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Here is your chance to enter—or nominate a colleague for—the 2021 dvm360®/VHMA Practice Manager of the Year contest, sponsored by Nationwide.

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What’s a good sign of a hospital design done right? For Scott Morey, DVM, MS, co-owner of Fenton River Veterinary Hospital in Stafford Springs, Connecticut, it’s driving around the entire veterinary practice before he leaves because that last, longing look isn’t enough to capture the full imagery.

“Every time I leave here, I pull out and look back at the building for a minute. I get that feeling of satisfaction, of having an idea and seeing it through to the finished product,” says Morey.

Set on 2.3 acres, the hospital features fully structural hammer-beam style timber framing, a wide front porch, and gable ends. Clapboard vertical barn board siding, carriage-house style garage doors, and an exterior lit with gooseneck light fixtures and lighting behind the timbers provide a warm ambiance.

Morey co-owns the practice with his wife Heidi Morey, MS, DVM, who spends most of her time working out of their original practice one town over.

The unique design doesn’t just catch Morey’s eye; it also impressed the judges of the 2021 

 Hospital Design Competition. Fenton River Veterinary Hospital earned top honors in the under-8,000-square-feet division of the competition.

Owners: Scott Morey, DVM, and Heidi Morey, DVM

Number of doctors: 4 full-time, 1 part-time

Structure type: New construction, freestanding

Morey and his wife initially launched their business as a mobile veterinary practice back in 2014. Business boomed and the couple found themselves quickly moving into a leasehold space the very next year. They’ve added on to the practice twice since then, due to the increasing demand for a large animal hospital. After looking into buildings to renovate or lease to no avail, the couple decided to build from scratch.

“The primary design objective was to create an upscale New England barn look with a warm ambiance while maintaining the feel of a modern hospital,” says Morey. “As a mixed animal practice, we needed both the inside and outside of the building to reflect the type of animals we’re caring for. We are cattle farmers and veterinarians at heart, which is reflected in the overall look of the hospital.”

To get started, Morey chose the shape and size of the building he wanted. He then worked with his architect to fit all the elements into the building in an efficient way. Morey wanted a wide reception area with plenty of space for clients to spread out upon entry—a design feature that serves Fenton River Veterinary Hospital well during these socially distanced pandemic days.

A custom-made inlayed logo is incorporated into the reception area floor. The entire floor is scratch-resistant, waterproof, and texture luxury vinyl planking.

Fully structural hammer-beam style timber framing lends authenticity to the barn style he chose. Friends from his youth who own a hammer-beam construction company helped make this design element come to fruition. As Morey puts it, “the beams you see aren’t just for decoration. Pull one down, and the building comes with it. They are truly structural.”

The wide front porch and gable offer a warm welcome to clients. Carriage house-style garage doors and gooseneck barn light accents complete the look. The large animal portion of the practice rests along the back of the hospital, offering easy access for these patients. In front of the large animal area sits surgery and treatment, with the exam rooms closer to the front of the hospital. This puts treatment and surgery between the 2 parts of the practice for convenience and as a buffer.

A unique surgery pass-through system came from an idea Morey had while working in his mobile truck. A tool drawer in the truck that can be opened from either side led to the idea for a passthrough drawer that can be accessed in surgery and in the treatment area, keeping tools organized and accessible.

Just because Morey wanted the hospital to look like a barn, doesn’t mean he wanted it to smell like one. With a good portion of his patients being large animals, smells and noises had a high possibility of making their way into the small animal and public areas of the hospital. For this reason, Morey made sure to pay special attention to odor and noise control features.

“We wanted to create an indoor, climate-controlled large animal facility (important for New England) for examination, hospitalization, and surgery,” he says. “We also made sure that surgery was close to the large animals’ area so that pigs, sheep, and goats can be easily moved in and out of the surgical suite. Even farm animals deserve to be operated on in a clean surgery room, thus improving the quality of medicine and surgery we provide.”

An indoor, climate-controlled area allows for examination, hospitalization, and surgery of large animals, something that was desperately needed in the new hospital. “Even farm animals deserve to be operated on in a clean surgery room,” Morey says.

The couple included an engineered heat, ventilation, and air conditioning system with 6 zones designed specifically for odor and animal health. There are high-efficiency air exchangers in each zone and the large animal room has an oversized air exchanger and exhaust fan system. The large animal zone is also heated with a propane radiant tube heater.

“High-efficiency air exchangers for each zone with varying fresh air intakes depending on the type of area serviced allows us to balance efficiency with odor and animal health,” he says. “All animal areas are on their own zones with air returns placed away from odor-producing areas. This allows client areas to not share any air with odor-producing areas. We also have a total of 20 exhaust fans throughout the building.”

With odors well under control, they went a step further to ensure noises also stay contained. Soundproof insulation in all interior walls, including the walls above the drop ceilings, helps minimize sound. Solid-core doors throughout the building help keep large animal sounds from carrying throughout the building, and dog barks from hitting clients’ ears.

As a voice of experience, Morey recommends that those who are looking to build to do their homework first.

Take a look at plans and photos of other hospitals and write down all the ideas that you like. Morey has read all of the 

 Hospital Design articles for the last 15 years; purchased floor plan books from 

 and has visited numerous hospitals to see what works.

“And don’t forget to ask other veterinarians what they hate as well!” he says. “I looked at a lot of online floor plans of veterinary practices and photos of lobbies, exam rooms, and treatment areas. I also talked to as many other veterinarians that I could about their facilities and what they wished they had or could change. Knowing what doesn’t work is just as helpful as knowing what does.”

Custom-built cabinetry through the hospital, especially in treatment, keeps the area tidy and all tools conveniently located. “We utilized every wall space we could for cabinets that store all of our equipment, keeping our countertops clean and ready to work all the time,” says Morey. “There are unique gull-wing door cabinets above the cage bank that store our patient warm-air heaters so they don't have to sit on the floor.”

With that said, he cautions that what you choose to build is a personal decision that must be made for your practice alone. “I truly think that veterinary hospitals should be designed to best fit the flow of the veterinarians working there. So just because another hospital has a certain plan or idea doesn't mean it will benefit your personal workflow.“

In the end, Morey says he got the barn-look hospital that suits his practice best with a convenient floor plan, great odor, and noise control, features that make practice easy, and loads of style. Best of all, it’s a place that showcases the kind of medicine these doctors practice.

“That warm-home feeling that our building gives off is the same feeling our doctors and technicians have for our patients and clients,” says Morey. “The people who work here feel good about the place; the building is a tool that makes delivering our care easier and spreads the message to the public about how we care for our clients and patients.”

Sarah A. Moser is a freelance writer in Lenexa, Kan.

Articles

Warmth and charm welcome clients like family into this quick-growing Connecticut mixed animal practice.

Upscale barn aesthetic serves up modern medicine

Happy Friday! We know you're busy. That's why remain dedicated to providing you with the latest and greatest veterinary news right at your fingertips.

To jumpstart the weekend, here's a look at this week's top headlines:

A recent Association of American Veterinary Medical Colleges (AAVMC) 

 revealed unintended bias in veterinary school admissions processes.

announced the second year of its Steve Marton Veterinary Student Scholarship

, which awards one first- or second-year veterinary student up to $50,000 towards their annual tuition fees.

, Dr Adam Christman is joined by Dr Chris Pachel who provides useful tips about discussing behavior recommendations and modifications with overwhelmed clients.

The Vet Recruiter founder and her team recently 

, a recruitment firm designed to help fill C-suite and board of directors positions within the animal health and veterinary technology industries.

, which helps expand free veterinary care to pets with homeless owners and street pets.

Stay tuned on social media and dvm360.com for more veterinary news.

News-wrap up: This week’s veterinary headlines, plus shedding light on bias in admissions processes

Due to the constant uncertainty surrounding the coronavirus disease 2019 (COVID-19) pandemic, many people, including your clients, are emotionally overwhelmed. When an anxious pet owner steps into your clinic, offering behavior recommendations can feel like a daunting task, especially when you’re strapped for time.

On this episode of The Vet Blast Podcast veterinary behavioralist Chris Pachel, DVM, DACVB, CABC, says the best way to approach these clients is by asking them what advice would be most meaningful.

“To me, this is such an important detail for us to nail down because I can give 300 resources, but the average client doesn’t have the time, bandwidth, or the comprehension to make sense of all that information without some guidance,” he tells Adam Christman, DVM, MBA.

Find out if clients are looking for a referral to a trainer? Or maybe, they just want you to listen to their concerns and devote extra time to correcting a certain behavior. Overall, finding out what matters most to the client in that given moment in time will help ease anxiety and save time for everyone.

For clients who struggle with communicating or aren’t sure what they’re looking for, Pachel recommends showing them a video, handing them a handout, and connecting them with a technician and/or trainer who can best address their current situation, instead of going through 20 to 30 minutes of dialogue and recommendations.

“Chances are neither you nor the client has the time, so we triage it just like we do everything else,” he says.

Listen below for more on triaging behavior recommendations and pet behavior modification advice.

Podcasts

On this episode of The Vet Blast Podcast, Dr Christman is joined by Dr Chris Pachel as they discuss some helpful nuggets for communicating with on-edge clients about behavior recommendations.

Episode 47: Tips for triaging behavior recommendations for overwhelmed clients

Veterinary education involves more than just acquiring special knowledge and skills but must also convey a broad array of values, attitudes, and behaviors that cannot be taught using the didactic curriculum. Mentoring, a crucial part of veterinary education, is more vital than ever as the profession continues to experience major socioeconomic challenges.

The coronavirus disease 2019 (COVID-19) pandemic has significantly impacted financial resources for higher education. Just like other professional schools, veterinary colleges were forced to shift most of their curriculum from in-person to online. Given the ongoing budget cuts, it’s no surprise that virtual teaching continues to monopolize veterinary education today. However, the increasingly remote connection between students and teachers is a major concern—not only in the clinical disciplines— but in biomedical sciences as well. The veterinary colleges must do more than transmit information and ensure that students participate actively in their professional education and training.

In my limited discussions, many veterinary students say they have supportive online instructors but admit that the lack of in-person interaction with teachers and fellow classmates is a significant deficiency in their education.

Students are unique individuals conditioned by a variety of past cultural experiences. Optimal opportunities for personal development require a flexible support system that offers effective in-person relationships with mentors who can guide students through the educational process. All students must cope with pressures, personal life disruptions, and in some cases, excessive educational debts. These issues demonstrate a dire need for mental health counseling as part of the mentoring process.

We tend to think of the mentor-mentee relationship as one-sided, but it is (or should be) a partnership. For me, there was nothing more rewarding than discussing contemporary issues with younger colleagues, many of whom had keener minds than myself. This “reverse mentoring” allowed me to gain new perspectives that changed my thinking and improved my leadership capabilities.

Developing a comprehensive mentoring program isn’t easy and might be approached differently by various institutions depending on the number of available advisors, budget limits, and more. Most colleges engage veterinarians outside the university—in general practice, government agencies, and corporate organizations —to serve as teachers and mentors in clinical rotations. Student engagement in the real world is a unique form of educational mentoring that may include business and political experience.

The willingness of busy faculty members and practitioners to devote significant time and energy to students’ general professional education will depend on whether or not their contributions are recognized and rewarded. In this regard, the values and attitudes of deans and department heads can be more important than the mere numerical assessment of teaching effectiveness. Strong collegiate leadership and dedicated resources are necessary for successful mentoring.

Veterinary education as we once knew it is gone and not coming back anytime soon. Irresistible changes are already overtaking us with high stakes. As we move forward, we have an unquestionable duty to maintain the excellent scientific and technical education that is the acknowledged strength of the current system. However, we must also fortify the professional development of veterinary students so they can make the best possible contributions to the field in the future.

Peter Eyre, DVM&S, BVMS, BSc, PhD, is professor and dean emeritus at Virginia-Maryland College of Veterinary in Blacksburg, Virginia.

“Education is what remains when you have forgotten all the facts you ever learned.”
—Albert Einstein


Commentary: The power of mentorship: Knowledge is not enough

ElleVet Sciences launched its brand-new national nonprofit organization—The ElleVet Project—last month to support its mission of providing free veterinary care, food, and supplies to homeless and street pets.

Formally known as the “Pets in Need Project,” ElleVet’s new 501(c)(3) organization was originally developed by cofounders Amanda Howland, CCO, and Christian Kjaer, CEO, a year after it was released as a pilot program in response to the coronavirus disease 2019 (COVID-19) pandemic. 

“The ElleVet Project is unique in that traveling to the homeless communities and treating pets where they live allows us to reach the invisible pets, who otherwise may never have access to care or services,” says Howland, in an organizational 

. “The outpouring of support was incredible—the Project resonated with people in a way we couldn’t have imagined.”

The pilot efforts gained support from numerous veterinarians and celebrities throughout the country. The 2020 project team treated over 1,200 pets, spent over $10,000 on emergency surgery cases and administered thousands of vaccines and pet food.

“We learned that when you treat the pets, you treat the people as well,” explains Kjaer. “People told me that by giving medical care to their pets, it literally allowed them to put food on their own tables.”

The Project is currently accepting donations, all of which go towards vaccines, medical supplies, and emergency surgeries. 

"We depend on donations to fund our mission," says Howland. "The more donations we get, the sooner we can get more mobile veterinary units on the road across the country."

The ElleVet Project will return to California in the second quarter of 2021 with a goal of treating more than 3,000 pets and will expand to treat pets across the US over the next 3 years.

To learn more about The ElleVet Project, go 

The ElleVet Project is designed to expand free veterinary care efforts to pets of the homeless and street pets. 

ElleVet launches new national nonprofit

Advances in veterinary medicine have improved longevity in companion animals,

 and the geriatric anesthesia caseload is increasing. A patient may be considered geriatric when it has completed 75% to 80% of its expected life span, which varies by species and breed.

 A large number of geriatric patients present with comorbidities that must be considered during anesthetic planning, but many have no known systemic disease. Nevertheless, even “healthy” geriatric patients have a decreased functional capacity to respond to stress that does not become apparent until anesthesia and surgery. To avoid unexpected poor outcomes, anesthesia for all geriatric patients must be approached with special consideration of their altered physiologic responses to drugs and stress.

Geriatric patients have decreased cardiovascular reserve and diminished compensatory mechanisms compared with adult animals. In adults, hypotension triggers a baroreceptor reflex that increases heart rate and contractility, whereas in geriatric animals this reflex is reduced.

These patients are more reliant on adequate plasma volume for blood pressure maintenance, but renal free water excretion is less efficient, and the geriatric heart and lungs are more susceptible to congestive heart failure and pulmonary edema. Geriatric patients have decreased blood pressure under normal conditions, resulting in a higher resting heart rate and longer circulation time.

 The latter causes a longer onset of effect for injectable drugs, which may lead to premature repeated and excessive drug administration. As the cardiac conduction system ages, it becomes more susceptible to arrhythmias, especially when the aging cardiopulmonary system fails to meet the increased myocardial oxygen demands associated with pain and stress.

The aging lungs have decreased functional residual capacity—the reserve volume available for gas exchange during apnea—and thus faster onset of hypoxemia. Decreased chest wall compliance means the work of breathing is increased, while the aging muscles fatigue more quickly. These changes increase the risk of hypoventilation during anesthesia. Hypercapnia causes acidosis and decreased cardiac contractility, which negatively affect blood pressure. Sometimes the patient will mount a sympathetic response to the hypercapnia, but this can be equally detrimental, with tachycardia increasing myocardial oxygen demand and vasoconstriction reducing renal and hepatic blood flow.

Many geriatric animals have reduced renal mass, renal filtration, and excretion.

 Similarly, they have reduced hepatic mass, which leads to a decrease in total hepatic enzymatic function and blood flow, causing delayed drug clearance. Vasoconstriction that can occur in response to stress or pain reduces renal and hepatic blood flow, compromising renal perfusion and further reducing metabolic function. Of course, any disease of the kidneys and/or liver will further alter drug metabolism and clearance, exacerbate the hemodynamic consequences of anesthesia, and predispose the patient to acute kidney injury.

Geriatric patients require lower doses of anesthetic drugs to produce the same clinical effect.

 This phenomenon, combined with delayed onset due to longer circulation time, places these patients at a higher risk for overdose from repeated drug administration, resulting in excessive anesthetic depth and prolonged recoveries.

Visual and hearing impairment, as well as cognitive dysfunction, are common in aging pets (

). These conditions predispose patients to confusion and stress during hospitalization, which is exacerbated by restraint. The sympathetic response to stress can be detrimental in these patients, as their vital organs lack the functional reserve to compensate for stress-related tachycardia, vasoconstriction, and increased oxygen demand.

Figure 1. A 14-year-old dog with cataracts and hearing impairment staying warm after recovery from anesthesia for CT and rhinoscopy.

Some geriatric patients have excess fat and an increased volume of distribution for most anesthetic drugs. This prolongs the duration of action but does not warrant an increased dose, as geriatric patients usually require a lower dose for a given clinical effect. Geriatric patients may alternately present with very little fat, which, in conjunction with reduced muscle mass, increases their risk for hypothermia (

). Hypothermia impairs cardiovascular function, reduces anesthetic drug requirements, prolongs recovery, and causes discomfort and shivering. Shivering exacerbates pain, stimulates catecholamine release, and increases oxygen demand.

Figure 2. This 15-year-old dog has muscle wasting and no excess fat.

Between the decreased muscle mass and higher incidence of osteoarthritis, geriatric patients should be transported and positioned with care. Adequate padding of dependent areas and reducing stress on joints and ligaments are essential. When considering analgesic drugs, the pain associated with positioning should be considered in addition to the procedure itself.

The practitioner should complete a thorough history, including a review of comorbidities and medications. Diagnostic tests should be performed and reviewed ahead of time to screen for new comorbidities or determine the extent of known disease. These should include blood work (especially packed cell volume/total solids, liver enzymes, blood urea nitrogen, creatinine, symmetric dimethylarginine, electrolytes, thyroid panel, and clotting profile if indicated), urinalysis, and diagnostic imaging (chest x-rays, with or without abdominal ultrasound if indicated by abnormalities on physical exam or blood work). Abnormalities should be corrected prior to anesthesia when possible; otherwise, referral to a specialty practice for further workup and preanesthetic optimization should be considered.

Most medications should be continued, with few exceptions. Angiotensin-converting enzyme (ACE) inhibitors (benazepril, enalapril) should be withheld the morning of anesthesia to reduce the incidence of refractory hypotension

; telmisartan, an angiotensin receptor blocker used increasingly for the treatment of protein-losing nephropathy, acts on the same pathway, and withholding this drug may be prudent. The antithrombotic medication clopidogrel should be discontinued 10 days prior to surgery but can be continued for nonsurgical procedures. Patients receiving prednisone for hypoadrenocorticism should receive an increased dose (ie, double their normal morning dose) to help them tolerate the stress associated with anesthesia and surgery.

Some medications can also alter the effects of sedative and anesthetic drugs. For example, phenobarbital induces hepatic enzymes and can hasten drug clearance, but the clinical effect of sedative and anesthetic drugs may be more pronounced. Patients receiving medications that affect vasomotor tone (ACE inhibitors, calcium channel blockers, pimobendan) are at a higher risk for hypotension from vasodilating agents, especially acepromazine and inhalant agents. A drug reference should be consulted for a list of potential drug interactions.

Premedication is the use of sedative and analgesic agents prior to the induction of anesthesia. This practice reduces stress associated with restraint and anesthesia, facilitates intravenous catheter placement, reduces the doses of anesthetic drugs required, provides preemptive analgesia, and improves the quality of recovery. Combination protocols capitalize on drug synergism, allowing a reduced dose of each drug. Onset and clinical effect can be unpredictable in geriatric patients, and the practitioner should be prepared to provide supplemental oxygen using a face mask upon onset of sedation.

The combination of an opioid appropriate for the level of pain anticipated and a benzodiazepine offers analgesia and mild sedation in geriatric patients with minimal cardiorespiratory effects. In very anxious or fearful patients for whom a benzodiazepine will offer inadequate sedation, a low dose of acepromazine (0.01-0.03 mg/kg) can be considered, weighing the benefits of superior sedation with the risk for hypotension.

Alpha-2 agonists (eg, dexmedetomidine) decrease cardiac output,

 which is not desirable given the age-related changes in cardiovascular function and cardiac reserve. However, these drugs also reduce sympathetic tone and the detrimental effects associated with increased circulating catecholamines. Use of a conservative dose (0.5-2 mcg/kg) in combination with an opioid and benzodiazepine may be useful in the stressed geriatric patient.

Ketamine at a moderate intramuscular dose of 1 to 2 mg/kg in dogs or 2 to 3 mg/kg in cats is a safe and effective alternative to dexmedetomidine when an opioid/benzodiazepine combination will not provide adequate sedation. Ketamine at moderate to high doses should be avoided in patients with pre-existing tachycardia, hypertension, or hypertrophic cardiomyopathy due to the potential for sympathetic stimulation and increased myocardial oxygen demand.

Alfaxalone can also be used for intramuscular sedation in geriatric cats and dogs at doses of 1 to 3 mg/kg, in combination with an opioid and benzodiazepine. This is especially useful in fearful geriatric cats for whom ketamine is contraindicated due to the presence of cardiac disease. The high volume required makes this most practical for small patients and may warrant 2 injections to reduce muscle trauma. The level of sedation is unpredictable, and the patient may require supplemental oxygen or even intubation depending on the effect.

Induction of anesthesia should be achieved with injectable agents. Mask and chamber inductions may cause a life-threatening stress response, and the dose of inhalant required to induce anesthesia causes significant cardiovascular depression. Furthermore, these techniques expose personnel to high levels of waste anesthetic gases.

Propofol is commonly used in geriatric patients because it can be titrated slowly to effect and the duration is short due to rapid redistribution. Propofol is also the drug of choice for patients with reduced liver function, because metabolism is largely extrahepatic. However, propofol can cause significant cardiovascular (bradycardia, vasodilation, decreased contractility, hypotension) and respiratory (hypoventilation, apnea) derangements. The total dose needed can be reduced by titrating at a rate of 1 mg/kg/min,

and by using a co-induction agent such as ketamine and/or a benzodiazepine.

Alfaxalone has a similar effect profile to propofol, but with better maintenance of cardiac output owing to preservation of the baroreceptor reflex,

 although the extent to which this is true in geriatric patients remains to be elucidated. Alfaxalone should be titrated at a rate of 0.5 mg/kg/min

 and may be combined with ketamine and/or a benzodiazepine.

Because etomidate has minimal cardiorespiratory effects, it is ideal for patients with significant cardiac or respiratory disease. Adverse effects include pain on injection, gagging, and hemolysis. Co-induction with midazolam and administration with intravenous fluids running can mitigate these effects. In dogs, I have found that intravenous lidocaine administered just before etomidate seems to reduce pain on injection.

Ketamine at doses required for anesthesia induction (2-6 mg/kg intravenously) causes tachycardia and increased myocardial oxygen demand, and thus is not ideal as a primary induction agent in geriatric patients with decreased cardiac reserve. However, it can be considered for use as a co-induction agent at lower doses.

General anesthesia can be maintained with a variety of drugs and drug combinations. Regardless of drug choice, anesthetized patients should be intubated and receive oxygen supplementation, with ventilatory support as needed. An experienced veterinary nurse or doctor should monitor the patient using pulse oximetry, capnography, electrocardiography, blood pressure and temperature measurement, and hands-on assessment of anesthetic depth (palpebral, jaw tone), mucous membrane color and refill time, and pulse quality.

Inhalant anesthetics (eg, isoflurane, sevoflurane) cause vasodilation, decreased cardiac contractility, and respiratory depression. Geriatric patients are particularly susceptible to the resulting hypotension, hypoventilation, and hypoxemia. Therefore, use of a multimodal anesthetic protocol to reduce inhalant anesthetic requirements is recommended. A ketamine continuous-rate infusion (CRI) can be administered during anesthesia to provide analgesia and reduce anesthetic requirements without causing sympathetic stimulation. Adding 120 mg ketamine to 1 L of fluids and administering at a rate of 5 mL/kg/hour will provide a ketamine infusion of 10 mcg/kg/min. Other CRIs I use commonly to reduce anesthetic requirements include fentanyl (5-20 mcg/kg/hour) and lidocaine (25-75 mcg/kg/min).

Local blocks are effective for reducing anesthetic requirements, improving patient comfort in the postoperative period, and reducing systemic opioid use (

). Local anesthetics are the only drugs that completely block nociceptive transmission, and I consider locoregional anesthesia to be an essential component of a multimodal approach to anesthesia and analgesia.

Figure 3. An infraorbital block is performed in a geriatric cat prior to a nasal biopsy.

For critical or sick geriatric patients, inhalant anesthetics may not be well tolerated, and a total intravenous anesthesia technique should be considered. A propofol CRI (0.1-0.4 mg/kg/min) can be used but tends to have similar cardiovascular and respiratory effects to inhalant anesthetics. Alfaxalone at a rate of 0.05 to 0.2 mg/kg/min appears to have a more favorable cardiovascular effect profile. Use of other concurrent CRIs (fentanyl, ketamine, and/or lidocaine) can reduce the requirement for propofol or alfaxalone.

During anesthesia, many geriatric patients require additional cardiovascular support. Judicious use of fluid therapy is recommended, and fluid boluses should be reserved for patients with evidence of hypovolemia. Anticholinergics are often indicated to maintain heart rate in the normal range to optimize cardiac output and blood pressure. Ephedrine, dopamine, or dobutamine may be indicated for refractory hypotension, with the optimal choice depending on species and concurrent disease. Keep in mind that hypothermia may cause bradycardia and hypotension that are refractory to pharmacologic intervention.

About half of all anesthesia-related deaths in dogs and cats occur during recovery, mostly during the first 3 hours.

 Compared with adults, geriatric animals are especially predisposed to prolonged recoveries due to slower drug clearance, more profound responses to anesthetic drugs, and increased incidence of hypothermia, hypotension, and hypoxemia. Pulse oximetry, respiration, heart rate, blood pressure, and temperature should be monitored at regular intervals until these vitals return to within normal limits or near baseline (

). Patients with visual or hearing impairment or cognitive dysfunction may become confused and agitated during recovery, and may require additional time to recover. In elderly humans, full return of cognitive function to preoperative levels after general anesthesia may require up to 2 weeks.

 In older laboratory animals given general anesthesia, impairment of learning persists long after the effects of anesthetic agents have dissipated.

Figure 4. Pulse oximetry monitoring of a geriatric brachycephalic dog during recovery from anesthesia.

Geriatric dogs and cats are at an increased risk for anesthesia-associated complications because of the normal physiologic changes that occur with aging. They are also more likely to present with concurrent diseases. Anesthesia for these patients should be performed only after a thorough preanesthetic assessment and patient stabilization. Reduction of stress and pain in the perianesthetic period is essential to avoid excessive sympathetic stimulation. While no specific drug protocol has been shown to decrease morbidity or mortality in geriatric patients, the practitioner should use a multimodal approach and tailor anesthetic protocols to each individual patient, taking into account aging changes and comorbidities. Patients should be monitored closely from premedication to full recovery from anesthesia, and the practitioner should be prepared to provide ventilatory and cardiovascular support beyond that which most healthy adult animals require. Advanced age is neither a disease nor a contraindication to anesthesia but demands special care and attention from the practitioner to promote the best outcomes for these patients.

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Hampton CE, Riebold TW, LeBlanc NL, Scollan KF, Mandsager RE, Sisson DD. Effects of intravenous administration of tiletamine-zolazepam, alfaxalone, ketamine-diazepam, and propofol for induction of anesthesia on cardiorespiratory and metabolic variables in healthy dogs before and during anesthesia maintained with isoflurane. 

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Molly Allen, DVM, DACVAA, is an anesthesiologist at BluePearl Specialty + Emergency Pet Hospital in Waltham, Massachusetts. Her special interests include anesthesia training, patient safety, advanced locoregional techniques, and strategies for promoting enhanced recovery from anesthesia in small animal patients.

Because the risk for anesthesia-associated complications increases in patients with advanced age, a thorough preanesthetic assessment and patient stabilization and monitoring are required for the best outcomes. 



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IDEXX: Contributing to something bigger

Nominations now open for dvm360®/VHMA Practice Manager of the Year award