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Anaesthesia: where can we maximise efficiency and save time?

The anaesthetic process: where can we maximise efficiency and save time?

Improving efficiency and “saving time” are key to increasing throughput in busy clinical practice, especially when the normal working environment has been disrupted, where there is an increased demand for services, or when surgical lists become overloaded.  This article provides potential solutions for some common bottlenecks and inefficiencies during the anaesthetic process. A summary of the main points can be downloaded here.  For additional information please follow the links to more comprehensive articles or consult the publications in the further reading and reference lists. 

Planning

The principles of time management are based on an adage developed by the British Army: “Proper Planning and Preparation Prevents Poor Performance”.  Brian Tracey (https://www.briantracy.com/) said “Every minute you spend in planning saves 10 minutes in execution”. This principle is applicable to all areas of veterinary practice, including anaesthesia, where bottlenecks or efficiencies have been identified. The use of forward planning, tailor-made anaesthetic protocols, and the utilisation of checklists, can deliver considerable time and cost saving benefits, and potentially expedite increased productivity and revenue.    

Anaesthetic checklists

Anaesthetic checklists are simple, standardised, quickly completed devices with a limited number of steps that are designed to reduce morbidity and mortality whilst improving efficiency and productivity.  Checklists are an aide memoire for all essential steps in the anaesthetic process: from the point of admission and patient assessment through to recovery and discharge. Checklists facilitate the identification of small errors which, if overlooked, could lead to devastating results, and they are invaluable in busy and/or stressful clinical settings.  They emphasise teamwork; effective communication e.g. handover of cases; situation awareness/management; and decision-making. To be used effectively one person should read the questions out loud and record the response, and a second person should perform the checks (Gasson & Wager, 2013; McMillan, 2016).  It may be necessary to have a separate brief checklist for each stage of the anaesthetic process.  Good teamwork from experienced anaesthetists, surgeons, nurses and support personnel will help ensure the best possible outcome and although there may be some initial resistance to the introduction of anaesthetic checklists the benefits will be rapidly recognised, and their use will become routine. For further information on checklists please click on the following links: 
Are you using safety checklists in your practice?
ASA Classification and Patient Safety Checklists
Association of Veterinary Anaesthetists (AVA) Anaesthetic Safety Checklist and the AVA Anaesthetic Safety Checklist Implementation Manual

Pre-anaesthetic assessment

Prior to any anaesthetic, and regardless of procedure, even if minor or routine, every patient should be thoroughly assessed via signalment, acquisition of a detailed medical history and execution of a thorough physical examination. All appropriate diagnostic procedures should be performed, and an American Society of Anaesthesiologists (ASA) physical status score allocated (see below).  The keys to performing a successful anaesthetic, to reducing patient risk and to improving efficiency are the identification of patient factors that may influence the procedure. This information will then permit appropriate anaesthetic planning and preparation.

Although every patient should have an individually tailored anaesthetic protocol some animals e.g. brachycephalics, rabbits, gastric dilatation & volvulus, Caesarean section or cardiac patients, are at higher risk of anaesthetic related morbidity or mortality (Brodbelt et al, 2008). Therefore, anaesthetic protocols for these patients may require specific modifications to provide the most appropriate and efficient anaesthetic experience. For further information on anaesthesia for specific conditions or species please click on the following links: 
The gastric dilation and volvulus (GDV) patient
Cardiac patients
Brachycephalic dogs
Dental procedures
Geriatric patients
Canine Cushing's disease
Rabbits
Coronary circulation in the rabbit
Caesarean sections - pre-anaesthetic considerations.

ASA physical status classification

Brodbelt et al (2008) calculated the peri-anaesthetic death rate in healthy (ASA I-II) dogs to be 1:1849 but for ASA III-V patients, where physical status was significantly compromised, the risk increased to 1:75, with inadequate monitoring and hypothermia the most important causal factors. Therefore, following all pre-anaesthetic assessments an ASA physical status category should be assigned.  The ASA classification can give direction for selection of the most suitable anaesthetic protocols (see below) and will aid in the identification of potential issues that may arise so that advanced planning for such eventualities can be performed.  As mentioned above, planning and preparation will save not only time but potentially devastating consequences for the patient. The following links provide more detailed information on the value of ASA physical status classification: 
Achieving Safer Anaesthesia with ASA
ASA Classification and Patient Safety Checklists
Downloadable ASA Veterinary Guide

IV cannulation

Short-term peripheral intravenous (IV) cannulation provides secure and patent access, optimises the speed and efficacy of drug, fluid and blood product administration (Beal & Hughes, 2000), reduces the potential for tissue irritation/tissue necrosis following accidental perivascular administration (Crow, 1997), provides a means for blood sample collection (Tan et al, 2003), and reduces the incidence of sepsis, thrombus formation, thrombophlebitis, and air emboli (Brismar & Nystrom, 1986; Karapinar & Cura, 2007; Nickel, 2019). A patent IV cannula, together with planning for anaesthetic emergencies, facilitates the efficient management of such events. Peripheral IV cannulation also offers improved patient welfare by avoiding the requirement for repeated injections. For further information on IV cannulation please click here

Premedication

Balanced anaesthesia is “a technique of general anaesthesia based on the concept that administration of a mixture of small amounts of several neuronal depressants (narcotics and inhalation agents) maximises the advantages, but not the disadvantages of, the individual components of the mixture” (Stedman, 2011). Premedication is a vital component of most anaesthetic procedures and has considerable effects on the characteristics of the ensuing induction, maintenance and recovery.

Premedication should always be tailored to the individual patient and take into consideration the clinical history, species & breed, age, personality, ASA Physical Status, the proposed procedure and its probable duration, and the anticipated or current severity of pain.  The experience of the anaesthetist and surgeon and the availability of equipment and facilities should also be born in mind. Set “routine” protocols and blanket premedication should be avoided as there is no “one size fits all”.

The route of administration and dose of each drug can influence the intensity of the effect, the speed of onset and duration of effect. Intravenous administration of premedicants can be advantageous as lower doses of drugs may be possible compared to the intramuscular or subcutaneous routes and the time to peak effect, and therefore induction of anaesthesia, will generally be shorter than other routes, thus saving time.  Additionally, the intensity and duration of clinical effects, and the potential to be antagonised, will guide the speed of recovery. 

Different premedication protocols have varying effects on: the reliability and duration of sedation and anxiolysis; the degree, speed of onset and duration of analgesia; the extent of dose sparing on other anaesthetic or CNS depressant drugs; the scale of cardiovascular and/or respiratory depression; muscle relaxation; and on whether some or all of the drugs can be antagonised. No single drug possesses all of the characteristics required for premedication in most patients therefore multiple products tend to be co-administered.  Most commonly a combination of phenothiazines (acepromazine), alpha-2 agonists (medetomidine or dexmedetomidine), opioids (methadone, buprenorphine or butorphanol), or benzodiazepines (diazepam or midazolam) are used.  Some authors describe the use of the ASA physical status classification to broadly select the most suitable premedication and anaesthetic protocols (Murrell, 2007; Murrell, 2016). Link to ASA/premed NL presentation PDF

For further information on the characteristics of each premedicant drug please click on these links: Opioids; Phenothiazines/acepromazine; Alpha-2 agonists; Benzodiazepines.

Further reading – Murrell (2007) & Murrell (2016)

Preoxygenation

The delivery of 3 minutes of supplemental oxygen prior to induction of anaesthesia has been demonstrated to delay haemoglobin desaturation in the event of apnoea by approximately 5 minutes compared to 1 minute for animals breathing room air (McNally et al, 2009).  Delivery by facemask is the most effective but if the patient is not amenable an option is to use flow-by although it is less effective (Ambros et al, 2018).  The Alfaxan Multidose SPC states preoxygenation is essential in pet rabbits prior to induction of anaesthesia.  Although preoxygenation takes approximately 3 minutes immediately prior to (and during) induction, the knowledge that there is generally a 5 minute delay to desaturation should apnoea occur reduces the levels of stress during IPPV. However, appropriate use of induction agents will minimise the incidence of apnoea (see below). 

Induction - route of administration and effects on efficiency

The route of administration of induction agents can have a significant effect on the speed of onset, and duration, of anaesthesia.  When administered intravenously the dose of induction agent can be controlled and titrated to effect, and lower doses of drugs may be possible compared to intramuscular or subcutaneous administration, thus aiding a more rapid recovery. Drug absorption is reliable following intravenous administration generally producing a rapid onset and shorter duration than via other routes.  The early onset of stage III anaesthesia provided by intravenous induction permits rapid intubation and therefore efficient oxygenation and volatile control of anaesthetic depth, together with protection of the airway from regurgitation. Intramuscular administration e.g. the “triple”, is generally a pre-determined, one dose, mixture that cannot be titrated to effect and individual responses can vary.  Time to onset, peak effect and recovery following IM administration are slower than IV (Seymour & Gleed, 1999) and larger doses are  often required.  As airway management may not be as rapid as that provided by IV induction there is a potential for regurgitation/aspiration, and for hypoxia should respiratory depression occur.  Subcutaneous administration of anaesthetic induction agents, when compared to IM, has similar or more profound issues: inability to titrate to effect; large doses required; slower onset of action; wide variability in response; potential for prolonged recovery (Seymour & Gleed, 1999).  See table 1.

The intravenous administration of induction agents is key to not only delivering a more clinically acceptable experience for the patient, but it also provides a time saving advantage and improved efficiency i.e. rapid onset of action and shorter duration, leading to a measured recovery. For further information on routes of administration please open this article on IV induction of anaesthesia

Please click here to download a PDF of this table

Optimising recovery

Delayed recoveries can be potentially detrimental to the patient, are stressful for both the animal and the clinic staff, and can be both time and financially costly. Some of the main causes of delayed recoveries are hypothermia, hypotension, hypoglycaemia, and the effects of drugs administered as part of the anaesthetic protocol.

Hypothermia

Heat loss commonly begins as soon as premedicants are administered and temperature management should be considered an essential part of any anaesthetic.  Pottie et al (2007) described that for every 1oC fall in core temperature metabolic rate declines by 10% with a resultant increase in recovery times. Brodbelt et al (2008) reported that the recovery times of hypothermic patients were twice as long as normothermic animals and were also less predictable. In dogs and cats hypothermia is generally accepted to begin at temperatures below 36°C although recent studies suggest the clinical effects begin prior to this cut-off (Pottie et al, 2007).  In addition to delayed recoveries other consequences of hypothermia include: depression of the central nervous system with consequential reduction in minimal alveolar concentration (MAC) of volatiles and reduced requirement for other CNS depressant drugs; ventricular arrythmias as a result of myocardial irritation; suppression of the baroreceptor reflex; increased blood viscosity and increased myocardial work-load; post-operative shivering with resultant increased myocardial oxygen demand (by up to 400%) (Mohta et al, 2009; Self, 2015) together with a left-shift of the oxyglobin-haemoglobin dissociation curve impeding the uptake of oxygen by the tissues; reduced muscular activity potentially leading to hypoventilation; depression of the immune system; reduced urine production with consequential reduced drug/drug metabolite elimination; hypocoagulation potentially leading to haemorrhage (Duke-Novakovski et al, 2016). 

Management of body temperature, including regular monitoring, should begin following premedication and continue through to recovery and discharge.  For further information on hypothermia please follow this link.  

Should a patient with a normal temperature experience a delayed recovery then other potential aetiologies e.g. hypoglycaemia and/or hypotension should be investigated and consideration given to antagonising the effects of administered drugs. For further information please click on the following links:
Anaesthesia for brachycephalic patients
Anaesthesia for geriatric patients
Anaesthetic considerations for dental procedures
Canine Cushings disease and anaesthetic considerations
Blood pressure management
Opioids
Benzodiazepines/acepromazine
Alpha-2 agonists
Benzodiazepines

Analgesia and nursing

Excitable recoveries are unpleasant for both the patient and staff, and can be time consuming to manage.  Although there are multiple causes of such recoveries, the main ones are a full bladder (Mosing, 2016) and inadequate analgesia.  The bladder of all patients, regardless of whether they have/are receiving fluid therapy or not, should be checked and managed prior to recovery.  Inadequate analgesia may occur in the recovery period for several reasons e.g. the clinical effects of analgesics administered at the time of premedication have declined; actual pain is greater than anticipated; inappropriate (or no) analgesic selected. Generally, opioids, administered in the premedication protocol, are the mainstay of pain relief. If the analgesic effects have declined then a “top-up” should be administered prior to recovery.  If an opioid has been administered that does not provide adequate analgesia it should be changed to a more appropriate drug (Murrell, 2007; Dugdale, 2010; Kerr, 2016; Murrell, 2016) and multimodal analgesic techniques used where appropriate (see below). Additional information may be found in this article on opioids.

The administration of several drugs with analgesic properties and with differing mechanisms of action e.g. opioids, non-steroidal anti-inflammatory agents, local anaesthetics and drugs such as ketamine, alpha-2 agonists or paracetamol (not cats), will maximise the pain relief (multimodal analgesia) and can play a significant role in ensuring a smooth anaesthetic and a controlled recovery.  The use of locoregional anaesthesia e.g. via dental nerve blocks, line/splash blocks, intratesticular blocks for castration, wound soaker catheters, are simple and inexpensive ways of maximising analgesia and should considered for all surgical patients. Further information on multimodal analgesia may be found in the following links:
Practical acute pain assessment
Introduction to local anaesthesia
Dental nerve blocks
Opioids
Alpha-2 agonists

From this information it is clear that the regular and meticulous monitoring and management of temperature, together with thorough nursing care and careful selection of analgesic and anaesthetic drug protocols, are essential for patient welfare and time management.

The information in article is summarised in this useful quick-reference guide.


Patient stability and the time saving benefits of Alfaxan Multidose

In the UK Alfaxan Multidose, with the active ingredient alfaxalone, is currently licenced for intravenous induction of anaesthesia in the dog, cat and pet rabbit, and for the maintenance of anaesthesia for up to 60 minutes (via bolus or constant rate infusion) in the dog and cat.  The neutral pH and aqueous formulation mean it does not cause discomfort on injection and does not irritate tissues if inadvertently administered perivascularly.  Alfaxan Multidose can be used with all commonly administered classes of premedicants e.g. opioids, alpha-2 agonists, phenothiazines (acepromazine) and benzodiazepines. It can be readily incorporated into current anaesthetic protocols and conversion to its use is easily learned with minimal stress. For detailed information on alfaxalone, it's benefits, and a comparison to other commonly used induction agents, please click on the following links:

Induction characteristics

The intravenous administration of alfaxalone typically provides a reliable, rapid and smooth induction with minimal stage II excitation.  Intubation can be completed promptly thus reducing the risk of regurgitation/aspiration, and the transition to volatile maintenance is efficient, timesaving and stress-free.

Respiratory stability

The incidence of apnoea is low with alfaxalone if it is administered slowly (Luna et al, 2004; Grint et al, 2008; Muir et al, 2008; Muir et al, 2009; Schnell et al, 2014). In a study by Metcalfe et al (2014) the incidence and duration of apnoea in bitches admitted for Caesarean section were less with alfaxalone than with propofol. Indeed, Keates and Whittem (2012) demonstrated that it required 2.5 times more alfaxalone than propofol (based on the SPC dose) to cause the same degree of apnoea in dogs. Despite this, preoxygenation prior to induction of anaesthesia is recommended and the Alfaxan Multidose SPC states it is essential in pet rabbits.  The low incidence of apnoea with Alfaxan Multidose demands minimal ventilatory support and can therefore provide considerable labour-, time- and cost-saving benefits. A summary of the findings of Keates & Whittem (2012) may be found by clicking the link.

Cardiovascular stability

A cardiovascularly balanced patient potentially has a reduced requirement for intervention as a result of e.g. hypotension, and the maintenance of cardiac output preserves tissue perfusion, peripheral pulse and mucous membrane colour thus contributing to anaesthetic stability.  Unlike some other induction agents, when Alfaxan Multidose is used as recommended there is minimal depression of the cardiovascular system with only marginal changes to blood pressure. This is thought to be due to preservation of the baroreceptor reflex (Muir et al, 2008; Okushima et al, 2014) which generates the frequently observed compensatory increase in heart rate (Muir et al, 2008; Muir et al, 2009; Psatha et al, 2011; Okushima et al, 2014). Okushima et al (2014) demonstrated that alfaxalone was more likely to maintain or increase HR at anaesthetic induction after opioid premedication than propofol i.e. propofol resulted in a greater negative chronotropic effect. Please follow the link for a summary of the paper by Okushima et al (2014).

ASA III-V patients

Psatha et al (2011) demonstrated that alfaxalone was suitable for induction of anaesthesia in dogs considered to be a high anaesthetic risk (ASA physical status category III-V). The study compared fentanyl & diazepam induction (+/- propofol), which is considered a “gold standard”, cardiovascularly friendly protocol, with alfaxalone alone.  Blood pressure remained stable compared to pre-induction values and did not differ between protocols. In Caesarean section patients both placental and foetal blood flow are pressure dependent therefore, the minimal cardiovascular depression afforded by alfaxalone may be beneficial in maintaining blood pressure and foetal perfusion.  A summary of the Psatha et al (2011) study may be accessed by clicking the link.

Muscle relaxation & intubation

The good muscle relaxation which follows the administration of Alfaxan Multidose can be beneficial during endotracheal intubation, especially in pet rabbits and brachycephalic patients.  As described above, efficient intubation delivers rapid control of the airway permitting oxygen administration and volatile maintenance, and also offers protection of the airway from regurgitation/aspiration.

Transition to volatile maintenance

A full IV induction dose of alfaxalone provides stage III anaesthesia for approximately: 8-12 minutes in the dog; 20-25 minutes in the cat; and 10 minutes in the rabbit (Gil et al, 2012). As with all induction agents however, there can be individual variation.  The depth and duration of action generally allow sufficient time for airway management and a smooth transition to volatile maintenance without the need for high initial concentrations of volatile. Not only does this permit clinical staff to focus on patient monitoring and preparation but can also reduce the initial amount of volatile used, and therefore cost.

Metabolism & recovery

Alfaxalone undergoes rapid and predictable metabolism with a plasma elimination half-life of 25 minutes in the dog, 45 minutes in the cat, and 46 minutes in the rabbit (Alfaxan Multidose SPC, 2018).  This facilitates a smooth recovery with minimal hangover effects so the patient can be discharged clear-headed. In a study by Doebeli et al (2013b) dams induced for Caesarean section with alfaxalone had a significantly shorter recovery times than those induced with propofol (mean 10 vs 26 minutes respectively).

Due to the relatively short half-life of alfaxalone it is recommended that following completion of the clinical/surgical intervention all procedures e.g. cleaning, application of dressings, injection etc. be completed before ceasing administration of the volatile maintenance agent. To ensure a smooth recovery a suitable level of analgesia should be present together with a degree of sedation. This may necessitate topping-up, or adding to, the premedicant drugs.  The bladder should be checked and emptied if necessary and the patient then moved to a warm, quiet recovery area prior to extubation.  All stimulation e.g. noise, touch etc should be minimised although careful and regular monitoring should continue until the patient is fully recovered. 

As can be appreciated from the mean recovery times reported by Doebeli et al (2013b) (10 minutes for alfaxalone compared to 26 minutes for propofol) the smooth and predicatable recovery associated with alfaxalone can deliver considerable time saving benefits, and the animal can be potentially discharged earlier than following the use of other induction agents. 

Caesarean sections

When administered for induction of anaesthesia in canine Caesarean sections, including giant breeds (Melandri et al, 2019), alfaxalone has an excellent safety profile with puppy vigour, vitality and Apgar scores numerically superior to propofol (Doebeli et al, 2013a; Metcalfe et al, 2014). When combined with: the more rapid recovery than propofol (Doebeli et al, 2013b) (which permits early suckling, bonding and discharge): the cardiovascular stability; and the minimal apnoea (Metcalfe et al, 2014), the clinical and time-saving benefits of alfaxalone induction in these patients are clear. The following links are to articles discussing anaesthesia for canine Caesarean sections: Physiology & pre-anaesthetic considerations; Anaesthetic protocol options and peri-anaesthetic considerations. Please note these articles are currently being updated and will be published in the coming months.


Thus, induction of anaesthesia with Alfaxan Multidose, unlike some other induction agents, supports the preservation of cardiac output and tissue/organ perfusion aiding the maintenance of physiological equilibrium. Additionally, alfaxalone is a suitable induction agent for all ASA physical status category patients with no requirement to modify induction protocols.  

For detailed information on alfaxalone, it's benefits, and a comparison to other commonly used induction agents, please click on the following links:

Guidelines for optimising induction of anaesthesia in the dog, cat and rabbit, and for maintenance of anaesthesia in the dog and cat using Alfaxan Multidose, together with recommended doses, are summarised in the following downloadable documents:

 

Conclusion

  • Planning of individualised anaesthetic protocols and the use of checklists can eliminate time wastage and increase productivity.
  • Careful pre-anaesthetic assessments and assigning an ASA physical status category can assist in selecting appropriate premedication/anaesthetic protocols and highlight potential complications, or requirements for additional patient management, thus reducing the incidence of potentially devastating consequences and save time during periods of stress.
  • Intravenous cannulation allows rapid delivery of drugs, permits blood sampling and efficient management of emergencies.
  • Selecting a tailor-made premedication protocol, and administering the drugs intravenously (if appropriate for the patient and/or drug), the time from premedication to induction, and the duration of recovery, can be minimised.
  • The low incidence of apnoea when Alfaxan Multidose is administered for induction of anaesthesia reduces the requirement for IPPV with considerable time saving advantages as a result. 
  • Maintenance of a stable cardiovascular system following the use of Alfaxan Multidose reduces the requirement for intervention e.g. as a result of hypotension, in the early stages of general anaesthesia
  • The muscle relaxation observed following alfaxalone administration can be beneficial when intubating difficult patients such as rabbits and brachycephalics. 
  • The duration of clinical action of Alfaxan Multidose, together with minimal stage II excitement and efficient intubation, reduces the requirement for initially high volatile concentrations. This is not only economical but is less stressful than with some other induction agents and potentially reduces the incidence of volatile induced hypotension. 
  • The rapid metabolism of alfaxalone permits a controlled, clear-headed recovery, although adequate analgesia and a degree of sedation should be present. 
  • Alfaxan Multidose can be used for all ASA physical status categories including e.g. giant breeds and Caesarean sections, meaning that one induction agent can be used for all dog, cat and pet rabbit patients. 
  • Good nursing management of e.g. body temperature and pain together with ensuring the patient’s bladder is not full, will aid a smooth recovery. This allows a controlled return to a normal physiological state when nursing supervision can potentially be reduced, and the patient returned to a ward or discharged.  

A useful downloadable summary if the information in this article may be obtained here

Further reading

Dugdale A. (2010). Veterinary Anaesthesia: Principles to Practice. John Wiley & Sons.

Murrell J. 2007. Choice of premedicants in cats and dogs. In Practice29(2): 100-106.

Murrell J. (2016). Pre-anaesthetic medication and sedation. In: T. Duke-Novakovski., M. de Vries. & C. Seymour. (eds), BSAVA Manual of Canine and Feline Anaesthesia & Analgesia. (3rd ed).  British Small Animal Veterinary Association. Gloucester, UK

About Alfaxan Multidose 

Article by
Dr. Karen Heskin
BVSc CertSAO MRCVS

Veterinary Technical Manager, Jurox UK

Originally published: Wednesday, 15th July 2020

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Keep reading... More news items that may interest you.

Anaesthetic recovery: How can we minimise complications?

Anaesthetic recovery is a high risk period for complications and death (Brodbelt et al, 2008). In this article Courtney Scales DipVN NCert(Anaesth) RVN discusses how we can reduce the potential risks and improve the recovery experience for our patients.

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Paper summary: Nebulised adrenaline in the postoperative management of brachycephalic obstructive airway syndrome in a Pug

Laryngeal oedema is a potentially life-threatening complication of invasive BOAS surgery. In this case study by Ellis and Leece (2017) the use of nebulised adrenaline to successfully manage this condition is described.

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Reducing anaesthetic risk in the perioperative period – a team approach

Sadly, complications can occur during the peri-anaesthetic period with potentially detrimental effects on the patient. In this article Lou Northway, VNCertECC NCert(Anaesth) RVN, examines the most common causes of adverse peri-anaesthetic events and the steps that can be taken to reduce their incidence.

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Paper summary: Effects of hypothermia on recovery from general anaesthesia in the dog.

This paper by Pottie et al (2007) examines the effects of hypothermia on recovery from general anaesthesia in the dog.

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How can we calm and sedate the uncooperative kitty?

Uncooperative, aggressive or stressed cats are commonly encountered in the veterinary clinic. This article examines the aims for calming these patients, the importance of planning and considers selected sedative protocols.

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Paper summary: Intramuscular butorphanol/alfaxalone combination for sedation of cats prior to echocardiography

The sedation of cats prior to cardiac examination requires a drug protocol that has minimal effects on the cardiovascular system. This study examined a combination of butorphanol and alfaxalone administered intramuscularly on echocardiographic assessment and on cardiovascular function.

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Paper summary: The effect of propofol or alfaxalone on post-induction heart rate in healthy dogs

The maintenance of heart rate and cardiac output are essential to ensure adequate organ perfusion. This study by Okushima et al examined the effects of alfaxalone versus propofol on heart rate at the time of induction of anaesthesia.

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Paper summary: Effect of intravenous dose escalation with alfaxalone and propofol on the occurrence of apnoea in dogs.

Apnoea following induction of anaesthesia can result in both morbidity and mortality if not identified early and managed successfully. In this 2012 article by Keates and Whittem alfaxalone and propofol were administered to dogs at 1x, 2x, 5x, 10x and 20x multiples of the labelled dose to determine the incidence of apnoea and the respiratory safety profile of each drug.

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Intravenous induction of anaesthesia in dogs, cats and pet rabbits.

In this article Karen Heskin, Veterinary Technical Manager for Jurox UK, and Carl Bradbrook, RCVS & European Veterinary Anaesthesia and Analgesia Specialist and President of the Association of Veterinary Anaesthetists, discuss the three most commonly used intravenous induction agents for cats, dogs and pet rabbits in the UK. To complement this discussion we have created three useful summaries to download as quick reference guides for your clinical personnel.

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ASA Classification and Patient Safety Checklists

As clinics and hospitals reduce routine treatments and move towards critical and emergency care during the COVID-19 crisis, to complement our previously published articles on ASA classification and the use of checklists in anaesthesia, we have created this short slide presentation to act as a useful summary.

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Paper summary: Proportion of litters of purebred dogs born by Caesarean section.

It is recognised that brachycephalic dog breeds are more likely to experience dystocia and require Caesarean section. This study examined the influence of breed on the incidence of interventional surgery.

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Caesarean section. Part 1: Physiology relevant to anaesthesia.

In this first of four parts discussing anaesthesia for the Caesarean section we examine the anaesthesia-relevant physiological changes that occur during pregnancy.

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Under Pressure: Practical blood pressure assessment and management.

The monitoring of blood pressure under anaesthesia is critical for patient care. In this article Claire Roberts, RVN and owner of SynergyCPD, examines the physiology, monitoring and management of blood pressure in anaesthetised patients.

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Cardiovascular stability with Alfaxan Multidose

Cardiovascular stability is a major feature of Alfaxan Multidose. In this article we examine the benefits for your patients and the supporting evidence.

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Paper summary: Effect of lingual swab placement on pulse oximetery readings

This study by Mair et al (2016) examined what effect the placement of swabs of different thicknesses and colour would have on pulse oximetry readings.

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Practical pulse oximetry for the Veterinary Nurse

Pulse oximetry is one of the most commonly performed monitoring procedures in veterinary anaesthesia. In this article Courtney Scales, RVN and owner of Anursethesia discusses the why and how we use pulse oximeters, the advantages and pitfalls, and how to manage abnormal readings.

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Paper summary: Comparison of direct and oscillometric blood pressure assessment using a veterinary specific device

Blood pressure management requires accurate monitoring. In this summary of an article by Acierna et al (2013) we compare a veterinary specific oscillometric device to direct blood pressure measurement.

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Having their best interests at HEART: Coronary collateral circulation in the rabbit, stress & the effects of alpha-2 agonists, phenothiazines and volatiles.

How extensive is the coronary collateral circulation in the rabbit and what are the effects of stress and drugs on the heart of this species?

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Co-induction of anaesthesia. Is there a clear advantage?

In this article Matt Gurney, RCVS/ECVS specialist in Veterinary Anaesthesia and Analgesia, examines whether co-induction techniques are advantageous.

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What are the benefits of slow administration of alfaxalone and does co-induction with alfaxalone/midazolam have any benefits in healthy dogs?

In this summary of a study by Miller et al (2019) we examine if there are any benefits to an alfaxalone/midazolam induction over alfaxalone alone in the healthy dog.

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Peri-anaesthetic management of the gastric dilation and volvulus (GDV) patient

In this article Carl Bradbrook discusses the peri-ananesthetic management of the canine gastric dilatation and volvulus (GDV) patient.

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Paper summary: Clinical efficacy and cardiorespiratory effects of alfaxalone, or diazepam/fentanyl for induction of anaesthesia in dogs that are a poor anaesthetic risk.

In this summary of a paper by Psatha et al (2011) we examine the clinical benefits of alfaxalone in high-risk patients when compared to the induction protocol of diazepam + fentanyl.

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Getting to the HEART of the matter - considerations for anaesthetising the cardiac patient.

In this article Miranda discusses the challenges of anaesthetising patients with cardiac disease and how protocols can be modified to accommodate these patients.

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Paper summary: How does buprenorphine compare to butorphanol for postoperative analgesia in cats?

A prospective multi-centre clinical trial comparing buprenorphine vs butorphanol for postoperative analgesia in cats.

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Paper summary: Analgesic effects of maxillary and inferior alveolar nerve blocks in cats undergoing dental extractions.

With dental surgery one of the most commonly performed procedures in small animal practice, what benefits do dental nerve blocks provide in cats?

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What should we consider when anaesthetising patients, including geriatrics, for dental procedures?

What should we consider when anaesthetising both adult and senior patients admitted for dental treatment?

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Checklist for geriatric dental anaesthesia

This article summarises and combines "Anaesthesia for the geriatric patient" and "What should we consider when anaesthetising patients, including geriatrics, for dental procedures?" into a single checklist for anaesthesia for the geriatric dental patient. A downloadable summary is also available by following the link.

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How do we recognise, assess and treat chronic pain in companion animals?

In this article Ian Self, Associate Professor in Veterinary Anaesthesia and Analgesia, School of Veterinary Medicine and Science, Nottingham, reflects on the recognition, assessment and management options for chronic pain in companion animals

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The physiology of acute and chronic pain.

In this article, which accompanies " How do we recognise, assess and treat chronic pain in companion animals?", Ian Self describes the physiology of acute and chronic pain

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What should we consider when anaesthetising the geriatric patient?

With an increasing number of anaesthetics being performed in older pets is there anything we should be aware of or do differently? In this article Carl Bradbrook examines the management of anaesthesia in geriatrics..

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Paper summary: What effect does does rapid, high volume fluid therapy have on cardiovascular function?

In this summary of a paper by Valverde (2012) we examine the effects of high-volume, rapid fluid therapy on cardiovascular function and hematological values during isoflurane-induced hypotension in healthy dogs.

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Paper summary: Pre-anaesthetic screening of geriatric dogs

In this summary of a paper by Joubert (2007) we examine the value of pre-anaesthetic screening in geriatric dogs and how the results influence the anaesthetic process.

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Anaesthesia for Canine Cushing's disease: What should we assess and what should we monitor?

Cushing's disease (hyperadrenocorticism) is relatively common in the dog and this article discusses the appropriate pre-anaesthetic assessment we should perform and why careful monitoring is essential.

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Paper summary: How frequently are intravenous catheters removed as a result of complications due to bacterial contamination?

In this summary of a paper by Ramos (2018) we examine the incidence of bacterial colonisation of intravenous catheters removed as a result of cannula complication

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What's the Point? Peripheral Intravenous Cannulation.

Peripheral venous cannulation is a common invasive procedure in small animals, but what are the best-practice insertion techniques and what can we do to avoid complications?

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Rabbit Anaesthesia – Understanding Your Patient.

How does the anatomy, physiology, behaviour and response to drugs affect your decision making when anaesthetising the rabbit patient?

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Paper summary: Heated intravenous fluids alone fail to prevent hypothermia in cats under general anaesthesia.

In this summary of a paper by Jourdan et al (2017) we examine the common practice of warming intravenous fluids and the effect on patient temperature.

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​Considerations for anaesthesia of the brachycephalic dog.

In this article Matt Gurney discusses the induction of anaesthesia and intubation of the brachycephalic patient.

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Watch the induction and intubation of a brachycephalic.

Induction of anaesthesia and intubation of a brachycephalic dog with Matt Gurney.

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Paper summary: The effect of omeprazole on oesophageal pH in dogs during anaesthesia

This summary of a publication by Panti et al., examines the effect of orally administered omeprazole on gastro-oesophageal reflux in the anaesthetised dog.

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How does a syringe driver benefit your patients?

Syringe drivers are becoming increasingly commonplace in modern veterinary practice and are a useful tool for multiple applications. This article looks at the science behind constant rate infusions and the basics of syringe driver use.

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Paper summary: Pet owner opinions about anaesthesia, pain and surgery in small animals

In this paper we explore perceptions and opinions of Canadian pet owners about anaesthesia, pain and surgery in small animals.

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Achieving Safer Anaesthesia with ASA and Joanne Michou MA VetMB DipECVAA MRCVS

How can a Veterinary version of the ASA Physical Status Classification help you achieve safer anaesthesia? To find out how watch our webinar.

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Paper summary: ASA classification and risk of anaesthetic related death in dogs and cats.

This scientific paper assessed whether the American Society of Anesthesiologists (ASA) Physical Status Classification correlated with the risk of anaesthetic death in dogs and cats.

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New! Methadyne, Our New Methadone Now Available

This is our third product launch this year, and the latest addition to our anaesthesia and analgesia portfolio, Methadyne, contains 10mg/ml methadone as its active ingredient. It can be administered for analgesia of moderate to severe pain in dogs and cats, to provide neuroleptanalgesia, and as part of a patient’s premedication protocol prior to general anaesthesia.

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A retrospective comparison of two analgesic strategies after uncomplicated tibial plateau levelling osteotomy in dogs.

In this review we summarise a publication by Bini (2018) examining two protocols for the administration of methadone following TPLO surgery in dogs.

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Practical Acute Pain Assessment

In this summary of acute pain assessment, Carl Bradbrook examines why we should be monitoring patients for pain and looks at the commonly used scoring systems.

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Alfaxan for the maintenance of anaesthesia: Peer reviewed clinical papers.

In this article we have identified the key clinical peer reviewed papers to support the use of Alfaxan for maintenance of Anaesthesia in Cats and Dogs.

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TIVA or not? (Total intravenous anaesthesia).

In this article the Jurox UK Technical Team discuss the use of intravenous agents to maintain anaesthesia in the dog and cat.

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Benzodiazepines - can they help reduce anaesthesia related side effects?

In part 4 of this series on premedicant agents we examine the pros and cons of benzodiazepines.

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Paper summary: Effect of benzodiazepines on the dose of alfaxalone needed for endotracheal intubation in healthy dogs

This paper examined whether a benzodiazepine, administered as a co-induction agent with alfaxalone, improved endotracheal intubation, and reduced the dose of alfaxalone, in the dog

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Putting methadone in its place in your pain management.

In this article we examine why methadone could be considered the analgesic of choice for many of our patients and understand its importance in modern veterinary medicine. The article includes a link to a downloadable summary sheet.

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Food for Thought: Pre-anaesthetic Fasting

In this article Karen examines why we fast our canine and feline patients prior to anaesthesia and what the current recommendations are. Karen also investigates why rabbits are different and should not be starved before anaesthesia.

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​Purr-fecting Pain Management

In this article summary we examine which of the two opioids, buprenorphine or butorphanol, provides the most appropriate analgesia following ovariohysterectomy in the cat.

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Perspectives on Premeds - Phenothiazines: from Mental Health to Premedication

In this article from the Perspectives on Premeds series, Karen takes us through the properties and uses of phenothiazines in modern veterinary practice.

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Methadone with Acepromazine - when is enough, enough?

This study looks at the effects of three methadone doses combined with acepromazine on sedation and some cardiopulmonary variables in dogs.

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AceSedate®, Our New Acepromazine, Available Now.

We have extended our anaesthesia and analgesia portfolio with the launch of AceSedate®. Containing the tried and trusted, long-acting sedative agent acepromazine as its active ingredient, AceSedate can be used for the premedication, sedation and tranquilisation of cats and dogs.

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Time: is 30 minutes long enough?

This recent study examined whether the application of EMLA cream, for 30 or 60 minutes, would be a useful tool to improve patient compliance prior to intravenous cannula placement in the veterinary clinical practice setting.

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Caesarean Section Survival Guide. Part 2: Anaesthetic Protocol Selection & Peri-operative Considerations.

In this second instalment of the 2-part article, we explore premedication, induction, maintenance & monitoring, recovery and analgesia for the Caesarean section patient.

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Buprenorphine: it’s not all static in rabbits

Opioids are well known for causing gastrointestinal stasis in mammalian species. This recent paper examined the effects of a single high dose of buprenorphine on the rabbit gastrointestinal tract using non-invasive imaging techniques.

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Caesarean Section Survival Guide. Part 1: Physiology & Pre-anaesthetic Considerations.

In the first instalment of this 2-part review Karen examines the physiological changes that occur during pregnancy and how those adjustments can affect the selection of anaesthetic protocols for the increasingly common Caesarean section.

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No leeway for the spay: A comparison between methadone and buprenorphine for perioperative analgesia in dogs undergoing ovariohysterectomy.

This recent paper compares post-operative pain scores and requirement for rescue analgesia following premedication with methadone or buprenorphine, in combination with acepromazine or medetomidine, in 80 bitches undergoing ovariohysterectomy.

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Cardiac arrest - the human factor

Cardiac arrest in dogs and cats is, thankfully, relatively rare. However, when it does happen it can have devastating consequences for the animal, owner and the veterinary team. This study examined the common causalities leading up to a cardiac arrest with the aim of changing protocols to improve outcomes.

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Are you Using Safety Checklists in your Practice?

In this article, Carl focuses on the benefits of introducing a safety checklist in practice to reduce patient morbidity, mortality and to improve communication between members of the veterinary team. The article contains links to the AVA safety checklist as well as a link to a customisable list that you can adapt to your practice needs. 

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The Big Chill - Temperature Management in Sedated and Anaesthetised Patients

The effects of hypothermia are very far reaching throughout the peri-anaesthetic process. In this article, James takes us through the interesting mechanisms of body cooling and warming, the clinical relevance of hypothermia and what we can do to prevent it.

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Keeping the Finger on the Pulse -  Nuances in CV Monitoring

All patients are exposed to the risks associated with general anaesthesia. Continuously monitoring anaesthetised patients maximises patients safety and wellbeing. In this article, Dan takes us through the common monitoring techniques that provide information about the cardiovascular status of your patient. 

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Effect of Maropitant on Isoflurane Requirements & Postoperative Nausea & Vomiting

Despite being widely recognized in humans, postoperative nausea and vomiting (PONV), and the role of maropitant in reducing inhalational anaesthetic requirements have been poorly documented in dogs. This recent study evaluates PONV and isoflurane requirements after maropitant administration during routine ovariectomy in bitches.

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New! Alfaxan® Multidose Now Available

We are happy to announce we have enhanced our anaesthesia and analgesia portfolio with the introduction of Alfaxan®Multidose for dogs, cats and pet rabbits.

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Sevoflurane requirement in dogs premedicated with medetomidine and butorphanol

Little information is available about the effect that different doses of medetomidine and butorphanol may have when using sevoflurane for maintenance of anaesthesia in dogs. This recent study evaluates heart rate and median sevoflurane concentration required at different dose rates.

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Capnography II - What happened to the elephants? A summary of abnormal traces

In this second article of the capnography series, James provides a guide to a few of the most common traces that you will encounter during surgery. Scroll to the end of the article to download a printable capnography cheatsheet. 

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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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