1. Handling and Restraint
   Cats respond most favorably to quiet and gentle but firm handling over brief periods of time.
   1. Gradual acclimation to handling and restraint techniques over 1-2 weeks can facilitate positive human-feline interactions and alleviate excess anxiety when cats are handled for research or veterinary purposes.
   2. To avoid excess anxiety in the pre- and post- anesthetic periods, the environment should be devoid of extraneous noise, including loud talking and laughing.
   3. The amount and duration of manual restraint should be kept to the minimum required to accomplish the necessary procedure.
   4. To minimize the time required for restraint, equipment and reagents should be ready for use prior to handling the animal.
   5. Pre-anesthetic doses of sedatives or tranquilizing agents are often used to facilitate immobilization or anesthetic induction, and to reduce anxiety.
2. Fasting
   1. Withhold food for at least 8 hours but no longer than 24 hours prior to sedation or anesthesia in order to reduce the risk of regurgitation and aspiration.
      1. Fasting periods for greater than 24 hours related to specialized procedures (ie. gastrointestinal procedures) should be described in the protocol.
   2. Do not withhold water prior to anesthesia or sedation.
   3. For neonatal or unhealthy animals, special care is required. Consult a ULAM faculty veterinarian prior to fasting these animals.
3. Apply sterile non-medicated ophthalmic ointment to the eyes to prevent corneal drying during anesthesia or sedation.

1. More information on anesthetic/sedation monitoring requirements can found in Anesthesia and Sedation Monitoring Guidelines.
2. The goal of monitoring should be to maintain normal cardiac function, respiratory function, and body temperature. Understanding the basic physiologic effects of the anesthetics used is paramount to correctly interpreting monitoring parameters. More information on anesthetic and sedative effects on physiologic parameters can be found in Anesthesia and Analgesia Drug Descriptions. 
3. Table 1: Physiologic Data of Cats

   	Temperature	Heart Rate       (Beats per minute)	Respiratory Rate       (Breaths per minute)	Blood Pressure (mmHg)
   Without sedation       or anesthesia	100.5 - 102.5 F       (38.1 - 39.2 C)	120 - 140 at rest	16 - 40 at rest	90 - 160 Systolic       50 - 90 Diastolic       90 - 100 Mean Arterial Pressure (MAP)
   With sedation       or anesthesia	T > 98 F       (>37 C)	>100	10 - 20	70 - 90 Mean Arterial Pressure (MAP)

1. Hypothermia
   1. An external heat source should be provided during the entire anesthetic and recovery period to prevent hypothermia. For examples of approved external heat supplementation products, refer to Anesthesia and Sedation Monitoring Guidelines.
2. Endotracheal Intubation
   1. Placement of an endotracheal tube is recommended for most general anesthesia protocols. Endotracheal tubes with an inflatable cuff are preferred. Tubes with an outer diameter of 3.0mm to 3.5mm are typically adequate for most adult cats.
      1. A supraglottic airway device (e.g. v-gel®) is a suitable alternative for intubation in cats. For more information and training regarding this method of intubation, please contact the ULAM Training Core.
   2. Intubation may be difficult in cats due to the frequent occurrence of laryngospasms. Repeated, unsuccessful attempts at endotracheal intubation may result in trauma and swelling of the airway.
   3. To facilitate intubation, 2% lidocaine (0.1ml) can be topically applied to the laryngeal folds using a syringe or swab soaked with lidocaine at least one minute prior to intubation (NOTE: Local anesthetic sprays containing benzocaine have been reported to induce methemoglobinemia in cats and should be avoided).
   4. Once intubated, the ET cuff should be inflated to a light seal, just until no leakage is heard when the animal is given a breath. Over-inflation of the cuff should be avoided to prevent trauma and secondary complications to the trachea.
   5. Contact the ULAM Training Core ([email protected] or 734-763-8039) to set up a time to learn how to correctly and safely perform endotracheal intubation in the cat.
3. Vascular Access and Fluid Support
   1. The placement of indwelling catheter(s) is advised. The cephalic vein of the forelimb or the medial saphenous vein of the hind limb are common sites for IV catheter placement.
   2. Intravenous fluids (e.g. Normosol or Lactated Ringers) should be supplied at a rate of 5-10 ml/kg/hr for an adult cat undergoing a procedure of 30 minutes or more. More information on appropriate fluid rates can be found in Guidelines on the Performance of Surgery in Non-Rodent Mammals.

1. More information on required monitoring parameters during post-operative recovery can be found in Guidelines on the Performance of Surgery in Non-Rodent Mammals and Anesthesia and Sedation Monitoring Guidelines.
2. Recover animals in clean kennels or transport cages. Animals must be fully recovered prior to return to their housing location.
3. Food and water should be withheld until the animal is fully recovered and ambulating normally.
   1. Kittens less than 10 weeks old or weighing less than 2 kg should be fed small amounts within two hours of anesthesia to prevent hypoglycemia.
4. Supplemental heat should be provided and rectal temperature, heart rate, respiratory rate, and mucous membrane color should be monitored every 15 minutes until cats are fully awake.
5. The endotracheal tube may be removed when active swallowing efforts are noted.
   1. Never leave a cat unattended with an endotracheal tube in place and ensure that the cuff is completely deflated prior to movement or extubation.

1. Detailed information on all approved anesthetics and sedatives can be found in Anesthesia and Analgesia Drug Descriptions.
2. In consultation with a ULAM veterinarian, oral gabapentin can be given 12 hours before any procedure to lightly sedate fractious cats.
3. All sedatives should be administered prior to the intended procedure based on the time to effect, which is generally 15-20 minutes for IM administration. Duration of action for sedative-analgesic combinations for use in minor procedures is generally 15-60 minutes depending upon combination used.
4. Contact ULAM Veterinary Staff ([email protected] or 734-936-1696) with questions regarding specific applications (i.e. kittens <10 weeks of age), drugs or medications. 
5. Table 2: Sedation Dosage Information

   Drug	Dosage and Route a	Notesa
   Dexmedetomidine	Up to 40 up/kg       IM	Light to moderate sedation with mild to moderate analgesia; dose should be titrated to the response of the patient.    Appropriate for minor procedures such as restraint, radiographs, bandage changes, etc.    Preferred over xylazine as xylazine often causes vomiting in cats. Reverse with atipamazole at the same volume as dexmedetomidine (SC, IM, IV).
   Acepromazine       + Butorphanol	0.1 mg/kg       + 0.2 - 0.4 mg/kg       IM, IV	Moderate sedation combination, with moderate analgesia.    Useful for painful or fractious animals.    Use lower dose range for IV.
   Dexmedetomidine       + Butorphanol	Up to 20 ug/kg       + 0.2 - 0.4 mg/kg       IM, IV	Moderate sedation combination, with moderate analgesia.    Useful for painful or fractious animals.    Reverse dexmedetomidine portion with atipamezole IM at the same volume as dexmedetomidine.    Use lower dose range for IV.
   Ketamine       + Dexmedetomidine       + Butorphanol	2.2 - 6.6 mg/kg       + 0.011 - 0.033 mg/kg       + 0.22 - 0.66 mg/kg       IM	Deep sedation with moderate analgesia at high end of dose range.    Appropriate for minor surgical procedures such as wound management, castration, laceration repair.    Also useful for injectable anesthetics (see Procedures section 6.b). Reverse dexmedetomidine portion with atipamezole IM at the same volume as dexmedetomidine.

   ^a Intramuscular (IM), Intravenous (IV), Subcutaneous (SC)

1. Anticholinergics
   1. May be administered prior to or in conjunction with alpha-2 agonists (e.g., dexmedetomidine) or opioids to counteract bradycardia and hyper salivation. Contact the ULAM Veterinary Staff ([email protected] or 734-936-1696) for recommendations regarding appropriate use of these drugs. 
   2. Table 3: Anticholinergics Dosage Information

      Drug	Dosage and Route a	Notes a
      Atropine	0.02 - 0.04 mg/kg       IM, IV, SC	Onset 10 - 15 minutes after IM injection.    Duration: 45 - 60 minutes    Use lower IV doses to avoid tachycardia.
      Glycopyrrolate	0.005 - 0.01 mg/kg       IM, IV, SC	Duration of action up to 4 hours.    Does not cross blood brain barrier.    Less tachycardia compared to atropine.    Not for emergency use.

      ^a Intramuscular (IM), Intravenous (IV), Subcutaneous (SC)

2. Injectable Anesthetic
   1. Supplemental oxygen should be provided for all injectable anesthetic protocols. Consider intubation for any animals undergoing anesthesia to allow for airway control and administration of oxygen or inhalant anesthetic.
   2. If, for minor procedures, isoflurane is not utilized, in combinations involving ketamine, anesthesia can be prolonged by supplementing with ketamine only, of which ¼ of the original dose is typically adequate. 
   3. Table 4: Injectable Anesthetic Dosage Information

      Drug	Dosage and Route a	Notes a
      Propofol	3 - 6 mg/kg.       IV	For anesthetic induction only.    Utilize slow bolus dosing (over 60 seconds) to effect.    Repeat administration past 3 consecutive days not recommended; associated with Heinz body anemia.    Caution: Apnea possible with rapid injection, intubate and assist in breathing if this occurs.
      Ketamine       + Midazolam	5 - 10 mg/kg       + 0.2 - 0.4 mg/kg       IM, IV	Induction protocol.    Use lower dose range for IV.
      Ketamine       + Dexmedetomidine       + Butorphanol	2.2 - 6.6 mg/kg       + 0.011 - 0.033 mg/kg       + 0.22 - 0.66 mg/kg       IM, IV	"Kitty Magic" induction protocol.    Can reverse dexmedetomidine upon recovery with ½ volume atipamezole IM.    Use lower dose range for IV.
      Ketamine       + Dexmedetomidine       + Hydromorphone	5 mg/kg       + 0.01 mg/kg       + 0.1 mg/kg       IM	Provides injectable anesthesia for procedures lasting 45 - 60 minutes.    Can also be used as induction protocol.    Can reverse upon recovery with ½ volume atipamezole IM.

      ^a Intramuscular (IM), Intravenous (IV)

3. Inhalation Anesthetics 
   1. Table 5: Inhalation Anesthetic Dosage Information

      Drug	Dosage	Notes
      Isoflurane	To effect.  Typically:       3 - 5% induction       0.1 - 3% maintenance	Dose dependent cardiac and respiratory depression.    Calibrated vaporizer and passive or active scavenging use required. Sedation should be used in conjunction with mask or chamber induction to avoid injury and minimize breath holding.
      Sevoflurane	To effect. Typically:       7 - 9% for induction       0.1 - 6% for maintenance	Preferred for mask or chamber inductions.    Dose dependent cardiac and respiratory depression.    Calibrated vaporizer and passive or active scavenging use required.

1. Extreme care must be taken to ensure that a proper level of anesthesia and analgesia is achieved prior to administering a neuromuscular blocking agent.
2. Neuromuscular blocking agents require special monitoring procedures which are detailed in Anesthesia and Analgesia Drug Descriptions.
3. Concurrent positive pressure ventilation is required. Reversal of NMBAs with neostigmine and glycopyrrolate is possible under specific conditions. Consult the ULAM veterinarians for instructions on NMBA reversal. 
4. Table 6: Neuromuscular Blocking Agent Dosage Information

   Drug	Dosage and Route a	Duration	Notes
   Atracurium	0.2 mg/kg IV       Re-dose w/ 0.1 mg/kg IV	20 - 35 minutes	Give a tenth of this dose initially (priming dose), followed 4 - 6 minutes later with the remaining does.
   Pancuronium	0.044 - 0.11 mg/kg IV	30 - 45 minutes	0.044 mg/kg if repeat bolus needed.    May increase heart rate.

   ^a Intravenous (IV)

1. Recommended for all procedures.  May be used with minimally invasive procedures such as skin biopsy, or as a supplement to sedation, anesthesia, and analgesia
2. Table 7: Local Anesthetic Dosage Information 

   Drug	Dosage and Route a	Onset and Duration	Notes a
   Lidocaine       1 - 2%	2 mg/kg       SC infiltration or local nerve block	Onset: 5 - 10 minutes       Duration: 1 - 2 hours	Mix 0.9ml lidocaine, 0.1 ml of sodium bicarbonate and 2.0 ml sterile water to reduce sting of injection in awake patients.
   Bupivacaine       0.25 - 0.5%	0.5 - 1 mg/kg       SC infiltration or local nerve block	Onset: 20 - 30 minutes       Duration: 4 - 8 hours	Cardio-toxic: aspirate prior to injection, do not give IV.    Can be diluted with saline to increase volume.    A sustained-release formulation of bupiviacaine (Nocita) is available and its use can be discussed with a ULAM veterinarian

   NOTE: Addition of 1:200,000 epinephrine delays absorption and prolongs local anesthesia
   ^a Intramuscular (IM), Intravenous (IV), Subcutaneous (SC)

1. Signs of Pain in Cats
   May include, but are not limited to, the following:
   1. Quiet, lethargic, reluctant to move
   2. Purring
   3. Salivation
   4. Decreased appetite
   5. Rough hair coat
   6. Hunched posture
   7. Abnormal vocalization
   8. Abnormal gait
   9. Guarding, licking, chewing or scratching a painful area
   10. Social isolation
   11. Abnormal aggression
   12. Increased resting respiratory rate or effort (e.g. >40 bpm)
   13. Increased resting heart rate (e.g. >220 bpm)
2. For an example of a visual scoring system from Colorado State University see Appendix A.
3. Prevention and Management of Pain
   Prevention of pain by administering analgesics prior to anesthetic recovery is more effective than treatment after signs have developed. Several analgesics are available.
   1. Very low doses of dexmedetomidine (IV) or acepromazine (IV) titrated to effect, or in combination with an opioid, are very useful for treating post-operative agitation or dysphoria. However, dexmedetomidine and acepromazine do not have any analgesic properties when used alone, so additional agents are necessary for painful procedures.  Contact the ULAM veterinarians for these recommendations.
   2. Non-Steroidal Anti-Inflammatory Drugs (NSAIDs) - Acetaminophen is toxic to cats and its use is contraindicated. In addition, aspirin has delayed metabolism and should be avoided in cats. Robenacoxib is a newly approved NSAID that can be safely administered for 3 consecutive days.
   3. Please contact the ULAM veterinarians for additional analgesia therapy options such as local anesthesia blocks, epidurals, or intra-articular injections.
4. Preemptive Analgesia
   1. Opioids, such as buprenorphine, can reduce the dose of anesthetics required for surgical anesthesia and increase the respiratory depression associated with anesthetics.
   2. When preemptive analgesia is used, consider reducing the dose of anesthetic (whether inhalant or injectable) to the low end of the recommended range.
   3. Anesthetic depth must be carefully monitored and drug doses may need to be titrated to maintain appropriate levels.
   4. With new projects, sexes, or anesthetic analgesic combinations, assess a subset of animals before expanding to use in a larger cohort.
   5. Opioid side effects
      1. Cats administered opioids may show an increase in compulsive or stereotypic behaviors such as purring, grooming, or kneading their paws. Higher doses do not correlate with greater sedation and may produce CNS excitation or agitation.
      2. CNS excitation can be mitigated by using lower doses in combination with a sedative such as acepromazine, diazepam, or midazolam. The use of opioids (particularly hydromorphone) has been associated with transient hyperthermia in cats.
      3. Rectal temperatures should be monitored until cats are fully recovered for identification and appropriate treatment of hyperthermia (see Procedures section 11.c). 
5. Table 8: NSAID and Opioid Dosage Information

   Drug	Dosage and Routea	Duration of Effect	Notesa
   NSAIDs
   Carprofen	1 - 4 mg/kg SC x 1 dose	24 hours	One-time administration; caution advised
   Ketoprofen	2 mg/kg SC	24 hours	Limit dosing to a maximum of 5 consecutive days; caution advised
   Meloxicam	0.3 mg/kg SC x 1 dose	24 hours	One-time injection; caution advised.    Contact ULAM veterinarians for recommendations regarding oral meloxicam dosing
   Robenacoxib       (Onsior®)	2.5 - 6 kg BW:       1 whole tablet PO (6 mg)       6.1 - 12 kg BW:       2 whole tablets PO (12 mg)       2 mg/kg SC	24 hours           24 hours           24 hours	Recommended for a maximum of 1 dose per day for up to 3 days.    Cannot be accurately dosed in cats <2.5kg.    May be given with a small amount of food. Tablets should not be broken.    Subcutaneous (SC) injection can be interchanged with oral tablets.
   Opioids
   Buprenorphine	0.01 - 0.04 mg/kg       IM, IV, OTM*, SC**	6 - 8 hours	Re-dose as needed every 6 - 8 hours.    Dose at the high end of the range for more severe pain.    A more concentrated formulation of buprenorphine (Simbadol) can be used to increase the duration of effect and decrease the frequency of dosing. Please consult with a ULAM veterinarian before use        * OTM (oral transmucosal) administration has been shown to provide similar analgesic           efficacy to IM and IV routes.           **Evidence has shown that SC administration does not reliably reach therapeutic plasma           levels, IM or IV route recommended for treatment of acute pain.
   Fentanyl       Transdermal       Patch	12.5 ug/hr patch	72 - 96 hours	Fentanyl delivery from the patch is highly variable.    Side effects may include inappetance, agitation sedation and increased body temperature.    Apply 24 hrs prior to intended procedure.
   Hydromorphone	0.05 - 0.1 mg/kg       SC, IM, IV	2 - 6 hours	Transient hyperthermia, reverse w/ naloxone (0.01 - 0.04 mg/kg IM, IV, SC as needed)
   Oxymorphone	0.025 - 0.1 mg/kg       SC, IV, IM	2 - 6 hours	Reverse w/ naloxone (0.01 - 0.04 mg/kg IM, IV, SC as needed)
   Tramadol	1 - 2 mg/kg       PO	12 - 24 hours	Dose 2 - 4 times per day.    Toxicity risk when combined with SSRI or Tricyclic Antidepressants.
   Other
   Gabapentin	5-10 mg/ kg       PO	8 - 12 hours	Dose 2 - 3 times per day    Recommended as an adjunct therapy for acute post-operative pain, not as a sole analgesic.    Side effects include sedation.

    ^aIntramuscular (IM), Intravenous (IV), Subcutaneous (SC), Oral Transmucosal (OTM)

1. In the event of an anesthetic crisis, turn anesthetic gases off and contact a ULAM veterinarian at 734-936-1696 immediately.
2. Reverse anesthetic agents, if appropriate.
3. Use the following guidelines to support the animal until the veterinarian arrives:
   • A - Ensure a patent Airway: Place a cuffed endotracheal tube or confirm patency of tube already in place.
   • B - Assist in Breathing if necessary: Turn anesthetic gases off and ventilate with pure oxygen. A rapid ventilation rate (> 20 breaths per minute) is recommended to remove carbon dioxide, prevent acidosis, and decrease cerebral pressure.
   • C - Provide Cardiovascular Support as indicated: This can include rapid chest compressions (30-40% of lateral dimension; 80-120/minute) with the animal in lateral recumbency, and rapid infusion of intravenous crystalloid fluids (50-60 ml/kg bolus) to support perfusion.

Reversal agents are not required with sedation or anesthetic protocols, but can be useful to reduce prolonged recovery times or in the event of anesthetic complications. Analgesic effects are also reversed with the use of reversal agents, and pain management should be modified accordingly.

1. Atipamezole (Antisedan ®) is used extra-label for reversal of the sedative and analgesic effects of dexmedetomidine in cats.
   1. The dose volume of atipamezole is the same as the preceding dose volume of dexmedetomidine, given IM.
   2. Atipamezole can also be used extra-label to reverse xylazine sedation, at a dose of 0.025-0.050 mg/kg IM.
2. Naloxone is used extra-label for opioid reversal in the event of respiratory depression.
   1. A dose of 0.01 - 0.04 mg/kg IV, IM, or SC has duration of action of 45-90 minutes, and may need to be re-dosed if the duration of action of the opioid given is longer than 90 minutes.
3. Naloxone is also used extra-label for adjunctive treatment of post-anesthetic hyperthermia in cats, when temperatures exceed 41.1°C; 106°F.
   1. A dose of 0.01 mg/kg IM or SC has been shown to return temperatures to normal <30 minutes.

1. Alterations to the environment and gentle handling can greatly reduce stress and ultimately reduce hyperalgesia in animals following surgery or painful procedures. Such alterations include:
   1. An adequate acclimation period (minimum of 7 days).
   2. The use of Feliway (a pheromone spray).
   3. Maintaining familiar toys/blankets within the animal’s vicinity.
   4. Having soft bedding options, hiding spaces, and perches that suit the animal’s preferences.
   5. Ensuring that all interactions with the animal are positive experiences prior to a procedure will help reduce stress when handling is required. This may include visiting animals for the sole purpose of play or treats and ending all restraint sessions with a reward.
2. Localized thermal modifications can increase comfort and promote return to function in the immediate post-operative period.
   1. Cold compresses can reduce pain and inflammation for acute pain.
   2. Hot compresses are recommended for procedures resulting in chronic pain.