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according to the latest findings from the Confidential Enquiry into Perioperative Equine Fatalities (CEPEF4). The large international study shows that advances in anaesthetic techniques, monitoring and recovery management have reduced the number of horses dying after anaesthesia, although the risks remain substantially higher than those seen in both human and small animal medicine.
Approximately every 10 years, the CEPEF project brings together veterinary hospitals around the world to assess the safety of equine general anaesthesia and identify factors that influence patient outcomes. The fourth phase of the study (CEPEF4) analysed 47,396 general anaesthetic procedures performed at 93 veterinary centres across 28 countries between November 2020 and June 2023, making it the largest and most comprehensive assessment of equine anaesthesia undertaken to date.
Researchers followed every horse for seven days after anaesthesia, recording whether the animal survived, was euthanased or died, while also analysing 249 different patient, surgical and anaesthetic variables.
The overall mortality rate associated with general anaesthesia was 1.2%, representing a substantial improvement compared with the 1.9% reported in the previous major enquiry (CEPEF2) in 2002. Horses undergoing procedures unrelated to colic had an even lower mortality rate of 0.6%, compared with 0.9% previously. Among horses requiring emergency surgery for colic, where patients are already critically ill, mortality fell from 7.8% to 4.2%.
Despite this encouraging progress, horses remain one of the highest-risk domestic species to anaesthetise. In comparison, modern human anaesthesia carries an anaesthesia-related mortality estimated at around one death in 100,000 to 200,000 anaesthetics (approximately 0.001% or lower) in healthy patients. In dogs, reported anaesthetic mortality is typically around 0.05–0.2% in healthy animals, increasing in those that are seriously ill. Even with recent improvements, healthy horses therefore continue to face a considerably greater risk.
The study highlights the recovery period as the most dangerous stage of anaesthesia. Unlike people or dogs, horses are large prey animals whose instinct is to stand as quickly as possible when they regain consciousness. This natural behaviour can result in panic, falls and catastrophic injuries while they are still uncoordinated.
Among otherwise healthy horses undergoing non-colic procedures, fractures sustained during recovery accounted for more than one-third (35.7%) of all deaths. Abdominal complications were responsible for 18.1%, while central nervous system disorders accounted for 13.2%.
The researchers also identified several factors associated with increased risk. Pregnant mares, geriatric horses, animals in poor body condition, patients with more severe underlying disease, urgent procedures and anaesthetics lasting either less than one hour or more than two hours all carried greater odds of death.
Importantly, the study also identified clinical practices associated with improved survival. Horses whose anaesthesia included invasive blood pressure monitoring, end-tidal carbon dioxide measurement, arterial blood gas analysis and continuous body temperature monitoring experienced significantly lower odds of death. Adequate pain relief, including combinations of opioid drugs with non-steroidal anti-inflammatory medications before anaesthesia, together with the administration of alpha-2 agonist sedatives immediately before recovery, were also associated with improved outcomes.
The findings provide valuable evidence that continued investment in monitoring equipment, careful anaesthetic management and recovery protocols is improving safety for equine patients. They also offer practical guidance to veterinarians when planning anaesthesia for higher-risk horses and help owners make informed decisions about treatment.
Although healthy horses can still die following routine anaesthesia, the steady decline in mortality over successive CEPEF studies demonstrates how advances in veterinary medicine continue to make equine anaesthesia safer. Researchers believe the extensive CEPEF4 database will continue to generate new insights that could further reduce risks in the years ahead, particularly during the critical recovery period where the greatest opportunities for improvement remain.
For more details, see:
Miguel Gozalo-Marcilla, José I. Redondo, Regula Bettschart-Wolfensberger, Luis Domenech, Javier Doménech, G Mark Johnston, Polly M. Taylor.
The Confidential Enquiry into Perioperative Equine Fatalities: phase 4 (CEPEF4) – a worldwide observational, prospective, multicentre cohort study in 2025.
Veterinary Anaesthesia and Analgesia (2025) Vol 52, (5), p 525-538.
https://doi.org/10.1016/j.vaa.2025.06.005
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