Anesthesia for Patients with Cancer: Paraneoplastic Syndromes

By Dr. Zubair Khalid, DVM, MS, PhD · 2026-08-11

Key Takeaways

• Paraneoplastic syndromes, systemic disturbances remote from the primary tumor, significantly elevate anesthetic risk in cancer patients, often exceeding the risk posed by the tumor's mass effect. Preanesthetic screening including CBC, biochemistry (especially ionized calcium and glucose), coagulation panel, and blood pressure is critical to identify these occult derangements before drug administration.
• Hypercalcemia of malignancy, the most common metabolic paraneoplastic syndrome, necessitates pre-induction assessment of hydration, cardiac rhythm (ECG for QT shortening and arrhythmias), and renal function; volume expansion with crystalloids is the primary intervention, and anesthesia should be deferred until the patient is hemodynamically stable.
• Tumor-associated hypoglycemia, caused by insulin secretion or IGF production, requires frequent intraoperative blood glucose monitoring and dextrose supplementation, with anticipation of abrupt changes in glucose requirements post-tumor resection.
• Hematologic paraneoplastic syndromes like anemia and thrombocytopenia necessitate evaluation of chronicity and bleeding risk, potentially requiring transfusion to optimize oxygen-carrying capacity or careful planning for regional anesthesia and platelet products.
• Perioperative management should focus on minimizing the neuroendocrine stress response through multimodal analgesia, considering regional techniques where feasible, and maintaining normothermia, normovolemia, and adequate tissue perfusion, which may confer long-term oncologic benefits though evidence remains largely preclinical.
• Anesthetic drug selection must be tailored to specific paraneoplastic abnormalities; for hypercalcemic patients, caution is advised with drugs that sensitize the myocardium to catecholamines or impair renal excretion, while hypoglycemic patients require continuous glucose monitoring and cautious use of sedatives and vasodilators.

Cancer patients presenting for anesthesia carry a dual burden: the mass effect of their primary disease and the systemic disturbances that tumors create at a distance. These remote effects, the paraneoplastic syndromes, often determine anesthetic risk more than the tumor itself. This article provides a diagnostic-reasoning framework for the practicing small animal veterinarian, linking specific paraneoplastic presentations to their anesthetic implications. It covers the metabolic, hematologic, and neurologic syndromes most relevant to perioperative care, and it explains how the physiologic derangements of cancer influence drug selection, monitoring priorities, and recovery planning. Chemotherapy protocols are excluded, the focus is on the patient as they arrive for surgery, biopsy, or diagnostic imaging.

The anesthetist must distinguish between abnormalities caused by the tumor, by prior treatment, or by unrelated comorbidity. Paraneoplastic syndromes can precede tumor diagnosis, appear after treatment begins, or emerge during disease progression. Their recognition changes anesthetic risk stratification and may alter the surgical plan itself. This article assumes the reader is familiar with standard anesthetic techniques and monitoring as outlined in the AAHA anesthesia and monitoring guidelines for dogs and cats, and it builds on that foundation with cancer-specific considerations.

At a Glance

Pathophysiology of Paraneoplastic Syndromes

Paraneoplastic syndromes arise from tumor secretion of bioactive substances, from immune cross-reactivity between tumor antigens and normal tissues, or from metabolic competition between tumor and host. The tumor may produce hormones, growth factors, cytokines, or antibodies that act at distant sites. Alternatively, the tumor may consume substrates so avidly that normal organ function fails, as with glucose consumption by large mesenchymal tumors.

The clinical expression depends on tumor type, secretory rate, and host organ reserve. A small insulinoma can cause profound hypoglycemia, while a large carcinoma may produce no paraneoplastic effect at all. The anesthetist should therefore screen for paraneoplastic syndromes based on tumor type and clinical signs, not tumor size alone. The MSD Veterinary Manual professional edition provides species-specific summaries of the recognized paraneoplastic syndromes in dogs and cats, including their typical tumor associations and diagnostic criteria.

Hypercalcemia of Malignancy

Hypercalcemia is the most common metabolic paraneoplastic syndrome in small animals. It results from tumor secretion of parathyroid hormone-related protein, from local osteolysis by skeletal metastases, or from calcitriol production by lymphoma cells. The clinical signs, polyuria, polydipsia, weakness, and vomiting, overlap with those of renal failure and pancreatitis, so the diagnosis requires ionized calcium measurement.

Anesthetic risk tracks the severity and chronicity of hypercalcemia. Acute severe hypercalcemia impairs myocardial conduction, shortens the QT interval, and predisposes to ventricular arrhythmias. It also reduces renal concentrating ability, producing volume depletion that compounds the cardiovascular effects. The anesthetist should assess hydration status, measure ionized calcium, and obtain an electrocardiogram before induction. Volume expansion with crystalloids is the first intervention, followed by furosemide or other agents as indicated. Anesthesia should be deferred until the calcium concentration is reduced and the patient is hemodynamically stable.

Hypoglycemia and Metabolic Competition

Tumor-associated hypoglycemia occurs through two mechanisms: insulin secretion by pancreatic beta-cell tumors and insulin-like growth factor production by non-islet cell tumors. The latter mechanism predominates in large sarcomas and hepatocellular carcinomas. Clinical signs range from lethargy to seizures and coma, and they may be exacerbated by fasting before anesthesia.

Blood glucose should be measured at presentation, during fasting, and at regular intervals intraoperatively. Dextrose supplementation is indicated when glucose falls below the reference interval, and the anesthetist should anticipate that tumor resection may abruptly change glucose requirements. Insulinoma patients may become hyperglycemic after tumor removal, while patients with non-islet cell tumors may require ongoing dextrose support. The MSD Veterinary Manual professional edition notes that perioperative glucose monitoring should continue into the recovery period, as rebound hyperglycemia is common after insulinoma resection.

Hematologic Paraneoplastic Syndromes

Anemia, thrombocytopenia, leukocytosis, and hyperviscosity each alter anesthetic management. Anemia reduces oxygen-carrying capacity and lowers the margin of safety for any hypoxemic event. The chronicity of anemia matters: a patient with slowly progressive anemia has compensatory increases in cardiac output and tissue oxygen extraction, while acute blood loss does not allow such adaptation. Packed cell volume, total solids, and reticulocyte count should be interpreted together to determine whether the anemia is regenerative, nonregenerative, or dilutional.

Thrombocytopenia in cancer patients may result from immune-mediated destruction, bone marrow infiltration, or consumptive coagulopathy. The bleeding risk depends on platelet count and function, not on the platelet count alone. Regional anesthesia is relatively contraindicated in severely thrombocytopenic patients, and the anesthetist should plan for alternative analgesic strategies. Hyperviscosity from monoclonal gammopathy, most commonly seen in multiple myeloma, impairs tissue perfusion and increases the risk of thrombosis. Dehydration worsens hyperviscosity, so perioperative fluid management must maintain adequate intravascular volume without overloading the patient.

Anesthesia and Tumor Progression

The perioperative period may influence long-term cancer outcomes through effects on immune surveillance. Surgical trauma, anesthetic drugs, and inadequate analgesia all suppress cell-mediated immunity, and this suppression occurs precisely when circulating tumor cells are most vulnerable to immune clearance. The perioperative anesthesia care and tumor progression review summarizes evidence that volatile anesthetics and opioids may impair immune function, while local anesthetics and nonsteroidal anti-inflammatory drugs may have protective effects. These findings remain largely preclinical, and the clinical data are mixed.

A meta-analysis of anesthetic technique and cancer survival found an overall survival benefit associated with epidural anesthesia compared with general anesthesia alone, but no significant difference in recurrence-free survival. A separate study of epidural analgesia in colorectal cancer surgery found no overall association with recurrence, though a post hoc analysis suggested benefit in older patients. The surgical stress and immune suppression literature supports the rationale for minimizing the neuroendocrine stress response, but the methodology of a randomized trial on regional analgesia and breast cancer recurrence illustrates how difficult these questions are to answer definitively.

For the practicing veterinarian, the practical implications are straightforward. Use multimodal analgesia to minimize opioid requirements. Consider regional techniques where anatomically feasible and where coagulation status permits. Maintain normothermia, normovolemia, and adequate tissue perfusion. These measures improve immediate anesthetic safety and may confer long-term benefit, though the evidence base does not support claims of guaranteed oncologic advantage.

Preanesthetic Assessment and Risk Stratification

The preanesthetic evaluation of a cancer patient begins with a targeted history and physical examination directed at the paraneoplastic syndromes most likely to complicate anesthesia. A complete blood count, serum biochemistry panel, and urinalysis should be performed within 24 to 48 hours before the procedure. Additional testing is guided by the tumor type and the clinical signs present. For example, a patient with a thymoma or lymphoma requires a serum calcium measurement, while a patient with an insulinoma needs serial blood glucose determinations.

The physical examination should specifically assess hydration status, mucous membrane color, capillary refill time, pulse quality, and auscultation of the heart and lungs. A patient with hyperviscosity syndrome may present with injected mucous membranes, retinal vessel tortuosity on fundic examination, or neurologic signs. A patient with paraneoplastic hypoglycemia may appear lethargic or obtunded. These findings alter the anesthetic plan substantially.

Risk stratification follows the American Society of Anesthesiologists physical status classification, but the clinician must recognize that a cancer patient with a paraneoplastic syndrome may be physiologically unstable despite a seemingly localized tumor. The AAHA anesthesia and monitoring guidelines recommend that every patient receive an individualized anesthetic plan based on the specific comorbidities identified, not on the procedure alone.

Anesthetic Drug Selection in the Paraneoplastic Patient

Drug selection is driven by the specific paraneoplastic abnormality present. For hypercalcemic patients, drugs that undergo renal excretion or that may exacerbate cardiac arrhythmias require particular caution. Volatile anesthetics sensitize the myocardium to catecholamines, and hypercalcemia already shortens the QT interval and predisposes to ventricular arrhythmias. A balanced technique using a benzodiazepine and an opioid for premedication, followed by induction with a drug that has minimal cardiovascular depression, is appropriate. The clinician should consult a current formulary for specific drug choices and doses, as individual patient status varies widely.

For hypoglycemic patients, the anesthetic plan must include continuous glucose monitoring. Premedicants that cause sedation should be used at reduced doses, because a depressed level of consciousness may mask the early signs of neuroglycopenia. Induction agents that cause vasodilation should be used cautiously, as the compensatory sympathetic response to hypoglycemia may already be exhausted.

Opioid selection deserves specific attention. The literature on perioperative opioids and tumor progression is mixed, with some animal models suggesting that opioids may influence immune function, while refined animal models indicate that opioids can be used safely for perioperative pain management when dosed appropriately. The clinical priority is adequate analgesia, because uncontrolled pain amplifies the neuroendocrine stress response, which itself suppresses cell-mediated immunity. Multimodal analgesia, including nonsteroidal anti-inflammatory drugs where not contraindicated, is recommended as an essential component of the perioperative plan.

Monitoring Parameters and Their Interpretation

Monitoring in the paraneoplastic cancer patient extends beyond standard cardiopulmonary parameters. The AAHA anesthesia and monitoring guidelines mandate continuous assessment of heart rate, respiratory rate, blood pressure, oxygen saturation, and end-tidal carbon dioxide. The paraneoplastic patient requires additional parameters depending on the syndrome present.

Blood pressure monitoring is particularly important in the hyperviscous patient. Hypotension further reduces blood flow in an already hyperviscous circulation, increasing the risk of thrombotic complications. Direct arterial blood pressure monitoring should be considered for major procedures in these patients.

Perioperative Fluid and Metabolic Management

Fluid therapy in the paraneoplastic patient is not routine. Hypercalcemic patients require aggressive fluid diuresis with 0.9% sodium chloride to promote calciuresis, but the rate must be titrated against cardiac function. Hypoglycemic patients require a dextrose-containing maintenance fluid, with blood glucose checked frequently to avoid overshooting into hyperglycemia.

The hyperviscosity patient presents a particular challenge. Aggressive fluid administration reduces viscosity but may precipitate volume overload in a patient with compromised cardiac function. The decision to administer fresh frozen plasma or to perform plasmapheresis preoperatively depends on the severity of the hyperviscosity and the urgency of the procedure. This decision is made on a case-by-case basis, and consultation with a specialist is appropriate when available.

Analgesia and the Perioperative Period

The WSAVA Global Pain Council guidelines emphasize that pain recognition and treatment are essential components of veterinary practice. In the cancer patient, adequate analgesia serves a dual purpose: it fulfills the welfare obligation and it attenuates the neuroendocrine stress response that suppresses cell-mediated immunity.

The choice between regional and systemic analgesia has been the subject of considerable investigation. A meta-analysis of retrospective and prospective studies found an overall survival benefit associated with epidural anesthesia compared with general anesthesia alone, particularly in colorectal cancer, but no significant improvement in recurrence-free survival. A separate retrospective study of colorectal cancer surgery found no overall association between epidural use and recurrence, although a post hoc analysis suggested benefit in older patients. The evidence is therefore inconclusive, and the decision to use regional analgesia should be based on patient factors and procedural requirements instead of on an assumed survival benefit.

The MSD Veterinary Manual provides species-specific guidance on analgesic drug selection and dosing. Local anesthetics have demonstrated antitumor effects in basic science models, and their inclusion in a multimodal plan is reasonable. However, the clinician should not delay or compromise analgesia while awaiting definitive evidence of survival benefit.

Documentation and Communication

The anesthetic record for a paraneoplastic cancer patient must document the specific syndrome identified, the monitoring parameters used, and the values obtained throughout the procedure. Blood glucose measurements, electrocardiographic findings, and fluid therapy rates should be recorded at intervals appropriate to the patient's status. Any deviation from the planned anesthetic technique, and the reason for that deviation, must be noted.

Communication with the owner before anesthesia should address the specific risks associated with the paraneoplastic syndrome, the monitoring plan, and the anticipated recovery period. The AVMA practice resources provide guidance on informed consent and professional communication standards. The clinician should also communicate with the surgical team regarding any planned transfusion support, the need for intraoperative glucose supplementation, or the requirement for postoperative intensive monitoring.

Recognized Complications and Early Detection

The paraneoplastic patient deteriorates along predictable pathways, and each has an early warning sign that precedes overt failure. Hypercalcemia reduces cardiac contractility and shortens the QT interval, the earliest detectable change is often a progressive bradycardia that does not respond to anticholinergic doses that would be effective in a normocalcemic patient. Monitor the ECG continuously and compare heart rate against the preinduction baseline instead of against population norms. Hypoglycemia presents as deepening unconsciousness out of proportion to anesthetic depth, with or without tremor. A blood glucose measurement at 30 minute intervals during long procedures identifies the downward trend before seizure activity begins.

Paraneoplastic erythrocytosis raises blood viscosity and predisposes to thromboembolism. The earliest signs are subtle: an increasing alveolar dead space, a widening arterial to end-tidal carbon dioxide gradient, or a sudden rise in peak inspiratory pressure without bronchospasm. Hyperviscosity also slows capillary perfusion, so pulse oximetry waveforms become dampened and poorly responsive to increased inspired oxygen fraction. Thrombocytopenia and paraneoplastic coagulopathies declare themselves through mucosal oozing at surgical sites, hematuria, or petechiae on non-dependent skin. Check a platelet count and buccal mucosal bleeding time before any procedure that involves an airway instrument or an incision into a vascular bed.

Tumor lysis syndrome, though less common in small animal oncology than in human medicine, can be triggered by anesthetic drugs that cause catecholamine release or by surgical manipulation of large, chemosensitive masses. Serial potassium and phosphorus measurements during recovery, instead of a single preoperative panel, detect the developing electrolyte disturbance. Hyperkalemia produces tall T waves and a shortened QT interval before it progresses to bradyarrhythmia or ventricular tachycardia.

Common Errors and Corrective Action

The most frequent error is treating the paraneoplastic abnormality as a static laboratory finding instead of a dynamic process. A calcium or glucose value obtained the morning of surgery may be irrelevant by the time the patient is positioned. Repeat point-of-care testing immediately before induction and at intervals during the procedure.

A second error is aggressive fluid resuscitation in the hypercalcemic patient. Volume expansion is appropriate, but overzealous crystalloid administration in a patient with paraneoplastic cardiac dysfunction or erythrocytosis can precipitate pulmonary edema or hemodilutional coagulopathy. Titrate fluids against central venous pressure, urine output, and serial hematocrit measurements instead of against a fixed rate.

Less experienced clinicians often withhold analgesia in the paraneoplastic patient out of concern for hemodynamic instability. This is counterproductive. Inadequately controlled pain amplifies the surgical stress response, which promotes catecholamine release, hyperglycemia, and immunosuppression. The perioperative period is a critical window for preserving cell-mediated immunity, and multimodal analgesia that includes regional techniques and nonsteroidal anti-inflammatory drugs where not contraindicated is part of the anesthetic plan, not an optional addition.

A third error is assuming that a normal preoperative coagulation panel excludes paraneoplastic coagulopathy. Paraneoplastic syndromes can produce qualitative platelet dysfunction, acquired von Willebrand disease, or hyperfibrinolysis that standard clotting times do not detect. If the history includes unexplained bruising, epistaxis, or prolonged bleeding from minor wounds, request a buccal mucosal bleeding time and consider viscoelastic testing if available.

Troubleshooting Table

Limitations of the Evidence

The evidence base for anesthetic technique and cancer outcome is drawn largely from human retrospective studies and animal models, and the results are not uniformly consistent. A meta-analysis of epidural anesthesia versus general anesthesia for cancer surgery found an overall survival benefit but no significant improvement in recurrence-free survival, and the benefit was most pronounced in colorectal cancer. A separate retrospective study of colorectal surgery patients found no association between epidural use and recurrence overall, though a post hoc analysis suggested benefit in older patients. These conflicting findings mean the clinician should not choose an anesthetic technique solely on the basis of oncologic outcome claims. The current consensus is that regional anesthesia is valuable for analgesia and stress reduction, but its effect on tumor progression remains an area of active investigation instead of settled fact.

Expert opinion also differs on the use of nonsteroidal anti-inflammatory drugs in the paraneoplastic patient. Some authors argue they should be an essential component of multimodal analgesia based on preclinical evidence of antitumor effects. Others caution against their use in patients with paraneoplastic thrombocytopenia, renal impairment, or gastrointestinal ulceration. The safe approach is to weigh organ-specific risk against analgesic benefit on a case-by-case basis, following the multimodal principles in the WSAVA pain guidelines.

Referral and Escalation Criteria

Referral to a specialist anesthesiologist or oncologist is warranted when the paraneoplastic abnormality cannot be stabilized despite appropriate medical management. Specific triggers include ionized calcium that remains elevated despite aggressive fluid therapy and bisphosphonate administration, refractory hypoglycemia requiring continuous dextrose infusion, or a platelet count below the threshold considered safe for the planned procedure. Patients with suspected paraneoplastic cardiomyopathy, pulmonary thromboembolism, or disseminated intravascular coagulation should be stabilized before any non-emergency procedure.

Laboratory involvement is indicated when the paraneoplastic syndrome is the first presentation of an undiagnosed malignancy. A complete workup, including imaging, cytology, and histopathology, should precede elective anesthesia whenever feasible. Regulatory reporting is rarely required for paraneoplastic syndromes themselves, but veterinarians should be aware of their obligations under local practice standards and animal welfare legislation. The AVMA practice resources and the WOAH terrestrial animal health standards provide guidance on professional responsibilities and reporting requirements where they apply. When in doubt about a specific legal obligation, consult the relevant regulatory body in your jurisdiction before proceeding.

Frequently Asked Questions

How Should I Adjust My Anesthetic Plan When Advanced Monitoring Equipment Is Unavailable?

Prioritize the physical examination and basic monitoring. Pulse quality, mucous membrane color, capillary refill time, and serial blood pressure measurement with a Doppler device provide meaningful trend data. Capnography is ideal but not mandatory if you can observe thoracic excursions and auscultate lung fields regularly. For paraneoplastic patients, the most dangerous omissions are unmeasured glucose in hypoglycemic cases and unmeasured calcium in hypercalcemic cases. If in-house laboratory testing is unavailable, consider a preoperative referral for biochemistry. Document the monitoring limitations in the medical record and shorten anesthetic time where possible. The AAHA anesthesia and monitoring guidelines recommend that the anesthetic plan be adjusted to the available resources while maintaining patient safety as the priority.

What Is the Minimum Preoperative Database for a Cancer Patient With Suspected Paraneoplastic Disease?

A complete blood count, serum biochemistry profile, and urinalysis are the minimum. The biochemistry profile must include calcium, glucose, albumin, and liver enzymes. A blood smear review is warranted when the complete blood count shows thrombocytopenia, leukocytosis, or circulating nucleated red cells. Coagulation testing, either prothrombin time and activated partial thromboplastin time or viscoelastic testing, is indicated before any procedure with anticipated blood loss. Thoracic imaging is appropriate when hypercalcemia or a cranial mediastinal mass is suspected. The MSD Veterinary Manual emphasizes that paraneoplastic syndromes may be the first clinical evidence of malignancy, so a thorough database serves both anesthetic planning and diagnostic purposes.

How Do I Manage Anesthesia in a Cat With Suspected Paraneoplastic Alopecia or Skin Fragility?

Skin fragility in cats with pancreatic or biliary carcinoma demands meticulous handling. Apply padding under all extremities, avoid adhesive tape directly on skin, and use minimal restraint. Place intravenous catheters with care and secure them with a light wrap instead of tension. Induction and recovery areas should have thick bedding. These cats often have concurrent cachexia and hepatic involvement, so dose anesthetic drugs to lean body weight and consider dose reduction for hepatically cleared agents. Monitor body temperature closely because poor body condition impairs thermoregulation. The WSAVA Global Pain Council Guidelines support a multimodal analgesic approach that minimizes opioid requirements while addressing the substantial pain these fragile patients experience.

What Should I Tell an Owner When a Paraneoplastic Syndrome Is Suspected but Not Yet Confirmed?

Explain that the blood test abnormalities may be caused by the tumor itself instead of by direct organ invasion. Use concrete language: the tumor is producing a substance that affects the body, and treating the tumor is often the most effective way to correct the abnormality. Describe the anesthetic risks honestly, including the specific risks of hypoglycemia, hypercalcemia, or clotting abnormalities. Clarify that the immediate procedure may be diagnostic, such as biopsy, and that definitive treatment decisions will follow histopathology. Provide written estimates that include the cost of intraoperative monitoring, repeated blood work, and potential rescue therapies. The AVMA practice resources offer guidance on client communication and informed consent that supports this conversation.

How Should I Document Paraneoplastic Findings and Anesthetic Decisions in the Medical Record?

Record the specific paraneoplastic abnormality, its severity, and the date of confirmation. Document the preoperative stabilization steps, including fluid therapy, glucose supplementation, or calcium-lowering treatment, with patient response. Note the rationale for each drug selection, particularly if you chose propofol over a volatile agent or avoided an opioid. Record all monitoring values at intervals no longer than five minutes during the procedure. Include a problem list that names each paraneoplastic concern and the corresponding intraoperative plan. If you deviate from standard protocols, state the reason. This documentation supports continuity if the patient returns for repeat procedures and provides a defensible record of clinical reasoning.

Does the Choice of Anesthetic Technique Influence Long-Term Outcomes in Veterinary Cancer Patients?

The evidence in human medicine is mixed. A meta-analysis of retrospective and prospective studies found improved overall survival with epidural anesthesia compared with general anesthesia alone, but no significant difference in recurrence-free survival. A separate retrospective study of colorectal cancer patients found no overall association between epidural use and recurrence. Basic science suggests that volatile anesthetics may promote tumor formation while propofol may have protective qualities, and that regional anesthesia may preserve immune function. However, these findings come from human studies and animal models, and direct translation to veterinary patients is uncertain. The review of perioperative anesthesia care and tumor progression concludes that current evidence does not justify withholding opioids or regional techniques in veterinary cancer patients.

Related Clinical & Scientific Guides

• Anesthetic Machine Leak Testing and Pressure Checks: A Step-by-Step Protocol
• Anesthetic Depth Assessment: Reflexes, Eye Position, and Ventilation
• Anesthesia for Patients with Obesity: Challenges and Solutions

References and Further Reading

• Ondansetron: a selective 5-HT(3) receptor antagonist and its applications in CNS-related disorders.. 2001.
• Perioperative Anesthesia Care and Tumor Progression.. 2017.
• Association between epidural analgesia and cancer recurrence after colorectal cancer surgery.. 2010.
• Surgery as a risk factor for breast cancer recurrence and metastasis: mediating mechanisms and clinical prophylactic approaches.. 2006.
• Can regional analgesia reduce the risk of recurrence after breast cancer? Methodology of a multicenter randomized trial.. 2008.
• The effect of anesthetic technique on survival in human cancers: a meta-analysis of retrospective and prospective studies.. 2013.
• AAHA Anesthesia and Monitoring Guidelines for Dogs and Cats. AAHA.
• WSAVA Global Pain Council Guidelines. WSAVA.
• MSD Veterinary Manual, Professional Edition. MSD Veterinary Manual.

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This article is educational professional reference material for veterinary audiences. It is not a substitute for veterinary diagnosis, individual clinical judgment, current product labeling, or applicable regulatory requirements.