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How can we calm and sedate the uncooperative kitty?

CALMING THE UNCOOPERATIVE KITTY 

The uncooperative and stressed cat can present a challenge to the entire veterinary team. Ensuring safe, but good sedation and a cooperative patient while minimising team stress can be achieved by a carefully thought through plan and preparation.

Aims of calming our feline patients

We have all come across the “angry” kitty that requires examination and perhaps even blood sampling or to be admitted to the clinic for further investigations or a surgical procedure. They are often our geriatric patients, and may have multiple comorbidities that already increase their procedural risk. Careful, gentle handling of a stressed cat is essential, along with consideration for the presence of any areas of pain, particularly associated with osteoarthritis, and how this may impact on restraining for examination or blood sampling.

Which procedures are we likely to be trying to safely perform?

  • Blood sampling
  • IV cannula placement
  • Non-invasive procedures such as clinical examination and diagnostic imaging
  • Preparation for general anaesthesia (always following appropriate clinical examination and administration of analgesia)

It is unlikely that an oral or IM sedation combination will always provide sufficient sedation to complete all non-invasive procedures (such as abdominal ultrasound or radiography). What it is likely to achieve though, is sufficient sedation for physical examination, blood sampling and IV cannula placement, and then allow the team to prepare everything required for any further procedures.

Preparation

If the owner informs you prior to consultation that their cat is unpredictable, fearful or easily stressed then it make senses to plan ahead and consider if sedation prior to their visit or admission to the clinic is warranted. Discuss options with the client to decide the most appropriate way to administer any medication prior to examination; this may be using the oral route at home or on arrival at the clinic, or intramuscular administration at the clinic. It is likely that even if oral medications can be given prior to visiting the clinic, that this may not be sufficient to complete all necessary clinical investigations. Having this conversation with the client prior to the planned visit helps to make the whole visit less stressful for the entire team, and the client is prepared for the possible difficulties along the way.

When preparing to sedate these unpredictable feline patients with limited clinical information it is important to be prepared for potential complications.

Always;

  • Have a plan B if the initial sedation proves insufficient or cannot be administered in the planned manner
  • Prepare equipment needed to gain IV access
  • Prepare equipment needed for induction of anaesthesia and orotracheal intubation
  • Have oxygen and the ability to deliver it available (e.g. a breathing system)
  • Have monitoring equipment available to ensure patient safety during sedation
  • Ensure equipment is available to allow safe handling of stressed and sedated cats

Patient examination

Only a limited clinical examination of a stressed cat is likely to be possible, and in some circumstances will be impossible. Therefore, decisions on sedation and its route of administration may have to be made based on little information. In this situation, use of medications with low risk of unwanted effects, particularly to the cardiovascular system are most appropriate. Once the patient is calm or sedated sufficiently then a more thorough physical examination should always be performed prior to administration of any further sedation, and in particular before converting to anaesthesia.

Sedation options

There are a number of sedation options available to us to provide safe conditions for both our feline patients and our team. Sedation may be given PO, IM or SC, or a combination of the mentioned routes in the uncooperative cat.

Note; Some of the options discussed in this article describe the off-label use of the sedative and anaesthetic agents detailed.

Timings

Oral medications such as gabapentin or trazodone require administration prior to consultation, examination or procedure. For gabapentin, administration around 1 to 2 hours prior to examination will be required to ensure maximal effect, and in the case of trazodone, administration around 30 to 90 minutes is required for its effect. Gabapentin is more likely to result in a calm, rousable feline patient and provided clients are advised of the likely effects can be considered for home administration. Trazodone, on the other hand may lead to profound sedation and an unrousable feline patient, and this certainly appears more difficult to predict. This scenario is therefore less likely to be useful in the home setting and best reserved for use in the clinic.

Sedation management

Let’s now explore the options reported in the literature with regard to sedation in our more challenging, unwell feline patients. With all of the sedation protocols discussed it is important that IV access is secured once safe to do so, for two reasons; to allow any emergency drugs to be administered if required and to allow sedation to be topped up or conversion to anaesthesia, if this becomes necessary or was already planned. The level of patient support and monitoring should be considered on a case by case basis, to include provision of fluid therapy, analgesia, supplementary inspired oxygen and the use of electronic monitoring methods and/or hands-on monitoring.

Gabapentin and trazodone

There are two studies examining the use of gabapentin as a sedative prior to veterinary treatment. The dose suggested from this work to give the highest chance of a beneficial effect is 20mg/kg PO around 2 hours prior to examination.  The effects were noted to have worn off around 8 hours post administration, something that should be discussed with owners as ataxia and salivation may be noted during this period.

A study examining the use of trazodone prior to transportation for veterinary examination administered 50mg PO and observed reduced anxiety, as scored by both the owner and the veterinary surgeon in 10 healthy cats compared to a placebo group. In another study of 12 healthy cats, the same oral dose of 50mg was administered, with no differences noted in echocardiographic measurements before and after trazodone, although systolic BP was reduced with no change in HR. Sedation was observed in all cats.

Further work is required on the administration of gabapentin and trazodone, in particular when used in combination to achieve the most appropriate effect and reduce stress associated with handling and examination of our feline patients.

In the clinic setting ask the client, where possible to administer 20mg/kg gabapentin (either liquid or tablet) at home around 2 hours before they are due to leave for the clinic. The dose should be towards the lower end of the range if there is already documented evidence of renal disease. If the cat is already in the clinic then this may be administered prior to examination (allowing 1 to 2 hours) and procedures. If this proves insufficient within this time period and the cat cannot be safely restrained for IM injection then trazadone 5-10mg/kg may be administered orally in addition, with an expected onset time of around 30 to 90 minutes. The use of gabapentin and/or trazodone, either at home or during the clinic visit does not preclude administration of further sedation or proceeding to anaesthesia, but dose adjustment of any subsequent medications may be required.

For hospitalised cats, gabapentin at 5-10mg/kg BID may be considered to provide a calming effect and reduce the stress associated with being in the clinic and away from home. The dose may have to be adjusted during hospitalisation depending on the effect observed.

Alfaxalone

There are a number of studies examining the use of alfaxalone, administered by the IM and SC routes in cats for sedation. It has been shown to be comparable (when used with butorphanol) to other sedative combinations and is likely to prove extremely useful in cases where full examination is not possible and there are concerns about concurrent cardiac, renal or other disease. It is best used in combination with another sedative or analgesic drug, and care should be taken to consider the volume that is required. When high volumes are required or in larger cats the dose may need to be split to allow safe injection and to ensure minimising pain on injection.

Alfaxalone has been studied at doses most commonly in the 2-3mg/kg IM range in combination with butorphanol (0.2-0.4mg/kg IM) and its sedation is usually effective within 15-30 minutes, with a duration of effect of around 45 minutes. One study compared 2mg/kg with 5mg/kg and observed the 5mg/kg to provide more effective sedation and did not find any significant adverse effects between doses. The volume to be administered with 5mg/kg is likely to be the most significant issue with this high dose, and importantly, this high dose may not always be required. I would advise starting with 2-3mg/kg, and use the lower end of the dose range in cases with anticipated comorbidities and in the geriatric feline. A study examining echocardiographic measurements in healthy cats administered alfaxalone 2mg/kg and butorphanol 0.2mg/kg IM documented reduction in ejection fractional shortening, but no other measurements were affected. This information gives some confidence to using this protocol when performing investigations into undiagnosed cardiac disease, with further caution, in terms of dosing, advised in the sick or compromised patient. When sedating a sick, fractious feline patient it is important to consider the list of items detailed above to ensure patient safety.

Alfaxalone has also been administered using the SC route. In one study 3mg/kg alfaxalone was combined with butorphanol 0.2mg/kg SC in cats diagnosed with hyperthyroid disease. The time to maximal sedation was around 45 minutes, and this must be considered when using this approach to ensure sufficient time for the desired effect. Another study investigated 3mg/kg alfaxalone SC with 0.02mg/kg buprenorphine IM. Note here that two separate injections were used which may be a problem in certain difficult cases, and therefore combining the two drugs may be more appropriate. The SC route may be useful in larger cats or those with muscle wastage, provided they can be restrained adequately for injection.

Further sedation

Once the patient is calm enough for IV placement, blood sampling and clinical examination these results should be used to decide on the selection of additional, appropriate sedation if required. Further sedation options will be best administered by the IV route and may include the alpha-2 agonists, benzodiazepines and opioids.

Continuing or converting to anaesthesia

If the plan is to continue on to anaesthesia or conversion to anaesthesia is required then IV access is essential prior to this step. The level of sedation achieved with the drugs administered so far must be considered when calculating the patient’s requirements for induction of general anaesthesia and endotracheal intubation, primarily to ensure excessive depth of anaesthesia is avoided in this initial period. If a surgical procedure is planned then appropriate analgesia should be provided prior to the procedure commencing. Even when butorphanol was administered as part of the sedation protocol then a mu opioid agonist, such as methadone or buprenorphine may still be given at this time. Monitoring during anaesthesia should ensure patient safety and be appropriate with regard to the planned procedure.

Recovery

The recovery period may be prolonged when oral and IM or SC sedation has been used, and there are no antagonists or reversal agents to the sedatives used. Good patient monitoring in the recovery period is essential, including regular checks of body temperature and cardiorespiratory status and provision of analgesia if required. Some patients may show signs of excitability in the immediate recovery period, which generally passes within the first 30 to 60 minutes. Ataxia and muscle weakness may be evident for several hours, and if patients are discharged home then owners should be advised to keep their cats indoors overnight to prevent injury. Finally, care must be taken to recover the feline patient in an appropriate environment to ensure they can be safely transferred to the owner to be discharged from the clinic.

Article by
Carl Bradbrook
BVSc CertVA DipECVAA FRCVS.

RCVS and EBVS® European Specialist in Veterinary Anaesthesia and Analgesia.

Carl graduated from the University of Liverpool in 2002 and after a few years in mixed practice undertook a residency in anaesthesia and intensive care at The Royal Veterinary College. He has worked in both private and university specialist centres and most recently worked as an independent anaesthesia consultant. 

Carl is an RCVS Recognised Specialist and a European Veterinary Specialist and is currently President of the Association of Veterinary Anaesthetists. Carl joined Anderson Moores Veterinary Specialists in October 2018. In 2020 he was awarded Fellowship of the Royal College of Veterinary Surgeons. His main areas of interest are the use of regional local anaesthetic techniques, monitoring of ventilation and neuroanaesthesia.

Originally published: Wednesday, 12th August 2020

References

Further reading

Deutsch J, Jolliffe C, Archer E, Leece EA, 2017. Intramuscular injection of alfaxalone in combination with butorphanol for sedation in cats. Vet Anaesth Analg. 44(4)

Fries RC, Kadotani S, Vitt JP, Schaeffer DJ, 2019 Effects of oral trazodone on echocardiographic and hemodynamic variables in healthy cats. J Feline Med Surg. 21(12): 1080-1085.

Granfone MC, Walker JM, Smith LJ, 2018. Evaluation of an intramuscular butorphanol and alfaxalone protocol for feline blood donation: a pilot study. J Feline Med Surg. 20(8): 793-798.

Hudec CP, Griffin CE, 2020. Changes in the stress markers cortisol and glucose before and during intradermal testing in cats after single administration of pre-appointment gabapentin. J Feline Med Surg. 22(2): 138-145.

Orlando JM, Case BC, Thomson AE, Griffith E, Sherman BL, 2016. Use of oral trazodone for sedation in cats: a pilot study. J Feline Med Surg. 18(6): 476-82.

Pankratz KE, Ferris KK, Griffith EH, Sherman BL, 2018. Use of single-dose oral gabapentin to attenuate fear responses in cage-trap confined community cats: a double-blind, placebo-controlled field trial. J Feline Med Surg. 20(6): 535-543.

Reader RC, Barton BA, Abelson AL, 2019. Comparison of two intramuscular sedation protocols on sedation, recovery and ease of venipuncture for cats undergoing blood donation. J Feline Med Surg. 21(2): 95-102.

Ribas T, Bublot I, Junot S, Beaufrere H, Rannou B, Gagniere P, Cadore JL, Pariaut R, 2015. Effects of intramuscular sedation with alfaxalone and butorphanol on echocardiographic measurements in healthy cats. J Feline Med Surg. 17(6): 530-6.

Stevens BJ, Frantz EM, Orlando JM, Griffith E, Harden LB, Gruen ME, Sherman BL, 2016. Efficacy of a single dose of trazodone hydrochloride given to cats prior to veterinary visits to reduce signs of transport- and examination-related anxiety. J Am Vet Med Assoc. 249(2): 202-7.

Tamura J, Ishizuka T, Fukui S, Oyama N, Kawase K, Itami T, Miyoshi K, Sano T, Pasloske K, Yamashita K, 2015. Sedative effects of intramuscular alfaxalone administered to cats. J Vet Med Sci. 77(8): 897-904.

van Haaften KA, Forsythe LRE, Stelow EA, Bain MJ, 2017. Effects of a single preappointment dose of gabapentin on signs of stress in cats during transportation and veterinary examination. J Am Vet Med Assoc. 251(10): 1175-1181.

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Pain, what a Pain! (Part 2) – Practical Tips On How To Perform Dental Nerve Blocks In Companion Animal Practice

In this second article of the Pain, what a Pain! series, Dan takes us through the LRA techniques associated with dental and oral surgery. In this article, you will find practical tips and pictures on common dental nerve blocks as well as safety concerns to consider.

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​Peri-anaesthetic mortality and nonfatal gastrointestinal complications in pet rabbits

This recent retrospective study looks at the cases of 185 pet rabbits admitted for sedation or general anaesthetic and evaluates the incidence and risk factors contributing to peri-anaesthetic mortality and gastrointestinal complications.

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Pain, what a Pain! How Locoregional Anaesthesia can Improve the Outcome and Welfare of Veterinary Patients (Part 1)

In this first article out of a series of two, Dan takes us through an introduction and practical tips for appropriate local anaesthesia delivery. Find out why these anaesthesia techniques, that are well recognised in human medicine, have seen an increase in popularity in veterinary medicine over the recent years

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Perspectives on Premeds – Opioids

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This second article aims to provide a refresher on opioids.

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Effects of Dexmedetomidine with Different Opioid Combinations in Dogs

Read the highlights of a recently published research paper that evaluates cardiorespiratory, sedative and antinociceptive effects of dexmedetomidine alone and in combination with morphine, methadone, meperidine, butorphanol, nalbuphine and tramadol. 

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Preoxygenation Study Highlights

This study evaluates the effectiveness of two methods of preoxygenation in healthy yet sedated dogs and the impact of these methods on time taken to reach a predetermined haemoglobin desaturation point (haemoglobin saturation (SpO2) of 90%) during an experimentally induced period of apnoea.

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Capnography – Not Just a Load of Hot Air

Capnography is the measurement of inhaled and exhaled carbon dioxide (CO2) concentration. The graphical illustration of CO2 within respired gases versus times is known as the capnogram.

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Perspectives on Premeds – Alpha-2 Agonists

Perspectives on Premeds is a series of articles touching on different pharmacological, physiological and clinical aspects of pre-anaesthetic medication. This first article aims to provide a refresher on α2 agonists.

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Alfaxan - now licensed for use in pet rabbits

Jurox Animal Health is delighted to announce that Alfaxan is now licensed for cats, dogs and pet rabbits. This is an exciting advance and could change the way rabbits are anaesthetised in the U.K.

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