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• W4308655302 abstract "The case report by Aßmann et al. (2023) in this issue reported the surgical management of an accessory carpal bone fracture, repaired under standing sedation. This sets the tone for the debate between the risks and benefits of standing sedation versus general anaesthesia in horses undergoing fracture repair. It has been well documented that the risk of anaesthetic-related mortality in horses is high (Bidwell et al., 2007; Dugdale et al., 2016; Gozalo-Marcilla et al., 2021; Jago et al., 2015; Johnston et al., 1995, 2002; Laurenza et al., 2020; Mee et al., 1998a, 1998b; Mitchell, 1969; Proudman et al., 2006; Senior et al., 2007; Tevik, 1983; Young & Taylor, 1993) compared with dogs, cats (Brodbelt et al., 2008; Shoop-Worrall et al., 2022) and humans (Li et al., 2009; Pignaton et al., 2016). With 41,824 cases gathered from 62 clinics over a 6-year period, the Confidential Enquiry into Perioperative Equine Fatalities 2 (CEPEF-2) published 20 years ago continues to be the biggest multicentre observational study to date (Johnston et al., 2002). The authors reported an overall anaesthetic-related mortality rate up to 7 days post-anaesthesia of 1.9%, of which 0.9% corresponded to noncolic cases and 7.8% to colic cases (Johnston et al., 2002). This multicentre observational prospective study is currently being repeated (CEPEF-4) and the preliminary results published to date include a sample size of 8656 cases (6701 procedures under general anaesthesia and 1955 under standing sedation) from 69 different centres (Gozalo-Marcilla et al., 2021). The authors report a reduction in overall general anaesthesia-related mortality within the seven-day outcome period from 1.9%, reported 20 years ago by the CEPEF-2 (Johnston et al., 2002), to 1% (Gozalo-Marcilla et al., 2021). This reduction is mainly due to a reduction in general anaesthesia-related mortality of colic cases: from 7.8% (Johnston et al., 2002) to 3.4% (Gozalo-Marcilla et al., 2021). For noncolic cases this reduction has also been significant: from 0.9% (Johnston et al., 2002) to 0.6% (Gozalo-Marcilla et al., 2021). The CEPEF-4 is a ground-breaking project as it is the first large multicentre observational prospective study investigating the incidence of standing sedation-related fatalities in horses. The authors reported a 0.2% mortality rate of the 1955 horses that underwent standing sedation for various procedures (Gozalo-Marcilla et al., 2021). As expected, the incidence of standing sedation-related fatalities seems lower than that of general anaesthesia, supporting the fact that standing sedation removes the risk of mortality imposed by recovery from general anaesthesia. This is well highlighted by the authors in the case report. In addition to the literature cited by the authors, the preliminary results of the CEPEF-4 corroborated the findings from recent studies (Dugdale et al., 2016; Laurenza et al., 2020) suggesting a shift from intra-operative mortality to post-operative anaesthetic-related mortality. This could be a result of better cardiovascular and respiratory monitoring techniques as well as a better understanding of how to manage intra-operative complications. Currently, the post-anaesthetic period is the phase that carries the highest risk for anaesthetic-related death: 75.7% of the fatalities reported occurred in the post-operative period (42.4% during the recovery period and 33.3% within 7 days post-anaesthesia) (Gozalo-Marcilla et al., 2021). The risk factors associated with poor recovery quality from anaesthesia have been reviewed elsewhere (Loomes & Louro, 2022a, 2022b). Age, type of surgery, duration of anaesthesia, temperament and other risk factors can affect how well a patient recovers from general anaesthesia. Regrettably, the anaesthetist is unable to control for these risk factors, so in order to improve the quality of recovery numerous pharmacological interventions and recovery techniques have been devised. However, there is no definite consensus about the effectiveness of many of these interventions and their effects on mortality and morbidity during the post-anaesthetic period. This case report describes a complicated fracture repair performed over 120 minutes. As the authors mention, recovery from general anaesthesia can be particularly challenging for a patient undergoing fracture repair surgery, and it has been shown that these patients are at an increased risk of recovery-related fatalities when compared to other surgical groups (Johnston et al., 1995, 2002; Laurenza et al., 2020; Mee et al., 1998a). Patients undergoing such treatments are likely to be stressed, frightened, weary and may experience significant pain and fluid imbalances, all of which may have an impact on an animal's ability to withstand the negative consequences of general anaesthesia and surgery. In addition, fracture repair surgery is frequently a lengthy, difficult procedure that is typically carried out in an emergency situation. The preliminary results of the CEPEF-4 report a mortality rate of 4.2% (7/166 cases) for fracture repair surgery performed under general anaesthesia versus 3.6% (1/28 cases) for those performed under standing sedation (Gozalo-Marcilla et al., 2021). The risk of catastrophic re-fracture is evident in this data with four of the seven fatalities after general anaesthesia being due to re-fracture either in recovery or in the stable; however, re-fracture was also reported as the reason for euthanasia after surgery under standing sedation (Gozalo-Marcilla et al., 2021). The risk of fracture failure cannot be completely eliminated even after standing repair as was also documented in one case series where fracture propagation and open comminution of the fracture during stall confinement occurred in 7.7% of horses (1/13 cases) after standing repair of a metatarsal spiral fracture (Russell & Maclean, 2006). Another known anaesthetic complication in horses, post-anaesthetic colic (PAC) has been reported in 2.5%–18.5% of horses undergoing general anaesthesia (Borland et al., 2017; Jago et al., 2015; Skrzypczak et al., 2020; Thibault et al., 2019). There is limited evidence regarding the incidence of PAC in horses undergoing standing sedation for surgical and nonsurgical procedures. The incidence of colic post-gastroscopy performed under standing sedation was reported to be 2.9% (17/573 of cases) (Spanton et al., 2020). A retrospective study reported an incidence of post-sedation colic of 1.4% (1/73 of cases) in horses undergoing standing sedation for a variety of surgical and nonsurgical procedures versus 3.4% (6/173 of cases) for horses undergoing general anaesthesia (Thibault et al., 2019). When scrutinising post-anaesthetic or post-sedation colic as a cause of death in horses, the differences are minimal between standing sedation (0.15%; 3/1955 cases) and general anaesthesia (0.10%; 7/6701 cases) (Gozalo-Marcilla et al., 2021), but further studies are required to clarify this PICO question. A recent case series documented that a similar proportion of cases of caecal dysfunction occurred in horses with a history of general anaesthesia (18.9%; 7/37 cases) compared to standing sedation (16.2% 6/37 cases) (Gough et al., 2022). Since several of the factors implicated in the development of caecal dysmotility may be common to surgical procedures performed either under general anaesthesia or standing sedation, comparable results could be expected. Short-term follow-up of standing fracture repair cases reported an 8.8% (3/34 cases) incidence of PAC (Payne & Compston, 2012). One horse suffered a caecal impaction refractory to medical therapy which ruptured, necessitating euthanasia. Two further horses had post-operative gastrointestinal complications (colon impaction, colitis) but both recovered uneventfully with medical management (Payne & Compston, 2012). The factors implicated in the development of PAC, such as management changes associated with injury and hospitalisation, travel, pain administration of alpha 2 agonists and opioids, may be common to both standing sedated procedures and those performed under general anaesthesia. There is no doubt that standing fracture repair has grown rapidly in popularity in recent years. The main incentive for this technique may be to avoid the aforementioned risks associated with recovery from general anaesthesia, however, as Aßmann and colleagues discuss, standing surgeries may pose additional risks for the surgical team making careful patient selection crucial. Furthermore, movement of the horse, maintenance of a sterile surgical field, uncomfortable work position, extra physical demands on the surgeon, increased risk of damage to surgical equipment, poor visibility of anatomic structures due to inadequate tissue retraction and difficulty controlling haemorrhage may pose additional challenges in the standing patient (Payne & Compston, 2012; Perez-Olmos et al., 2006; Richardson, 1998; Russell & Maclean, 2006). Alpha-2-adrenoreceptor agonists are undoubtedly the main-stem component of any standing sedation in horses (Vigani & Garcia-Pereira, 2014). Aßmann and colleagues utilised a combination of detomidine and morphine to provide sedation and analgesia in their case, the use of which is supported by other authors for standing surgery (Cillán-García et al., 2020). Morphine was substituted for butorphanol by other authors (Jimenez-Rihuete & O'Meara, 2022; Lean & Ahern, 2020; Russell & Maclean, 2006), but the analgesia afforded by butorphanol is short-lived and has been shown to be inadequate for post-castration analgesia (Love et al., 2009) and inferior to morphine in experimentally induced synovitis (Carregaro et al., 2014). Systematic review concluded that butorphanol has poor analgesic effects at doses used in clinical practice (Bowen et al., 2020). Pure mu-agonists such as morphine may elicit a reduction in gastrointestinal motility (Boscan et al., 2006); however, a recent study demonstrated that intravenous infusion of detomidine and methadone provided sufficient sedation and analgesia with minimal cardiovascular and respiratory effects for standing procedures in horses and effects on gastrointestinal motility associated with this infusion were similar to the equivalent infusion dose of detomidine without methadone (Gozalo-Marcilla et al., 2019). Bolus dosing of sedation alone may produce intermittent peaks and troughs of levels of sedation and risk over- or under-sedation (Vigani & Garcia-Pereira, 2014) as was experienced by Russell and Maclean (2006) when heavy sedation caused limb buckling and sudden movement which had the potential to induce excessive strain on the fracture line, and catastrophic failure. Tailored administration of sedation using a variable rate intravenous infusion pump and low levels of detomidine alleviated this problem considerably (Russell & Maclean, 2006). Aßmann and colleagues highlight the importance of effective locoregional anaesthesia techniques in the standing patient to reduce the risk of sudden movement in response to surgical stimulation. A variety of locoregional techniques have been reported for standing fracture repair according to the desired region of anaesthesia. Russell and Maclean (2006) refined their technique after one horse moved suddenly in response to penetration of the medulla by the drill-bit causing breakage of the drill-bit inside the bone. However, it has been recommended that since the administration of sedation and effective local anaesthesia, may render a nonweight-bearing horse fully weight-bearing, the horse should not be allowed to move once the local anaesthesia has taken effect as further displacement of the fracture could happen on the unprotected affected limb (Perez-Olmos et al., 2006). The temperament of the horse is paramount as it is imperative that the horse stands square and remains still throughout the duration of surgery (Compston & Payne, 2013; Lean & Ahern, 2020). The mare in the current case reported was considered to be ‘an excellent candidate for a standing procedure’, however, in some cases despite ideal preparation, some horses are just not amenable to standing procedures. In that event, surgery under general anaesthesia should be chosen as the safest option for both horse and veterinary team (Compston & Payne, 2013). While the vast majority of standing procedures go smoothly, the risk of an animal suddenly jumping out of stocks or collapsing to the ground remains a real concern (de Bont, 2021). Facilities must be available for rapid induction of general anaesthesia and completion of the procedure in an anaesthetised patient if unforeseen complications occur. This is a strong motive for carrying out the procedure in, or close to, a padded induction room (Compston & Payne, 2013). Additionally, padded flooring may decrease drill vibration thus reducing disruption to the horse and aiding sedation (Compston & Payne, 2013; Perez-Olmos et al., 2006). While a standing technique may optimise safety for the equine patient, it may increase the risk of physical injury to the surgical team. The operated limb in the case report was a forelimb which poses some risk of strike or kick injury but operating on a hindlimb may increase this risk further. Jimenez-Rihuete and O'Meara (2022) reported the use of a bale of shavings as a kick barrier between the hindlimb and the surgeon during olecranon fracture repair to offer reassurance against a forward kick from a hindlimb. During standing procedures, sterile technique may be compromised either due to the location of the stocks within a multi-purpose room, movement of the horse and sterile drapes or the proximity of the surgical field to the floor (de Bont, 2021). It is conceivable that there may be an increased risk of infection when a fracture repair is carried out when the horse is standing (Jimenez-Rihuete & O'Meara, 2022). In a case series of olecranon fracture repairs undertaken standing, radiographs were not carried out until all or most of the intended screw holes were filled to help limit the risk of contamination of the surgical field (Jimenez-Rihuete & O'Meara, 2022). In the standing horse, anatomical familiarity may be an advantage compared to adjustment for rotational alterations which may occur during lateral recumbency. Fracture apposition and re-alignment may also prove easier in the standing patient; however, intra-operative endoscopy may be more challenging and limited for some procedures. Cost savings may be cited as an advantage of standing fracture repair; however, the main driving force behind development of these techniques should always be the welfare of the horse and in particular in avoiding anaesthesia-related risk (Compston & Payne, 2013). Furthermore, the cost savings may not actually be as favourable as expected and some authors have suggested that since the cost of the staff, implants and consumables remain the same for standing procedures compared to general anaesthesia, the total cost would be similar (Jimenez-Rihuete & O'Meara, 2022). Finally, it is important to consider that not all fracture types are candidates for standing repair. Fractures amenable to repair standing include those that are incomplete and minimally or nondisplaced (Cillán-García et al., 2020; Payne & Compston, 2012). This factor makes direct comparison of return to racing data difficult, but the general consensus is that return to racing time was similar for fracture repair performed via standing techniques compared with general anaesthesia (Compston & Payne, 2013). In conclusion, performing fracture repair in horses under standing sedation does remove the risks associated with post-anaesthetic recovery; however, surgery in the standing horse involves consideration of additional factors. Detailed planning, patient selection, provision of appropriate facilities, adverse or unexpected event preparedness and an experienced surgical team are all imperative for success. K. Loomes and L. Louro contributed in equal amounts to preparation of the manuscript. No conflicts of interest have been declared." @default.
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• W4308655302 title "Is general anaesthesia avoidable for limb fracture repair in horses?" @default.
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