LVT, VTS (Anesthesia & Analgesia), MS
Changing the face of veterinary medicine is Heather’s goal, and she works with a strong team of thought leaders who are dedicated to revolutionizing the team experience. Heather has 15 years of experience in the veterinary industry on both the medical and leadership side. She is a veterinary technician specialist in anesthesia and analgesia and has earned a master’s degree in industrial and organizational psychology from George Mason University.Read Articles Written by Heather Carter
A trip to the veterinary clinic can be a source of stress and worry for dogs and cats.1 Stress has the potential to mask the chief complaints described by the client; impede physical examination, diagnostic testing, and treatment administration; and put the veterinary team at risk if the stress results in aggressive behavior.2
This experience can be substantially improved by directing clients to administer a sedative and/or an anxiolytic to their pet before arrival for the veterinary visit.3,4 The benefits of reducing or eliminating stress for the veterinary patient before a hospital visit are multifactorial, extending not only to the patient but also to the client and the veterinary team (TABLE 1). This article describes some of the benefits of using medication to minimize stress in veterinary patients. This information can be used to educate clients and minimize any reluctance on their part to premedicate their pets.
Why Minimize Patient Stress?
An immediate benefit of previsit medication is improved patient comfort. The stress associated with veterinary visits can be harmful to the patient’s mental wellbeing and can impede the examination, diagnosis, treatment, and overall patient care,5 ultimately influencing/limiting future veterinary visits and possibly leading to a need for prolonged care. Another benefit is the patient’s ability to recover mentally from a veterinary visit. One study found that 58.5% of cats continued to exhibit ongoing distress after returning home from veterinary visits.6
Patients’ stress in unpredictable surroundings or clients’ anticipation of stress can lead clients to avoid bringing their pet in for veterinary care. Most clients do not like to see their beloved pet stressed, and some may fear injury to the pet if involved in a struggle for restraint. One study found that 28% of cat owners and 22% of dog owners reported that they would bring their pets to the veterinarian more often if the visit was not associated with so much stress.7
Previsit medication can thus increase client compliance with regard to scheduling and keeping veterinary appointments. Avoiding veterinary visits can ultimately lead to a need for advanced medical care if the pet does not receive timely and appropriate care, thereby imposing a financial burden.
The veterinary practice also benefits when patient stress is alleviated. The benefits of having premedicated patients include decreased daily workload (due to increased efficiency) and boosted team morale (due to reduced confrontation with distressed patients and clients). Previsit medication eliminates the need to have several team members assist with anxious patients; reduces their risk for injury if they need to restrain fearful patients; and increases the chances of successful and efficient completion of examination, diagnostic testing, and treatment administration. Although initially arranging for previsit medication takes time (educating clients, determining the medication protocol, calculating dosages, writing and filling scripts), the trade-off is that patients that are less stressed may struggle less and enable faster care by fewer people. Reducing the risk for staff injury benefits not only the individual team member but the hospital as well. This is achieved by decreasing workers’ compensation claims and staff time off work due to injury, limited abilities after returning to work, and perhaps new fear of handling patients.
How Can Patient Stress Be Minimized?
The negative experiences described above can be substantially improved when patients are given a sedative and/or anxiolytic before arrival for the veterinary visit (TABLE 2) and/or during the visit (TABLE 3).1
The following case example (provided with permission by Jordan Sanchez, LVT) describes how previsit medication can benefit everyone involved. Bunny, a 55-kg, 8-year-old, neutered male Akita-mix dog, was presented for a lateral thoracotomy to remove a lung mass. During previous visits, Bunny was noted to be fractious, stressed, and untouchable; because of the lung pathology, his stress could result in dyspnea and collapse.
To prevent injury to the patient and to keep the veterinary team safe, a previsit sedation protocol was planned. Because of Bunny’s level of aggression, a multimodal protocol was chosen. The benefits of a multimodal protocol include the ability to increase the effectiveness of each drug through interactions in several areas of the nociceptive pathway.10 A modified “chill protocol” was prescribed to reduce stress and mitigate dyspnea and/or collapse.
Developed at The Cummings School of Veterinary Medicine at Tufts University, the chill protocol was created as a way to alleviate stress and promote calmness in the aggressive and anxious patient.11 The chill protocol is a combination of 3 orally administered medications that reduce anxiety and/or aggression11: gabapentin, melatonin, and oral transmucosal (OTM) acepromazine (TABLE 4). Within this protocol, gabapentin has properties that promote anxiolysis, sedation, and analgesia.11 Despite a lack of published data on the merits of gabapentin to treat and reduce anxiety, Costa et al. indicate that anecdotal clinical experience supports its use.11 Melatonin is a naturally occurring hormone in humans that has the potential to benefit dogs with fear-motivated aggression and/or anxiety.11
Because of Bunny’s level of aggression, the veterinarian substituted trazodone for melatonin (TABLE 5). Acepromazine synergistically works to promote sedation and calming. This phenothiazine derivative tranquilizer agonistically exerts sedative effects via the dopamine receptors in the central nervous system.12
The client’s adherence to the timing and delivery of the chill protocol enabled the nursing team and doctors to safely examine and treat Bunny. Additional benefits included a markedly decreased monitored anesthesia care requirement, decreased staff stress, and smoother patient recovery.
Continued delivery of this protocol for each visit enabled the team to take follow-up chest radiographs every 6 weeks without incident. The protocol was paired with Fear Free techniques and philosophies. By using pheromones, exhibiting calm and relaxed body language, quiet voices, and avoiding direct eye contact, the veterinary team was able to position Bunny for radiographs with minimal restraint.
Note that use of acepromazine as a treatment for anxious patients has been reported to be contraindicated.13 Anecdotal evidence in Bunny’s case demonstrated repeated success with OTM administration of acepromazine. Other contributors to this success include client compliance, veterinary team competency, and use of Fear Free techniques.
Oral and/or injectable medications do not solve every concern with regard to veterinary patient anxiety. Previsit medications are only one aspect of improving patient health, team morale, efficiency, and safety; previsit medication works best when combined with additional techniques. The veterinary team should observe the patient’s body language. Incorporating low-stress/Fear Free techniques into daily practice enables the team to tailor treatment plans to address individual patient needs. When interacting with patients, especially anxious or fearful patients, avoid punishment, loud voices, and force. Forceful and excessive patient restraint is frightening and painful3 and can result in injury to the patient and/or the veterinary team. Other stressful interactions to avoid include leaning over or reaching for a patient (which the patient can interpret as a threat), scruffing cats, dumping cats out of their carriers, or squatting face-to-face using direct eye contact with a worried patient.14
Reducing patient stress should be a priority in any veterinary setting. Although it may take time to initiate a previsit medication protocol for each patient, ultimately reducing or eliminating patient stress through medication before and/or during the visit can benefit everyone involved.
1. Quimby JM, Smith ML, Lunn KF. Evaluation of the effects of hospital visit stress on physiologic parameters in the cat. J Feline Med Surg. 2011;13(10):733-737. doi:10.1016/j.jfms.2011.07.003
2. Nibblett BM, Ketzis JK, Grigg EK. Comparison of stress exhibited by cats examined in a clinic versus a home setting. Appl Anim Behav Sci. 2014;173:68-75. doi:10.1016/j.applanim.2014.10.005
3. Lloyd JKF. Minimising stress for patients in the veterinary hospital: why it is important and what can be done about it. Vet Sci. 2017;4(2):22. doi:10.3390/vetsci4020022
4. Overall KL. Behavioral supplements and medications. In: Overall KL, ed. Manual of Clinical Behavioral Medicine for Cats and Dogs. 1st ed. Elsevier. 2013:457-512.
5. Erickson A, Harbin K, MacPherson J, Rundle K, Overall KL. A review of pre-appointment medications to reduce fear and anxiety in dogs and cats at veterinary visits. Can Vet J. 2021;62(9):952-960.
6. Mariti C, Bowen JE, Campa S, Grebe G, Sighieri C, Gazzano A. Guardians’ perceptions of cats’ welfare and behavior regarding visiting veterinary clinics. J Appl Anim Welf Sci. 2016;19(4):375–384. doi:10.1080/10888705.2016.1173548
7. Riemer S, Heritier C, Windschnurer I, Pratsch L, Arhant C, Affenzeller N. A review on mitigating fear and aggression in dogs and cats in a veterinary setting. Animals (Basel). 2021;11(1):158. doi:10.3390/ani11010158
8. Bleuer-Elsner S, Medam T, Masson S. Effects of a single oral dose of gabapentin on storm phobia in dogs: a double-blind, placebo-controlled crossover trial. Vet Rec. 2021;189(7):e453. doi:10.1002/vetr.453
9. van Haaften KA, Forsythe L, Stelow EA, Bain MJ. Effects of a single preappointment dose of gabapentin on signs of stress in cats during transportation and veterinary examination. JAVMA. 2017;(10):1175-1181. doi:10.2460/javma.251.10.1175
10. Epstein ME. Multimodal approach to pain management analgesia: not “too much,” rather a safe and effective synergy. dvm360. May 1, 2011. Accessed July 2022. https://www.dvm360.com/view/multimodal-approach-pain-management-analgesia-not-too-much-rather-safe-and-effective-synergy-proceed
11. Costa RS, Karas AZ, Weil-Borns S. Chill protocol to manage aggressive & fearful dogs. Clinician’s Brief. May 2019. Accessed September 2022. https://www.cliniciansbrief.com/article/chill-protocol-manage-aggressive-fearful-dogs
12. Love L. Oral sedatives and anxiolytics for veterinary visits. North American Veterinary Anesthesia Society. Updated July 27, 2019. Accessed July 2022. https://www.mynavas.org/post/oral-sedatives-and-anxiolytics-for-veterinary-visits
13. Frank D, Gauthier A, Bergeron R. Placebo-controlled double-blind clomipramine trial for the treatment of anxiety or fear in beagles during ground transport. Can Vet J. 2006;47(11):1102-1108.
14. Yin S. Low Stress Handling Restraint and Behavior Modification of Dogs & Cats: Techniques for Developing Patients Who Love Their Visits. 1st ed. Cattle Dog Publishing; 2009.