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Hypoxemia (SpO 2 , 95%, severe SpO 2 , 90%) is uncommon when a patient is intubated and breathing 100% oxygen. 44  Observation of mucous  nembrane color is not a sensitive indicator of hypoxemia as cyanosis will likely not occur until hypoxemia is profound. 45 Continuous assessment of oxygenation is best accomplished with pulse oximetry. With low SpO 2 , the anesthetist may be tempted to troubleshoot the pulse oximeter by repositioning the probe, moistening the mucous membranes, or trying a different monitor. These measures may work if the issue is indeed the probe, but prior to troubleshooting the probe, verify that the patient is properly intubated and connected to the oxygen source and that the supply of oxygen is adequate. Hypoventilation can cause hypoxemia, so adequate ventilation should be ensured, as previously described. Insertion of the ETT past the thoracic inlet can cause one-lung intubation with decreased pulmonary surface area for gas exchange. If one-lung intubation is likely, the ETT can be pulled out slightly, with the goal to move the tip of the ETT into the trachea. Hypoxemia can be secondary to atelectasis, in patients with abdominal distention or obesity positioned in dorsal recumbency, or to primary pulmonary (e.g., pneumonia) or pleural (e.g., pleural effusion) disease. If this is expected, manual or mechanical ventilation should be instituted and a positive-end expiratory pressure (PEEP) valve (2.5–5 cm H 2 O) can be added to the expiratory limb of the circuit to open collapsed airways. Decreased oxygen delivery to the tissues from perfusion issues (rather than respiratory issues) can also cause decreased SpO 2 readings. Treat indicators of poor perfusion such as slow capillary refill time, brady- or tachycardia , hypotension , and weak pulses. If no improvement occurs with these treatments, the patient should be positioned in sternal recumbency as soon as possible and recovered from anesthesia with continued oxygen support. 

Staff training is critical for anesthetic safety. Although this is actually the first step in anesthesia, this section has been placed separately in order to emphasize its importance. Providing quality patient care through scientific and knowledge based practice is the mission of veterinary medicine. A cornerstone of the implementation and success of this objective is the veterinary staff, from the veterinarians, technicians, and assistants to the receptionist/office personnel.

Multimodal Analgesic Drug Considerations for the Four Phases of Anesthesia Preanesthesia: NSAIDs, opioids, alpha-2 agonists, ±maropitant, +/- gabapentin Induction: Sometimes opioids, potentially ketamine (induction dose = loading dose for continuous rate infusion [CRI]) Maintenance: Local/regional blocks, CRI (opioid, lidocaine, ketamine, alpha-2 agonists, combinations), boluses of opioids or alpha-2 agonists Recovery: NSAIDs, boluses of opioids or alpha-2 agonists, continue CRI, ±maropitant, ±gabapentin or other adjunctive drugs

Follow the links below to fine tune your protocols on the day of anesthesia to improve the anesthesia experience from " doorknob to doorknob. "

2011 AAHA Anesthesia Guidelines for Dogs and Cats 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats 2018 AAFP Feline Anesthesia Guidelines 2013 AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats 2019 AAHA Dental Care Guidelines for Dogs and Cats 2015 AAHA Canine and Feline Behavior Management Guidelines

Once the patient has been discharged, the anesthesia continuum comes full circle. Pet owners can benefit from receiving anesthetic discharge instructions , in addition to a surgical discharge form. This guides postoperative care by the pet owner and alleviates their concerns, addressing possible complications that could be encountered and outlining when the veterinary team should be contacted.

Feline or canine testicular block INDICATIONS: Feline and canine castrations. INSTRUCTIONS: Choose the desired local anesthetic.* Calculate the low end of the dose of 1 mg/kg (cat)/ 2 mg/kg (dog) of bupivacaine, ropivacaine, or 4 mg/kg (cat), 6 mg/kg (dog) of lidocaine. Complete a rough surgical scrub of the testicles and the incision site (scrotal [cat] or prescrotal [dog]). Insert a 22-gauge needle into the center of the testicle with the tip of the needle pointed toward the spermatic cord. Aspirate and inject ½ of the calculated volume into each testicle or inject until the testicle suddenly feels turgid, whichever occurs first. † The drug migrates up the spermatic cord and provides pain relief from surgical crushing of the cord and associated vessels. To provide pain relief from the incision: Cats: Continue infiltrating as the needle exits the testicular body to block the skin and subcutaneous tissue. Dogs: Inject local anesthetic in skin and subcutaneous tissue at the incision site.

Anesthesia, which is an integral part of daily care in veterinary hospitals, cannot be defined merely by the time that the patient is unconscious, but rather by a continuum of care that begins at home with the owner and does not end until the patient returns home to the owner for follow-up care. Anesthesia is a multidimensional procedure involving not only the patient’s individual characteristics but also specific and critical equipment, appropriate drugs and drug dosages, diligent physiologic monitoring and support, thorough client communication, and highly trained staff.

For additional information on other dental nerve block techniques, see the 2019 AAHA Dental Care Guidelines for Dogs and Cats . Caudal mandibular (inferior alveolar) regional blocks  INDICATIONS: Dental and orofacial surgery on the mandible (i.e., dental extractions, mass removals, fracture repair, etc.) This desensitizes all tissues to midline on the ipsilateral side.  INSTRUCTIONS:  1.  Select and calculate the full dose of a local anesthetic, i.e., lidocaine (cats = 2–4 mg/kg, dogs = 4–6 mg/kg), bupivacaine (cats = 1 mg/kg, dogs = 2 mg/kg), or ropivacaine (cats = 1 mg/kg, dogs = 2 mg/kg).*  2.  Prior to the procedure or extraction is performed, choose intraoral vs. extraoral approach, based on clinical indication, and personal preference. 3. The mandibular foramen or nerve can often be palpated on the lingual side of the mandible, just rostral to the angle of the mandible and just caudal to the last molar in approximately the middle 1/3 rd of the mandible (as measured from dorsal to ventral). NOTE:  The foramen is often difficult to palpate in very small patients like cats and small dogs.

Intraperitoneal lavage technique for dogs and cats INDICATIONS: Feline and canine ovariohysterectomies. (This technique may be more effective than mesovarium block because analgesia will be provided at both the ovarian and uterine surgical sites.) INSTRUCTIONS: Select and calculate the full dose of a local anesthetic, i.e., lidocaine (cats = 2–4 mg/kg, dogs = 4–6 mg/kg), bupivacaine (cats = 1 mg/kg, dogs = 2 mg/kg), or ropivacaine (cats = 1 mg/kg, dogs = 2 mg/kg). If necessary, dilute the drug with saline–the total volume needs to be a minimum of 0.4–0.6 mL/kg to lavage or bathe the entire abdominal cavity. Immediately after making the incision or after completing the abdominal procedure but before closing the incision, “bathe” or “lavage” the peritoneal cavity with the local anesthetic by instilling it into the abdomen through the incision (literally just squirting it in the abdomen).* Close the incision as usual, leaving the local anesthetic in the abdomen.