X0123-Ch019-023.

qxd 9/20/05 9:20 AM Page 227

ANESTHESIA AND ANALGESIA FOR FOALS 227

CHAPTER 21 tial Enquiry into Perioperative Equine Fatalities (CEPEF) is

an observational multi-institutional prospective study of
recovery outcome at 7 days postoperatively, which was initi-
ated by Johnston and others in 1991 to provide evidence-
based data on risk factors associated with equine anesthesia.1
Anesthesia and This study is the basis for the following discussion on
anesthetic risk in foals.
Analgesia for Foals The most common procedures performed in foals include
orthopedic surgery (correction of angular limb deformities
Sheilah A. Robertson and joint flushes) and urogenital surgery (Table 21-1). The
greatest risk associated with anesthesia and surgery occurs in
foals between birth and 4 weeks of age (Table 21-2), and
abdominal surgery is the procedure that carries the highest
mortality rate (Table 21-3).
Foals undergo a rapid physiologic transition during the first Inhalant agents are associated with more deaths than
year of life. Many changes involving the respiratory, cardio- injectable anesthetic protocols (Table 21-4). If only inhalant
vascular, central nervous, and renal systems are unique to agents are used, the fatality rate is 4.4%, compared with
foals, and they have a major impact on their anesthetic 0.8% for total intravenous anesthetic (TIVA) techniques. In
management. Foals require sedation or general anesthesia the past, inhalant agents were used primarily because of the
for a variety of reasons, but the most common procedures belief that neonates, including foals, could not effectively
are orthopedic and urogenital. The overall perioperative metabolize injectable drugs. Future studies on foal anes-
mortality rate for equine patients under 1 year of age is thesia should focus on total intravenous techniques such as
1.9%, which is higher than the rate reported for the general those discussed for adults in Chapter 20.
horse population.1,2 Foals between birth and 4 weeks of age
pose the greatest risk associated with anesthesia, and within
this group abdominal surgery has the highest mortality rate. PHYSIOLOGY OF NORMAL FOALS
Data show that the choice of anesthetic technique has a The anesthetist must be aware of the normal physiologic
significant impact on outcome. values in healthy foals to avoid misinterpretation of data.7–10
Despite the risks, the demand for anesthesia in critically For example, murmurs may be “normal” and arterial oxygen
ill foals sent to referral centers is greater than ever. Newer values low in the first week of life.
surgical and imaging techniques that require general anes-
thesia, such as laparoscopy3 and magnetic resonance
imaging (MRI),4 are becoming popular. Importantly, pain Cardiovascular System
management is an integral component of perioperative care, Heart rates are approximately 100 beats per minute during
and techniques that are appropriate for foals must be the first month of life, decreasing to an average of 77 at 2
included in the anesthetic plan. months and 60 at 3 months of age7,10 (Table 21-5). These
changes most likely reflect a transition from sympathetic
dominance to increased vagal influence as the cardio-
RISKS ASSOCIATED WITH ANESTHESIA vascular system matures.
IN FOALS Echocardiographic evidence indicates that left ventricular
Although outcomes have been reported for surgical treat- function (as measured by the shortening fraction) is similar
ment of colic5 and uroperitoneum6 in foals, it has been in foals and adults,10 but cardiac output is primarily rate
difficult to differentiate between mortality associated with dependent. If cardiac indices are adjusted for metabolic size,
anesthesia itself and the surgical procedure. The Confiden- foals have a cardiac index (mL/min per kilogram)7 at least

TABLE 21-1. Reasons for Anesthesia in Foals

Abdominal, Orthopedic,
Age of Colic Not Colic Fracture Not Fracture Urogenital ENT Other Total in
Foal (mo) N (%) N (%) N (%) N (%) N (%) N (%) N (%) Group (N)
<1 53 (8) 41 (6) 19 (3) 322 (47) 178 (26) 30 (4) 37 (5) 680
1-2 55 (5) 21 (2) 23 (2) 774 (68) 137 (12) 49 (4) 72 (6) 1131
3-5 54 (5) 23 (2) 23 (2) 474 (41) 438 (38) 51 (4) 96 (8) 1159
6-11 84 (6) 20 (1) 19 (1) 477 (32) 674 (45) 70 (5) 148 (10) 1492
Total for each 246 (6) 105 (2) 84 (2) 2047 (46) 1427 (32) 200 (4) 353 (8) 4462
procedure

ENT, ear, nose, or throat surgery.

Data from the Confidential Enquiry into Perioperative Equine Fatalities (Johnston GM, Taylor PM, Holmes MA, et al: Equine Vet J 1995,27:193).
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 228

228 RECENT ADVANCES IN ANESTHESIA

TABLE 21-2. Perioperative Fatality Rate in Foals TABLE 21-4. Anesthesia Technique and Perioperative
Fatality Rate in Foals Aged <12 Months
Age of Foals Animals in Group Fatality Rate
(mo) (N) (%) Fatality
Anesthesia Technique Anesthesias Deaths Rate
<1 680 4.26
(N) (N) (%)
1-2 1131 1.50
IV induction + 3258 56 1.7
2-5 1159 1.38
maintenance with
6-11 1492 1.54 inhalant
All (0-11 months) 4462 1.9 Single IV bolus only 378 2 0.5
IV induction and IV 259 2 0.8
Data from the Confidential Enquiry into Perioperative Equine Fatalities (Johnston
GM, Taylor PM, Holmes MA, et al: Equine Vet J 1995,27:193).
maintenance
Inhalant agent for 567 25 4.4
induction and
maintenance
TABLE 21-3. Risk from Surgical Procedures in Foals
Aged <12 Months Total number of 4462 85 1.9
anesthesias
Surgical Procedure Foals Deaths Fatality
(N) (N) Rate (%) Data from the Confidential Enquiry into Perioperative Equine Fatalities (Johnston
GM, Taylor PM, Holmes MA, et al: Equine Vet J 1995;27:193).
Abdominal 311 40 12.9
Ear, nose, or throat 197 3 1.5
try are used, the MAP may be as low as 50 mm Hg in normal
Fracture 77 7 9.1 1-day-old foals, rising to 60 to 70 mm Hg at 2 to 3 weeks
Orthopedic (not fracture) 2031 16 0.8 of age.10 More recently, indirect oscillometric techniques
Urogenital 1411 16 1.1 have been validated against direct arterial blood pressure
measurement, and true blood pressure readings are higher
Other 350 3 0.9
than those reported from Doppler studies.13 MAP dictates
organ perfusion; therefore, this is the most valuable blood
Data from the Confidential Enquiry into Perioperative Equine Fatalities (Johnston
GM, Taylor PM, Holmes MA, et al: Equine Vet J 1995;27:193).
pressure variable to obtain. In conscious 30- to 46-hour-old
foals, direct MAP ranged from 59 to 113 mm Hg13 and from
69 to 111 mm Hg using oscillometric techniques.14
twice that of adults,11,12 yet their stroke volume is lower (see
Table 21-5). Therefore, any decrease in a foal’s heart rate has
a significant impact on cardiac output. Respiratory System
Mean arterial blood pressure (MAP) values vary with the Respiratory rate is high at birth,15,16 and it declines over the
measurement technique employed. If indirect techniques first 6 months of life. At 1 week of age, the respiratory rate
such as Doppler ultrasound or electronic sphygmomanome- (43 ± 8 breaths/min),15 is four times that of adult horses.17

TABLE 21-5. Cardiovascular Variables in Normal Foals and Adults

Variable AGE
12 h 24 h 6-8 d 14 d 21 d 30 d 60 d 4-6 wk Adult
† † † † ‡
Heart rate 89 ± 4* 106 ± 17 114 ± 9* 95 ± 5* 110 ± 11 103 ± 14 77 ± 9 84 ± 16 37 ± 2§
(beats/min) 111 ± 18† 100 ± 11†
Cardiac index 180 ± 10* 197 ± 12* — 222 ± 21* — — — 167 ± 16‡ 68.9 ± 3.1§
(mL/kg/min) 72.2 to 99#
Stroke volume 90.4 ± 5.7* — — 164 ± 25.9* — — — 151 ± 25‡ 889 ± 55§
(mL)
Total peripheral 858 ± 70* — — 497 ± 87* — — — — 333 ± 18§
resistance
(dynes•sec•cm−5)
Mean arterial 88 ± 2* 59-113¶ 97 ± 5* 100 ± 3* — — — 115 ± 6‡ 133 ± 4§
pressure (mm Hg)

*Thomas WP, Madigan JE, Backus KQ, et al: J Reprod Fertil Suppl 1987;35:623.
†
Lombard CW, Evans M, Martin L, et al: Equine Vet J 1984;16:342.
‡
Dunlop CI: Vet Clin North Am Equine Pract 1994;10:67.
§
Steffey EP, Dunlop CI, Farver TB, et al: Am J Vet Res 1987;48:7.
#
Bonagura JD, Muir WW: In Muir WW, Hubbell JAE (eds): Equine Anesthesia: Monitoring and Emergency Therapy, St Louis, 1991, Mosby.
¶
Nout YS, Corley KT, Donaldson LL, et al: J Vet Emerg Crit Care 2002;12:75.
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 229

ANESTHESIA AND ANALGESIA FOR FOALS 229

Minute ventilation also declines over this age range,15 with than 1.008).21 Iohexol clearance may offer a clinically useful
the high values early in life being necessary to meet the high method for assessing renal function in neonatal foals.23
metabolic rate of foals.16 Oxygen consumption in 1- to 7- In normal 1- to 10-day-old foals, the pharmacokinetics of
day-old foals is 6 to 8 mL/kg per minute, which is two to amikacin, a renally excreted antibiotic, suggest maturation
three times that of adults,16 and this must be taken into of kidney function during this time.24 Hypoxemia and
account when low-flow anesthetic techniques are used. Tidal azotemia can markedly alter excretion of amikacin,25 and
volume in foals is similar to that in adults, as are values for the dosage and dosing interval of renally excreted drugs may
arterial partial pressure of carbon dioxide. Some of these require adjustment in compromised foals.
variables are shown in Table 21-6.
Newborn foals are hypoxic.16,18 At 1 hour of age, values
are 60.9 ± 2.7 (mean ± standard error of the mean) mm Hg Central Nervous System
and gradually increase to 86.9 ± 2.2 mm Hg by day 7, which Changes in drug disposition in growing foals may be
is still below adult values of 104 ± 5 mm Hg.19 Body posi- explained by alterations in body composition, hepatic
tion influences arterial oxygenation,9,16 with values up to 14 metabolism, and renal excretion. An additional factor to
mm Hg lower in foals that are laterally recumbent than in consider, especially in regard to anesthetic agents, whose site
foals in the upright position.16 The anesthetist should also of action is the central nervous system (CNS), is the perme-
be aware of the age-related responses to oxygen adminis- ability of the blood-brain barrier, which separates cerebral
tration.18,20 Although the rise in arterial oxygen pressure spinal fluid (CSF) and nervous tissue from the intravascular
(PaO2) with oxygen therapy in normal foals is significant, compartment.26,27 Age-related changes in permeability have
the response is much less in the first 2 days of life compared been reported in some species,27 but much less is known
with day 7 and is not influenced by duration of oxygen about the foal. The buffering ability of the CSF is also
therapy (2 minutes versus 20 minutes) or method of admin- important to consider, as changes in CNS pH may directly
istration (face mask versus nasal insufflation).20 The changes affect brain function and may also alter drug dissociation
in response to oxygen may be a result of ductal closure or and action.
differences in ventilation and perfusion. Premature foals Geiser and colleagues studied the CSF buffering capacity
failed to show a response to oxygen therapy,18 and this of foals less than 12 days of age by measuring the pH and
should be borne in mind when emergency anesthesia is PCO2 of arterial and venous blood and the CSF during
performed in these patients. normocapnia and hypercapnia.26 As in other neonates, the
CSF of foals was more acidic than blood during normo-
capnia (PaCO2, 35 to 40 mm Hg).26 Hypercapnia (PaCO2
Renal Function greater than 45 mm Hg) produced a rapid increase in
Renal function is an important determinant of the excretion CSF PCO2 and a drop in pH. In contrast with blood, the
of many drugs. Studies show that although foal kidneys may buffering capacity of the CSF was poor and can be explained
be structurally immature, they are functionally mature. The by the lack of protein, a major buffering system in blood,
glomerular filtration rate and effective renal plasma flow and the low permeability of the blood–CSF interface to
from 1 to 10 days of age are not significantly different from bicarbonate ions compared with highly soluble CO2. Acute
those of adults.21,22 Blood urea nitrogen values of less than increases in PaCO2 that may occur in sick, sedated, or
2 mmol/L are normal up to 3 months of age,21 whereas the anesthetized neonatal foals may have far-reaching effects
mean adult value is 3.5 mmol/L. Rapid incorporation of not only because of their poor CSF buffering capacity but
amino acids into proteins is thought to be the cause of the also as a result of vasodilation of cerebral vessels, which
low value in foals. Urine production in 4-day-old foals was results in increased cerebral blood flow and intracranial
148 ± 20 mL/kg per day and had a low specific gravity (less pressure.26

TABLE 21-6. Respiratory and PaO2 Values in Normal Foals and Adults
Variable AGE

24 h 48 h 7d 14 d 1 mo 2 mo Adult
† † † † †
Respiratory rate 42 ± 4* 54 ± 10 43 ± 8 38 ± 11 34 ± 11 32 ± 8 11 ± 4‡
(breaths/min) 44 ± 7* 42 ± 5* 16 ± 2§
Tidal volume 6.4 ± 0.5* 15.8 ± 2.5† 17.4 ± 2.9† 14.3 ± 1.9† 13.1 ± 1.6† 9.8 ± 2.6† 14.3 ± 2.3‡
(mL/kg) 6 ± 0.5* 8 ± 1.2*
Minute ventilation — 848 ± 231† 744 ± 169† 523 ± 126† 436 ± 116† 300 ± 42† 162 ± 45‡
(mL/min/kg)
PaO2 (mm Hg) 68 ± 4* 75 ± 3* 87 ± 2* — — — 104 ± 4§

*Stewart JH, Rose RJ, Barko AM: Equine Vet J 1984;16:323.

†
Koterba AM, Wozniak JA, Kosch PC: Equine Vet J 1995;27:257.
‡
Koterba AM, Kosch PC, Beech J, et al: J Appl Physiol 1988;64:337.
§
Wagner AE, Muir WW 3rd, Hinchcliff KW: Am J Vet Res 1991;52:651.
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 230

230 RECENT ADVANCES IN ANESTHESIA

Clinical Chemistry of life suggest that glucuronide synthesis matures rapidly36

28
Bauer and coworkers monitored serum chemistry values in normal foals, but the longer half-life in one premature
in several equine breeds during the first year of life and foal indicates that their livers are less mature. Elevated
reported significant changes for alkaline phosphatase, bilirubin values in the first week of life may be a result of
aspartate transaminase, urea nitrogen, and total, direct, and low glucuronyl transferase activity in foals.28
indirect bilirubin, but not for electrolytes or glucose,
emphasizing the need to consult age-specific reference values
when interpreting this information in a clinical situation. SEDATION
Mean serum glucose values ranged from 8.0 to 9.3 mmol/ Foals require sedation for a variety of reasons, including
L during the first 3 months, with foals less than 12 hours radiography, bandage and cast changes, intravenous catheter
of age having values of 8.0 ± 1.6 mmol/L.28 Smyth and placement, intensive care procedures, and arthrocentesis,
colleagues reported that 1-day-old foals that had been fasted and they should be sedated prior to general anesthesia.
for 2 hours had serum glucose values of 6.0 ± 0.7 mmol/L.29 Information on the effects of the commonly used sedatives
Full-term foals were able to maintain plasma glucose values (xylazine, detomidine, diazepam, acepromazine) on foals is
for 2 hours after birth without suckling, but premature foals available.
had mean values of only 2.31 mmol/L.30 There are no significant differences in the cardiopul-
Blood lactate is a useful indicator of tissue perfusion, monary responses to high dosages (1.1 mg/kg IV) of the
but reference values may vary with age and source of the alpha2-agonist xylazine in healthy 10- and 28-day-old
sample. In Thoroughbred foals aged 1 to 6 months, jugular foals.37 Unlike adults given a similar dosage, most foals
blood values ranged from 0.9 to 1.65 mmol/L,31 whereas become recumbent. Foals’ heart rates fell by about 20% to
arterial blood lactate values in 2-day-old foals were 2.17 ± 30% without the second-degree atrioventricular block that is
0.49 mmol/L.32 typically seen in adults. A biphasic (initial increase followed
by a decrease) change in blood pressure, similar to that in
adult horses, occurred, but the MAP did not fall below
Hematology 60 mm Hg.37
Hematologic values change during a foal’s first 12 months.33 Respiratory rhythm is markedly disrupted after xylazine
Hemoglobin and packed cell volume (PCV) fell during the administration in foals. Frequent upper airway noise
first 2 weeks of life and then remained in the low normal indicative of respiratory obstruction lasted for 20 minutes,
range reported for adults, with no differences noted between after which time respiration became slow and regular.37 The
Thoroughbred and Quarter Horse foals.33 PCV was 0.43 ± noise is thought to result from upper airway collapse sec-
0.03, 0.40 ± 0.03, 0.38 ± 0.03 L/L at birth, 1 and 3 days ondary to muscle weakness. Despite this response, healthy
respectively and progressively fell to 0.34 ± 0.04 L/L at foals showed no changes in PaO2 or PaCO2. Foals with respi-
1 month of age. Hemoglobin and PCV values lower than ratory disease, including those with preexisting upper airway
those reported for healthy foals may result in decreased obstructions such as guttural pouch tympany or strangles,
oxygen delivery to tissues. Total plasma proteins values were may not compensate for these respiratory insults and should
60 ± 8 g/L at day 1 and did not vary more than 10% during not be given xylazine. Alternatively, it can be given after
the first year.33 establishing an airway by nasotracheal intubation.38 Lower
dosages (0.2 to 0.3 mg/kg IV) provide adequate sedation in
a clinical setting and are associated with fewer cardiovas-
PHARMACOKINETICS cular changes.39
The disposition of many drugs in foals is different from that Rectal temperature fell significantly after xylazine admin-
in adults, and appropriate changes in both dosage and dose istration in foals and remained low for more than 2 hours,
interval may be needed to avoid subtherapeutic or toxic by which time the sedative effects had worn off.40 Body
concentrations. Pharmacokinetics may be influenced by temperature should be monitored in all foals given xylazine,
both body composition and organ maturation, especially and extremes of environmental temperature are best
hepatic and renal function. For several drugs, marked phar- avoided. Unlike in adult horses, xylazine did not produce
macokinetic differences have been noted between newborns, hypoinsulinemia and hyperglycemia in 10- and 28-day-old
1-week-old foals, 1-month-old foals, and foals older than 1 foals, suggesting differences in pancreatic response to α2-
month. As a percentage of their body weight, foals have adrenergic agonists in neonates.40 Increased urination occurs
greater total body water, blood plasma, and extracellular after xylazine administration,40 and this should be consid-
fluid (ECF) volumes than adults34,35 (see Chapter 3). In foals ered when it is used to sedate hypovolemic foals.
up to 1 month of age, the ECF accounts for 35% to 40% of Detomidine has been studied in foals between 2 weeks
body weight, compared with 25% in adult horses,34 and this and 3 months of age.41 Increasing the IV dosage from 10 to
may influence the uptake and distribution of anesthetic 40 µg/kg did not provide a greater degree of sedation, but it
drugs. did prolong the duration of action: sedation lasted 28 ± 4
minutes after 10 µg/kg, and 73 ± 7 minutes after 40 µg/kg.
Analgesia as assessed by skin prick was noted only at the
Hepatic Metabolism 40-µg/kg dosage, but this was inconsistent and present in
The liver is the main site of drug metabolism, and it is less than 50% of foals. As in xylazine-treated foals, respi-
important to have data on age-related hepatic function so ratory stridor and increased urine production were observed.
that the anesthetist can make appropriate drug choices. The Unlike in foals given xylazine, recumbency did not occur
pharmacokinetics of chloramphenicol during the first week even after high dosages of detomidine. This agent is less
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 231

ANESTHESIA AND ANALGESIA FOR FOALS 231

desirable than xylazine for sedation and analgesia of young be associated with cardiac arrhythmias, which increases the
foals, as even low dosages (10 µg/kg) are associated with a anesthetic risk and must be corrected before surgery. Serum
60% incidence of arrhythmias.41 potassium can be decreased by draining the abdomen, by
Diazepam is widely used in foals as a tranquilizer, muscle administering intravenous fluids (0.9% NaCl or 5% dex-
relaxant, and anticonvulsant. The pharmacokinetics of trose), and by correcting the metabolic acidosis with sodium
diazepam at a commonly used clinical dosage (0.25 mg/kg bicarbonate. Insulin is only rarely required.
IV) have been studied in foals at 4, 21, 42, and 84 days of Although the focus of attention is the foal, the mare must
age.42 Several pharmacokinetic variables were different when not be forgotten. Allowing the dam to be present at induc-
the 4-day-old foals were compared with foals of the other tion of anesthesia is extremely valuable, because this ensures
ages; the most clinically significant difference was the lower a calm foal. Suckling prior to anesthesia ensures adequate
clearance in the 4-day-old age group, because this deter- blood glucose levels, and regurgitation or vomiting is not a
mines whether or not diazepam could accumulate if problem. After the foal has lost consciousness, the mare can
repeated doses or constant-rate infusions are used. In foals be housed nearby but must be sedated, as most mares
21 days and older, pharmacokinetic data were similar to become agitated when separated from their foals. Xylazine
those reported for adult horses.42,43 Compared with the values (0.3 to 0.5 mg/kg IV) or detomidine (0.01 mg/kg IV) pro-
seen in other adult species, the free fraction of diazepam was duces rapid and profound sedation in mares that can be
much higher, and this could result in a greater clinical extended by the addition of acepromazine (0.04 mg/kg IM).
effect.42 Lower binding ability of fetal albumin or compe-
tition for binding sites by elevated bilirubin levels in foals
GENERAL ANESTHESIA
may explain this relatively high free fraction. The active
metabolite desmethyldiazepam was measurable in all foals Injectable Agents
between 4 and 84 days of age42 but was not detected in adult Matthews and coworkers reported their experiences with
horses after administration of diazepam.43 These data sug- propofol in healthy foals.46 Their protocol was 0.5 mg/kg of
gest a difference between foals and adults in hepatic xylazine IV followed 5 minutes later by a bolus of propofol
biotransformation and elimination of drugs. The cardiopul- (2 to 3 mg/kg) given over 45 to 60 seconds. As in other
monary effects of diazepam have not been reported in foals, species, propofol must be given slowly to prevent apnea.
but dosages of up to 0.4 mg/kg produced no changes in Immediately after induction, foals were intubated, they were
cardiac output, blood pressure, or blood gas values in adult given 100% oxygen, and an infusion of propofol was started
horses.43 (approximately 0.3 mg/kg per minute). After infusions of
Clinical effects of diazepam in foals are not widely docu- up to 2 hours, foals had smooth and rapid recoveries.
mented. One study comparing xylazine to diazepam plus Cardiopulmonary variables were generally well maintained
butorphanol as a premedicant for foals undergoing even when foals were placed in dorsal recumbency. A mild
periosteal stripping concluded that xylazine provided better respiratory acidosis (PaCO2 of 60 mm Hg or less) was
muscle relaxation.44 When diazepam (0.1 to 0.2 mg/kg IV) documented but considered clinically acceptable in healthy
is administered to foals less than 2 months of age, the foals. It must be emphasized that these foals were all given
usual response is profound sedation, muscle relaxation, and oxygen supplementation, as hemoglobin saturation declines
recumbency, whereas in older foals (2 to 4 months old), significantly if foals are allowed to breathe room air during
sedation and muscle relaxation are less pronounced and not propofol anesthesia (my personal experience).
always accompanied by recumbency (in my personal Foals may react to surgical stimuli when anesthesia is
experience). These observations correlate with the research maintained with propofol alone. Therefore, this technique is
studies described earlier. These age-related responses may more suited for short, nonpainful procedures such as cast
occur because of differences in permeability of the blood- changes and radiography, when a rapid smooth recovery is
brain barrier in younger foals. desirable. Alternatively, propofol anesthesia could be com-
Acepromazine can be used in foals, and commonly used bined with a local anesthetic in some situations, or seda-
dosages are 0.03 to 0.05 mg/kg (IM or IV). In adult horses, tives, analgesics, or dissociative agents such as xylazine,
acepromazine decreases the fatality rate associated with butorphanol, or ketamine (respectively) could be added to
general anesthesia,1 which may be a reflection of its anti- the protocol. Propofol used alone without premedication
arrhythmic properties. Hypotension secondary to vasodi- provides approximately 5 minutes of general anesthesia.
lation is not observed unless foals are hypovolemic. In dogs, propofol is an appropriate agent for patients with
Vasodilation and sedation may enhance heat loss, but there neurologic disease.47,48 In foals, a single bolus should be
are no reported studies confirming this. adequate for collection of CSF samples. For MRI studies in
foals suffering from neurologic disorders, propofol could be
administered as a continuous infusion, and in these
THE PREANESTHETIC PERIOD patients, PaCO2 should be closely monitored and hyper-
The preoperative workup varies depending on the physical capnia avoided.
status of the foal and the intended surgical procedure. Blood The pharmacokinetics of ketamine have not been
work and physical examination results must be correlated described for the foal, but in adult horses recovery after a
with the distinct age-related changes described earlier. bolus results from redistribution.49 Ketamine at a dosage of
Electrolytes should be measured in foals with uroperi- 2.2 mg/kg IV is recommended for foals and is usually given
toneum; in one study, 48% of foals had abnormalities, which after premedication with xylazine or diazepam, or after
included hyponatremia, hypochloremia, and hyperkalemia administration of the centrally acting muscle relaxant
accompanied by a metabolic acidosis.6,45 Hyperkalemia may guaifenesin.39
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 232

232 RECENT ADVANCES IN ANESTHESIA

Total Intravenous Anesthesia ANALGESIA

TIVA is associated with a lower mortality rate in both adults Pain has negative physiologic and psychological effects in all
and foals. The so-called triple drip is widely used in foals,39 species and should be treated. There are very few studies on
but oxygen supplementation is required to prevent hypoxe- pain assessment in foals and few on the efficacy of analgesic
mia. Dunlop39 recommends making a triple-drip mixture agents. Traditionally, analgesia is provided by nonsteroidal
using a 1-L bag of 5% guaifenesin and adding 250 mg of anti-inflammatory agents (NSAIDs), opioids, α2-agonists,
xylazine and 1000 mg of ketamine. Induction can be and local anesthetics. A detailed review of analgesic drugs
achieved with 1 to 2 mL/kg of this mixture. Anesthesia is and techniques of pain management used in horses can be
maintained using a rate of 2 to 3 mL/kg per hour, with the found in Chapter 23.
infusion rate adjusted on the basis of the clinical signs of It is not unusual for foals to respond to pain more
depth of anesthesia. TIVA techniques are discussed fully in abruptly and profoundly than adults—for example, during
Chapter 20. the initial incision at the start of a surgical procedure—even
when the anesthetic depth appears adequate. Dunlop
remarked during a study that evaluated the anesthetic
Inhalant Agents potency of isoflurane that foals were hyperresponsive to the
The CEPEF data strongly suggest using TIVA techniques, initial noxious stimulus.39 To block the initial response to
or to induce the patient with injectable agents followed surgery, local infiltration of the surgical site with lidocaine
by maintenance with inhalant agents rather than relying or bupivacaine is a simple and effective technique, as these
totally on inhalant agents. For the foreseeable future, agents also provide some analgesia in the early post-
inhalant agents will continue to be used in foals, so the operative period.
advantages and disadvantages of each should be well The agonist-antagonist opioid butorphanol has been
understood. used safely in foals and is given IV or IM (0.1 to 0.2 mg/kg).
The time from induction to lateral recumbency was the Morphine and fentanyl at dosages similar to those used in
same for halothane and isoflurane (approximately 41/2 adults have been used, but there are no reports on the
minutes) when administered by mask to unmedicated foals pharmacokinetics or pharmacodynamics of these drugs in
up to 2 months of age,50 and induction was smooth in both foals.
groups. After 80 to 90 minutes of anesthesia, time to sternal Several pharmacokinetic studies of NSAIDs (including
recumbency was significantly faster in the isoflurane group phenylbutazone,54 ibuprofen,55 ketoprofen,56 and flunixin
(8.03 ± 0.93 minutes) than in the halothane group (13.6 ± meglumine57,58) in foals have been published. Many of these
1.5 minutes); however, time to suckling was not different. were primarily aimed at the use of these drugs for their
Both agents were associated with a similar increase in PaCO2 antiendotoxin effect rather than as analgesics. There are
values despite the lower respiratory rate in isoflurane- differences in volume of distribution, half-life, and clearance
anesthetized foals. In adult horses, there is no difference in for phenylbutazone (2.2 mg/kg IV) between foals and
overall mortality between halothane and isoflurane,2 but adults, with foals less than 24 hours old showing a reduced
such data are not yet available for neonatal foals. ability for drug elimination.54
Sevoflurane is the most recent inhalant agent to be Potential side effects of these drugs include gastrointesti-
introduced to the veterinary market. In adult horses, its nal ulceration, nephrotoxicity, and platelet dysfunction.
cardiopulmonary effects are similar to those of isoflurane51 High dosages (5 mg/kg twice daily for 7 days) of phenylbu-
but recovery is more rapid because of its low solubility.52 tazone did not produce clinical signs of renal or gastro-
Read and coworkers compared isoflurane and sevoflurane as intestinal disease, or changes in complete blood counts or
sole agents for anesthesia in six 1- to 3-month-old foals and clinical chemistries in healthy 7- to 10-day-old foals, but
noted no differences between the two agents in induction renal changes could be detected through premortem ultra-
and recovery characteristics or times.53 Direct MAPs were sonic examination, and gastric ulcers and histologic changes
low in both groups for the first 30 minutes after induction, in the kidneys were found at necropsy.59 In healthy 5- to 10-
with a mean of only 44 ± 7 mm Hg and 46 ± 8 mm Hg for week-old foals, ibuprofen at dosages up to 25 mg/kg three
sevoflurane and isoflurane, respectively, at 10 minutes.53 times daily for 6 days produced no unwanted side effects,
Although MAP improved between 30 and 60 minutes, the but the authors cautioned that this may not be true in foals
cardiac index remained low. The latter varied between with compromised renal function.55 In healthy 1-day-old
93 and 117 mL/kg per minute in both isoflurane- and foals, dosages of ketoprofen must be increased to 1.5 times
sevoflurane-anesthetized foals, which represents approxi- the adult dosage of 2.2 mg/kg to achieve therapeutic plasma
mately a 50% decrease compared with the mean values concentrations, but because of reduced elimination, dosing
reported for conscious foals.7,39 The respiratory depressive intervals may need to be lengthened.56 It is also suggested
effects of sevoflurane could not be assessed because that the dosage of flunixin meglumine, like that of keto-
intermittent positive pressure was used.53 profen, be increased in 1-day-old foals but that the dosing
Inhalant agents seem suitable for maintenance of interval be extended.57 However, when treating septic or
anesthesia, and using sedatives, tranquillizers, or analgesic dehydrated foals, further adjustments must be made. The
agents decreases the minimum alveolar concentration, pharmacokinetics of flunixin meglumine (1.1 mg/kg IV) are
which may offset the cardiorespiratory depressant effects of different in foals at 1 day of age, 10 to 11 days, and 27 to 28
the volatile agents. On the basis of the information days of age.58 Drug elimination was significantly decreased
available, all currently available inhalant agents are suitable in the youngest foals, most likely because of decreased
for use in foals. hepatic metabolism and renal clearance. Despite these
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 233

ANESTHESIA AND ANALGESIA FOR FOALS 233

differences, dosages of up to 2.2 mg/kg given over 5 days in Blood pressure can be measured directly or indirectly and
2-day-old foals caused no clinical, complete blood count, provides useful information on cardiovascular status,
clinical chemistry, or pathologic changes.60 Doses of 6.6 mg/ provided the clinician understands the correlation of cardiac
kg did result in gastrointestinal ulceration.60 These studies output, systemic vascular resistance, and blood pressure, and
suggest that the use of NSAIDs to treat acute perioperative is aware of the age-related changes in blood pressure. Direct
pain in young foals should be safe and effective, but care measurement requires insertion of an arterial catheter (with
should be taken in compromised foals. all the associated problems discussed later in this chapter),
and for this reason indirect methods are often used. The
ultrasonic Doppler technique using a tail cuff as described
MONITORING AND INTRAOPERATIVE CARE by Lombard and coworkers10 was not validated against a
Monitor is derived from the Latin word monere, which means direct blood pressure measurement and may have under-
“one that warns.” Monitoring vital functions in anesthetized estimated the blood pressure of neonatal foals. An electronic
foals is essential for a successful outcome, but monitoring sphygmomanometer gave consistently lower readings than
equipment displays only numbers, and the anesthetist must directly measured blood pressure in anesthetized pony
know what values are normal and how to intervene if aber- foals,14 but the authors felt it was sufficiently accurate if a
rations occur. For these reasons, it is important to be familiar correction factor was used.
with the physiologic data of neonatal foals described earlier. More recently, the accuracy of an indirect oscillometric
In addition, the anesthetist’s physical senses, skill, and expe- monitor (ProPaq Encore 206EL, Protocol Systems, Inc,
rience play a vital role in determining anesthetic depth. Beaverton, Ore) has been reported in both awake and
Many of the techniques described for monitoring criti- anesthetized foals.13 There was good agreement between this
cally ill neonatal foals, reviewed in depth by Corley,32,61 technique (cuff placed around the tail) and direct meas-
apply to anesthetized foals. During anesthesia, ventilation urement (greater metatarsal artery) for mean and diastolic
and oxygenation must be maintained, and therefore these blood pressure, but agreement was less satisfactory for
variables must be monitored. Optimizing organ perfusion is systolic blood pressure. MAP is more clinically relevant, as
a primary goal of the anesthetist, but perfusion per se is this is a better predictor of organ perfusion. The authors
difficult to measure. Indirect markers of perfusion include recommended a ratio of cuff bladder width to tail girth of
cardiac output, blood pressure, urine output, and blood between 1:1.9 and 1:2.8, and in practical terms, a 52-mm
lactate values. Hypothermia has far-reaching deleterious bladder was suitable for foals aged 1 to 2 days and weighing
effects, so body temperature should be closely monitored 44 to 68 kg.
and active warming techniques employed. Foals may be On the basis of published results,13,14 a MAP of 60 mm
susceptible to hypoglycemia, so blood glucose should be Hg or below should prompt the clinician to intervene.
monitored. Corley suggests that supportive therapy be initiated at an
MAP of 69 mm Hg and published data indicating that MAPs
less than 60 mm Hg in foals less than 1 week old are
Cardiovascular Monitoring associated with a higher mortality rate.32 Foals with low
Cardiac output is the parameter that most accurately assesses blood pressure may require fluid therapy or inotropic sup-
cardiovascular function, but its measurement has until now port (see Chapter 1).
been restricted to the research arena because of the technical Urine output in foals is approximately 6 mL/kg per hour.21
challenges and dangers associated with cardiac catheteri- Urine production reflects adequacy of perfusion, cardio-
zation, which include endocardial damage. New, less inva- vascular and hydration status, and renal function.32 Urine
sive technology that requires only a venous and a peripheral production can be measured after placing a urinary catheter
arterial catheter and lithium as a marker has revolutionized using a sterile technique and attaching it to a closed
cardiovascular monitoring, making it the only validated collection system.32 Less than expected urine production
technique currently suitable for clinical use.32,62 This tech- should prompt the anesthetist to review the hydration and
nique, termed lithium dilution (LiDCO Ltd, Cambridge, cardiovascular status of the foal.
United Kingdom), is commercially available. Even more
recently, a noninvasive cardiac output technique (NICO,
Novametrix, Wallingford, Conn) based on the Fick principle Respiratory Monitoring
and partial rebreathing of CO2 has performed well when Arterial oxygen values in foals change with age and are lower
compared with the lithium dilution technique in dogs,63 than in adults. However, hypoxemia is a potential problem
and it is being evaluated in neonatal foals (personal com- in awake and anesthetized neonatal foals but frequently
munication, A. Valverde, 2004). This technology can be used goes unnoticed because clinical signs are nonspecific;
only in intubated animals, but because nasotracheal therefore, reliable monitoring techniques are required. The
intubation is easily performed,38 it may be adaptable to gold standard is arterial blood gas measurement, but obtain-
conscious foals. ing a sample by direct needle puncture may be technically
Cardiac output monitoring is invaluable in critically ill difficult, maintaining an arterial catheter is challenging,
foals in the perioperative period. It allows the anesthetists to and the site is a potential access for infection.64 In addition,
make prompt and appropriate treatment decisions and to only periodic information can be obtained. For these rea-
monitor the response to fluid therapy, inotropes, or sons, pulse oximetry has been evaluated in foals.32,64 Pulse
vasopressors. Normal values were discussed earlier in this oximetry is a continuous, noninvasive technique for esti-
chapter. mating arterial oxygen saturation (SaO2). Commercially
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 234

234 RECENT ADVANCES IN ANESTHESIA

available monitors are inexpensive, but clinicians must be lungs to be eliminated, sudden decreases in ETCO2 can
aware of their limitations. In anesthetized foals, the accuracy reflect a cardiovascular crisis.
of one pulse oximeter (Nellcor N-200, Nellcor Puritan
Bennett, Inc, Pleasanton, Calif) with three different trans-
ducers (fingertip, adhesive, and forehead reflectance types) Blood Glucose
placed at several sites (ear, lip, tongue, and ventral tail base) Both hypoglycemia and hyperglycemia are undesirable in
was evaluated.64 Pulse oximetry is a valuable technique, anesthetized patients. In a conscious animal, hypoglycemia
but the transducer type, placement site, and range of SaO2 may result in seizure activity, coma, and CNS damage, all of
values have a significant effect on reliability, so pulse oxime- which are masked by general anesthesia. In the past, the
try should not totally replace arterial blood gas analysis. A detrimental effects of hyperglycemia were underestimated,
fingertip-type transducer placed on the ear or tongue is the but human data strongly implicate elevated blood glucose
most clinically useful technique. values as a cause of increased postoperative infection and
Carbon dioxide values reflect the balance between pro- mortality.68-70
duction (metabolic rate), cardiovascular function (transport Problems associated with interpreting glucose results in
of CO2 from tissues to the lungs), and elimination (venti- foals include the analytical technique, sample site (venous,
lation). As previously discussed, increases in PaCO2 may have arterial, or capillary), and which references are used as nor-
deleterious effects on CNS function. Elevated CO2 values mal values. The anesthetists must know whether the analyti-
may occur in weak and compromised foals, and most seda- cal technique they use measures plasma, serum, or whole
tives and general anesthetic agents produce respiratory blood glucose so that the correct reference data are used. For
depression and hypercapnia. convenience, bed-side analyzers are commonly used in the
The partial pressure of arterial CO2 (PaCO2) is the most operating room. In dogs71 and foals,72 there are wide varia-
reliable indicator of pulmonary ventilation, but because of tions in the accuracy of commercially available portable
the difficulty in obtaining arterial blood samples, venous9 blood glucose monitors. Cohn and coworkers71 concluded
and end-tidal CO265 values have been studied in foals. End- that up to 67% of clinical treatment decisions would have
tidal or end-expired CO2 (ETCO2) reflects alveolar CO2 ten- been erroneously altered had the clinician relied on results
sion, which in turn is closely related to arterial CO2, and is obtained from some portable blood glucose meters and,
widely used as a noninvasive method for monitoring venti- according to their study, a point-of-care analyzer (i-STAT
lation in anesthetized and intubated animals.66 Capnography portable clinical analyzer, Heska Corporation, Fort Collins,
refers to the graphic display of CO2 concentration over time Colo) was the only acceptable portable method.71 To track
and is preferred over capnometry, which provides the anes- trends accurately, blood samples should be collected from
thetist with only a numerical display of CO2 concentrations. the same site and analyzed using the same technique.
The attraction of capnography is the continuous display of Healthy foals scheduled for short procedures are unlikely to
information compared with intermittent blood gas analysis. have problems associated with blood glucose, but premature
Interpretation of the waveform not only provides informa- foals and sick foals, especially those that may be septic and
tion on patient factors but also alerts the anesthetist to those undergoing surgery lasting several hours, should be
equipment malfunction, such as kinked endotracheal tubes, monitored. To preserve normoglycemia, foals should be
airway obstruction, exhausted carbon dioxide absorbent, allowed to suckle up until the time of anesthesia and
and incompetent one-way valves. Currently, there are two allowed access to their mare’s milk as soon as possible after
main types of capnograph available—the mainstream and recovery.
the sidestream—and in dogs, the former was considered
more accurate.67 However, the authors warned that under
hypercapnic conditions (i.e., PaCO2 greater than 60 mm Hg), Body Temperature
ETCO2 values do not accurately reflect the severity of hypo- Foals are susceptible to heat loss because of their high ratio
ventilation, as determined by the gold standard of arterial of surface area to body weight, and their lack of sub-
CO2 measurement.67 The reliability of ETCO2 measurement cutaneous fat. Hypothermia decreases metabolism of
in spontaneously breathing, isoflurane-anesthetized foals anesthetic drugs, delays recovery, and results in postanes-
has been reported.65 A gradual increase in both PaCO2 and thetic shivering, which increases oxygen requirements. Very
ETCO2 occurred over a 90-minute period, with arterial CO2 low heart rates (less than 60 beats per minute) associated
always greater than ETCO2.65 During the first 60 minutes, with rectal temperatures less than 36° C (less than 97° F)32
ETCO2 was a useful indicator. After 60 minutes, ETCO2 was are detrimental to foals because their cardiac output is more
not predictive and greatly underestimated arterial CO2 dependent on heart rate than that of adults. Shivering is
values—for example, at 90 minutes, the mean ETCO2 value unpleasant and may increase postoperative pain because of
was 63 mm Hg and PaCO2 was 78 mm Hg. The widening of involuntary muscle activity around surgical wounds.
the arterial to end-tidal gradient could be explained by Although not well documented in the veterinary literature,
hypoventilation and decreased pulmonary capillary perfu- intraoperative hypothermia interferes with clotting enzymes,
sion of alveoli.65 As in other species,66 the limitations of causing increased blood loss in humans.73,74 Postoperative
capnography must be understood. Capnography may be infections are increased and wound healing is delayed by
useful for short anesthetic procedures, but it cannot totally hypothermia, because cold-induced vasoconstriction results
replace blood gas analyses. This technology is primarily in decreased wound perfusion and oxygen delivery. In addi-
thought of as a respiratory monitor, but because carbon tion, antibody and cell-mediated immune systems are
dioxide must be transported in blood from tissues to the depressed by low body temperatures.68,74,75 Core temper-
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 235

ANESTHESIA AND ANALGESIA FOR FOALS 235

ature (at the esophagus, tympanic membrane, or pulmonary adequate organ perfusion. If hypotension occurs, the cause
artery) is considered the most critical value, but in a clinical must be identified, and it may be hypovolemia, hemorrhage,
setting and in awake foals, it is impractical to obtain. For decreased cardiac output, or vasodilation, or a combination
these reasons, peripheral or shell temperature, usually a of any of these. If fluid losses are thought to be the problem,
rectal temperature, is measured. The relationship between they can be addressed as discussed earlier.
core and peripheral temperature is not well documented in Bradycardia has a marked effect on cardiac output and
foals, but in anesthetized adult horses, rectal temperatures blood pressure in foals because of their high heart rate and
did accurately reflect core temperature.76 fixed stroke volume. One of the main causes of bradycardia
Preventing hypothermia is important and can be done is hypothermia, and this must be prevented or treated,
using simple and relatively inexpensive techniques such as because heart rate does not respond to anticholinergic
dry, light-weight blankets, circulating warm water blankets, therapy in this situation. Bradycardia may result from vagal
and forced warm air devices (Bair Hugger Therapy, Arizant, stimulation such as bladder manipulation. Such stimuli
Inc, Eden Prairie, Minn). Additionally, cold operating rooms should be stopped and anticholinergics (atropine or glyco-
and excessive use of cold evaporative skin preparation pyrrolate) may be required. Anesthetic agents, in particular
solutions such as alcohol should be avoided. the inhalant agents discussed previously, are potent
cardiovascular depressants. For these reasons, the depth of
anesthesia should be closely assessed and, if possible, the
Fluid Therapy vaporizer setting decreased. In addition, the use of an
The fluid intake (milk plus water) of foals is high, with anesthetic-sparing drug such as xylazine, acepromazine, and
animals aged 11 to 18 days drinking 246 g/kg and those lidocaine (as an infusion) is recommended to reduce the
aged 30 to 44 days consuming 202 g/kg.77 Maintenance fluid requirement for inhalant agents.
rates in neonatal foals are variable but higher than in Although inotropes and vasopressors may be used to
adults,78 and as much as 120 mL/kg per day is required in increase blood pressure, the goal is to improve organ perfu-
foals up to 1 month of age. Neonates are less tolerant of sion, so increasing cardiac output and blood flow should be
blood loss and dehydration because of their cardiovascular the first line of treatment.61 Monitoring cardiac output is the
physiology,39 so fluid status must be closely monitored and ideal and, as described previously, clinically acceptable
promptly treated. Foals that are septic, have diarrhea, or techniques are now available. Dobutamine is a widely used
have lost blood but require surgery should be rehydrated inotrope in equine anesthesia and effectively increases car-
before they are anesthetized. Hypovolemia is best treated diac output.80,81 In 1-month-old isoflurane-anesthetized
with balanced ionic crystalloid solutions such as Normosol- foals, 3 µg/kg per minute of dobutamine doubled the car-
R, Plasmalyte, or lactated Ringer’s solution.78 Large volumes diac output by increasing both heart rate and stroke
of saline should be avoided, as this can promote acidosis.78 volume,39 whereas in adult horses the increase is primarily
The response to therapy can be assessed by measuring blood related to stroke volume. These differences between adults
pressure, urine output, and, if the technology is available, and foals are a result of the changing sympathetic and vagal
blood lactate. During surgery, similar fluids should be control of the heart with age. Despite the increased cardiac
administered to replace respiratory and evaporative losses as output, mean blood pressure in dobutamine-treated foals
well as blood loss, although the actual fluid administration increased only from 60 to 70 mm Hg because of a significant
rate will vary with each individual case. For a healthy foal decrease in peripheral vascular resistance.39 Therefore, blood
undergoing an elective procedure, 10 mL/kg per hour should pressure readings may not reflect the benefits of dobut-
be adequate. Foals with uroperitoneum and hyperkalemia amine, and monitoring increases in heart rate and urine out-
require specific fluid therapy (see Chapter 3). If blood glu- put may be useful when cardiac output cannot be measured.
cose monitoring indicates it, dextrose may be added to the Vasopressor agents such as epinephrine (adrenaline) and
intravenous fluids. phenylephrine should be used with caution because they
Colloids, including dextrans and hetastarch, may be increase cardiac afterload, their effects may vary in different
required if total protein and albumin are low or if there is a organs, and despite an increase in systemic blood pressure,
poor response to crystalloid therapy. Hetastarch is readily perfusion of the gastrointestinal tract and kidneys can be
available and frequently used in neonatal resuscitation61 at a severely compromised.61 Vasopressin is receiving a lot of
dosage of 3 mL/kg body weight infused at a rate of 10 mL/kg attention as a therapeutic agent in nonresponsive vasodila-
per hour. Blood loss or anemia can be treated with cross- tory shock,82 and it has been used in foals,83 but its place in
matched whole blood, but the use of polymerized bovine treatment of the critically ill and anesthetized foal will not
hemoglobin (Oxyglobin solution, Biopure Corporation, be clear until further studies are conducted. Vasopressors
Cambridge, Mass) has been reported in adult horses79 and should be used only when the blood pressure has not
could be used in foals. In addition to providing hemoglobin responded to other therapies. A comprehensive discussion
for oxygen carriage, this product is a potent colloid (see of inotropes and vasopressors is outside the scope of this
Chapter 4). chapter and the reader is directed to the reviews by Corley.61,83

Blood Pressure Support RECOVERY

During anesthesia, blood pressure can easily be measured. It Foals should be allowed to recover in a dry, warm envi-
is recommended that a mean arterial blood pressure of ronment, and they should be propped up in sternal
greater than 70 mm Hg be maintained at all times to ensure recumbency to optimize their PaO2. If they shiver, supple-
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 236

236 RECENT ADVANCES IN ANESTHESIA

mental oxygen should be provided to prevent hypoxemia. population. It would be prudent to monitor PaCO2 and
When they can be assisted to stand, foals should be reunited cardiovascular function closely during this procedure.
with their dam and allowed to suckle to maintain their fluid In conclusion, anesthetizing foals can be a challenge.
and caloric intake and to reestablish maternal bonding. However, it should be possible to decrease the currently
unacceptable fatality rate in this group of patients. The
clinician should have knowledge of foals’ unique physiol-
NEW TECHNIQUES AND CHALLENGES ogy, age-specific pharmacologic data, evidence-based studies
Two techniques that require new anesthetic skills and of anesthetic risk factors, and emerging technology (in
knowledge are MRI and laparoscopic surgery. Neurologic particular, measurement of cardiac output).
disorders are common in foals, but until recently diagnosis
has been hampered by the inability to image the brain.4 MRI
is considered the diagnostic technique of choice for many REFERENCES
CNS disorders and has become increasingly accessible to
veterinarians over the past few years. The challenges of anes- 1. Johnston GM, Taylor PM, Holmes MA, et al: Confidential Enquiry
thesia in an MRI unit include working in a confined space of Perioperative Equine Fatalities (CEPEF-1): Preliminary results,
Equine Vet J 1995;27:193.
with limited access to the patient and the incompatibility
2. Johnston GM, Eastment JK, Taylor PM, et al: Is isoflurane safer
of conventional anesthetic equipment with the magnetic
than halothane in equine anaesthesia? Results from a prospective
field and radiofrequency pulses.84 If inhalant anesthesia is multicentre randomised controlled trial, Equine Vet J 2004;36:64.
used, the ferrous material in anesthesia machines must be 3. Fischer AT Jr: Laparoscopically assisted resection of umbilical
replaced or the equipment adapted so that the machine structures in foals, J Am Vet Med Assoc 1998;214:1813.
remains outside the critical Gauss line (magnetic flux 4. Chaffin MK, Walker MA, McArthur NH, et al: Magnetic resonance
density). Alternatively, special MRI-compatible equipment imaging of the brain of normal neonatal foals, Vet Radiol
must be purchased, and this option may not be practical for Ultrasound 1997;38:102.
veterinary clinics. However, a more practical alternative is 5. Vatistas NJ, Snyder JR, Wilson WD, et al: Surgical treatment for colic
TIVA.4,46 In both situations, monitoring equipment must be in the foal (67 cases): 1980-1992, Equine Vet J 1996;28:139.
6. Kablack KA, Embertson RM, Bernard WV, et al: Uroperitoneum in
chosen and used carefully to prevent patient burns85 and
the hospitalised equine neonate: Retrospective study of 31 cases,
interference with the image. Excellent guidelines for anes-
1988-1997, Equine Vet J 2000;32:505.
thesia and monitoring in an MRI unit can be found at the 7. Thomas WP, Madigan JE, Backus KQ, et al: Systemic and pul-
website of the Anesthesia Patient Safety Foundation monary haemodynamics in normal neonatal foals, J Reprod Fertil
(www.apsf.org/index.php). Suppl 1987;35:623.
Chaffin and colleagues described an anesthetic technique 8. Machida N, Yasuda J, Too K, et al: A morphological study on the
suitable for MRI in neonatal (3-6 days of age) foals.4 obliteration processes of the ductus arteriosus in the horse, Equine
Xylazine (0.5 mg/kg IV) was followed 5 minutes later by a Vet J 1988;20:249.
bolus of propofol (0.2 to 0.4 mg/kg IV). After endotracheal 9. Madigan JE, Thomas WP, Backus KQ, et al: Mixed venous blood
intubation, a constant rate infusion of propofol (0.2 to gases in recumbent and upright positions in foals from birth to 14
days of age, Equine Vet J 1992;24:399.
0.4 mg/kg) was started, and the rate was adjusted up or
10. Lombard CW, Evans M, Martin L, et al: Blood pressure, electro-
down depending on the depth of anesthesia. Oxygen was
cardiogram and echocardiogram measurements in the growing
insufflated through the endotracheal tube using a long non- pony foal, Equine Vet J 1984;16:342.
rebreathing (Bain) circuit attached to an oxygen supply 11. Steffey EP, Dunlop CI, Farver TB, et al: Cardiovascular and respi-
outside the MRI chamber. For reasons previously discussed, ratory measurements in awake and isoflurane-anesthetized horses,
PaCO2 should be monitored in compromised foals, and Am J Vet Res 1987;48:7.
controlled ventilation is required to avoid the hypercapnia 12. Bonagura JD, Muir WW: The cardiovascular system. In Muir WW,
that occurs in spontaneously breathing foals during propo- Hubbell JAE, editors: Equine Anesthesia: Monitoring and
fol anesthesia. Ventilation can be assisted in an MRI unit Emergency Therapy, St Louis, 1991, Mosby.
using an Ambu bag attached to the endotracheal tube, or 13. Nout YS, Corley KT, Donaldson LL, et al: Indirect oscillometric and
direct blood pressure measurements in anesthetized and conscious
manual ventilation with a bag attached to the breathing
neonatal foals, J Vet Emerg Crit Care 2002;12:75.
circuit. An oscillometric blood pressure monitor can be
14. Franco RM, Ousey JC, Cash RS, et al: Study of arterial blood
placed outside the magnetic field and attached by a long pressure in newborn foals using an electronic sphygmomanometer,
cable. Equine Vet J 1986;18:475.
Laparoscopic surgery under general anesthesia has been 15. Koterba AM, Wozniak JA, Kosch PC: Ventilatory and timing param-
reported for resection of umbilical structures3 and ruptured eters in normal horses at rest up to age one year, Equine Vet J
bladder repair in foals86 (see Chapter 71). Advantages may 1995;27:257.
include better visibility of intra-abdominal structures and 16. Stewart JH, Rose RJ, Barko AM: Respiratory studies in foals from
less postoperative soft tissue swelling and discomfort.3 birth to seven days old, Equine Vet J 1984;16:323.
However, the effects of insufflation with carbon dioxide, 17. Koterba AM, Kosch PC, Beech J, et al: Breathing strategy of the adult
horse (Equus caballus) at rest, J Appl Physiol 1988;64:337.
abdominal distention, the Trendelenburg position, and
18. Rose RJ, Hodgson DR, Leadon DP, et al: Effect of intranasal oxygen
longer anesthesia time must also be considered.3 In adult
administration on arterial blood gas and acid base parameters in
horses, CO2 insufflation produced hypercapnia, acidosis, spontaneously delivered, term induced and induced premature
and an increase in cardiac work.87 In foals, no anesthetic- foals, Res Vet Sci 1983;34:159.
related complications were noted during or after laparoscopy,3 19. Wagner AE, Muir WW 3rd, Hinchcliff KW: Cardiovascular effects of
but the cardiopulmonary changes associated with this xylazine and detomidine in horses, Am J Vet Res 1991;52:651.
technique have not been critically evaluated in this patient 20. Stewart JH, Rose RJ, Barko AM: Response to oxygen administration
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 237

ANESTHESIA AND ANALGESIA FOR FOALS 237

in foals: Effect of age, duration and method of administration on Meeting, San Diego, Calif, 1997.
arterial blood gas values, Equine Vet J 1984;16:329. 45. Richardson DW, Kohn CW: Uroperitoneum in the foal, J Am Vet
21. Brewer BD, Clement SF, Lotz WS, et al: Renal clearance, urinary Med Assoc 1983;182:267.
excretion of endogenous substances, and urinary diagnostic indices 46. Matthews NS, Chaffin MK, Erickson SW, et al: Propofol anesthesia
in healthy neonatal foals, J Vet Intern Med 1991;5:28. for non-surgical procedures of neonatal foals, Equine Pract
22. Holdstock NB, Ousey JC, Rossdale PD: Glomerular filtration rate, 1995;17:15.
effective renal plasma flow, blood pressure and pulse rate in the 47. Wooten TL, Lowrie CT: Comparison of cerebrospinal fluid pressure
equine neonate during the first 10 days post partum, Equine Vet J in propofol- and thiopental-anesthetized eucapnic dogs, Vet Surg
1998;30:335. 1993;22:148.
23. Gonda KC, Wilcke JR, Crisman MV, et al: Evaluation of iohexol 48. Steffen F, Grasmueck S: Propofol for treatment of refractory seizures
clearance used to estimate glomerular filtration rate in clinically in dogs and a cat with intracranial disorders, J Small Anim Pract
normal foals, Am J Vet Res 2003;64:1486. 2000;41:496.
24. Magdesian KG, Wilson WD, Mihalyi J: Pharmacokinetics of a high 49. Waterman AE, Robertson SA, Lane JG: Pharmacokinetics of intra-
dose of amikacin administered at extended intervals to neonatal venously administered ketamine in the horse, Res Vet Sci
foals, Am J Vet Res 2004;65:473. 1987;42:162.
25. Green SL, Conlon PD, Mama K, et al: Effects of hypoxia and 50. Steffey EP, Willits N, Wong P, et al: Clinical investigations of
azotaemia on the pharmacokinetics of amikacin in neonatal foals, halothane and isoflurane for induction and maintenance of foal
Equine Vet J 1992;24:475. anesthesia, J Vet Pharmacol Ther 1991;14:300.
26. Geiser DR, Andrews FM, Rohrbach BW, et al: Cerebrospinal fluid 51. Grosenbaugh DA, Muir WW: Cardiorespiratory effects of sevoflu-
acid-base status during normocapnia and acute hypercapnia in rane, isoflurane, and halothane anesthesia in horses, Am J Vet Res
equine neonates, Am J Vet Res 1996;57:1483. 1998;59:101.
27. Saunders NR, Knott GW, Dziegielewska KM: Barriers in the 52. Matthews NS, Hartsfield SM, Mercer D, et al: Recovery from
immature brain, Cell Mol Neurobiol 2000;20:29. sevoflurane anesthesia in horses: Comparison to isoflurane and
28. Bauer JE, Harvey JW, Asquith RL, et al: Clinical chemistry reference effect of postmedication with xylazine, Vet Surg 1998;27:480.
values of foals during the first year of life, Equine Vet J 1984;16:361. 53. Read MR, Read EK, Duke T, et al: Cardiopulmonary effects and
29. Smyth GB, Young DW, Duran SH: Maturation of insulin and induction and recovery characteristics of isoflurane and sevoflurane
glucose responses to normal feeding in foals. Aust Vet J 1993; in foals, J Am Vet Med Assoc 2002;221:393.
70:129. 54. Wilcke JR, Crisman MV, Sams RA, et al: Pharmacokinetics of
30. Fowden AL, Silver M, Ellis L, et al: Studies on equine prematurity: phenylbutazone in neonatal foals, Am J Vet Res 1993;54:2064.
3. Insulin secretion in the foal during the perinatal period, Equine 55. Breuhaus BA, DeGraves FJ, Honore EK, et al: Pharmacokinetics of
Vet J 1984;16:286. ibuprofen after intravenous and oral administration and assess-
31. Lumsden JH, Rowe R, Mullen K: Hematology and biochemistry ment of safety of administration to healthy foals, Am J Vet Res
reference values for the light horse, Can J Comp Med 1980;44:32. 1999;60:1066.
32. Corley KT: Monitoring and treating haemodynamic disturbances in 56. Wilcke JR, Crisman MV, Scarratt WK, et al: Pharmacokinetics of
critically ill neonatal foals: Part 1. Haemodynamic monitoring, ketoprofen in healthy foals less than twenty-four hours old, Am J
Equine Vet Educ 2002;14:270. Vet Res 1998;59:290.
33. Harvey JW, Asquith RL, McNulty PK, et al: Haematology of foals up 57. Crisman MV, Wilcke JR, Sams RA: Pharmacokinetics of flunixin
to one year old, Equine Vet J 1984;16:347. meglumine in healthy foals less than twenty-four hours old, Am J
34. Kami G, Merritt AM, Duelly P: Preliminary studies of plasma and Vet Res 1996;57:1759.
extracellular fluid volume in neonatal ponies, Equine Vet J 58. Semrad SD, Sams RA, Ashcraft SM: Pharmacokinetics of and serum
1984;16:356. thromboxane suppression by flunixin meglumine in healthy foals
35. Spensley MS, Carlson GP, Harrold D: Plasma, red blood cell, total during the first month of life, Am J Vet Res 1993;54:2083.
blood, and extracellular fluid volumes in healthy horse foals during 59. Leveille R, Miyabayashi T, Weisbrode SE, et al: Ultrasonographic
growth, Am J Vet Res 1987;48:1703. renal changes associated with phenylbutazone administration in
36. Adamson PJ, Wilson WD, Baggot JD, et al: Influence of age on the three foals, Can Vet J 1996;37:235.
disposition kinetics of chloramphenicol in equine neonates, Am J 60. Carrick JB, Papich MG, Middleton DM, et al: Clinical and
Vet Res 1991;52:426. pathological effects of flunixin meglumine administration to
37. Carter SW, Robertson SA, Steel CJ, et al: Cardiopulmonary effects of neonatal foals, Can J Vet Res 1989;53:195.
xylazine sedation in the foal, Equine Vet J 1990;22:384. 61. Corley KT: Monitoring and treating haemodynamic disturbances in
38. Webb AI: Nasal intubation in the foal, J Am Vet Med Assoc critically ill neonatal foals: Part 2. Assessment and treatment,
1984;185:48. Equine Vet Educ 2002;14:328.
39. Dunlop CI: Anesthesia and sedation of foals, Vet Clin North Am 62. Corley KT, Donaldson LL, Furr MO: Comparison of lithium dilu-
Equine Pract 1994;10:67. tion and thermodilution cardiac output measurements in anaes-
40. Robertson SA, Carter SW, Donovan M, et al: Effects of intravenous thetised neonatal foals, Equine Vet J 2002;34:598.
xylazine hydrochloride on blood glucose, plasma insulin and rectal 63. Gunkel CI, Valverde A, Morey TE, et al: Comparison of non-
temperature in neonatal foals, Equine Vet J 1990;22:43. invasive cardiac output measurement by partial carbon dioxide
41. Oijala M, Katila T: Detomidine (Domosedan) in foals: Sedative and rebreathing with the lithium dilution method in anesthetized dogs,
analgesic effects, Equine Vet J 1988;20:327. J Vet Emerg Crit Care 2004;14:1.
42. Norman WM, Court MH, Greenblatt DJ: Age-related changes in the 64. Chaffin MK, Matthews NS, Cohen ND, et al: Evaluation of pulse
pharmacokinetic disposition of diazepam in foals, Am J Vet Res oximetry in anaesthetised foals using multiple combinations of
1997;58:878. transducer type and transducer attachment site, Equine Vet J
43. Muir WW, Sams RA, Huffman RH, et al: Pharmacodynamic and 1996;28:437.
pharmacokinetic properties of diazepam in horses, Am J Vet Res 65. Geiser DR, Rohrbach BW: Use of end-tidal CO2 tension to predict
1982;43:1756. arterial CO2 values in isoflurane-anesthetized equine neonates, Am
44. Robertson SA, Holcombe SJ, Colon J, et al: Comparison of xylazine J Vet Res 1992;53:1617.
or diazepam/butorphanol followed by ketamine and diazepam for 66. Hackett TB: Pulse oximetry and end tidal carbon dioxide
induction of foals undergoing periosteal stripping. In Proceedings monitoring, Vet Clin North Am Small Anim Pract 2002;32:1021.
of the American College of Veterinary Anesthesiologists Annual 67. Teixeira Neto FJ, Carregaro AB, Mannarino R, et al: Comparison of
X0123-Ch019-023.qxd 9/20/05 9:20 AM Page 238

238 RECENT ADVANCES IN ANESTHESIA

a sidestream capnograph and a mainstream capnograph in foals sucking grazing mares, Equine Vet J 1992;24:295.
mechanically ventilated dogs, J Am Vet Med Assoc 2002;221:1582. 78. Palmer JE: Fluid therapy in the neonate: not your mother’s fluid
68. Hunt TK, Hopf HW: Wound healing and wound infection: What space, Vet Clin North Am Equine Pract 2004;20:63.
surgeons and anesthesiologists can do, Surg Clin North Am 79. Belgrave RL, Hines MT, Keegan RD, et al: Effects of a polymer-
1997;77:587. ized ultrapurified bovine hemoglobin blood substitute admin-
69. Gore DC, Chinkes D, Heggers J, et al: Association of hyperglycemia istered to ponies with normovolemic anemia, J Vet Intern Med
with increased mortality after severe burn injury, J Trauma 2002;16:396.
2001;51:540. 80. Young LE, Blissitt KJ, Clutton RE, et al: Temporal effects of an
70. DiNardo MM, Korytkowski MT, Siminerio LS: The importance of infusion of dobutamine hydrochloride in horses anesthetized with
normoglycemia in critically ill patients, Crit Care Nurs Q halothane, Am J Vet Res 1998;59:1027.
2004;27:126. 81. Swanson CR, Muir WW 3rd, Bednarski RM, et al: Hemodynamic
71. Cohn LA, McCaw DL, Tate DJ, et al: Assessment of five portable responses in halothane-anesthetized horses given infusions of
blood glucose meters, a point-of-care analyzer, and color test strips dopamine or dobutamine, Am J Vet Res 1985;46:365.
for measuring blood glucose concentration in dogs, J Am Vet Med 82. Holmes CL, Landry DW, Granton JT: Science review: Vasopressin
Assoc 2000;216:198. and the cardiovascular system: Part 2. Clinical physiology, Crit Care
72. Magdesian KG: Monitoring the critically ill equine patient, Vet Clin 2004;8:15.
North Am Equine Pract 2004;20:11. 83. Corley KT: Inotropes and vasopressors in adults and foals, Vet Clin
73. Schmied H, Kurz A, Sessler DI, et al: Mild hypothermia increases North Am Equine Pract 2004;20:77.
blood loss and transfusion requirements during total hip arthro- 84. Peden CJ, Menon DK, Hall AS, et al: Magnetic resonance for the
plasty, Lancet 1996;347:289. anaesthetist: Part II. Anaesthesia and monitoring in MR units,
74. Doufas AG: Consequences of inadvertent perioperative hypother- Anaesthesia 1992;47:508.
mia, Best Pract Res Clin Anaesthesiol 2003;17:535. 85. Dempsey MF, Condon B: Thermal injuries associated with MRI,
75. Kurz A, Sessler DI, Lenhardt R: Perioperative normothermia to Clin Radiol 2001;56:457.
reduce the incidence of surgical-wound infection and shorten 86. Edwards RB, Ducharme NG, Hackett RP: Laparoscopic repair of a
hospitalization. Study of Wound Infection and Temperature bladder rupture in a foal, Vet Surg 1995;24:60.
Group, N Engl J Med 1996;334:1209. 87. Donaldson LL, Trostle SS, White NA: Cardiopulmonary changes
76. Tomasic M, Nann LE: Comparison of peripheral and core associated with abdominal insufflation of carbon dioxide in
temperatures in anesthetized horses, Am J Vet Res 1999;60:648. mechanically ventilated, dorsally recumbent, halothane anaes-
77. Martin RG, McMeniman NP, Dowsett KF: Milk and water intakes of thetised horses, Equine Vet J 1988;30:144.

CHAPTER 22 MANAGEMENT OF HORSES DURING RECOVERY

General Aspects
During recovery, external stimuli (noise, bright light, phys-
ical stimuli) should be minimized. The horse’s head should
Recovery from be protected by a padded head cover. The recovery box
should have a padded floor and walls. Ideally, the box would
Anesthesia have an octagonal shape to prevent horses from being
trapped in the corners. In some clinics, horses are placed on
Regula Bettschart-Wolfensberger heavy foam pads for the recovery. These pads prevent the
patients from making premature attempts to rise, because it
takes a controlled and coordinated effort to “get out” of
them and attain sternal recumbency. Frequently, human
assistance is necessary to roll them from the mattress onto
the recovery box floor. Because the patients cannot leave
Recovery is one of the most critical phases of equine anes- the mattress too early, there is additional time for inhalant
thesia. Recent results from a multicenter prospective study of anesthetic to be exhaled, which eventually results in a
equine anesthetic fatalities reported that 23% of all non- smoother recovery. Soft mattresses may also prevent nerve
survivors sustained inoperable orthopedic lesions during damage in cases of prolonged recovery. Depending on the
recovery.1 Because of the size and temperament of the horse, nature of the surgery, the premises, and the personal pref-
it is not possible to continue full monitoring, and mechan- erences of anesthetists and surgeons involved, assistance
ical ventilation during recovery and even fluid adminis- during recovery (ropes, slings, hoists) may be desirable.2
tration are discontinued in most cases. Significant problems Sling assistance is sometimes (6%) not well tolerated, and to
such as hypoxemia or hypotension that may develop can prevent self-inflicted injury, the patients may have to be re-
be recognized only in severe cases. Once the horse starts anesthetized. Fracture patients are most successfully recov-
to wake up, intervention is dangerous for personnel and, ered in a hydro pool (my personal experience).
depending on the size of the horse and its temperament, In the early stages of recovery, an anesthetist should stay
often simply impossible. This chapter describes all aspects of with the horse. Thereafter, continuous observation of the
recovery from anesthesia in horses. horse will reveal problems at an early stage, allowing imme-