Mortality and morbidity in equine anaesthesia

Equine peri-anaesthetic mortality and morbidity are of interest to anaesthetists, practitioners, horse owners and insurance companies. The largest prospective study, ‘The Confidential Enquiry into Perioperative Equine Fatalities’ (CEPEF) was conducted more than 20 years ago. It included over 40,000 horses from multiple centres and reported mortality to be 1.9% that decreased to 0.9% when only elective cases were considered. This is in stark contrast to mortality rates in small animal (dogs: 0.17%, cats: 0.24%) and human anaesthesia (0.04–7/10,000). In spite of developments in understanding the pathophysiology of equine anaesthesia mortality has not decreased in the intervening years. The main contributors to peri-anaesthetic equine mortality are cardiac arrest, fractures and myopathy or neuropathy. Spinal cord myelopathy and cerebral necrosis are less common. Malignant hyperthermia and hyperkalaemic periodic paralysis are diseases associated with genetic mutations that can be triggered during general anaesthesia and may be fatal if not recognised and treated immediately. Morbidities are reported less frequently, presumably because often they do not cause permanent harm and may resolve within a short period of time. Complications in equine anaesthesia are numerous and include injuries at induction and recovery, damage to the airway associated with orotracheal or nasotracheal intubation, post-anaesthetic myopathy or neuropathy, regurgitation and aspiration of stomach contents, ocular injuries and complications associated with intravascular cannulation. Hypotension, hypoventilation, hypoxaemia, hypothermia and dysrhythmias may occur both during the maintenance phase of anaesthesia but also in recovery. Airway obstruction during recovery has repeatedly been reported over the years as causing pulmonary oedema, which is often fatal if the airway is not restored extremely quickly. This review summarises the literature on the risk of mortality and morbidity. Information has been gathered from single case reports as well as larger research studies.     

Sevoflurane inhibits equine myeloperoxidase release and activity in vitro

Objective To investigate the effects of the volatile anaesthetic sevoflurane on the release of total and active myeloperoxidase (MPO) by non‐stimulated and stimulated polymorphonuclear neutrophils (PMNs) in whole blood from healthy horses. Study design In vitro experimental study. Animals Adult healthy horses. Methods Samples of whole venous blood were collected and incubated in air or in air plus 2.3% or 4.6% sevoflurane for 1 hour. PMNs were stimulated with N‐formyl‐methionyl‐leucyl‐phenylalanine (fMLP), with a combination of cytochalasin B (CB) and fMLP or with phorbol myristate acetate (PMA). Total and active MPO contents released by PMNs in blood were measured by enzyme‐linked immunosorbent assay (ELISA) and specific immunological extraction followed by enzymatic detection (SIEFED) respectively. Additional experiments were performed to assess the effect of sevoflurane on the peroxidase and chlorination cycles of purified equine MPO using Amplex Red and 3’‐(p‐aminophenyl) fluorescein as fluorogenic substrates respectively. Results As compared with air alone, 1 hour exposure of whole blood to 4.6% sevoflurane in air significantly inhibited the release of total and active MPO by unstimulated and both fMLP‐ and CB + fMLP‐stimulated PMNs but not by PMA‐stimulated PMNs. Although 2.3% sevoflurane had no effect on total MPO release by unstimulated and stimulated PMNs, it significantly reduced the release of active MPO by unstimulated and fMLP‐stimulated PMNs. Additionally, sevoflurane reversibly inhibited the activity of MPO, especially the peroxidase cycle of the enzyme. Conclusions and clinical relevance Although our experimental study was not designed to assess the effects of sevoflurane in vivo, this inhibition of MPO release and activity may have relevance for anaesthetized horses and deserves further studies to examine the clinical importance of these findings.     

Glyceryl guaiacolate in equine anaesthesia

GG is a useful sedative and anaesthetic agent in horses. Used alone, or in conjunction with barbiturates, it produces a uniformly smooth recovery from anaesthesia.

The need to infuse large volumes to obtain the desired effect is a disadvantage of this agent. Few critical studies have been made on the short and long term effects of administration of GG to horses. Its pharmacology and clinical use are described and indicate that it is a safe and useful drug.     

Sevoflurane anaesthesia in chickens during spontaneous and controlled ventilation

A crossover study design was used to investigate the dose-related effects of sevoflurane at end-tidal concentrations of 2.2 to 4.4 per cent on the respiratory rate, blood gases, heart rate, arterial blood pressure and ocular signs of chickens during spontaneous and controlled ventilation. The mean (sd) carbon dioxide partial pressure (PaCO2) increased as the concentration of sevoflurane increased, and was 86 (29) mmHg at an end-tidal concentration of 4.4 per cent during spontaneous ventilation, but was maintained between 29 and 42 mmHg during controlled ventilation. The heart rate increased as the concentration of sevoflurane increased during spontaneous ventilation, but did not change during controlled ventilation. Sevoflurane decreased arterial blood pressure during both spontaneous and controlled ventilation, but a dose-dependent decrease in arterial blood pressure was observed only during controlled ventilation. The mean arterial blood pressure at an end-tidal concentration of 4.4 per cent was significantly higher during spontaneous ventilation than during controlled ventilation. Controlled ventilation prevented the increases in PaCO2 and heart rate that were observed during spontaneous ventilation. The decrease in arterial blood pressure during spontaneous ventilation was less than that during controlled ventilation, possibly owing to the effects of hypercapnia.     

Effects of detomidine or romifidine during maintenance and recovery from isoflurane anaesthesia in horses

ObjectiveTo evaluate the effects of detomidine or romifidine on cardiovascular function, isoflurane requirements and recovery quality in horses undergoing isoflurane anaesthesia.Study designProspective, randomized, blinded, clinical study.AnimalsA total of 63 healthy horses undergoing elective surgery during general anaesthesia.MethodsHorses were randomly allocated to three groups of 21 animals each. In group R, horses were given romifidine intravenously (IV) for premedication (80 μg kg^–1), maintenance (40 μg kg^–1 hour^–1) and before recovery (20 μg kg^–1). In group D2.5, horses were given detomidine IV for premedication (15 μg kg^–1), maintenance (5 μg kg^–1 hour^–1) and before recovery (2.5 μg kg^–1). In group D5, horses were given the same doses of detomidine IV for premedication and maintenance but 5 μg kg^–1 prior to recovery. Premedication was combined with morphine IV (0.1 mg kg^–1) in all groups. Cardiovascular and blood gas variables, expired fraction of isoflurane (Fe′Iso), dobutamine or ketamine requirements, recovery times, recovery events scores (from sternal to standing position) and visual analogue scale (VAS) were compared between groups using either anova followed by Tukey, Kruskal-Wallis followed by Bonferroni or chi-square tests, as appropriate (p < 0.05).ResultsNo significant differences were observed between groups for Fe′Iso, dobutamine or ketamine requirements and recovery times. Cardiovascular and blood gas measurements remained within physiological ranges for all groups. Group D5 horses had significantly worse scores for balance and coordination (p = 0.002), overall impression (p = 0.021) and final score (p = 0.008) than group R horses and significantly worse mean scores for VAS than the other groups (p = 0.002).Conclusions and clinical relevanceDetomidine or romifidine constant rate infusion provided similar conditions for maintenance of anaesthesia. Higher doses of detomidine at the end of anaesthesia might decrease the recovery quality.     

Transnasal endoscopic treatment of equine sinus disease in 14 clinical cases

Transnasal endoscopic sinus treatment was used in four horses diagnosed with primary sinusitis and 10 horses with dental sinusitis. Pre-existing (n = 5) or surgically created (n = 9) sinonasal fistulae were used as portals for transnasal endoscopic exploration, debridement and lavage of the inflamed sinus cavities. Endoscopic sinonasal fistulation was performed using either trans-endoscopic diode laser fibre (four cases) or an electrocautery instrument under endoscopic control (five cases). All procedures were performed on standing sedated horses with the use of local anaesthesia. In six cases, the ventral concha was fenestrated in order to gain a portal into the ventral conchal and rostral maxillary sinus. In two cases the dorsal concha was fenestrated to access the caudal group of the paranasal sinuses. One case required fenestration of the ventral conchal bulla due to its empyema. Post-operative bleeding was controlled with a nasal cavity tamponade for 24 h. Endoscopic lavage and debridement of the inflamed sinuses were performed every 2–3 days. Medical treatment consisted of antibiotic and anti-inflammatory drugs. In the cases of dental sinusitis, the underlying dental pathology was addressed. Median hospitalisation time was 10 days (range 5–25 days) and the median number of endoscopic procedures (including the initial procedure) was 4 (range 3–7). Cases were followed-up by telephone consultations with their owners. Intervals between discharge and last follow-up ranged from 4 to 22 months (median 9.5 months). Complete recovery was reported in 10 cases, clinical improvement (occasional nonpurulent discharge) in two cases. Two cases were readmitted due to recurrence of the purulent nasal discharge; both subsequently underwent trephination of the affected sinuses and made a full recovery after removal of the remaining pathological sinus content.     

Historical and clinical features of 200 cases of equine sinus disease

The historical and clinical findings in 200 referred cases of equine sinus disease were reviewed retrospectively. Univariable and multivariable analyses were performed to detect significant differences in historical or clinical features between various categories of sinus disease. The causes of sinus disease were classified as subacute primary (less than two months duration) (n=52), chronic primary (more than two months duration) (n=37), dental (n=40), sinus cyst (n=26), traumatic (n=13) or mycotic sinusitis (n=7), sinus neoplasia (n=10), dental-related oromaxillary fistula (n=8) and intrasinus progressive ethmoid haematoma (n=7). The majority of sinus disorders were of chronic duration at the time of referral and most (including 97 per cent of chronic primary sinusitis cases) had not responded to previous antibiotic therapy and/or sinus lavage in some cases. Clinical signs included unilateral nasal discharge in most cases, including purulent or mucopurulent discharge in all horses with primary, dental and mycotic sinusitis. Haemorrhagic nasal discharge was a feature of traumatic sinusitis and intrasinus progressive ethmoid haematomas. Firm facial swellings and nasal airflow obstruction were features of sinus cysts and neoplasms. Ipsilateral lymphadenitis was a more prominent feature of sinus disease with active infections such as primary, dental or mycotic sinusitis.     

The effect of detomidine (Domosedan) on the maintenance of equine pregnancy and foetal development: ten cases

Detomidine was administered throughout 10 pregnancies in eight mares. An intravenous injection of 20 micrograms/kg body weight was given weekly from Day 14 to Day 60 of gestation and thereafter every four weeks until parturition. One mare suffered torsion of the large colon and was destroyed on Day 86; the foetus was normally developed. A further mare aborted at 167 days. The remaining eight pregnancies continued to full term. One foal was delivered by caesarean section because of torticollis and, of the seven foals born spontaneously, one had bilateral upward patellar fixation at one month old. Therefore, although only six of the 10 foals developed normally, the other four cases showed no pathological similarities to suggest a common cause. Although these data were based on a small number of mares, they did not suggest that the repeated administration of detomidine had specific adverse effects on the pregnancies.     

Flow cytometry: clinical applications in equine medicine

The use of flow cytometry in veterinary diagnostics is becoming a valuable clinical tool with a broad range of applications. Physical characteristics of cells can be determined by the flow cytometer laser and electronics through the measurement of changes in light scatter properties. Other components and functions of cells can be defined through the application of fluorochrome dyes that have an affinity for cellular components. Traditionally, common clinical applications are immunophenotyping of cells of the hematopoietic system with fluorescent-labeled antibodies raised against specific cell surface proteins. Other approaches have been used to elucidate changes in cell function and DNA content. This review is intended to provide the reader with the fundamental uses of flow cytometry. Examples of clinical applications in equine patients include immune-mediated hemolytic anemia, immune-mediated thrombocytopenia (IMT), chronic inflammatory disease, and neoplasia.     

Analysis of the variations in clinical signs shown by 254 cases of equine headshaking

A national survey of headshaking in 254 horses was undertaken to describe the clinical signs of the condition as observed by horse owners. Principal component analysis was used to determine the underlying structure of 11 signs and the criteria by which the affected horses could be most effectively differentiated; the analysis suggested five components with a variance greater than one which together explained over 60 per cent of the total variance. Other analyses of the data indicated that headshaking could develop at any age and that twice as many males were affected as females; 64 per cent of the horses shook their heads seasonally and geldings were more likely than mares to be seasonally affected. Seasonal headshaking tended to be significantly worse on sunny days but improved on rainy days, windy days, at night and indoors.     

Thromboelastography in equine medicine: Technique and use in clinical research

Thromboelastography (TEG) is a viscoelastic, whole blood‐based assay that integrates information from both the cellular and soluble components of coagulation, providing a global evaluation of the haemostatic system. This contrasts with the conventional coagulation assays (i.e. platelet count, prothrombin time [PT], activated partial thromboplastin time [aPTT] and fibrinogen concentration [FIB]), which only provide information about one component (e.g. clotting factors in the case of PT and aPTT) of the haemostatic process, requiring the combination of several assays for a complete evaluation of haemostasis. Thromboelastography is an old technology that has been used in human medicine for over 50 years. However, it is relatively new in veterinary medicine and has only been applied to horses in the last 5 years. Clinical applications in human medicine include diagnosis and monitoring of coagulopathies. Currently, extensive research is being carried out to expand the use of TEG in dogs and cats. Therefore, it is expected that the use of this technique will also further expand in horses in the near future. To date, the available studies in the equine species have evaluated TEG in healthy horses, horses with gastrointestinal disease, septic foals, horses with exercise‐induced pulmonary haemorrhage (EIPH) and a filly with Glanzmann's thrombasthenia. The main objective of this review is to introduce the TEG technique to equine clinicians, providing information on how the TEG functions, blood sample collection and processing, variables measured and their interpretations, normal reference values and areas of potential clinical application.     

Controlled mechanical ventilation in equine anaesthesia: Physiological background and basic considerations (Part 1)

Controlled mechanical ventilation (CMV) is routinely used in equine anaesthesia, with many different options available to mechanically deliver breaths. The complexity of respiratory pathophysiology in anaesthetised horses and the wide range of devices available is described in this scoping review. The first part of the review outlines basic equine respiratory physiology and pathophysiology during anaesthesia to illustrate what makes horses prone to inefficient gas exchange and ventilation when they are recumbent. The difference between spontaneous ventilation and CMV is reviewed and basic considerations of CMV are explored in more detail.     

The equine gastrosplenic ligament: Anatomy and clinical considerations

A gelding was referred for colic and inguinal wound evaluation. Abdominal ultrasound showed distended, oedematous and immotile small intestine abaxial to the spleen. An exploratory laparotomy revealed jejunal incarceration through a rent in the gastrosplenic ligament (GSL). The rent in the GSL was opened and surgical correction (resection and anastomosis of nonviable jejunum) performed. The GSL was left open. The horse recovered uneventfully and one year after surgery no further episodes of colic have been observed.     

Partial intravenous anaesthesia in the horse: a review of intravenous agents used to supplement equine inhalation anaesthesia. Part 1: lidocaine and ketamine

ObjectiveTo review the literature with regard to the use of different intravenous agents as supplements to inhalational anaesthesia in horses. These drugs include lidocaine, ketamine, opioids and α₂-agonists. The Part 1 of this review will focus in the use of lidocaine and ketamine.Databases usedPubmed &; Web of Science. Search terms: horse, inhalant anaesthesia, balanced anaesthesia, partial intravenous anaesthesia, lidocaine, ketamine.ConclusionsDifferent drugs and their combinations can be administered systemically in anaesthetized horses, with the aim of reducing the amount of the volatile agent whilst improving the recovery qualities and providing a multimodal analgesic approach. However, full studies as to whether these techniques improve cardiopulmonary status are not always available and potential disadvantages should also be considered.     

Detomidine-butorphanol sedation in equine clinical practice

Combinations of detomidine (mean dose rate 13 micrograms/kg) and butorphanol (mean dose rate 26 micrograms/kg) were used to sedate 61 horses for a variety of surgical or diagnostic procedures in general equine practice. Three horses were sedated on more than one occasion. The degree of sedation was graded from 3 to 0 (deep sedation to no effect) and any side effects were recorded. Forty-three per cent of the horses were graded 3, 46 per cent were graded 2, 8 per cent were graded 1 and 3 per cent were graded 0. Bradycardia and ataxia were the major side effects. The combination was judged to be effective and safe for use in general practice. In 56 horses (92 per cent) the necessary procedure was carried out under excellent conditions and in only one horse was the degree of sedation considered to be totally unsatisfactory.