pain control WSAVA guidelines, specifically caesarean protocols

Re: pain control WSAVA guidelines, specifically caesarean protocols

Laurence Webb — Fri, 19 Dec 2014 21:07:44 GMT

Pardale (paracetemol and codeine) has no contraindication for use in pregnancy or lactation (although " in animals less than 6 weeks of age or in aged animals may involve additional risk. If such use cannot be avoided, animals may require a reduced dosage and careful clinical management")

I routinely give it for post-op analgesia for caesareans and could see the lack of contraindication as justification for giving IV paracetemol as a premed or during the procedure.

Typically I give no pre-med, induce with propofol then give buprenorphine as soon as the pups are out. I give Pardale post op. Additional buprenorphine as required.

Admittedly my choice of NSAID is influenced more by litigation concerns than clinical concerns!

Re: pain control WSAVA guidelines, specifically caesarean protocols

Robin Grimmer — Fri, 19 Dec 2014 21:07:44 GMT

[quote user="bob lehner"]

[quote user="Robin Grimmer"]

[quote user="bob lehner"]

I think I am correct in saying that there is not a single opiod or nsaid licensed for peri/post-operative use which does not have some sort of disclaimer or restriction on use in pregnancy and/or lactation.

[/quote]

Carprofen injection ( eg Rimadyl, Carprieve) has no c/i for pregnancy or lactation however tablets are contra indicated.

[/quote]

Ummm - from Rimadyl SA Injn data sheet:

'In the absence of any specific studies in pregnant target animals, such use is not indicated.'

and - 'Use in any animal less than 6 weeks of age, or in aged animals may involve additional risk. If such use cannot be avoided, animals may require a reduced dosage and careful clinical management.'

[/quote]

Doesn't say you can't use it in lactating animals though, does it? So as long as you give it after you've got the pups out, you are complying with the data sheet ;)

Re: pain control WSAVA guidelines, specifically caesarean protocols

bob lehner — Fri, 19 Dec 2014 19:37:28 GMT

[quote user="Robin Grimmer"]

[quote user="bob lehner"]

[/quote]

Carprofen injection ( eg Rimadyl, Carprieve) has no c/i for pregnancy or lactation however tablets are contra indicated.

[/quote]

Ummm - from Rimadyl SA Injn data sheet:

'In the absence of any specific studies in pregnant target animals, such use is not indicated.'

Re: pain control WSAVA guidelines, specifically caesarean protocols

Robin Grimmer — Fri, 19 Dec 2014 08:44:16 GMT

[quote user="bob lehner"]

[/quote]

Carprofen injection ( eg Rimadyl, Carprieve) has no c/i for pregnancy or lactation however tablets are contra indicated.

Re: pain control WSAVA guidelines, specifically caesarean protocols

John Flynn — Thu, 18 Dec 2014 20:01:14 GMT

Me + average bitch caesarean:

iv cannula + drip, pre-oxygenate, clip if not going to stress patient unduly

propofol to effect and iv paracetamol (15mg/kg)

maintain on iso (I don't have sevo)

morphine/methadone iv on removal of pups

5 days paracetamol going home (30mg/kg orally 2-3 times daily).

I think has worked as well as anything I've tried over the years, though I do surprisingly few these days.

My aim would be to use drugs pre-pup-removal that are easily eliminated by the pups (+bitch) for rapid recovery. propofol seems to fit this bill and as long as pups are breathing then a volatile will be eliminated. acepromazine longer-acting (and I'm sure I read somewhere that ion-trapping occurred in the fetus giving higher concentrations then needing eliminated) and needs bit more work to eliminate for a neonate so I've always tended to avoid it (rightly or wrongly). A rapidly eliminated opioid such as remifentanil would seem fine to me, but the morphine/methadone ones I work with are again a little longer-acting that would want in a pup ideally I reckon. Finally, the theory of pre-emptive analgesia is, well, a theory in my reckoning and giving a full opioid before pup removal versus after pup removal may not have a dramatic clinical effect on the bitch (other than sparing on the other drugs).

If I was to try to improve, I think it would be by using more local anaesthetic on the bitch in these cases.

Re: pain control WSAVA guidelines, specifically caesarean protocols

vetbl.locum — Thu, 18 Dec 2014 17:14:29 GMT

Oops that should be 'expert' based medicine

Re: pain control WSAVA guidelines, specifically caesarean protocols

mariette asselbergs — Thu, 18 Dec 2014 17:07:38 GMT

In Mozambique human caesareans were done under diazepam/ketamine cri drip anaesthetic. I think here they use epidural.

Mariette

Re: pain control WSAVA guidelines, specifically caesarean protocols

vetbl.locum — Thu, 18 Dec 2014 16:57:02 GMT

Quote

' Pain relief should only be administered after all the fetuses have been delivered. An intravenous catheter can be used for infusions of opioids during surgery (but after delivery of the puppies) and may be used systemically later on.'

If it's good enough for her then surely OK for the rest of us. But best to get informed consent from the owner, as others have suggested.

(She also says - 'Premedication for caesarean sections should be avoided.').......

Why avoid premed ? Surely it is used to reduce doses of induction agents and calm the bitch. Etc No analgesia that takes the style of GA back 30years.

This that quote evidence or export based medicine?

Does anyone know what the medics do ?

However generally agree that it is a muddle given the vague comments in data sheets 😢 If we vets are confused what chance of owner giving informed consent 😈

Re: pain control WSAVA guidelines, specifically caesarean protocols

bob lehner — Thu, 18 Dec 2014 10:32:43 GMT

[quote user="Laura Kidd"]

Interestingly there are only contraindications for buprenorphine in multi-dose vials ( Buprevet and Vetergesic multidose) rather than individual vials ( vetergesic 0.3 mg/ml) where pregnancy is only mentioned under special precautions.

Butorphanol as 'Dolorex': 'The safety of this veterinary medicinal product has not been established in the target species during pregnancy and lactation. The use of the product during pregnancy and lactation is not recommended'

[/quote]

The whole thing is a muddle - as you point out different formulations/brands of the same product give contrary advice. Almost certainly because the pharma companies just don't have the data.

Anyway - there was an article on C-sections in the recent BSAVA Companion mag by Angelika von Heimendahl (Specialist in SA repro and co-editor of the BSAVA Manual of Repro.) :

If it's good enough for her then surely OK for the rest of us. But best to get informed consent from the owner, as others have suggested.

(She also says - 'Premedication for caesarean sections should be avoided.').

Re: pain control WSAVA guidelines, specifically caesarean protocols

Laura Kidd — Wed, 17 Dec 2014 21:25:33 GMT

Re: pain control WSAVA guidelines, specifically caesarean protocols

Michael Woodhouse — Wed, 17 Dec 2014 18:34:44 GMT

The issue with the butorphanol was not because the product was used, but because consent to use the product wasn't obtained. That was my reading of it.

We use medetomedine/butorphanol IV (half the usual dose and then induce a couple of minutes later with propofol. Reverse the alpha two by giving the puppies a needlefull of antipam. Seems to work very well, give good anaesthetics and strong puppies. Explicitly explain that we WILL be using drugs not licensed during a caeser, but no option.

I do give NSAIDs, but remember they will interfere with natural prostaglandin release that is required for uterine involution and the expulsion of any remaining placentae. For this reason I would also give oxytocin and antibiotic (we've stopped using antibiotic routinely).

Re: pain control WSAVA guidelines, specifically caesarean protocols

Bibs — Wed, 17 Dec 2014 16:29:18 GMT

It looks like that's these case. Buprenorphine might be the only one with a specific contraindication in whelping it seems.

Re: pain control WSAVA guidelines, specifically caesarean protocols

bob lehner — Wed, 17 Dec 2014 16:03:51 GMT

[quote user="Neil Wheadon"] I quite like the Comfortan idea[/quote]

From the Comfortan data sheet:

'Methadone diffuses across the placenta. Studies in laboratory animals have shown adverse effects on reproduction. The safety of the product during pregnancy and lactation has not been assessed in the target species. The use of the product is not recommended during pregnancy.'

Re: pain control WSAVA guidelines, specifically caesarean protocols

Joyce Whitehead — Wed, 17 Dec 2014 13:11:35 GMT

I'm pretty certain VDS settled the case, as they couldn't defend off licence use in the circumstances. I certainly agree the bulldog sounds a difficult one. I'm a dinovet, and in my first job (1983) we had a bulldog breeder so we quickly got very good at caesarians, as most of them were unable to whelp naturally. In those dark and distant days we used SA Immobilon, then gave any sleepy pups some Revivon post op. Not recommended as a technique though! I have also given ACP as a premed without opioid in some cases.

Re: pain control WSAVA guidelines, specifically caesarean protocols

Bibs — Wed, 17 Dec 2014 11:07:52 GMT

[quote user="Joyce Whitehead"]There was a VDS case not so long ago that hinged on buprenorphine being used as a premed for a Caesarian and the vet was sued for pups that died, as it is specifically contraindicated in whelping bitches. So I'm another that goes for propofol to effect then NSAIDs post op, and opioid at that stage if we feel it is needed. Having had two Caesars myself, I had a post op epidural of opioid then NSAIDs after that (paracetamol by day two).

[/quote]

Do you know what happened in this case? I vaguely remember hearing about it. I'm assuming the VDS couldn't defend the vet because of the specific contraindications in the data sheet?

I am thinking that in future I might employ a bupivacaine line block more because I often wonder if the pain relief is adequate with just post op nsaid and a partial opioid. That plus consider using methdone once the pups are out rather than buprenorphine. I have started using methadone for bitch spays if I'm able to depending on where I'm locuming and one place even encourage all the vets to use line blocks for bitch spays also.

The only other thing that bothers me is if I get another crazy bulldog who freaks out when trying to be induced. On the datasheet for ACP is only says "not for use in pregnant animals" but nothing specific about whelping, but I suppose I'd have to be doubly careful because I'd be dealing with a short nosed breed and acp.

Is there anything "safe" to pre med these difficult dogs with?

Re: pain control WSAVA guidelines, specifically caesarean protocols

Neil Wheadon — Wed, 17 Dec 2014 10:41:58 GMT

[quote user="Nicola M"]Are NSAIDs such a no-no? I've always avoided metacam as specifically states in data sheet contraindicated for pregnancy/lactation but rimadyl it doesn't mention can't use after pups out.[/quote]

Interesting point

The data sheet says

Use in dogs less than 6 weeks of age, or in aged dogs, may involve additional risk. If such use cannot be avoided, such dogs may require a reduced dosage and careful clinical management.

My take is that caesarians = financial gain

Financial loss = Looking to blame someone

Metacam = NSAID = Rimadyl

Neil = Looking for a quiet life

I quite like the Comfortan idea

Neil

PS If I have time, I IV premed with ACP to reduce the propofol (and usually have 10 minutes before start surgery)

Re: pain control WSAVA guidelines, specifically caesarean protocols

Hannah Wynne Richards — Wed, 17 Dec 2014 08:42:10 GMT

No Dysphoria is more of a prob with morphine Obviously dysphoria would be more of a problem in Caesars than most ops, because the bitch might attack the pups, but I've never seen it with Comfortan, and I use it a lot - for most ops in fact.

Wynne

Re: pain control WSAVA guidelines, specifically caesarean protocols

Nicola Cole — Tue, 16 Dec 2014 23:48:13 GMT

Are NSAIDs such a no-no? I've always avoided metacam as specifically states in data sheet contraindicated for pregnancy/lactation but rimadyl it doesn't mention can't use after pups out.

Re: pain control WSAVA guidelines, specifically caesarean protocols

David Mills — Tue, 16 Dec 2014 23:43:49 GMT

The problem, as far as I can see, is that without a premed, you have to give more induction. Which then crosses the placenta. Also your induction is going to wear off quickly so the bitch will be maintained on iso, which will also cross the placenta - and without a premed the inhaled % might need to be higher. So you can premed and give less, but with more drugs at lower concentration crossing the placenta.

I doubt there is one size fits all. But, for me, things i.e. neonates are more likely to suffer respiratory or cardiac depression with induction and maintenance agents, so I like to minimise these if possible. Therefore I would reach for ACP and opioid in Caesarians as a premed IV (if possible) before inducing - not buprenorphine following the vds thing.

The current evidence (study this year) is that there is no difference between alfaxalone and propofol in terms of perinatal deaths.

There is an argument for reversible premeds in these circumstances, so that the neonates can be 'reversed' once exteriorised. Medetomidine data sheet does contain a contraindication in pregnant animals but nothing about Caesarians I can see. Interesting thought.

Re: pain control WSAVA guidelines, specifically caesarean protocols

Neil Wheadon — Tue, 16 Dec 2014 22:40:13 GMT

[quote user="Hannah Wynne Richards"]

No pre-med alfaxan locals/c either side of mid-line and comfortan

Wynne

[/quote] Like Wynne, I line block a lot, including bitch spays, trimodal analgesia is difficult to achieve in caesarians though as NSAID's are a no. I give buprenorphine post op once the pups are out, but do like the sound of Comfortan. If you believe the hype a single S/C injection lasts 12 hours. My only concern would be the potential sedation/dysphoric effects. (Do you get this Wynne?) Neil

Re: pain control WSAVA guidelines, specifically caesarean protocols

Emily Rainbow — Tue, 16 Dec 2014 21:30:11 GMT

as a student I saw Pethidine used as a pre-med then propofol to effect, and metacam given once pups out. Saw 2 done that way with no probs. pups perhaps a little slow on one but got going all ok in the end.

Re: pain control WSAVA guidelines, specifically caesarean protocols

Nicola Cole — Tue, 16 Dec 2014 19:52:45 GMT

+1 for no premed, then NSAID +/- buprenorphine once pups out.

Re: pain control WSAVA guidelines, specifically caesarean protocols

Hannah Wynne Richards — Tue, 16 Dec 2014 18:29:57 GMT

No pre-med alfaxan locals/c either side of mid-line and comfortan

Wynne

Re: pain control WSAVA guidelines, specifically caesarean protocols

Joyce Whitehead — Tue, 16 Dec 2014 15:47:07 GMT

There was a VDS case not so long ago that hinged on buprenorphine being used as a premed for a Caesarian and the vet was sued for pups that died, as it is specifically contraindicated in whelping bitches. So I'm another that goes for propofol to effect then NSAIDs post op, and opioid at that stage if we feel it is needed. Having had two Caesars myself, I had a post op epidural of opioid then NSAIDs after that (paracetamol by day two).

Re: pain control WSAVA guidelines, specifically caesarean protocols

Bibs — Tue, 16 Dec 2014 15:46:07 GMT

I read the same thing the other day and was wondering the same thing. I also have given no pre med and just given IV propofol and then usually buprenorphine + nsaid once pups out. A line block would probably help with analgesia as there is no pre emptive analgesia given but I have not done this in a c section yet (I suppose it would delay surgery a few minutes). I did once have a nervous bulldog to do a c section on who should never have been bred. She hated being restrained and struggled even with minimal restraint when trying to get near to place an IV to the point I had to stop for a bit because I thought she was going to develop respiratory distress. I did wonder if a pre med might have been best in her case but I suppose judged against what most vets seem to do in there UK that wouldn't be seen a usual.