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Pathophysiology
The terminology used to describe the pathophysiology of
pain is confusing, so defining a few terms relevant to the
management of perioperative pain is important. Nociception
is defined as the neural response to a noxious stimulus. Specifically, nociception includes signal transduction and nerve
conduction in the peripheral nervous system, and synaptic
transmission, projection, and modulation of nociceptive input in the central nervous system (Fig 1). Pain, on the other
hand, is a complex sensation that requires integration of
nociceptive and other sensory input at the cortical level. Pain
is defined as an unpleasant sensory or emotional experience
that is associated with actual or potential tissue damage. Pain
can be further classified anatomically as somatic or visceral
pain, or temporally as acute or chronic pain. Recent neuroanatomical and functional imaging studies suggest that pain
is one component of an interoceptive system that is primarily
responsible for maintaining internal homeostasis, and that
there are significant differences among species in the neural
components that make up this system.11
Most perioperative pain is due to surgical trauma and inflammation. Some patients may have preexisting tissue
trauma and inflammation, and others may have pain associated with nerve injury. Although a small number of surgical
patients may experience both inflammatory and neuropathic
pain, inflammatory pain is by far the most common type of
perioperative pain. The mechanisms of inflammatory pain
are reasonably well understood and form the basis for rational, effective, multimodal analgesic therapy. Neuropathic
pain is relatively uncommon in surgical patients, and the
mechanisms of neuropathic pain are similar to those of inflammatory pain.12,13 Consequently, clinicians should focus
on understanding the pathophysiology and management of
inflammatory pain.
Nociceptive Pathways
Ascending nociceptive pathways begin in the peripheral
tissues and project to the dorsal horn of the spinal cord, brain
stem, thalamus, and cerebral cortex (Fig 1). The nociceptive
pathways are composed of 3 general types of neurons. The
first-order neurons are primary afferent neurons, and these
neurons are responsible for transduction of noxious stimuli
and conduction of electrical signals to the dorsal horn of the
spinal cord. The second-order neurons are projection neurons, and these neurons receive input from the primary afferent neurons and project to the medulla, pons, midbrain, thalamus, and hypothalamus. Third-order supraspinal neurons
integrate input from spinal neurons and project to subcortical and cortical areas where pain is finally perceived. Supraspinal processing of afferent nociceptive input is also
Figure 1. Overview of nociceptive and antinociceptive pathways. Surgical trauma activates mechanical, chemical, and
thermal nociceptors. Action potentials are conducted to the
dorsal horn of the spinal cord by primary afferent nerve
fibers. Second-order projection neurons encode and relay signals to the brainstem and thalamus. Third-order neurons in
the thalamus project to the limbic system and somatosensory
cortex where pain is perceived. Descending antinociceptive
pathways modulate nociceptive processing at the level of the
thalamus, brainstem, and spinal cord. Different classes of
analgesic drugs act at different sites in the nociceptive and
antinociceptive pathways. Multimodal analgesic therapy inhibits processing of nociceptive input at 2 or more sites. PAG,
periaqueductal gray; RVM, rostroventral medulla.
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closely integrated with regulation of the autonomic nervous
system.
Primary afferent neurons are bipolar neurons. The cell
bodies of these bipolar neurons are located in the trigeminal
and dorsal root ganglia, and their axons project peripherally
to somatic and visceral tissues and centrally to the dorsal
horn of the spinal cord. Some primary afferent neurons respond to noxious or high-threshold stimuli, and others respond to non-noxious or low-threshold stimuli (touch). Afferent nociceptive neurons have free nerve endings that
change or transduce noxious mechanical, thermal, or
chemical stimuli into electrical signals. Somatic tissues have a
higher density of nociceptive nerve fibers and smaller receptive fields, whereas visceral tissues have a lower density of
nociceptive nerve fibers and larger receptive fields. These anatomical differences may account for some of the qualitative
differences between somatic (discrete) and visceral (diffuse)
pain.
Primary afferent neurons are classified by axon diameter,
the presence or absence of myelination, and their response to
mechanical, thermal, and chemical stimuli. A afferent neurons have large, myelinated axons that conduct impulses at a
velocity of greater than 30 m/sec. The free nerve endings of
these fibers respond to non-noxious mechanical stimuli
(touch) but do not respond to noxious stimuli directly. A
nociceptive neurons have small, myelinated axons that conduct impulses at a velocity of 3 to 30 m/sec. The free nerve
endings of these fibers contain membrane-bound receptors
that respond primarily to intense mechanical and thermal
stimuli and are called mechanothermal nociceptors. C nociceptive neurons have small, unmyelinated axons that conduct nerve impulses at a velocity of less than 3 m/sec. The free
nerve endings of these fibers contain membrane-bound receptors that respond to chemical as well as thermal and mechanical stimuli and are called polymodal nociceptors. Small, myelinated A fibers carry the nociceptive input responsible for
the fast, sharp pain that occurs immediately after injury. The
nociceptive input responsible for the prolonged dull pain that
occurs several seconds later is carried by small, unmyelinated
C fibers. Silent nociceptive neurons are also present in somatic tissues. The free nerve endings of these neurons only
respond to mechanical and thermal stimuli after they are
activated by chemical (inflammatory) mediators. This classification scheme is derived from analysis of fibers that innervate the somatic tissues (skin). Visceral pain is qualitatively
different from somatic pain and is typically dull and poorly
localized. Visceral pain also lacks the fast and slow components that are characteristic of somatic pain.
Transduction of mechanical, thermal, and chemical stimuli by the free nerve endings of A and C nociceptive fibers is
mediated by membrane-bound receptors.13-15 Most of these
receptors are nonselective cation channels that are gated
by temperature, chemical ligands, or mechanical shearing
forces. Activation of these channels increases inward conduction of Na and Ca2 ions, which ultimately depolarizes the
membrane and generates a burst of action potentials. The
mechanisms of mechanical signal transduction are not well
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Antinociceptive Pathways
Mammals also have descending antinociceptive pathways
that modulate nociceptive input at spinal and supraspinal
levels (Fig 1). The antinociceptive pathways begin at the supraspinal level and project to neurons in the dorsal horn of
the spinal cord. The periaqueductal gray matter (midbrain),
locus ceruleus (pons), and nucleus raphe magnus (medulla)
are all important structures in the modulation of nociceptive
input. The periaqueductal gray matter receives direct input
from the thalamus and the hypothalamus, and indirect input
from the insular cortex and the anterior cingulate cortex.
These neurons in the periaqueductal gray matter send projections to neurons in the nucleus raphe magnus, which project
to the dorsal horn of the spinal cord. Neurons in the locus
ceruleus project directly to the dorsal horn, and they may also
receive input from the periaqueductal gray matter.
Endogenous opioids (endorphins, enkephalins, dynorphins), serotonin, and norepinephrine are the primary neurotransmitters in the descending antinociceptive pathways.
Axons that originate in the nucleus raphe magnus release
serotonin in the dorsal horn of the spinal cord and are called
serotonergic neurons. Similarly, neurons that originate in
the locus ceruleus release norepinephrine in the dorsal horn
and are called noradrenergic neurons. Supraspinal release
of endogenous opioid peptides activates both types of neurons, whereas supraspinal release of release of -aminobutyric acid (GABA) inhibits both types of neurons. Supraspinal
inhibition of descending antinociceptive pathways is mediated by GABAA receptors. At the supraspinal level, endogenous opioids not only activate descending antinociceptive
pathways, but inhibit GABA-mediated inhibition of these
same pathways, which is called disinhibition.
Release of norepinephrine and serotonin in the dorsal horn
of the spinal cord, and subsequent release of enkephalins and
Protective
Discrete or well localized
No peripheral or central sensitization
Proportionate to the peripheral stimulus
Subsides once the inflammatory response resolves
Pain can be differentiated from touch
Responds well to conventional analgesic therapy
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Table 2. Characteristics of Pathological Pain
Debilitating
Diffuse or poorly localized
Significant peripheral and central sensitization
Disproportionate or exaggerated response to the peripheral stimulus
Continues beyond resolution of the inflammatory response
Pain cannot be differentiated from touch
Does not respond well to conventional analgesic therapy
Clinical Pharmacology
The primary goal of perioperative multimodal analgesic therapy is to limit the development of peripheral and central
sensitization, and prevent the development of pathological
pain. Effective analgesic therapy also blunts the neuroendocrine response, reduces major complications, and improves
outcome. There are 5 major classes of analgesic drugs, and
each class blocks or modulates nociceptive input at one or
more sites of action (Fig 1). Alpha-2 agonists and opioids
alter the central perception of pain. Activation of supraspinal
and spinal alpha-2 receptors and opioid receptors also inhibits synaptic transmission in the dorsal horn of the spinal cord.
Dissociative anesthetics (ketamine) block NMDA receptors
on projection neurons, which inhibit the development of central sensitization. Peripheral and central neural blockade
with local anesthetics also inhibits the development of central
sensitization. COX inhibitors reduce inflammation, which
limits the development of peripheral sensitization. COX inhibitors also reduce the synthesis of prostaglandins in the
dorsal horn of the spinal cord, which limits the development
of central sensitization.
Opioids
Endorphins, enkephalins, and dynorphins are the endogenous ligands for spinal and supraspinal opioid receptors.
Currently, 3 major classes of opioid receptors have been
cloned: OP1 (), OP2 () and OP3 (). OP1, OP2, and OP3
receptors modulate supraspinal and spinal analgesia, as well
as sedation, bradycardia, respiratory depression, and gastrointestinal motility. Receptor subtypes of each of these classes
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have been identified, and expression of these subtypes varies
among tissues. There are also significant differences in the
expression of opioid receptors among species. Parenteral administration of opioids usually causes sedation in dogs,
whereas administration of high doses of opioids can cause
excitation and dysphoria in cats. Respiratory depression is a
significant side effect in human patients, but ventilation is
better maintained in cats and dogs. Butorphanol, morphine,
hydromorphone, and fentanyl are the opioids used most
commonly in small animals. Buprenorphine and tramadol
have also been used perioperatively to a limited extent.
Opioid agonists are the safest and most effective class of
analgesic drugs used for the management of perioperative
pain in cats and dogs. Morphine, hydromorphone, and fentanyl are the opioid agonists used most commonly in small
animals. These analgesic drugs are agonists at all 3 types of
opioid receptors. Opioid agonists are equally efficacious in
treating moderate to severe pain, but differ in potency and
duration of action. Intraoperative administration of morphine, hydromorphone, or fentanyl reduces isoflurane requirements by 30% to 50% in cats and dogs.36-39 Significant
respiratory depression can occur intraoperatively and postoperatively if the additive effects of opioid agonists and general anesthetics are not considered. Morphine and hydromorphone are often administered as preanesthetics, and
vomiting can occur with either drug. High doses of hydromorphone ( 0.1 mg/kg) can also cause significant postoperative hyperthermia in cats.40-42 Morphine and hydromorphone have an intermediate duration of action (2-4 hours)
after parenteral administration. The preanesthetic intramuscular dose range for morphine in cats and dogs is 0.2 to 0.4
mg/kg. Hydromorphone is approximately 5 times more potent than morphine, and the preanesthetic intramuscular
dose range for hydromorphone in cats and dogs is 0.05 to 0.1
mg/kg. Approximately half of the preanesthetic dose of morphine or hydromorphone can be given intraoperatively or
postoperatively. Morphine can also be given epidurally alone
or in combination with local anesthetics. The dose range for
preoperative or postoperative epidural administration of
morphine is 0.1-0.3 mg/kg. At this dose range, the onset time
is slow (1-2 h), but the duration of action in long (12-24 h).
Morphine can also be given postoperatively as an intravenous constant-rate infusion at a dose range of 0.1 to 0.2
mg/kg/h. Morphine has a relatively long duration of action
and the drug will accumulate over time. As a result, patients
should be monitored closely, and the infusion rate should be
reduced as needed. Fentanyl can also be given intravenously
as a preanesthetic. The drug is approximately 100 times more
potent than morphine and has a relatively short duration of
action (0.5 hour). The preanesthetic intravenous dose range
for fentanyl in cats and dogs is 0.001 to 0.005 mg/kg. Fentanyl is less likely to accumulate over time, and the drug is
often given intraoperatively to dogs as an intravenous constant rate infusion. The amount of inhalation anesthetic required to maintain adequate anesthetic depth is reduced by
30% to 50%, which improves cardiovascular function.
Minute ventilation may decrease, and positive-pressure ven-
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tilation may be required to prevent significant hypoventilation (PaCO2 60 mm Hg). Intraoperatively, the dose range
for fentanyl in dogs is 0.005 to 0.01 mg/kg/h. Fentanyl can
also be given postoperatively as an intravenous constant-rate
infusion at a dose range of 0.001 to 0.005 mg/kg/h. Objective
clinical data on the use of intraoperative and postoperative
fentanyl infusions in cats are limited.
Fentanyl patches were designed to be applied to human
skin. Even in healthy cats and dogs, systemic absorption of
fentanyl from transdermal patches is erratic.43,44 In surgical
patients, altered body temperature, peripheral circulation,
and hydration can all compromise transdermal absorption of
fentanyl. On the other hand, heating pads and forced-air
warmers can dramatically increase fentanyl absorption intraoperatively and postoperatively. Consequently, preoperative
and intraoperative use of fentanyl patches should be avoided.
Once normal body temperature, peripheral circulation, and
hydration are restored, fentanyl patches can be used postoperatively with reasonable efficacy. Onset time is very slow,
and there is a 12- to 24-hour lag before effective plasma
concentrations are reached. If the patch stays properly adhered to on the patient, plasma fentanyl concentrations are
maintained for 3 to 5 days. Transdermal fentanyl is dosed at
a rate of 0.003 to 0.005 mg/kg/h in cats and dogs.
Opioid agonist-antagonists are also used to manage perioperative pain in cats and dogs. Butorphanol is the opioid
agonist-antagonist used most commonly in small animals.
Butorphanol is an agonist at the OP2 () receptor and an
antagonist or partial agonist at the OP3 () receptor. The
analgesia produced by butorphanol is not as profound as that
produced by opioid agonists, and its duration of action is
relatively short (1-2 hours). However, side effects (vomiting,
respiratory depression, bradycardia) are less likely to occur
after administration of butorphanol than after administration of morphine, hydromorphone, or fentanyl. Intraoperative administration of butorphanol also reduces isoflurane
requirements by 10% to 20% in cats and dogs.36,45 Butorphanol can be used perioperatively to manage mild to moderate pain. The preanesthetic intramuscular dose range for
butorphanol in cats and dogs is 0.2 to 0.4 mg/kg. Approximately half of the preanesthetic dose can be given intraoperatively or postoperatively. Butorphanol can be given postoperatively as an intravenous constant-rate infusion at a dose
range of 0.1 to 0.2 mg/kg/h. Small intravenous doses of butorphanol (0.1 mg/kg) can also be given postoperatively to
reverse sedation and respiratory depression caused by administration of excessive doses of opioid agonists.
NMDA Antagonists
Glutamate is the endogenous agonist for spinal and supraspinal NMDA receptors. Blockade of NMDA receptors in
the dorsal horn of the spinal cord prevents windup and the
development of central sensitization. Ketamine is the most
widely used NMDA antagonist in veterinary medicine. Ketamine is supplied as a racemic mixture of 2 optical enantiomers. S() ketamine has 4 times the affinity of L() ket-
Local Anesthetics
Local anesthetics have the unique ability to produce complete blockade of sensory nerve fibers and prevent the development of central sensitization. Consequently, peripheral
and central neural blockade are often used in combination
with other analgesic and anesthetic drugs to manage perioperative pain. Local anesthetics block the generation and conduction of nerve impulses by inhibiting voltage-gated sodium
channels in nerve fibers. Lidocaine is also given systemically
to manage pain and to reduce ileus after abdominal surgery.
The mechanism of action of systemic administration of lidocaine is unclear, but peripheral, central, and antiinflammatory mechanisms have been proposed.48
Lidocaine, mepivacaine, and bupivacaine are the local anesthetics used most commonly in cats and dogs. Lidocaine
has a fast onset (10 minutes) and a short duration of action
(1-2 hours) and is used for short diagnostic and surgical
procedures. Mepivacaine is similar to lidocaine in potency
and onset, but has a longer duration of action (2-3 hours),
causes less tissue irritation, and has a higher therapeutic index. Bupivacaine is approximately 4 times the potency of
lidocaine and mepivacaine, has a slow onset (20 minutes),
and a long duration of action (4-6 hours) and is used for most
77
given subcutaneously to cats and dogs immediately after surgery at a dose of 2 mg/kg. Therapy with ketoprofen can be
continued at a dose of 0.5 mg/kg twice daily for 3 to 5 days.
Meloxicam and carprofen have a slow onset time (1-2 hours)
and a long duration of action (24 hours). These drugs do not
appear to inhibit platelet function and do not prolong bleeding time in healthy animals. Meloxicam can be given subcutaneously to dogs immediately after surgery at a dose of 0.2
mg/kg. Therapy with meloxicam can be continued at a dose
of 0.1 mg/kg once daily for 3 to 5 days. Carprofen can be
given subcutaneously to dogs immediately after surgery at a
dose of 4 mg/kg. Therapy with carprofen can be continued at
a dose of 4 mg/kg once daily for 3 to 5 days. Deracoxib is also
labeled for perioperative use in dogs, but no parenteral formulation is available. Side effects are not usually a problem in
healthy animals with normal platelet, gastrointestinal, and
renal function. There is little benefit to preoperative administration of COX inhibitors, and there is significant risk for
patients with compromised platelet and renal function.
COX Inhibitors
Prostaglandins play a central role in inflammation and the
development of peripheral sensitization. Production of prostaglandins in the dorsal horn of the spinal cord also contributes to the development of central sensitization. Inhibition of
constitutive (COX-1) and inducible (COX-2) cyclooxygenase inhibits the conversion of arachadonic acid to prostaglandins and thromboxanes and produces a peripheral antiinflammatory effect. In the dorsal horn, inhibition of COX
produces a central analgesic effect. COX inhibitors vary in
their selectivity for the different isoenzymes, as well as their
ability to produce central analgesic and antiinflammatory
effects.52,53
Several COX inhibitors are approved for perioperative use
in cats and dogs. COX inhibitors are usually given postoperatively alone or in combination with opioids. Parenteral formulations of ketoprofen, meloxicam, and carprofen are
available in Canada and the United States and are better
suited for perioperative administration. Ketoprofen has a
rapid onset (0.5 hour), a short half-life, and an intermediate
duration of action (12 hours). The drug inhibits platelet function but does not appear to prolong bleeding time in healthy
animals undergoing elective surgery.54 Ketoprofen can be
Figure 2. Components of balanced anesthesia. General anesthetics (propofol, isoflurane) are used to induce hypnosis or
a loss of consciousness, but these drugs have very low therapeutic indices and produce significant cardiopulmonary depression at clinically relevant doses. Concurrent administration of analgesic drugs not only attenuates autonomic
responses (increased heart rate and arterial pressure, increased respiratory rate) to surgical trauma, but reduces the
amount of intravenous and inhalation anesthetics required to
induce and maintain anesthesia. Administration of alpha-2
agonists and local anesthetics can also improve muscle relaxation.
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Table 3. Examples of Anesthetic and Pain Management Protocols for Healthy Cats*
Preoperative Management
Intraoperative Management
Postoperative Management
Comments
Castration
(Protocol 1)
Premedication
Acepromazine: 0.1-0.2
mg/kg, IM
Butorphanol: 0.2-0.4
mg/kg, IM
Premedication
Medetomidine: 0.01-0.02
mg/kg, IM
Butorphanol: 0.2-0.4
mg/kg, IM
Premedication
Acepromazine: 0.1-0.2
mg/kg, IM
Hydromorphone: 0.05-0.1
mg/kg, IM
Mild pain
Mild pain
Induction
Thiopental: 8-12 mg/kg, IV to
effect
Isoflurane: 3%
Maintenance
Isoflurane: 1.5%-2.5%
Induction
Thiopental: 4-6 mg/kg, IV to
effect
Isoflurane: 3%
Maintenance
Isoflurane: 1.0%-2.0%
Moderate pain
Some patients may require
additional hydromorphone
postoperatively.
Moderate pain
Some patients may require
additional hydromorphone
postoperatively.
Moderate pain
Digital nerve block reduces
anesthetic requirements
and improves analgesia
postoperatively.
Castration
(Protocol 2)
Ovariohysterectomy
(Protocol 1)
Ovariohysterectomy
(Protocol 2)
Onychectomy
(Protocol 1)
Premedication
Medetomidine: 0.01-0.02
mg/kg, IM
Hydromorphone: 0.05-0.1
mg/kg, IM
Glycopyrrolate: 0.01 mg/
kg, IM
Premedication
Acepromazine: 0.1-0.2
mg/kg, IM
Hydromorphone: 0.05-0.1
mg/kg, IM
Induction
Propofol: 4-6 mg/kg, IV to
effect
Isoflurane: 3%
Maintenance
Isoflurane: 1.5%-2.5%
Digital nerve block
0.5% bupivacaine:
0.5-1.0 mL
Do not exceed a total dose of
2 mg/kg.
Surgical Procedure
79
*Some of these drugs are not approved for use in cats in Canada or the United States.
Clinical Management
Moderate pain
Digital nerve block reduces
anesthetic requirements
and improves analgesia
postoperatively.
Ketoprofen: 2.0 mg/kg, SC
immediately after recovery from
anesthesia
Ketoprofen: 1.0 mg/kg, PO
once daily for 2-3 days
Premedication
Medetomidine: 0.01-0.02
mg/kg, IM
Hydromorphone: 0.05-0.1
mg/kg, IM
Glycopyrrolate: 0.01 mg/
kg, IM
Onychectomy
(Protocol 2)
Induction
Propofol: 2-3 mg/kg, IV to
effect
Isoflurane: 3%
Maintenance
Isoflurane: 1.0%-2.0%
Digital nerve block
0.5% Bupivacaine:
0.5-1.0 mL
Do not exceed a total dose of
2 mg/kg.
Comments
Preoperative Management
Surgical Procedure
Table 3. Continued
Intraoperative Management
Postoperative Management
80
Table 4. Examples of Anesthetic and Pain Management Protocols for Healthy Dogs*
Surgical Procedure
Postoperative Management
Comments
Induction
Propofol: 4-6 mg/kg, IV to effect
Isoflurane: 3%
Maintenance
Isoflurane: 1.5%-2.5%
Induction
Propofol: 2-3 mg/kg, IV to effect
Isoflurane: 3%
Maintenance:
Isoflurane: 1.0%-2.0%
Mild pain
Mild pain
Induction
Thiopental: 8-12 mg/kg, IV to
effect
Isoflurane: 3%
Maintenance
Isoflurane: 1.5%-2.5%
Induction
Ovariohysterectomy Premedication
(Protocol 2)
Medetomidine: 0.005-0.01 mg/ Thiopental: 4-6 mg/kg, IV to
kg, IM
effect
Hydromorphone: 0.05-0.1 mg/ Isoflurane: 3%
kg, IM
Isoflurane: 3%
Glycopyrrolate: 0.005-0.01
Maintenance
mg/kg, IM
Isoflurane: 1.0%-2.0%
Dentistry with an
Premedication
Induction
upper canine
Midazolam: 0.1-0.2 mg/kg, IM Propofol: 4-6 mg/kg, IV to effect
extraction
Hydromorphone: 0.05-0.1 mg/ Isoflurane: 3%
kg, IM
Maintenance
Isoflurane: 1.0%-2.0%
Infraorbital nerve block
0.5% Bupivacaine: 0.5-1.0 mL
Moderate pain
Some patients may require
additional hydromorphone
postoperatively.
Moderate pain
Some patients may require
additional hydromorphone
postoperatively.
Moderate pain
Infraorbital nerve block
reduces anesthetic
requirements and improves
analgesia postoperatively.
Premedication
Acepromazine: 0.05-0.1 mg/kg,
IM
Butorphanol: 0.2-0.4 mg/kg,
IM
Castration
Premedication
(Protocol 2)
Medetomidine: 0.005-0.01 mg/
kg, IM
Butorphanol: 0.2-0.4 mg/kg,
IM
Glycopyrrolate: 0.005-0.01
mg/kg, IM
Ovariohysterectomy Premedication
(Protocol 1)
Acepromazine: 0.05-0.1 mg/kg,
IM
Hydromorphone: 0.05-0.1 mg/
kg, IM
Intraoperative Management
Castration
(Protocol 1)
Preoperative Management
81
and techniques also have the potential to reduce major complications and improve outcome. In a busy practice setting,
simple, straightforward anesthetic and pain management
protocols are the best choice for most patients. Pain can be
managed safely and effectively in the vast majority of surgical
patients with opioids, COX inhibitors, and peripheral or
central neural blockade. Alpha-2 agonists, NMDA antagonists, and other adjunctive drugs are helpful in patients with
significant short-term or long-term central sensitization. And
last, atraumatic surgical technique is the first, and most important, step in the prevention of peripheral and central sensitization and the development of pathological pain. Examples of balanced anesthetic and pain management protocols
for routine surgical procedures in healthy cats and dogs are
outlined in Tables 3 and 4, respectively.
*Some of these drugs are not approved for use in dogs in Canada or the United States.
References
Moderate pain
Epidural anesthesia reduces
anesthetic requirements and
improves analgesia
postoperatively.
Meloxicam: 0.2 mg/kg, SC
immediately after recovery from
anesthesia
Meloxicam: 0.1 mg/kg, PO
once daily for 4-6 days
Premedication
Midazolam: 0.1-0.2 mg/kg, IM
Hydromorphone: 0.05-0.1 mg/
kg, IM
Cruciate repair
Induction
Thiopental: 8-12 mg/kg, IV to
effect
Isoflurane: 3%
Maintenance
Isoflurane: 1.0%-2.0%
Epidural anesthesia (lumbosacral)
0.5% Bupivacaine: 1.0 mL/5 kg
2.5% Morphine: 0.2 mg/kg
Comments
Preoperative Management
Surgical Procedure
Table 4. Continued
Intraoperative Management
Postoperative Management
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