Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Andrea Brodie — Sun, 15 Nov 2020 20:15:15 GMT

I tend to pretty much stick to www.vasg.org protocols. Gives me a variety of safe choices adapted to whatever practice situation I am in (I am a relief vet).

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Benjamin Alyoshkin — Sun, 15 Nov 2020 14:06:59 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226455#226455"]n essence I believe that a one size fits all approach isn't the way to go, there are too many variables and that includes surgical skill which will affect the analgesia needed for these cases.[/quote]

Completely sharing this approach. As a locum, my access to routine surgery varies depending on assignments, routine blanket analgesia and anaesthesia in the last 3-4 years was possible in charity shelters abroad, but the means of monitoring surgical patients there were limited. In the UK, for healthy uncomplicated neutering procedures I tend to think but not always end up using the following multi-modals:

DOG castration: buprenorphine 0.02mg/kg or methadone 0.3mg/kg +/-medetomidine 5-20 ug/kg intramuscular in same syringe +/-midazolam 0.2mg/kg 20-30 min pre-induction,

Bitch spay: methadone 0.3mg/kg +/-medetomidine 5-20 ug/kg intramuscular in same syringe +/-midazolam 0.2mg/kg 20-30 min pre-induction

+ lidocaine 2% i/d on each side of incision line, intratesticular, +/-splash prior to closure

CAT castration: triple (buprenorphine 0.02mg/kg, medetomidine 60ug/kg, ketamine 6mg/kg, but taken on board what other contributors say about using quadruple and reducing the discomfort of stinging and risk of staff trauma. I’ll move to quadruple from now on or use ketamine separately with delay, as many of my triple inductions already are two-step - partial im for as long as the cat tolerates it before the needle comes out, then I normally wait until the animal is deeply sedated to inject the remaining cocktail.

Spay: buprenorphine 0.02mg/kg or methadone 0.3mg/kg +/-medetomidine 20 ug/kg + midazolam 0.2mg/kg intramuscular in same syringe 20-30 min pre-induction

+ lidocaine 2% i/d on each side of incision line, intratesticular, +/-splash prior to closure

RABBITS: both sexes

Buprenorphine 0.05mg/kg im

EMLA cream on clipped ear(s) ca30 min prior to induction

Medetomidine 0.05mg/kg iv

Ketamine 5mg/kg in 5ml saline iv or 10mg/kg im

ivft 4ml/kg

+ lidocaine 2% i/d on each side of incision line, intratesticular, +/-splash prior to closure

I prefer not to use ACP for routine neutering procedures as there are more reliable and reversible medx available, unless there is no choice in the surgery in question. Ironically, I have developed an acquired ‘taste’ for occasionally using ACP with methadone for healthy non-brachycephalic animals for uncomplicated sedation, seems to be the wrong timing as many surgeries I go to now do not stock injectable ACP.

The biggest discovery for me this summer was a clinical discussion at a wildlife shelter with a leading world wildlife anaesthetist, who does not strictly use the multi-modal approach I graduated with in 2013, which is a revelation for me. They are a strong advocate of ketamine with a powerful alpha2 including in canids, mustelids, arguing the case of it being a safe drug. I recently had a perfect candidate, used ket at 6mg/mg with medetomidine, midazolam 0.2mg/kg as opiates did not seem to be the option (rightly or wrongly) for that dog, all went really smoothly.

A couple of years ago, another anaesthetist suggested that buprenorphine in cats, for reasons not completely understood, can be a better analgesic than methadone, and can be given on top of it, if methadone does not appear to give the required pain relief. Wonder if there are any thoughts on that out there?! Another factor on opiate mechanism from the same anaesthetist was to give all of them im, not s/c, the former gives analgesic, latter - sedative effect...

I enjoy good pain control and anaesthesia but sadly cannot say the same about monitoring using the equipment, seems to have lost many skills of perianaesthetic control so heavily reliant on nurse team nowadays.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Arlo Guthrie — Wed, 11 Nov 2020 10:30:07 GMT

[quote userid="14901" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226604#226604"]Methadone / ACP / medetomidine / meloxicom premed, propofol induction, iso or sevo maintain. [/quote]

A warm welcome to the forums Nicola Valentine Great name, by the way. Same as my grandparents (and my middle name!)

While I'm here, can I persuade a few more of you to vote for the post you've found most interesting, helpful, or agree with.

Luke Bam is in the lead at the moment, but we haven't had a lot of votes (I am not sure why not!)

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Nicola Valentine — Wed, 11 Nov 2020 08:58:04 GMT

Methadone / ACP / medetomidine / meloxicom premed, propofol induction, iso or sevo maintain.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Ross Milner — Wed, 11 Nov 2020 03:23:26 GMT

We used a 0.1 ml per 10 kg dose of domesedan and torbugesic for dogs in my practice for many years in UK followed by propofol and isoflurane , cats had same but aproximately 0.2 mls per 5 kg domesdan and torbugesic . I like the idea of having a reversing agent for premed if needed , especially for those patients taking a while to wake up post operatively.

Interestingly im now doing locums in New Zealand, and back to acp/morphine/atrophine premed and iv alfaxon for induction and maintained on isoflurane. They seem to sleep for an awful long time afterwards compared to what im used to!

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Anthony Dennison — Mon, 09 Nov 2020 17:33:59 GMT

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226506#226506"]I've routinely done the 2 syringe approach for a few years now and notice no loss in time and have happier cats[/quote]

Fair point, my experience is a lot of cats react to just the dom & torb syringe as well but it may be my injection technique. In a very busy practice like ours it just takes preparation and planning which can be lacking some days, forming a log jam.

But then that is educating our staff better rather than giving up on it, so the 2 injection method will continue, which I'm fine with on the whole.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Lindsey Edwards — Sat, 07 Nov 2020 16:08:43 GMT

I give dom/torb together then administer ket once cat is drowsy and it takes effect whilst clip/prep takes place. Less reactive cars and less risk of staff injury, would need to wait for sedation before clipping for most of my rural cats anyway!

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Neil Wheadon — Fri, 06 Nov 2020 13:11:56 GMT

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226497#226497"]Cats - triple combination DTK. I prefer to do it all in one syringe, but recently as a practice the protocol has been to give the dom and torb, wait a few minutes then give the ketamine 'because then there's less of a reaction to the ketamine'. Means things take longer which can be frustrating. [/quote]

Balance the 'lost minute' maybe against a cat on feeling the ketamine sting, goes through the roof, bites a nurse and you never get the whole dose in properly.

I've routinely done the 2 syringe approach for a few years now and notice no loss in time and have happier cats

Neil

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Dinu Catilina — Fri, 06 Nov 2020 12:32:32 GMT

I'm not an anaesthetist so take my views with a pinch of salt. We also do not touch ACP anymore and we use only medetomidine/methadone for painful procedures but at 0.2mg/kg methadone.

We changed for BOAS surgery from methadone to paracetamol only and found a massive difference, dogs are breathing better in recovery and I think this has something to do with the laryngeal relaxation caused by methadone.

We use IV paracetamol on everything other than cats.

Triple for cats and I will intubate with the largest tube possible and no cuff.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Anthony Dennison — Fri, 06 Nov 2020 09:43:50 GMT

Our normal dog premedicant is ACP/Methadone (buprenorphine for dog castrates)

Animals with a higher ASA grade, I have recently been using 0.2mg/kg each of midazolam and comfortan (I think after a discussion on here when I had a caesarian crash and die on me). Works very well, though sometimes higher doses of propofol are required.

Reasoning for using ACP?

We tried switching to medetomidine and methadone but were finding dogs going really bradycardic and it made all our nurses nervous.

Cats - triple combination DTK. I prefer to do it all in one syringe, but recently as a practice the protocol has been to give the dom and torb, wait a few minutes then give the ketamine 'because then there's less of a reaction to the ketamine'. Means things take longer which can be frustrating.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Iain Richards — Thu, 05 Nov 2020 09:48:23 GMT

Spash block. Funny this, it's niggled me for a while about them that while I was happy to sue them and the idea of direct analgesia was sound, something wsan't right - I'd forgotten abou thte pH issues.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Arlo Guthrie — Thu, 05 Nov 2020 08:37:00 GMT

(Arlo Guthrie - assume such a reply OK and this is a discussion - or are you wanting a single post and for us to shut up?)

[/quote]

Yes, discuss away.

Looks to me, as a non-vet, as though this discussion is developing in the way that I hope it would. Thoughtful posts and although I am supremely ill-qualified to judge, it seems like some ideas and thoughts being shared which even old hands might find interesting.

If you agree, please use the share buttons at the top right of the thread to share a link to this discussion in any facebook groups you may be a member of, or use the email link to colleagues you think might be interested in joining in, or reading.

And please do VOTE for any posts which you found interesting, or leaned something from, or strongly agree with. Link in the bottom right hand corner. Luke Bam currently in the lead, but not many votes yet!

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Chris Barker — Thu, 05 Nov 2020 07:55:54 GMT

[quote userid="4367" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226441#226441"]NItrous in the gas mix[/quote]

Nitrous seems to have been forgotten by most people Wouldn't be without it, adding analgesia and thereby minimising the % of gaseous agent necessary. And as it blow off so quickly, lightening the patient at the end of the procedure is simple and swift. And you can use it in rebreathing circuits if you use them semi-open . We train all our RVNs with it, but it seems to be the forgotten agent

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Neil Wheadon — Wed, 04 Nov 2020 23:55:53 GMT

[quote userid="8991" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226457#226457"]I'm not sure about splash blocks. They are commonly used but there is a wide pH difference between e.g. lidocaine and animal tissue which makes direct surface absorption very slow (it's why EMLA cream doesn't work). It's a different story if injected of course as a lot of that will go into cells. Most studies looking at splash blocks of different procedures (OVH, TECAs) show no improvement in pain scores with splash blocks. [/quote]

That's an interesting comment because I do try to inject it using an insulin syringe with a fine needle as I was never convinced it wouldn't just run off the tissues.

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226456#226456"]Very interested - obviously my bias is large animal work so more of my surgical patients are awake than asleep. Do you use procaine/mepivacaine as the licenced options or jump to human products?[/quote]

Being a locum, I don't order things. I use the lidocaine from the crash boxes. Bought in vials of 10 they often approach their sell by date so in my eyes it's not costing a great deal. Out of interest I used to use the 100ml farm animal bottles for disbudding but SA practices don't have this. Any informed opinion on this?

Neil

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

David Mills — Wed, 04 Nov 2020 23:40:44 GMT

You live and learn. Hypnovel not much cheaper for 20 x 1ml single (daily) use vials so wouldn't be restrictive. Depends on the number of neuters I suppose, and it has plenty of other uses.

[quote userid="3169" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226456#226456"]I may need to revisit Comfortan. Don't like the recording aspect. Licenced doses suggested to be too high and may explain apnoea when we started with it. Have used it occasionally since, but not a fan. Still seems effective as top up analgesia (in more major ops) despite the theory that butorphanol will reverse it (thinking sedate to radiograph, discover #).[/quote]

0.2-0.3mg/kg normally sufficient, some use lower, it's lower in quads. Can use as CRI as well, very effective.

The theory of being reversed by butorphanol is a bit of nonsense. For that to be true to any clinically significant effect all the mu opioid receptors would have to be occupied (they aren't, probably about 10-20%). Same applies for when people say you can't top up buprenorphine (or butrophanol) with methadone - still works well. If you're concerned about reversing, just stock some naloxone, works very quickly and effectively. You'll be recording ketamine anyway so it's only one more entry.

Quads offer lower doses of all the components so possibly a safer anaesthetic. There is improved analgesia from the methadone. You can reverse the medetomidine before 45 minutes because of the midazolam. Midaz gives good muscle relaxation and gets young animals eating post-op. The recovery with lower doses of other agents is very quick. They go down within 2-3 minutes and the injection stings less as less ketamine in it.

I'm not sure about splash blocks. They are commonly used but there is a wide pH difference between e.g. lidocaine and animal tissue which makes direct surface absorption very slow (it's why EMLA cream doesn't work). It's a different story if injected of course as a lot of that will go into cells. Most studies looking at splash blocks of different procedures (OVH, TECAs) show no improvement in pain scores with splash blocks.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Michael Woodhouse — Wed, 04 Nov 2020 23:23:23 GMT

[quote userid="14235" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226439#226439"]I believe butorphanol is a mu receptor antagonist rather than partial agonist and although historically I realise many have used this quite happily in combination with additional analgesics, we now try to avoid its use in any ‘painful’ procedure. [/quote]

The world's greatest resource (Wikipedia) says:

Butorphanol exhibits partial agonist and antagonist activity at the μ-opioid receptor, as well as partial agonist activity at the κ-opioid receptor (K_i = 2.5 nM; EC₅₀ = 57 nM; E_max = 57%)

If you put 5ml of butorphanol into the vein of a 500kg colicing horse (when on farm, with a limited formulary), your belief in it's analgesic qualities will be restored.

Tend to agree. Tried it as a new grad with medetomidine (both at the same time and 20-30 mins later) for spays and found unreliable sedation, unpredictable analgesia and unstable anaesthetics.

*cough* Dormazolam from Dechra. Horse licence but we have to use a vet product 1st. 28 day broach and £20 a bottle makes a few cat neuters expensive.

I may need to revisit Comfortan. Don't like the recording aspect. Licenced doses suggested to be too high and may explain apnoea when we started with it. Have used it occasionally since, but not a fan. Still seems effective as top up analgesia (in more major ops) despite the theory that butorphanol will reverse it (thinking sedate to radiograph, discover #).

[quote userid="8958" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29467/open-discussion-what-is-the-best-anaesthetic-and-analgesia-protocol-with-reasons-for-routine-neutering-in-healthy-animals/226455#226455"]I use local anesthesia whenever I can. If I cut the abdominal muscles if I miss the linea they get splash blocks. I also use local infiltration of the surgical site. I feel local is highly underrated.[/quote]

Very interested - obviously my bias is large animal work so more of my surgical patients are awake than asleep. Do you use procaine/mepivacaine as the licenced options or jump to human products?

I don't mean to be an arse with the cascade, but it is law. I think for a level playing field we should stick to it wherever possible. What does the quad protocol offer me that triple doesn't?

(Arlo Guthrie - assume such a reply OK and this is a discussion - or are you wanting a single post and for us to shut up?)

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Neil Wheadon — Wed, 04 Nov 2020 23:11:11 GMT

Good question, locumming in many practices I see all sorts of combinations

Completely agree with this. Note the following anecdote

A recent practice changed to this and they had issues where the dogs appeared deeper than they were. Quite un-nerving to pull on something and the legs move

I actually quite like ACP, familiarity maybe, however see far too many microdoses used often with 0.5ml max quoted whilst the Derek Flaherty chart is on the wall giving greater doses. In one memorable place the inductions were awful (breath holding, head swinging, limb flaying) simply because they were afraid to use enough premed (solved when 1ml/40kg used)

I'm working with a nurse at the moment who has an interest in anesthesia. We used a dose specifically designed for pugs and in both the anesthesia was faultless, she has another combo for French Bulldogs, will try that. Maybe a lesson is to tailor for different breeds?

I use local anesthesia whenever I can. If I cut the abdominal muscles if I miss the linea they get splash blocks. I also use local infiltration of the surgical site. I feel local is highly underrated.

In essence I believe that a one size fits all approach isn't the way to go, there are too many variables and that includes surgical skill which will affect the analgesia needed for these cases.

Neil

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

David Mills — Wed, 04 Nov 2020 18:13:27 GMT

Cats - quad medetomidine/ketamine/methadone/midazolam.

I don't see an issue with licensing. There is no veterinary licensed midazolam. The 'combination' argument for licensing is nonsense to my mind - if we were to adhere to that then we wouldn't use polypharmacy. And if I don't want to use d/t/k then it doesn't apply anyway.

Quad GAs are superb. Quick recoveries. No iso required <45minutes. Have done fracture repairs under these and oxygen only. Very little post-op pain.

NSAID after induction, giving after tissue damage seems pretty pointless.

Dogs - premed medetomidine and methadone, place IV catheter, propofol induction. IV NSAID and paracetamol for all procedures unless contraindicated (paracetamol - can't really think of one other than being feline). ACP rarely used other than for heat stroke.

Buprenorphine - crap drug to my mind. Analgesia onset is 45 minutes (sedation 5-10 minutes). Variable activity, long action means often get animals slower recoveries and looking depressed. Some vets seem to love it, giving it for everything admitted (inlcuding vo/di cases - bizarre). I think it actually causes more profound sedation, anorexia and a dog/cat looking 'ill' than pure mu opioids. Hate it. Would gladly get rid of it.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Iain Richards — Wed, 04 Nov 2020 17:52:01 GMT

Not far off, but I'd be having methadone in the mix rather than butorphanol for dogs. It allows better control and top up if needed.
Alfaxan for preference, but propofol is fine

NItrous in the gas mix

Cats - young neuters get dom/torb/ket essentailly 0.1/.02/0.1 same syringe i/m enough to do a spay, although we got in teh habit of a tube for O2 and meant we could top up if playing hunt the ovary. REverse with 0.05 atipam.

If older or longer op then as for dogs.

Essentail that whatever one uses the triad is tick - analgesia, relaxation, narcosis

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Luke Bam — Wed, 04 Nov 2020 17:20:39 GMT

I do like the idea of everything being licensed for combined use, but at the same time we have ran a few analgesia audits for our routine neutering and have adjusted our analgesia protocols accordingly.

I believe butorphanol is a mu receptor antagonist rather than partial agonist and although historically I realise many have used this quite happily in combination with additional analgesics, we now try to avoid its use in any ‘painful’ procedure.

The following apply to the ‘average’, young, fit and healthy animal:

Cat spays and castrates tend to be given medetomidine and burpenorphine. Admittedly the level of sedation is not as heavy as with butorphanol, but our audit a few years ago suggested they were more comfortable. Always receive perioperative NSAID (generally meloxicam) and will also get three days post-op NSAID for the spays.

Dog castrates receive buprenorphine and medetomidine in most cases although I would consider swapping to methadone for a more boisterous dog due to the improved sedative effect (and also if I was performing a scrotal ablation). Peri and post op NSAID of course.

Bitch spays generally receive methadone and medetomidine. Peri and post-op NSAID a must.

Induction is achieved through IV propofol or Alfaxalone depending on vet preference. We maintain anaesthesia using isoflurane and oxygen generally via an ET tube but will mask cat castrates if safe to do so.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Joyce Whitehead — Wed, 04 Nov 2020 16:12:30 GMT

I use exactly the same as Michael for cats, medetomidine/ketamine/butorophanol and nsaid when reversed or just about to be. Female cats home on a few days of meloxicam (our standard pre op nsaid), Tom cats just a jab on the day.

Cats get oxygen by mask, I only tube if expected to be a longer surgery, eg pregnant.

Dogs all tubed and maintained on iso, with multiparameter monitor as well as nurse with stethoscope and anaesthetic chart for all.

Dogs vary a bit more, agressive or overly nervous dogs I use medetomidine and butophanol, at 0.1ml/10kg, slightly more medetomidine if a very large dog, again much the same as Michael. I like to give my nsaid (generally meloxicam) at premed, although some of my colleagues give it once asleep. My more routine premed is acp/buprenorphine in the same syringe, usually s/c unless we are short of time and then IM. I give acp at 0.1ml/10kg usually, and bupe at 0.02mg/kg. This is a fairly low acp dose but it’s what I’m happy with. Years ago I worked for a vet that used to give massive acp doses (like 1.5ml to a 25kg dog) and saw too many fainting dogs for my liking!

I definitely prefer to work with what I know.

All dogs sent home with a 10ml bottle of metacam to use for 4-7 days, unless we can’t get it in which case it might be carprofen.

RE: Open Discussion: What is the best anaesthetic and analgesia protocol, with reasons, for routine neutering in healthy animals?

Michael Woodhouse — Wed, 04 Nov 2020 14:39:21 GMT

Dogs:

Medetomidine/butorphanol premed (0.1ml/10kg of each, bit higher if small or bouncy, max out at 0.5/0.5 in a big dog)

NSAID (usually carprofen, but have been using meloxicam due to supply issues) at premed, home with 3-5 days of carprofen

Propofol induction (via IV cannula)

Iso maintanance

Cats:

Medetomidine/butorphanol/ketamine - triple comination in the same syringe

NSAID at same time as triple if friendly, when asleep if more frisky. Home with 5ml bottle of generic meloxicam (unless cat castrate then no further NSAID)

O by mask and iso if needed (rarely)

Justification:

Everything licenced (including in combination). Excellent analgesia and sedation from medetomidine, whilst protecting blood pressure - nice stable anaesthetics.

Reversable if there is a problem (although also reverses analgesic properties so don't do so routinely).

Cost effective, multi dose vials and marketplace competition.

We know tubing cats is a risk, and unless spraying lots of water/blood in the mouth then it's not one I want or feel the need to take

I know partial agonist a tad contraversial (versus methadone), but I tried it, found more apneoa and animals no happier post op.Use if something especially painful after surgery or for more major things (like orthopaedics). More likely to reach for paracetamol is a wimp.

I remember the old adage - a safe anaesthetic is a familiar one. I've tried pretty much everything (except sevo) and very happy with this for simplicity with stable anaesthetics.

Don't keep ACP injection in the practice anymore.