medetomidine / buprenorphine pre-meds

Re: medetomidine / buprenorphine pre-meds

Bob Russell — Fri, 16 Mar 2012 15:57:28 GMT

[quote user="Julie Innes"]

I did switch to dom/ vetergesic when ACP became harder to get and , despite persevering with it for about 6mths, I didn't like it, and eventually went back to ACP/ vetergesic.

I found some dogs were very sleepy (especially my greyhounds, of which I do a lot) and some seemed to come round from the GA then get sleepy again later. I found with a lot of smaller dogs especially that their respiratory and heart rate seemed to drop quite alarmingly with the domitor combo, and I didn't feel comfortable with it. I was using the same dosages as everyone else here, by the looks of it. If I reversed it, they had horrible recoveries, so I felt I couldn't win!

I persevered with it, because at first I thought it was just me being a dinosaur and not wanting to change things, but eventually, after a couple of worrying GA's, I decided to change back.

[/quote]

This was our experience too.

We stuck with it but have returned to ACP (French version) with a small sigh of relief!

Re: medetomidine / buprenorphine pre-meds

Clive Ansell — Thu, 15 Mar 2012 13:50:12 GMT

Aggressive, unruly, unhandled 15.0Kg Cocker Spaniel this morning for a 2cm skin mass removal; ga: 0.3ml Domitor/ 1.0ml Vetergesic i/d (i/d = intra dog. in one syringe as only just able to jab the f******g thing) - wait 15 min - 0.5 ml i/m ketamine - intubate and maintain on 0.5% iso in o2. no reversal. intra op metacam. surgery and anaesthesia uneventful with a slow and gentle recovery - everyones happy. s/c sutures, only recheck if necessary.

Re: medetomidine / buprenorphine pre-meds

Gerry Henry — Thu, 15 Mar 2012 11:01:17 GMT

Cats; TDK, iv fluids, intubate and maintain on 1% iso; methadone post op if any sign of pain breakthrough; NSAIDs intra op. Never need to reverse.

Dogs: Methadone IM followed 30mins later by ketamine (0.05mls/Kg BW) and metomidine (0.04mls/Kg BW) im (bit nippy), same syringe; intubate when recumbent and maintain on 0.5% isofluorane for routines, 1% for speys and orthos; everything iv fluids. Very occasional apnoea 2 - 3 mins (just ventilate for them, no big deal). Lovely, smoothe anaesthetic, smoothe recovery, no problems, no deaths - ever, in 4 years. Second, subsequent shots of methadone can be given on recovery if required, NSAIDs intra-op obviously. If still deep post procedure give 10% volume of metomidine as reversing agent; just enough to improve colour/breathing. You'll never go back to iv anything.

Re: medetomidine / buprenorphine pre-meds

Mark Holmes — Thu, 15 Mar 2012 06:39:50 GMT

Don't reverse them or at least wait until they are off gas for 10 minutes. Recovery form reversed sedation has always been ok but they need to be sedated not under Ga.

Re: medetomidine / buprenorphine pre-meds

Michael Woodhouse — Thu, 15 Mar 2012 00:29:48 GMT

[quote user="james herriot lied"]From tomorrow, we're going to start reversing with half-doses of atipamazole to see what difference that makes.[/quote]

Less smooth recovery! I rarely reverse them now, but tried it for a little while. You are also eliminating the analgesic effects from the alpha 2, that will work alongside your opioid and NSAID.

Re: medetomidine / buprenorphine pre-meds

james herriot lied — Wed, 14 Mar 2012 23:36:29 GMT

Thanks for the comments, Julie.

We're currently trying to do a reasonably objective review of the effects of dom/vetergesic premeds. Whilst undoubtedly, the d/v premedded dogs need less propofol than the a/v dosed patients, and intubation is easier still, they DO come round a little slower and seem to have a bit of a re-entry. This is, however, smooth, and as we've confined this premed to elective procedures lately, the recovery is uneventful. From tomorrow, we're going to start reversing with half-doses of atipamazole to see what difference that makes.

Currently, loving the induction but my natural paranoia is liking the recoveries a lot less.

Re: medetomidine / buprenorphine pre-meds

Julie Innes — Wed, 14 Mar 2012 23:12:51 GMT

I did switch to dom/ vetergesic when ACP became harder to get and , despite persevering with it for about 6mths, I didn't like it, and eventually went back to ACP/ vetergesic.

I persevered with it, because at first I thought it was just me being a dinosaur and not wanting to change things, but eventually, after a couple of worrying GA's, I decided to change back.

Re: medetomidine / buprenorphine pre-meds

Mark Hedberg — Wed, 14 Mar 2012 21:27:23 GMT

[quote user="robloxley"]

I half remember something about beneficial effects of peripheral vasoconstriction from medetom with reference to particular types of heart disease, possible outflow tract obstructions?

[/quote]

I read it was a renal protectant as it maintained central blood pressure, which is good for kidney function. I remember it was not recommended for heart patients as increases peripheral resistance which is bad for cardiac output. (Full disclosure: this was CPD from a rep.)

Re: medetomidine / buprenorphine pre-meds

Rob Loxley — Wed, 14 Mar 2012 19:28:11 GMT

I half remember something about beneficial effects of peripheral vasoconstriction from medetom with reference to particular types of heart disease, possible outflow tract obstructions?

Re: medetomidine / buprenorphine pre-meds

Julian Earl — Wed, 14 Mar 2012 18:47:24 GMT

[quote user="Mark Holmes"]

[quote user="Dagmar Steele"]

[quote user="Mark Holmes"]

[quote user="Clive Ansell"] Only use in healthy animals with no sign of cardiac disease of course.[/quote]

Whats considered a sign of cardiac disease? A murmur or evidence of CHF?

[/quote]

i would not use it in either of them as long as the murmur has not been fully explored and proven to be benign.

[/quote]

If a dog is fit, (ie can exercise without restriction, CRT <sec normal pulses and heart rate etc) then the presence of a murmur does not worry me at all. In fact acp should theoretically (although in practice doesn't) worry me more I think as blood is wasted peripherally through vasodilation than being encouraged centrally.

In dogs with evidence of cardiac failure or CHF I generally use morphine/hypnovel premed.

[/quote]

I have sedated dogs with fairly severe heart disease with acp/butorphanol at very low dose rates. It works extremely well, safely (so far0 and lasts up to about 45-60 minutes.

Dose rates (with thanks to source Mark Patteson): acp (2mg/ml) 0.05ml/10kg; butorphanol 0.1ml/10kg, both iv via the same syringe. It takes maybe five minutes or so to work and the dogs arnice and relaxed. I drained 5.5 pints of abdominal fluid from a 12kg CKCS last week under this combination despite him having heart rate of 200+ and a grade 5 murmur. I regularly use the combination for dogs but not cats.

Re: medetomidine / buprenorphine pre-meds

Mark Holmes — Wed, 14 Mar 2012 17:26:54 GMT

[quote user="Martin Atkinson"]I use it all the time and I mix it in the same syringe. I have no issues using it in animals with cardiac disease, and regularly use it in cats with HCM [/quote]

Actually I find people, often new grads forget or don't realise how many cats die from handling stress if they have significant heart disease. I lose count of the numnber of times I have seen a cat being pinned to the table because "I don't want to knock it out due to its heart" I'm pretty sure I have killed far more cats with handling than with Dom and Torb and now routinely sedate rather than overly restrain.

Re: medetomidine / buprenorphine pre-meds

james hunt — Tue, 13 Mar 2012 23:22:07 GMT

The discrepancy in time to onset of effects of the medetomidine and buprenorphine could be a disadvantage or advantage, depending on your point of view - sedation from medetomidine within 10-15 minutes reducing dose of induction agent, then buprenorphine analgesia developing from about 30-40 min post premed, however if you're efficient you'll be mid op by the time you get the opioid analgesia so i might give the buprenorphine 15mins before the medetomidine or use an opioid like methadone or morphine with shorter onset time.

Re: medetomidine / buprenorphine pre-meds

Mark Hedberg — Wed, 29 Feb 2012 14:07:38 GMT

It's funny, for routine surgery I was always distinctly unimpressed with acp/buprenorphine. The bupe's great, just the acp was in general unreliable and unremarkable.

Dom/torb with premed doses (not sedating them, just using a low low dose of dom with the torb) was much better - you had a mellow, relaxed patient; a bit sleepy but not knocked head over heels.

Never used dom/bupe, but looked into it before I left my old practice.

Re: medetomidine / buprenorphine pre-meds

Hannah Wynne Richards — Wed, 29 Feb 2012 13:18:49 GMT

I'mavetergesic /ACP fan but use dom/torb in brachycephalics/history of epilepsy and IV dose of triple given IM for ferals (I doa lot of those )

Wynne

Re: medetomidine / buprenorphine pre-meds

Martin Atkinson — Wed, 29 Feb 2012 12:02:11 GMT

I use it all the time and I mix it in the same syringe. I have no issues using it in animals with cardiac disease, and regularly use it in cats with HCM - not sure what the 'many' better alternatives there are Clive!. I might be tempted to use Vetergesic instead now its in multi-use vials if I wanted longer analgesia.

Re: medetomidine / buprenorphine pre-meds

Laurence Webb — Tue, 28 Feb 2012 21:43:46 GMT

[quote user="Mark Holmes"]This is going to be REAALLY pedantic but Dom/Bup is not a licensed combination as far as I am aware[/quote]We've got a shiny dosage sheet from a manufacturer with medetomidine/buprenorphine doses on it, so I assume the combination is licensed. I assume it's Animalcare, because they make Vetergesic.

[quote user="Mark Holmes"]How does that work with casade and off license consent forms? [/quote] Our consent forms have a line about using unlicensed medications which all owners sign. Not sure how that stands up with combinations, but many combinations aren't specifically licensed anyway, eg Iso and Metacam (actually, it may well be, I just haven't checked)

Re: medetomidine / buprenorphine pre-meds

james herriot lied — Tue, 28 Feb 2012 19:55:19 GMT

[quote user="Andrew Kent"]

If you have access there was a feed on this topic at ACVIM in 2009 which suggested it was an insignificant effect now that we understand more about mechanism of action of these drugs.

[/quote]

Yes, I suspect it probably will go the way of pin firing and refusing to use steroids in IVDD . I do remember being told that the only time when using a bacteriostat (in isolation) instead of a -cide was clinically significant was in some obscure CNS form of syphillis. I also graduated less than 50 years ago, although I suspect closer to it than Michael.

However - and this was kind of the point I was making - the data sheet for ronaxan does say the following: "Doxycycline should not be used concurrently with other antibiotics especially bactericidal drugs such as the β-lactams". Which means using anything else alongside is off-label and therefore contrary to the cascade. Which we all adhere to slavishly. Further, it would be hard to justify the combo clinically in the face of, say, a PIC investigation.

Re: medetomidine / buprenorphine pre-meds

Niall Taylor — Tue, 28 Feb 2012 19:46:14 GMT

[quote user="Michael Woodhouse"]We were taught it was the case and graduated much more recently than 50 years ago.[/quote]

I graduated shortly after the discovery of fire and was taught this too but am quite happy it has been debunked as clinically insignificant.

[quote user="Michael Woodhouse"]I think it depends what it is you are treating and with witch antibiotic[/quote]

Oi! - leave the witch antibiotics to us genuine voodoo practitioners.

Cor, some people...

Niall VetFFVoo

Re: medetomidine / buprenorphine pre-meds

Andrew Kent — Tue, 28 Feb 2012 19:18:00 GMT

[quote user="Michael Woodhouse"]

[quote user="Andrew Kent"]I believe this advice was based on a study that was done over 50 years ago and has been subsequently shown not to be of clinical significance, it seems to be fairly common practice to combine doxycycline with quinolones or cephalosporins in animals with possible tick borne infections.[/quote]

We were taught it was the case and graduated much more recently than 50 years ago.

I think it depends what it is you are treating and with witch antibiotic

[/quote] If you have access there was a feed on this topic at ACVIM in 2009 which suggested it was an insignificant effect now that we understand more about mechanism of action of these drugs.

Re: medetomidine / buprenorphine pre-meds

mariette asselbergs — Tue, 28 Feb 2012 18:42:47 GMT

"Do many people use Dom/Torb/ketamine in dogs? I do sometimes for aggressive dogs, and in a low cost clinic "

Yes use it all the time but plus diazepam rectally to counteract the ketamine spasms and anxiousness. Also add vetergesic when wanting stronger painkilling effect. We don't have onhalation anaesthetic and we do all operations on healthy animals or operations on ill animals of owners who cannot afford high costs (we are not near any PDSA clinic). Works OK for us, only you have more time stress. We always have a half dose top up ketamine injection ready when we run out of time.

Mariette

Re: medetomidine / buprenorphine pre-meds

Michael Woodhouse — Tue, 28 Feb 2012 18:34:55 GMT

We were taught it was the case and graduated much more recently than 50 years ago.

I think it depends what it is you are treating and with witch antibiotic

Re: medetomidine / buprenorphine pre-meds

Andrew Kent — Tue, 28 Feb 2012 17:45:55 GMT

[quote user="james herriot lied"]So. i'd only really worry of the combo was contra-indicated, e.g. giving a bactericidal on top of ronaxan....................[/quote]

I believe this advice was based on a study that was done over 50 years ago and has been subsequently shown not to be of clinical significance, it seems to be fairly common practice to combine doxycycline with quinolones or cephalosporins in animals with possible tick borne infections.

Andy

Re: medetomidine / buprenorphine pre-meds

james herriot lied — Tue, 28 Feb 2012 17:00:53 GMT

Mea culpa - was writing one thing and thinking another: last week, needed to put a cat on ronaxan, but it was already on convenia. Still with the failing to engage brain before speaking.

So. i'd only really worry of the combo was contra-indicated, e.g. giving a bactericidal on top of ronaxan....................

Re: medetomidine / buprenorphine pre-meds

Andrew Kent — Tue, 28 Feb 2012 14:56:48 GMT

[quote user="james herriot lied"] I'd only really worry if the combo was contra-indicated, e.g. giving a bactericidal on top of convenia[/quote]

Since when was there a problem with this? There are many cases where 2 bactericidal antibiotics can have synergistic effects?

Re: medetomidine / buprenorphine pre-meds

james herriot lied — Tue, 28 Feb 2012 12:49:25 GMT

[quote user="Mark Holmes"]

This is going to be REAALLY pedantic

[/quote]

No, pendatous would be to mention the incorrect spelling of 'really', albeit for dramatic effect......

I'm not sure that the combination itself needs to be licensed. As mentioned above, it's given as two jabs - one for perioperative pain relief; one for premedication. That the two drugs undoubtedly interact synergistically might not be relevant - I'd only really worry if the combo was contra-indicated, e.g. giving a bactericidal on top of convenia. AFAIK, there's nothing else that I'd want to use routinely that would be licensed instead, in any case, and I'd certainly be able to argue for dom/vetergesic combo over dom/torb on clinical grounds for analgesia.

I'm sure the VMD would have a warm glow that we're all so vigilant though; clearly their work here is done.