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Sounding Board: Feline Mouth Gags

Clinician's Brief

May 2018

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Sounding Board: Feline Mouth Gags

DEAR EDITOR:

I was very pleased to see the article “Feline Complications from Mouth Gags” in the May 2018 issue of Clinician’s Brief. Despite the excellent investigative work and the studies performed to confirm that the use of mouth gags in cats can have serious consequences due to impaired or loss of blood flow to the brain, many clinicians remain unaware of this and continue to use mouth gags.

In reading the case presented in this article, which involves a cat that undergoing dental cleaning and maxillary premolar extraction, I have the following questions and concerns:

  • The cat received butorphanol and tiletamine–zolazepam for sedation/premedication. There is no further reference to analgesic drugs. Due to the short duration of action and the ceiling effect of butorphanol, this is likely inadequate analgesia for the procedure. Was pain assessed postoperatively? There is no mention of performing a dental block with local anesthetic agents, further opioid administration, nor NSAID administration. Was there a reason for this, or was it simply not included in the article?
  • It is stated that sedation was induced with propofol, but I believe anesthesia is intended here. In addition, the patient received 6 mg/kg IV “to effect.” It would be helpful to know how much was given, as the premedication should have greatly reduced the need for propofol.
  • The patient received IV fluids at 10 mL/kg/hr. However, the AAFP and AAHA fluid therapy guidelines recommend starting at 3 mL/kg/hr in cats that are normovolemic, and this cat likely would have been considered bright and alert. The fluid rate for dogs and cats is discussed in detail, and 10 mL/kg/hr is considered excessive, leading to problems such as fluid overload and hemodilution. The blood volume of the cat is significantly lower (on a mL/kg basis) than in a dog. This, along with the high incidence of hypertrophic cardiomyopathy in cats, has led to the AAFP/AAHA recommendations.

Again, I applaud the authors for raising awareness regarding the use of mouth gags in cats and look forward to their response regarding these concerns.

Sincerely,

Sheilah Robertson, PhD, BVMS(Hons), DACVAA, DECVAA, DACAW, DECAWBM (WSEL), MRCVS


THE AUTHORS RESPOND:

Thank you so much for the thoughtful questions and comments.

We agree that adequate analgesia is part of the standard of care. In the article, we simply did not include a complete analgesic plan following the premedications. Dental blocks with local anesthetic, followed by an NSAID and an additional opioid (eg, buprenorphine, morphine, hydromorphone), would be appropriate. Pain should be assessed continually in the postoperative period and therapy adjusted as needed.

It is important for readers to be aware of the AAFP and AAHA fluid therapy guidelines for normovolemic cats. Because the cat in this article was apparently normovolemic, the lower fluid rate of 3 mL/kg/h would be appropriate.

Again, thank you for sharing your concerns.

Most sincerely,

Shelly Olin, DVM, DACVIM

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