PARTIAL IV ANESTHESIA IN HORSES

Luisito S. Pablo, DVM, MS, Diplomate ACVA

University of Florida, Gainesville, Florida
Equine general anesthesia in an operating room setting has been challenging. Prolonged
hypotension in horses can lead to postanesthetic myopathy. When they move on the surgery
table, injury to the personnel, contamination of the surgical site and surgical equipment failure
may occur. Regardless of the recovery technique utilized, injury cannot be fully prevented
because of the size and nature of most equine patients. In fact, recovery may be the most
challenging part of equine anesthesia. The challenges in equine anesthesia are supported by a
prospective study showing higher mortality in anesthetized horses compared with small animals.
There has been a trend in equine anesthesia to utilize injectable agents together with an
inhalant during general anesthesia performed in operating room conditions. This technique has
been called partial intravenous anesthesia (PIVA). These are the reasons for using this technique:
(1) smoother transition from induction to maintenance, (2) better maintenance condition, (3) less
use of positive inotropic agent, (4) recovery may be better, and (5) analgesia is provided
intraoperatively.
Drugs Used
There are several drugs that can be utilized for PIVA. Presently, the choice of the drug(s)
is based primarily on familiarity, convenience, availability, record keeping issue, and personal
preference. There are not enough studies to evaluate and compare the different regimes that can
be used in PIVA. There are many combinations available to practitioners. Table 1 shows the
combinations evaluated and published in scientific journals.
Alpha2-agonists: Medetomidine (dexmedetomidine), xylazine, romifidine, or detomidine
can be used singly or in combination with other drugs. The main advantage of alpha2-agonists is
the sedation that it produces which can be utilized during anesthesia and in recovery. It also
possesses analgesia although it is of shorter duration. It reduces the anesthetic requirement for
inhalant agents. Since alpha2-agonist is usually used as a premedicant, there is no need to
administer a bolus dose before starting the infusion.
Lidocaine: When given intravenously, lidocaine is known to provide central analgesia. It
has been shown to reduce the anesthetic requirement of inhalant agent in horses. It can also be
used singly or in combination with other drugs. A bolus dose of lidocaine is necessary before
starting the CRI. The bolus dose of lidocaine is 1.5-2.0 mg/kg given over 10 minutes. The CRI
rate is 2.4-3.0 mg/kg/hour. It is recommended to stop the infusion of lidocaine 30 minutes before
the end of anesthesia.
Ketamine: Ketamine is a dissociative agent which produces anesthesia at a higher dose.
At lower doses, it is thought to minimize windup and helps in providing analgesia. The dose that
will provide the latter effect in horses is not definitely known nor well studied. The published
CRI rate for ketamine ranges from 0.98-3.6 mg/kg/hour. Since horses are typically induced using
a combination that includes ketamine, a bolus dose prior to starting the infusion is not needed.
Ketamine alone as a CRI is not recommended because of the possible cataleptic effect in
recovery. If used by itself, the infusion should be discontinued 15-30 minutes before stopping the
inhalant agent.
Guaifenesin: Guaifenesin is a centrally acting muscle relaxant. It has been used with
ketamine and an alpha2-agonist for CRI. This combination has been studied and resulted in

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minimal cardiovascular effect and good recovery. With the increased cost of compounded
guaifenesin and unwanted muscle relaxation (authors personal experience) in recovery, the
author does not use guaifenesin in PIVA. The published dose for PIVA is 25.0 mg/kg/hour.
Opioids: Opioids are not commonly used as part of CRI during anesthesia. Morphine is
inconsistent in reducing the minimum alveolar concentration (MAC) of inhalants in horses.
Fentanyl reduces the MAC in horses to a lesser degree compared with other species. Handling of
controlled drugs, especially CIIs, is another hindrance to the widespread use of these drugs as
CRI during anesthesia. There are no published data on the use of butorphanol CRI during
anesthesia. The author has used butorphanol (0.02 mg/kg/hour) together with lidocaine and
ketamine in horses with severe pain.
Technique
After deciding on the drugs that will be used for PIVA, the next step is making the
preparation for infusion. There are three main ways of administering the drugs for CRI: (1) using
a syringe pump, (2) a fluid bag administered using an infusion pump, and (3) a fluid bag
administered by determining the drops per second or seconds between drops.
When the syringe pump is used, the drugs should be given without dilution. Calculate the
amount (mg) of the drug needed for one hour. Convert the amount of the drug from mg to ml by
dividing the amount (mg) by the concentration (mg/ml) of the drug. Add up the volume of the
drugs and the syringe pump is set up to deliver in ml/hour.
Here is a sample calculation when using a single syringe pump and more than one drug
without dilution:
Drugs: Xylazine 1.0 mg/kg/hour; ketamine 2.0 mg/kg/hour
Body weight: 500-kg horse
Total dose/hour: Xylazine 500 mg and ketamine 1000 mg
Drug concentrations: Xylazine 100 mg/ml and ketamine 100 mg/ml
Total ml per hour (Total dose/hour concentration): Xylazine 5 ml and lidocaine 10 ml
Setting on the syringe pump: 5 ml + 10 ml = 15 ml per hour
When utilizing a fluid bag for administration, the drugs will be diluted. Using an infusion
pump, the solution can be administered accurately in ml/hour. When an infusion pump is not
available, the solution will be administered by determining the rate in drops per second or the
number of seconds between drops.
Using the same drugs in the example above and utilizing an infusion pump, it is
important that the amount of drugs to be added to a bag of crystalloid fluid is known. To figure
out the amount of drugs to be added to a bag of fluids, use this formula:
Amount of drug (mg) = [CRI dose (mg/kg/hour) Fluid rate (ml/kg/hour)] x Total vol of fluid
(ml)
Sample calculation:
The total volume of fluid is the bag size = 1000 ml (can be 500 ml). Normal saline can be used.
The fluid rate has to be determined knowing the body weight of the horse and the approximate
duration of the procedure. For adult horses, use fluid rates 1 ml/kg/hour. The lower fluid rate
leads to less number of times a solution has to be prepared. For example, if the procedure is
about 3 hours and the horse weighs 500 kg. If you use 1.0 ml/kg/hour, the volume administered
is 500 ml/hour. The 1,000 ml-bag will be finished in 2 hours and another bag has to be prepared
because it is a 3-hour procedure. For this example then, use 0.5 ml/kg/hour and the 500-kg horse
will get 250 ml/hour. The 1000-ml bag will be good for more than 3 hours.

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Drug Calculation for this example using the formula above:

Xylazine (mg) = (1 mg/kg/hr 0.5 ml/kg/hr) x 1000 ml = 2,000 mg
2,000 mg 100 mg/ml = 20 mL of xylazine
Ketamine (mg) = (2 mg/kg/hr 0.5 ml/kg/hr) x 1000 ml = 4,000 mg
4,000 mg 100 mg/ml = 40 ml
Before adding the drugs to the fluid bag, 60 ml of fluid has to be discarded. The drugs are added
to the bag of fluid and the infusion pump is set to run at 250 ml/hour (500 kg x 0.5 ml/kg/hour)
When controlling the rate of fluid administration manually, there are two ways of going about
preparing the solution for administration. One way is to have a single preparation (known
amount of drugs added to a bag) for the clinic, and the rate of infusion will change according to
the body weight of the horse. Most clinics utilize this method because the bag can be reused and
less calculation is needed. The other way involves having a fixed rate of infusion (e.g. 1 drop
every second) and then calculating the amount of drug to be added to the bag of fluid. It is more
common to use the method with a fixed concentration and the rate of infusion is determined
based on the body weight of the horse. For efficiency, a spreadsheet can be prepared. For a
known concentration of the drug in a bag of fluid, this formula is used to determine the rate of
infusion:
Drops/sec= [Body wt (kg) x Dose (mg/kg/hr) Drug conc. in the bag (mg/ml) 3600] x Drip set
(drops per minute)
Sample calculation for xylazine CRI:
Horse weight - 450 kg
Xylazine dose - 1.0 mg/kg/hr
Given concentration of xylazine in the bag - 1 mg/ml (10 ml of 10% xylazine in a 1000-ml bag
of fluid)
Drip set - 10 drops/ml
Drops/sec = 450 kg x 1.0 mg/kg/hr 3600 x 10 = 1.25 drops/sec or 1 drop every 0.8 sec
The other method involves fixing the rate of infusion, e.g. one drop every 2 seconds using a drip
set of 10 drops/ml, and the amount of drugs will vary depending upon the weight of the horse.
This formula is still used: Amount of drug (mg) = [CRI dose (mg/kg/hour) Fluid rate
(ml/kg/hour)] x Total vol of fluid (ml). To determine the fluid rate, this formula is used:
Ml/kg/hr = [Drops per min Drip set (drops/ml)] x 60 mins/hr body weight (kg)
The drops per minute can be 20, 30, or 60 depending upon the persons choice of counting drops.
Lets assume that the fluid rate is set as 1 drop every second (60 drops per min) and lidocaine
CRI (3 mg/kg/hr) is needed for a 500 kg horse, the amount of lidocaine can be calculated as
follows:
Ml/kg/hour = 60 drops/min 10 drops/ml x 60 mins/hr 500 kg = 0.72 ml/kg/hour
Mg of lidocaine needed = (3 mg/kg/hr 0.72 ml/kg/hour) x 1000 ml =4,166.7 mg
Lidocaine concentration - 20 mg/ml
Ml of lidocaine needed = 4,166.7 mg 20 mg/ml = 208.3 ml
Before adding lidocaine to the bag of fluid, 208.3 ml of the fluid has to be discarded.
This preparation of lidocaine will then be infused to this 450-kg horse at the rate of one drop per
second.

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Table 1: Methods of PIVA published in scientific journals

Drugs Used

Dose

Inhalant
used
Sevoflurane

When CRI started and

stopped
Started after tracheal
intubation;
Stopped when
sevoflurane was
discontinued

References

Guaifenesin
Ketamine
Xylazine

25.0 mg/kg/hr
1.2 mg/kg/hr
0.3 mg/kg/hr

Guaifenesin
Ketamine
Medetomidine

24.5 mg/kg/hr
0.98 mg/kg/hr
0.0012 mg/kg/hr

Sevoflurane

Started after tracheal

intubation;
Stopped when
sevoflurane was
discontinued

Yamashita et al,
2002

Lidocaine

1.5 mg/kg over 10

mins; 2.4 mg/kg/hr

Isoflurane

Enderle et al,
2008

Ketamine

3.6 mg/kg/hr
Reduce rate by 65%
after 50 mins. and
stop 15 mins before
end of anesthesia
2.0 mg/kg over 10
mins; 3.0 mg/kg/hr

Started after tracheal

intubation;
Stopped 15 minutes
before end of anesthesia

Isoflurane

Started 30 mins after

anesthetic induction;
Stopped 30 mins before
end of anesthesia
Started 30 mins after
anesthetic induction;
Stopped with inhalant
Started 30 mins after
anesthetic induction;
Stopped 30 mins before
end of anesthesia

Valverde et al,
2010

Lidocaine

Medetomidine
Lidocaine

5 g/kg
2.0 mg kg over 10
mins; 3.0 mg/kg/hr

Isoflurane

Yamashita et al,
2009

Valverde et al,
2010

References
1. Enderle AK, Levionnois OL, Kuhn M: Clinical evaluation of ketamine and lidocaine intravenous
infusions to reduce isoflurane requirements in horses under general anaesthesia. Vet Anaest Analg
2008;35:297-305
2. Valverde A, Rickey E, Sinclair M, et al: Comparison of cardiovascular function and quality of
recovery in isoflurane-anaesthetised horses administered a constant rate infusion of lidocaine or
lidocaine and medetomidine during elective surgery. Equine Vet J 2010;42:192-199
3. Yamashita K, Muir III WW, Tsubakishita S, et al: Infusion of guaifenesin, ketamine, and
medetomidine in combination with inhalation of sevoflurane versus inhalation of sevoflurane
alone for anesthesia in horses. J Am Vet Med Assoc 2002;221:1150-1155
4. Yamashita K, Muir III WW: Intravenous anesthetic and analgesic adjuncts to inhalation
anesthesia, in Muir WW, Hubbell JAE (eds): Equine Anesthesia Monitoring and Emergency
Therapy. Missouri, MO, Saunders Elsevier, 2009, pp 260-276

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