Feline Sedation And A Spotlight On Urinary Tract Trauma

Show Notes

This month Dr. Sam Taylor is in conversation with Dr Matt Gurney about feline sedation and the use of low dose ketamine. We're also featuring our monthly JFMS clinical spotlight interview in which Head Of ISFM, Nathalie Dowgray, discusses feline urinary tract trauma with Dr Zoë Halfacree.

Recording during ISFM’s Rhodes Congress, Dr Sam Taylor is joined by specialist in anaesthesia and analgesia Dr Matt Gurney. He talks about his early experiences using subcutaneous low dose ketamine, how it can help our patients and the different options they have for sedation.

Nathalie then sits down with Dr Zoë Halfacree to discuss her JFMS clinical spotlight article Urinary Tract Trauma in Cats: Stabilisation, Diagnosis and Management and Zoë shares advice on how we can reduce the risk of iatrogenic ureteral trauma when we're catheterizing cats.

For further reading material please visit:

https://journals.sagepub.com/doi/epub/10.1177/1098612X231159073

http://www.alfaxan.co.uk/news/intramuscular-alfaxalone-in-the-cat

Tune in next month for more interviews recorded at ISFM in Rhodes, and next month's clinical spotlight interview.

Host:

Nathalie Dowgray, BVSc, MANZCVS, PgDip, MRCVS, PhD, Head of ISFM,, International Society of Feline Medicine, International Cat Care, Tisbury, Wiltshire, UK

Speakers:

Samantha Taylor, BVetMed(Hons) CertSAM DipECVIM-CA MANZCVS FRCVS, Feline Medicine Specialist and ISFM Academy Lead

Dr Matt Gurney, BVSc CertVA PgCertVBM DipECVAA FRCVS, RCVS and European Specialist in Anaesthesia and Analgesia.

Dr Zoë Halfacree, MA VetMB CertVDI CertSAS FHEA DipECVS FRCVS, RCVS and EBVS® European Specialist in Small Animal Surgery

For ISFM members, the full recording of this discussion is available for you to listen to at portal.icatcare.org. To become an ISFM member, or find out more about our Cat Friendly schemes, visit icatcare.org

Creators & Guests

Host

Nathalie Dowgray

What is Chattering With ISFM?

Welcome to Chattering With ISFM, the official monthly podcast of the International Society of Feline Medicine, hosted by Nathalie Dowgray (Head of ISFM). Each month, we chatter about cats and cat-friendly practices with industry experts and contributors to The Journal of Feline Medicine and Surgery. Each episode contains highlights from our longer discussions and interviews, which are accessible to ISFM members at portal.icatcare.org. If you would like access to our full episodes, would like to become an ISFM member, or find out more about our Cat-Friendly schemes, visit icatcare.org.

Nathalie Dowgray: Hello, welcome
to the March 2023 episode of

Chattering with ISFM. I’m
Nathalie Dowgray, Head of ISFM

and host of this months podcast.
This month we are sharing

another of our in conversation
with sessions that were recorded

live at our Rhodes congress last
year. Dr Sam Taylor is speaking

with Dr Matt Gurney on feline
pain management and we are also

featuring our monthly JFMS
clinical spotlight interview.

This month I’m speaking with Dr
Zoë Halfacree on feline urinary

tract trauma. We hope you enjoy
this episode.

Sam Taylor: So Matt is the
clinical director at Anderson

Moores Vet Specialists. And I
think as you all know, he's an

RCVS and European specialist in
anaesthesia and analgesia. He's

very passionate about pain
management and does lots of

lectures on this subject and we
know him also as the co founder

of zero pain philosophy.
Subcutaneous low dose ketamine.

Can you tell us a bit about how
that works? Why it works? When

you use it? Yeah, what are the
indications for this?

Matt Gurney: I'd love to be able
to tell you how it works and why

it works bit I don't honestly
know. I first used subcutaneous

ketamine in a dog, it was a dog
with lumbosacral disease. And

this dog was struggling on
nonsteroidals and I can't

remember what else we'd added.
And we gave the dog 0.5mg/kg of

ketamine subcutaneously. And it
made a difference. And we said,

okay, fine, let's just work out
how long this makes a difference

for. And he ended up having
0.5mg per/kg subcutaneously

every month. And this went on
for 18 months, two years. And

then he became progressively
more painful. And we started

doing this every two weeks, and
then every one week and then

when we got to every one week
stage, she said look, I know

that we're getting right to the
end. And this is my line in the

sand to say that enough is
enough. So that's an example of

where we went from managing him
on a monthly basis right into a

kind of palliative setting.
Really, for me that was the sort

of basis of my use of ketamine.
I have used it in cats since. I

use a slightly lower dose, I use
0.3mg/kg in cats. And he

responds very well to that. And
if we're going to do anything

novel, or we're not quite 100%
sure about, let's identify those

behaviours. What are the pain
behaviours in that individual

patient. Have a conversation
with the owner, work out three

to five pain behaviours, make
your intervention, reassess

using those pain behaviours. And
whatever else the owner notices

in the meantime, you can
guarantee, the minute you

trigger an owner in a consult to
start thinking about behaviours,

they go away, and then they
notice things. We definitely

need to get to the stage where
we can start a prospective

study. I don't think we can
really run that against a

placebo because that'd be
challenging from an ethics point

of view. We probably need to do
a group that have subcutaneous

ketamine and subcutaneous
methadone maybe, methadone is

licensed to be used
subcutaneously. So, I think you

could arguably say that that is
a suitable control treatment.

Ketamine is what we refer to as
the antihyperalgesic. So when we

have a central sensitization and
activation of the NMDA receptor,

it's the NMDA receptor that we
think we're switching off with

ketamine. Although ketamine does
have a lot of other actions. So

actually, this effect, it could
be another receptor, or ion

channel action rather than an
NMDA action we're talking about

with subcut ketamine. With
central sensitization, we see a

general sensitivity so we see
allodynia hyperalgesia, we're

looking to drive down that
hyperalgesia with our use of

medications that target the NMDA
receptor, hence the word

antihyperalgesic rather than
analgesic. Most of my

experiences with a population
coming into the hospital anyway

that are suffering with pain, I
think there are two categories

there, there are those painful
patients that are coming in for

x procedure, absolutely. I would
use ketamine in those patients.

In a general practice
population, a chronic pain

clinic population. If you're
seeing those patients on a

repeated basis, maybe you've
tried subcutaneous ketamine, it

doesn't work and I would always
try that to start with because

it's it's quick, easy, it's
cheap. If that's not working, if

you're just scratching your head
with what do I do next with this

patient? I would bring them into
the hospital. I normally say a

12 to 24 hours CRI, some people
don't want to leave the pet

overnight, so, and we don't
honestly know, is 12 hours

better? Is 24 hours better? We
know in human clinics, they

bring people in for the day. I
think it varies from clinic to

clinic how long people get those
ketamine infusions for. So yes,

it is definitely something that
I think is worth doing in those

chronically painful patients.
Definitely.

Sam Taylor: If you can't examine
a cat, and you don't have any

blood, so you don't have any
sort of knowledge of its general

health. What sedation protocol
would you use in that situation?

Matt Gurney: We are thinking a
lot more about before that cat

even comes into the clinic now
and thinking about Gabapentin as

part of the perianaesthetic care
for a cat, I use 20 mgs/kg one

or two hours before either the
visit to the vet or we need to

try and get that blood sample or
get that IV. So I think there is

a huge value to thinking ahead
and using Gabapentin in those

cases. We know that that's a
suitable option in healthy cats.

We've studied that in
hypothyroid cats, you can read

that paper open access in JFMS.
And we also have a licenced

pregabalin coming at some stage,
so that's a fantastic option

that we need to think about
beforehand. If we then move on,

we've then got to ask the
question, what do we actually

need to do with the cat? Are we
then looking at subcutaneous

option are we then looking at an
intramuscular option? If you go

on alfaxan.co.uk there is an
article on IM alfaxalone in

cats. It's got all of the
options that are available

there. We also talk about
subcutaneous options. So there

was a study from the University
of Melbourne, and they looked at

3mg/kg of alfaxalone and
0.3mg/kg of butorphanol

subcutaneously. The aim of that
study was to get these cats

relaxed enough that 45 minutes
later, the cats could be pilled.

And they were still able to hold
their heads up and swallow a

pill. So it's a very mild level
of sedation, but that might be

suitable for your purposes. And
then moving forward to needing a

deeper level of sedation. We are
really looking at intramuscular

options in that circumstance.
And alfaxalone is a brilliant

drug in those cases. For those
ones, like you say Sam, we might

not have bloods, we might not
have an echo, maybe we know that

cats got a murmur, but we can't
touch it. The combination we

tend to use for the feisty
hypothyroid cats, so let's say

we've given them gabapentin, and
we've given them Trazodone as

well. And we need to sedate our
cats that come in to the

radioactive iodine clinic, we
need to do their bloods, we need

to clip a patch on the back of
their neck, we need to give them

their their radioactive iodine
injection, we need to do that in

a safe manner. So none of our
staff get injected with

radioactive iodine. So we do
need to restrain these cats

chemically. Alfaxalone,
midazolam, butorphanol, is my go

to combination for that. When we
have either undetermined cardiac

disease, we're actually some of
those cats, we do have those

echo results and we know what's
going on. The doses, I'm not

going to verbalise the doses
now, but take a look at that

article on the Alfaxan website
because that goes through all of

those options for you.

Sam Taylor: Brilliant, thank you
very much. I think we could

spend the whole day asking you
questions, but we don't quite

have time. So we're gonna let
you go. And say thank you very

much.

Nathalie Dowgray: And now we're
speaking with Dr Zoë Halfacree

about her JFMS clinical
spotlight article on Urinary

Tract Trauma in cats.
Why were you interested in

writing an article specifically
on surgical management of

urinary tract trauma?

Zoë Halfacree: So I was
approached to write the article,

which I was really happy to do,
I think it's valuable to discuss

urinary tract trauma in the cat
because it is something that

occurs quite often. And whilst
we do have notes and evidence

base of new literature to
support our decision making, it

was useful, I feel to provide
some case examples to help

people have that information
being more accessible.

Nathalie Dowgray: Building of
that, do you have any tips or

advice of things we can do to
just try and reduce the risk of

iatrogenic ureteral trauma when
we're catheterizing cats?

Zoë Halfacree: Yeah, sure. There
are a few really important ones.

The key one is that the cat
should be adequately sedated or

anaesthetised so that they are
fully relaxed. Unfortunately, if

they you know, were not
adequately sedated, then there

would be a significant risk of
causing iatrogenic trauma. And

having the patient adequately
sedated, also allows more

careful manipulation of the
penis in the prepuce. One key

aspect to recognising the cat is
that where the penile urethra

sits, sort of caudal to the
pelvis orientated caudally, and

there's a change in angulation
as the penile urethra comes to

meet the pelvic urethra, and
it's that point going between

the penile urethra and the
pelvic urethra, where it's most

common for iatrogenic and
catheter injuries to occur

because the catheter trajectory
is going up and damages the

dorsal surface of the urethra.
And so the real key is to

actually when the patient is
having the catheter inserted is

to pull the penis caudally you
so that you're stretching that

out and straightening that out,
and then the catheter should

advance straight ahead

Nathalie Dowgray: Thank you for
listening, if you are an ISFM

member you can hear more from Dr
Halfacree with her full

interview being available on the
ISFM members podcast, to access

this please visit
portal.icatcare.org. As well as

the podcast you can access all
the other ISFM member benefits

including Dr Gurney’s lectures
from our ISFM Rhodes congress,

monthly webinars, the discussion
forum and much more. Don’t

forget, JFMS is now an open
access journal so if you wish to

read Dr Halfacress clinical
spotlight article then please do

follow the link in the show
notes. We'll be back again next

month with more interviews
recorded at ISFM Rhodes and next

month's JFMS Clinical spotlight
interview. If you don’t want to

miss it make sure you sing up to
Chattering with ISFM on you

preferred podcast platform.