Oral Pre-Visit Pharmaceuticals for Euthanasia; Go big

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I’ll be the first to tell you I like my patients calm and peaceful before euthanasia. Who wouldn’t? Relaxed pets are easier to work with and this leads to a better experience for everyone. Serenity of mind and body before euthanasia is always welcomed. This is especially true for those pets who may be fearful with new people, in unfamiliar or disliked places, and for those with aggressive tendencies.

Clients sometimes ask me if the pet knows death is coming and might be more anxious. In my opinion, pets do not know. If they are anxious, they are reacting to their environment; the nervous mood of their owners (often overwhelmed because of the pending loss), the veterinary hospital setting (perhaps a place of unpleasant memories and another reason I love home euthanasia so much), and their physical condition (most are sick and not feeling well). My job and that of my veterinary colleagues is to learn what we can about the pet’s state of mind ahead of the appointment and provide oral pre-visit pharmaceuticals (PVPs) whenever applicable. Think ‘EuHarmony’.

PVPs can be sedatives or anesthetics, combined together or given individually, although I like the synergistic effects of the combos. What we give depends on the species we are working with and their tolerances. Many protocols in literature give a lower starting point for patients who need to wake up, however with euthanasia work, deep sleep, really deep sleep is desired. We reach for higher doses for greater impact; aka go big. This is especially true with aggressive pets who put handlers at risk. Let’s get them snoring if possible before the appointment even starts.

The Companion Animal Euthanasia Training Academy (CAETA) already recommends pre-euthanasia sedation or anesthesia via a 1-step or 2-step protocol. If using oral drugs before injectables, we call this a 2-step protocol (1st step is oral, 2nd step is injectable) followed by the euthanasia technique. Oral PVPs must be fed or squirted into the mouth up to 2 hours before the appointment. The Chill Protocol, developed by Dr. Karas at the Cummings School of Veterinary Medicine at Tufts University, recommends some PVPs be given the night before and the morning of. I like this and feel it works well to pre-load the pet for even better relaxation.

Modified Oral Chill Protocol for Canine and Feline Euthanasia* (the regular Chill Protocol has lower doses)
~Gabapentin (25 mg/kg) and melatonin (5 mg) administered the evening before the scheduled appointment.
~A combination of gabapentin (60 mg/kg) and melatonin (5 mg) administered at least 1 to 2 hours before the scheduled appointment.
~Acepromazine (0.1 mg/kg)* liquid administered into the mouth for absorption 30 minutes before the scheduled appointment.
*Note this is a 3-step protocol requiring 3 separate dosings of varied drugs.

Oral Pre-Euthanasia Sedatives/Anesthetics (Compiled from various sources)
The following pharmaceuticals, given 1-2 hours prior to euthanasia, can be used alone or in combination with others for greater effect. All responses variable and there are no guarantees to efficacy every time. There are many more sedatives and anesthetics available than listed here. Trazadone and gabapentin are ideally suited for pre-dosing the night before and day of the appointment.
Cats
Alprazolam 0.5mg/kg up to 8mg per cat (variable response)
Trazodone 100mg (variable response)
Buprenorphine 0.3ml per cat OTM
Phenobarbital 10mg/kg
Gabapentin 100-150mg per cat
Pentobarbital 85 mg/kg (255mg/kg is considered an oral fatal dose)
At the appointment: Telazol (liquid) 5-7.5mg/kg plus acepromazine (liquid) 0.1mg/kg – both oral transmucosal (OTM) or buccal

Dogs
Diazepam 2.2mg/kg (use with caution, can be unpredictable)
Gabapentin 60mg/kg
Pentobarbital 85 mg/kg (255mg/kg is considered an oral fatal dose)
Trazodone < 20lb = 50mg, 20-50lbs = 100mg, > 50 lbs = 200mg, > 100 lbs = 300mg
Acepromazine 2.2mg/kg (low oral bioavailability so best used in combination with another drug(s))
Phenobarbital 10mg/kg
At the appointment: Telazol (liquid) 10mg/kg (not well documented in dogs) plus acepromazine (liquid) 0.1mg/kg – both OTM or buccal
At the appointment: Detomidine gel (7.6mg/ml) 0.1ml per 7kg on average (Profound sedation in under 10 minutes in Dr. Cooney’s experience, especially for smaller dogs. Other sources suggest 0.1ml per 40kg.)


It is important for owners to understand that oral sedatives and/or anesthetics will alter their pet’s mentation and actions right up until euthanasia. We want to be sensitive to this and encourage owners to create quiet, calm space around their pet and to begin saying goodbye when the drugs are given. Once the pet is sleeping, owners may feel a bit of disconnect. Therefore being mentally prepared for these final moments is important.

Owners should also understand how a sedated pet behaves and how those with aggressive tendencies must be handled with extra care in case there is decreased inhibition. A thorough conversation beforehand is very helpful to outline what is expected, as well as informing owners how to safely administer drugs and keep them away from other pets. Of course sometimes the oral meds do not make a significant impact and the pet remains awake. It is hard to predict who will fully succumb to the drugs and who won’t. I let my clients know we do our best and that no matter what, we will proceed with gentleness when the time comes.

*Oral transmucosal or buccal administration in dogs suggests a lower dose of 0.05mg/kg however it is common for some drug to miss the mouth altogether and the higher dose of 0.1mg/kg should ensure a sufficient dose is given.

References

Comparison of five regimens for oral administration of medication to induce sedation in dogs prior to euthanasia. Ramsay EC, Wetzel RW. J Am Vet Med Assoc. 1998 Jul 15;213(2):240-2. Erratum in: J Am Vet Med Assoc 1998 Oct 15;213(8):1170.

https://www.cliniciansbrief.com/article/chill-protocol-manage-aggressive-fearful-dogs?utm_source=Social&utm_medium=CB&utm_campaign=Facebook&fbclid=IwAR353bjQ8M3p9slR3xow0loCcaSkoIfglpFqgDipSfm7ZSqtHjfxw3JnYKk

https://doi.org/10.1016/j.cvsm.2019.12.004

https://www.vasg.org/oral_sedation_for_difficult_dogs.htm

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Kathleen Cooney

DVM, CHPV, CCFP Founder, Director of Education for the Companion Animal Euthanasia Training Academy
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