Journal Pre-proof

The American College of Veterinary Anesthesia and Analgesia Small Animal

Anesthesia and Sedation Monitoring Guidelines 2025

K. Bailey, J. Briley, L. Duffee, T. Duke-Novakovski, T. Grubb, L. Love, K. Kruse-Elliott,

M. Martin-Flores, C. McKune, A. Oda, D.S.J. Pang, L.P. Posner, R. Reed, J. Sager,
D.M. Sakai, A.W. Schultz, S Tenenbaum Shih
PII: S1467-2987(25)00071-6
DOI: https://doi.org/10.1016/j.vaa.2025.03.015
Reference: VAA 1084

To appear in: Veterinary Anaesthesia and Analgesia

Received Date: 13 February 2025

Accepted Date: 22 March 2025

Please cite this article as: Bailey K, Briley J, Duffee L, Duke-Novakovski T, Grubb T, Love L, Kruse-
Elliott K, Martin-Flores M, McKune C, Oda A, Pang D, Posner L, Reed R, Sager J, Sakai D, Schultz A,
Shih ST, The American College of Veterinary Anesthesia and Analgesia Small Animal Anesthesia and
Sedation Monitoring Guidelines 2025, Veterinary Anaesthesia and Analgesia, https://doi.org/10.1016/
j.vaa.2025.03.015.

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© 2025 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American
College of Veterinary Anesthesia and Analgesia.
MONITORING RECOMMENDATIONS

The American College of Veterinary Anesthesia and Analgesia Small Animal Anesthesia

and Sedation Monitoring Guidelines 2025

Short title/Running Head: ACVAA 2025 Small Animal Monitoring Guidelines

Authors:

K Baileya, J Brileya, L Duffeeb, T Duke-Novakovskic, T Grubbd, L Love a,1,2, K Kruse-Elliotte,2,

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M Martin-Floresf, C McKuneg, A Odah, DSJ Pangi, LP Posnera, R Reedj, J Sagerk, DM Sakail,

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AW Schultzm, S Tenenbaum Shihn

1
Corresponding author
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Lydia Love
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Department of Molecular Biomedical Sciences

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NC State University College of Veterinary Medicine

1060 William Moore Drive, C-285

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Raleigh, NC 27606
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[email protected]

2
Co-first authors

a
Department of Molecular Biomedical Sciences

NC State University College of Veterinary Medicine

Raleigh, NC USA

b
Massachusetts Veterinary Referral Hospital

Woburn, MA, USA

c
VCA Canada

Central Victoria Veterinary Hospital

Victoria, BC, Canada

d
Veterinary Anesthesia & Analgesia Consulting & Education (VetAACE)

Uniontown, WA, USA

e
Sage Veterinary Centers and Ethos Veterinary Health

Reno, NV USA

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f
Department of Clinical Sciences

College of Veterinary Medicine

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re
Cornell University
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Ithaca, NY, 14853, USA

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g
Mythos Veterinary LLC

Gainesville, FL, USA

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Jo

h
CONSCIOUS

Tokyo, Japan

i
Faculty of Veterinary Medicine

University of Calgary

Calgary, Alberta, Canada

&
Faculty of Veterinary Medicine

Université de Montréal

St-Hyacinthe, Quebec, Canada

j
Department of Large Animal Medicine

University of Georgia

Athens, GA, USA

k
Veterinary Emergency Group

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White Plains, NY, USA

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Department of Small Animal Medicine and Surgery
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University of Georgia
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Athens, GA, USA

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m
Midmark Animal Health

Tampa, FL, USA

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Jo

n
Veterinary Referral Associates

Gaithersburg, MD, USA

All authors participated in conceptualization, literature review, and manuscript writing.

The following authors are employees of or consultants for a company that manufactures

monitoring equipment (Midmark): AW Schultz and J Sager. DSJ Pang is co-Editor-in-Chief of

the journal Veterinary Anaesthesia and Analgesia.

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1 Abstract

2 The American College of Veterinary Anesthesia and Analgesia (ACVAA) in collaboration with the

3 North American Veterinary Anesthesia Society and the Academy of Veterinary Technicians in

4 Anesthesia and Analgesia have revised and expanded the 2009 guidelines (ACVA 2009). The 2025

5 guidelines include updated recommendations for monitoring circulation, oxygenation, ventilation, body

6 temperature, neuromuscular blockade, and anesthetic depth in feline and canine patients. Monitoring

7 during sedation (sedation specific guidelines are in the Monitoring During Sedation Section),

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8 recommendations for personnel managing the patient, and the use of cognitive aids have been

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9 incorporated. This document is meant to establish guidelines for monitoring small animals during

10
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sedation and in the perianesthetic time period. Further information concerning techniques, reference
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11 values, differential diagnoses, and details of various interventions can be found in the reference literature
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12 cited at the end.

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13 These guidelines use objective, evidence-based criteria whenever possible; however, some of the
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14 recommendations are a consensus of expert opinion and clinical experience. This document is intended
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15 to guide monitoring of small animal patients during sedation and anesthesia; it is not to be construed as a

16 standard of care as the choice of monitoring techniques and methods can vary depending on the type of

17 practice and spectrum of care considerations. Alternative methods are suggested if a minimally

18 recommended technique is unavailable.

19 Keywords: anesthesia monitoring, guidelines, small animal, pulse oximetry, capnography,

20 neuromuscular blockade.

21
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22

23 Audience: Anyone providing anesthesia or sedation in small animal practice including but not limited to

24 veterinary technicians, veterinary assistants, veterinary paraprofessionals, veterinary professionals in

25 training, primary care and specialist veterinarians, as well as administrators.

26 Definitions:

27 Minimum Recommendations: Applicable to all anesthetized small animals (Table 1). If a minimum

28 monitoring modality cannot be used, the reason should be documented in the medical record.

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29 Alternatives: To be used only when minimum recommended options are not available. Their use should

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30 be documented in the medical record. re
31 Advanced Recommendations: Options to consider for veterinary patients with co-existing disease and/or
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32 unstable patients (Table 1).

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33 Monitoring Depth of Anesthesia

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34 Objective: To achieve an adequate anesthetic depth to prevent patient awareness and movement while
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35 minimizing cardiorespiratory and other physiological side effects of anesthetic agents.

36 Minimum Recommendations:

37 1. A dedicated anesthetist (see Personnel section) should repeatedly observe the animal to assess eye

38 position, muscle tone, including jaw muscle tone, and reflexes, including the palpebral reflex or

39 peripheral reflexes such as withdrawal of a limb. Special considerations for monitoring anesthetic

40 depth in the face of neuromuscular blockade use are outlined in that section below.

41 During anesthesia with volatile agents, the eyes will generally rotate ventromedially, body and

42 jaw muscle tone will be relaxed, and the palpebral reflex will be sluggish or absent (Bleijenberg et

43 al. 2011). Patients anesthetized with injectable protocols, especially with dissociative-based
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44 approaches, may not display the traditional progressive signs of reflex depression and muscle

45 relaxation.

46 2. A dedicated anesthetist should anticipate and monitor for indication of sympathetic responses,

47 including increases in heart rate, respiratory rate, and arterial blood pressure, in response to noxious

48 stimuli.

49 Advanced Recommendations:

50 1. Monitoring of inspired and expired inhalant concentrations is indicated whenever such technology is

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51 available to ensure adequate but not excessive inhalant delivery to the patient.

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52 2. Mathematical transformations of the electroencephalogram, e.g., Bispectral Index (BIS) or Patient
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53 State Index, may be useful in some clinical or laboratory settings (March & Muir 2003; Sakai et al.
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54 2023).
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55 Circulation Monitoring
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56 Objective: To confirm adequate tissue perfusion, ensuring delivery of oxygen and nutrients and removal
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57 of metabolic waste products.

58 Minimum Recommendations:

59 1. A dedicated anesthetist (see Personnel section) should continuously observe the patient, using

60 intermittent subjective clinical assessments to supplement readings from electronic monitors,

61 including manual palpation of the pulse, auscultation of the heart using an external or esophageal

62 stethoscope and/or continuous pulse rate detection via Doppler flow probe, and assessment of

63 capillary refill time.

64 2. Oscillometric blood pressure monitoring should be utilized with measurements taken at least every 5

65 minutes.

66 A mean arterial pressure < 60-65 mmHg should prompt assessment of the patient and
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67 intervention, which may include decreasing anesthetic depth, managing bradycardia and

68 intravascular volume status, and/or the use of inotropes or pressors.

69 Algorithms of oscillometric blood pressure monitors vary by manufacturer and have an impact

70 on the performance of the monitor. Clinicians are encouraged to check monitoring brands against

71 validation studies that compare performance against the American College of Veterinary Internal

72 Medicine Hypertension Consensus Panel and Veterinary Blood Pressure Society Recommendations

73 (AHCP-VBPS Validation) (Skelding & Valverde 2020a,b).

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74 3. Continuous electrocardiogram (ECG) monitoring to detect any changes in heart rate, rhythm, or

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75 conduction abnormalities.

76
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4. Time-based capnography is reflective of pulmonary perfusion when ventilation is constant and
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77 should be monitored continuously.
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78 Alternative Recommendations:
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79 When an oscillometric blood pressure device is unavailable or unreliable, a Doppler flow probe and
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80 sphygmomanometer with a cuff can be substituted. Doppler blood pressure (BP) readings generally
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81 display poor agreement with invasively measured pressures (da Cunha et al. 2014; Kennedy & Barletta

82 2015; Skelding & Valverde 2020b). Doppler BP readings of 90 mmHg or below should prompt

83 assessment of the patient and intervention as described for oscillometry. Doppler flow probes also

84 provide an audible signal of peripheral blood flow and pulse rhythm. The plethysmograph and audible

85 signal from a pulse oximeter can also be used to confirm the rate and rhythm of peripheral pulses.

86 Advanced Recommendations:

87 In addition to the minimum recommendations:

88 1. Invasive blood pressure measurement via arterial catheterization should be considered for critically

89 ill patients, complex diagnostic or interventional procedures, or patients with advanced

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90 cardiovascular disease.

91 In certain environments, including during magnetic resonance imaging, invasive pressure

92 measurement may be helpful in providing continuous cardiovascular monitoring when other

93 monitoring modalities may experience interference.

94 2. Dynamic indices of hemodynamic variables, including Plethysmographic Variability Index (PVI)

95 from a pulse oximeter waveform, Systolic Pressure Variation (SPV) or Pulse Pressure Variation

96 (PPV) from the invasive arterial pressure waveform during positive pressure ventilation can provide

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97 information on fluid responsiveness.

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98

99 3.
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Other forms of fluid responsiveness monitoring may be considered when available, including
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100 transthoracic or transesophageal echocardiography and ultrasound evaluation of caudal vena cava
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101 distensibility.
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102

103 4. Venous blood gas and lactate analysis can be useful in evaluating global perfusion parameters.
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104 Oxygenation Monitoring

105 Objective: To ensure adequate oxygenation of blood.

106 Minimum Recommendations:

107 1. The anesthetist should perform a routine anesthetic equipment check using a standardized checklist

108 prior to use of the machine and regularly assess the function of the oxygen source, flowmeter, and

109 breathing circuit throughout the anesthetic event.

110 2. A dedicated anesthetist (see Personnel section) should regularly assess mucous membrane color

111 (pink, cyanotic, or pale) and ventilatory efforts (chest excursion, auscultation, and reservoir bag

112 movement).
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113 Assessment of mucous membrane color requires access to the patient and appropriate lighting

114 (Comroe & Botelho 1947). In addition, the anesthetist should inflate the endotracheal tube cuff until

115 there is no audible leak at a breathing circuit manometer pressure of 20 cmH2O (or use a cuff

116 manometer) and perform bilateral auscultation of the chest following intubation to help ensure that

117 the endotracheal tube is placed in the trachea, rather than into one bronchus.

118 3. Pulse oximetry is recommended in all heavily sedated or anesthetized small animal patients.

119 The use of pulse oximetry has been associated with a decreased risk of mortality in veterinary

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120 anesthesia (Brodbelt et al. 2007; Itami et al. 2017; Matthews et al. 2017). A transmission probe on

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121 the tongue, ear, toe, or fold of skin can be utilized or a reflectance probe can be placed on a shaved

122
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or hairless area such as the underside of the base of the tail or metatarsus (Nixdorff et al. 2021). The
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123 variable pitch pulse tone and low saturation alarm should be easily audible. Pulse oximetry is a late
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124 indicator of an oxygenation problem when oxygen is being supplemented and therefore any value <
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125 95% should be investigated to ascertain patient status and rule out technical issues. Patient

126 (respiratory or cardiovascular) and equipment issues are potential causes of hypoxemia during
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127 sedation and anesthesia.

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128 Advanced recommendations:

129 1. Arterial Blood Gas (ABG) analysis and measurement of the partial pressure of oxygen in arterial

130 blood (PaO2) are useful for assessing pulmonary gas exchange.

131 Determination of PaO2 should be considered in patients with persistently low pulse oximetry

132 readings, pre-existing pulmonary disease, those undergoing thoracic or pulmonary procedures, or

133 situations in which ventilation-perfusion mismatch or shunt may occur (Farrell et al. 2019).

134 2. Measurement of the inspired oxygen concentration (FIO2) confirms that adequate oxygen is being

135 delivered to the patient.

136 This monitoring modality is recommended whenever possible to confirm functional oxygen
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137 supply and to ascertain the percentage of oxygen delivered to the patient. In addition, FIO2

138 monitoring should be employed if the use of medical air mixtures is planned.

139 3. Co-oximetry (with an arterial blood sample) is more reliable than standard pulse oximetry when

140 dysfunctional hemoglobins are present (e.g., carboxyhemoglobin, methemoglobin) and will provide

141 more accurate oxygen hemoglobin saturation values.

142 Ventilation Monitoring

143 Objective: To ensure adequate ventilation.

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144 Minimum Recommendations:

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1. A dedicated anesthetist should consistently monitor the patient by observation of thoracic wall
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146 and/or reservoir bag/ventilator bellows movements during inhalation and exhalation, auscultation
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147 using a stethoscope (esophageal or external) for respiratory sounds to supplement other objective
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148 monitoring as necessary and utilize a manometer to assess peak airway pressures during positive

149 pressure ventilation.

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150 2. Time-based capnography (inspired and expired carbon dioxide CO2 analysis with a waveform)

151 should be utilized as it provides information on the partial pressure of carbon dioxide in respiratory

152 gases, can be used to evaluate the integrity of the endotracheal tube (or laryngeal mask airway) and

153 breathing circuit, pulmonary perfusion (including during cardiopulmonary resuscitation), and

154 ventilation status, and is useful in the differential diagnosis of hypoxemia (Hogen et al. 2018,

155 Wollner et al. 2020; Chrimes et al. 2022).

156 Inspiratory CO2 concentrations should be, or approach, 0 mmHg with normally functioning

157 anesthetic delivery equipment and minimal mechanical dead space. Mild increases in end-tidal CO2

158 concentrations may be tolerated in healthy patients but values > 60 mmHg should be addressed,

159 including decreasing anesthetic depth if possible and instituting positive pressure ventilation.
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160 Alternative Recommendations:

161 1. A capnometer can be used if a capnograph is not available.

162 Capnometry displays the partial pressure of inhaled and exhaled carbon dioxide and the

163 respiratory rate but does not display the waveform.

164

165 2. An apnea monitor is designed to create audible noise during exhalation, or alarm during prolonged

166 periods of apnea.

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167 If capnography and capnometry are not available, an apnea monitor may be used though it will

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168 not evaluate adequacy of ventilation and may add dead space to the breathing circuit.

169
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3. During positive pressure ventilation, if an airway pressure manometer is not available, the anesthetist
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170 should visually evaluate the patient for adequate, but not excessive, thoracic excursions.
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171 Advanced Recommendations:

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172 1. Arterial (or venous) blood gas sampling enables measurement of partial pressure of carbon dioxide
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173 (PCO2).
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174 Measurement of arterial carbon dioxide (and oxygen) should be considered when ventilation is

175 abnormal prior to the procedure (patients with forebrain or brainstem disease, significant pulmonary

176 or pleural disease, or patients with significant ventilation-perfusion mismatch).

177 2. Spirometry can be used to provide information on lung/chest wall compliance and tidal volume.

178 Tidal volume measurement should be considered when changes in tidal volume are possible,

179 such as during thoracotomy and with asthmatic patients. Displayed spirometry loops can be analyzed

180 for abnormalities such as those produced by endotracheal tube cuff leaks, spontaneous breathing

181 during ventilator use, changes in pulmonary compliance, and the presence of airway secretions.

182
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183 Temperature Monitoring

184 Objective: To identify, prevent, and manage moderate to severe deviations from normal temperature

185 ranges.

186 Minimum Recommendations

187 1. The use of a digital thermometer to measure rectal body temperature at least every 15 minutes is

188 recommended in all moderately to heavily sedated, or anesthetized, small animal patients.

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189 2. Continuous measurement of body temperature via a thermistor inserted into the esophagus or rectum

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190 is desirable.

191
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3. Body temperature can be measured at different sites.
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192 Core body temperature refers to the temperature of internal organs and is measured invasively in
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193 the pulmonary artery using special intravenous catheters with thermistors. Esophageal and rectal
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194 temperature measurements are clinically reasonable substitutes in veterinary patients (Southward et

195 al. 2006; Hymczak et al. 2021). When a site other than rectal or esophageal placement is used for
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196 temperature measurement (e.g., axillary, nasal, tympanic, pharyngeal), any deviations from
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197 normothermia should be confirmed using a standard measurement site when possible (Ward et al.

198 2023).

199 4. Monitoring of body temperature at least every 30 minutes should continue into the recovery period

200 to confirm return and maintenance of normothermia.

201 5. If body temperature decreases below 37.8˚C/100˚F, safe active external warming should be

202 instituted.

203 Passive insulation with towels, blankets, or drapes and protection from tables should always be

204 utilized. Safe active external warming methods include forced warm air, conductive blankets with a

205 functioning sensor, and warm water blankets. Electric heating pads, microwaved objects (e.g., rice
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206 socks, heated disks), and warmed saline bags may cause burns. Recommended devices must be

207 maintained appropriately to avoid malfunction and the risk of burns.

208

209 Neuromuscular Blockade (NMB) Monitoring

210 Objective: To characterize effectiveness of neuromuscular transmission when using nondepolarizing

211 neuromuscular blocking agents (NMBA). This allows for identification of the onset of action of the

212 NMBA and quantification of the depth of neuromuscular blockade (i.e., deep, moderate, shallow, and

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213 minimal) (Table 2). Neuromuscular blockade monitoring guides the re-dosing or titration of infusion

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214 rates of NMBAs, assesses conditions for administration of reversal agents, and ensures adequate

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restoration of neuromuscular function before emergence from anesthesia.
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216 Minimum Recommendations:

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217 1. A peripheral nerve stimulator (PNS) should be used to provide subjective (visual or tactile)

218 assessment of muscular responses (twitches) (Martin-Flores 2025).

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219 Assessment includes the detection of twitches via Train of Four (TOF) count, 0 – 4, or Double
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220 Burst Suppression (DBS) count, 0–2 and identifying a fade within the TOF or DBS during shallow

221 or minimal NMB. NMBAs should not be administered without a peripheral nerve stimulator.

222 Capnometry or capnography, spirometry, and other ventilation monitors are not adequate surrogates

223 to monitor neuromuscular function (Martin-Flores et al. 2014). This recommendation differs from

224 the previous guidelines (ACVA 2009).

225 2. As normal function cannot be determined by subjective means (Martin-Flores et al. 2019), it is

226 recommended to always administer pharmacological reversal when subjective PNS is used.

227 3. It is mandatory to only administer NMBAs during general anesthesia (injectable or inhalant).

228 Neuromuscular blockade will cease all skeletal neuromuscular function without inducing
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229 unconsciousness. Some clinical signs of the depth of anesthesia commonly used, such as muscle

230 (jaw) tone, palpebral reflex, or eye position, will be abolished (Cullen & Jones 1980). The loss of

231 ability to monitor muscle tone and peripheral reflexes may require greater emphasis on close

232 monitoring of autonomic responses, and the analysis of inhaled anesthetic agent concentrations

233 should be considered.

234 4. Heart rate monitoring should be in place when reversal agents are administered as they are

235 associated with an increase in vagal tone and could lead to life threatening bradyarrhythmia.

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236 Pre-treatment with anticholinergic drugs may be warranted but does not negate the need for pulse

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237 rate and ECG monitoring.

238 Advanced Recommendations:

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239 1. Objective quantification of the TOF ratio (T4:T1) or the DBS ratio (DBS2:DBS1), typically
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240 expressed as ratio (0 to > 1) or percentage (0 to > 100%).

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241 Baseline values often are > 1. Quantitative assessment allows the detection of residual NMB.
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242 Indirect reversal agents such as neostigmine should not be administered during deep neuromuscular
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243 blockade (i.e., TOF count = 0) as they will be ineffective. Reversal is more effective and predictable

244 as the level of neuromuscular blockade decreases.

245

246 Monitoring in the Immediate Recovery Time Period

247 Objective: To ascertain normal progression from the anesthetized state to independent maintenance of

248 homeostasis. The first three hours following the cessation of anesthesia in companion animals carries the

249 highest risk of morbidity and mortality (Brodbelt et al. 2008; Redondo et al. 2023).

250 At minimum, each physiological variable described below should be assessed at frequent regular time

251 intervals throughout the immediate postanesthetic period until the patient is deemed physiologically
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252 stable (warm, oriented, ambulatory, pain- and nausea-free) by the attending clinician and

253 cardiorespiratory variables have returned to normal. Patients that require ongoing physiological

254 monitoring and supportive care should remain under continuous observance and may require transfer to

255 an appropriate care unit (e.g., an intensive care unit) for continued management.

256 Minimum Recommendations:

257 1. The recovery period encompasses the time from discontinuation of the delivery of anesthetic agents,

258 through extubation, until the patient can maintain their own physiological stability (see #9 below)

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259 and is therefore ready for discharge. Patients should be under continuous visual observation until this

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260 time.

261
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2. The anesthetist or designated recovery personnel should ensure patient safety through continued
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262 monitoring of physiological variables and communication of patient status with the team during the
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263 recovery period. At least one more person should be immediately available to help with patient care
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264 and in emergency situations.

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265 3. Oxygenation should be regularly assessed by examination of mucous membrane color, ventilatory
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266 efforts (patency of upper airway, chest excursions, and auscultation) and the use of a pulse oximeter

267 when possible. Monitoring of minimum requirements as previously described continues during the

268 immediate postanesthetic period.

269 4. Circulation should be regularly assessed by assessment of heart rate, rhythm, and in patients that

270 have been or are unstable, continued blood pressure measurements. Monitoring of minimum

271 requirements as previously described continues during the immediate postanesthetic period.

272 5. Ventilation should be regularly assessed by evaluating chest excursion and thoracic auscultation.

273 Monitoring of minimum requirements as previously described continues during the immediate

274 postanesthetic period.

275 6. Temperature: Monitoring of minimum requirements as previously described continues during the

276 immediate postanesthetic period.

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277 7. Pain assessment should be performed utilizing a pain scoring instrument for acute postoperative pain

278 (e.g., the Feline Grimace scale, Glasgow Composite Measures Pain Scale-Short Form, UNESP-

279 Botucatu Multidimensional Composite pain scale). These scales have been validated to various

280 degrees in certain clinical situations (Reid et al. 2007; Evangelista et al. 2019; Belli et al. 2021).

281 Clinicians must evaluate which scale is most appropriate for their clinical setting.

282 8. Documentation must be provided using a written or electronic record of the postanesthetic recovery

283 anesthesia event, including drugs administered, monitoring values, and interventional notes (see

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284 Record Keeping section below).

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285 9. Patient discharge should only occur once the patient is normothermic, mentally oriented, and

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286 ambulatory (unless the disease or surgical intervention precludes this), nausea- and pain-free.
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287 Advanced Recommendations:
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288 1. Advanced monitoring recommendations as described in previous sections either continuously or at

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289 regular time intervals until the patient's vital parameters have returned to normal and are deemed stable.
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290 Monitoring During Sedation

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291 Objective: To ensure adequate oxygenation and hemodynamic stability in sedated patients to prevent,

292 recognize, and manage physiological abnormalities (Table 3)

293 Sedation is a dynamic continuum of central nervous system (CNS) depression and drowsiness

294 during which the patient displays less awareness of their surroundings while continuing to be responsive

295 to noxious stimuli. When deep enough, sedation may overlap with general anesthesia (ASA 2024). For

296 any moderate to profound sedation procedure, monitoring of cardiopulmonary status is required, an

297 intravenous catheter should be placed, and endotracheal intubation equipment and supplemental oxygen

298 should be readily available. Emergency medications and reversal agents should be calculated with a

299 digital or printed drug calculation sheet and be immediately available. Discharge criteria for when a
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300 patient has recovered from sedation and is ready to be released to the client and home are similar to

301 recommendations for general anesthesia.

302 Sedation can be classified as mild, moderate, or deep/profound. Depth of sedation is dynamic and should

303 be evaluated frequently by a dedicated, trained individual.

304 1. Mild sedation: Patient will readily respond to stimuli but is less likely to exhibit anxiety, excitement,

305 or other behaviors that interfere with ability to complete minimally painful procedures, such as a

306 basic physical examination, simple blood draw, or minor grooming procedures. The patient may not

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307 become or remain recumbent. While respiratory or cardiovascular problems are rare, continual

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308 observation during mild sedation is recommended and objective monitoring equipment should be

309 available. The following are recommended:

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310 a. Palpation of pulse rate, rhythm, and quality
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311 b. Observation of mucous membrane color and capillary refill time

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312 c. Observation of respiratory rate and pattern

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313 d. Auscultation of heart rate and respiratory sounds

314 2. Moderate sedation: Patient remains responsive to auditory stimuli, light tactile stimulation, can

315 reposition if assisted or stimulated but is otherwise content to lie recumbent. Patients can usually

316 maintain a patent airway, ventilate and oxygenate adequately, and maintain stable cardiovascular

317 function. However, they should be observed continuously and monitored for any change in

318 respiratory or cardiovascular status. The following are recommended:

319 a. Supplemental oxygen (by face mask or nasal prongs) (Ambros et al. 2018).

320 b. All recommended monitoring for mild sedation

321 c. Temperature monitoring

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322 d. Pulse oximetry

323 e. Other monitoring equipment, including BP and ECG, when indicated by patient status

324 3. Deep or profound sedation: Patient is not easily aroused but may still respond to repeated or painful

325 stimuli. In this state they cannot readily maintain sternal recumbency or reposition from lateral

326 recumbency. Deeply sedated patients often require assistance to maintain a patent airway,

327 oxygenation, or ventilation, but cardiovascular function is typically maintained. Deeply sedated

328 patients must be monitored for respiratory and cardiovascular abnormalities. The following is

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329 recommended:

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330 a. Supplemental oxygen (e.g., via face mask, nasal prongs, oxygen collars, nasal cannula,

331 etc.) -p
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332 b. All recommended monitoring for moderate sedation

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333 c. Consider monitoring ECG, noninvasive blood pressure, and capnography via nasal prong
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334 or catheter
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335 d. Intubation should be performed if the patient is not maintaining their airway or is not

336 ventilating adequately

337 Personnel and Record Keeping Recommendations

338 Objective: To ensure patient safety and maintain a record of drug administration, physiological

339 parameters, and prescribed interventions.

340 The presence of vigilant, trained personnel during the perianesthetic period is a key determinant

341 for patient safety.

342 Minimum Recommendations:

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343 1. The anesthesia care team may consist of a combination of veterinary anesthesiologists, non-

344 specialist veterinarians, veterinary anesthesia residents, veterinary technician specialists in

345 anesthesia and analgesia, credentialed veterinary technicians, and veterinary professionals in

346 training. In some jurisdictions, veterinary assistants and veterinary paraprofessionals may also be

347 part of an anesthesia care team.

348

349 2. A licensed veterinarian credentialed veterinary technician, veterinary student under the direct

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350 supervision of a licensed veterinarian, hereby known as the anesthetist, should be responsible and

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351 always remain with the anesthetized patient, whether using sedation, partial or total intravenous

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352 anesthesia, or inhalational anesthesia. In some jurisdictions, a veterinary assistant under the
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353 supervision of a licensed veterinarian or a veterinary paraprofessional may fill this role. This
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354 individual is responsible for the perianesthetic preparation of the patient, including perianesthetic

355 physical examination, equipment selection, including functional testing for accuracy, anesthetic drug
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356 administration, and vital parameter monitoring as described in previous sections.

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357
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358 3. Equipment Checklist: The anesthetist should utilize a standardized anesthesia checklist, including an

359 equipment checklist, prior to the start of the anesthetic event.

360

361 4. Emergency drugs and reversal agents: Doses should be calculated prior to sedation or anesthesia and

362 immediately available to the anesthetist. A digital (printed or immediately available on a hand-held

363 device) spreadsheet should be utilized.

364

365 5. Patient Evaluation: The anesthetist should perform patient history evaluation, review current

366 medication, and perform a patient physical examination prior to the administration of anesthetic
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367 drugs.

368

369 6. Anesthetic Protocol: An individual anesthetic protocol should be created for each patient; a licensed

370 veterinarian should approve the protocol.

371

372 7. Record Keeping: Documentation of the anesthetic procedure is a key component of anesthetic safety

373 during the event, for retrospective study, in case reviews, and is a part of the medical record.

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374 a. The anesthetist should create and maintain a written or electronic record of the perianesthetic

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375 anesthesia event, including recovery, documenting drugs administered, monitored

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376 physiologic values, and interventional notes.
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377 b. While vigilant monitoring of the patient is continuous, heart rate, arterial blood pressure,
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378 arterial oxygen saturation, and end-tidal carbon dioxide should generally be recorded every 5
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379 minutes, and all other physiological variables at least every 15 minutes. In unstable

380 hemodynamic conditions, more frequent recording may be desirable (Gravenstein 1989,
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381 Walsh et al. 2013, Sun et al. 2015, ASA 2020).

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382 8. Patient Monitoring: The anesthetist should use patient monitoring recommendations as described

383 above for circulation, ventilation, oxygenation, and temperature regulation through use of hands-on

384 patient evaluation and electronic or multiparameter devices. The anesthetist should monitor vital

385 parameter alarms alongside set reference ranges.

386 9. Communication: Direct and frequent communication of patient status should occur between the

387 anesthetist and the veterinary team, including the surgeon.

388 a. A surgical safety checklist, tailored to the environment, should be utilized by the anesthesia

389 and surgical team to ensure quality standards and assess perianesthetic communication.
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390 b. If complications arise during the anesthetic period, intervention is administered by the

391 anesthetist with oversight by a prescribing veterinarian if necessary.

392 c. If a patient is transferred to another team member, including during the immediate recovery

393 period, patient care communication must be directed from the anesthetist to the team

394 member; including patient signalment, anesthetic protocol, anesthetic complications

395 encountered, interventions administered, and post-operative plan. A standardized handoff

396 checklist is recommended.

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397 Advanced Recommendations:

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398 1. A board-certified veterinary anesthesiologist should lead the anesthesia care team whenever

399 possible.
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401 References

402 ACVA (2009) Monitoring Guidelines Update https://acvaa.org/veterinarians/guidelines/ accessed

403 12/28/2024

404 Ambros B, Carrozzo MV, Jones T (2018) Desaturation times between dogs preoxygenated via face

405 mask or flow-by technique before induction of anesthesia. Vet Anaesth Analg 45(4), 452-458. doi:

406 10.1016/j.vaa.2018.03.004.

407 ASA (2020) Standards for Basic Anesthetic Monitoring https://www.asahq.org/standards-and-practice-

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408 parameters/standards-for-basic-anesthetic-monitoring accessed 02/04/2025

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409 ASA (2024) Statement on Continuum of Depth of Sedation: Definition of General Anesthesia and

410 -p
Levels of Sedation/Analgesia https://www.asahq.org/standards-and-practice-parameters/statement-on-
re
411 continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedation-analgesia
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412 accessed 12/28/2024

na

413 Belli M, de Oliveira AR, de Lima MT, et al. (2021) Clinical validation of the short and long UNESP-
ur

414 Botucatu scales for feline pain assessment. PeerJ 9:e11225. doi: 10.7717/peerj.11225.
Jo

415 Bleijenberg EH, van Oostrom H, Akkerdaas LC, et al. (2011) Bispectral index and the clinically

416 evaluated anaesthetic depth in dogs. Vet Anaesth Analg 38(6), 536-543. doi: 10.1111/j.1467-

417 2995.2011.00651.x.

418 Brodbelt DC, Pfeiffer DU, Young LE, et al. (2007) Risk factors for anaesthetic-related death in cats:

419 results from the confidential enquiry into perioperative small animal fatalities (CEPSAF). Br J Anaesth

420 99(5), 617-623. doi: 10.1093/bja/aem229.

421 Brodbelt DC, Pfeiffer DU, Young LE, et al. (2008) Results of the confidential enquiry into perioperative

422 small animal fatalities regarding risk factors for anesthetic-related death in dogs. J Am Vet Med Assoc.

423 233 (7), 1096–1104. doi: 10.2460/javma.233.7.1096.

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424 Chrimes N, Higgs A, Hagberg CA, et al. (2022) Preventing unrecognised oesophageal intubation: a

425 consensus guideline from the Project for Universal Management of Airways and international airway

426 societies. Anaesthesia 77(12), 1395-1415. doi: 10.1111/anae.15817.

427 Comroe JH & Botelho S. (1947) The unreliability of cyanosis in the recognition of arterial anoxemia.

428 Am J Med Sci 124(1), 1-6. doi: 10.1097/00000441-194707000-00001.

429 Cullen LK & Jones RS (1980) The nature of suxamethonium neuromuscular block in the dog assessed

430 by train-of-four stimulation. Res Vet Sci 29 (3), 281–288.

of
431 da Cunha AF, Saile K, Beaufrère H, et al. (2014) Measuring level of agreement between values obtained

ro
432 by directly measured blood pressure and ultrasonic Doppler flow detector in cats. J Vet Emerg Crit Care

433 24(3), 272-278. doi: 10.1111/vec.12161. -p

re
lP

434 Evangelista MC, Watanabe R, Leung VSY, et al. (2019) Facial expressions of pain in cats: the

435 development and validation of a Feline Grimace Scale. Sci Rep 9(1):19128. doi: 10.1038/s41598-019-
na

436 55693-8.
ur

437 Farrell KS, Hopper K, Cagle LA, et al. (2019) Evaluation of pulse oximetry as a surrogate for PaO2 in
Jo

438 awake dogs breathing room air and anesthetized dogs on mechanical ventilation. J Vet Emerg Crit Care

439 29(6), 622-629. doi: 10.1111/vec.12898.

440 Gravenstein JS, de Vries A, Beneken JE (1989) Sampling intervals for clinical monitoring of variables

441 during anesthesia. J Clin Monit 5(1), 17-21. doi: 10.1007/BF01618365.

442 Hogen T, Cole SG, & Drobatz KJ (2018) Evaluation of end-tidal carbon dioxide as a predictor of return

443 of spontaneous circulation in dogs and cats undergoing cardiopulmonary resuscitation. J Vet Emerg Crit

444 Care 28(5), 398-407. doi: 10.1111/vec.12755.

 5128

445 Hymczak H, Gołąb A, Mendrala K, et al. (2021) Core Temperature Measurement-Principles of Correct

446 Measurement, Problems, and Complications. Int J Environ Res Public Health 18(20):10606. doi:

447 10.3390/ijerph182010606.

448 Itami T, Aida H, Asakawa M, et al. (2017) Association between preoperative characteristics and risk of

449 anaesthesia-related death in dogs in small-animal referral hospitals in Japan. Vet Anaesth Analg 44(3),

450 461-472. doi: 10.1016/j.vaa.2016.08.007.

451 Kennedy MJ & Barletta M. (2015) Agreement Between Doppler and Invasive Blood Pressure

of
452 Monitoring in Anesthetized Dogs Weighing <5 kg. J Am Anim Hosp Assoc 51(5,)300-5. doi:

ro
453 10.5326/JAAHA-MS-6163.

454 -p
March PA & Muir WW. (2003) Bispectral analysis of the electroencephalogram: A review of its
re
455 development and use in veterinary anesthesia. Vet Anaesth Analg 32, 241-255.
lP

456 Martin-Flores M, Sakai DM, Campoy L, et al. (2014) Recovery from neuromuscular block in dogs:
na

457 restoration of spontaneous ventilation does not exclude residual blockade. Vet Anaesth Analg 41(3),
ur

458 269–277. doi: 10.1111/vaa.12109.

Jo

459 Martin-Flores M, Sakai DM, Tseng CT, et al. (2019) Can we see fade? A survey of anesthesia providers

460 and our ability to detect partial neuromuscular block in dogs. Vet Anaesth Analg 46, 182–187. doi:

461 10.1016/j.vaa.2019.01.002.

462 Martin-Flores M (2025) Neuromuscular block: Monitoring, reversal, and residual blockade in small

463 animals. Vet Ophthalmol 28(1), 88-93. doi: 10.1111/vop.13112.

464 Matthews NS, Mohn TJ, Yang M, et al. (2017) Factors associated with anesthetic-related death in dogs

465 and cats in primary care veterinary hospitals. J Am Vet Med Assoc 250(6), 655-666. doi:

466 10.2460/javma.250.6.655.
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467 Nixdorff J, Zablotski Y, Hartmann K, et al. (2021) Comparison of Transmittance and Reflectance Pulse

468 Oximetry in Anesthetized Dogs. Front Vet Sci 8:643966. doi: 10.3389/fvets.2021.643966.

469 Redondo JI, Otero PE, Martínez-Taboada F, et al. (2023) Anaesthetic mortality in dogs: A worldwide

470 analysis and risk assessment. Vet Rec 195(1): e3604. doi: 10.1002/vetr.3604

471 Reid J, Nolan A, Hughes J, et al. (2007) Development of the short-form Glasgow Composite Measure

472 Pain Scale (CMPS-SF) and derivation of an analgesic intervention score. Animal Welfare 16(S1):97-

473 104. doi:10.1017/S096272860003178X

of
474 Sakai DM, Trenholme HN, Torpy FJ, et al. (2023) Evaluation of the electroencephalogram in awake,

ro
475 sedated, and anesthetized dogs. Res Vet Sci 159, 66-71. doi: 10.1016/j.rvsc.2023.04.008.

-p
re
476 Skelding A & Valverde A. (2020a) Non-invasive blood pressure measurement in animals: Part 1 -
lP

477 Techniques of measurement and validation of non-invasive devices. Can Vet J 61(4), 368-374.
na

478 Skelding A & Valverde A. (2020b) Review of non-invasive blood pressure measurement in animals:

479 Part 2 - Evaluation of the performance of non-invasive devices. Can Vet J 61(5), 481-498.
ur
Jo

480 Southward ES, Mann FA, Dodam J, et al. (2006) A comparison of auricular, rectal and pulmonary artery

481 thermometry in dogs with anesthesia-induced hypothermia. J Vet Emerg Crit Care 16, 172–175.

482 doi:10.1111/j.1476-4431.2005.00158.x

483 Sun LY, Wijeysundera DN, Tait GA, et al. (2015) Association of intraoperative hypotension with acute

484 kidney injury after elective noncardiac surgery. Anesthesiology 123(3), 515-523. doi:

485 10.1097/ALN.0000000000000765.

486 Walsh M, Devereaux PJ, Garg AX, et al. (2013) Relationship between intraoperative mean arterial

487 pressure and clinical outcomes after noncardiac surgery: toward an empirical definition of hypotension.

488 Anesthesiology 119(3), 507-515. doi: 10.1097/ALN.0b013e3182a10e26.

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489 Ward R, McMillan M, & Gittel C. (2023) Body temperature measurement in anesthetized dogs -

490 comparison of nasal, axillary, rectal and esophageal temperature. Tierarztl Prax Ausg K Kleintiere

491 Heimtiere 51(3), 161-167. doi: 10.1055/a-2103-3162.

492 Wollner E, Nourian MM, Booth W, et al. (2020) Impact of capnography on patient safety in high- and

493 low-income settings: a scoping review. Br J Anaesth 125(1):e88-e103. doi: 10.1016/j.bja.2020.04.057.

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Table 1. Summary of minimum and advanced monitoring recommendations for monitoring

physiological variables during anesthesia in dogs and cats. CNS = central nervous system;

ECG = electrocardiogram; EEG = electroencephalography; PVI = plethysmographic

variability index; PPV = pulse pressure variation; SPV = systolic pressure variation.

BODY SYSTEM RECOMMENDATION MINIMUM ADVANCED

ALL Dedicated anesthetist ● ●

Physical signs of anesthetic depth

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● ●

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including muscle tone, eye position, &

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reflexes
CNS
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Inspired/expired inhalant concentrations
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EEG-based monitors ●
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Continuous ECG ● ●
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Non-invasive blood pressure (oscillometric) ● ●

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CIRCULATION Invasive blood pressure ●

Dynamic hemodynamic variables (e.g., PVI,

●
SPV, and PPV)

Pulse oximetry ● ●

Arterial blood gas analysis ●

OXYGENATION
Oxygen concentration in inspired gas ●

Co-oximetry ●

VENTILATION Capnography ● ●
 Blood gas analysis ●

Spirometry ●

TEMPERATURE Rectal/esophageal temperature ● ●

●: recommended

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Table 2. Characteristics of neuromuscular blockade (NMB) are assessed subjectively and

objectively. Note that normal function and minimal neuromuscular blockade cannot be

effectively distinguished by subjective means alone (Martin-Flores et al. 2019).

NMB Objective monitoring* Subjective (visual) monitoring

Normal function TOF ratio ≥ 90% Cannot be determined

Minimal NMB TOF ratio 40%–89% TOF count 4

Shallow NMB TOF count 4—TOF ratio 39% TOF count 4

f
Moderate NMB TOF count 1–3 TOF count 1–3

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Deep NMB TOF count 0 TOF count 0

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* via acceleromyography. TOF = train-of-four. The threshold for normal function has been

increased from the ACVA 2009 Monitoring Guidelines (ACVA 2009).

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Table 3. Monitoring for the sedation continuum in small animal practice

Deep or Profound
Moderate Sedation
Sedation
Mild Sedation Patient remains
Patient is not easily
Patient will responsive to auditory
aroused but may still
readily respond to stimuli, light tactile
Sedation respond to repeated or
stimuli. May or stimulation, can
Guidelines painful stimuli. The
may not assume reposition if assisted or

f
patient cannot readily

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lateral stimulated but is
maintain sternal

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recumbency. otherwise content to lie
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recumbent.
recumbency or reposition
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from lateral recumbency.
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Dedicated
● ● ●
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anesthetist
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Pulse oximetry ● ●
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Temperature ● ●

Oscillometric

blood pressure, May be indicated by

Consider strongly
ECG, and patient status

capnography

ECG = electrocardiogram, ●: recommended

Declaration of interests

☐ The authors declare that they have no known competing financial interests or personal relationships
that could have appeared to influence the work reported in this paper.

☒ The authors declare the following financial interests/personal relationships which may be considered
as potential competing interests:

AW Schultz reports a relationship with Midmark Corp that includes: employment. J Sager reports a
relationship with Midmark Corp that includes: consulting or advisory. VAA Editor in Chief DSJ Pang If
there are other authors, they declare that they have no known competing financial interests or
personal relationships that could have appeared to influence the work reported in this paper.

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