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The
Veterinary Journal
The Veterinary Journal 182 (2009) 152–161
www.elsevier.com/locate/tvjl

Review

Perioperative mortality in small animal anaesthesia

Dave Brodbelt *
Department of Veterinary Clinical Sciences, Royal Veterinary College, Hawkshead Lane, North Mymms, Hertfordshire AL9 7TA, UK

Accepted 14 June 2008

Abstract

Anaesthetic complications have been studied intermittently in small animal practice. Current estimates suggest that approximately
0.1–0.2% of healthy and 0.5–2% of sick dogs and cats die of an anaesthetic-related death. This is substantially greater than the risk
of mortality reported in human anaesthesia. Recent work has identified the post-operative period as the highest risk period and has doc-
umented a number of risk factors for mortality. Knowledge of factors associated with anaesthetic-related death and high risk peri-oper-
ative periods could aid patient management and reduce complications.
Ó 2008 Elsevier Ltd. All rights reserved.

Keywords: Anaesthesia; Death; Small animals; Risk factors; Peri-operative

Introduction of anaesthesia and suggests that further improvements to

Peri-operative anaesthetic complications have been
infrequently evaluated in veterinary practice (Jones,
2001). The first major study of anaesthetic-related death
was undertaken in the United Kingdom (UK) approxi-
mately 20 years ago and documented the risk of anaes-
thetic-related death in dogs and cats at approximately
0.23% and 0.29%, respectively (Clarke and Hall, 1990).
Subsequent international work has reported the risk of
anaesthetic-related death in both dogs and cats as approx-
imately 0.1–0.2% (Dodman and Lamb, 1992; Dyson et al.,
1998; Joubert, 2000; Brodbelt et al., in press-a). Although
still relatively uncommon, this range is substantially higher
than in human anaesthesia, where the risk of anaesthetic-
related death has been recorded as approximately 0.02–
0.05% (Eagle and Davis, 1997; Biboulet et al., 2001; Kawa-
shima et al., 2001).
Although species differences may partially account for
this large discrepancy between risks in human and veteri-
nary anaesthesia, it is likely that a major component of
the difference in risk of death reflects different standards
*
Tel.: +44 01707 666625; fax: +44 1707 666574.
E-mail address: dbrodbelt@rvc.ac.uk.
small animal anaesthetic practice could be made. In human
anaesthesia, the level of training of personnel involved is
generally higher, patients are routinely monitored to a
greater degree, there is a wider range of anaesthetic equip-
ment available, and there is much greater access to high
dependency and intensive care units for post-operative
patient management compared to that seen in small animal
anaesthesia. An evaluation of perioperative mortality in
small animals and the identification of major contributory
factors could therefore encourage improvements in clinical
veterinary practice and reduce mortality.
Risks of anaesthetic-related death
In small animal anaesthesia, the risk of death has been
intermittently documented over the last 50 years, with
reports of trends towards higher risks in referral centres
compared to primary practice-based studies, and reduc-
tions in risks over time. Referral and university-based stud-
ies generally had higher death risks due to the nature of
their patients and procedures, whilst practice-based studies
tended to reflect healthier populations and simpler proce-
dures. Similarly, anaesthetic practice and monitoring
equipment and personnel available have improved over

1090-0233/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.tvjl.2008.06.011
 D. Brodbelt / The Veterinary Journal 182 (2009) 152–161
time and generally risks have decreased. Direct compari-
sons of reports have been complicated by the differing pop-
ulations anaesthetised, the study methods used, the case
definition of anaesthetic mortality adopted and the period
of follow-up used. However, in general, comparisons of
studies based on the primary or referral nature of the pop-
ulations anaesthetised have been most relevant.
Initial institution-based studies from the USA docu-
mented a wide range in risks of mortality. An early study
at the Angell Memorial Animal Hospital in Boston (Albr-
echt and Blakely, 1951) published risks of anaesthetic death
of 0.26% in dogs, 0.36% in cats and 5% in other species
(rabbits, monkeys etc.). Anaesthetic death was defined as
any death occurring from the time of induction of anaes-
thesia until the patient returned to consciousness or its
pre-operative condition. Colorado State University
reported higher risks of 1.08% in dogs and 1.79% in cats
between 1955 and 1957, based on a similar definition of
anaesthetic death (Lumb and Jones, 1973). The high risks
were attributed to students anaesthetising the majority of
the animals under veterinarian supervision, the complex
nature of procedures and the poor patient health status
of their referral population.
The Wheatridge Animal Hospital reported anaesthetic
death risks of 0.23% in dogs and 0.40% in cats between
1960 and 1969 (Lumb and Jones, 1973). Anaesthetic death
was defined as death interrupting recovery from anaesthe-
sia and resulting from either sole consequence of anaesthe-
sia, airway obstruction while anaesthetised, or resulting
from tissue damage due to inadequate oxygenation during
cardiac arrest and subsequent resuscitation. At a similar
time the University of Missouri Veterinary Hospital
reported mortality risks of 0.8% in dogs and 0.53% in cats,
although their case definition was not stated (Lumb and
Jones, 1973).
More recent referral centre studies have reported lower
risks of mortality, suggesting that standards have improved.
Further work at Colorado State University documented
risks of 0.43% in dogs and 0.26% in cats between 1979
and 1981 and 0.43% in dogs and 0.35% in cats between
1993 and 1994 (Lumb and Jones, 1984; Gaynor et al.,
1999). The articles suggested the improvements were related
to the use of safer drugs and techniques and better supervi-
sion of students undertaking anaesthesia. Louisiana State
University reported higher risks of peri-operative death of
1.49% of dogs and 5.80% of cats at their institution between
1995 and 1996, although this related to all deaths, not just
anaesthetic-related mortality (Hosgood and Scholl, 1998,
2002). Work at The Royal Veterinary College in the UK
reported an anaesthetic-related mortality risk of 0.58% in
dogs (Brodbelt et al., 2006). Based on the more recent work
described above, the risk of anaesthetic-related death in the
referral setting would appear to be of the order of 0.25–
0.60% in dogs and cats.
Studies undertaken in small animal practice have gener-
ally documented lower risks of mortality than referral-
based studies. An early practice-based study evaluated
153
feline mortality in Scotland and published a risk of death
of 0.31% (Dodman, 1977). This was followed by a further
survey of small animal anaesthetic practice, undertaken in
Vermont, USA, which reported the risk of death of 0.11%
and 0.06% in dogs and cats, respectively (Dodman and
Lamb, 1992). A similar study was undertaken in Finland
in 1993 which found a risk of death of 0.13% in small ani-
mals (Rintasalo and Vainio, 1995). The most recent retro-
spective work evaluated mortality in a South African
practice population in 1999 and 2005 and estimated a mor-
tality risk of 0.08–0.10% in dogs and cats (Joubert, 2000,
2006). The health status of the patients anaesthetised in
these studies was not recorded, although they were likely
to reflect relatively ‘healthy’ animals. Further these reports
all relied on practitioners’ recall of animal deaths over an
extended time period and, given the often unclear case def-
initions, the studies were likely only broadly to reflect the
level of risk in practice.
The first prospective multi-centre cohort study of small
animal practice complications was undertaken between
1984 and 1986 in the UK (Clarke and Hall, 1990). Fifty-
three practices were recruited, 41,881 anaesthetics were
recorded and anaesthetic risks of death of 0.23% in dogs
and 0.29% in cats were reported. For healthy patients,
showing no or only mild to moderate systemic disease
(American Society of Anesthesiologists [ASA] grades 1–
2), the death risks were 0.12% in dogs and 0.18% in cats,
whereas in ill patients (severe systemic disease limiting
activity through to life threatening disease with the patient
not expected to survive 24 h; ASA grades 3–5) >3% of dogs
and cats died perioperatively. Perioperative deaths in
healthy patients (ASA 1–2) occurring during or shortly
after surgery were considered ‘primarily due to anaesthesia’
unless an obvious surgical cause was present, whilst in sick
patients (ASA 3–5) all deaths independent of cause were
reported.
This report was followed by a further prospective multi-
centre cohort study of anaesthetic mortality in small ani-
mal veterinary practice in Ontario, Canada (Dyson et al.,
1998). During the 6 month study period, 8087 dogs and
8702 cats were anaesthetised and 0.11% of dogs and
0.10% of cats had cardiac arrests and died. For healthy ani-
mals (ASA 1–2), the risks were 0.067% in dogs and 0.048%
in cats, whereas for sick patients (ASA 3–5) 0.46% of dogs
and 0.92% of cats died of a cardiac arrest. Only periopera-
tive deaths within an unspecified follow-up period, result-
ing from cardiac arrest were included.
The most recent multi-centre small animal practice-
based study, the Confidential Enquiry into Perioperative
Small Animal Fatalities (CEPSAF), was undertaken in
the UK between 2002 and 2004, and 98,036 anaesthetics
and sedations were recorded in dogs and 79,178 in cats,
at 117 participating centres (Brodbelt et al., in press-a).
Anaesthetic and sedation-related death was defined as per-
ioperative death within 48 h of termination of the proce-
dure, except where death was due solely to inoperable
surgical or pre-existing medical conditions, i.e. anaesthesia
154 D. Brodbelt / The Veterinary Journal 182 (2009) 152–161

and sedation could not be reasonably excluded from con-
tributing to the death.
In the CEPSAF study, the risk of anaesthetic and seda-
tion-related death was approximately 0.17% in dogs and
0.24% in cats (Table 1). In healthy patients (ASA 1–2),
the risks were 0.05% and 0.11% in dogs and cats, respec-
tively, whilst in sick patients (ASA 3–5) >1% of dogs and
cats died (Table 2). Rabbits were the third most commonly
anaesthetised species in practice but the risks of anaes-
thetic-related death were substantially higher, with 0.73%
of healthy rabbits and 7.37% of sick rabbits dying. The
risks in other small animal species were also high, at
between 1% and 4% (Table 1). Few studies have evaluated
the perioperative risks in ‘exotic’ species in practice but the
results from CEPSAF demonstrate a high level of mortality
(Brodbelt et al., in press-a). It is likely that many practitio-
ners were relatively inexperienced in the anaesthetic man-
agement of these species.
There are limited data available on the anaesthetic man-
agement of rabbits in practice, but evidence from CEPSAF
indicated that placement of endotracheal tubes and the
provision of oxygen were less commonly performed in rab-
bits and that intraoperative monitoring was more superfi-
cial (Brodbelt, 2006). Additionally, rabbits and other
‘exotic’ species may exhibit stress on induction of anaesthe-
sia, often have a high surface-area to volume ratio (predis-
posing to perioperative hypothermia), and have a
predilection to preoperative diseases involving respiratory,
digestive and fluid balance disorders (Aeschbacher, 1995;
Flecknell, 1996). Many rabbits presenting for anaesthesia
have been reported to carry Pasteurella multocida respira-
tory infections (Flecknell, 1996). Moreover, exotic species
are generally small and have fewer easily accessible veins
for venous catheterisation and endotracheal intubation is
more technically demanding than in dogs and cats (Aes-
chbacher, 1995; Flecknell, 1996). Given a relative lack of
experience of anaesthetising these species, the presence of
more superficial patient management and the greater
potential for complications, a higher risk of anaesthetic
death could be anticipated.
Recent estimates of anaesthetic-related death risks in
small animal practice seem therefore to be of the order of
0.1–0.2%, with the risk in healthy dogs and cats being
approximately 0.05–0.10% and in sick dogs and cats 1–
2% (Clarke and Hall, 1990; Dodman and Lamb, 1992;
Dyson et al., 1998; Joubert, 2000, 2006; Brodbelt et al.,
in press-a). In more recent work (Clarke and Hall, 1990;
Brodbelt et al., in press-a), cats appeared to be at greater
risk of death than dogs, and rabbits and other companion
animal species at even higher risk. In referral institutions
mortality ranged from 0.30% to 0.60% in dogs and cats,
which probably reflected the poorer health of these patients
(Hosgood and Scholl, 1998, 2002; Gaynor et al., 1999;
Brodbelt et al., 2006, in press-a). The risks of death were

Table 1
Anaesthetic and sedation-related risk of death in small animals in CEPSAF (Brodbelt et al., in press-a)
Species Number of anaesthetic and Number anaesthetised and Risk of anaesthetic-related death
sedation-related deaths sedated (95% confidence interval)
Dog 163 98,036 0.17% (0.14–0.19%)
Cat 189 79,178 0.24% (0.20–0.27%)
Rabbit 114 8209 1.39% (1.14–1.64%)
Guinea pig 49 1288 3.80% (2.76–4.85%)
Hamsters 9 246 3.66% (1.69–6.83%)
Chinchilla 11 334 3.29% (1.38–5.21%)
Rat 8 398 2.01% (0.87–3.92%)

Table 2
Risk of anaesthetic and sedation-related death in healthy and sick dogs, cats and rabbits in CEPSAF (Brodbelt et al., in press-a)
Species Health statusa Number of deathsb Estimated number of Risk of anaesthetic-related
anaesthetics and sedations death (95% confidence interval)
Dog Healthy 49 90,618 0.05% (0.04–0.07%)
(ASA 1–2)
Sick 99 7418 1.33% (1.07–1.60%)
(ASA 3–5)
Cat Healthy 81 72,473 0.11% (0.09–0.14%)
(ASA 1–2)
Sick 94 6705 1.40% (1.12–1.68%)
(ASA 3–5)
Rabbit Healthy 56 7652 0.73% (0.54–0.93%)
(ASA 1–2)
Sick 41 557 7.37% (5.20–9.54%)
(ASA 3–5)
a
ASA 1–2: no/mild preoperative disease, ASA 3–5: severe preoperative disease.
b
Only deaths where detailed information was available were included here.
 D. Brodbelt / The Veterinary Journal 182 (2009) 152–161 155

lower than those seen with equine anaesthesia, where Table 3

approximately 1–2% of horses have been reported to die Timing of death in dogs, cats and rabbits in CEPSAF (Brodbelt et al., in
press-a)
from an anaesthetic-related death (Tevik, 1983; Clarke
and Gerring, 1990; Young and Taylor, 1993; Mee et al., Timing of death Dogs Cats Rabbits
1998a,b; Johnston et al., 2002; Bidwell et al., 2007). In After premedication 1 (1%) 2 (1%) 0
comparison to humans, where a comparable risk of anaes- Induction of anaesthesia 9 (6%) 14 (8%) 6 (6%)
Maintenance of anaesthesia 68 (46%) 53 (30%) 29 (30%)
thetic-related death was approximately 0.02-0.05% (Eagle Post-operative death a 70 (47%) 106 (61%) 62 (64%)
and Davis, 1997; Biboulet et al., 2001; Kawashima et al., 0–3 h post-operative 31 66 26
2001), the risk of death in all small animal species is high, 3–6 h post-operative 11 9 7
suggesting that there remains room for improvement. 6–12 h post-operative 12 7 13
12–24 h post-operative 13 12 9
24–48 h post-operative 3 10 3
Timing of death Unknown time 0 2 4
Totalb 148 (100%) 175 (100%) 97 (100%)
The timing of anaesthetic deaths is relevant when evalu-
a
ating mortality, since the identification of high risk periods Post-operative deaths were additionally categorised by time after
anaesthesia.
could allow better targeting of resources and veterinary b
Only deaths where detailed information was available were included
manpower. Early work in referral institutions identified here.
variable high risk periods, whilst practice-based studies
tended to highlight the intra-operative period as being of
greatest risk. Albrecht and Blakely (1951) reported only operative period, could have substantially reduced the risk
one death during induction and one during recovery, with of death.
the remainder of the deaths occurring during maintenance
of anaesthesia. In contrast, work at Colorado State Univer- Causes of death
sity in the 1950s reported that of 36 deaths, 17% of dogs
and cats died during induction and 22% during mainte- Investigation into the causes of anaesthetic deaths
nance, but the vast majority (61%) died during recovery allows a more complete evaluation of mortality and, when
(Lumb and Jones, 1973). Later work at Colorado (1979– risk factors are identified, the knowledge of the major
1981) reported mostly intraoperative deaths (Lumb and causes of death can aid the understanding of potential
Jones, 1984) and work there in the 1990s found only 25% underlying mechanisms related to these risk factors. Peri-
of dogs and cats died during recovery with the rest dying operative death may result from pre-existing disease,
during anaesthesia (Gaynor et al., 1999). Other referral anaesthetic, surgical and procedural causes, or a combina-
institutions reported differing high risk periods; Hosgood tion of all of these. The underlying physiological cause may
and Scholl documented 9/14 (61%) deaths in dogs and 4/ also be multi-factorial, involving the failure of a number of
7 (57%) in cats post-operatively (1998, 2002), although body systems, and when classifying a specific cause the pri-
the number of deaths recorded was small and included all mary precipitating aetiology has generally been reported.
causes of death. Cardiovascular and respiratory complications represent
In the primary practice setting, only the larger studies the major causes of peri-operative anaesthetic-related
quantified the timing of fatalities. Clarke and Hall (1990) deaths documented in the small animal literature, although
reported deaths occurring principally during anaesthesia. gastrointestinal, neurological and hepato-renal causes have
In dogs, 22% died during induction of anaesthesia, 55% also been reported.
during maintenance and 18% in recovery, whereas 30% of Cardiovascular causes form a major proportion of peri-
cats died during induction, 39% during anaesthesia and operative deaths and include cardiac pump failure and vas-
31% during recovery. Similarly in the study from Ontario cular collapse, resulting in failure of blood delivery to the
(Dyson et al., 1998), most dogs and cats died during anaes- vital tissues. Cardiac arrest has been reported to result
thesia (6/9 dogs and 7/8 cats) and only 33% and 13% of from cardiac arrhythmias associated with increased circu-
dogs and cats died post-operatively, respectively (3/9 dogs lating catecholamines, myocardial hypoxia, specific anaes-
and 1/8 cats). CEPSAF recently highlighted that the post- thetic agents, pre-existing pathology, specific procedures
operative period was the most common time for dogs, cats (e.g. vagal traction and eye enucleation) and with myocar-
and rabbits to die (Brodbelt et al., in press-a) with >60% of dial depression due to relative anaesthetic overdose (Hall
cats and rabbits, and nearly 50% of dogs dying during this and Taylor, 1994; Hall et al., 2001). Hypovolaemia and cir-
time period (Table 3). This trend would suggest that since culatory failure were the other major cause of cardiovascu-
the last practice-based studies, standards of maintenance lar collapse and they have been seen in patients with pre-
and monitoring during anaesthesia have improved, how- existing pathology that were insufficiently stabilised prior
ever greater care in the post-operative period is increasingly to anaesthesia (Lumb and Jones, 1973; Clarke and Hall,
required. Interestingly, most of these post-operative deaths 1990; Dyson et al., 1998; Brodbelt et al., in press-a).
occurred within 3 h of termination of the procedure, sug- Early work suggested that between 30% and 70% of
gesting increased vigilance, particularly in the early post- deaths resulted from relative anaesthetic overdose and
156 D. Brodbelt / The Veterinary Journal 182 (2009) 152–161
myocardial depression, cardiac arrhythmias or circulatory
failure and hypovolaemia (Lumb and Jones, 1984; Clarke
and Hall, 1990; Dyson et al., 1998; Hosgood and Scholl,
1998; Joubert, 2000). Dogs more frequently than cats dem-
onstrated cardiovascular complications in one study
(Clarke and Hall, 1990) and high risk patients in particular
were more likely to die from circulatory failure, as they
were often hypovolaemic prior to anaesthesia (Clarke
and Hall, 1990). In the CEPSAF enquiry, deaths were
reported to be due to cardiovascular causes in 23% of dogs
and 6% of cats and were either cardiovascular or respira-
tory in 37% and 57% of dogs and cats, respectively (Brod-
belt et al., in press-a). In this study, cardiovascular and
respiratory causes were combined when it was difficult to
assess whether cardiovascular signs proceeded respiratory
or vice versa. Cardiovascular causes in CEPSAF included
clinical descriptions of apparent cardiac arrest often on
induction or during anaesthesia, and cardiovascular col-
lapse, frequently involving the poorer health status patients
(Brodbelt et al., in press-a).
Respiratory complications represented the other main
cause of anaesthetic-related deaths. Problems with airway
maintenance and inadequacy of ventilation were the princi-
pal factors resulting in death. Failed endotracheal intuba-
tion, trauma to the upper airway, inadequate ventilation
and delivery of an hypoxic inspired gas mixture have all
been documented (Lumb and Jones, 1984; Clarke and Hall,
1990; Dodman and Lamb, 1992; Dyson et al., 1998; Hos-
good and Scholl, 1998, 2002; Brodbelt et al., in press-a).
Respiratory complications were an underlying cause of
death in 30–40% of dogs and about 40–50% of cats (Lumb
and Jones, 1984; Clarke and Hall, 1990; Dyson et al.,
1998). Endotracheal intubation problems and respiratory
obstruction represented a major cause of death in cats
(Clarke and Hall, 1990; Dyson et al., 1998). In dogs, com-
plications with endotracheal intubation and respiratory
failure were also reported, although in brachycephalic dogs
respiratory obstruction was the principal cause of respira-
tory complications (Clarke and Hall, 1990; Dodman and
Lamb, 1992; Dyson et al., 1998). In CEPSAF, respiratory
and respiratory or cardiovascular causes accounted for
50% of deaths in dogs and 66% in cats. Respiratory causes
were reported in animals where clinical signs of airway
obstruction, hypoventilation and failure of gas exchange
were described (Brodbelt et al., in press-a).
Causes other than respiratory and cardiovascular com-
plications have been infrequently reported in small ani-
mals, but have included post-operative renal failure, iliac
thrombosis, regurgitation and gastric contents inhalation,
anaphylactic reactions, failure to regain consciousness
and death from unknown causes (Clarke and Hall, 1990;
Dodman and Lamb, 1992; Dyson et al., 1998; Joubert,
2000; Brodbelt et al., in press-a). In CEPSAF, 5% of dogs
and cats died of a neurological cause, 1–3% from renal
causes, and approximately 20% were classified as of
unknown cause, often occurring when patients were not
being closely observed (Brodbelt et al., in press-a). Neuro-
logical causes included failure to regain consciousness
necessitating euthanasia and post-operative seizures result-
ing in death or euthanasia, whilst renal causes included
renal failure with death or euthanasia following. Interest-
ingly, 59% of rabbit deaths were recorded in CESPAF as
of unknown cause, with only 39% classified as of cardiopul-
monary causes (Brodbelt et al., in press-a). Again, many of
the ‘unknown’ cause rabbits died when they were being less
closely monitored, although more of this group of deaths
occurred intra-operatively (compared to ‘unknown’ cause
deaths reported in dogs and cats) when only respiration
was being observed. This suggested that standards of mon-
itoring for many of these rabbits were suboptimal.
In summary, the range of causes of death appears to be
similar across studies and species, and focuses on cardio-
vascular and respiratory causes (Clarke and Hall, 1990;
Dodman and Lamb, 1992; Dyson et al., 1998; Hosgood
and Scholl, 1998, 2002; Brodbelt et al., in press-a). Others
causes have also been identified although less frequently.
An understanding of cause of death should aid awareness
of the underlying mechanisms of peri-operative deaths.
Major risk factors for death
Identification of major risk factors for anaesthetic-
related death could aid in the reduction of mortality. Early
institution studies suggested contributory factors without
providing any in-depth analysis of the risk factors (Albr-
echt and Blakely, 1951; Lumb and Jones, 1973). The use
of specific drugs was associated with higher mortality in
dogs and cats, and trauma patients, neutering procedures,
certain breeds including brachycephalic, terrier and Spaniel
breeds of dog, were frequently represented amongst the
fatalities (Albrecht and Blakely, 1951; Lumb and Jones,
1973, 1984). Old age and poor health status were associated
with increased odds of mortality in dogs and poor health
status only in cats in a subsequent referral-based study
(Hosgood and Scholl, 1998, 2002). Work at the Royal Vet-
erinary College also reported poor health status increasing
odds, and premedication with acepromazine was associated
with reduced odds of death in dogs (Brodbelt et al., 2006).
Although identifying important risk factors, all of these
studies were single centre referral studies with small sample
sizes and had limited ability to detect more than a small
number of major risk factors.
Early practice-based work was also limited in its ability
to evaluate risk factors. The study of feline anaesthesia
undertaken by Dodman (1977) identified a trend to
reduced risk with thiopentone/halothane anaesthesia rela-
tive to other drugs. The retrospective study undertaken in
Vermont by Dodman and Lamb (1992) identified high risk
with xylazine administration and brachycephalic breeds,
although in both of these studies quantification of risk fac-
tors was limited. Clarke and Hall (1990) identified a num-
ber of risk factors for anaesthetic death in healthy dogs and
cats. Higher risks were seen in healthy dogs and cats fol-
lowing administration of the a2 agonist, xylazine, and there
 D. Brodbelt / The Veterinary Journal 182 (2009) 152–161 157

was reduced risk with premedication with atropine or ace-
promazine. In cats, endotracheal intubation, induction of
anaesthesia with a volatile agent, thiopentone, methohexi-
tone, ketamine, halothane, ether and nitrous oxide use
were also associated with higher risks of death and admin-
istration of alphadolone/alphaxalone (Saffan) with reduced
risk. In dogs, Pekingese were the most commonly reported
breed to die, and halothane and thiopentone use were also
associated with lower death risks. The Ontario study iden-
tified similar risk factors with xylazine administration and
sick patients (ASA 3–5) being at increased odds of cardiac
arrest in dogs, whilst in cats, sick patients (ASA 3–5) were
at greater risk and the presence of a technician monitoring
anaesthesia reduced risk (Dyson et al., 1998).
Recently, risk factors in dogs and cats were evaluated in
multivariable logistic regression models in CEPSAF (Brod-
belt et al., 2007, in press-b). Major risk factors were evalu-
ated adjusting for other variables and confounders, and
odds ratios for increased (odds ratio >1.0) or decreased
odds (odds ratio <1.0) of anaesthetic-related death were
reported (Dohoo et al., 2003).
In cats, 175 anaesthetic and sedation-related deaths were
compared to 555 randomly selected non-deaths (Brodbelt
et al., 2007). Increasing ASA grade, procedural urgency,
major versus minor intended procedures, increasing age,
extremes of weight, endotracheal intubation and the use
of fluid therapy were associated with increased odds of
anaesthetic and sedation-related death (Brodbelt et al.,
2007) (Table 4). Pulse and pulse oximetry monitoring were
associated with a reduction in odds. In dogs, 148 anaes-
thetic and sedation-related deaths were compared to 487
randomly selected non-deaths and, similarly, increasingly
poor health status (ASA grade), increasing procedural
urgency, major versus minor intended procedures, old age
and low weight were associated with anaesthetic-related
death. Additionally, increasing intended duration of the
procedure and the anaesthetic induction and maintenance
combination used were associated with increased odds of
anaesthetic-related death. Maintenance with halothane
after induction of anaesthesia with an injectable anaesthetic
agent and dogs undergoing total inhalational anaesthesia
were both associated with an approximate sixfold increase
in odds compared to isoflurane maintenance after induction
of anaesthesia with an injectable anaesthetic agent.
The association between patient health status (ASA
grade) and anaesthetic-related death was repeatedly docu-
mented in many of the studies described (Clarke and Hall,
1990; Dyson et al., 1998; Hosgood and Scholl, 1998; Brod-
belt et al.,2006, 2007, in press-a) and is consistent with work
published in the equine and medical literature (Tiret et al.,
1986; Buck et al., 1988; Pedersen, 1994; Tikkanen and
Hovi-Viander, 1995; Wolters et al., 1996; Biboulet et al.,
2001; Morita et al., 2001; Donati et al., 2004; Johnston et
al., 2004). Pre-existing pathology may reduce the therapeu-
tic index of administered anaesthetics, predispose to car-
diopulmonary depression and depress other physiological
function significantly. Moreover, in CEPSAF, procedural
urgency was associated with increased odds of death (Brod-
belt et al.,2007, in press-b) and this is in an agreement with
work in human and equine anaesthesia (Tiret et al., 1986;
Buck et al., 1988; Pedersen et al., 1990; Biboulet et al.,
2001; Johnston et al., 2002; Newland et al., 2002; Donati

Table 4
Multivariable model of risk factors for anaesthetic and sedation-related death in cats in CEPSAF (Brodbelt et al., 2007)
Risk factor Categories Odds Ratio 95% Confidence Interval P value
Health status (ASA grade a) ASA 4–5 vs ASA 3 vs ASA 1–2 (trend b) 3.2 2.0–5.0 <0.001
Urgency of procedure Emergency vs. urgent vs. scheduled (trend b) 1.6 1.0–2.5 0.05
Intended procedure Minor procedure 1
Major procedure 2.7 1.4–5.4 0.005
Age 0–0.5 years 0.4 0.1–2.4
0.5–5 years 1
5–12 years 1.7 0.9–3.0
12 years –max 2.1 1.1–3.9 0.058
Weight 0–2 kg 15.7 2.9–83.6
2–6 kg 1
6 – max 2.8 1.1–7.4
Unknown 1.1 0.2–5.5 0.002
Endotracheal (ET) intubation No ET tube 1
ET tube 1.9 1.0–3.7 0.042
Pulse and pulse oximeter used None 1
Pulse assessed only 0.3 0.2–0.6
Pulse oximeter used only 0.2 0.1–0.5
Pulse and pulse oximeter 0.2 0.1–0.4 <0.001
Perioperative intravenous fluids No fluids given 1
IV catheter used only 0.7 0.2–2.5
IV fluids given 3.9 2.2–7.1 <0.001
Odds ratios >1.0 indicate increased odds, whilst odds ratios <1.0 reduced odds of anaesthetic-related death.
a
ASA 1–2, healthy/moderate disease only; ASA 3, severe disease, limiting activity; ASA 4–5, life threatening disease.
b
Trend represents the odds ratio for a one-category increase in the risk factor.
158 D. Brodbelt / The Veterinary Journal 182 (2009) 152–161
et al., 2004). This is likely to reflect the ability to assess and
stabilise patients preoperatively, and due to the tendency
for urgent procedures to be presented outside of normal
working hours, to reflect staffing levels and personnel fati-
gue. Hence, greater attention to preoperative assessment of
patient health status and procedural urgency and improved
stabilisation prior to the procedure could have substan-
tially reduced deaths.
Increased risk with increasing age, independent of
patient physical status (ASA grade), was also identified
as an important risk factor. Only the more recent work
in small animals reported this (Hosgood and Scholl,
1998; Brodbelt et al., 2007, in press-b), but work in equine
(Johnston et al., 2002, 2004) and human anaesthesia sup-
port the association (Pedersen, 1994; Tikkanen and Hovi-
Viander, 1995; Biboulet et al., 2001; Morita et al., 2001;
Donati et al., 2004). Old patients may be more susceptible
to the depressant effects of anaesthetics, to hypothermia
(via impaired thermoregulatory mechanisms) and to pro-
longed recovery due to tendencies to reduced metabolic
function and hypothermia (Waterman, 1981; Dhupa,
1995; Meyer, 1999). Particular care should be taken when
anaesthetising older patients.
Increased odds of death reported for small dogs and cats
in CEPSAF (Brodbelt et al., 2007, in press-b) were consis-
tent with work in paediatric anaesthesia (Campling et al.,
1990). Smaller patients could be more prone to drug over-
dose, to hypothermia and to peri-operative management
difficulties (e.g. intravenous catheter placement, endotra-
cheal intubation). Increased risk with increasing weight
seen in cats was likely to reflect, at least in part, risks asso-
ciated with obesity (Brodbelt et al., 2007). Interestingly,
although there was a tendency to a breed association in
dogs in CEPSAF, after adjusting for weight this associa-
tion dropped out. This suggested that a major aspect of
the risk associated with breed could be related to high risk
breeds generally being small (Brodbelt et al., in press-b).
Nonetheless, other work has reported increased complica-
tions with brachycephalics and terrier breeds (Lumb and
Jones, 1973; Clarke and Hall, 1990; Dyson et al., 1998),
and caution with the anaesthesia of these breeds may be
advisable.
Increasing risk for patients presenting for major com-
pared to minor procedures as documented in CEPSAF
(Brodbelt et al., 2007) was consistent with work in equine
(Johnston et al., 2002, 2004) and human anaesthesia (Tiret
et al., 1986; Newland et al., 2002; Donati et al., 2004).
More complex and invasive procedures were likely to
impose greater stress on patient physiology and when
assessing patient risk prior to anaesthesia, assessment of
the intended procedure’s complexity should be considered.
Increasing duration, in addition to the type of procedure,
was associated with increased risk in dogs in one study
(Brodbelt et al., in press-b). In human anaesthesia,
increased duration has been reported as a risk factor (Fow-
kes et al., 1982; Pottecher et al., 1984; Tiret et al., 1986) and
in equine anaesthesia, Johnston et al. (2002) documented
increased risk with longer duration procedures. Prolonged
procedures could expose the patient to potentially longer
periods of physiological compromise, increased hypother-
mia and fluid loss, and could be expected to predispose
to greater risk (Hall et al., 2001).
The previously unreported association of increased risk
of death associated with fluid therapy administration in
cats in CEPSAF was surprising (Brodbelt et al., 2007).
Although this may have reflected, at least in part, residual
confounding, a component of the increased odds may have
been related to excessive administration of fluids and fluid
overload. A 3 kg cat has a blood volume of the order of
170 mL (Hall and Taylor, 1994) and with few veterinary
practices measuring central venous pressure or using fluid
pumps to administer intravenous fluids, the potential for
volume overload is clearly possible. Careful fluid adminis-
tration and monitoring is recommended in cats, although
further work is needed to confirm this observation.
The reduction in odds of anaesthetic-related death with
pulse and pulse oximetry monitoring in cats in CEPSAF
has not been reported previously in small animals (Brod-
belt et al., 2007). Theoretical analyses in human anaesthe-
sia support these findings and have suggested pulse
oximetry would have detected 40–82% of reported peri-
operative incidents, and when combined with capnography
88–93% (Eichhorn et al., 1986; Tinker et al., 1989; Webb
et al., 1993). These associations suggest that some form
of assessment of cardiovascular function (pulse quality
and rate) and respiratory function (oxygen saturation)
may be important in minimizing mortality. Pulse oximetry
was not routinely available in veterinary practice at the
time of the last UK study (Clarke and Hall, 1990), and
one could speculate that this monitoring device, now
widely adopted, has contributed to the reduced risk of
anaesthetic death reported in the UK. Pulse oximetry
should be recommended for routine use in practice.
The role of specific anaesthetic drugs in anaesthetic
death has been evaluated in a number of small animal stud-
ies. The premedication administered was a risk factor in a
number of studies in dogs, cats and also in horses (Clarke
and Hall, 1990; Dyson et al., 1998; Johnston et al., 2002;
Brodbelt et al., 2006). Early work identified acepromazine
as being associated with reduced odds of death (Clarke
and Hall, 1990; Brodbelt et al., 2006) and major morbid
complications (Dyson et al., 1998), compared to no pre-
medication whilst the a2 agonist, xylazine, was associated
with increased odds of death (Clarke and Hall, 1990;
Dyson et al., 1998). In CEPSAF, although there were
trends to reduced odds with the administration of acepro-
mazine, after adjustment for major confounders this was
not a major factor in dogs or cats. Further, when evaluat-
ing premedication with the newer a2 agonist medetomidine,
no increase odds of death was detected and in fact a ten-
dency to reduced odds was seen (Brodbelt et al., 2007, in
press-b). Xylazine has been found to reduce the threshold
to catecholamine-induced arrhythmias under halothane
anesthesia (Muir et al., 1975; Tranquilli et al., 1986), whilst
 D. Brodbelt / The Veterinary Journal 182 (2009) 152–161
medetomidine did not (Pettifer et al., 1996). This difference,
combined with a greater awareness of the physiological
effects and a better understanding of the optimal method
of administration of a2 agonists, may be the basis of a lack
of increased risk with medetomidine compared to acepro-
mazine observed in CEPSAF.
The specific induction agent used did not appear impor-
tant in CEPSAF, in contrast to the tendency to increased
risk with the use of thiopentone and ketamine in cats, lower
risk with alphadolone/alphaxalone (Saffan) in cats and thi-
opentone in dogs in the last UK study (Clarke and Hall,
1990; Brodbelt et al., 2007, in press-b). The lack of a con-
sistent difference in risks with different induction agents is
likely to reflect that any effect of an induction agent was
small. The maintenance agent used, however, was relevant
to dogs in CEPSAF, and isoflurane appeared to be associ-
ated with reduced odds compared to halothane following
induction of anaesthesia with an injectable anaesthetic
agent. This is supported by clinical studies indicating that
though isoflurane induces greater respiratory depression
and vasodilation than halothane, it causes less direct myo-
cardial depression, and sensitises the heart less to catechol-
amine-induced arrhythmias; on balance it would appear to
cause less overall cardiovascular depression (Joas and Ste-
vens, 1971; Steffey et al., 1975; Steffey and Howland, 1977;
Hellebrekers, 1986; Tranquilli et al., 1988; Grandy et al.,
1989; Lemke et al., 1993; Hikasa et al.,1996, 1997; Hodgson
et al., 1998).
Thus, only the later studies have critically evaluated risk
factors for death (Clarke and Hall, 1990; Dyson et al.,
1998; Hosgood and Scholl, 1998, 2002; Brodbelt, 2006;
Brodbelt et al.,2006, 2007, in press-b). Commonly reported
risk factors for death include poor health status, old age,
and poor monitoring, endotracheal intubation in cats and
possible breed associations in dogs (Clarke and Hall,
1990; Dyson et al., 1998; Hosgood and Scholl, 1998,
2002; Brodbelt et al., 2006; Brodbelt et al., 2007, in press-
b). Additionally, CEPSAF identified a number of previ-
ously unreported risk factors including the use of pulse
oximetry and pulse monitoring reducing odds and fluid
therapy increasing odds of death in cats and isoflurane
maintenance being associated with reduced odds compared
to halothane after an induction of anaesthesia with an
injectable anaesthetic agent in dogs (Brodbelt et al., 2007,
in press-b). Knowledge of these risk factors can aid veteri-
narians in identifying preoperatively those patients at
greatest risk of mortality and to manage perioperative
patients appropriately to reduce mortality.
Conclusions
Anaesthetic mortality is increasingly rare in small ani-
mal practice, however in comparison to human anaesthesia
there remains room for improvement. Closer attention to
patients, particularly in the early post-operative period,
greater preoperative evaluation and preparation of patients
and modification of anaesthetic practices could aid a reduc-
159
tion in mortality. Further work is merited to continue to
assess the risk of anaesthetic death and to further evaluate
risk factors identified in reported studies.
Conflict of interest statement
The authors declare that there are no conflicts of
interest.
Acknowledgements
The author would like to acknowledge comments on the
manuscript from Dr K.W. Clarke, the hard work of all the
practices that took part in CEPSAF, and CEPSAF co-
investigators Drs J.L.N. Wood and L.E. Young, and Pro-
fessor D.U. Pfeiffer. CEPSAF was endorsed by the AVA,
BSAVA and BVHA and funded by Pfizer Animal Health.
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