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Proceedings of the
59th Annual Convention of the
American Association of
Equine Practitioners
- AAEP -
December 7-11, 2013
Nashville, TN, USA

Next Meeting :

Dec. 6-10, 2014 - Salt Lake City, Utah, USA

Reprinted in the IVIS website with the permission of the AAEP

Published in IVIS with the permission of the AAEP Close this window to return to IVIS

HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT

How to Safely Anesthetize a Horse for Sixty

Minutes or More in the Field

John A.E. Hubbell, DVM, MS, Diplomate ACVAA

Author’s address: Department of Veterinary Clinical Sciences, The Ohio State University, 601
Vernon L. Tharp Street, Columbus, OH 43210; e-mail: John.Hubbell@cvm.osu.edu. © 2013 AAEP.

1. Introduction be accomplished with the use of small doses of

Most equine veterinarians perform short-duration
anesthesia frequently, but only 10% anesthetize
horses for greater than 30 minutes weekly.1 Ap-
proximately 50% of equine veterinarians anesthetiz-
ing horses for greater than 30 minutes use inhalants
for maintenance of anesthesia, with the balance us-
ing repeated injections of induction drugs or guaife-
nesin recipes.1 Almost all equine veterinarians
(87%) anesthetizing horses for greater than 30 min-
utes use an assistant to monitor the depth of anes-
thesia and administer additional anesthetic drugs
as required.1 This report will provide recommen-
dations on how to safely anesthetize a horse for 60
minutes or more in the field with the use of inject-
able agents.
2. Background Information
The risks of morbidity and mortality increase with
increasing duration of anesthesia.2 The increase in
risk associated with longer anesthetic durations is
probably heightened in larger horses such as warm-
bloods or drafts because of the difficulty of assisting
in recovery in a field situation. Foals less than 1
month of age appear to be at increased risk for
anesthetic complications.2 Fortunately, most foals
respond to sedation and thus many procedures can
sedatives, such as xylazine, and physical restraint
combined with local anesthesia. The topic of anes-
thesia of the foal in the field has been addressed
previously.3
Successful management of equine anesthesia be-
yond short, single-administration techniques re-
quires careful evaluation of the patient and adept
planning of the procedure to keep the duration of
anesthesia to a minimum. An intravenous (IV)
catheter should be placed because constant-rate or
intermittent administration of anesthetic drugs is
required to maintain an anesthetic plane.4 The
site of anesthesia and surgery should be chosen on
the basis of avoiding hard surfaces, the availability
of padding (especially for the head), and the quality
of footing (nonslip), anticipating concerns during the
recovery phase. Padding, if available, should be
placed under the points of the shoulder and the hip.
For horses in lateral recumbency, the lower front leg
is traditionally pulled forward with the goal of re-
ducing pressure on the radial nerve.
Much of the success of equine field anesthesia is
predicated on the maintenance of light levels of an-
esthesia. The need to administer additional anes-
thetic agents to deepen the level of anesthesia is
determined on the basis of changes in respiration,

NOTES

472 2013 Ⲑ Vol. 59 Ⲑ AAEP PROCEEDINGS

Proceedings of the AAEP Annual Convention, Nashville, TN, USA - December 7-11, 2014
Published in IVIS with the permission of the AAEP
HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT
increases in muscle tone, or movement. Heart rate
and ocular signs are less reliable indicators of anes-
thetic depth when a ketamine-based technique is
used. Limiting movement while administering ad-
ditional anesthetic drugs is important; thus, most
practitioners combine restraint with ropes with the
anesthetic techniques.5
No single IV bolus injection of a drug or drug
combination safely produces 60 minutes of anesthe-
sia in the horse. Anesthesia should be induced
with the use of techniques described for short-term
equine field anesthesia.6 –10 The induction tech-
niques usually produce approximately 15 to 25 min-
utes of anesthesia. During this period, the horse
should be positioned for surgery and the halter re-
moved or loosened to prevent facial paralysis as a
result of compression of the facial nerve.
The use of intravenous infusions is preferred, but
intermittent boluses of the induction drugs can be
used. Xylazine and ketamine can be given at the
rate of 30% to 50% of the initial dose (xylazine 0.5
mg/kg and ketamine 1.1 mg/kg) combined in the
same syringe.11 The administration of a second
dose of the combination extends the anesthetic pe-
riod approximately 10 minutes. Subsequent bo-
luses in response to movement appear to be less
effective, perhaps because sympathetic activation is
or may be associated with the variations in anes-
thetic depth. Co-infusions of xylazine and ket-
amine have been used to extend short-term IV
anesthesia.12 Induction is accomplished through
the use of standard techniques, and an infusion of
xylazine (2.1 mg/kg per hour) and ketamine (5–7
mg/kg per hour) is begun. The technique has been
used for durations of 70 minutes.
Guaifenesin recipes (combinations) are widely
used to extend anesthesia beyond 20 minutes in the
horse. Guaifenesin (5%) solution is combined with
xylazine and ketamine to produce a solution com-
monly referred to as “triple drip,” or “GKX.”13 “Tri-
ple drip” is formulated by adding 1000 to 2000 mg of
ketamine and 500 mg of xylazine to a liter of 5%
guaifenesin. The combination is administered to ef-
fect up to a rate of 2 mL/kg of body weight per hour.
The combination produces excellent muscle relax-
ation and suitable analgesia. The degree of muscle
relaxation and lack of movement are the best indi-
cators of the depth of anesthesia. The quality of
recovery is generally good if the anesthetic period is
kept to less than 1 hour. “Triple drip” should not be
used for anesthetics greater than 1 hour in duration
unless oxygen supplementation and respiratory sup-
port is provided. Guaifenesin in combination with
ketamine and detomidine can also be used to pro-
long field anesthesia.14,15 The recipe uses 10%
guaifenesin supplemented with detomidine (0.04
mg/mL) and ketamine (4 mg/mL), given to effect.
The required rate of infusion approximates 0.6 to 0.8
mL/kg per hour (approximately one half of the “tri-
ple drip” rate). Recoveries are generally longer
than after inhalant anesthesia but have been judged
Proceedings of the AAEP Annual Convention, Nashville, TN, USA - December 7-11, 2014
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good to excellent. Midazolam has been substituted
for guaifenesin in recipes with ketamine and xyla-
zine to produce IV anesthesia.16 Midazolam (50
mg), ketamine (1000 mg), and xylazine (500 mg) are
added to 1 liter of isotonic fluids and administered at
a rate of 2.2 mL/kg per hour. The combination is
infused at a rate equivalent to “triple drip” (2.2
mL/kg per hour) and is similarly effective, in the
author’s experience. The concentration of ket-
amine in the recipes has been varied, with increased
concentrations (2 mg/mL) recommended when par-
ticularly painful procedures are contemplated.3
The assumption of lateral recumbency at induc-
tion is associated with ventilation/perfusion mis-
matches that can cause hypoxemia. Horses
positioned in dorsal recumbency have further dete-
rioration of pulmonary function. Oxygen supple-
mentation through insufflation or the use of a
demand valvea is recommended, particularly when
anesthesia is extended beyond 60 minutes.17,18 Per-
sons performing IV anesthesia routinely should con-
sider the purchase of an oxygen tank and regulator
to facilitate emergency oxygenation and ventilation
of the patient.19 Placement of an orotracheal tube
helps to ensure a patent airway and facilitates the
administration of oxygen or the delivery of assisted
ventilation. Orotracheal intubation should be con-
sidered if there is risk of respiratory obstruction or
regurgitation or if the horse is to be positioned with
the neck in an abnormal position. Horses can be
ventilated by adapting a nasogastric tube onto a
pressure-reducing valve attached to an oxygen tank.
The tube is inserted into one nostril and the nasal
openings are momentarily occluded. The nostrils
are released when the chest wall rises to a normal
inspiratory level. The process is repeated until
spontaneous ventilation resumes. The techniques
described usually produce tolerable levels of cardio-
vascular depression, but, as anesthesia is extended,
the importance of monitoring increases.
3. Recommendations
Equine anesthesia should not be undertaken lightly.
The risk of morbidity or mortality in equine anes-
thesia is greater than that in the other commonly
anesthetized domestic species.2,16,17 A history
must be obtained, a physical examination must be
performed, and the results must be documented.
The horse’s body weight is estimated, and the amount
of drug to administer is based on that weight. If
significant fluid deficits are present, they should be
corrected before anesthetic induction and supple-
mented during the anesthetic procedure. All drugs
administered with the route and time of administra-
tion are recorded in the medical record. Indices of
cardiac and respiratory function are recorded at
least every 10 minutes during the anesthetic period,
and results are recorded. The horse should be mon-
itored until it returns to a standing position.
The assumption of lateral recumbency is associ-
ated with the development of ventilation-perfusion
AAEP PROCEEDINGS Ⲑ Vol. 59 Ⲑ 2013 473
Published in IVIS with the permission of the AAEP
HOW-TO SESSION: FIELD ANESTHESIA AND PAIN MANAGEMENT
mismatches and the shunting of blood through the
lungs resulting in less than optimal oxygenation.
This level of oxygenation is well tolerated for short
periods, but oxygen supplementation should be con-
sidered if anesthetic periods greater than 30 min-
utes are anticipated. Induce anesthesia using
drugs and techniques that are familiar to you.
The intravenous combination of diazepam or mida-
zolam and ketamine administered to horses fully
sedated with xylazine or detomidine is use-
ful. Once the horse is positioned for surgery (ap-
proximately 10 minutes after induction), an infusion
of guaifenesin in combination with xylazine and ket-
amine at a rate of 2.2 mL/kg per hour is begun.
The horse’s respiratory rate, heart rate, and muscle
tone are monitored, and the rate of infusion is ad-
justed up or down on the basis of the operator’s
assessment of anesthetic depth. The infusion is
discontinued as the surgery is completed. The
horse is rolled to lateral recumbency for recovery.
The halter and attached lead rope are replaced.
References and Footnote
1. Hubbell JAE, Saville WJA, Bednarski RM. The use of seda-
tives, analgesic and anaesthetic drugs in the horse: an elec-
tronic survey of members of the American Association of Equine
Practitioners (AAEP). Equine Vet J 2010;42:487– 493.
2. Johnston GM, Taylor PM, Holmes MA, et al. Confidential
enquiry of perioperative equine fatalities (CEPEF-1): prelim-
inary results. Equine Vet J 1995;27:193–200.
3. Bidwell LA. How to anesthetize foals on the farm for minor
surgical procedures, in Proceedings. Am Assoc Equine Pract
2009;55:48 – 49.
4. Wagner AE. Balancing total intravenous anesthesia and
inhalant anesthesia in horses, in Proceedings. Am Assoc
Equine Pract 2009;55:7–12.
5. Robertson JT, Muir WW. Physical restraint. In: Muir WW,
Hubbell JAE, editors. Equine Anesthesia Monitoring and
Emergency Therapy. 2nd edition. St Louis: Saunders Else-
vier; 2009:109 –120.
6. Hubbell JAE. Options for field anesthesia in the horse, in
Proceedings. Am Assoc Equine Pract 1999;45:120 –121.
474 2013 Ⲑ Vol. 59 Ⲑ AAEP PROCEEDINGS
Proceedings of the AAEP Annual Convention, Nashville, TN, USA - December 7-11, 2014
Close this window to return to IVIS
7. Branson KR. Sedation and anesthesia for field surgeries, in
Proceedings. Am Assoc Equine Pract 2011;57:296 –298.
8. Muir WW, Skarda RT, Milne DW. Evaluation of xylazine
and ketamine hydrochloride for anesthesia in horses. Am J
Vet Res 1977;38:195–201.
9. Kerr CL, McDonell WN, Young SS. A comparison of romifi-
dine and xylazine when used with diazepam/ketamine for
short duration anesthesia in the horse. Can Vet J 1996;37:
601– 609.
10. Brock N, Hildebrand SV. A comparison of xylazine-diaze-
pam-ketamine and xylazine-guaifenesin-ketamine in equine
anesthesia. Vet Surg 1990;19:468 – 474.
11. McCarty JE, Trim CM, Ferguson D. Prolongation of anes-
thesia with xylazine, ketamine, and guaifenesin in horses:
64 case (1986 –1989). J Am Vet Med Assoc 1990;197:1646 –
1650.
12. Mama KR, Wagner AE, Steffey EP, et al. Evaluation of
xylazine and ketamine for total intravenous anesthesia in
horses. Am J Vet Res 2005;66:1002–1007.
13. Greene SA, Thurmon JC, Tranquilli WJ, et al. Cardiopul-
monary effects of continuous intravenous infusion of guaife-
nesin, ketamine, and xylazine in ponies. Am J Vet Res 1986;
47:2364 –2368.
14. Taylor PM, Kirby JJ, Shrimpton DJ, et al. Cardiovascular
effects of surgical castration during anaesthesia maintained
with halothane or infusion of detomidine, ketamine, and
guaifenesin in ponies. Equine Vet J 1998;30:304 –309.
15. Taylor PM, Luna SPL, White K, et al. Intravenous anaes-
thesia using detomidine, ketamine and guaiphenesin for lap-
arotomy in pregnant pony mares. Vet Anaesth Analg 2001;
28:119 –125.
16. Hubbell JAE, Aarnes TK, Lerche P, et al. Evaluation of a
midazolam-ketamine-xylazine infusion for total intravenous
anesthesia in horses. Am J Vet Res 2012;73:470 – 475.
17. Martinez EA, Wagner AE, Driessen B, et al. American Col-
lege of Veterinary Anesthesiologists guidelines for anesthesia
in horses. Available at http://www.acva.org/docs/Equine. Ac-
cessed December 27, 2012.
18. Hubbell JAE. A review of the American College of Veteri-
nary Anesthesiologists guidelines for anesthesia of horses, in
Proceedings. Am Assoc Equine Pract 2008;54:48 –53.
19. Hubbell JAE. Review of support of ventilation in the anes-
thetized horse, in Proceedings. Am Assoc Equine Pract
2010;56:33–37.
a
Equine demand valve, JD Medical Distributing Co, Inc, Phoe-
nix, AZ 85029 – 4914.