Currently available sedative analgesic agents have opened up a wonderful world of opportunity to practice with intelligent
compassion: to work smarter, not harder when managing patients that resent a variety of necessary procedures.
This session will focus on strategies that combine opioids, sedative/tranquilizers, and dissociative agents to provide predictable
chemical restraint with properties that include rapid onset, reversibility, and minimal potential for clinically significant
Overview of presentation:
Veterinary medicine often has a tough side to it; brute-a-caine is the general term for gathering enough people to overcome
any physical resistance by the patient to force their compliance. It seems expedient to just get the job done but the consequences
of these events are often inadequately considered.
With heavy physical restraint, there is high-level stress for both the patient and the staff, there is every expectation that
the patient will generate a substantial negative association with the practice, and there is predictable risk of physical
harm, including death, to the patient as well as the risk of physical harm to the staff. As an extension of this overall negative
association, when the patient has a negative association with the practice, the client is likely to avoid trips to the practice
for routine care, impacting the business of veterinary medicine. What seems easiest in the short term has ongoing life-long
The first step in the effective utilization of procedural sedation is to recognize which patients require it. We try to build
the most positive relationship that we possibly can from the earliest patient visits. Freeze dried liver treats are in the
canine rooms and a variety of strained meat baby foods are in the feline exam room. Every attempt is made to distract the
patient from the unpleasantries of their initial vaccinations.
When blood draws and other more challenging needs arise, we conduct those away from the DVM in a room apart from the outpatient
area, making an attempt to diffuse negative associations. If the patient becomes agitated by a procedure we consider abandoning
the event that day, postponing it until a future visit. We then set up a series of "Happy Visits" prior to the next stressful
event making an attempt to build a more positive bond with both client and patient. This is a more successful sequence when
managing canine compared to feline patients.
When all else fails, procedural sedation is woven into the patient's visits. Whenever possible, we avoid trying to gain control
of a highly agitated patient preferring to reschedule a patient that has become highly reactive to another day (if their condition
allows). To do otherwise risks escalating hostilities and escalating drug requirements.
For the toughest patients, procedural sedation is the only way we can gain enough control to perform even the most basic of
all procedures: a physical examination. This reduces the safety of the event as these patients require more aggressive drug
combinations while offering the clinician the least understanding of their health status.
Simply put, the timing of the medication administration has a crucial impact to the success of the process. A known difficult
patient should be given their sedative IM medication combination as a soon as they walk through the door of the practice.
If they are allowed to become increasingly agitated, their medication strategy is less likely to be effective delaying the
patient procedure and forcing the need for additional drugs.
For cats, we prefer to have the patient transported to the practice in a simple 2-part plastic carrier that has an easily
removed top. The patient is ushered into an exam room that has a calming pheromone diffuser in place. The top of the carrier
is removed and the patient is quickly covered with a towel that has also been sprayed with a calming pheromone. The staff
member gently but firmly presses the patient against the floor of the carrier while a second staff member lifts the towel
off of the lower lumbar area allowing a quick IM injection in the lumbar epaxial musculature using a 25 g or 27 g needle.
The patients head is uncovered and the staff exits the room leaving instructions with the owner to open the door when the
patient begins to act sleepy. Subdued lighting may help accelerate the medication's effects. The staff member returns in 10
minutes if the owner hasn't already come to the door. If the patient escapes into the room we use a clam-shell cat collection
device to safely gather up the patient and easily allow for the IM injection while restrained in the mesh. We can usually
gain control of even the toughest cats using this method. What varies is the choice of drugs for these patients; usually ketamine
is required to securely gain control of these agitated tough cats.