Vol.18, No.
8 August 1996 V
Continuing Education Article
FOCAL POINT
★ Excellent restraint techniques are
necessary to perform high-quality
radiography while minimizing
human exposure to radiation.
KEY FACTS
■ Veterinary personnel should
never place any part of their
bodies within the primary x-ray
beam while restraining animals.
■ Nonmanual restraint should
always be used for properly
anesthetized patients undergoing
radiography.
■ Some anesthetic agents can alter
the radiographic appearance of
the esophagus.
■ Manual restraint can be used for
ultrasonography because it does
not involve ionizing radiation.
■ Appropriate chemical restraint is
the minimum amount of sedation
needed for the efficient and safe
completion of the examination.
Restraint Methods for
Radiography in Dogs
and Cats
Ohio State University Cornell University
Peter V. Scrivani, DVM Nathan L. Dykes, DVM
Richard M. Bednarski, DVM, MS
C. Wendy Myer, DVM, MS
E xcellent restraint methods are necessary for making high-quality radio-
graphs of small animals because few of these patients would otherwise
remain properly positioned. There are many reasons to practice good re-
straint techniques (see the box).
This article reviews various forms of restraint used in small animal radiogra-
phy. Physical restraint can be manual or nonmanual. Pharmacologic agents
used for chemical restraint have to be carefully chosen on the basis of the pa-
tient’s clinical condition and the kind of radiographic study to be performed.
Stress is a factor in disease progression and anesthetic complications.1 One of
the goals in restraint is to reduce patient stress. The positioning, noise, and un-
familiar surroundings associated with the radiographic examination are stress-
ful and can exacerbate clinical signs. The stress of the examination may be
more hazardous than the risks associated with judicious sedation. Stress can be
significantly reduced by performing the examination in a quiet, dimly lit set-
ting and using appropriate sedatives and analgesics.1
PHYSICAL RESTRAINT
Physical restraint of patients includes manual and nonmanual techniques.
Many clinicians prefer to use manual restraint because it is quick, easy, and of-
fers excellent results. However, manual restraint increases the risk of radiation
exposure of personnel. Nonmanual restraint is achieved by using devices (see
the box) to position and hold the patient. Chemical restraint may be combined
with physical restraint methods to facilitate examination (Tables I through III).
Manual Restraint
Manual restraint is sometimes clinically necessary when patients are uncoop-
erative. Chemical restraint may be clinically contraindicated (e.g., in cases of
trauma, pneumothorax, gastric volvulus, shock, or heart failure). Also, certain
dynamic procedures require the presence of the veterinarian.
Small Animal The Compendium August 1996

A useful technique for manual restraint of feral cats
has been described.2 The cat is placed in dorsal recum-
bency and restrained by persons situated cranially and
caudally to the cat. The caudal end of the cat remains
fixed in place as the cranial end is gently swung left and
right immediately prior to
Reasons to Practice positioning for radiographic
Good Restraint exposure.
Obviously, manual re-
Techniques straint entails the highest risk
of radiation exposure for per-
The following are
sonnel. Keeping radiation
reasons why proper exposure as low as reasonably
sedation and nonmanual achievable (ALARA) 3 in-
restraint techniques volves limiting the number
should be substituted for of times that manual re-
manual restraint for straint is performed as well
as the number of persons in-
radiography whenever
volved in each procedure and
possible:
following proper safety pre-
cautions.
■ Minimizes exposure of Veterinary personnel can
personnel to radiation reduce their exposure to ra-
by reducing the diation by wearing lead
aprons and gloves as well as
number of times
thyroid and iris shields. Hu-
manual restraint is man exposure can also be de-
used and the number creased by reducing the
of persons involved number of people in the
per procedure room or near the equipment
■ Minimizes stress for while film is being exposed.
X-rays obey the inverse-
the patient and for
square law: The energy of
personnel the x-ray beam is inversely
■ Reduces the patient’s proportional to the square of
perception of pain the distance from the source
■ Allows high-quality of the beam. 4 Using film/-
radiographic screen combinations that
minimize the amount of ra-
examinations
diation required is also rec-
■ Expedites radiographic ommended.5 Veterinary per-
examination sonnel should never place
■ Reduces the likelihood any part of their bodies with-
that a fractious patient in the primary x-ray beam
will injure personnel while restraining animals.
New York State mandates
or that excessive
that when an animal under-
manipulation will goes radiographic exami-
injure the patient nation, only the persons
necessary to perform the
examination may be in the room during exposure and
animals or film should be held only when clinically
necessary under extreme conditions.6 Monitoring of
exposure (e.g., by dosimeter badges) is helpful for eval-
uating the efficacy of radiation safety precautions. In
New York State, monitoring is required when estimat-
ed exposure from external sources in 1 year exceeds
10% of the applicable annual limit.6 Different limits
are established for adults, minors, and declared preg-
nant women.6 Nevertheless, it is prudent to monitor
all personnel who are occupationally exposed to radia-
tion to evaluate the effectiveness of radiation safety
practices.
Nonmanual Restraint
Many devices can be used to position and restrain a
patient, thus rendering manual restraint unnecessary
(see the box). These devices can also be used along with
manual restraint to limit the
number of persons required Devices for
to position the dog or cat. Positioning and
An atraumatic orange plastic
Restraint
intravenous tubing clamp is
used at Cornell University to ■ Sandbags
restrain cats and ferrets (Fig-
ure 1). The clamp is applied ■ Sponges
to the loose skin over the an- ■ Tape
imal’s shoulders. Remark- ■ Roll gauze
ably, many of the animals lie ■ Plastic clamp
motionless in the correct po- ■ Rope
sition for radiography. ■ Roll cotton
Sandbags and tape are
commonly used for position- ■ Towel
ing and restraint. To work ■ Trough
best, the sandbags should be ■ Muzzle
no more than two thirds full.
Such partial filling allows the bag to be draped over the
patient or wrapped around a limb, thus conforming to
the patient’s contours. For example, restraint for a
dorsoventral view of the thorax can be achieved by
draping sandbags over the neck; the sandbag acts more
like a strap than like a weight. The weight of the sand is
in the most lateral parts of the bag; thus, the non-
weighted center portion is in contact with the patient.
Sandbags can also be used to position the limbs or
torso away from areas of interest. To produce a lateral
view of the shoulder, for example, the neck can be held
in extension with a sandbag so that soft tissue is not su-
perimposed over the shoulder joint. Care must be taken
not to place sandbags over areas of interest because
sand attenuates the x-ray beam. Wrapping the sandbags
with plastic helps keep them clean and sanitary.
Nonradiopaque positioning devices (e.g., foam
sponges or cotton) can be used during the examination.
Sponges of various sizes and shapes facilitate position-
ing of patients. For example, taking a straight lateral

REDUCING RADIATION EXPOSURE ■ ALARA ■ TUBING CLAMP ■ SANDBAGS

The Compendium August 1996 Small Animal

TABLE I
Drugs Used for Chemical Restraint for Radiography of Dogs and Cats
Anesthetic Agent Therapeutic Class Route Dosage Comments
Acepromazine Phenothiazine Subcutaneous, 0.02–0.10 mg/kg; Use in animals that are tractable;
maleate tranquilizer intramuscular, or maximum 3 mg provides better restraint if
intravenous per dog or cat combined with opioids
Butorphanol Opioid Subcutaneous, 0.05–0.20 mg/kg; Patients are sensitive to sound
intramuscular, or maximum dose of and vibration
intravenous 4.5 mg per dog or
cat when used as a
sedative
Oxymorphone Opioid Subcutaneous, 0.05–0.10 mg/kg; More potent analgesic and
intramuscular, or maximum dose of sedative than butorphanol;
intravenous 4.5 mg per dog or induced panting may be a
cat when used as a problem; patients are sensitive to
sedative sound and vibration; controlled
drug
Diazepam Benzodiazepine Intravenous or 0.10 mg/kg Use in old or debilitated patients
intramuscular and when acepromazine is
contraindicated; unpredictable
absorption when given
intramuscularly; liver disease may
prolong elimination
Midazolam Benzodiazepine Intramuscular or 0.05–0.10 mg/kg Similar to diazepam; more
intravenous predictable rate of absorption
when given intramuscularly
Xylazine α2-Adrenergic Subcutaneous, 0.1–0.5 mg/kg Monitor pulse rate and quality;
agonist intramuscular, or use only in healthy patients
intravenous
Ketamine Dissociative agent Intramuscular or 1.0–5.0 Poor muscle relaxation when used
intravenous alone
Diazepam and Benzodiazepine Intravenous 1:1 or 1:2 mixture; Poor muscle relaxation when used
ketamine plus dissociative 1 ml per 10 kg alone; good when short duration
agent of effect is desired
Tiletamine and Benzodiazepine Intramuscular 6.5 mg/kg Similar to diazepam and ketamine
zolazepam plus dissociative (commercially combination but offers better
agent available mixture) muscle relaxation and longer
duration; prolonged recovery
Thiopental sodium Ultra–short-acting Intravenous 8–20 mg/kg; Inject half the calculated dose,
barbiturate maximum dose of then administer to effect; monitor
500 mg for respiration; calculate dose on the
induction basis of lean body weight
Propofol Alkylphenol Intravenous Induction 2 to 4 Extremely rapid rate of onset and
mg/kg; maintenance recovery; may be too expensive
0.2–0.6 mg/kg/min for use in large dogs or long
procedures
Halothane Halogenated Inhalation 0.5%–1.5% Offers excellent muscle relaxation
hydrocarbon maintenance for extended periods
Small Animal
TABLE I (continued)
Anesthetic Agent Therapeutic Class Route
Isoflurane Halogenated ether Inhalation
Atropine Parasympatholytic Subcutaneous,
intramuscular, or
intravenous
Glycopyrrolate Parasympatholytic Subcutaneous,
intramuscular, or
intravenous
Naloxone Opioid antagonist Intravenous
Yohimbine α2-Adrenergic Intravenous
antagonist
thoracic or spinal radiograph of a deep-chested dog can
be difficult because the sternum falls toward the table.
A nonradiopaque sponge or roll cotton can be used un-
der the sternum to align the torso perpendicular to the
x-ray beam. Roll cotton is especially helpful for lateral
cervical radiography because it can be placed under the
neck to keep all the cervical vertebrae in the same
plane.
Roll gauze and tape also are useful for other types of
positioning (e.g., internally rotating the pelvic limbs
during radiography to produce a ventrodorsal view of
the pelvis with the hip joints extended; Figure 2).
These devices often have more to do with positioning
than restraining patients. However, they reduce the
need for manual restraint because proper patient posi-
tioning can be obtained without someone being in the
room during film exposure.
Making the patient comfortable often facilitates the
radiographic examination. A padded trough can be used
to position dogs in dorsal recumbency because many
dogs with bony backs do not like to lie in that position.
Simply placing a towel on the table underneath the
spinous processes also makes them more comfortable.
Draping a towel over the patient’s eyes calms some pa-
tients and eliminates their desire to follow the radiogra-
pher out of the room. However, placing a towel over the
eyes makes other patients more anxious. Analgesics may
be necessary to make the examination more comfort-
able. Analgesics will be discussed in more detail under
Chemical Restraint.
Certain animals (especially cats) respond best to min-
POSITIONING ■ PADDED TROUGH ■ BLINDFOLD ■ TONE OF VOICE
The Compendium August 1996
Dosage Comments
1.0%–3.0% Restraint similar to halothane;
maintenance rapid rate of onset and
elimination
0.02–0.04 mg/kg Used to prevent oral and
respiratory tract secretions and
prevent bradycardia; cardiac
rhythm must be monitored when
this drug is used
0.01 mg/kg Similar to atropine
0.04 mg/kg Used to reverse opioid agonist
0.10 mg/kg Used to reverse xylazine
imal restraint, whereas others do not. Some animals re-
spond to gentle, calming voices (“staaaay”) during the
whole procedure whereas others respond better to com-
manding voices (“STAY!”). Physical restraint should be
tailored to each patient and requires patience and prac-
tice. After using these techniques for a while, the clini-
cian can often predict what will work best for a particu-
lar patient.
Restraining devices can be used with or without chemi-
cal restraint to eliminate the need for manual restraint in
virtually all radiographic examinations. Indeed, they
should routinely be used for all patients radiographed
while under general anesthesia. There is no excuse for
manually restraining properly anesthetized patients. Non-
manual positioning methods have been well described
and are readily available. Published textbooks offer a more
complete description of nonmanual positioning.7,8
CHEMICAL RESTRAINT
The ideal chemical restraint for radiography would
be easy to use and economical and provide rapid onset
and predictable, rapid recovery. It would produce excel-
lent muscle relaxation and minimal physiologic distur-
bance and should produce sufficient sedation and anal-
gesia for the radiographic procedure to be performed
without manual restraint.
Sufficient sedation refers to the degree of immobi-
lization required and varies with the nature of the pa-
tient and the type of examination. When nonmanual
restraint techniques are used, sedation is seldom re-
quired for obtaining routine views of the thorax or
Small Animal
abdomen. Sedation is usual-
ly necessary for orthopedic
examinations, and complete
immobilization is necessary
for detailed radiographs of
the skull.
Administration of one or
a combination of the drugs
described below is recom-
mended to reduce patient
perianesthetic stress, de-
crease the total dose of any
one anesthetic agent, man-
age pain, and facilitate gen-
tle induction and recovery
when an inhalant or in-
jectable anesthetic is neces-
sary for restraint.1,9 Premedi-
cation slightly prolongs
recovery but improves the
quality of the recovery.
Premedication should be
given 20 minutes before ei-
ther the examination or fur-
ther administration of anes-
thetics. We have found that
intramuscular or subcuta-
neous administration pro-
duces excellent sedation and
is relatively easy to deliver to
fractious patients. After ad-
ministration of the seda-
tives, the patient should be
placed in a quiet holding
area to achieve maximum
sedative effect. Judicious flu-
id administration and an in-
travenous catheter are rec-
ommended during extended
procedures and when pa-
tients require critical care.
Agents Used
Chemical restraint pro-
tocols are based on the ef-
fectiveness of the agent in
providing restraint for ra-
diography, safety for the pa-
tient, convenience for the
clinician, and availability. Some protocols have the dis-
advantage that the drugs are controlled substances and
require appropriate registration and record keeping.
Physiologic status, temperament, and intensity and
PREMEDICATION ■ CARDIOPULMONARY STATUS ■ BODY TEMPERATURE
The Compendium August 1996
TABLE II duration of restraint must
Sedation Protocols for Canine Radiographya be considered. The patient
must be examined before it
Drugs Routes is sedated.
SEDATION/
Table I lists drugs that are
PREMEDICATIONb used to provide restraint for
Acepromazine Subcutaneously, radiography. The dose range
intramuscularly, or provides flexibility for inten-
intravenously sity and duration of re-
Acepromazine plus Subcutaneously, straint required and the ani-
butorphanol intramuscularly, or mal’s physiologic status. In
intravenously general, lower doses are used
for shorter-term or milder
Diazepam (or midazolam) Intravenously or
plus butorphanol intramuscularly restraint, for sick or debili-
tated animals, for puppies
Xylazine plus butorphanol Subcutaneously, and kittens, and for intra-
intramuscularly, or venous administration. The
intravenously
specific indications, con-
IMMOBILIZATION traindications, mechanism
Short (≤15 minutes) of action, use, and pharma-
Thiopental Intravenously cokinetics of these drugs
Diazepam plus ketamine Intravenously have been described else-
where.1,9–11 The patient’s car-
Propofol Intravenously diopulmonary status (and
Medium the body temperature of
(15 to 30 minutes) small patients) should be
Thiopental Intravenously monitored during chemical
restraint.
Propofol Intravenous drip
Long (≥30 minutes) c Acepromazine
Induction with diazepam Intravenously Minor diagnostic proce-
plus ketamine or with dures in healthy, tractable
propofol or with thiopental animals can be performed
using acepromazine, which
The patient is intubated, Inhalant
is a phenothiazine tranquil-
and anesthesia is maintained
with halothane or isoflurane izer. Contraindications to
the use of acepromazine in-
Propofol Intravenous drip clude liver disease, dehydra-
tion, hypovolemia, anemia,
a
These recommendations apply to the general canine popula- a history of seizures, or
tion and must be adjusted on the basis of the individual pa- bleeding diathesis. Acepro-
tient’s clinical situation. This table is designed to suggest a
stepwise protocol if additional restraint is required. For exam- mazine does not provide
ple, an agent used for immobilization can be given if the analgesia. Recovery is re-
agent used for sedation provides insufficient restraint. This portedly prolonged in boxer
regimen may be followed by intubation and inhalant anesthe- dogs.10
sia if further restraint or a longer examination is needed.
b
Adding atropine or glycopyrrolate is recommended unless it
is contraindicated. Butorphanol and
c
Premedication is recommended unless it is contraindicated. Oxymorphone
Many patients require se-
dation and restraint more profound than can be pro-
vided by acepromazine alone. The opioids butorphanol
and oxymorphone can be used with acepromazine to
achieve more profound sedation. Opioids provide vari-
The Compendium August 1996 Small Animal

able degrees of sedation, eu- movement artifact) and is

phoria, excitement, dyspho- not a controlled drug in
ria, and analgesia. most states. Oxymorphone,
Usually, opioids provide however, is a more potent
insufficient restraint for ra- analgesic. The effects of bu-
diography when used alone torphanol and oxymor-
unless the patient is debili- phone can be reversed with
tated. When combined with opioid antagonists (e.g.,
a tranquilizer (i.e., neurolep- naloxone). Also, the respira-
tanalgesia), however, they of- tory and central nervous
fer excellent restraint of dogs system depression induced
for radiography. In cats, by oxymorphone can be re-
neuroleptanalgesia produces versed with butorphanol.
only mild to moderate re- Figure 1A
straint. Butorphanol is an Xylazine
excellent antitussive agent10; Xylazine produces calm-
when a patient is coughing, ing, muscle relaxation, and
butorphanol may be useful analgesia by stimulating α2-
to facilitate induction and adrenergic receptors in the
avoid motion artifact. central nervous system. We
Opioids depress respira- find that xylazine used alone
tory function and therefore provides inferior restraint
should be used cautiously in for radiography in compari-
patients with existing respi- son with other drug regi-
ratory depression. Bradycar- mens discussed in this arti-
dia is often induced but is cle. Xylazine is less useful in
counteracted by an antimus- debilitated patients because
carinic drug, such as at- of respiratory depression,
ropine or glycopyrrolate. hypotension, and bradycar-
Opioids do not interfere dia. It is useful for restrain-
with vision, hearing, or per- ing young, healthy patients.
ception of touch or vibra- When combined with bu-
tion. Dogs therefore remain torphanol or oxymorphone,
sensitive to noise, and exam- xylazine produces excellent
inations should therefore be restraint. Glycopyrrolate
performed in a quiet area. and atropine diminish the
The combination of ace- associated bradycardia, as
promazine and butorphanol Figure 1B with the opioids. The effects
has been evaluated for its ap- Figure 1—An awake cat positioned for routine thoracic radio- of xylazine can be reversed
plicability to the radiographic graphs. The cat is positioned with sandbags and restrained with yohimbine.
examination of dogs and can only by the clamp technique. (A) Sternal recumbency. (B)
be used for even the most Right lateral recumbency. Benzodiazepines
difficult positions without Benzodiazepines (e.g., di-
manual restraint12 (Figure 2). azepam and midazolam)
Dogs given this combination may exhibit flaccid relax- produce muscle relaxation and a mild calming effect in
ation or may remain fairly alert and ambulatory. Never- debilitated animals and dysphoria in young, healthy an-
theless, if these dogs are quietly and deliberately posi- imals. When given alone, diazepam may aggravate
tioned, they tend to remain motionless until aroused. aggression if a dog is already fractious. Benzodiaze-
Oxymorphone can be used as an alternative to butor- pines should be combined with an opioid to produce
phanol (for combination with acepromazine) and also more predictable sedation. Because injection of diaze-
provides excellent restraint.12 However, butorphanol has pam may be painful, intravenous or deep intramuscular
some important advantages over oxymorphone. Butor- injection is recommended. For small animals (<10
phanol induces less panting (and therefore leads to less kg), midazolam is preferred because it is water soluble.

VISION ■ HEARING ■ PANTING ■ BRADYCARDIA ■ RESPIRATION

Small Animal
Benzodiazepines are used when
acepromazine is contraindicated
or in old or debilitated animals.
In animals with liver disease,
benzodiazepine elimination may
be delayed and an opioid used
alone is preferred if sedation is
required.
Parasympatholytics
As mentioned, parasympa-
tholytics (e.g., atropine or gly-
copyrrolate) may be given in
combination with the drugs dis-
cussed above to reduce salivary
volume and counteract para-
sympathetically induced brady-
cardia. Bradycardia often occurs
after administration of an opi-
oid or an α2-adrenergic agonist.
Parasympatholytics are relatively
effective in preventing this
drug-induced bradycardia and
should be given concurrently
with these drugs.
Ketamine and Tiletamine
The dissociogenic drugs ke-
tamine and tiletamine induce
excellent immobilization and
provide superficial analgesia.
Rigidity of the extremities is
produced because of poor mus-
cle relaxation. Such effects as
hallucinations, confusion, agita-
tion, and fear have been de-
scribed by human patients who
have received these drugs; simi-
lar effects apparently occur in
animals. Ketamine or tiletamine
should be used only cautiously
in patients with severe liver dis-
ease. Cats eliminate at least
some ketamine unchanged in
urine. This agent should there-
fore be used cautiously if a cat
has renal disease.
Ketamine used alone is a poor
choice for radiography. Either
ketamine or tiletamine can be
combined with other sedatives
to improve restraint and muscle
relaxation and improve the
SALIVATION ■ BRADYCARDIA ■ RENAL DISEASE ■ SIGHT HOUNDS
Figure 2A
Figure 2B
Figure 2—(A) A dog properly positioned for ven-
trodorsal radiographs of the pelvis for evaluation for
hip dysplasia. Acepromazine and butorphanol seda-
tion was used. A trough, sandbags, gauze, sponges,
and white tape were used for positioning. (B) Al-
though anesthesia facilitates examination, it has no
effect on the radiographic appearance of the pelvis.
The Compendium August 1996
quality of recovery. Intravenous
diazepam and ketamine are use-
ful when quick recovery is de-
sired, but this combination pro-
vides poor muscle relaxation.
Muscle relaxation and quality
of recovery are improved if the
patient is premedicated with
acepromazine (or acepromazine
plus butorphanol) before ke-
tamine (or ketamine plus di-
azepam) is given.
The combination of tile-
tamine and the benzodiazepine
zolazepam produces better
muscle relaxation. However, re-
covery is prolonged by this
combination and zolazepam is a
class III controlled substance.
Thiopental
Thiopental sodium is an ul-
tra–short-acting barbiturate
useful for short-term restraint
or intubation prior to gas anes-
thesia. Thiopental is useful for
special procedures when 15 to
20 minutes of immobilization
is required. Thiopental can
cause cardiac and respiratory
depression. Apnea of up to sev-
eral minutes duration is com-
mon after rapid administration.
Thiopental can precipitate
ventricular arrhythmia. If thio-
pental is preceded by a tran-
quilizer (e.g., acepromazine or
diazepam), the incidence of
arrhythmia is reduced. Thio-
pental can induce prolonged
recovery in sight-hound breeds
(e.g., greyhounds).
Propofol
Propofol is a nonnarcotic,
nonbarbiturate anesthetic drug
with a rapid onset of effect, short
duration of action, and smooth,
quiet recovery. Like barbiturates,
it offers excellent muscle relax-
ation for radiography. It can be
given as repeated intravenous in-
jections or continuous infusion.
The Compendium August 1996 Small Animal

It transiently lowers blood pressure but is not arrhythmo-
genic. Transient apnea occurs commonly unless the drug
is administered slowly over 30 to 60 seconds. Currently, it
is relatively expensive. The cost of the dose that would be
needed for a large dog could be prohibitive.
Inhalant Anesthetics
Halothane and isoflurane are commonly used in-
halant anesthetics. They provide excellent restraint and
muscle relaxation, and prolonged anesthesia can be
maintained. Because of their relatively rapid uptake and
elimination, there is good control of anesthetic depth.
Methoxyflurane has relatively high solubility in blood
and is therefore less desirable because of slow recovery.
A disadvantage of inhalant anesthetics is that special
equipment is required for delivery.9 Halothane and
isoflurane cause similar respiratory depression, and both
can cause cardiac depression. Isoflurane causes less car-
diac depression than does halothane. Isoflurane is pre-
ferred for patients with hepatic disease and for old or
debilitated patients.
Mask induction is inadvisable for unpremedicated,
alert, healthy patients because excitation immediately
precedes an appropriate plane of anesthesia. In addi-
tion, gas induction of anesthesia (as opposed to induc-
tion via injection) increases the exposure of personnel
to anesthetic gas. Mask induction should be reserved
for sick, debilitated patients that will not resist induc-
tion. Premedication facilitates mask induction and is
recommended. When intubation is expected to be dif-
ficult or when oxygenation is poor because of disease,
the patient should be allowed to breathe 100% oxygen
through a mask for about 5 minutes before induction
of anesthesia.
Recovery
Mildly sedated patients can be discharged to well-pre-
pared owners at the discretion of the attending veteri-
narian. The owner should be advised of what to moni-
tor and what to do in case of an emergency. Patients
that are fractious or in pain should be observed
throughout recovery to prevent injury to the owner or
the animal. The patient should be examined again be-
fore discharge.
RECOMMENDATIONS FOR DIAGNOSTIC
RADIOGRAPHY
Canine Patients
Sedation
When chemical restraint is indicated, high-quality

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Small Animal
radiographs can be obtained
with sedation alone and do
not require general anesthe-
sia. The combination of ace-
promazine plus butorphanol
is the first choice. In most
dogs, this combination of-
fers appropriate restraint for
most radiographic proce-
dures and can be combined
with other anesthetic drugs
if further restraint is needed.
In geriatric or debilitated
dogs, or when acepromazine
is contraindicated, midazo-
lam or diazepam can be sub-
stituted. Xylazine is useful as
a substitute for aceproma-
zine for young, healthy dogs.
Immobilization
Short. If complete immo-
bilization is required for less
than 15 minutes, either in-
travenous diazepam plus ke-
tamine or intravenous thio-
pental or propofol is recom-
mended. Premedication is
recommended. Undesirable
muscle rigidity is commonly
encountered if intravenous
diazepam and ketamine are
given alone.
Medium. Immobilization
for 15 to 30 minutes is best
accomplished by using in-
travenous thiopental or
propofol. After appropriate
sedation, intravenous thio-
pental or propofol is given
as a bolus to induce hypno-
sis. Additional boluses are
given to extend the length
of anesthesia. Intravenous
propofol may be prohib-
itively expensive for large
dogs but otherwise offers ex-
cellent restraint and a short,
predictable recovery. In or-
der to avoid prolonged re-
covery, the total dose of
thiopental should not ex-
ceed 20 mg/kg.
MUSCLE RIGIDITY ■ CONTRAST PROCEDURES ■ AGGRESSIVE CATS
The Compendium August 1996
TABLE III
These protocols are good
Sedation Protocols for Feline Radiography
a for certain contrast proce-
dures (e.g., urethrocystogra-
Drugs Routes phy or arthrography), when
SEDATION/ Subcutaneously,
several sites are being radio-
PREMEDICATION intramuscularly, or graphed, or when the pa-
Acepromazine plus intravenously tient is fractious. If possible,
butorphanol an endotracheal tube should
be inserted.
Diazepam (or midazolam) Intravenously or Long. Inhalation anesthe-
plus butorphanol intramuscularly sia should be used when im-
mobilization is required for
IMMOBILIZATION an extended time. Inhala-
Short (≤15 minutes) tion anesthesia is also pre-
Acepromazine, Intravenously ferred for patients that are
butorphanol, and ketamine fractious or in pain and for
examinations that require
Diazepam, butorphanol, Intravenously strict immobilization (e.g.,
and ketamine skull or spinal radiographs).
Propofol infusion with pre-
Propofolb Intravenous drip
medication is another op-
tion that is useful for ex-
Medium tended examinations when
(15 to 30 minutes)b immobilization is necessary.
Thiopental Intravenously
Tiletamine and zolazepam Intramuscularly Feline Patients
Sedation
Acepromazine, Intramuscularly Sedation often provides
butorphanol, and ketamine insufficient restraint of cats
for radiography but may be
Midazolam, butorphanol, Intramuscularly helpful in selected cases. Se-
and ketamine
dation with acepromazine
Propofol Intravenous drip and butorphanol can be use-
ful in aggressive cats if com-
Long (≥30 minutes)b bined with manual restraint.
Induction with diazepam Intravenously
plus ketamine or with Immobilization
thiopental or with propofol Short. Relatively low dos-
or induction with ketamine Intramuscularly es of ketamine are common-
ly incorporated into anes-
Intubation and maintenance Inhalant thetic protocols for feline
with halothane or isoflurane radiography because immo-
bilization is usually neces-
Propofol Intravenous drip sary. Muscle rigidity can
a
These recommendations pertain to the general feline popula- pose problems if the patient
tion and must be adjusted on the basis of the individual pa- was not premedicated or if
tient’s clinical situation. This table is designed to suggest a no tranquilizer is used. In-
stepwise protocol if additional restraint is required. For exam- travenous acepromazine,
ple, an agent used for immobilization can be given if the butorphanol, and ketamine
agent used for sedation provides insufficient restraint. This
regimen may be followed by intubation and inhalant anesthe- or diazepam, butorphanol,
sia if further restraint or a longer examination is needed. and ketamine are useful
b
Premedication is recommended unless it is contraindicated. combinations for quick ex-
aminations (<15 minutes).
Small Animal
As an alternative, propofol preceded by acepromazine
or diazepam is useful.
Medium. Certain contrast examinations (e.g., cys-
tography) or examination of several sites requires 15 to
30 minutes of immobilization. Thiopental or propofol
is given intravenously after premedication. Thiopental
or propofol offers flaccid immobilization and is excel-
lent for radiography.
The combination of tiletamine and zolazepam also
offers excellent restraint and good muscle relaxation for
15 to 30 minutes. Premedication is unnecessary. Intra-
muscular acepromazine, butorphanol, and ketamine or
midazolam, butorphanol, or ketamine also offer useful
restraint. We find that these combinations produce less
muscle rigidity when given intramuscularly than when
given intravenously. Xylazine combined with ketamine
is not recommended because of prolonged recovery.
Long. Intravenous propofol (or inhalation anesthesia
after premedication and rapid induction) is useful dur-
ing long examinations, when the patient is fractious or
in pain, or when the examination requires strict flaccid
immobilization (e.g., skull or spinal radiographs). Cats
can be premedicated using many of the same protocols
recommended for dogs (Tables II and III). Ketamine
can be given initially to feral cats. Tank induction with
halothane or isoflurane is occasionally necessary for fer-
al cats but is not recommended because of the associat-
ed pollution with waste anesthetic gas and because exci-
tation occurs before an adequate plane of anesthesia is
achieved.
Contrast Studies in Dogs and Cats
Chemical restraint is generally useful for all contrast
procedures except when sedation adversely affects the
interpretation of the examination or is contraindicated.
In general, sedation is seldom recommended for
esophagrams and contrast radiography of the upper
gastrointestinal tract because it alters contractility and
muscle tone, prolongs emptying times, and increases
the risk of aspiration of contrast medium. The proto-
cols listed in Tables II and III can be used for all con-
trast procedures, except for a few special situations dis-
cussed below.
Myelography requires general anesthesia. Because
seizures are a potential sequela of myelography,13 drugs
that may lower the patient’s seizure threshold (e.g., ace-
promazine) are not recommended. Ketamine increases
intracranial pressure and is therefore not recommend-
ed. Hyperventilation to reduce intracranial pressure is
indicated when increased intracranial pressure is pre-
sent or suspected.1
Most routinely used sedatives adversely affect gas-
trointestinal motility. Xylazine produces generalized
MYELOGRAPHY ■ GASTROINTESTINAL OBSTRUCTION ■ MOTILITY
The Compendium August 1996
bowel distention consistent with survey radiographic
findings of gastric dilatation and adynamic ileus.14 In
addition, effective gastrointestinal contractions are in-
hibited for approximately 2 hours.15 Yohimbine, which
is an α2-adrenergic blocking agent, reverses the pharma-
cologic effects of xylazine—including both the sedative
and gastrointestinal effects.15 Parasympatholytic drugs
(e.g., atropine) produce gastrointestinal atony.15 Barbi-
turates and opioids prolong gastric emptying time and
therefore are not recommended.9
Sedation is occasionally necessary for gastrography or
upper gastrointestinal examination.16,17 We recommend,
however, that no sedation be used if the dog is coopera-
tive or a functional abnormality is suspected. If seda-
tion is required, then acepromazine is used at the rec-
ommended dose (Table I). If further sedation is
necessary and mechanical ileus (e.g., foreign body or
tumor) is suspected, then butorphanol (0.05 mg/kg) is
also given. This combination depresses gastrointestinal
motility but allows for examination of mechanical caus-
es of obstruction in a reasonable amount of time (2 to
5 hours). We have found that higher doses of butor-
phanol adversely affect gastrointestinal motility and
emptying times.
In cats, ketamine (2.7 mg/kg) plus acepromazine
(0.05 mg/kg) intramuscularly or ketamine (5.5 mg/kg)
intramuscularly is recommended for sedation during
contrast studies of the upper gastrointestinal tract.17
Gastric emptying is almost twice as fast as in controls.
However, this is usually not a problem if the diagnostic
differential is mechanical obstruction.17 If a functional
motility problem is suspected, ketamine (2.7 mg/kg)
and diazepam (0.1 mg/kg) intramuscularly are recom-
mended even though motility will be mildly affected.17
The effect of a combination regimen of ketamine
and diazepam on contrast studies of the canine upper
gastrointestinal tract has not been studied. Because of
the short duration of action, this combination does
not offer effective sedation for the complete examina-
tion, which may last 2 to 5 hours. It may, however,
prove useful for the administration of contrast medi-
um.
Many drugs affect swallowing.18,19 Because sedation
can enlarge the radiographic appearance of the esopha-
gus and predispose the patient to gastric reflux and as-
piration, it is preferable to perform esophagraphy
without sedation. High doses of acepromazine (0.2 to
0.4 mg/kg) reportedly affect the canine gastroe-
sophageal sphincter region and therefore are not rec-
ommended for esophagraphy in dogs.19 The recom-
mended dose (Table I) of acepromazine can be used
cautiously during esophagraphy if sedation is
required.20,21
Small Animal
Ultrasonography
Ultrasonography can usually be performed with
manual restraint because it does not expose personnel
to ionizing radiation and because most patients are co-
operative. Restraint devices are helpful when staff sup-
port is limited and the patient is tractable. An inclined,
padded trough facilitates ultrasonographic examination
of the abdomen. Strict immobilization is seldom re-
quired, and mild sedation is often satisfactory. Chemi-
cal restraint is necessary when patients are aggressive or
uncooperative, when staff support is limited, or during
ultrasonographically guided biopsy.
The sedative dose used for dogs undergoing ultra-
sonography is usually lower than that used in dogs un-
dergoing radiography. Unruly cats often respond well
to the combination of intramuscular acepromazine and
butorphanol. Although this combination is less appro-
priate for radiography because it does not immobilize
cats, it usually relaxes them enough for the ultrasono-
graphic examination to be performed. The higher dose
of butorphanol (0.2 mg/kg) is recommended in cats. A
small dose of ketamine (1 to 5 mg/kg) can be added if
the combination of acepromazine and butorphanol is
inadequate.
Intravenous diazepam–ketamine is better suited to
ultrasonography than to radiography because mild
muscle rigidity is not a problem. Unless premedication
is given, however, this combination may not offer suffi-
ciently prolonged restraint.
Opioids used alone can be successful in restraining
debilitated patients. Feral animals require immobiliza-
tion or heavy sedation (Tables I through III) as well as a
muzzle for the entire examination.
Sedation is generally required for ultrasonographical-
ly guided core biopsy but not for fine-needle aspiration
of cells or fluid. Intravenous propofol or diazepam–ke-
tamine is ideally suited for dogs and cats because these
drugs are short acting and offer an appropriate degree
of restraint. Although pain in veterinary patients is not
easily recognized, premedication with an opioid (e.g.,
butorphanol [0.4 mg/kg]) is recommended. Pain man-
agement is better if analgesic drugs are given before the
painful event.1
Oxymorphone-induced panting makes examination
or biopsy difficult. Propofol alone does not provide
analgesia.
Phenothiazines and barbiturates are not recom-
mended when the spleen or left kidney is to be sam-
pled because these drugs produce venous congestion
in the spleen (anesthetic-induced splenomegaly). 22
The splenomegaly impairs access to the left kidney,
and biopsy samples taken from the congested spleen
are poorly suited for the detection of pathologic
ULTRASONOGRAPHICALLY GUIDED BIOPSY ■ SPLENOMEGALY ■ ECHOCARDIOGRAPHY
The Compendium August 1996
changes. 22,23 Also, anesthetic-induced splenomegaly
may increase the risk of hemorrhage after splenic
biopsy. 22,23 In our experience, anesthetic-induced
splenomegaly results in an enlarged spleen of normal
echogenicity. If patients with severe liver disease re-
quire immobilization, isoflurane alone or propofol is
recommended.
Chemical sedation is seldom used for echocardiogra-
phy in adult dogs and cats, although adult cats require
sedation more often than do adult dogs. Intramuscular
acepromazine (low dose) plus butorphanol given 20
minutes prior to examination is recommended when
sedation is necessary for a dog or cat.
In general, puppies and kittens require chemical se-
dation during echocardiographic examination for con-
genital heart defects because they will not lie still for
the required 30-minute examination. Intramuscular
acepromazine plus butorphanol is recommended for
puppies and kittens. The combination of intravenous
acepromazine (0.03 to 0.05 mg/kg) and buprenor-
phine hydrochloride (0.075 to 0.01 mg/kg) is useful
in dogs and puppies because it is relatively safe and
consistently offers excellent restraint and quick recov-
ery.24 However, buprenorphine is a class V controlled
substance. Some adult cats and kittens require addi-
tional sedation with a low dose of intramuscular ke-
tamine.
CONCLUSION
The use of nonmanual physical restraint techniques,
especially in conjunction with judicious chemical re-
straint, allows most patients to be restrained and prop-
erly positioned for virtually all types of radiographic
procedures without personnel in the room during ex-
posure of radiographic film. The degree of chemical re-
straint required varies from none to sedation to general
anesthesia.
The recommendations for sedation given in this arti-
cle apply to the general population of dogs and cats and
must be tailored to the specific needs of each patient.
Appropriate chemical restraint is the minimum amount
of sedation needed for the efficient and safe completion
of the examination and varies depending on the pa-
tient, the type of examination, and the practitioner’s
skill in nonmanual restraint.
Some dynamic contrast procedures (e.g., urethrog-
raphy or esophagraphy) and the occasional patient
require personnel to be present in the room during
film exposure. However, using nonmanual restraint
techniques and limiting the use of manual restraint
to situations in which they are clinically necessary
can reduce the lifetime exposure of personnel to ra-
diation. These techniques become easy and routine
 The Compendium August 1996
with patience and practice but must be adjusted for
each new case.
7.
About the Authors 8.
Drs. Scrivani, Bednarski, and Myer are affiliated with the
Department of Veterinary Clinical Sciences, College of 9.
Veterinary Medicine, Ohio State University. Dr. Dykes is
10.
affiliated with the Department of Clinical Sciences, Col-
lege of Veterinary Medicine, Cornell University, Ithaca, 11.
New York. Dr. Bednarski is a Diplomate of the American
College of Veterinary Anesthesiologists. Drs. Myer and
Dykes are Diplomates of the American College of Veteri- 12.
nary Radiology.
13.
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6. New York State Department of Health, Bureau of Environ-
DID REACHING A DIAGNOSIS
PUZZLE YOU?
PUZZLE US WITH IT, TOO!
We are looking for submissions for the column, “WHAT’S
YOUR DIAGNOSIS?” Any intriguing case in veterinary
medicine is welcome. The diagnosis may have turned out
to be quite an O. Henry twist in the story, or it may have
simply been a stumper. If you have one, send it in.
Articles should be 500 words long, with most of the evidence
presented; the diagnosis itself should be summed up in one to two
sentences at the end. Relevant x-rays, ultrasonograms, photos of the
patient’s condition, electrocardiograms, or other pictorial clinical
evidence is also welcome. Honorarium is provided upon publication.
Small Animal
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Plumbe DC: Veterinary Drug Handbook. White Bear Lake,
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CONTACT:
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Email: lmiller.vls@medimedia.com
Small Animal
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The Compendium August 1996
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