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PA I N M A N A G E M E N T
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Our readers say ...
NSAIDs—Routinely
Illustration by Bill Celander
You have asked ...
What do you dispense/
prescribe for pain control
at home following
ovariohysterectomy?
We routinely dispense an NSAID for
use at home after ovariohysterectomies. We use a lot of deracoxib and
meloxicam. The meloxicam, because of
its liquid formulation, is usually used in
smaller animals; deracoxib in larger dogs. After
a few days at home, owners are instructed to try
to taper off the drug as soon as possible. The
animals seem to feel better, the owners are happier, and we sleep better knowing we are helping to stop their discomfort.
Al Wagener, VMD
Black Mountain, North Carolina
Preemptive Management
in Its Broadest Sense
All clients are given the option of preemptive
pain management while in the hospital and also
at home (as two separate packages and
charges). There are also two at home packages:
1) NSAIDs only—currently using either dera-
coxib, carprofen, or meloxicam or 2) NSAIDs
plus a fentanyl patch.We strongly urge clients to
consider preemptive versus “treat pain as you
see it” management. Most clients choose the inhospital protocol, which can include injectable
NSAIDs, opioids, and perhaps an epidural narcotic as well. Due to the expense of the patch,
most clients choose the basic NSAID at-home
package.
Jeff Rhody, DVM
Laurel, Maryland
One-Shot Approach
Working as a staff veterinarian in a shelter, a
nonprofit organization, I perform between 20
and 30 spay/neuter surgeries a day. The pain
control used in dogs (males and females) is
buprenorphine, while butorphanol mixed with
ketamine and medetomidine is used in cats as
part of the anesthesia protocol. These injections
are given once, at the time of surgery.
Isabelle Vivies, DVM
Fort Lauderdale, Florida
The next questions are:
>Do you feel that your local animal
shelter poses serious financial
competition to your clinic? Does it
provide important services for pets
of indigent people and for abused
animals?
>>Are you concerned about legal
liability regarding zoonotic
parasitic disease? What precautions
do you take to protect patients and
clients and thus your practice and
yourself?
What the EXPERT says ...
Sheilah A. Robertson, BVMS (Hons), PhD, MRCVS, Diplomate ACVA & ECVA, University of Florida
Preemptive and Postoperative
Approaches to Pain Management
variohysterectomy is a painful procedure in both dogs and cats, and patients should receive
both preemptive and postoperative analgesics. Ovariohysterectomy involves both somatic and
visceral pain which—on a scale of mild, moderate, or severe—is likely to be moderate and
last several days. Many female cats undergo onychectomy at the same time as ovariohysterectomy,
thereby increasing the intensity and duration of pain. Behavioral changes after ovariohysterectomy
are well documented and can be minimized with the use of appropriate analgesic agents.1, 2
O
Pain is easier to prevent than treat and this is the basis of preemptive analgesia. If steps are taken
to use analgesics as part of the anesthetic plan, the postoperative requirements may be reduced,
simplifying the treatment of outpatients once they return home.
c o n t i n u e s
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CONTINUED
NSAIDs & Other Drugs
Nonsteroidal antiinflammatory agents (NSAIDs) provide
effective analgesia for canine ovariohysterectomy.
Preoperative carprofen is more effective than postoperative administration,3 and meloxicam is more effective
than butorphanol.4 NSAIDs offer the advantages of being
noncontrolled substances with a long duration of action—often 20 to 24
hours after a single dose. Both carprofen and meloxicam are now available in
the United States for use in dogs in an injectable formulation, making it easy to
incorporate them into the anesthetic premedication protocol. Both drugs can
be continued in the postoperative period. Carprofen is available as caplets or
chewable tablets and the oral preparation of meloxicam is a palatable honeyflavored liquid; both require just once-a-day dosing. However, it should be
pointed out that carprofen is the only licensed NSAID for perioperative use in
dogs undergoing soft tissue surgery. There are no licensed NSAIDs for use in
cats in the U.S. but in other countries carprofen, ketoprofen, and meloxicam
have been effective for providing postoperative analgesia in cats for the first
day after ovariohysterectomy.5
Approval Status
Cats are more susceptible to the toxic side effects of NSAIDs because of their
limited ability to metabolize these compounds; however, with appropriate doses
and dosing intervals NSAIDs can be used safely. Carprofen is licensed for cats
in the United Kingdom but only in injectable form and for one dose. Although
the oral preparation of meloxicam is not approved for multiple-day dosing, it
has been widely used this way in cats with few reported side effects. Ketoprofen can also be used for several days in cats, but requires compounding.
NSAIDs do not decrease anesthetic requirements, so it is advisable to incorporate a sedative and/or an opioid at the time of surgery. Sedatives, such as acepromazine or medetomidine, decrease requirements for induction or maintenance agents and usually result in better-maintained blood pressure and respiration. Opioids are also recommended prior to surgery as they provide
additional analgesia and anesthetic-sparing actions. In dogs morphine, hydromorphone, and buprenorphine are all excellent choices and in cats the latter
would appear to be most appropriate.6 Butorphanol is short acting and provides insufficient analgesia for abdominal surgery.7 Other techniques that may
minimize the requirements of postoperative analgesics include local anesthetics instilled into the abdomen and incision.8
Once the animal returns home, administration of analgesics must be simple
for the owner to ensure compliance. The choices are opioids or NSAIDS.
Dogs
NSAIDs are simple to administer and in dogs the obvious choice would be
oral carprofen for 3 to 4 days starting 24 hours after the injectable formulation is given. Options for oral opioids include butorphanol and morphine.
The analgesia provided by butorphanol is inferior to that of the NSAIDs.4 Many
owners do not like the sedation that may be seen with some opioids, especially morphine, so they may not be a good choice for home use. In addition, the
opioids have the added inconvenience of being controlled substances.
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Cats
Meloxicam is easily administered to cats and can be given for several days.
For an ovariohysterectomy, the injectable preparation can be given preoperatively or immediately postoperatively with oral dosing beginning on the first
day after surgery. Buprenorphine provides excellent analgesia for up to 6
hours and can be absorbed by the oral mucous membranes.9 Cats do not
resent the taste of the injectable formulation administered orally and it can
be given easily by owners at home. Cats often become euphoric on opioids
but they remain easy to handle. Because of opioid-induced mydriasis, they
should be kept away from bright light. Opioids are recommended for a maximum of 3 days; longer use can lead to inappetence. Although controlled,
buprenorphine is a schedule III drug.
Transdermal Fentanyl
To simplify administration and provide a long duration of action, transdermal fentanyl (TDF) patches have been studied in both dogs and cats
undergoing ovariohysterectomy.10, 11 Although attractive because they offer
a “hands-off” approach, uptake is not always adequate in every animal.
The patches are best applied at least 12 hours prior to surgery to allow
time for steady-state plasma concentrations to be achieved; this is not
always convenient for outpatient procedures. Elevated rectal temperatures
in cats have been reported after TDF use. Another factor to be considered
is the patient’s environment. If there are children in the home, the issues
of a schedule II drug and the potential for accidental human exposure
should be carefully considered.
If adequate preemptive analgesia is provided, most bitches can be sent
home with an oral NSAID such as carprofen (4 mg/kg preoperatively
[injectable formulation]; then 4 mg/kg PO Q 24 H) for 3 to 4 days. The
choices for cats are meloxicam for up to 3 days (0.3 mg/kg pre- or postoperatively [injectable formulation]; then 0.1 mg/kg Q 24 H) or buccal
buprenorphine (0.01–0.02 mg/kg administered onto oral mucous membranes every 6-8 hours) for 2 to 3 days.
I premedicate with acepromazine, buprenorphine or morphine, and
injectable carprofen; induce with propofol or diazepam and ketamine; and
maintain on isoflurane. Postoperatively, I give 1 or 2 further in-hospital
doses of opioids starting 4 hours after the premedication dose. Dogs are
sent home with oral carprofen (caplets or chewable) for 3 to 4 days. It is
important not to switch from one NSAID to
another but use the same one for the course of
perioperative pain management. As with all
NSAIDs, if the dog vomits, refuses to eat, or has
blood in the feces, the owner should be instructed to stop medication and call. ■
See Aids & Resources, back page, for
references, contacts, and appendices.
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aids & resources
C O N T I N U E D F R O M PA G E
56
Reducing postoperative pain for dogs: local anesthetic and analgesic
techniques. Quandt JE, Rawlings CR. Compend Contin Educ Pract Vet
18:101-111, 1996.
SERUM ALKALINE PHOSPHATASE • Cynthia R.L. Webster
References
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disease: 270 cases (1980-1990). Center SA, Slater R, Manwarren T,
Prymak B. JAVMA 201:1258-1264, 1992.
3. Quantification of bone alkaline phosphatase in canine serum. Sanecki
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Dorner J. Vet Clin Path 17:66-70, 1995.
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Hoffman W, Hungerford L, et al. JAVMA 203:534-539, 1993.
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hyperadrenocorticism. Ristic JME, Ramsey IK, Heath HJ, Herrtage ME.
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11. Effect of long term phenobarbital treatment on the liver in dogs.
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J Vet Intern Med 14:277-281, 2000.
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Steinberg S, Van Winkle TJ. JAVMA 199:1060-1066, 1991.
14. Prognostic significance of serum alkaline phosphatase activity in
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W. J Vet Intern Med 14:587-592, 2000.
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