How do you go about updating medical guidelines after 16 years? With so much change in the landscape of veterinary medicine since 2009, a working group of anesthesia and analgesia specialists had its work cut out.
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Lydia Love, DVM, DACVAA, was one of 17 authors who contributed to the new American College of Veterinary Anesthesia and Analgesia (ACVAA) Small Animal Anesthesia and Sedation Monitoring Guidelines, which were published in July. Dr. Love discusses the process involved with such a large undertaking, the key updates that will interest practitioners, and how the recommendations blend a mix of evidence-based information and a consensus of expert opinion.
Can you explain the process of reviewing the literature, consulting experts, and ultimately, updating the guidelines?
Dr. Love: The guidelines were prepared by the ACVAA with input from members of the North American Veterinary Anesthesia Society and the Academy of Veterinary Technicians in Anesthesia and Analgesia. A group of ACVAA volunteers first reviewed the 2009 guidelines to confirm that an update was needed. Once that was established, the authors of the guidelines were broken into working groups to review the available literature and incorporate it into the new recommendations. Wherever a strong evidence base was lacking, the working groups reached a consensus on best practices. Once the guidelines were prepared, they were released for comments to all ACVAA members, then revised when appropriate, and submitted for approval by the ACVAA Board of Directors. Open access publication was obtained in the journal Veterinary Anaesthesia and Analgesia.
What factors affect the decision to update and expand the guidelines (i.e., lapsed time, new data, adverse trends)?
Dr. Love: The decision to update and expand the guidelines was influenced by several factors, including an evolving understanding of patient safety in anesthesia. A key underlying reason is that much has changed in veterinary anesthesia over the past 16 years, especially in monitoring resources, capabilities, training, and equipment; plus, we know significantly more than we did in 2009. We were able to integrate new scientific data and research findings that have emerged over the years, leading to a refinement of best practices. The previous version of the guidelines had a softer focus on information that could be obtained from objective monitoring and did not mention some of the standard patient safety techniques (e.g., checklists and other cognitive aids) that are in use today. I also believe that the 2025 guidelines cover anesthesia maintenance with an emphasis on a “dedicated anesthetist,” who remains with the patient at all times, as well as a detailed breakdown of the anesthesia care team, which underscores an evolution in the understanding of the importance of trained personnel and their vigilance.
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In comparison to the guidelines released in 2009, these guidelines categorize recommendations as “minimum,” “alternative,” and “advanced.” Was this an initiative to streamline standard-of-care for anesthesia and sedation monitoring?
Dr. Love: We identified minimum monitoring recommendations for any clinical environment alongside alternatives for situations where minimum recommendations are unavailable and advanced recommendations for patients with coexisting diseases, unstable conditions, or those undergoing advanced interventions. In doing so, we attempted to provide contextualized recommendations to address spectrum-of-care concerns across various clinical environments. While we believe there are certain monitoring capabilities that mitigate the risks for general anesthesia in any situation, we recognize that economic and ethical environments differ among practices.
Did you find any specific point or area to be a substantial revision?
Dr. Love: There are several key areas within the 2025 guidelines that involve substantial revision, notably the detailed information about monitoring during sedation and incorporation of cognitive aids and checklists. The guidelines now explicitly describe the continuum of sedation from conscious to anesthetized, highlighting the fact that where the patient ends up on that spectrum can be variable and sometimes unpredictable. There are detailed recommendations for monitoring during mild, moderate, and deep/profound sedation—highlighting a broadened scope of care and vigilance with the acknowledgement that critical physiologic abnormalities can occur even during sedation.
I would also highlight the addition of capnography as a minimum monitoring recommendation. Capnography is more readily available than it used to be because it is typically integrated into multiparameter monitors. That technology provides so much valuable information, including the integrity of the anesthesia equipment as well as how the patient is moving respiratory gases, their lung perfusion, and metabolic state. Capnography can alert the user to things that can lead to hypoxemia and also aid in the differential diagnosis of potentially fatal hypoxemia, if it occurs. Finally, capnography is essential for evaluating the effectiveness of CPR efforts.
The topic of monitoring during the use of a neuromuscular blockade was also substantially revised. Now, the guidelines unequivocally state that neuromuscular blocking agents should not be administered without a peripheral nerve stimulator because normal neuromuscular function cannot be determined by subjective means.
The integration and emphasis on cognitive aids represents a notable enhancement that aims to improve patient safety and ensure consistent, high-quality care. The guidelines now explicitly recommend that the anesthetist utilize a standardized anesthesia checklist, including an equipment checklist, prior to the start of anesthesia. Furthermore, it is advised that the doses of emergency drugs and reversal agents be calculated before sedation or anesthesia and be readily available (with the recommendation to use a digital or printed spreadsheet for these calculations).
To improve team communication and quality standards, the guidelines also recommend using surgical safety checklists tailored to the environment and standardized handoff checklists when transferring patient care, particularly during the immediate recovery period. These checklists are crucial for completing all necessary tasks, reducing human error, and ensuring thorough communication.
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Did you find any data to be an exciting or impactful addition?
Dr. Love: I am excited by the formalization of the recommendation for the use of cognitive aids, reflecting a proactive approach to enhancing patient safety and standardizing best practices. One of the tenets of patient safety approaches in healthcare is to simplify and standardize workflows. Cognitive aids, such as checklists and handoff tools, provide structure and clarity around best practices while enhancing communication and teamwork.
The guidelines include the recommendation for the anesthetist to utilize a standardized anesthesia equipment checklist prior to the start of anesthesia. This ensures that critical equipment is functional and ready, preventing last-minute surprises. The impact of such checklists is strongly supported by recent research, including a study I recently completed that found that the introduction of an anesthesia equipment checklist in a veterinary student live animal laboratory resulted in an 88% reduction in equipment set-up errors. This pragmatic approach to leveraging proven safety strategies, which have demonstrably improved outcomes in human medicine, for veterinary practice is a progressive and impactful development within the 2025 guidelines.
The Study
The American College of Veterinary Anesthesia and Analgesia Small Animal Anesthesia and Sedation Monitoring Guidelines 2025.
Bailey K, Briley J, Duffee L, et al. Vet Anaesth Analg.
doi:10.1016/j.vaa.2025.03.015