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Given the description, it seems this pet potentially experienced an anaphylactic-like reaction to the premedication drugs, primarily buprenex or dexmedetomidine. The cyanosis associated with the event may have been a result of the underlying heart disease. If the patient hasn’t had a recent echocardiogram, I would recommend it be completed before the next anesthesia event. My thought on this case is to try a locoregional approach with local anesthetics to see if we can perform the procedure with adequate analgesia without administering opioids or alpha-2 agonists. Cerenia can also cause seizures or similar symptoms that you described in this past attempt. It wasn’t listed as a medication given to this patient for this past procedure, but just in case I wouldn’t include it as part of the preoperative therapy.
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<p> PREOPERATIVE MEDICATIONS: <br>
Gabapentin: 10 mg/kg PO. Given 2-3 hours before the procedure, gabapentin will provide sedation and help facilitate the placement of the catheter. <br>
Diphenhydramine: 2 mg/kg IM given 60 minutes before anesthesia. <br>
Dexamethasone SP: 0.2 mg/kg IV given 60 minutes before anesthesia. <br>
If further sedation is required, I would consider Acepromazine (0.01-0.02 mg/kg IM) 30-60 minutes before the catheter placement. <br>

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After induction, I would try a local ring block around the affected digit with bupivacaine before administering an opioid since our goal is to prevent another anaphylactic-like reaction. If the patient is still reacting to the surgery, you may consider a low dose of Hydromorphone at 0.03 mg/kg IV given slowly. <br>

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<p> INDUCTION: <br>
Propofol OR Alfaxalone: 4-6 mg/kg IV
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Please provide supplemental oxygen (100 %) via face mask for 5 minutes before induction. It is important that the face mask remains on the patient’s face through the induction period to prevent hypoxemia if the patient becomes apneic.

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<p> MAINTENANCE: <br>
Isoflurane: 1.3-1.8 % <br>
Sevoflurane: 2.4-3.0 % <br>

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<p> FLUID THERAPY: <br>
Isotonic crystalloid fluids – 3-5 mL/kg/h

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<p>INTRAOPERATIVE MONITORING:<br>
MONITORING: pulse oximetry, ECG, noninvasive blood pressure, end-tidal CO2 and temperature <br>
For intraoperative hypotension, I would consider a constant rate infusion of dobutamine at 3-5 mcg/kg/min. <br>
For intraoperative bradycardia (Heart Rate < 70 bpm), I would consider giving Atropine (0.01-0.02 mg/kg IV) OR Glycopyrrolate (0.005-0.01 mg/kg IV).

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<p> Locoregional for digit amputation:<br>
Bupivicaine (0.5%): 2 mg/kg (total dose) for a ring block around the affected digit. Given the patient’s weight, the full volume will not be needed for the block. Typically, 3-5 mL is sufficient.
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<p> POSTOPERATIVE PLAN:<br>
Oral NSAIDs may be started that evening or the next morning.
<br><br>Please continue to monitor the patient with pulse oximetry in the postoperative period for 30 minutes. If her SPO2 reading falls below 95%, please provide supplemental oxygen via face mask. <p/>