Included in today’s surgery list was a labrador that required cranial cruciate repair. We needed to considered a number of points prior to surgery. These included:
Patient health status (ASA anaesthetic risk score / PA bloods).
Premed considerations (based on the patient ASA rating coupled with the level of pain expected from the procedure)
Antibiotic requirements (IV antibiotics pre / peri-operatively).
Pain management options (pre / peri / post-surgery).
Thermoregulation (maintaining patient body temperature peri / post-surgery).
Anaesthetic Pro has a feature that allows users to determine a patient’s ASA risk rating. The user can then outline how that patient will be handled prior to, during, and post anaesthesia.
Cruciate surgery is very painful and requires a multimodal approach to pain management. This starts with the premed. We don’t have Recuvrya in New Zealand so this isn’t a consideration. There are many appropriate medication options so personal preference and experience will come into play. The inclusion of an opioid is essential. Other pain medications just don’t cut it where serious pain is anticipated (direct nerve block being the exception). My preference is morphine. It is relatively cheap, long lasting, and provides good pain management. It has some negative side effects such as nausea, urine retention, and dysphoria.
Epidurals are a nice way of extending patient pain control using quite small medication volumes. Morphine provides 18 – 24hrs of effective pain management. A good epidural maintains a very smooth anaesthetic at low inhalation agent settings.
After closing the stifle marcain can be infused which provides 4 – 6 hours local block. Studies have shown that local anaesthetic agents have a toxic effect on chondrocytes, potentially damaging joint cartilage. A one off application appears to cause little harm, and the benefit to the patient outweighs potential harm.
Pain management established prior to or during surgery will add to post surgery pain control. NSAIDs can be used before or after anaesthesia (if licensed as such). Their inclusion will be dictated by the patient’s health status. If there is concern about the effectiveness of the epidural (even when all indicators point to the right place, you only know your epidural is effective when you see positive results), post op pain management can be provided using a CRI. I have used fentanyl patches in the past but found results quite variable. If breakthrough pain is experienced, top up doses of opioids can be given.
Every patient is different. Some show a very exaggerated response to pain while others are seriously stoic. They all need some form of pain management. Having a plan in place prior to surgery certainly helps. This should be flexible because situations change. To ensure staff are equiped to handle the fluid nature of patient pain management, Anaesthetic Pro is used to calculate drug volumes. We have used this software application in our practice now for the past few years. Staff enjoy its ease of use and the fact complex calculations can be run in a matter of seconds.