Orthopaedic pain relief

Re: Orthopaedic pain relief

Siobhan Steven — Fri, 30 Dec 2011 22:45:04 GMT

Obviously there are many protocols that may be used, and depending on who you talk to there are pros & cons for each one. Even working with Ortho Specialists I've found they each like their own way of doing things. I've worked with one surgeon who was VERY atraumatic in his surgical methods (I'm not insinuating any surgeons try not to be but his skills where at another level...this is at a University). My protocol with his patients was ACP (0.35mg/kg)/Methadone (0.3-0.5mg/kg) premed, Alfaxalone induction (which has no proven analgesic properties) and O2/Iso maintenance (again no analgesia). I would have some Methadone kept aside to give I.V if needed in Sx (if this happened it would be titrated and may be in the area of 0.1-0.2mg/kg to effect, this wouldn't be necessary most times but maybe at Sx commence). After Sx these guys would get Methadone IM q5 at 0.3mg/kg overnight, so if Sx finished at say, 1.00pm they would get 3 more injections by the time I got back in the morning (it is a 24hr ICU facility). They would also get Carprophen (Rimadyl) SQ or Meloxicam (Metacam) post Sx injection(when sternal). I would give Carprophen to larger dogs because they could go home on 7 days of chews, just worked out way cheaper than a big bottle of Metacam, smaller dogs went home with a small bottle of Metacam, cause if the little guys were fussy about a chew you could imagine the owner trying to pill it so it was just easier to shove the dropper in their mouth :) With this protocol the Iso would run at 1.2-1.5% throughout Sx, obviously if it wasn't effective this wouldn't be possible. We would dispense Tramadol tabs (usually SR) for some cases, about two patients in two years, for say, an osteomylitis referral that was seriously compromised. But, for example, every patient that had this protocol would wake up the next morning, hop out of its cage, walk to toilet outside, toe touching. These were primarily cruciate (TPLO) type Sx, carpal arthrodesis, fractures with ex fixes or plates and deviation corrections.

They would also get 0.22 mg/kg of Cephazolin SLOW IV 20 minutes prior to Sx commencement (so during prep after all monitoring equipment was on). And then q2, through Sx. If for some reason we thought the Sx was compromised, and by that I mean the dog had had a recent skin problem (that was cleared up but still questionable) or it was a extra long Sx, I would give another dose post op, but our guys never went home on AB's due to the level of asepsis.

We would apply a modified RJ's bandage that we would instruct needed removal in 3 days, this is just to help minimise inflammation (In an area where its hard to apply a RJ I would get a student to ice it as this is the preferred method of minimising inflammation)

Other surgeons would ask for epidurals, which are fine, you just have to be good at giving them as they have to work...you will gauge this when Sx starts and you see the vitals stay at lovely levels...or skyrocket. We also use varying CRI concoctions, of which there are so many your better off getting a good book and implementing one that everyone feels safe with. Fent patches are used by some, as pointed out they don't kick in for (and this is a contentious point) anywhere from 8-12hours, so the patient needs to be maintained on something for this time. The patches themselves last for up to 72 hours ( we would write the date & time, dose and 'Fentanyl' on the elastoplat covering).

So an opioid SQ/IM or maintaining a CRI if you have 24hr staff (which you have to be careful you don't narc out the patient as the patch takes effect-assuming it does). Though if you have 'narced' it out on a Fent CRI once its turned off it only takes 20mins to metabolise, and then the patch should take over in time. Things to be aware of with patches are, the prep used on the patients skin may effect the uptake of the drug, the patients temperature may effect the dispersal/uptake (so hypothermia, heatpads etc may = underdose or overdose, at the very least varying amounts dispensed...), the area it is placed will effect it,or fat dog may change the dose uptake...all sorts of things, but there are people who swear by them. We don't use Morphine as the potential emetic properties vs similar results with Methadone means methadone wins

Sorry its so long winded!

Re: Orthopaedic pain relief

Gillian Mostyn — Fri, 30 Dec 2011 22:26:51 GMT

[quote user="Ceri Boyd"]We use augmentin I/V during op, every 90 minutes. [/quote]

Why this frequency? Is this by infusion or bolus? How often would you repeat this?

I've usually given it q 6-8 hours so am curious where your protocol comes from?

Re: Orthopaedic pain relief

Ceri Boyd — Fri, 30 Dec 2011 21:40:21 GMT

Hi :)

Pre-meds are usually acp/morphine combo... depending on op we either use epidural or MLK drip - morphine, lidocaine, ketamine infusion.

Also use vetergesic/morphine injections for pain relief - find that the majority of cases do well on MLK's and nothing else needed.

We use augmentin I/V during op, every 90 minutes.

Hope that helps, we are by no means an ortho specialist but we have been seeing more & more cases and our patients generally do well with our protocol :)

Re: Orthopaedic pain relief

Stuart Ford-Fennah — Fri, 30 Dec 2011 18:47:01 GMT

[quote user="SmegSlayer"]

we premeded with pethidine and when clipping clipped an area for a fentanyl patch to be attached. pain relief was then given by i/m morphine until the fentanyl patch kicked in.

[/quote]

worth remembering it may take 36-48hrs for the fentanly patch to work depending on site, temperture etc

Re: Orthopaedic pain relief

SmegSlayer — Fri, 30 Dec 2011 17:56:36 GMT

we premeded with pethidine and when clipping clipped an area for a fentanyl patch to be attached. pain relief was then given by i/m morphine until the fentanyl patch kicked in.

Re: Orthopaedic pain relief

Stuart Ford-Fennah — Fri, 30 Dec 2011 16:44:52 GMT

Hi Claire,

Lots of options here - too many to really go into

1) Methadone = good start :-) we will use either 0.2 or 0.3mg/kg works quite well q 4-6hrs (try and pain score your patients to see how long it lasts in each individual) (we will often also give an NSAID - will give post op IF worries re renal probs)

2)Morphine - dificul;t to justify on cscade mow there is a licenced methadone..

3) Vetergesic partial op2 opioid so not as good at anaglesia - good in patients who are having analgesia reduced

2) CRI infusion - a bit extream you may thing but if you have a good IV line the aptient needs no further needles :-) i wouldnt want any more needles than necesary. We will use any combination of (mixed in 1l of Hartmanns or 0.9% saline) 1ml ketamine (100mg/ml conc) 1ml Dexmedatomidine (only comes in one strength) 20ml fentanyl (50micrograms/ml) and we will give a bolus of 1-3ml/kg follwed by a 1-3ml/kg/hr cri infusion - there are a few other variations of this concoction out there so dont think this is the onl recipy.

Hope that helps a little

Ohh we use either augumentin IV or Zinacef IV as our peri op ab's

Regards
Stu