Multimodal perioperative anaesthesia

RE: Multimodal perioperative anaesthesia

Carl Bradbrook — Tue, 19 May 2020 17:01:17 GMT

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia"]Lower doses of methadone as a premedicant - 0.1-0.2mg/kg as opposed to the 0.3mg/kg my practice uses. Would this be across the board for all operations using methadone as a premed, or just sick animals, or those with a compromised cardiovascular system?[/quote]

We routinely start with 0.2mg/kg methadone IV, but I am nearly always happy to give more if needed in an individual animal. I also tend to use the IV route if we have that available, and only normally choose IM if the animal doesn't tolerate IV placement prior to premedication or a procedure.

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia"]Line blocks - how regularly do you use them, only when trying to reduce other opioid doses?[/quote]

Local anaesthetic techniques make such a big difference to patient comfort, to the stability of anaesthesia and the requirement of anaesthetic maintenance agents. We always use a local anaesthetic technique when one is suitable for a procedure and patient- ranging from line blocks for coeliotomy, to epidural anaesthesia, specific nerve blocks and infiltration. A line block can make a big difference during skin and abdominal incision and during closure.

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia"]CRIs - using these to reduce gaseous anaesthetics, and also reduce wind up. How often do you use them?[/quote]

If a local anaesthetic technique is not appropriate then I would select an analgesic infusion, and we may use one in combination in certain cases. Our most common infusions are opioid based, e.g. fentanyl. We also use ketamine and lidocaine.

[quote userid="11308" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia"]Epidurals - useful for hindlimb orthopaedic surgery? Higher chances of post-op complications caused by the ataxia that may come with it. Where else could they be used[/quote]

For unilateral pelvic limb surgery we use femoral/sciatic nerve blocks, although occasional an epidural may be more useful- perhaps in a very small dog or cat. It is important to be aware of the duration of action of the local anaesthetic used as this will dictate the length of loss of motor function. Our nurse team will sling walk dogs out until return of motor function. If there is any particular concern you can select lidocaine (shorter duration of action) or use an opioid alone. I find them also useful for some abdominal procedures, perineal surgery and tail procedures.

There are loads of options and some great resources out there for finding information on infusions and local anaesthetic techniques as examples.

Carl

RE: Multimodal perioperative anaesthesia

Clive Ansell — Tue, 12 May 2020 06:06:48 GMT

[quote userid="9440" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia/222480"]Can you remind me of the quad protocol.[/quote]

The kitten quad is comprised of medetomidine, ketamine, midazolam and buprenorphine or Methadone in equal volume in the same syringe, based on body surface area dosing. The very useful Kitten Quad Calculator is available as free iPhone or Android App.

Midazolam potentiates the effects of the other anaesthetic agents (reducing the doses required and thus reducing side effects such as hypotension), and acts as a mild appetite stimulate post op.

[quote userid="9440" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia/222480"]I think there was some discussion about part of it being off cascade ?[/quote]

Due to the inclusion of midazolam, the kitten quad protocol is considered off licence, and some folk seem to cite this as a reason for not using it. Given that there is no specific veterinary licenced Midazolam available, it is perfectly legal to use the human version as per the cascade regs as long as a reasonable clinical argument can be put forward for its use.

App

Kitten Quad

RE: Multimodal perioperative anaesthesia

janine redman — Mon, 11 May 2020 21:11:14 GMT

Can you remind me of the quad protocol. I think there was some discussion about part of it being off cascade ?

RE: Multimodal perioperative anaesthesia

Anthony Todd — Mon, 11 May 2020 18:59:26 GMT

Crikey, and I'm the dinosaur and behind it all......???

MJV would have done 6 C/S,[daily usual] a B/S and pinned a femur by then! And all with the sweetest, atraumatic, perfect result you could wish for!!

RE: Multimodal perioperative anaesthesia

Clive Ansell — Mon, 11 May 2020 17:50:42 GMT

[quote userid="2235" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia/222471"]

Clive Ansell said:
Having to place cat spays and cat castrates on i/v fluids

Seriously?!

[/quote]

Yep. in a corporate practice bogged down with nonsense protocols.

In my last locum witnessed a cat spay one afternoon taking an hour and half! homeopathic dose acp --> 20 minutes before homeopathic dose vetergesic, --> didn't do anything --> nurses tried to place i/v line, buggered both cephalics --> cat now very angry and stressed --> needed crush cage to dom/ket --> eventually got line in sephenous vein --> vet went off duty as her shifted ended before cat ready --> I did the actual spay in about 10 minutes and cat was on IVFT for <15 minutes in the end. no nsaid until recovery. Farcical.

RE: Multimodal perioperative anaesthesia

Rob Davis — Mon, 11 May 2020 17:26:46 GMT

[quote userid="5012" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia/222468"]Having to place cat spays and cat castrates on i/v fluids[/quote]

Seriously?!

RE: Multimodal perioperative anaesthesia

Clive Ansell — Mon, 11 May 2020 16:36:32 GMT

Prefer Methadone and Medetomidine in dogs as a pre-med. Don't really rate ACP at all, and like the reliability and reversibility of Medetomidine. Ok with Buphrenorphine, but prefer Methadone. Will use Butorphanol with Medetomidine if requiring sedation rather than analgesia, for taking radiographs etc.

Prefer giving nsaid's pre op with pre-med. done so for 24 years and as far as I am aware, not a single issue as arisen as a result of.

Propofol for induction, although I don't see it as any better or safer than low dose thiopentone used with a good pre-med. Only used Alfaxan occasionally, but have seen a few stormy recoveries with it, including a fractious GSD that seizured.

Big fan of quad combination in cats, using Methadone. Started using it for CPL neuters, and then tried it with success in a few stroppy old cats for dental work. Really like it. triple combo next best thing. I fine it frustrating where practices use low dose acp/buph in stroppy cats, then can't get i/v lines, stress the cats, and finish up giving medetomidine (which I would have dome in the first place) Again, never had any issues at all

What I find difficult is some of the protocols imposed at some of the corporate practices. Personally, I would ignore them and do my own thing, but nursing staff are usually reluctant too, so I tend not too. Things like standard low dose pre-meds that don't work, trying to get i/v lines in difficult patients where pre-meds haven't and won't work. Having to place cat spays and cat castrates on i/v fluids, unable to give nsaid until on recovery - in one clinic last year, cats were given dom/ket, so no opiate or nsaid for analgesia pre/peri op. I find the situation frustrating to say the least.

RE: Multimodal perioperative anaesthesia

Michael Woodhouse — Mon, 11 May 2020 08:31:04 GMT

Usually draw up and charge 1ml. Give each puppy 0.05-0.1ml. I did a caeser on Saturday on a Frenchie and the puppies wake up to squeaking very quickly.

Shamefully I'm usually operating so I'm not sure if they give it IM/SC but I doubt it much matters. Vigorous towel rubs will get it absorbed quickly.

RE: Multimodal perioperative anaesthesia

janine redman — Mon, 11 May 2020 07:20:02 GMT

So reverse the puppies with what amount please same dose as mother or %age dose ?

thanks

RE: Multimodal perioperative anaesthesia

Michael Woodhouse — Mon, 11 May 2020 00:27:49 GMT

[quote userid="9440" url="~/001/veterinary-clinical/small-animal/anaesthesia/f/discussions/29086/multimodal-perioperative-anaesthesia/222423"]

Hi what dose of medetomidine would you use

a) routine

b) caesarean

c) brachycepalic caesarean

[/quote]

0.1ml/10kg for all. If small and bouncy or aggressive then double it. If >50kg I generally stop at 0.5ml. Routinely given s/c, but will use same dose IV quite happily.

With a caesarean I'd reverse the puppies, almost never reverse a dog if used as part of a GA protocol. Usually reverse cats.

RE: Multimodal perioperative anaesthesia

janine redman — Sun, 10 May 2020 22:56:01 GMT

Hi what dose of medetomidine would you use

a) routine

b) caesarean

c) brachycepalic caesarean

Thanks

RE: Multimodal perioperative anaesthesia

Dinu Catilina — Sun, 10 May 2020 19:17:02 GMT

This is a very interesting subject Anthony, thank you. I'll write what we do but we are all general practitioners without a special interest in anaesthesia.

Methadone: we use boluses at 0.3mg/kg IV for all surgeries except compromised patients where we go 0.2mg/kg (like in a caesarian for example). I never used it in a CRI.

Premedication: medetomidine for everything except caesarians. In compromised patients we use midazolam/diazepam. I haven't used ACP for the past 2 years and I don't miss it a bit.

Induction: propofol. We tried alfaxan for caesarians and we had some strange recoveries, frantic jumpy bitches that were difficult to manage. We never saw this issue with propofol.

Line blocks: rarely but I would use nerve blocks for teeth extractions, intraarticular bupivicaine, splashes after amputations.

Ketamine: I would use it as bolus intraoperatively if we think pain is not controlled well.

CRI with lidocaine, we used them for ortho work, pancreatitis, we find it easy to work with and the pain control if excellent.

I don't do epidurals.

Cats: I like to triple.