Veterinary Anaesthesia and Analgesia 2018, xxx, 1e10 https://doi.org/10.1016/j.vaa.2018.08.

005

REVIEW ARTICLE
64
65
1 How to score sedation and adjust the 66
2 67
3 Q1 administration rates of sedatives in horses: a 68
4 69
5 literature review and introduction of the Ghent 70
6 71
7 Sedation Algorithm 72
Q11
8 73
9 74
10 75
Q10 Stijn Schauvliegea, Charlotte Cuypersa, Anneleen Michielsena, Frank Gasthuysa &
11 76
12 Miguel Gozalo-Marcillaa,b
a 77
13 Department of Surgery and Anaesthesia of Domestic Animals, Faculty of Veterinary Medicine,
78
14 Ghent University, Merelbeke, Belgium
79
15 b
Department of Veterinary Surgery and Anaesthesiology, Faculty of Veterinary Medicine and 80
16 Animal Science, S~
ao Paulo State University (UNESP), Botucatu, SP, Brazil 81
17 82
18 83
Correspondence: Stijn Schauvliege, Department of Surgery and Anaesthesia of Domestic Animals, Faculty of Veterinary Medicine,
19 84
Ghent University, Salisburylaan 133, B-9820, Merelbeke, Belgium. E-mail: [email protected]
20 85
21 86
22 87
23 88
24 89
25 90
26 91
27 Q2 Abstract alpha-2 agonists. Studies are needed to validate 92
28 this algorithm. 93
29 Objective To summarize the different methods
94
30 used to assess sedation and/or adjust the dose or
Keywords Ghent Sedation Algorithm, horse, 95
31 administration rate of alpha-2 agonists in horses 96
32 and to propose an algorithm to adjust the admin- score, sedation.
97
33 istration rate of a constant rate infusion of an 98
34 alpha-2 agonist in horses.
Introduction Q3
99
35 100
36
To avoid the risks of general anaesthesia (Johnston
Databases used PubMed and Web of Science; 101
37 et al. 2002), and given the considerable advances in Q4
search terms: horse, sedation and score. 102
38 equine dentistry, orthopaedics and laparoscopic
103
39 Conclusions Most authors distinguish between surgery in the last two decades, an increasing 104
40 sedation depth, sedation quality and degree of number of procedures are currently performed in 105
41 ataxia. These three features are evaluated using the standing, sedated horse. Providing optimal 106
42 scoring systems similar to those classically used to 107
conditions (a good level of sedation with little to no
43 108
assess pain, i.e. simple descriptive scales, numerical ataxia or responses to surgical or other stimuli) for
44 109
45 rating scales (NRS), visual analogue scales and/or these procedures is a challenge for the anaesthetist,
110
46 multifactorial sedation scales. In addition, head and usually requires the use of combinations of
111
47 height above the ground is often used as a measure sedative and analgesic drugs with locoregional 112
48 of the depth of sedation. Very few authors have techniques. Many studies are being performed in 113
49 described how to adjust the administration rate or this area, mostly in experimental settings, although 114
50 dose of alpha-2 agonists. Based on the available 115
a few clinical studies are also available (Table 1). In
51 116
literature, the Ghent Sedation Algorithm was these studies, different scales or scoring systems to
52 117
53 developed, which assigns scores (NRS) for degree assess depth and quality of sedation have been
118
54 of ataxia, sedation depth and surgical conditions, described. In addition, a few authors described pro-
119
55 and uses these to prescribe changes in the tocols to adjust the infusion rate of sedatives and/or 120
56 administration rate of constant rate infusions of administer additional boluses of sedatives or 121
57 122
58 123
59 124
60 125
61 1 126
62 127
63 128
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
Table 1 Scoring systems used to evaluate depth and quality of sedation and degree of instability/ataxia obtained with
3 68
alpha-2 agonists in experimental and clinical studies in horses
4 69
5 70
6 Reference Depth of sedation Quality of sedation Ataxia Algorithm to 71
7 adapt 72
doses/rates
8 73
9 74
Experimental studies
10 75
Bryant et al. (1991) HHAG (%) NRS (0e3) responses to NRS (0e3) e
11 stimuli
76
12 Clarke et al. (1991) HHAG (cm) NRS (0e3) responses to NRS (0e3) e 77
13 stimuli 78
14 England et al. (1992) HHAG (%) NRS (0e3) responses to NRS (0e3) 79
15 stimuli 80
16 Luna et al. (1992) HHAG (cm) 81
17 MFSS (0e8), calculated as sum of NRS scores (0e2) for e e 82
18 drooping of eyelid, drooping of lower lip, response to tactile 83
19 stimulation and response to introducing a probe into the ears 84
20 Hamm et al. (1995) HHAG (cm) NRS (0e3) responses to NRS (0e3) e 85
21 stimuli 86
22 NRS (0e3) subjective 87
23 prediction of response to 88
24 clinical procedures 89
25 Figueiredo et al. SDS for behaviour Presence or absence of facial Scale (0e1) for e 90
(2005) NRS (0e3) oedema, lip separation, head posture
26 91
& ear ptosis
27 92
Rohrbach et al. (2009) MFSS (0e10) calculated as e Included in depth e
28 93
sum of NRS scores for attitude of sedation (0e3)
29 94
(0e3), standing ability (0e3),
30 95
head (0e2), eyes (0e1) and
31 ears (0e1)
96
32 Ringer et al. (2012a) HHAG (%) e VAS (0e10 cm) e 97
33 Ringer et al. (2012b) HHAG (%) e VAS (0e10 cm) e 98
34 Wojtasiak-Wypart HHAG (cm) e e e 99
35 et al. (2012) NRS (0e3) 100
36 Poller et al. (2013) NRS (0e3) for head height NRS (0e3) response to stimuli e e 101
37 MFSS (0e9) calculated as sum of NRS scores for head height 102
38 and response to stimuli 103
39 Ringer et al. (2013) HHAG (%) NRS (0e3) response to stimuli NRS (0e4), static & e 104
40 VAS (0e10 cm) in motion 105
41 VAS (0e10 cm) 106
42 Risberg et al. (2014) VAS (0e10 cm) based on simultaneous evaluation of degree e e 107
43 and quality of sedation 108
44 Santonastaso et al. HHAG (%) NRS (0e3) response to stimuli e e 109
45 (2014) 110
Costa et al. (2015) HHAG (cm) NRS (0e3) response to stimuli NRS (0e3) e
46 111
de Vries et al. (2016) MFSS (0e10) as in Rohrbach e NRS included in depth
47 112
et al. (2009) of sedation (as in
48 113
Rohrbach et al. 2009)
49 114
Cenani et al. (2017) HHAG (cm) VAS (0e10 cm) for general NRS (0e3) e
50 115
activity and alertness
51 Pressure at which horse
116
52 responded to algometer and 117
53 distance at which horse 118
54 noticed an approaching 119
55 umbrella 120
56 Gozalo-Marcilla et al. HHAG (cm) NRS (0e3) response to stimuli NRS (0e3) e 121
57 (2017) 122
58 VAS (0e10 cm) based on subjective assessment of depth of sedation and degree of 123
59 ataxia 124
60 Medeiros et al. (2017) HHAG (%) NRS (0e3) NRS (0e3) e 125
61 126
62 2 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
Table 1 (continued )
3 68
4 Reference Depth of sedation Quality of sedation Ataxia Algorithm to 69
5 adapt 70
6 doses/rates 71
7 72
Clinical studies
8 73
Hamm & Jo €chle SDS SDS e e
9 74
(1991)
10 75
Donaldson et al. NRS (1e3) e e e
11 76
(2000)
12 77
Freeman & England HHAG (cm) VAS (0e10 cm) responses to VAS (0e10 cm) e
13 (2000) Distance ear tips stimuli
78
14 Thickness upper lip 79
15 Leece et al. (2008) NRS (1e3) e e e 80
16 Virgin et al. (2010) e VAS (0e10) e e 81
17 € ppel & Leece
Klo NRS (1e4) e e e 82
18 (2011) 83
19 Hopster et al. (2013) e NRS for introduction mouth NRS (1e4) Yes 84
20 gag (1e4), chewing, head 85
21 movements and tongue 86
22 movements (1e5) and 87
23 sedation quality (1e10) 88
24 Marly et al. (2014) MFSS (0e11) calculated as MFSS (0e6) calculated as Included in depth of Yes 89
25 sum of NRS scores for attitude sum of NRS scores for sedation 90
26 (0e3), standing ability (0e4), response to dentist stimulation 91
27 head (0e1), eyes (0e1) and (0e3) and whether or not the 92
ears (0e2) procedure can be performed
28 93
(0 or 3)
29 94
VAS (0e10 cm)
30 95
Taylor et al. (2014) NRS (0e3) NRS (1e4) as ‘overall NRS (0e3) e
31 96
outcome’
32 97
Müller et al. (2017) e VAS (1e10) for quality of NRS (1e5) Yes
33 sedation and quality of tooth
98
34 extraction 99
35 NRS (1e5) chewing/head 100
36 movement/tongue activity 101
37 Romagnoli et al. NRS (0e3) e e e 102
38 (2017) 103
39 Sacks et al. (2017) Presence or absence of 3 specific conditions: head lower than Yes 104
40 withers, lower lip atonic, no reaction to introduction of pen in ear 105
41 106
42 HHAG, head height above the ground; MFSS, multifactorial sedation scale; NRS, numerical rating scale; SDS, simple descriptive scale; VAS, visual 107
analogue scale. ‘Responses to stimuli’ indicates that authors observed the response to auditory, visual or tactile stimuli, responses to nociceptive
43 stimulation (if applicable) are not shown in this table.
108
44 109
45 110
46 111
47 analgesics, based on the sedation score. Given the Materials and methods 112
48 lack of uniformity between authors, the aim of this 113
For the literature review, two databases were
49 review was to give an overview of the different 114
50
searched: PubMed and Web of Science. The following 115
sedation scales or scoring systems available, and
51 search terms were used: ‘horse’, ‘sedation’ and 116
whether/how these scoring systems have been used
52 ‘score’. The abstracts of all identified studies were 117
to adjust drug administration in research or clinical
53 evaluated to determine their suitability for inclusion. 118
54
settings. A secondary aim was to develop a protocol 119
Only studies where alpha-2 agonists were used,
55 for adjustment of the administration rate of seda- 120
where a scoring system was described to score seda-
56 tives under clinical circumstances, which could 121
tion, and which were published in the period
57 serve as a teaching method for veterinary students, 122
58
1990e2017, either in English or in German, were 123
and to increase the repeatability between anaes-
59 included in this review. For each paper, the type of 124
thetists when performing research on sedation
60 scoring system, the criteria used to describe the 125
protocols.
61 126
62 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 3 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
degree and quality of sedation and degree of ataxia, scores assigned to several parameters. Degree of
3 68
4 both under experimental and clinical conditions, as ataxia: 0) no change from unsedated animal; 1) 69
5 well as protocols to adjust the dose and/or rate of stable but slight swaying; 2) swaying and leaning on 70
6 administration of alpha-2 agonists, were recorded stocks; and 3) leaning on stocks, swaying with hind 71
7 and summarized. limbs crossed, forelimbs buckling at the knee 72
8 (Bryant et al. 1991). Response to stimulation: 0) no 73
9 Results response; 1) slow hesitant response; 2) medium 74
10 75
speed response; and 3) substantial, rapid response
11 76
Types of scoring systems (Bryant et al. 1991). Response to visual stimulation:
12 77
13 The most classical method to assess depth of sedation 0) undiminished response, animal moves away 78
14 in horses is the height of the head above the ground vigorously; 1) muted response, subdued reaction 79
15 and movements; 2) reaction significantly subdued; 80
(HHAG), either expressed in cm, or as a percentage
16 and 3) no signs of visual arousal (Hamm et al. 81
17
change compared to baseline (Table 1). However, 82
HHAG is usually measured on the undisturbed horse 1995).
18 83
Several authors have also used VAS scores
19 and does not always accurately predict the response 84
20 to stimulation (Hamm et al. 1995; Ringer et al. (Table 1), which consist of a continuous line, with a 85
21 2013). For this reason, in analogy with methods to description of the limits on either end of the scale [e.g. 86
22 assess pain, different scoring systems have been ranging from 0) excellent sedation to 10) no sedation 87
23 evident, procedure impractical without further 88
described to assess depth and/or quality of sedation,
24 physical or chemical restraint (Freeman & England 89
25
including simple descriptive scales (SDS), numerical 90
rating scales (NRS), visual analogue scales (VAS) and 2000)]. These scores can be used to assess the over-
26 91
what could be called ‘multifactorial sedation scales’ all depth of sedation under experimental conditions
27 92
28 (MFSS). (Risberg et al. 2014; Cenani et al. 2017), or the 93
29 The most basic type is the SDS, where the observer quality of sedation to perform the planned procedure 94
30 chooses one of several descriptors for the behaviour under clinical circumstances (Freeman & England 95
31 2000; Virgin et al. 2010; Marly et al. 2014; Müller 96
or depth or quality of sedation. Only a few authors
32 et al. 2017). Some authors have also used VAS 97
33
have used this type of score (Table 1). Hamm & J€ochle 98
(1991) evaluated sedation quality as very satisfac- scores to assess specific aspects of sedation, such as
34 99
ataxia, or the response to auditory/tactile stimulation
35 tory, satisfactory or unsatisfactory for the intended 100
36 operation, and classified the depth of sedation as (Freeman & England 2000; Ringer et al. 2013). 101
37 slight, moderate, deep or very deep, basing their de- Finally, a few authors have combined different 102
38 cision on the clinical observation of lowering of the scores to calculate a total sedation score, which, in 103
39 similarity with pain assessment scales, could be called 104
head, a widened distance between the ear tips, the
40 an ‘MFSS’ score (Table 1) (Luna et al. 1992; 105
41
degree of instability and the reduction in response to 106
sensorial stimuli (consisting of movement and the Rohrbach et al. 2009; Poller et al. 2013; Marly
42 107
et al. 2014; de Vries et al. 2016).
43 usual background noise in the hospital environment). 108
44 In a later study, the behaviour of horses before and 109
45 after the administration of romifidine was categorized Depth of sedation, quality of sedation and degree 110
46 as ‘violent’, ‘very nervous’, ‘anxious’, ‘alert/calm’, of ataxia 111
47 112
‘sedate/drowsy’, ‘obtunded’ or ‘comatose’ As stated by Ringer et al. (2013), it is important to
48 113
49
(Figueiredo et al. 2005). make a distinction between the depth (or degree) of 114
50 In contrast, a multitude of authors used NRS sedation (assessed in the nonstimulated horse) and 115
51 scores. These are similar to SDS scores, but assign a the quality of sedation (whether or not the horse will 116
52 number to each descriptor, normally in increasing respond to surgical or other stimuli). A third feature 117
53 or decreasing order of depth or quality of sedation. that should be described when evaluating sedation is 118
54 An NRS score can either be based on a single, overall 119
the degree of postural instability/ataxia. Since this is
55 120
impression of the animal, or NRS scores can be partly related to the depth of sedation, some authors
56 121
57
appointed for multiple parameters at the same time, included it in the overall assessment of degree of 122
58 such as the degree of ataxia, the response to different sedation (Rohrbach et al. 2009; Marly et al. 2014; de 123
59 types of stimulation (tactile, visual and/or auditory), Vries et al. 2016), but most authors report this var- 124
60 etc. (Table 1). The following are examples of NRS iable as a separate property of sedation (Table 1). 125
61 126
62 4 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
As mentioned earlier, to evaluate the depth/degree England et al. 1992; Hamm et al. 1995; Poller
3 68
4 of sedation, the most frequently used variable is the et al. 2013; Gozalo-Marcilla et al. 2017), movement 69
5 HHAG, but several authors have used NRS scores of people in the room (Hamm & J€ ochle 1991; Risberg 70
6 instead (Table 1). A few authors have also combined et al. 2014), opening an umbrella (Ringer et al. 71
7 several NRS scores into an MFSS for evaluation of the 2013) or moving an open umbrella towards the 72
8 degree/depth of sedation (Rohrbach et al. 2009; head of the horse (Cenani et al. 2017). Tactile stim- 73
9 Marly et al. 2014; de Vries et al. 2016), while yet ulation has been performed by touching the coronets 74
10 75
others have used an SDS, the distance between the or metatarsus with a pencil, pen or blunt probe
11 76
12 ear tips or the thickness of the upper lip (Table 1). (Clarke et al. 1991; England et al. 1992; Luna et al. 77
13 Assessing the quality of sedation is usually per- 1992; Freeman & England 2000; Ringer et al. 78
14 formed by observing the response to different types of 2013; Gozalo-Marcilla et al. 2017), touching the 79
15 stimulation (see section ‘Parameters used to evaluate withers with a blunt probe (Luna et al. 1992), tick- 80
16 sedation’). This response to stimulation is most often ling/touching (the inside of) the ear with a pen/finger 81
17 evaluated using an NRS score, although some au- (Clarke et al. 1991; England et al. 1992; Gozalo- 82
18 83
thors have also used VAS or MFSS scores (Table 1). Marcilla et al. 2017; Medeiros et al. 2017) or push-
19 84
20 The degree of ataxia or instability is usually eval- ing an algometer against the neck of the horse 85
21 uated by observing the spontaneous posture of the (Cenani et al. 2017). Although some authors have 86
22 standing horse and/or describing the degree of also observed the response to nociceptive stimulation 87
23 leaning on the stocks (England et al. 1992; in sedated animals, this is used for evaluating anal- 88
24 Figueiredo et al. 2005; Rohrbach et al. 2009; gesia rather than for sedation and will not be dis- 89
25 Hopster et al. 2013; Müller et al. 2017). Alterna- cussed further here. 90
26 91
tively, the horse can be pushed to detect swaying Other parameters that have been considered
27 92
28 (Gozalo-Marcilla et al. 2017; Medeiros et al. 2017), include the distance between the ear tips, the degree 93
29 observed at walk on a flat surface (Ringer et al. 2013) of closure/drooping of the eyelids, eye alertness, de- 94
30 or observed when the horse walks over a wooden bar gree of facial oedema, degree of lip separation and 95
31 (Freeman & England 2000). Again, NRS scores are degree of head/ear movement (Luna et al. 1992; 96
32 most often used to assess the degree of ataxia, but Figueiredo et al. 2005; Rohrbach et al. 2009; 97
33 occasionally VAS scores have been used, and some Wojtasiak-Wypart et al. 2012; Romagnoli et al. 98
34 99
authors have included the degree of ataxia in the 2017). In addition, some authors have also recorded
35 100
36 assessment of the depth of sedation (Table 1). the presence or absence of specific behaviour, such as 101
37 excitatory phenomena (restlessness, head shaking, 102
38 Parameters used to evaluate sedation: increased lacrimation or salivation) (Poller et al. 103
39 experimental versus clinical settings 2013), or any other effects that occurred during the 104
40 experiment (England et al. 1992). 105
41 Experimental studies 106
42 107
Under experimental conditions, beside the HHAG and Clinical studies
43 108
44 subjective scores for the overall impression and/or the 109
While many of the abovementioned parameters can
45 degree of instability or ataxia, the response to audi- 110
be used under clinical circumstances, some can only
46 tory, visual, tactile and/or nociceptive stimulation is 111
be used under experimental conditions. These obvi-
47 often used to predict how the horse would respond to 112
48 ously include the degree of ataxia at walk and the 113
a surgical/nonsurgical procedure. Examples of audi-
49 response to deliberate auditory, visual, tactile or 114
tory stimulation are clapping the hands behind the
50 nociceptive stimulation (especially when a blindfold 115
horse (Clarke et al. 1991; England et al. 1992;
51 and/or ear plugs are used), but even the HHAG 116
52 Gozalo-Marcilla et al. 2017; Medeiros et al. 2017), 117
cannot be used when the horse’s head is supported
53 banging on an empty metal bucket (Hamm et al. 118
(e.g. during dental procedures). Assessing the depth
54 1995; Freeman & England 2000), the usual back- 119
of sedation and titrating sedatives to effect during a
55 ground noise in a hospital environment (Hamm & 120
56 procedure can therefore be challenging. As opposed 121
J€ochle 1991; Risberg et al. 2014), cracking a plastic
57 to a uniform type of sensorial stimulation, the 122
bag (Poller et al. 2013), a horse ‘nicker’ or a metallic
58 anaesthetist rather relies on the response to surgery 123
noise (Ringer et al. 2013). Visual stimulation has
59 and introduction of a mouth gag, the degree of 124
60 been performed by waving a piece of cloth or a bag 125
chewing and the degree of tongue movement
61 towards/close to the head (Clarke et al. 1991; 126
62 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 5 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
(Hopster et al. 2013; Müller et al. 2017). Urination, The Ghent Sedation Algorithm
3 68
4 shaking/twitching the head or muzzle, snoring and 69
From this literature review, it can be concluded that
5 persistent forward movement in the stocks have also 70
currently described ways of assessing and adjusting
6 been taken into account (Marly et al. 2014). 71
sedation depth and quality have some shortcomings
7 72
8 for use under clinical conditions, especially when a 73
Protocols for adjustment of dose and rate of
9 head support is used for dental or other procedures. 74
alpha-2 agonists
10 Under these circumstances, the HHAG, as well as the 75
11 Sacks et al. (2017) described a simple protocol to response to different types of stimulation, cannot be 76
12 adjust the dose of dexmedetomidine or medetomidine used. In addition, the currently described techniques 77
13 when used for premedication (initial doses 3.5 and 7 to adjust the administration rate of sedatives mainly 78
14 79
15
mg kg 1, respectively). In their study, the sedation consist of administering boluses when sedation is
80
16 before induction of anaesthesia was considered insufficient to perform the procedure. Although 81
17 inadequate and a supplemental dose of dexmedeto- administration of a bolus is the quickest way to in- 82
18 midine or medetomidine (0.5 and 1 mg kg-1, respec- crease depth and/or quality of sedation once it is 83
19 tively) administered when one of the following considered insufficient, an algorithm that provides a 84
20 conditions were not met: 1) head height lower than more stable plane of sedation, thus preventing the 85
21 the withers (eyes as benchmark); 2) lower lip atonic; need for additional boluses, would be more useful for 86
22 87
and 3) no reaction to stimulation with a pen if clinical purposes. In addition, no clear guidelines can
23 88
24 touching the inside of the ears. be found in literature to manage a situation where 89
25 However, very few authors have described pro- the level of sedation is considered too deep. 90
26 tocols to adjust the administration rate of alpha-2 Based on this literature review, the Ghent Sedation 91
27 agonists (and, if applicable, concomitant sedative or Algorithm (GSA) for adjustment of alpha-2 adminis- 92
28 analgesic drugs) when performing surgical proced- tration rates was developed at Ghent University, 93
29 ures on standing horses (Table 1). In two studies on taking the degree of ataxia, the apparent depth of 94
30 95
horses undergoing tooth extraction, different combi- sedation and the surgical conditions into account,
31 96
32 nations of constant rate infusions of romifidine [bolus with NRS scores from 0 to 3 for the three parameters 97
33 30 mg kg 1; infusion 40 mg kg 1 hour 1 (Hopster (Table 2). These scores are based on the most often 98
34 et al. 2013) or 50 mg kg 1 hour 1 (Müller et al. used criteria to evaluate sedation in the current re- 99
35 2017)] and constant rate infusions of butorphanol view. Using the three NRS scores, a decision is made 100
36 (Hopster et al. 2013; Müller et al. 2017) midazolam to increase or decrease the administration rate of 101
37 or ketamine (Müller et al. 2017) were used. In both alpha-2 agonists according to a detailed algorithm 102
38 103
studies, the infusion rate of the different drug com- (Table 3). After the initial sedation, continuous
39 104
40 binations was maintained constant, but when a high administration of the alpha-2 agonist is immediately 105
41 score (indicating a light sedation) was reached for the started at the rate normally used by the individual 106
42 reaction to introduction of the mouth gag, chewing, clinician. During the infusion, the algorithm allows 107
43 head movements, tongue movements and quality of the evaluator to objectively act in any of the possible 108
44 sedation, a bolus of romifidine (10 mg kg 1) was 64 scenarios (three parameters with four possible 109
45 administered. In another study on horses undergoing scores for each parameter); for example, maintain, 110
46 111
dental or ophthalmologic procedures using an infu- increase or decrease the rate of sedative, give a bolus
47 112
48 sion of romifidine (bolus 80 mg kg 1; infusion 29 mg or stop the infusion. Even the situation of stopping the 113
49 kg 1 hour 1) with or without butorphanol (Marly standing procedure and performing general anaes- 114
50 et al. 2014), separate MFSS scores were determined thesia is considered. Ideally, the anaesthetist contin- 115
51 for depth and quality of sedation. If the level of uously assesses the three NRS scores and makes 116
52 sedation was considered too deep, the administration adjustments as soon as this is needed. For research 117
53 rate of sedatives was reduced by 25%, while a bolus of purposes, it is suggested to record scores and make 118
54 119
romifidine (20 mg kg 1) was administered and the adjustments (when needed) at intervals of maximally
55 120
56 procedure interrupted for 5 minutes if sedation was 5 minutes. However, preliminary findings during 121
57 evaluated or considered insufficient to perform the clinical use suggested that for certain combinations of 122
58 procedure. This bolus was repeated up to two times, scores, the level of sedation tended to become grad- 123
59 and if sedation was still insufficient, a rescue bolus of ually deeper while the algorithm did not prescribe a 124
60 butorphanol was administered. change in the administration rate of the alpha-2 125
61 126
62 6 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
agonist, finally resulting in overly deep levels of degree) of sedation (assessed in the nonstimulated
3 68
4 sedation and the need for larger, more abrupt re- horse) and the quality of sedation (whether or not the 69
5 ductions in the dose. Therefore, an adjustment was horse will respond to surgical or other stimuli). In 70
6 made: if during 10 minutes (or on two consecutive addition, the degree of postural instability/ataxia 71
7 timepoints when scoring at 5 minute intervals), the must be evaluated. 72
8 scores for sedation and surgical condition are, Several scoring systems have been used by different 73
9 respectively, 2 (good sedation) and 3 (outstanding authors to achieve this. The depth of sedation has very 74
10 75
surgical conditions), while there is no or only mini- often been described using the HHAG. This is an
11 76
12 mal ataxia (score 0 or 1), the alpha-2 agonist objective, easily measurable and continuous (or semi- 77
13 administration rate is reduced, for example, by 25% continuous) variable, enabling more powerful statisti- 78
14 of the original rate (for detomidine, changes in the cal analysis than for discrete scores (if a t-test can be 79
15 rate by 2.5 mg kg 1 minute 1 are proposed, since the used and the normal distribution assumption holds). 80
16 initial rate of detomidine infusion for standing surgi- Unfortunately, the HHAG does not necessarily predict 81
17 cal procedures of the authors is usually around 10 mg the response to stimulation or surgery. Some authors 82
18 83
kg 1 minute 1). The same is done if a score of 2 is have used an SDS to score sedation instead. The main
19 84
20 given for all aspects during 10 minutes (or on two disadvantages to the use of an SDS are the inherent 85
21 consecutive timepoints when scoring at 5 minute subjectivity, the low discriminative capacity (especially 86
22 Q5 intervals), representing good sedation and adequate if only a few descriptors are considered) and the diffi- 87
23 surgical conditions, but with clear swaying/leaning culty to analyse the data statistically. The disadvan- 88
24 against the stocks. tages of NRS scores are similar to those of SDS scores. 89
25 Although statistical analysis of NRS scores (ordinal 90
26 Discussion 91
variable) is more feasible than for SDS scores, it is still
27 92
28 Before protocols can be developed to adjust the dose suboptimal, as the variable is a numerical, but discrete 93
29 or administration rate of alpha-2 agonists for sedation scale. Finally, VAS scores can also be used to evaluate 94
30 in standing horses, the ‘level’ of sedation must be sedation (overall level, or specific aspects of sedation). 95
31 Although a VAS scores is still subjective, as a contin- 96
evaluated. As stated by Ringer et al. (2013), a
32 uous variable it can usually be analysed with 97
33
distinction must be made between the depth (or 98
34 99
35 100
Q9 Table 2 Scoring system to assess position/ataxia, sedation depth and surgical condition in standing horses
36 101
37 102
38 Position/ataxia Clinical signs 103
39 104
40 0 Standing square, bearing equal weight on all four legs. 105
41 1 One hind limb in resting position and/or slight swaying. 106
42 2 Clear swaying or leaning against the stocks (not bearing weight on maximally one of the four limbs). 107
43 3 Very pronounced leaning (possibly not bearing weight on several limbs) and/or attempts to become 108
44 recumbent. 109
45 Sedation depth 110
0 No sedation. Animal is alert with normal posture and response to environment/contact with assessor.
46 111
Normal objection to intervention. Ears responsive to surroundings (moving).
47 112
1 Mild sedation. May or may not lean on head support, relaxed facial muscles. Reduced responses to
48 113
background activity in the room. Ears partially responsive to surroundings. Light or no ptosis of the ears.
49 114
2 Good sedation. Leans on head support. No response to background activity in the room. Pendulous lower
50 115
lip. Ears mildly responsive to surroundings. Moderate ear ptosis. Eyelids partially closed.
51 3 Marked sedation. Leans strongly on head support. No response to background activity in the room.
116
52 Pendulous lower lip. Pronounced ear ptosis, minimal/no movement of ears. Eyelids partially or fully closed. 117
53 Eye may be rotated, little to no movements of the eye. 118
54 Surgical condition 119
55 0 Excessive interference from the horse. Impossible to perform surgery. 120
56 1 Moderate interference from the horse. Strong movements, heavy chewing and movement of the tongue. 121
57 Repeated attempts to pull away or lift the head. 122
58 2 Acceptable interference from the horse. Small movements, moving the tongue or chewing. Little or no 123
59 attempts to pull away or lift the head. 124
60 3 No interference from the horse. Hardly any movement. 125
61 126
62 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 7 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
Table 3 Algorithm to adjust the alpha-2 agonist infusion rate in order to maintain/achieve the minimum level of ataxia,
3 68
with an adequate plane of sedation and surgical condition; 64 possible scenarios are considered depending on the three
4 different parameters and the four possible scores for each parameter 69
5 70
6 71
7 Ataxia 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 72
Sedation 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3
8 73
Surgical condition 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3
9 74
Action B B [[ e B B [ e B B e e B B Y Y
10 75
Ataxia 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1
11 76
Sedation 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3
12 77
Surgical condition 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3
13 Action B B [[ e B B [ e B B e e B B Y Y
78
14 Ataxia 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 79
15 Sedation 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 80
16 Surgical condition 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 81
17 Action B B [ e B B e e B B e Y [ [ Y YY 82
18 Ataxia 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 83
19 Sedation 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 84
20 Surgical condition 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 85
21 Action GA Y S S GA Y S S GA S S S GA S S S 86
22 87
23 Each evaluation is performed every 5 minutes. e, maintain the same administration rate. [ or Y, respectively, increase or decrease the alpha-2 agonist 88
infusion rate, for example, by 20e25% of the original rate (for detomidine, changes by 2.5 mg kg 1 min 1 are proposed). [[ or YY, increase or decrease
24 the infusion rate by 40e50% of the original rate (for detomidine, changes by 5 mg kg 1 min 1 are proposed). If during 10 minutes the scores 1e2e3,
89
25 0e2e3 or 2e2e2 (ataxiaesedationesurgical condition) are given, then Y. B, administer a bolus (25% of dose used for initial sedation) of the alpha-2 90
26 agonist and [ rate (as above); GA, impossible to perform surgery in the standing horse, proceed to general anaesthesia; S, stop infusion. 91
27 92
28 parametric tests (provided the data are normally anaesthetists, infrequent need for abrupt changes in 93
29 94
distributed). Under most circumstances, continuous administration rate (bolus/discontinuing the infu-
30 95
ordinal regression provides the most powerful statisti- sion) and good scores for quality of the procedure.
31 96
32 cal analysis, although both distribution-free and However, these findings may be biased, as they are 97
33 normal-distribution methods can be considered under subjective. Before the algorithm can be advised for 98
34 specific conditions (Heller et al. 2016). use in experimental or clinical settings, dedicated 99
35 Under experimental conditions, the response of studies are needed to evaluate the agreement be- 100
36 sedated horses to different types of stimulation can be tween different anaesthetists, to evaluate perfor- 101
37 102
used to assess the depth and quality of sedation. Un- mance of the algorithm with different alpha-2
38 103
fortunately, this is not possible under clinical condi- agonists and to identify possible shortcomings.
39 104
40 tions, nor can the HHAG be used when the head is Another limitation of this short review is the possi- 105
41 supported (e.g. for dental surgery). Hence, only a limited bility of incomplete retrieval of studies reporting seda- 106
42 number of authors have reported sedation scores for tion scores, for example, studies that are not included in 107
43 clinical patients, and protocols to maintain a sufficient the databases searched, which are published in other 108
44 depth and quality of sedation (Hopster et al. 2013, languages than English or German, or where the ab- 109
45 110
Marly et al. 2014, Müller et al. 2017). These authors stract does not clearly mention the use of sedation
46 111
used a constant administration rate of the sedative and scores. Finally, some aspects of the scoring system
47 112
48 administered a bolus of the sedative when sedation had described in Table 2 are aimed primarily at dental 113
49 become insufficient. In addition, Marly et al. (2014) procedures, more specifically the degree of leaning on 114
50 reduced the administration rate by 25% when the the head support and the presence or absence of 115
51 level of sedation had become too deep. However, to the chewing and movement of the tongue. However, pre- 116
52 author’s knowledge, the GSA is the first algorithm liminary findings during other procedures suggest that, 117
53 118
which allows constant ‘up’ or ‘down’ adjustment of the when these specific details are not taken into account,
54 119
administration rate of alpha-2 agonists, possibly leading the scoring system and GSA can still be used.
55 120
56 to a more stable depth and quality of sedation. 121
57 Results from a recent study (Gozalo-Marcilla et al. Conclusion 122
58 2018) and preliminary findings under clinical cir- The GSA allows constant adjustment of sedation 123
59 cumstances when using the GSA with detomidine 124
depth and quality, and may be useful under both
60 infusions suggest a good agreement between 125
61 clinical and experimental conditions; however, 126
62 8 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 66
2 67
further research is needed to evaluate inter-observer Freeman SL, England GCW (2000) Investigation of
3 68
agreement, as well as performance of the algorithm romifidine and detomidine for the clinical sedation of
4 69
for various types of procedures and with different horses. Vet Rec 147, 507e511.
5 70
Gozalo-Marcilla M, Luna SPL, Crosignani N et al. (2017)
6 alpha-2 agonists and/or other classes of sedatives. 71
7 Sedative and antinociceptive effects of different com- 72
8 binations of detomidine and methadone in standing 73
Acknowledgements
9 horses. Vet Anaesth Analg 44, 1116e1127. 74
10 This cooperation work between institutions was Gozalo-Marcilla M, Luna SPP, Gasthuys F et al. (2018) 75
11 supported by S~ao Paulo Research Foundation Clinical applicability of detomidine and methadone 76
12 (FAPESP), Scholarship grant numbers 2014/00474- constant rate infusions for standing surgery in horses. 77
13 5 and 2017/01425-6.
Vet Anaesth Analg (under review). Q8 78
Q6
14 Hamm D, J€ ochle W (1991) Sedation and analgesia with 79
15 dormosedan® (Detomidine hydrochloride) or acepro- 80
Authors’ contributions
16 mazlne for suturing of the vulvar lips in mares (Cas- 81
17 SS: data collection, preparation and revision of lick’s surgery). J Equine Vet Sci 11, 86e88. 82
18 manuscript. CC: data collection and revision of Hamm D, Turchi P, J€ ochle W (1995) Sedative and 83
19 analgesic effects of detomidine and romifidine in hors- 84
manuscript. AM and FG: revision of manuscript.
20 es. Vet Rec 136, 324e327. 85
21
MGM: data collection, preparation and revision of 86
Heller GZ, Manuguerra M, Chow R (2016) How to
22 manuscript. 87
analyze the visual analogue scale: myths, truths and
23 88
clinical relevance. Scand J Pain 13, 67e75.
24 Conflict of interest statement 89
Hopster K, Bienert-zeit A, Hopster-iversen C et al. (2013)
25 90
Authors declare no conflict of interest. Einfluss von Ketamin oder Midazolam in kombination mit
26 91
einer dauertropfinfusion von romifidin und butorphanol
27 92
References auf die sedierungsqualit€at w€ ahrend zahnextraktionen
28 93
29 am stehenden pferd. Pferdeheilkunde 29, 220e227. 94
Bryant CE, England GCW, Clarke KW (1991) Comparison Kl€
oppel H, Leece EA (2011) Comparison of ketamine and
30 95
of the sedative effects of medetomidine and xylazine in alfaxalone for induction and maintenance of anaes-
31 96
32 horses. Vet Rec 129, 421e423. thesia in ponies undergoing castration. Vet Anaesth 97
33 Cenani A, Brosnan RJ, Madigan S et al. (2017) Phar- Analg 38, 37e43. 98
34 macokinetics and pharmacodynamics of intravenous Leece EA, Corletto F, Brearley JC (2008) A comparison of 99
35 romifidine and propranolol administered alone or in recovery times and characteristics with sevoflurane and 100
36 combination for equine sedation. Vet Anaesth Analg isoflurane anaesthesia in horses undergoing magnetic 101
37 Q7 44, 86e97. resonance imaging. Vet Anaesth Analg 35, 383e391. 102
38 Clarke KW, England GCW, Goossens L (1991) Sedative Luna SPLP, Beale NJJ, Taylor PMM (1992) Effects of 103
39 and cardiovascular effects of romifidine, alone and in atipamezole on xylazine sedation in ponies. Vet Rec 104
40 combination with butorphanol, in the horse. J Vet 130, 268e271. 105
41 Anaesth 18, 25e29. Marly C, Bettschart-Wolfensberger R, Nussbaumer P 106
42 Costa GL, Cristarella S, Quartuccio M et al. (2015) Anti- et al. (2014) Evaluation of a romifidine constant rate 107
43 nociceptive and sedative effects of romifidine, tramadol infusion protocol with or without butorphanol for 108
44 and their combination administered intravenously dentistry and ophthalmologic procedures in standing 109
45 slowly in ponies. Vet Anaesth Analg 42, 220e225. 110
horses. Vet Anaesth Analg 41, 491e497.
46 de Vries A, Pakkanen SA, Raekallio MR et al. (2016) 111
Medeiros LQ, Gozalo-Marcilla M, Taylor PM et al. (2017)
47 Clinical effects and pharmacokinetic variables of romifi- 112
Sedative and cardiopulmonary effects of dexmedeto-
48 113
dine and the peripheral alpha-2 adrenoceptor antagonist midine infusions randomly receiving, or not, butor-
49 114
MK-467 in horses. Vet Anaesth Analg 43, 599e610. phanol in standing horses. Vet Rec 181, 402.
50 115
Donaldson LL, Dunlop GS, Holland MS et al. (2000) The Müller TM, Hopster K, Bienert-Zeit A et al. (2017) Effect
51 116
recovery of horses from inhalant anesthesia: a compar- of butorphanol, midazolam or ketamine on romifidine
52 117
ison of halothane and isoflurane. Vet Surg 29, 92e101. based sedation in horses during standing cheek tooth
53 118
54 England GC, Clarke KW, Goossens L (1992) A comparison removal. BMC Vet Res 13, 381. 119
55 of the sedative effects of three alpha 2-adrenoceptor Poller C, Hopster K, Rohn K et al. (2013) Nociceptive 120
56 agonists (romifidine, detomidine and xylazine) in the thermal threshold testing in horses - effect of neuro- 121
57 horse. J Vet Pharmacol Ther 15, 194e201. leptic sedation and neuroleptanalgesia at different 122
58 Figueiredo JP, Muir WW, Smith J et al. (2005) Sedative stimulation sites. BMC Vet Res 9, 135. 123
59 and analgesic effects of romifidine in horses. Int J Appl Ringer SK, Portier K, Torgerson PR et al. (2013) The 124
60 Res Vet Med 3, 249e258. effects of a loading dose followed by constant rate 125
61 126
62 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary 9 127
63 Anesthesia and Analgesia., ▪, 1e10 128
64 129
65 130
Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005
 Sedation scoring systems in horses S Schauvliege et al.
1 27
2 28
infusion of xylazine compared with romifidine on medetomidine for isoflurane balanced anaesthesia in
3 29
sedation, ataxia and response to stimuli in horses. Vet horses. Vet Anaesth Analg 44, 1128e1138.
4 30
Anaesth Analg 40, 157e165. Santonastaso A, Hardy J, Cohen N et al. (2014) Phar-
5 31
Ringer SK, Portier KG, Fourel I et al. (2012a) Develop- macokinetics and pharmacodynamics of xylazine
6 32
7 ment of a romifidine constant rate infusion with or administered by the intravenous or intra-osseous route 33
8 without butorphanol for standing sedation of horses. in adult horses. J Vet Pharmacol Ther 37, 565e570. 34
9 Vet Anaesth Analg 39, 12e20. Taylor P, Coumbe K, Henson F et al. (2014) Evaluation of 35
10 Ringer SK, Portier KG, Fourel a I et al. (2012b) Devel- sedation for standing clinical procedures in horses us- 36
11 opment of a xylazine constant rate infusion with or ing detomidine combined with buprenorphine. Vet 37
12 without butorphanol for standing sedation of horses. Anaesth Analg 41, 14e24. 38
13 Risberg Å, Spadavecchia C, Ranheim B et al. (2014) Virgin J, Hendrickson D, Wallis T et al. (2010) Compar- 39
14 Antinociceptive effects of three escalating dexmedeto- ison of intraoperative behavioral and hormonal re- 40
15 midine and lignocaine constant rate infusions in sponses to noxious stimuli between mares sedated with 41
16 conscious horses. Vet J 202, 489e497. caudal epidural detomidine hydrochloride or a 42
17 Rohrbach H, Korpivaara DVMT, Schatzmann U et al. continuous intravenous infusion of detomidine hydro- 43
18 (2009) Comparison of the effects of the alpha-2 ago- chloride for standing laparoscopic ovariectomy. Vet 44
19 nists detomidine, romifidine and xylazine on nocicep- Surg 39, 754e760. 45
20 tive withdrawal reflex and temporal summation in Wojtasiak-Wypart M, Soma LR, Rudy JA et al. (2012) 46
21 horses. Vet Anaesth Analg 36, 384e395. Pharmacokinetic profile and pharmacodynamic effects 47
22 Romagnoli N, Al-Qudah KM, Armorini S et al. (2017) of romifidine hydrochloride in the horse. J Vet Phar- 48
23 49
Pharmacokinetic profile and partitioning in red blood macol Ther 35, 478e488.
24 50
cells of romifidine after single intravenous administra-
25 51
tion in the horse. Vet Med Sci 3, 187e197. Received 5 March 2018; accepted 23 August 2018.
26 52
Sacks M, Ringer SK, Bischofberger AS et al. (2017)
Available online xxx
Clinical comparison of dexmedetomidine and

10 © 2018 Published by Elsevier Ltd on behalf of Association of Veterinary Anaesthetists and American College of Veterinary
Anesthesia and Analgesia., ▪, 1e10

Please cite this article in press as: Schauvliege S, Cuypers C, Michielsen A et al. How to score sedation and adjust the
administration rates of sedatives in horses: a literature review and introduction of the Ghent Sedation Algorithm,
Veterinary Anaesthesia and Analgesia (2018), https://doi.org/10.1016/j.vaa.2018.08.005