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Please give the Pimobendan and Lasix orally the morning of surgery. Oral Cerenia, Gabapentin and Trazadone can also be given in the morning before surgery to prevent nausea and limit anxiety.
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<p> PREOPERATIVE MEDICATIONS: <br>
Acepromazine: 0.02 mg/kg IM. <br>
This dose may be given if the patient is resistant to catheter placement. The oral Gabapentin and Trazadone may eliminate the need to give Acepromazine, but given the breed, this patient may become aggressive with handling. I also worry about this patient having a subclinical tracheal collapse episode that can be exacerbated by stress. <br> The main side effects with Acepromazine include prolonged sedation and intraoperative hypotension. <br>
The acepromazine may be given in combination with the opioid intramuscularly. <br>
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Buprenorphine: 0.02 mg/kg IM or IV. <br>
OR <br>
Hydromorphone: 0.05 mg/kg IM or IV. <br>
Midazolam: 0.2 mg/kg IV. <br>
Midazolam will reduce the amount of induction drug or inhalant required to maintain general anesthesia during surgery. It can lead to prolong sedation in the recovery period, but it is reversible with Flumazenil, 0.02 mg/kg IV <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 mL/kg/hr during surgery <br> I do not recommend fluid boluses in this patient due to the potential for congestive heart failure after surgery.

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<p>INTRAOPERATIVE MONITORING:<br>
MONITORING: pulse oximetry, ECG, noninvasive blood pressure, end-tidal CO2 and temperature <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).<br>
Given the concurrent mitral valve disease, I would rely on maintaining the heart rate above 100 bpm to facilitate a mean blood pressure above 60 mmHg. This can be done with an anticholinergic or by reducing the amount of inhalant during general anesthesia.
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<p> Locoregional Techniques:<br>
Lidocaine (2%): 2 mg/kg total dose. The ear is a challenge for locoregional techniques given the limited amount of skin and cartilage. However, I would attempt a block either before removal or by infiltrating lidocaine during closure. Every bit helps!
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<p> POSTOPERATIVE PLAN:<br>
Oral NSAIDs are not recommended given that this patient is on Lasix and it can lead to kidney damage.
<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/>