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New Member:
illinois

Posted on Wednesday, Nov 7, 2007 - 7:14 pm:

I have not seen this bad situation posted and I hope someone can help. I brought my 8 y.o. horse to a local horse vet for teeth flotation. The horse was sedated, procedure done in my presence, and the horse given a reversal drug of yohimbine. The horse died within minutes of being given yohimbine. The horse was not given a health check, no forms were signed and I was not given any warnings about the drugs used. I am so sad. I have kept notes of the whole incident and it has been 4 weeks. I have met with the vet and asked for him to consider giving me compensation. He said he has filed it with his insurance. What should I do? Get a lawyer? Thanks.
Member:
stevens

Posted on Wednesday, Nov 7, 2007 - 9:21 pm:

Jane,

I'm so sorry about your horse; what a terrible thing to happen.

I'm not a lawyer, but I'm not sure you're looking at malpractice. If the vet exercised standard practices using standard drugs at the appropriate doses, I think it's a very unfortunate case of bad luck.

Again, please accept my condolences on the loss of your horse.

Chris
Member:
scooter

Posted on Thursday, Nov 8, 2007 - 6:34 am:

Is it common procedure to give a horse a reversal drug after standard procedures? My vet has never done this and if he would ask I would decline.

Sorry for your loss
Moderator:
DrO

Posted on Thursday, Nov 8, 2007 - 7:43 am:

Welcome Jane,
I am saddened to welcome you over such a devastating and unexpected event. Chris has it right, the question was did the veterinarian do anything that did not represent a recognized standard of care and was this contributory to the horses death. Sometimes unexpected reactions occur but it would take a thorough review of the procedure the veterinarian followed and perhaps a necropsy of the horse to determine this.

Yohimbine is a drug with well established properties of reversing some of the alpha-2-agonist sedatives (like xylazine and detomidine) depressant effects on the nervous system and cardiovascular system. It does not reverse the depressant effects on the respiratory system in some studies and in others may increase it. I am uncertain but this is probably a dose related effect. In reviewing the past twenty years of experiences with yohimbine in the scientific and veterinary literature I cannot find another case of death related to its use. I do not use the drug however so do not have any personal experiences with it.
DrO
PS: Here is a pretty good study of yohimbines effects:
J Vet Pharmacol Ther. 1993 Sep;16(3):350-8.
Influence of yohimbine and tolazoline on the cardiovascular, respiratory, and sedative effects of xylazine in the horse.
Kollias-Baker CA, Court MH, Williams LL.
Department of Surgery, Tuft's University School of Veterinary Medicine, North Grafton, MA 01536.

To determine the effects of yohimbine and tolazoline on the cardiovascular, respiratory and sedative effects of xylazine, four horses were sedated with xylazine and treated with either yohimbine, tolazoline or saline. Xylazine was administered as an intravenous (i.v.) bolus (1.0 mg/kg) followed by a continuous infusion at the rate of 12 micrograms/kg/min. Heart rate, respiratory rate, mean arterial pressure, arterial blood gases, and the chin-to-floor distance were recorded throughout the experiment. After 60 min, either yohimbine or tolazoline was administered i.v. in incremental doses until reversal of sedation (defined as the return of the chin-to-floor distance to baseline values) was achieved. A control group in which a saline bolus was administered instead of an antagonist drug was included for comparison. The average dose of yohimbine administered was 0.12 +/- 0.02 (SEM) mg/kg. While the average dose of tolazoline was 7.5 +/- 1.1 mg/kg. Both tolazoline and yohimbine antagonized the ventricular bradycardia and A-V conduction disturbances observed with xylazine administration. No change in mean arterial pressure was observed with xylazine or yohimbine administration, but tolazoline caused persistent mild systemic hypertension. There were no clinically significant changes in respiratory rate or arterial blood gas values with administration of either xylazine, yohimbine or tolazoline. The chin-to-floor distance decreased significantly with xylazine administration and increased significantly with administration of either yohimbine or tolazoline. In conclusion, both yohimbine and tolazoline successfully antagonized the cardiovascular and CNS depression associated with xylazine administration.
Member:
canter

Posted on Thursday, Nov 8, 2007 - 7:47 am:

Jane, I'm sorry for your loss. Very sad situation. I would have to agree with Chris, though. There's a degree of risk with any medical procedure, particularly anesthesia. Unless this is a clear cut case of negligence (horse had a known history of bad reaction to the drug and the vet ignored your warning or the reversal drug is contra-indicated against the particular anesthetic used...something like that) you are likely not going to be successful hiring a lawyer and suing for damages. Also, if you did not have a necropsy done, it would be difficult to prove cause of death.

Diane does bring up a good question though - my vet has never used a reversal drug after anesthesia either.

My condolances.
New Member:
illinois

Posted on Thursday, Nov 8, 2007 - 9:10 am:

Thank you doctor. You have precisely answered my concerns. I am seriously questioning the quality of care my horse was given prior to and during the event. It was only the vet and I present at the time the reversal was given and I have serious concerns that I need to look in to. Also, epinephrine was given to try and revive the horse. Was this correct if it was an allergic reaction to the drug? Should epinephrine be used with xylazine (Rompun)? The horse was having trouble breathing. A tracheotomy could have easily been done but it was not. There was no crash cart available at this facility ... he had to run out to his truck for epi and it took about 2-3 minutes. I was alone with my horse during this time and I knew he had died. THis is a hard situation I know, but I have to look in to it. Thank you for any input you may have.
Moderator:
DrO

Posted on Thursday, Nov 8, 2007 - 10:10 am:

Anytime a severe allergic reaction (anaphylaxis) is encountered the mainstay of emergency therapy is epinephrine. There is no specific contraindication of epinephrine in combination with xylazine or yohimbine that I am aware of and there is some logic in its use if xylazine related problems are encountered.
DrO
Member:
jojo15

Posted on Thursday, Nov 8, 2007 - 3:07 pm:

oh so tragic. and i'm getting the pit in the stomach feeling just thinking about it. and shivers. From your last post it's obvious those three minutes him running to the truck was like a lifetime. And torture.

I think all who read this take heed to always have epi on hand. I waste so much of it i can't tell you. And my vets all find me "funny" when i say to not give the shot yet. and then run in the house to get the epi. Or i draw it even when i know i've given this shot before. always. I'm still to new to it to not do it.

Whether or not that would have helped your horse i don't know. but, a reminder to all of us that do our own shots. I know its no condelence. And very sorry for your loss...
New Member:
illinois

Posted on Thursday, Nov 8, 2007 - 8:30 pm:

I wish to thank everyone for their honesty and compassion toward my horse. He was really great ... not a bad bone in his body, and he would go anywhere I asked him. He just loved to get in the trailer to go somewhere. I really miss him.

Jane
Member:
lilo

Posted on Friday, Nov 9, 2007 - 11:08 pm:

Dear Jane - Please accept my sincere condolences on the loss of your horse. My very good friend had a similar experience earlier this year, when she lost her special gelding at 23 years of age following a dental procedure.

I will post after looking at my email discussions with my friend, because I want to get the details right of the drugs that were used.

Dr. O,

After reading this post, I looked up the sedatives under medications.

The following paragraph is copied from that section of the horseman's advisor:

"Overdosage
Accidental overdosage generally cause an exacerbation of the toxic effects: cardiac arrhythmias, hypotension, and profound CNS and respiratory depression may occur. Seizures have also been reported after overdoses. There has been much interest in using alpha-blocking agents as antidotes or reversal agents to xylazine. Yohimbine (0.014 mg/ lb IV) has been suggested to be used. Mechanical respiratory support with respiratory stimulants (e.g., doxapram) seen rational for the horse with sever respiratory depression. Epinephrine should NOT be used."

What caught my attention was: Epinephrine should NOT be used. Of course, this was in the section about overdosage, but when my friend and I researched Dormosedan, the sedative used in her case on the 23 year old gelding, we also found that epinephrine was not to be used.

Again - so sorry about the loss of your horse, Jane.

Lilo
Member:
kamibroo

Posted on Friday, Nov 9, 2007 - 11:58 pm:

I'm so sorry for you and your horse.

I'm in eastern Ohio and have had horses sedated for dental work and many other things. I've personally had easily 50+ horses sedated (dental, geldings, stiching up, exams) and know of at least that many again through friends over a 7 year period.

Typically they always use Rompum. I have never seen a reversal drug used or even heard of one used in this area. Its generally accepted that the horse will need a certain amount of time to come out of the effects and they are protected accordingly until they're fully functional again.

Is it possible he was using the reversal drug because there were problems going on with the rompum?

If your vet has filed it with his insurance, it sounds like he is attempting to provide some sort of compensation. You might check out your state licensing agency and ask them for guidance. They may have a complaint handling process that would not require an attorney. It would seem like the market value of the horse would play a big role determining if the expense of an attorney is worth considering.

Again, I'm so sorry for your loss.
Moderator:
DrO

Posted on Saturday, Nov 10, 2007 - 8:44 am:

Hello Lilo,
There are rational reasons to expect epinephrine to help with xylazine toxicity as one of the toxic effects of the sedative is to block catecholamines which slows the heart rate and respiration. However there have been experiments with epinephrine and xyalzine to see if they can counteract the pharmacological toxic effects of each other and unfortunately a beneficial effect has not been seen in experiments. Yohimbine should be used to counteract xylazine toxicity and NOT epinephrine.

On the other hand if I had a horse dieing acutely in front of me and epinephrine was all I had or if the yohimbine did not work I would certainly give it a try. I do not know of a specific contraindication of its use and in the case of an allergic reaction might be life saving.
DrO
Member:
suzym

Posted on Saturday, Nov 10, 2007 - 11:22 am:

Jane, words fail me. I am so sorry for your dreadful loss.

My vet always sedates my horses for dental work, and he has never used a reversal drug. I wonder if this vet always does this, or was he thinking that he may have overdosed your horse on the xylazine?

I don't blame you for wanting to understand just what happened. I would feel the same way.

I will be thinking about you.

Suzy
Member:
sunny66

Posted on Saturday, Nov 10, 2007 - 8:28 pm:

I'm so sorry Jane, my horse has been given the reverse drug by a previous vet who I no longer use with no adverse affects. Current vet has seen a horse fly backwards after someone gave him the reverse drug, not sure how they did it, but the horse ended up ok. Current vet won't use it.

Again, I'm very very sorry to hear about your beloved boy.
Member:
mandrie

Posted on Saturday, Nov 10, 2007 - 9:55 pm:

Jane, please accept my condolences. You may consider asking your vet for the name of his insurance company, and the adjuster assigned to the claim, then contacting them directly to see if you can reach a resolution.
New Member:
illinois

Posted on Sunday, Nov 11, 2007 - 8:53 am:

Thanks to everyone for their heartfelt sympathy regarding my horse and friend.
I followed up with my vet who said he turned it in to his insurance. I called his local agent who said the main office in NY would contact me. They never did. I contacted the main office who said they had already issued a decision to the local agent (I now realize I am being given the run-around). The NY main insurance office said that this incident had a veterinary exclusion clause. I said okay, what type of insurance policy is this? They said this is a farm liability insurance policy. AT this point I was livid -- not at the NY office, but at my vet and his local agent for filing a malpractice claim with a farm liability policy! It had been 4 weeks now, and I still feel in my heart that he owes me something. The horse (Sammy) is worth $3500. I let 3 days go by to cool off, and then I called the vet for a meeting. He was congenial and agreed to a Wednesday morning. That day came and he had to reschedule for THursday. I went to the meeting and was met by him, his fiance and his neighbor (who is a friend of mine also). This was not what I had bargained for, and I felt overwhelmed. I handled myself professionally and gracefully and asked him to consider giving me $3500 in compensation for my horse. He said he handed it to his insurance company and they would make a decision, and somebody would contact me in 7-10 days. I asked him if it was his malpractice insurance, and he said yes. Friends, I have left out many details, of course. At the time of the death, the vet said "he would make things right" and he would "get me a new horse". Yes, I did decline the autopsy when he asked me, and when I did he said that "you're doing the right thing." Maybe I should use our mutual friend for arbitration. I will do all I can without a lawyer even possibly through small claims court. My issue mainly is that yohimbine was not necessary and I was never asked if I wanted it ... he just went ahead and did it. Also, the vet was not prepared for an emergency. He had to run to his truck, there was no immediate assistance from his tech or other veterinarian, a tracheotomy or ventilator were not available either. I don't know if it would have helped. But he simply was not prepared and I took my horse to his facility so that he would have the best of care. I feel he did not. What do you think?
Member:
scooter

Posted on Sunday, Nov 11, 2007 - 11:28 am:

Jane what a horrible story. I would be sick too.

I don't know if this incidence actually is malpractice...I rather doubt it, especially without an autopsy.

I don't think giving a reversal drug is standard procedure, but under certain circumstances I suppose it is used.

I see from your post you were at his farm so maybe he did it for the trailer ride home so you didn't have to wait an hour for the horse to be stable enough to travel.

Have you checked your farm insurance? I think mine covers things like this...my horses are listed seprately on it and I stated their value.

Surprisingly sometimes even home owners insurance will cover something like this.

I know my vet doesn't have epi right on his person when giving tranqs or vaccinations, I always ask what he is giving and how much and why...before he jabs them with anything....even banamine.

I don't know if as horse owners that is our responsibility or not. I have refused injections before...the vet I used before I have now wanted to give a colt a reversal drug after his gelding..he just wouldn't wake up...probably too much tranq. I declined and the vet stayed until he came to keeping a close eye on him, the vet was there for over an hour.

Every horse seems to have their own tolerance for certain tranqs I have one that takes half a dose and one you have to double dose. There are so many variables to it all and I pay close attention to how they all react.

I'm sure your vet feels terrible, and couldn't for see the outcome. I think this is something you may have to chalk up to a horrible freak accident. I have had more than my share of them as a horse owner I have learned something from each one of them, and have become rather paranoid about my horses in the process.

I am so sorry for your loss he sounds like he was a wonderful, well cared for animal.
Member:
lilo

Posted on Sunday, Nov 11, 2007 - 11:47 am:

Hello Dr. O,

Thanks for your response. I want to point out that my friend did not consider legal action against the veterinarian at any time.

The reason I am posting about her case here is that it just happened earlier this year and it was a wake-up call - just like Jane's unfortunate loss.

This was a different sedative than the one used on Jane's horse. However, it led us to research the particular sedative: Dormosedan (detomidine hyDrOchloride).

I downloaded some information - it is a pdf document and I cannot cut and paste from it.
Therefore I copied:

"Adverse reactions: Occasional reports of anaphylactic-like reactions have been received, including one or more of the following: Urticaria, skin plaques, dyspnea, edema of the upper airways, trembling, recumbency and death. The use of epinephrine should be avoided since epinephrine may potentiate the effects of alpha(sub2)- agonists."

Link to entire document: www.pfizerah.com/PAHimages/compliance_pdfs/US_EN_DS_compliance.pdf

In this case horse was released following the dental procedure and then collapsed. The following drugs were administered following the collapse: "Blaine was not given another shot until after he went down - when he was
given '50 mg yohimbine IV, shorty followed by 1.5 cc epinephrine IV' "

My friend took the horse to Colorado State University for a necropsy. A definite cause of death could apparently not be established. The lungs were filled with fluid - his heart seemed in good shape, there were some enlarged cells in the liver.

"The report also showed some liver disease (some cells were bigger that they should have been). I asked how in the world do horses get that? Uncommon, but can be caused in older horse by an accumulation of chemicals from their feed. She thought this might have been why I had so much trouble keeping weight on him. It wasn’t bad enough to contributed to his death though."
The final report was issued Aug 14 and the cause of death “remains obscure”.

I am really posting this for general information, and maybe this is not in the right location for most folks to see. The items in quotes are either copied from the PDF document or from my friend's emails. Dr. O, if you think I should move this information or start a new post, please let me know. I guess it is good to be reminded that there are risks whenever sedatives are used.

Lilo
Member:
illinois

Posted on Sunday, Nov 11, 2007 - 7:28 pm:

I was also told that a necropsy would probably not reveal anything. My neighbor who boards horses has had at least 4 horses over the years brought in for a necropsy and there were no definite findings as to the cause of death.

My one other question to Dr. O is "Would a tracheotomy or ventilator have helped my horse in addition to the epinephrine?" My horse, Sammy, was revived with epi once but then crashed again and was not resuscitated. He was breathing hard before he stumbled and went down. Fluid in the lungs?
Moderator:
DrO

Posted on Sunday, Nov 11, 2007 - 7:53 pm:

This is pertinent to Jane's discussion Lilo so let's continue this here. It is a complicated pharmacological discussion but let's see if we can hash this out.

First let me say when Jane first posted I went looking through my pharmacological texts and equine formularies and could not find a specific contraindication listed for the use of epinephrine nor could I find in Pubmed a single case of epi associated death in horses sedated with xylazine or yohimbine.

So I went looking at the specific pharmacology. I suspect the reason for the warning in the detomidine insert is that both detomidine and epinephrine are adrenergic a2 receptor agonist so they would be expected to potentiate each other. However epinephrine is a more powerful a1 agonist and also stimulates b1 and b2 receptors, and some of these effects are opposite of the a2 receptors. Also epinephrine is a potent suppressor of the immune system which accounts for its use in severe allergic reactions. Because of the different adrenergic reactions xylazine and epinephrine have been tested for possibly counteracting the toxic effects of the other, primarily epi induced arrhythmia. The results have not been that great. But in these experiments I cannot find where the use of one potentiated the ill effects of the other. It is a ying and yang thing: there are good and bad effects when used together and without testing it is difficult to know which predominates. The testing I can find says it is a wash. On the other hand yohimbine is a pretty dependable reversal agent for the effects of xylazine.

The case of anaphylaxis is a special case where I don't know of a good reason not to use epinephrine and if that is what the detomidine manufacturer is saying I want to see their tech support back it up. If you suspected a allergic reaction to one of the alpha-2 sedatives I would consider it irresponsible to not give epinephrine. The mechanism of the disease has no relation to there catecholamine effects.

In horses hypoxemia due to fluid in the lungs is the classic cause of death from anaphylaxis Lilo so the question I have concerning your friends horse is, "was the epi given fast enough or enough given to do any good?" And if it was given promptly and in adequate doses I wonder what could have been done differently to save the horse? Possibly very rapid administration of very high doses of very rapid acting coritcosteroids but I would not want to make the call if that would have made a difference.
DrO
Moderator:
DrO

Posted on Monday, Nov 12, 2007 - 6:42 am:

Hello Polo,
Whether a tracheostomy and/or ventilation would help in such a case depends. For instance if obstruction of the upper airways had occurred and no significant lower airway pathology so the ventilation would help oxygenate the blood it might have been beneficial. In the case of an equine anaphylaxis reaction fluid in the lungs most likely would prevent such action of being benefit as the horse cannot use the air or oxygen being forced into the lungs.

Ventilation alone is beneficial whenever respiration is severely depressed but other pathology is not life threatening. It would be considered standard therapy for any drug overdose in humans and small animals where breathing becomes irregular and consciousness lost but most large animal practitioners do not have the equipment on hand unless they use gas anesthesia.
DrO
Member:
lilo

Posted on Monday, Nov 12, 2007 - 11:34 am:

Dr. O,

Thank you for your detailed response. My horses have been sedated in the past, and I never worried much about it. Their teeth are due to be floated next spring, and I will certainly talk to my vet ahead of time to see what his experiences have been and what his response would be in case of trouble.

Lilo
Moderator:
DrO

Posted on Monday, Nov 12, 2007 - 9:28 pm:

The alpha-two agonist groups of sedatives are very safe. Despite what must be a bit over ten thousand sedations of horses over my career, I have had but one serious adverse reaction to sedation and that was a faint from ace use in a horse that had bleed worse than I realized.

I know this is little consolation to Polo but it is very important here to understand how much safer veterinary medicine is for both the veterinarian and the horse with the advent and proper use of these agents. As always see the articles on these sedatives for a complete description of indications and contraindications. Because of the disperity between my research and the label I do plan to pursue with the drug manufacturers the epi contraindication on the label and does it also apply in the case of allergic-like reaction. It may be next week before I can pursue this but if I find anything interesting I will post it here.
DrO
Member:
illinois

Posted on Monday, Nov 12, 2007 - 9:44 pm:

Thank you very much for your research and response to my questions, concerns and heartache. I sincerely appreciate your looking into this matter with the drug manufacturer.
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