Oral Sedation

Question 1

What is the active metabolite of Trazodone?

Answer 1

m-chlorophenylpiperazine

Question 2

What 3 injectable agents can be given oral transmucosal for oral sedation? Why are they commonly given at high doses?

Answer 2

1. Acepromazine
2. Dexmedetomidine
3. Buprenorphine

part of them are expected to be swallowed and undergo significant hepatic first-pass metabolism

Question 3

What is the mechanism of action of Trazodone? What causes the sedation?

Answer 3

blocks serotonin reuptake into presynaptic neurons and enhances release norepinephrine from presynaptic neurons

blocks alpha-1 adrenergic activity and antihistamine activity

Question 4

What occurs with moderate doses of Trazodone?

Answer 4

• blocks peripheral alpha-adrenergic activity
• blocks peripheral effects of serotonin, epinephrine, norepinephrine, and histamine

Question 5

What adverse effects have been noted in Trazodone usage in dogs and cats?

Answer 5

DOGS - sedation, increased appetite, behavioral disinhibition, vomiting, increased excitement, hepatotoicosis

CATS - drowsiness, paradoxical agitation, vocalization, GI bleeding (NOT COMMONLY USED)

Question 6

What drugs is it not recommended to use Trazodone with?

Answer 6

other antidepressant classes

• monoamine oxidase
• serotonin-norepinephrine reuptake inhibitors
• serotonin reuptake inhibitors

(one-time dose pre-hospital is safe)

Question 7

What is the use of Trazodone and SNRIs/SRIs associated with?

Answer 7

serotonin syndrome - agitation, restlessness, panting, hyperthermia, tachycardia, hypertension

Question 8

What is thought to be the mechanism of Gabapentin? What 3 effects does it have?

Answer 8

binds alpha-2 subunit of voltage-gated calcium channels, which influences glutamate, norepinephrine, and substance P

1. seizure control
2. neuropathic pain
3. sedation

Question 9

Why must liquid formulation of Gabapentin be used carefully?

Answer 9

may contain xylitol, which is toxic to dogs and birds

Question 10

What is excretion of Gabapentin important in cats?

Answer 10

high amounts of renal excretion —> reduce doses or there will be prolonged effect of sedation

Question 11

What are the 3 important aspects of the chill protocol for aggressive and fearful dogs?

Answer 11

1. Gabapentin (20-25 mg/kg) and Trazodone night before
2. Gabapentin, Melatonin, and Trazodone morning of, 2 hours before appointment
3. Acepromazine OTM 30 mins before appointment

Question 12

What medications are recommended for mild sedation?

Answer 12

• Butorphanol
• Midazolam (sicker/older)
• Acepromazine (healthy/younger)

observation a minimum —> may need O2 and monitors

Question 13

What medications are recommended for moderate sedation?

Answer 13

• Butorphanol
• Acepromazine
• low dose Dexmedetomidine

requires monitoring: pulse ox, BP, face mask O2, ECG

Question 14

What medications are recommended for profound sedation? In cats?

Answer 14

• Butorphanol
• increased Dexmedetomidine

CATS: add Ketamine or Alfaxalone

requires monitoring: pulse ox, BP, face mask O2, ECG

Question 15

What are the 3 most common “recipes” for at home oral sedation in cats?

Answer 15

1. 10-40 mg/kg of Gabapentin 2-3 hours before arrival or 2 hours before handling
2. Buprenorphine OTM at 0.03 mg/kg 1-2 hours before
3. Buprenorphine OTM + Acepromazine OTM 2 hours before arrival

Question 16

What are the 4 most common “recipes” for at home oral sedation in dogs?

Answer 16

1. Trazodone at 5-10 mg/kg 1-2 hours before arrival (lower dose for large dogs, higher dose for small dogs)
2. Gabapentin 10-20 mg/kg 2-3 hours before arrival + Acepromazine OTM 30 min before travel
3. Phenobarbital at 6-10 mg/kg 2 hours before travel
4. Dexmedetomidine 10-30 ug/kg OTM 20 minutes before handling

Question 17

How does time affect usage of oral sedation in-hospital?

Answer 17

TIME PERMITTING = same options as oral at home, but may not be effective due to in-hospital nervousness

SHORT ON TIME = rectal administration of Trazodone (Gabapentin capsules are not well absorbed)

Question 18

What does oral sedation aim to avoid?

Answer 18

• anxiety, fear, stress, pain
• high levels of induction and maintenance drugs in patients that won’t stay asleep
• injury to patient or staff

Question 19

What 5 things can stress before a procedure lead to?

Answer 19

1. autonomic, metabolic, hormonal, immunological and neuroendocrine changes
2. sympatho-adreno-medullary axis activation = fight or flight; increased HR, BP, RR, catecholamines, SNS activity, arrythmias
3. increased anesthetic requirements
4. hypothalamic-pituitary-adrenal axis activation = prolonged stress (increased glucocorticoids)
5. increased morbidity and mortality

Question 20

What 3 things does prolonged stress lead to?

Answer 20

1. sensitization to pain
2. longer post-surgery recovery
3. delayed healing

Question 21

What issues should be considered when using chemical restraint?

Answer 21

• What do you need to achieve?
• How long does it need to last?
• What are underlying important issues?
• What are the CNS, cardiovascular, respiratory, and hepato-renal consequences?

Question 22

What is considered mild sedation?

Answer 22

patient is responsive to stimulus, but less excitable/anxious, commonly used for physical exams, nail trims, and blood draws

Question 23

What is considered moderate sedation? What monitoring is commonly required?

Answer 23

patient is recumbent, but able to change positions and react to stimuli

mask administration of O2 and monitoring highly recommended

Question 24

What is considered deep sedation? What monitoring is commonly required?

Answer 24

MOST COMMON level of sedation used in vet med where the patient is recumbent, responds to stimuli, but is not easily aroused - laceration repair, FB removal

mask administration of O2, monitoring required; if you can intubate, you should!

Question 25

Why is multimodal anesthesia/analgesia recommended?

Answer 25

• can be catered to specific patient needs
• allows the use of lower doses of each drug, resulting in decreased side effects