Tremors after Surgery

[Joxer]

Yesterday, I took my 16 year old male cat Casper to the vet for treatment of an infected wound on his right back paw. I was nervous about any sort of anesthesia because he has stage 2 CKD and has reacted badly to anesthesia in the past, even before his CKD diagnosis. However, antibiotics (Clavamox) alone did not seem to be working. He had a suspected abscess, and the recommendation was to sedate him and drain it.

I expressed my reservations about anesthesia before Casper's procedure. It would not be performed by his regular vet, since this was an "emergency" appointment and she wasn't in that day. I was assured by the emergency vet that Casper would be given "light sedation" and maybe a local block (Lidocaine).

This is not what actually happened. Apparently, without any attempt to contact me, the treatment plan was changed to first Midazolam and Methadone, followed by Alfaxalone. The vet's explanation is that Casper was sedated and unresponsive when the wound was cleaned, but as she began to widen the wound and drain it, he seemed to be in pain. She did not administer an intramuscular injection of Lidocaine because it "stings", and instead gave him an intravenous injection of Alfaxalone.

Casper has been shaking on and off since the procedure, which was concluded more than 24 hours ago. He will sit and tremble, like he's shivering, and occasionally twitch. He did not do this before the procedure yesterday. I am concerned that the Alfaxalone, on top of the Midazolam and Methadone, was too much central nervous system depression. From what I've read, Alfaxalone is used to induce general anesthesia, not sedation, and certainly not "light" sedation. Casper's vet said everything went smoothly, Casper was monitored the whole time, and so forth. However, while he had an IV, he was not intubated (using a strange sort of reverse logic, this has been pitched to me as an advantage; I should not worry about the anesthesia because it was so mild that he did not have to be intubated). I am concerned that Casper had suppressed respiration during the procedure, became hypoxic and/or hypotensive, and possibly had a stroke or suffered some other form or brain damage.

I am wondering if anyone else has seen tremors, shaking, or muscle twitches in a cat 24 hours after anesthesia. I'd also like to know if the Alfaxalone, on top of the Midazolam and Methadone, makes sense as a "sedation" protocol, epecially without intubation. Having already spoken with the emergency vet regarding my concerns, I am confident that she will steadfastly insist that she did everything right. However, substituting general anesthesia (Alfaxalone) for local anesthesia (Lidocaine) when the problem is a pain response strikes me as a very odd judgment call for a vet to make. Alfaxalone is not an analgesic (pain killer). Also, local anesthesia is far safer, as it does not suppress heart rate and respiration to anywhere near the degree as general anesthesia. It seems that I consented to "light sedation" on Casper's behalf, and he was unnecessarily subjected to something much riskier.

 

[silent meowlook]

Hi. It sounds like Casper is in pain. Did they send you home with any medication for pain? Can you post a video of what he is doing? Have you called the hospital back to let them know he is shaking?

I am not a vet.

Afaxalone is an anesthetic agent that has the advantage of being able to be given IM. Midazolam is commonly used in conjunction with anesthetic agents. Midazolam has the advantage that it causes short term amnesia. So, if the cat has a bad experience, they won’t remember. Methadone is used for pain.

I personally would want the cat to be intubated and on oxygen, then if needed a gas anesthetic could be added.

What did they discover with the toe?

 

[Joxer]

Hi. It sounds like Casper is in pain. Did they send you home with any medication for pain? Can you post a video of what he is doing? Have you called the hospital back to let them know he is shaking?

I am not a vet.

Afaxalone is an anesthetic agent that has the advantage of being able to be given IM. Midazolam is commonly used in conjunction with anesthetic agents. Midazolam has the advantage that it causes short term amnesia. So, if the cat has a bad experience, they won’t remember. Methadone is used for pain.

I personally would want the cat to be intubated and on oxygen, then if needed a gas anesthetic could be added.

What did they discover with the toe?

"I personally would want the cat to be intubated and on oxygen"

So would I, if Casper were going to be under general anesthesia. But that wasn't supposed to happen.

His foot had an infected abscess, which was drained. He's walking much better now.

Vets usually want to do a mix of necessary and unnecessary things, so there are a lot of judgment calls to make. For example, they sent me home with a cone, and instructions to keep it on Casper whenever he wasn't eating. They stuffed him in his carrier with it on, and he couldn't even turn around. He was frantically scrabbling at the sides of the carrier with his claws. I had them remove it immediately, and never put it back on. That was absolutely the right decision, as it always has been. He licks his wounds a little, but doesn't hurt them, and with the cone on, he can't ever be comfortable. Vets seem not to consider the effect of stress on animals at all.

This is a large vet hospital with a lot of vets. Most of them are not very good. I've learned over the years which ones are okay, and found one very good vet who is Casper's regular vet. But for emergencies, there aren't a lot of options, and none of their emergency vets are people I would ever choose to have treat Casper. The only other emergency vet in town charges twice as much and averages four hour wait times (their own estimate) for treatment. In my experience, it's basically the same situation for people. Emergency medical care tends to be of very low quality.

 

[Joxer]

Hi. It sounds like Casper is in pain. Did they send you home with any medication for pain? Can you post a video of what he is doing? Have you called the hospital back to let them know he is shaking?

I am not a vet.

Afaxalone is an anesthetic agent that has the advantage of being able to be given IM. Midazolam is commonly used in conjunction with anesthetic agents. Midazolam has the advantage that it causes short term amnesia. So, if the cat has a bad experience, they won’t remember. Methadone is used for pain.

I personally would want the cat to be intubated and on oxygen, then if needed a gas anesthetic could be added.

What did they discover with the toe?

"Alfaxalone is an anesthetic agent that has the advantage of being able to be given IM. Midazolam is commonly used in conjunction with anesthetic agents. Midazolam has the advantage that it causes short term amnesia. So, if the cat has a bad experience, they won’t remember. Methadone is used for pain."

Right. Only in this case, Alfaxalone was given IV after the other two drugs. What I don't understand is why the vet chose Alfaxalone over a local injection of Lidocaine. Her reason, that Lidocaine stings, doesn't make any sense. It might sting for a minute before numbing the foot. That seems like the better risk to take over adding yet another CNS depressant (Alfaxalone) to Casper's body. Lidocaine is also what we discussed beforehand. I consented to light sedation, but general anesthesia was done instead, without no breathing assistance or consent from me.

I mentioned my concerns to the vet after I realized what she had done, and she was evasive and defensive. In my experience, medical "professionals" never admit mistakes. The question is whether I should report her to the management of the practice. With her as one of the two emergency vets, and the other very rough with Casper (when that vet last examined him, she found it hilarious that he screamed in pain the whole time) and rude to me, there are no emergency vets there that I trust. It leaves me with no good options when Casper has some sort of health crisis.

 

[fionasmom]

How is Casper now? Can you speak to the regular vet about this/about his current condition? I completely understand your anger as the same situation happened to me with a dog years ago where the regular vet had a family emergency and an ER vet subbed...a man I already disliked and considered careless.

Can you at all switch to the other vets in your community? My experience with reporting to the management, and maybe even your regular vet, is that they pull the wagons in a circle and support each other. Would you be burning bridges? Please understand that I am not telling you not to report this if you feel it is necessary.

 

[silent meowlook]

Hi. I understand your frustration with the situation.
How is your cat doing now?

The veterinarian should have made you aware that doing a local of lidocaine on a cat is not an option. Cats have a very low threshold for lidocaine and the amount needed to block the pain would cause potentially life threatening side effects such as tremors, seizure activity cardiac and respiratory depression and cardiac arrest. So, a local block for a procedure on a cat is never done. You should have been informed of that.

Midazolam should be given with afaxalone, because using just afaxalone will cause twitching in cats. The methadone is used for pain, although I have ever used it in cats.

Did they send you home with any pain medication?

ER is hard. Most of the vets I have known working ER were exhausted, over worked and generally less than kind. If they were kind it changed over about a year. That is just my opinion.

Most ER are not cat friendly, but in an emergency, you have no choice. I have never worked with an ER vet that actually cared more for cats than dogs. But, this is just my experience.

Shoving the cat with s cone on into a carrier is thoughtless, but not surprising.

I would switch your cat’s litter to shredded paper until the toes heal.

 

[Joxer]

Hi. I understand your frustration with the situation.
How is your cat doing now?

The veterinarian should have made you aware that doing a local of lidocaine on a cat is not an option. Cats have a very low threshold for lidocaine and the amount needed to block the pain would cause potentially life threatening side effects such as tremors, seizure activity cardiac and respiratory depression and cardiac arrest. So, a local block for a procedure on a cat is never done. You should have been informed of that.

Midazolam should be given with afaxalone, because using just afaxalone will cause twitching in cats. The methadone is used for pain, although I have ever used it in cats.

Did they send you home with any pain medication?

ER is hard. Most of the vets I have known working ER were exhausted, over worked and generally less than kind. If they were kind it changed over about a year. That is just my opinion.

Most ER are not cat friendly, but in an emergency, you have no choice. I have never worked with an ER vet that actually cared more for cats than dogs. But, this is just my experience.

Shoving the cat with s cone on into a carrier is thoughtless, but not surprising.

I would switch your cat’s litter to shredded paper until the toes heal.

"The veterinarian should have made you aware that doing a local of lidocaine on a cat is not an option. Cats have a very low threshold for lidocaine and the amount needed to block the pain would cause potentially life threatening side effects such as tremors, seizure activity cardiac and respiratory depression and cardiac arrest. So, a local block for a procedure on a cat is never done. You should have been informed of that."

This I did not know. The way the pre-op conversation went, is I related an experience early in Casper's life in which an hour-long anesthesia for a dental cleaning left him very sick for a few days afterward, with no appetite, vomiting, and diarrhea. The emergency vet responded by saying she would just use a light sedation with a local block (her words). Later on the phone, she said that Lidocaine was the medication she had intended to use for a local block, but had decided against. I never proposed either a local block or Lidocaine, but I liked the idea of local rather than general anesthesia.

My concern is that Casper is 16 years old and has CKD. It's very stable, and technically his kidney values are within the normal range, but that's the diagnosis from his regular vet. It occurred to me hours after his procedure that the emergency vet had not asked about any of his other medical conditions, though of course she was at the same practice as his regular vet and had easy access to all his medical records. Maybe she looked them up in advance; maybe not. I wish now that I had mentioned his CKD, but at the time I was focused on his foot, which was causing him a lot of pain.

According to the emergency vet, Casper was sedated to the point of unconsciousness for somewhere between 5-20 minutes. The impression I got was that he was deeply sedated for 5 minutes following the Alfaxalone injection, and then slowly woke up over the next 15 minutes.

The night of the procedure, he was intermittently shaking, as if he were really cold. That continued into the next evening, so about 24 hours. I haven't seen shaking today, but he still trembles whenever he's sitting and not doing anything else (grooming himself, for example). He also had his head cocked at a funny angle for awhile, just looking at me, which was unusual. His gait is still awkward, but I attribute that mostly to residual swelling and pain in his foot, which seems to be slowly improving. He's receiving Clavamox twice a day.

Casper has been remarkably healthy, despite his age and insistence on going outside a lot. I kept him indoors for most of the past week, but let him out briefly today. It's really important to him, and his foot wound no longer seems be open. I blame myself for not taking him in to get the wound cleaned out earlier. It initially seemed to be healing on its own, and the previous emergency experience was so unpleasant that I hoped not to repeat it.

 

[silent meowlook]

I doubt you’re telling the ER vet about the CKD would have changed what she did.
You are not to blame in this. This is purely lack of communication on the vets side.

 

[Joxer]

I doubt you’re telling the ER vet about the CKD would have changed what she did.
You are not to blame in this. This is purely lack of communication on the vets side.

I obtained Casper's medical records today. The "sedation" protocol (for a 4 kg 16 yr old cat with stage 2 CKD) was this:

Methadone - .8 mg
Midazolam - .4 mg
Alfaxalone - 4 mg
Maropitant - 4 mg

Maropitant was for nausea, and Casper has received that before without issues. My understanding is that Methadone and Midazolam were "preanesthetics" and Alfaxalone was the anesthetic. The emergency vet, who is no longer interested in talking to me, said by way of the practice's "client services representative" that the change in protocol from local block to IV Alfaxalone was so minor as to not warrant obtaining consent from me.

My question is whether this looks more like "sedation" (cat in an altered state of consciousness, but still breathing well on his own) or "general anesthesia" (cat unconscious and at risk of apnea and hypoxia without intubation)?

 

[silent meowlook]

Hi. The doses seem to be standard and could be used to induce anesthesia or as sedation.
The methadone is for pain. Hopefully they sent you home with pain medication as well. The Midazolam is sedation, similar to Valium.

When doing a painful procedure on a cat, sedation doesn’t work. Cats can override sedation in a second making it dangerous for not only the cat but the staff as well. Not to mention it being traumatic for the cat.

Although cats are predators, they are also prey. That makes them able to stress themselves Obote the sedation threshold.

So, I understand why the vet couldn’t do the procedure with only sedation. What I don’t understand is why she didn’t tell you that.

I think the bottom line is, what’s done is done. Nothing can reverse time and undo it. There is no point talking to them further about it because they will stand their gtt try puns on it and never understand the point you are trying to make.

 

[Joxer]

Hi. The doses seem to be standard and could be used to induce anesthesia or as sedation.
The methadone is for pain. Hopefully they sent you home with pain medication as well. The Midazolam is sedation, similar to Valium.

When doing a painful procedure on a cat, sedation doesn’t work. Cats can override sedation in a second making it dangerous for not only the cat but the staff as well. Not to mention it being traumatic for the cat.

Although cats are predators, they are also prey. That makes them able to stress themselves Obote the sedation threshold.

So, I understand why the vet couldn’t do the procedure with only sedation. What I don’t understand is why she didn’t tell you that.

I think the bottom line is, what’s done is done. Nothing can reverse time and undo it. There is no point talking to them further about it because they will stand their gtt try puns on it and never understand the point you are trying to make.

I finally got a call back from the medical director of the practice (it took her a month). She literally called back just to tell me that I was no longer welcome to take Casper there for emergency care. I didn't even dispute the bill; just complained about their quality of care, which was obviously terrible (unintubated general anesthesia leading to hypoxia and neurological damage).

It's been a really bizarre experience. If I had some way of purchasing antibiotics without going through a vet, I would never need emergency care for Casper anyway. It's awful that it took a $400 emergency appointment and likely permanent harm to my cat in order to procure $5 worth of antibiotics that it was obvious he needed before the vet even looked at him.

 

[fionasmom]

I am sorry that you were treated this way, especially over something like voicing a complaint. On the other hand, if this is who they are, it is probably better never to darken their doorway again with Casper so that something more untoward does not happen. Do you have other options for veterinary care and emergency care if it is needed? Are you in an area where there might be a choice of vets?

 

[Joxer]

I am sorry that you were treated this way, especially over something like voicing a complaint. On the other hand, if this is who they are, it is probably better never to darken their doorway again with Casper so that something more untoward does not happen. Do you have other options for veterinary care and emergency care if it is needed? Are you in an area where there might be a choice of vets?

I have a choice of vets, though I plan to keep going to the same practice for regular (non-emergency) care since Casper's regular vet is very good. For emergency care, there are very limited options. I'm basically left with one, which is more expensive, with longer wait times, and of course doesn't have all of Casper's medical records on file.

As I think back on my cats' record with emergency care, it's been of dubious value. It was necessary for Casper recently just because it was the only way to get antibiotics. The veterinary care he received did more harm than good. At his sister Xena's last emergency visit before she died, I was told that a $1300 hospitalization in which the only procedure performed was an enema, would clear up the constipation that was her only immediate medical problem. They sent her home after that, and she was hemorrhaging blood four days later, from a digestive system ravaged by cancer that they didn't even suspect. All the emergency visit did was add another layer of fear and suffering to her final days on earth.