suite d'une césarienne chez une chienne. L'impact des changements physiologiques associés à la gestation et à l'anesthésie sur les paramètres hémodynamiques ainsi que des techniques de gestion alternatives sont discutés.(Traduit par Dr Serge Messier).

Prevalence and management of pain in dogs in the emergency service of a veterinary teaching hospital.

A prospective, observational, cross-sectional study documenting the prevalence of pain in dogs presented to the emergency service of a veterinary teaching hospital and their handling (times to triage, examination, treatment) was conducted. Pain was assessed and compared using a validated and an unvalidated pain assessment scale. Sedation was monitored using a validated scale. A first evaluation was completed in 109 dogs. A second evaluation was completed for 95 dogs: 36 (38%) were identified as painful and 53% (19/36) were provided analgesia in the clinic. The remainder either did not receive analgesia (6/36, 17%) or were prescribed an analgesic for administration at home (11/36, 31%). Of dogs receiving analgesia in the clinic, most showed a decrease in pain score (15/19, 79%). Pain assessment scales were positively correlated (r = 0.69, P < 0.0001) but the unvalidated scale was insensitive in discriminating changes. Between painful and non-painful dogs, progression did not differ: admission to treatment [P = 0.96, 95% confidence interval (CI): -23 to 22 minutes] and examination to treatment (P = 0.73, 95% CI: 14 to 20 minutes). Suboptimal analgesic use suggests focused training in pain assessment and analgesic use guided by a validated pain assessment scale, is warranted.

Prévalence et gestion de la douleur chez des chiens présentés au service d'urgence d'un hôpital d'enseignement vétérinaire. Une étude prospective, observationnelle et transversale a été réalisée pour documenter la prévalence de la douleur chez les chiens présentés au service d'urgence d'un hôpital universitaire vétérinaire ainsi que leur gestion (délai pour le triage, examen et traitement). Une échelle validée d'évaluation de la douleur a été utilisée pour évaluer la douleur à l'admission et suivant le traitement en clinique. A titre de comparaison, une échelle non validée d'évaluation de la douleur a également été utilisé et le degré de sédation a été documenté à l'aide d'une échelle de sédation validée. Une première évaluation a été complétée chez 109 chiens. Sur les 95 chiens pour lesquels une deuxième évaluation a été complétée, 36 (38 %) ont été identifiés comme étant en douleur et 53 % (19/36) ont reçu de l'analgésie en clinique. Les chiens restants n'ont soit pas reçu d'analgésie (6/36, 17 %) ou ont reçu une prescription pour un traitement analgésique à la maison (11/36, 31 %). Pour les chiens ayant reçu un traitement analgésique en clinique, la grande majorité ont démontré une diminution de leur score de douleur (15/19, 79 %). Une corrélation positive entre les deux échelles d'évaluation de la douleur était présente (r = 0,69, P < 0,0001), mais l'échelle non validée n'était pas sensible pour distinguer les changements de score de douleur. Il n'y avait pas de différence significative entre les chiens en douleur et non en douleur concernant le délai entre l'admission et le traitement (P = 0,96, 95 % CI : ­23 à 22 minutes) ou entre l'examen et le traitement (P = 0,73, 95 % CI : 14 à 20 minutes). L'administration d'analgésie était suboptimal dans la population étudiée, suggérant qu'un entraînement ciblé pour reconnaître et traiter la douleur à l'aide d'une échelle validée est recommandé.(Traduit par Dr Frédérik Rousseau-Blass).

Teleconsulting in the time of a global pandemic: Application to anesthesia and technological considerations.

As a result of the various restrictions associated with the current COVID-19 pandemic, the practice of veterinary telehealth is likely to grow substantially. One area in which high quality care can be maintained while respecting physical distancing is teleconsulting, which describes the relationship between an attending and off-site consulting veterinarian. This guide uses a dentistry case to illustrate the provision of real-time anesthesia consulting, with a focus on the technological considerations central to facilitating live, 2-way video-communication. Case selection, teamwork, and patient safety are also discussed.

Téléconsultation en temps de pandémie globale : application à l'anesthésie et considérations technologiques. Comme résultats des différentes restrictions associées à la présente pandémie de COVID-19, la pratique de télésanté vétérinaire est appelée à croître considérablement. Un domaine dans lequel des soins de haute qualité peuvent être maintenus tout en respectant la distanciation physique est la téléconsultation, qui décrit la relation entre un vétérinaire traitant et un vétérinaire consultant hors-site. Ce guide utilise un cas de dentisterie pour illustrer les exigences de consultation en temps réel pour l'anesthésie, avec une emphase sur les considérations technologiques essentielles pour faciliter une communication vidéo bidirectionnelle en direct. La sélection de cas, le travail d'équipe et la sécurité du patient sont également discutés.(Traduit par Dr Serge Messier).

Misconceptions surrounding the relationship between journal impact factor and citation distribution in veterinary medicine.

OBJECTIVE: To define the relationship between journal impact factor (JIF) and citation distribution in veterinary journals. Citation distribution is a summary of the number of citations of individual papers published in a defined period, and JIF is said to represent the mean number of citations received by a paper published in a given journal. JIF is criticized for promoting unimportant differences between journals, exaggerating small differences in journal citation distributions by misrepresenting a skewed citation distribution. The hypothesis was that veterinary journals have a skewed citation distribution and that median citation rates between journals would be smaller than that indicated by JIF. STUDY DESIGN: Bibliometric study. ANIMALS: None. METHODS: A published method was used to generate journal citation reports from a commercial database, with search limits set for document ('article' and 'review') and the 2 year citation window of interest. Citation distributions [median (range)] and cumulative citations were calculated for Veterinary Anaesthesia and Analgesia (Vet Anaesth Analg, 2007-2017), 11 preselected subject- and species-specific and general veterinary journals (2016) and veterinary journals from the top (n = 10) and bottom (n = 10) of the Veterinary Sciences category ranking (2016) with a 10 year publication record. RESULTS: Citation distributions were right-skewed for all journals, with 15-20% of papers contributing approximately 50% of citations. For Vet Anaesth Analg, the median citation distribution [1 (0-2)] did not change despite JIF ranging from 1.044 to 2.064 between 2007 and 2017. Calculated median citation rates revealed minimal differences between journals, with only three groups identified: bottom (median citation 0), preselected (median citation 1) and top (median citation 2) journals. These groups represent over 100 places in the JIF (0.316-3.148) ranking. CONCLUSIONS: Ranking veterinary journals according to JIF is misleading, exaggerating differences while concealing minimally different citation distributions.

Investigating novel anatomical predictors for endotracheal tube selection in dogs.

The selection of an appropriate endotracheal tube (ET) for orotracheal intubation in dogs is based largely on experience, with no well-established guidelines available. This study examined relationships between several novel and published methods for selecting endotracheal tubes in a heterogenous population of 79 adult dogs. The following measurements were included: left and right nare width, nasal septum width, sum of left and right nares width plus the nasal septum width, total nose width and height, tracheal width, metacarpal and digital footpad width and height, and body mass. Using the Bland and Altman ratio method, the calculation of Cube Root Mass provided the greatest accuracy and precision, predicting actual ET size use within 3 to 4 tube sizes. A simpler to calculate, but less precise method was Width of Nose/3. The majority of published methods for estimating ET size performed poorly, including nasal septum and tracheal width.

Résumé ­Étude de nouveaux prédicateurs anatomiques pour la sélection de tube endotrachéal chez les chiens. La sélection d'un tube endotrachéal (TE) approprié pour intubation orotrachéale chez les chiens est basée largement sur l'expérience, sans qu'il n'y ait de directives bien établies de disponibles. La présente étude a examiné les relations entre plusieurs méthodes nouvelles et publiées pour sélectionner les tubes endotrachéaux dans une population hétérogène de 79 chiens adultes. Les mesures suivantes étaient incluses : largeur des narines droite et gauche, largeur du septum nasal, somme de la largeur des narines droite et gauche plus la largeur du septum nasal, largeur totale du nez et hauteur, largeur de la trachée, largeur et hauteur des coussinets plantaires métacarpiens et digitaux, et masse corporelle. Utilisant la méthode de ratio de Bland et Altman, le calcul de la racine cubique de la masse a fourni la meilleure exactitude et précision, prédisant la dimension actuelle du TE utilisé à l'intérieur de trois à quatre dimensions de tubes. Une méthode de calcul plus simple, mais moins précise, était Largeur du Nez/3. La majorité des méthodes publiées pour estimer la dimension du TE performait pauvrement, incluant celles utilisant la largeur du septum nasal et la largeur de la trachée.(Traduit par Dr Serge Messier).

ANESTHESIA OF AQUARIUM-HOUSED WALRUS ( ODOBENUS ROSMARUS): A CASE SERIES.

Walruses are a challenging species to anesthetize as a result of their large mass, limited access for drug delivery, unique physiology, and small number of reports describing anesthetic procedures. Three aquarium-housed walruses ( Odobenus rosmarus) ranging in age from 3 to 11 yr old (344-1,000 kg) were anesthetized for dental or ophthalmic surgical procedures, with one animal anesthetized twice and one anesthetized three times. Preanesthetic medication was with intramuscular midazolam (0.1-0.2 mg/kg) and meperidine (2-3 mg/kg). A catheter was placed in the extradural intravertebral vein, and anesthesia was induced with propofol to effect. Orotracheal intubation was performed and anesthesia maintained with isoflurane in oxygen using a circle breathing system connected to a ventilator. Intermittent positive pressure ventilation was used in all procedures. For the ophthalmic surgery, the neuromuscular blocking agent, cisatracurium, was given intravenously to provide a central eye and optimal surgical conditions. The neuromuscular block was antagonized with edrophonium. Total anesthesia times ranged from 1.5 to 6 hr. Midazolam and meperidine were antagonized with flumazenil and naltrexone, respectively, in five of six cases. Nonsteroidal anti-inflammatory agents were provided for analgesia. Recoveries were calm and uneventful. The described anesthetic protocols and case management were successful under the conditions encountered.

Sedation levels in dogs: a validation study.

BACKGROUND: The aim of this study was to assess validation evidence for a sedation scale for dogs. We hypothesized that the chosen sedation scale would be unreliable when used by different raters and show poor discrimination between sedation protocols. A sedation scale (range 0-21) was used to score 62 dogs scheduled to receive sedation at two veterinary clinics in a prospective trial. Scores recorded by a single observer were used to assess internal consistency and construct validity of the scores. To assess inter-rater reliability, video-recordings of sedation assessment were randomized and blinded for viewing by 5 raters untrained in the scale. Videos were also edited to allow assessment of inter-rater reliability of an abbreviated scale (range 0-12) by 5 different raters. RESULTS: Both sedation scales exhibited excellent internal consistency and very good inter-rater reliability (full scale, intraclass correlation coefficient [ICCsingle] = 0.95; abbreviated scale, ICCsingle = 0.94). The full scale discriminated between the most common protocols: dexmedetomidine-hydromorphone (median [range] of sedation score, 11 [1-18], n = 20) and acepromazine-hydromorphone (5 [0-15], n = 36, p = 0.02). CONCLUSIONS: The hypothesis was rejected. Full and abbreviated scales showed excellent internal consistency and very good reliability between multiple untrained raters. The full scale differentiated between levels of sedation.

Refinement of intraperitoneal injection of sodium pentobarbital for euthanasia in laboratory rats (Rattus norvegicus).

BACKGROUND: The Canadian Council on Animal Care and American Veterinary Medical Association classify intraperitoneal (IP) pentobarbital as an acceptable euthanasia method in rats. However, national guidelines do not exist for a recommended dose or volume and IP euthanasia has been described as unreliable, with misinjections leading to variable success in ensuring a timely death. The aims of this study were to assess and improve efficacy and consistency of IP euthanasia. In a randomized, blinded study, 51 adult female Sprague-Dawley rats (170-495 g) received one of four treatments: low-dose low-volume (LL) IP pentobarbital (n = 13, 200 mg/kg pentobarbital), low-dose high-volume (LH) IP pentobarbital (n = 14, 200 mg/kg diluted 1:3 with phosphate buffered saline), high-dose high-volume (HH, n = 14, 800 mg/kg pentobarbital), or saline. Times to loss of righting reflex (LORR) and cessation of heartbeat (CHB) were recorded. To identify misinjections, necropsy examinations were performed on all rats. Video recordings of LL and HH groups were analyzed for pain-associated behaviors. Between-group comparisons were performed with 1-way ANOVA and Games-Howell post hoc tests. Variability in CHB was assessed by calculating the coefficient of variation (CV). RESULTS: The fastest euthanasia method (CHB) was HH (283.7 ± 38.0 s), compared with LL (485.8 ± 140.7 s, p = 0.002) and LH (347.7 ± 72.0 s, p = 0.039). Values for CV were: HH, 13.4%; LH, 20.7%; LL, 29.0%. LORR time was longest in LL (139.5 ± 29.6 s), compared with HH (111.6 ± 19.7 s, p = 0.046) and LH (104.2 ± 19.3 s, p = 0.01). Misinjections occurred in 17.0% (7/41) of euthanasia attempts. Pain-associated behavior incidence ranged from 36% (4/11, LL) to 46% (5/11, HH). CONCLUSIONS: These data illustrate refinement of the IP pentobarbital euthanasia technique. Both dose and volume contribute to speed of death, with a dose of 800 mg/kg (HH) being the most effective method. An increase in volume alone does not significantly reduce variability. The proportion of misinjections was similar to that of previous studies.

The influence of demeanor on scores from two validated feline pain assessment scales during the perioperative period.

OBJECTIVE: To evaluate the effects of demeanor on validated pain assessment scales. STUDY DESIGN: Prospective, blind, clinical trial. ANIMAL POPULATION: Thirty three adult domestic cats scheduled for orchiectomy. METHODS: Cats were assessed for pain pre (baseline) and 1, 2, 4 hours postoperatively using two validated pain scales [Composite Measures Pain Scale-Feline (rCMPS-F) and UNESP-Botucatu multidimensional composite pain scale (psychomotor and pain expression subscales; U-B MCPS-psych and -painex)], and a demeanor scale. Return of sternal recumbency and postoperative feeding were recorded. Anesthesia consisted of a single intramuscular injection of dexmedetomidine-ketamine-hydromorphone with intratesticular lidocaine and atipamezole and meloxicam postoperatively. Following data collection, cats were assigned to two groups based on baseline demeanor scores (LO ≤ 5/21, 18 cats; HI ≥ 6/21, 15 cats) and data from each group compared. RESULTS: Baseline demeanor predicted pain scores with the U-B MCPS-psych scale: baseline [LO 0 (0-0), HI 2 (0-6), p = 0.0005], 1 hour [LO 1 (0-5), HI 3 (1-5), p = 0.02], and 4 hours [LO 0 (0-2), HI 1 (0-6), p = 0.01]. A similar pattern was observed with the rCMPS-F. This resulted in more crossings of the analgesic intervention threshold in the HI group: U-B UNESP-psych (9 versus 1, p = 0.005) and rCMPS-F (23 versus 3, p < 0.0001). In contrast, U-B MCPS-painex scores did not differ between LO/HI groups: baseline (p > 0.99), 1 hour (p = 0.34), 2 hours (p > 0.99) and 4 hours (p = 0.31). LO cats ate sooner (61% versus 33% by 1 hour, p < 0.0001) despite similar times to sternal recumbency (p = 0.48). CONCLUSIONS AND CLINICAL RELEVANCE: Demeanor affected pain assessment with U-B UNESP-psych and rCMPS-F scales, but not U-B UNESP-painex scale. Demeanor had a significant effect on postoperative feeding. These data highlight the potential for demeanor to confound pain assessment.

A systematic review of clinical audit in companion animal veterinary medicine.

BACKGROUND: Clinical audit is a quality improvement process with the goal of continuously improving quality of patient care as assessed by explicit criteria. In human medicine clinical audit has become an integral and required component of the standard of care. In contrast, in veterinary medicine there appear to have been a limited number of clinical audits published, indicating that while clinical audit is recognised, its adoption in veterinary medicine is still in its infancy. A systematic review was designed to report and evaluate the veterinary literature on clinical audit in companion animal species (dog, cat, horse). A systematic search of English and French articles using Proquest Dissertations and Theses database (February 6, 2014), CAB Abstracts (March 21, 2014 and April 4, 2014), Scopus (March 21, 2014), Web of Science Citation index (March 21, 2014) and OVID Medline (March 21, 2014) was performed. Included articles were those either discussing clinical audit (such as review articles and editorials) or reporting parts of, or complete, audit cycles. RESULTS: The majority of articles describing clinical audit were reviews. From 89 articles identified, twenty-one articles were included and available for review. Twelve articles were reviews of clinical audit in veterinary medicine, five articles included at least one veterinary clinical audit, one thesis was identified, one report was of a veterinary clinical audit website and two articles reported incomplete clinical audits. There was no indication of an increase in the number of published clinical audits since the first report in 1998. However, there was evidence of article misclassification, with studies fulfilling the criteria of clinical audit not appropriately recognised. Quality of study design and reporting of findings varied considerably, with information missing on key components, including duration of study, changes in practice implemented between audits, development of explicit criteria and appropriate statistical analyses. CONCLUSIONS: Available evidence suggests the application and reporting of clinical audit in veterinary medicine is sporadic despite the potential to improve patient care, though the true incidence of clinical audit reporting is likely to be underestimated due to incorrect indexing. Reporting standards of clinical audits are highly variable, limiting evaluation, application and repeatability of published work.

A comparison of alfaxalone and propofol on intraocular pressure in healthy dogs.

OBJECTIVE: To compare the effects of alfaxalone and propofol on intraocular (IOP) pressure in the canine eye. ANIMALS STUDIED: Twenty-three healthy adult dogs. PROCEDURES: Dogs were randomized to receive intravenous propofol (n = 11) or alfaxalone (n = 12) until loss of jaw tone, 20 min after intravenous premedication (acepromazine 0.02-0.03 mg/kg and hydromorphone 0.05-0.1 mg/kg). IOP was measured at baseline (BL), 20 min postpremedication (postpremed), loss of jaw tone (postinduct), and immediately following orotracheal intubation (postintub). Between- and within-treatment effects were analyzed with two-way and one-way repeated measures ANOVA with Bonferroni's post hoc test, respectively. P < 0.05 was considered significant. RESULTS: No significant IOP differences were detected between alfaxalone or propofol groups at any time point (P > 0.05). Propofol: IOP did not change between BL (15.5 ± 2.7 mmHg) and postpremed (16.2 ± 3.6 mmHg, P > 0.05), or postinduct (19.1 ± 5.2 mmHg) and postintub (21.0 ± 4.6 mmHg, P > 0.05), but differed significantly between BL and postinduct (P < 0.0001), and postintub (P < 0.0001). Alfaxalone: IOP did not change between BL (15.7 ± 2.8 mmHg) and postpremed (15.3 ± 4.1 mmHg, P > 0.05), or postinduct (19.2 ± 4.9 mmHg) and postintub (20.5 ± 4.5 mmHg, P > 0.05), but differed significantly between BL and postinduct (P < 0.01), and postintub (P < 0.0001). CONCLUSIONS: These data show a potentially clinically significant increase in IOP following induction with propofol or alfaxalone, but no difference between agents.

Modeling daily veterinary anesthetist patient care hours and probabilities of exceeding critical thresholds.

OBJECTIVE: Use a referral dental clinic model to study how to calculate accurate 95% upper confidence limits for probabilities of workloads (total case duration, including turnover time) exceeding allocated times. ANIMALS: Dogs and cats undergoing dental treatments. METHODS: Managerial data (procedure date and duration) collected over 44 consecutive operative workdays were used to calculate the daily anesthetist workload. Workloads were compared with a normal distribution using the Shapiro-Wilk test, serial correlation was examined by runs test, and comparisons among weekdays were made using the Kruskal-Wallis test. The 95% confidence limits for normally distributed workloads exceeding allocated times were estimated with a generalized pivotal quantity. The impact of a number of procedures was assessed with scatterplots, Pearson linear correlation coefficients, and multivariable linear regression. RESULTS: Mean anesthetist's workload was normally distributed (Shapiro-Wilk P = .25), without serial correlation (P = .45), and without significant differences among weekdays (P = .52). Daily workload, mean 9.39 hours and SD 3.06 hours, had 95% upper confidence limit of 4.47% for the probability that exceeding 16 hours (ie, 8 hours per each of 2 tables). There was a strong positive correlation between daily workload and the end of the workday (r = .85), significantly larger than the correlation between the end of the workday and the number of procedures (r = .64, P < .0001). CLINICAL RELEVANCE: There are multiple managerial applications in veterinary anesthesia wherein the problem is to estimate risks of exceeding thresholds of workload, including the costs of hiring a locum, scheduling unplanned add-on cases, planning for late discharge of surgical patients to owners, and coordinating anesthetist breaks.

Incidence and type of voluntary reported perianesthetic medication errors in community veterinary clinics in Calgary, Canada.

OBJECTIVE: To collect medication error (ME) data during the perianesthetic period from small animal clinics. SAMPLE: 6 small animal general practice veterinary clinics. METHODS: Small animal general practice veterinary clinics were recruited in this prospective observational study, with staff given a presentation on medical errors and instructed on how to submit medication error reports to an online reporting system. Errors were classified according to type and timing. RESULTS: A total of 2,728 general anesthesia or sedation procedures were performed, with 49 ME reports submitted. One duplicated report of the same error was excluded, resulting in a ME rate of 1.8%. Most reports (69% [33/48]) were near misses. The remaining 31% were MEs that reached the patient but did not cause harm. Wrong dose errors were the most common type (63% [30/48]), of which 80% (24/30) were calculation errors. Premedication/sedation and maintenance were the most reported stages, at 47% (20/43) and 23% (10/43), respectively. None of the MEs reported resulted in an adverse event, with an approximately 2:1 ratio of near-miss to no-harm MEs. The observed patterns of MEs reported, including type and timing, represent a target for further education. CLINICAL RELEVANCE: These results quantify the ME rate in general practice veterinary clinics, providing an initial benchmark for MEs during the perianesthetic period.