Clinical evaluation of balanced anesthesia using infusion of midazolam–ketamine–medetomidine in combination with inhalation of sevoflurane (MKM–OS anesthesia) in horses

MKM–OS anesthesia provides general anesthesia with minimum cardiovascular depression in experimental horses. The purpose of this study was to evaluate the effect of MKM–OS anesthesia in clinical cases. Sixty‐eight horses were anesthetized with MKM–OS anesthesia for selective or emergency surgery. The horse physical status was categorized based upon the American Society of Anesthesiologists (ASA) classification scheme. Forty‐four horses were classified as ASA I or II (low‐risk; 30 soft tissue, eight ophthalmic, and six orthopedic surgeries) and 24 horses were classified as ASA III to V (high‐risk; 24 emergency colic surgeries). All horses were administered medetomidine (0.005 mg kg^–1 IV) as premedication and anesthetized with ketamine (2.5 mg kg^–1 IV) and midazolam (0.04 mg kg^–1 IV). The horses were orotracheally intubated and connected to a large animal breathing circuit that delivered oxygen‐sevoflurane and administered the midazolam (0.8 mg mL^–1)‐ketamine (40 mg mL^–1)‐medetomidine (0.05 mg mL^–1) drug combination at a rate of 0.025 mL kg^–1 hour^–1. Surgical anesthesia was maintained by controlling the dial setting of the sevoflurane vaporizer and achieved by delivering 1.6–1.8% of end‐tidal sevoflurane concentration. All horses were mechanically ventilated during anesthesia. Hypercapnia and hypoxia were not sufficiently improved in high‐risk horses (PaCO₂; low‐risk 45–53 mm Hg versus high‐risk 56–60 mm Hg, p < 0.01: PaO₂ low‐risk 248–388 mm Hg versus high‐risk 95–180 mm Hg, p < 0.01). Heart rate was significantly higher in high‐risk horses (low‐risk 37–42 bpm versus high‐risk 44–73 bpm, p < 0.01). Dobutamine infusion was required in five low‐risk (11%) and 17 high‐risk horses (68%) to maintain mean arterial blood pressure >70 mm Hg. Eleven high‐risk horses died during the perioperative period (three euthanized during surgery, two died during recovery, six died after recovery). The quality of recovery was good in low‐risk horses and good to satisfactory in high‐risk horses. MKM–OS anesthesia provided excellent surgical anesthesia with minimal to mild cardiovascular depression in low risk‐horses and mild to moderate cardiovascular depression in high risk‐horses. The possibility of preserve cardiovascular function could be the advantage of MKM–OS anesthesia in high‐risk horses.