Case study on the unexpected death of an animal after sedation
Published in the March 2015 issue of Vetboard Victoria's newsletter
The following case study provides an opportunity for general reflection. The case study is based on a complaint about an individual set of circumstances at a particular time. As veterinary knowledge and professional and community standards and expectations change over time, readers should not assume that the Vet Board would make the same decision when presented with a similar complaint.
Background
A Mastiff dog was presented to Dr G for nail clipping. The dog was sedated to allow the nail clipping to be performed. During the procedure the dog ceased breathing and had no audible heartbeat. Resuscitation was performed but was unsuccessful. The owner claimed that the drug dosage administered to the dog was inappropriate and that they were not adequately advised of the risks of sedation.
Board decision
With the information provided to it, the Board found no evidence to support the allegation of unprofessional conduct; based upon the following reasons:
Negligent / Inadequate care
The Board considered that the veterinary care provided by Dr G was appropriate and that which would be reasonably expected of a registered veterinary practitioner. Upon making the appointment the owner requested that they be allowed to enter the clinic through the back entrance to minimise contact with other animals and their owners. The owner further requested that only they and the veterinary practitioner handle the dog. On the dog's arrival, Dr G attempted examination; however, the owner was unable to restrain the dog adequately for Dr G to safely proceed with nail clipping. Dr G informed the owner that in order to perform the nail clipping, chemical restraint would be required and that this would need to be administered before a clinical examination could take place. The Board considered Dr G’s assessment that it was not safe to proceed without the use of chemical restraint was reasonable. The safety of the practitioner, staff, and others in the vicinity (including the owner) is of paramount importance, and must be considered a priority when dealing with an animal whose temperament and reaction to handling is unpredictable. The Board considered that both the request of the owner to limit the dog’s contact / handling with others, and Dr G’s failed attempt to examine the dog, indicated that the dog was not amenable to handling by strangers.
The owner reported the dog to be in good health and a visual inspection of the dog by Dr G supported this; the dog appeared to be in good condition, and had no obvious abnormalities.
Supply and use of drugs
Due to the dog’s temperament and the owner’s inability to adequately restrain it, Dr G decided against weighing the dog, as the scales were located in the common waiting area. The Board considered this to be reasonable, given that Dr G was responsible for the safety of all others in the clinic. Dr G estimated the dog’s weight to be approximately 80kg, and this proved to be accurate when the dog’s body was weighed at necropsy. Dr G administered an initial dose of 1.2ml of Domitor® combined with 0.8ml of Torbugesic®. Fifteen to twenty minutes later, the dog was not adequately sedated and a further 0.6ml of Domitor® was administered. The dog was left for a further fifteen to twenty minutes to allow the sedation to deepen, and then a further ten minutes. At this stage the dog showed only mild signs of sedation. Dr G stated that they were not comfortable administering further sedation and gave the owner the option of reversing the sedation (using a reversal agent) and not clipping the nails, or making an attempt with the dog muzzled. The owner consented to muzzling the dog, and this was undertaken with the owner providing additional physical restraint. The nails were clipped and it was then noticed that the dog had ceased breathing. Resuscitation was immediately undertaken but was unsuccessful.
The combination of Domitor® and Torbugesic® is regularly used for sedation in veterinary medicine and is considered relatively safe. A benefit of Domitor® is that its effect is reversible, allowing for sedation to be maintained only as long as is required. The majority of other drugs used for sedation do not have this benefit. The Board were of the opinion that the decision to sedate the dog using a combination of Domitor® and Torugesic®, and the dose rate administered, were reasonable for a dog of its size.
The Board considered that the attempts made to resuscitate the dog were reasonable. The reversal agent was immediately administered and positive pressure ventilation and chest compressions were undertaken in a timely manner. Two doses of adrenaline were administered: one intravenously; the other directly into the heart. Resuscitation was continued for such a time as to allow the reversal agent to take effect. Dr G offered the owner the option of undertaking internal cardiac massage but this was declined.
Unanticipated death
The Board accepted that the dog’s death was unanticipated; however, it considered that the recommended sedation was justified and the subsequent veterinary care provided by Dr G was reasonable. All sedation has risks, many of which cannot be foreseen or anticipated. An adverse reaction is a potential risk with the use of any drug. Necropsy was undertaken but no definitive cause of death was established. The Board considered that the dog’s death, while very unfortunate, was not due to any unprofessional conduct on the part of Dr G.
Inadequate communication
The owner alleged that they were not adequately informed of the risks of sedation nor given adequate options for necropsy. The Board accepted Dr G’s statement that it is not usual practice to discuss the names and features of drugs to be used in great detail as this information is generally of limited benefit to the owner. The Board further accepted that it was likely that the sedation process was discussed in general terms and considered that any associated risks were reasonably judged to be negligible.
In their response to Dr G’s statement, the owner documented that they were given the option of having the post mortem performed at the clinic or at the University of Melbourne Veterinary Centre and that they agreed to have the post mortem done at the clinic. The Board was satisfied that the owner was given reasonable options for where the necropsy could be performed.
Relevant guidelines