Protecting My Puppy from Death by Veterinary Anesthesia

The scariest part of Moose’s recent dental abscess surgery was the anesthesia. After Falcon died, I began hearing a number of veterinary mistake horror stories, many of which were related to deaths caused by anesthesia.  While the specifics of each case varied, the narratives generally fell into one of two categories.

1. Inappropriate dose/medication – the dog/cat dies on the operating table, sometimes prior to the surgery.  In the cases where the pet owner did an autopsy, the report showed the vet used an inappropriate amount or type of medication than was required for that pet.
2. Death After the Surgery – the pet owner receives a call from the veterinary clinic after the surgery to report that the surgery went well, that the dog/cat is recovering and should be ready for pick up later that day.  When the pet owner goes to the vet to pick up their beloved pet, the vet informs them that the pet has died.

The explanations vary slightly, but in most cases, somebody at the vet mutters something about an allergic reaction to the anesthesia – a rare and completely unpredictable complication.  Their pet just happened to be one of the unlucky ones who had a reaction and unfortunately passed away.  In some cases, the pets are older, and the death is attributed to their age and/or a pre-existing health condition. But a surprisingly large proportion of the reported deaths are in young, healthy pets going in for spay/neuter procedures or teeth cleanings.

I want to emphasize that the stories I’ve heard are personal stories, often shared with me after somebody learned about the death of Falcon due to veterinary misdiagnosis and neglect.   I know many, many pet owners who have pets that have been spayed/neutered without issues or who have undergone surgical procedures with heart conditions and advanced age with no problems whatsoever. But, the proportion of anesthesia-related death stories I heard after Falcon’s death was striking.  Why was death from anesthesia so high amidst this select, unscientific gathering of people who have tragically lost their pets?  In my line of work, I’ve done a good amount of research related to medical errors in humans. And while the number of preventable deaths or injuries related to mistakes in human medicine is frighteningly high, I can’t remember a single anecdote about death by anesthesia. I know it happens in human medicine, but the volume of veterinary anesthesia horror stories I heard was alarming. And the stories of unnecessary loss were devastating and frightening.

How do I keep my dog safe during anesthesia?

When we chose to bring home such a tiny dog, we knew that Moose’s size would bring with it risks, one of which was anesthesia.  As he approached his first birthday, we spoke with our vet about the risks/benefits of neutering such a small puppy (2.5 pounds). Our vets (a husband and wife team who own and run a small clinic in Arlington, VA) talked us through the risks/benefits of the surgery. The biggest risk, of course, is anesthesia.  Because of his size, they felt they did not have sufficient experience anesthetizing such a small dog and that they weren’t comfortable using anesthesia with Moose. They gave us the names of several larger clinics that would have more experience with dogs of Moose’s size and would be better equipped to perform the procedure safely.  But our vet strongly recommended we consider taking Moose to a hospital associated with a veterinary school, so that the anesthesia would be overseen and administered by a board-certified veterinary anesthesiologist.  Then she told me something I found shocking – very few vet clinics actually have an anesthesiologist on staff and in most cases, the anesthesia is administered by a veterinary technician. While there are many excellent, well trained veterinary technicians, not all states require them to be licensed. Most had been trained on anesthesia, and many were very experienced in dosing dogs and cats for a variety of surgeries.  But, regardless of experience, the level of training and licensing seemed frighteningly low, especially compared to human medical standards.  No wonder I had heard so many deaths by anesthesia stories!

Moose was healthy and the risk of our 2.5-pound, city-apartment-dwelling Maltese finding a female dog small enough for him to hump, while she was in heat, is pretty minimal. So, my husband and I did what every frightened, busy, hyper-analytic dog owner would do. Think about it. (I’ll discuss why I’m not sure this is smart on a later blog post.)

When we learned that Moose had a tooth abscess that would no doubt require surgery, we knew we had to confront the anesthesia issue.  While I knew that there would always be risks associated with anesthesia, I was determined to learn as much about the process as possible, so that I could be sure that his care was the best we could find.  I put on my patient advocate hat, and I got to work.

I started with friends, asking anybody and everybody I knew who had a pet or was involved with pet care if they had experiences with anesthesiology and any tips that I should take into consideration. I emailed a Yahoo news group of other Maltese owners that Moose’s breeder moderates, asking for advice, suggestions and any information resources that might be helpful. I received some helpful suggestions, but I needed more.

From there I went to google, scouring pet-related Web sites and blogs, looking for tips, suggestions and advice. When that turned up surprisingly little information, I went to the veterinary professional societies. There I got lucky: Both the American College of Veterinary Anesthesiologists and the American Animal Hospital Association had both recently released guidelines for anesthesia and anesthesia monitoring.  I reviewed the information in detail and found some articles that were written when the guidelines were released. I found some incredibly helpful overviews of procedures and standards of care, as well as a number of interesting facts and figures (More on that in my related post.)  One thing that was missing from these documents, however, was basic background on what the process of delivering the anesthesia entailed. What were the steps, and what types of medications would be used?  I tried finding journal articles, but I could find no general review articles on the process, only articles about research into specific anesthesia issues.

Through a friend, I made contact with an incredibly helpful, understanding dog owner who also happened to be a member of the faculty at Cornell Veterinary School.  She was very helpful in walking me through the process of delivering the anesthesia.  Since I couldn’t find it anywhere else, I’ve provided my notes from the overview she provided during our conversation.  (Please note: I’m pretty sure this is an accurate representation of what was described, but any mistakes are no doubt related to my note taking and/or inability to read my own handwriting, rather than that of the gracious interviewee.)

Administering Anesthesia: Process and Protocol Overview

• The process begins with a sedative to calm the dog, typically ketamine with Valium or dexcetomidine (which helps with pain).
• Once sedated, the anesthesiologist inserts an IV into the dog’s vein, typically on the front leg.
• Once the IV is inserted, the anesthesiologist will give an IV injection of something to knock the dog out, so they can intubate him – very brief acting, such as propofol.
• Once intubated, the anesthesiologist administers a gas-like anesthetic. The gas tends to be a very safe drug, such as isofluroine or civofluorine.
• During the procedure, the surgeon/anesthesiologist will often administer some type of pain medication, which helps decrease the amount of anesthesia needed to keep the patient under.
• Throughout the process and the procedure, the surgery team will monitor the patient very closely, looking for changes in blood pressure and peripheral oxygen levels. If the blood pressure or oxygen levels begin to drop, they can administer IV fluids to help stabilize blood pressure before it becomes an issue.
• In addition to a visual monitor, the surgical team would likely have an audible monitor of heart beat, which helps the team detect any changes immediately, based on the audible rhythm of the patient’s heart.

She also suggested that the team would likely insert a stethoscope and EKG monitor through the intubation tube, so that they could get the most accurate measure.  When I asked the anesthesiologist at the University of Pennsylvania about this, I was told they no longer did this, because the equipment would occasionally send off sparks or shock the patient.  Instead, they used electrodes attached to sticky pads similar to what they use for human EKGs, with the pads being stuck to the dog’s paws.

Armed with this insight and information, I felt much better about my ability to advocate for Moose and ensure that the quality of care he would receive was consistent with clinical guidelines and best practices.  Prior to leaving for the hospital, I printed copies of both sets of guidelines, my notes from the conversation with the vet from Cornell, a couple of select articles on veterinary anesthesiology and my list of questions and prepared folders for me and my husband to have for quick references.  I also downloaded them onto my iPad, which I made sure was fully charged, in case I needed to google specific issues or questions while at the hospital.

Meeting the surgical team

When we met with the doctors the day before the surgery, I made sure that I met not only with the dental surgeon, but also with the anesthesiologist who would be overseeing Moose’s care.  In fact, I met with the head of anesthesiology for the University of Pennsylvania Veterinary School and hospital, Dr. Paula Larenza, who was incredibly helpful. She spent an hour with me, giving me a tour of the facilities, talking through and answering my many questions, showing me their monitoring equipment, safety checklists, emergency preparedness protocols and introducing me to some of the surgical nurses and support staff.  In addition, she gave me her email and told me to feel free to email her with questions or concerns.

By the time we left the hospital that day following Moose’s evaluation, I felt very hopeful and reassured.  They had demonstrated a willingness to answer all of my questions about quality of care and in fact had encouraged me to ask more if needed.  They were not dismissive, patronizing or arrogant. They seemed encouraged by my commitment to ensuring Moose’s care was the best possible, and I felt like they were with me in my efforts to keep my special little puppy safe and healthy.  I was still nervous about the surgery. There are no guarantees. But, I felt like the ground was laid for Moose’s surgical team to do the best job they could do for Moose the following morning when we brought him in for the procedure.

I was truly impressed with the care Moose received at the University of Pennsylvania Mathew J. Ryan Veterinary Hospital. The doctors and support team were wonderful. While I don’t have the names of everybody that supported Moose that day, I’ve listed the names that I do have below. I am thankful to each of them for the quality of care they provided to Moose:

Dr. Robert Menzies, Dental Surgeon

Dr. Paula Larenza, head of anesthesiology for UPenn Veterinary school and hospital

Dr. Manuel Boller, anesthesiologist attending

Dr. Joaquin Araos, anesthesiology resident

Teresa Scott, anesthesiology and surgery technician

Jennifer Wintergrass, fourth year veterinary student