Veterinary Pathology OnlineFirst, published on July 1, 2016 as doi:10.

1177/0300985816655853

Original Article
Veterinary Pathology
1-9
Perianesthetic Mortality in Domestic ª The Author(s) 2016
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Animals: A Retrospective Study DOI: 10.1177/0300985816655853
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of Postmortem Lesions and Review
of Autopsy Procedures

J. DeLay1

Abstract
Autopsy of animals that die in the perianesthetic period allows identification of anesthetic and surgical complications as well as
preexisting disease conditions that may have contributed to mortality. In most studies to date investigating perianesthetic
mortality in animals, inclusion of autopsy data is very limited. This retrospective study evaluated autopsy findings in 221 cases of
perianesthetic death submitted to a veterinary diagnostic laboratory from primary care and referral hospitals. Canine (n ¼ 105;
48%) and feline (n ¼ 90; 41%) cases predominated in the study, involving elective (71%) and emergency (19%) procedures. The
clinical history provided to the pathologist was considered incomplete in 42 of 221 cases (19%), but this history was considered
essential for evaluating the circumstances of perianesthetic death. Disease had been recognized clinically in 69 of 221 animals
(31%). Death occurred in the premedication or sedation (n ¼ 19; 9%), induction (n ¼ 22; 11%), or maintenance (n ¼ 73; 35%)
phases or in the 24 hours postanesthesia (n ¼ 93 animals; 45%). Lesions indicative of significant natural disease were present in
130 of 221 animals (59%), mainly involving the heart, upper respiratory tract, or lungs. Surgical or anesthesia-associated com-
plications were identified in 10 of 221 cases (5%). No lesions were evident in 80 of 221 animals (36%), the majority of which were
young, healthy, and undergoing elective surgical procedures. Lesions resulting from cardiopulmonary resuscitation were identified
in 75 of 221 animals (34%). Investigation of perianesthetic death cases should be done with knowledge of prior clinical findings and
antemortem surgical and medical procedures; the autopsy should particularly focus on the cardiovascular and respiratory system,
including techniques to identify pneumothorax and venous air embolism.

Keywords
anesthesia, surgery, autopsy, cardiopulmonary arrest, mortality, perioperative complications, veterinary medicine, cats, dogs,
cause of death, forensic pathology

Animals that die while sedated or anesthetized contribute to a
relatively small but important number of cases submitted for
autopsy to veterinary diagnostic laboratories. These cases are
stressful and emotional for both veterinarians and animal own-
ers and may potentially involve litigation or disciplinary action
by the veterinary licensing body.
There has been a trend over time toward a decrease in the
rate of anesthesia-associated mortality among veterinary
patients.4–6,8 This reduction is attributed to improvement in
both anesthetic drugs and protocols, as well as implementation
of progressively more advanced monitoring procedures. Retro-
spective studies from various geographic regions, and includ-
ing both referral institutions and general practices, have
identified variable overall rates of perianesthetic mortality in
animals, ranging from 0.11% to 1.5% in dogs, 0.06% to 1.08%
in cats, 1.39% in rabbits, 0.33% in ferrets, and 0.12% to 1.6% in
horses.2–4,6,8,10,12,13,18,19 In contrast, a recent North American
study of human patients identified an anesthesia-associated
mortality rate of 0.033%.30
Autopsy of animals that die in the perianesthetic period
allows identification of anesthetic and surgical complications
as well as preexisting disease conditions (either related or unre-
lated to the surgical or medical procedure) that may have
contributed to mortality. In some situations, iatrogenic contri-
bution to death may also be identified, as in cases of clinically
undetected postsurgical hemorrhage. In one study evaluating
the role of autopsy in human anesthesia malpractice claims, a
significant nonanesthestic contribution to death was identified
1
Animal Health Laboratory, University of Guelph, Guelph, ON, Canada
Supplemental material for this article is available on the Veterinary Pathology
website at http://vet.sagepub.com/supplemental.
Corresponding Author:
J. DeLay, Animal Health Laboratory, University of Guelph, Guelph, ON, N1G
2W1 Canada.
Email: jdelay@uoguelph.ca

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2 Veterinary Pathology
in 61% of cases.15 However, in most studies to date investigat-
ing perianesthetic mortality in animals, conclusions are based
on clinical information and expert review, and inclusion of
autopsy data is very limited.2–4,6,8,10,12,13 One study found that
autopsy was pursued only in approximately 10% of perianes-
thetic mortality cases.4 A recent study provides the most com-
prehensive information to date regarding morphologic lesions in
such cases and was limited to cats dying during or after general
anesthesia for uncomplicated sterilization procedures.9 In addi-
tion to the paucity of published reports of autopsy findings
related to perianesthetic death in animals, resources addressing
specific autopsy protocols and techniques for these cases are
limited mainly to human pathology references.7,9,14,28,29
This retrospective study evaluated cases of perianesthetic
mortality in domestic animals submitted for autopsy to a veter-
inary diagnostic laboratory over an 8-year period. Special con-
siderations for autopsy of perianesthetic mortality cases are
also discussed, based on these results and a review of the exist-
ing literature.
Materials and Methods
Perianesthetic mortality cases submitted to the University of
Guelph Animal Health Laboratory (AHL) from May 1, 2007 to
July 31, 2015 were identified retrospectively. Autopsy records
were searched in the laboratory’s information management
system (LIMS; Sapphire, LabVantage Solutions Inc, Somerset,
NJ, USA) using anesthesia-related etiology codes assigned by
the coordinating pathologist for each case, as well as by a free-
text search for the terms cardiopulmonary resuscitation (CPR),
anesthesia, cardiac arrest, and respiratory arrest. Inclusion in
the study was limited to cases in which death occurred within
24 hours of sedation or premedication for general anesthesia, or
for sedation alone, and for which gross autopsy was carried out
at the AHL. Cases for which the autopsy was conducted at
another clinic or institution, and for which only histopathology
samples were submitted to the AHL for examination, were
excluded. Those cases for which death occurred >24 hours after
general anesthesia or sedation were also excluded.
Data captured for each case from the LIMS search included
the species, breed, age, and sex of the animal; clinical history as
provided by the submitting veterinarian; and pathology diag-
noses. Individual case reports were reviewed by the author and
additional information was recorded based on both objective
and subjective information included in the clinical history and
pathology report, including pathologists’ comments and inter-
pretation. Based on this review, additional data recorded for
each case included autopsy lesion(s) interpreted by the case
pathologist as most clinically relevant to the animal’s death
and the category of these lesions (ie, cardiovascular, respira-
tory, neurologic, gastrointestinal, systemic, or neoplastic dis-
ease; lesions directly resulting from surgical or anesthetic
complication; or no significant lesions), phase of sedation or
general anesthesia during which death occurred (premedication
or sedation, induction, maintenance, postanesthetic recovery),
clinical description provided for anesthetic complication
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(cardiac and/or respiratory arrest, collapse, found dead, hypo-
tension), type of surgery (elective vs emergency, and specific
procedure), and history of CPR. Comments relating to clini-
cally recognized anesthetic or surgical complications, as well
as lesions interpreted by individual pathologists as potentially
associated with CPR, were also recorded when this information
was included in the clinical history or postmortem report,
respectively.
Results
A total of 17,417 autopsy cases were submitted to the AHL
between May 1, 2007 and July 31, 2015. The initial LIMS
search using anesthesia-related etiology codes and free-text
terms identified a subset of 608 potential perianesthetic mor-
tality cases. Of these, 221 cases met the inclusion criteria for
the study, representing 1.3% of all autopsy cases during this
time. These consisted of 174 cases originating from primary
care veterinary hospitals and 47 cases from veterinary referral
hospitals. Cases of dogs (n ¼ 105) and cats (n ¼ 90) predomi-
nated, with fewer cases of other species including horses
(n ¼ 9), rabbits (n ¼ 9), ferrets (n ¼ 4), and a guinea pig,
chinchilla, rat, and tortoise (n ¼ 1 each). The proportion of cases
from each species in the study compared with the total number
of autopsy cases for the same species during this time period is
shown in Supplemental Table S1. A total of 34 pathologists
and pathology trainees contributed to the 221 cases in the study.
Clinical history as provided by the submitting veterinarian
was considered incomplete in 42 of 221 cases (19%), based on
lack of information concerning the clinical status of the animal
at the time of surgery; the specific procedure being done for
which sedation or anesthesia was required; when during the
procedure and under what circumstances the animal died; and
whether CPR was performed on the animal. Both referral insti-
tutions (11 of 42; 26%) and primary care veterinary facilities
(31 of 42; 74%) contributed to the cases with incomplete his-
torical information. A total of 69 animals (31%) had evidence
of clinical disease prior to anesthesia, based on clinical his-
tories provided by veterinarians. The presurgical health status
of the animal, using American Society of Anesthesia (ASA)
guidelines,5 was included in the clinical history for only a
single animal in the study. Of the total 221 cases, 158 animals
(71%) were sedated or anesthetized for elective procedures;
emergency procedures were carried out in 42 animals (19%),
and the procedure was unknown based on the history provided
for 21 animals (10%).
Both gross and histologic examinations were carried out for
the majority of cases (218 of 221; 99%); evaluation was limited
to gross examination for 3 cases. For 2 cases, partial or com-
plete gross examination had been conducted by a veterinarian
prior to submission of the body to the diagnostic laboratory.
Timing of death was unknown for 14 cases (6%). Of the 207
cases in which the timing was specified, death occurred in the
premedication or sedation (n ¼ 19; 9%), induction (n ¼ 22;
11%), or maintenance (n ¼ 73; 35%) phases or in the 24 hours
postanesthesia (n ¼ 93; 45%).
DeLay 3

Table 1. Autopsy Lesions in Perianesthetic Mortality Cases at a Veterinary Diagnostic Laboratory.a

Lesions of Preexisting Diseases

Total No Significant Surgical
Species Autopsies (%)b Lesions Complication Total Cardiac Respiratory Systemic Neoplasia CNS GI

Dog 105 (3.6)c 45 (43) 5 (5) 55 (52) 26 (25) 15 (14) 11 5 2 1

Cat 90 (7.9) 31 (34) 4 (4) 55 (61) 29 (32) 17 (19) 9 0 0 0
Horse 9 (0.4) 0 0 9 4 2 3 0 0 0
Rabbit 9 (2.8) 4 0 5 0 3 2 0 0 0
Ferret 4 (6.5) 0 1 3 1 0 1 1 0 0
Guinea pig 1 (3.5) 0 0 1 0 0 0 1 0 0
Chinchilla 1 (4.2) 0 0 1 0 0 1 0 0 0
Rat 1 (3.4) 0 0 1 1 0 0 0 0 0
Tortoise 1 (50) 1 0 0 0 0 0 0 0 0
Total 221 (1.3) 81 10 130 61c 37 27c 7c 2 1

CNS, central nervous system; GI, gastrointestinal.

a
Data are presented as n or n (%).
b
Total number of autopsies of perianesthetic mortality cases (and percentage relative to total number of autopsies in the same time period, 2007–2015).
c
Three dogs had significant lesions in multiple disease categories.

A summary of autopsy findings is listed in Table 1. Among Table 2. Surgical and Anesthetic Complications Identified During
all species, 81 animals (37%) lacked lesions that reflected the Autopsy in Perianesthetic Mortality Cases.
cause of death (COD) or a contributing COD. No significant No. of No. of
lesions were identified in 4 of 9 rabbits (44%), 45 of 105 dogs Species Cases Diagnosis Cases
(43%), 31 of 90 cats (34%), and the single tortoise in the study.
The median age of animals with no significant postmortem Dog 5 Hemorrhage at inguinal surgical site 1
lesions was <1 year in each of these species (dogs: 9 months Hemoabdomen–ovariohysterectomy, 3 (1 each)
neuter, or gall bladder mucocele
[range, 3 months to 19 years]; cats: 7 months [range, 2 months to
resection
13 years]; and rabbits: 6 months [range, 3 months to 9.5 years]). Pleural and mediastinal emphysema 1
The majority of animals in which no lesions were identified had secondary to closed adjustable
undergone elective procedures (4 of 4 rabbits [100%]; 25 of 45 pressure-limiting valve
dogs [56%]; and 26 of 31 cats [84%]), including spay or neuter Cat 4 Accidental drug injection, confirmed by 1
surgeries in 25 of 45 dogs (56%) and 18 of 31 cats (58%). The toxicology
balance of cases included emergency surgeries and cases for Pneumothorax secondary to dehiscence 1
at tracheal surgical site
which the procedure was not documented in the clinical history
Hemoabdomen–ovariohysterectomy 1
provided by the submitting veterinarian or in the autopsy report. Perilaryngeal and upper respiratory tract 1
Specific anesthetic complications were reported clinically in 3 hemorrhage owing to endotracheal
of the canine cases with no significant autopsy lesions. A closed tube–induced trauma
adjustable pressure-limiting (APL) valve was identified during Ferret 1 Hemoabdomen–hepatic biopsy site 1
anesthesia in 2 cases involving a 4-month-old Shih Tzu and a
5-month-old Boston Terrier. Venous air embolism was identified
clinically as the COD in a 5-month-old Dachshund in which These included 55 of 105 dogs (52%), 55 of 90 cats (61%), 9 of
dyspnea developed immediately after the start of intravenous 9 horses (100%), 5 of 9 rabbits (56%), and 3 of 4 ferrets (75%),
fluid therapy and progressed to cardiac arrest; however, no gross as well as 1 each of the single guinea pig, rat, and chinchilla.
lesions were identified during the autopsy to confirm this. Among dogs with natural disease, 3 animals had multiple sig-
In addition to the above cases of anesthetic complications nificant lesions, involving 2 organ systems, that were deter-
without significant autopsy lesions, complications of the surgi- mined to be either the COD or contributed to the COD. These
cal or anesthetic procedure were confirmed at autopsy and the individuals are included in multiple natural disease lesion cate-
COD was attributed to these in 10 of 221 animals (5%), includ- gories. The majority of lesions involved the respiratory and
ing 5 dogs, 4 cats, and 1 ferret (Table 2). Of these, 7 cases cardiac systems.
involved surgical complications and 3 cases were directly Cardiac lesions were present in 61 of 130 (47%) animals
related to anesthetic procedures or equipment. No lesions indi- with evidence of natural disease, including 26 of 55 dogs
cative of surgical complication were identified in horses, rab- (47%), 29 of 55 cats (53%), 4 of 9 horses (44%), 1 of 3 ferrets
bits, or other species represented in the study. (33%), and the single rat in the study (Table 3). Death in ani-
The remaining 130 of 221 animals (59%) in the study had mals with cardiac lesions occurred most commonly during
gross and/or histologic lesions indicative of naturally occurring maintenance (20 of 61; 33%) and recovery (23 of 61; 38%)
disease that was considered the COD or a contributing COD. phases of anesthesia and infrequently in the phase of sedation

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4 Veterinary Pathology
Table 3. Cardiac Lesions Identified During Autopsy in Perianesthetic
Mortality Cases.
No. of
Species Cases Diagnosis
Dog 26 Cardiomyopathy
Congenital anomaly
Mild nonsuppurative myocarditis
Myocardial necrosis or infarct
Pulmonary or hepatic lesions consistent
with heart failure
Focal myocardial fibrosis
Cat 29 Primary cardiomyopathy
Myocardial fibrosis
Acute myocardial necrosis
Myocardial hypertrophy secondary to
hyperthyroidism
Acute subendocardial hemorrhage and
inflammation
Endocardial fibrosis
Pulmonary lesions consistent with heart
failure
Horse 4 Mild nonsuppurative myocarditis
Acute suppurative myocarditis
Valvular endocarditis
Pulmonary lesions consistent with heart
failure
Ferret 1 Cardiomyopathy
Rat 1 Hemopericardium
or induction. Among dogs and cats, cardiomyopathy was the
most frequently diagnosed cardiovascular condition. Lesions of
cardiomyopathy were identified in 12 of 26 dogs with cardiac
lesions (46%) (12 of 105 total dogs [11%]), representing 12
separate breeds: Macedonian Mountain Dog, Miniature Schnau-
zer, Whippet, Labrador Retriever, Border Collie, Toy Havanese
terrier, Pomeranian, Boxer, Maltese, Chihuahua, Yorkshire Ter-
rier, and mixed breed. The dogs ranged in age from 10 months to
16 years, with a median age of 4 years. No clinical indication of
cardiac disease was listed in the history provided for any of the
dogs. One dog was described as aggressive during preanesthetic
clinical examination and premedication. Nine dogs were under-
going elective procedures, 2 dogs were emergency surgical
patients (1 resulting from the presence of a gastric foreign body
and the other due to gastric perforation), and the specific reason
for anesthesia was unknown in 1 case. Cardiomyopathy was
diagnosed based on combined gross and histologic lesions in 9
dogs and on gross lesions alone in 3 dogs that lacked supporting
histologic lesions. Of the 10 dogs for which assessment of total
heart weight/body weight and ventricular weight ratios (left ven-
tricle þ septum/right ventricle) was carried out, abnormalities in
1 or both of these ratios supported cardiomyopathy in 5 cases
(50%).32
Lesions consistent with cardiomyopathy were identified in
21 of 29 cats with cardiac lesions (72%) and in 21 of 90 cats in
the study (23%) and included hypertrophic cardiomyopathy
(n ¼ 7 cats), unclassified cardiomyopathy (n ¼ 13 cats), and
fatty replacement of right ventricular myocardium (n ¼ 1 cat).
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Table 4. Respiratory Lesions Identified During Autopsy
in Perianesthetic Mortality Cases.
No. of No. of No. of
Cases Species Cases Diagnosis Cases
12 Dog 15 Aspiration pneumonia 5
4 Brachycephalic syndrome 3
3 Tracheal collapse syndrome 3
3 Pneumothorax 2
3 Laryngospasm 1
Severe acute pulmonary hemorrhage 1
1 Cat 17 Pneumothorax 5
21 Interstitial pneumonia 3
2 Upper respiratory tract obstruction 1
2 (laryngeal mucous plug)
1 Pulmonary vascular smooth muscle 2 (1 each)
hyperplasia and vascular/interstitial
1 smooth muscle hyperplasia
Bronchointerstitial pneumonia 1
1 Parasitic pneumonia, Aelurostrongylus 1
1 abstrusus
Aspiration pneumonia 1
1 Embolic pneumonia 1
1 Acute pulmonary edema 1
1 Severe laryngeal edema 1
1 Horse 2 Upper respiratory tract obstruction (from 1
pharyngeal lymphoid hyperplasia)
1 Aspiration pneumonia 1
1 Rabbit 3 Laryngotracheitis 1
Upper respiratory tract obstruction 2
Breed distribution of cats with lesions consistent with cardio-
myopathy included 14 Domestic Shorthair, 4 Domestic Long-
hair, and 1 each of Burmese, Egyptian Mau, and Maine Coon
breeds. The median age of cats diagnosed with cardiomyopathy
was 4 years, with a range of 5 months to 16 years. Of the 4 cats
with recognized clinical disease prior to anesthesia, signs of
congestive heart failure were described in 2 cats. Nineteen of
21 cats with cardiomyopathy were undergoing elective proce-
dures at the time of death; the reason for anesthesia in 2 cats
was not stated. Heart weight/body weight ratios were recorded
in 13 of 21 cases (62%), and left/right ventricular weight (left
ventricle þ septum/right ventricle) ratios were also recorded in
7 of 21 cases (33%). In these cases, increased left ventricle
weight supported a diagnosis of left ventricular hypertrophy,
compatible with cardiomyopathy in 2 of 7 cases (29%).27 A
diagnosis of cardiomyopathy was based on both gross and
histologic lesions in 11 cats, on histologic lesions alone in
9 animals, and on gross lesions alone in 1 case. In addition to
the 21 diagnoses of cardiomyopathy, left cardiac ventricular
hypertrophy was attributed to hyperthyroidism associated
with thyroid adenoma in 1 cat, and left ventricular endocardial
fibrosis or myocardial fibrosis was identified in 3 additional
cats but were not classified as cardiomyopathy.
Respiratory tract lesions were present in 37 of 130 animals
with natural disease (28%), including 17 of 55 cats (31%), 15 of
55 dogs (27%), 3 rabbits (60%), and 2 horses (22%) (Table 4).
Among animals with respiratory lesions, death was reported
most frequently during maintenance (10 of 37; 27%) and
DeLay 5

recovery (19 of 37; 51%) phases of anesthesia, with fewer Table 5. Autopsy Lesions Attributed to Resuscitation in
deaths during sedation (2 of 37; 5%) or anesthetic induction Perianesthetic Mortality Cases.a
(4 of 37; 11%). The timing of death was not provided in 2 cases. Frequency
Acute aspiration pneumonia was identified in 7 of 37 animals
with respiratory tract lesions (19%) and included 5 dogs, 1 cat, Lesion Dogs Cats
and 1 horse. Aspiration pneumonia was suspected as the primary
Pulmonary congestion, hemorrhage or edema 14 14
lesion in 2 dogs in which sepsis was also identified. Among the Multiorgan congestion or hemorrhage 11 14
30 dogs of brachycephalic breeds included in the study, lesions Pneumothorax 8 18
of brachycephalic syndrome were considered the COD or con- Pulmonary atelectasis 9 5
tributing to the COD in 3 dogs, all of which were English Bull- Thymic hemorrhage 1 2
dogs. Death occurred during recovery from anesthesia in each of Epicardial petechiae 0 1
these 3 dogs. In these 3 dogs, acute aspiration pneumonia and Pulmonary emphysema 0 1
ventricular septal defect were evident in 1 dog, and subaortic Diaphragmatic laceration 0 1
Liver laceration or hemoperitoneum 2 2
stenosis was present in 1 dog in which an episode of collapse had Thoracic or pericardial effusion 0 1
been described historically. Upper respiratory tract obstruction Laryngeal edema 0 1
and predisposition to aspiration as a result of brachycephaly, as Hemothorax 1 1
well as congenital cardiac anomalies, were considered to have Hemoperitoneum 1 0
contributed to the COD in these 3 animals. Focal acute myocardial necrosis 1 0
Significant systemic disease was evident in 27 of the 130 Gastric bloat 1 0
animals with natural disease (21%), including 10 dogs, 9 cats, 4 Ascites 1 0
Blood in trachea 0 1
horses, 2 rabbits, 1 ferret, and 1 chinchilla. The majority of Total number of animalsb 36 34
these animals (1 of 27; 63%) were anesthetized for emergency
a
surgery as a result of various causes, including a gastrointest- The table includes lesions that, in the pathologist’s opinion, were caused by
inal foreign body, intestinal torsion, and emergency caesarian resuscitation attempts.
b
A total of 22 dogs and 16 cats had multiple lesions attributed to resuscitation.
section. Among animals with lesions of systemic disease, death
occurred in the postanesthetic period in most cases and among
all species (18 of 27; 67%). Lesions consistent with sepsis, clinical history of 11 of 12 dogs (92%) and 16 of 22 cats (73%)
endotoxemia, and/or disseminated intravascular coagulation in which pneumothorax was identified postmortem. Resuscita-
were identified in the majority of animals (20 of 27; 74%). tion history was unknown for 1 dog and 6 cats.
Postsurgical myopathy was evident in 1 horse, and skeletal Neoplasia was evident and was considered the significant
muscle lesions compatible with malignant hyperthermia were COD in 5 of 105 dogs (5%), 1 of 4 ferrets (25%), and in the
present in 1 cat. Lesions of feline infectious peritonitis were single guinea pig in the study. Splenic hemangiosarcoma was
confirmed in a single cat. present in 4 dogs and was associated with hemoabdomen in 2
A variety of gross and histologic lesions were attributed by dogs, metastases involving myocardium and other organs in 1
specific case pathologists to resuscitation efforts after cardiopul- dog, and multiorgan infarction in 1 dog. A heart-base chemo-
monary arrest. Potential lesions reflective of CPR were identi- dectoma with a space-occupying effect and resulting heart fail-
fied in 75 of the 221 animals in the study (34%), including 36 of ure was identified in 1 dog. Disseminated lymphoma with
105 dogs (34%) and 34 of 90 cats (38%), as well as in 3 rabbits, 1 myocardial infiltration was evident in the guinea pig. A pan-
horse, and 1 ferret (Table 5). Pneumothorax; pulmonary conges- creatic endocrine tumor (suspected insulinoma) was confirmed
tion, hemorrhage, and/or edema; pulmonary atelectasis; and in 1 ferret and was considered likely to have caused hypogly-
multiorgan congestion and/or hemorrhage were the most com- cemia as a complicating factor during anesthesia.
mon lesions ascribed to CPR attempts in dogs and cats. Pneu- Lesions involving the central nervous or gastrointestinal
mothorax unaccompanied by primary intrathoracic disease was systems were present in 3 of 105 dogs (3%) and included
identified during autopsy in a total of 12 of 105 dogs (11%) and extensive granulomatous meningoencephalitis in an 8-year-
22 of 90 cats (24%), including cases in which the lesion was old American Staffordshire Terrier, caudal herniation of the
interpreted as potentially resulting from CPR, as well as those in cerebellum in a 7-year-old Pug anesthetized for emergency
which no such association was made by the pathologist. Pneu- dorsal laminectomy at C1 to C2, and acute hemorrhagic enter-
momediastinum and pleural emphysema were identified in 1 itis of unknown cause in a mixed breed dog.
additional dog for which a closed APL valve was identified
clinically prior to death (included with surgical and anesthetic
complication cases). Pneumothorax was confirmed at autopsy in Discussion
each of these cases by absence of normal negative intrathoracic Perianesthetic mortality is well recognized in veterinary med-
pressure when the diaphragm was incised from the abdominal icine, and several clinical studies over the past 20 years have
aspect. Pneumothorax was identified both clinically and during evaluated mortality rates and clinical causes.2–4,6,8,10,12,13
autopsy in 1 cat, confirming antemortem development of the However, the use of autopsy to confirm or corroborate the
condition in this particular animal. CPR was confirmed in the COD is infrequently reported in these studies,4,8 and only 1

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6 Veterinary Pathology
comprehensive study has documented postmortem findings of
perianesthetic mortality in animals.9 The retrospective study
reported here documents significant autopsy lesions in multiple
species of animals submitted to a North American veterinary
diagnostic laboratory over an 8-year time period. Dogs and cats
were overrepresented in the study compared with other species
and in the relative contribution of each to the overall autopsy
caseload of the laboratory. This likely reflects the increased
frequency of sedation, general anesthesia, and surgery among
these species compared with others in veterinary practice.
Insight from autopsy into the potential COD in the perianes-
thetic period is limited to conditions or occurrences producing
morphologic lesions detectable by gross or histologic examina-
tion. Death owing to several causes will not result in specific
lesions, including anesthetic overdose, endobronchial intuba-
tion, hypersensitivity or idiosyncratic reactions to anesthetic
drugs, hypotension, metabolic derangements, or cardiac dys-
rhythmias. As previously discussed,9 postmortem toxicologic
analysis is currently not practical for assessment of a potential
anesthetic drug overdose or drug-related side effects in
animals. As a result, the major emphasis in perianesthetic
mortality cases is placed on exclusion of preexisting conditions
that may have increased the inherent risk of general anesthesia
and contributed to the animal’s demise, as well as on the iden-
tification of lesions indicative of complications associated with
the surgical or anesthetic procedure.14,28,29
In human pathology, autopsy findings in perianesthetic
mortality cases may be divided into the following: (1) death
caused by the disease or injury for which the procedure was
being carried out; (2) death owing to preexisting disease other
than that for which the procedure was being carried out; (3)
death as a result of surgical complication; and (4) death attri-
butable to anesthesia when other causes have been
excluded.28 Conclusions in human medicolegal cases involv-
ing perianesthetic mortality may be based on both pathology
findings and expert clinical (anesthesia and surgery) review of
the case, although the requirement for autopsy and the
approach to the cases vary among institutions and jurisdic-
tions.15 Similar multidisciplinary review of perianesthetic
death cases in veterinary medicine could provide additional
insight into the COD in which postmortem findings do not
provide a conclusive COD. Although it is not commonly done
in routine veterinary diagnostic cases, consultation with veter-
inary anesthesiologists on these cases may be enlightening,
especially in complex cases with no significant lesions to
indicate the COD. In addition, correlation of lesions with
clinical history and events that occurred during anesthesia is
important. In this study, documented consultation with a
veterinary anesthesiologist occurred in only 2 cases. Com-
plete clinical records are required to facilitate this type of
multidisciplinary review. The clinical history provided was
limited in many cases in the present study and was considered
incomplete in 42 cases (19%). This emphasizes the need for
provision of more thorough clinical information to patholo-
gists in perianesthetic mortality cases. Autopsy recommenda-
tions in human perianesthetic mortality cases recognize the
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potential for misinterpretation of findings if clinical records
are not provided to allow correlation with autopsy findings.14
Currently, a single comprehensive literature report describes
postmortem lesions in perianesthetic mortality cases in ani-
mals.9 That report evaluated cats undergoing general anesthe-
sia for elective sterilization at 2 spay/neuter organizations.
Complications of the surgical or anesthetic procedure were
identified as the COD in 4% of animals in both the current
study and the prior study. Lesions indicative of naturally occur-
ring disease were present in 59% of all animals and in 61% of
cats in the current study, compared with 33% of cats in the
previous study. In the current study, no significant lesions were
identified in 36% of all cases and in 34% of all cats, compared
with an absence of lesions in 63% of cats in the previous study.
Variations in the overall rates of naturally occurring disease
and lesion absence between the current study and the prior
study may be partly explained by the more homogenous pop-
ulation with respect to ASA class and procedure (spay/neuter)
in that study . However even among cats undergoing elective
sterilization surgery in the current study, no lesions indicative
of the COD were identified in 44% of cats, compared with an
absence of lesions in 63% of cats in the previous study. Factors
contributing to the comparably lower rate of anesthesia-
associated death with no significant lesions among the cat
spay/neuter population in this study are unknown.
Emergency surgical procedures involved 19% of animals
in the current study, and clinical disease prior to anesthesia
was documented among 31% of animals in this study. An
increased risk of death during anesthesia is recognized with
increasing ASA classification prior to anesthetic induction,
correlating with progressively poorer physical status, in dogs,
cats, horses, and humans.3,4,8,10,34 Emergency procedures
have also been associated with an increased risk of anesthetic
death in horses and humans.12,19,34
Lesions associated with resuscitative efforts have been
described in humans and animals and must be distinguished
from lesions indicative of intercurrent disease.11,14,23,25,29 In
this study, a range of lesions identified in 34% of animals were
interpreted by pathologists as directly reflective of external
compression, internal cardiac massage, and/or positive pres-
sure ventilation in animals with cardiopulmonary arrest. The
majority of putative resuscitation-associated lesions involved
vascular stasis primarily in the lung but also in other organs.
Vigorous external chest compression was interpreted as the
cause of thymic hemorrhage, hemothorax, hemoabdomen,
lacerations in the liver and diaphragm, epicardial and pulmon-
ary hemorrhage, and pneumothorax. Rib fracture is also
reported as a resuscitation-associated lesion in humans, poten-
tially causing pneumothorax, but was not identified among
animals in this study.25 A recent prospective study of CPR
outcomes in dogs and cats identified lesions directly attributed
to resuscitation in 34% of dogs and cats, and these were similar
to presumed resuscitation-induced lesions in this study.17 Nota-
bly, pneumothorax was not identified in that study and may
reflect the experience of the personnel involved in resuscita-
tion, which was limited to cases at a referral institution. This
DeLay
suggests that although pneumothorax may be induced by
aggressive manual ventilation, especially in small animals with
low tidal volumes, careful examination for other potential
causes of pneumothorax should also be carried out.
Spontaneous pneumothorax may also develop antemortem
in dogs and cats, prior to resuscitation, and may contribute to
cardiopulmonary arrest during general anesthesia. Sponta-
neous pneumothorax in dogs most commonly results from
rupture of pulmonary blebs or bullae that are unassociated
with inflammatory, infectious, or neoplastic lung disease.26
In contrast, spontaneous pneumothorax in cats has been
reported only as a secondary event in conjunction with under-
lying, often extensive lung disease.16,22 Pneumothorax, pneu-
momediastinum, and subcutaneous emphysema may also
result from tracheal rupture, occasionally induced during the
placement of an endotracheal tube in cats.21,31 In this study,
pneumothorax was most frequently identified in cats (22
cases; 24%). Four of the 8 dogs with detectable pneumothorax
were of small breed, and all but 1 dog was 6 months of age or
younger. Pneumomediastinum was present in 1 dog in which
the APL valve on the anesthetic machine had remained
closed. Differentiation at autopsy between spontaneous ante-
mortem and resuscitation-induced pneumothorax is not pos-
sible; as a result, pathologists must be cautious in ascribing
significance to pneumothorax as a contributing factor in indi-
vidual cases of perianesthetic mortality.
Despite the difficulty in differentiating antemortem and
resuscitation-induced pneumothorax, the autopsy should eval-
uate the presence of this condition. Radiography at the start of
the examination, prior to opening the body, is the most reliable
method for confirming the presence and magnitude of pneu-
mothorax. During the autopsy, the presence of normal negative
intrathoracic pressure, which would help exclude significant
pneumothorax, can be confirmed by making a small incision
at the abdominal aspect of the diaphragm and observing col-
lapse of the concavity of the diaphragm into the thorax. In
humans, a recommended technique for detection of pneu-
mothorax involves careful dissection and removal of an inter-
costal muscle while preserving the underlying parietal pleural.7
Visceral pleura will be evident adjacent to parietal pleura in the
absence of pneumothorax, but it will not be visible if signifi-
cant air is present in the pleural cavity. Ruptured pulmonary
bullae, predisposing to spontaneous pneumothorax, may be
identified by submerging the entire lung in water and injecting
air into the trachea to inflate the lung while observing for air
bubble escape into the surrounding liquid.
Venous air embolism has been reported as an uncommon
but sometimes fatal complication of surgical and diagnostic
procedures during general anesthesia in animals.11,23,33 The
clinical outcome of air embolism depends on the volume and
rate of air introduction and on the clinical status of the ani-
mal.20,35 A fatal intravenous bolus dose of air >2 ml/kg in dogs
has been suggested, extrapolated from experimental data in
pigs.35 In the present study, air embolism was suspected as the
COD in 1 dog based on clinical information, although this was
not confirmed at autopsy. Various surgical manipulations may
Downloaded from vet.sagepub.com at City University Library on July 2, 2016
7
predispose to air embolism, including any surgery in which
large veins are incised.7 In dogs and cats, venous air embolism
has been associated with inadvertent intravenous injection of
air, dental procedures using a high-speed air-cooled drill, sur-
gical techniques using air insufflation, and cryosurgery
employing a spray technique.11,23,24,30,33 Air emboli introduced
inadvertently through intravenous injection may be a more
significant risk factor in small breed dogs and possibly cats,
because less air would be required to significantly affect the
heart and vasculature in these animals.23 Air emboli may result
in physical air lock of the right ventricle and/or pulmonary
hypertension.1 Patients undergoing procedures at higher risk
for this complication should be evaluated during the autopsy
using special dissection techniques for detection of potential air
emboli. These lesions may be easily missed during routine
autopsy. As with pneumothorax, radiography prior to opening
the body may identify air emboli in the thoracic cavity, primar-
ily within the right ventricle and major blood vessels.7 The
presence of an air embolus in the right ventricle of the heart
can be assessed by filling the unopened pericardium with
water, then making a full-thickness stab incision in the right
ventricular free wall or atrium, and monitoring for release of air
bubbles into surrounding water.7,23 Other techniques describe
en bloc dissection of heart and lungs (pluck), then submerging
the heart in water prior to incising the right ventricle and obser-
ving for air bubble escape.33 Air may also be aspirated from the
right ventricular lumen using an 18-gauge needle and large
syringe.11 Evaluating large veins for the presence of air bubbles
may also aid in confirmation of a diagnosis of fatal air embo-
lism. The state of preservation of the body is important to
consider when interpreting results of these specialized dissec-
tion techniques, because putrefaction may result in intravascu-
lar accumulation of air unrelated to the COD.
Established procedural guidance for autopsy of veterinary
perianesthetic mortality cases is limited. On the basis of the
results of this study, in combination with review of human and
veterinary literature, several recommendations can be made
regarding the autopsy procedure in these cases. Review of the
animal’s complete clinical history is imperative prior to begin-
ning the autopsy, and the pathologist must ensure that all rel-
evant information is obtained from the clinical veterinarian.
Gerdin et al9 provide recommendations for clinical information
to be included with autopsy submissions in cases of perianes-
thetic mortality. Results of preanesthetic bloodwork, anesthetic
and surgical records, and previous or concurrent disease con-
ditions should be included in the history. The clinician’s accu-
rate description of procedures around the time of the animal’s
death, as well as the animal’s condition leading up to the time
of death, can provide insight into potential causes of death. For
example, arrest immediately after intravenous catheter place-
ment could be suggestive of venous air embolism, or progres-
sively shallow respiratory efforts may support antemortem
pneumothorax. Direct dialogue between the pathologist and
clinician may be the most efficient and informative way to
obtain the level of clinical detail necessary for the pathologist
to be completely informed of circumstances surrounding the
8 Veterinary Pathology
animal’s death. Knowledge of potential complications inherent
to the specific surgical or other procedure involved will alert
the pathologist to purposely evaluate the lesions indicative of
these complications.14
The pathologist should proceed with external and internal
examination using a familiar autopsy protocol, but with
heightened attention to the heart, upper respiratory tract, and
lungs. Prior to opening, the body should be examined for
possible subcutaneous emphysema, and surgical incisions
should be examined and recorded. Radiography should be
considered for potential identification of pneumothorax,
pneumomediastinum, and venous air embolism. Presence of
pneumothorax may be assessed by incising the diaphragm or
dissecting intercostal muscles, as described above, and prior
to opening the thorax. Before dissection of lung and heart,
lungs may be submerged in water and inflated by air intro-
duced by large volume syringe via the trachea, monitoring for
air bubbles indicative of ruptured pulmonary bullae. Upper
airways should be evaluated for potential obstructive lesions,
including soft palate abnormalities, laryngeal edema or
hemorrhage, and mechanical obstruction by foreign bodies,
mucus, inflammatory exudate, or other debris. Assessment of
both the mucosal and outer surfaces of the trachea may iden-
tify lacerations or other traumatic lesions potentially associ-
ated with intubation. Evaluation of the pleural cavity, lung,
and visceral and parietal pleura should include documentation
of lung inflation, type and volume of any pleural fluid, and
character and distribution of lung lesions. Important compo-
nents of a heart examination include examination of each
cardiac chamber and inclusion of chamber weights, as well
as evaluation of the heart valves, myocardium, and endocar-
dium. The autopsy should include evaluation and documen-
tation of surgical sites, and the presence and volume of
hemorrhage at any site should be recorded. A thorough set
of tissue samples, including brain tissue, should be collected
for histologic examination in order to confirm or exclude
underlying natural disease processes. Samples should also
be collected for microbiologic testing, if deemed necessary
on the basis of gross lesions. Importantly, the interpretative
section of the pathology report should attempt to correlate the
clinical circumstances surrounding the perianesthetic death
with lesions identified during the autopsy.
This retrospective study attempts to help fill a void in the
veterinary literature regarding autopsy findings in animals
dying during or within 24 hours of sedation or general
anesthesia. Lesions indicative of significant, preexisting nat-
ural disease were identified in most animals, and surgical or
anesthesia-related complications were evident in a much
lower proportion of cases. However a significant number of
animals lacked lesions indicative of a potential COD. Exclu-
sion of underlying, preexisting disease and iatrogenic compli-
cations remains the primary goal in autopsy of perianesthetic
mortality cases. Pathologists must be aware of potential com-
plications and resultant lesions associated with various surgi-
cal and diagnostic procedures, as well as with lesions induced
by resuscitation efforts. Correlation of autopsy lesions with
Downloaded from vet.sagepub.com at City University Library on July 2, 2016
the clinical history and potential COD is an important part of
the pathology report.
Acknowledgements
I thank each of the 34 pathologists whose diagnostic reports
contributed to this study.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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