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A retrospective comparison of two analgesic strategies after uncomplicated tibial plateau levelling osteotomy in dogs.

Paper Summary : A retrospective comparison of two analgesic strategies after uncomplicated tibial plateau levelling osteotomy in dogs.

Bini G. et al. 2018. Veterinary Anaesthesia and Analgesia. 45: 557-565.

What did the research find?

In the population studied, the administration of methadone every 4 hours resulted in no greater analgesic effect, and was associated with more side effects, than administration guided by post-operative pain scoring.

How was it conducted?

The primary aim of this study was to investigate whether two different analgesic strategies were equally effective in providing post-operative analgesia, and to determine if administration of methadone every 4 hours, regardless of the patient’s pain score, was associated with opioid related side effects, in particular vomiting and reduced food intake.

In this retrospective, case-controlled study the clinical records of dogs having undergone a tibial plateau levelling osteotomy (TPLO) at Dick White Referrals, Cambridgeshire, UK in 2015 were examined. From 174 cases, 136 were included in the study. Among other exclusion criteria, those that had not received methadone in their pre-anaesthetic medication and those that had not undergone a peripheral nerve block (PNB) prior to surgery were not included in the study (PNBs being routinely performed to dogs undergoing a TPLO at this referral centre). Group division was as follows:

  1. 52 dogs in group PS - 0.2mg/kg methadone administered intravenously (IV) when the short form of the Glasgow Composite Measure Pain Scale (CMPS-SF) score was ≥5 out of 20, or 6 out of 24.
  2. 84 dogs in group Q4 – the same dose of methadone administered IV every 4 hours regardless of the patient’s pain score and the first dose given approximately 4 hours post-operatively (i.e. when the PNB was expected to be wearing off).

All cases received a non-steroidal anti-inflammatory drug (NSAID) as part of their peri-operative analgesia. In both groups, trained nurses or veterinary surgeons assessed pain scores in each patient every 2 hours in accordance with the clinics standard operating procedures.

Results

There was no significant difference between the two groups regarding age, body mass, ASA physical status, amount of methadone administered in premedication, amount of levobupivacaine administered for the PNB and duration of surgery as well as several other variables examined.

The dose of methadone administered was 0.21 ± 0.02mg/kg in both groups. In group PS, fewer doses and, consequently, less methadone during the 24h post-operative period was administered (p< 0.001). The number of postoperative observations recorded during the first 24 postoperative hours and the percentage of animals in which keywords ‘unsettled’, ‘sleeping’, ‘panting’, ‘toe-touching’ and ‘weight bearing’ were used, were similar between the groups. However, in dogs in group Q4 the keywords ‘vocalisation’ and ‘painful’ were used more frequently. The use of the keyword ‘reaction to wound palpation’ was more frequent in group PS (p = 0.03). Dogs were 23.42 times (1.37 to 400.40) more likely to vomit after methadone Q4, and the number needed to harm (NNH) for vomiting after administration of methadone Q4 was 5.7 (3.4 to 13.1). No dog in group PS vomited postoperatively. Food intake was 38% lower in dogs where methadone was administered Q4 compared to dogs in group PS.

It is important that both the subjectivity of the postoperative observations recorded, and the retrospective nature of this study need to be taken into consideration when interpreting the above results.

Why is it important?

The CMPS-SF is a validated tool specifically developed to guide postoperative analgesia in dogs (Reid et al. 2007).

The amount of postoperative methadone administration in group Q4 was four times higher than in group PS. Considering the similar anaesthetic technique and that every animal received a NSAID, it is plausible that the higher incidence of vomiting observed in group Q4 was caused by methadone administration to dogs not in need of analgesia, the pro-emetic effects of some opioids when used in non-painful animals appearing to be more pronounced (Pascoe, 2000).

In conclusion, the administration of methadone according to the CMPS-SF after uncomplicated TPLO in dogs in which a PNB was performed, resulted in better food intake and did not cause postoperative vomiting. The administration of methadone Q4, regardless of pain score, increased the incidence of side effects (vomiting and vocalization) and decreased food intake whilst not providing superior analgesia or better patient outcome according to short term indicators. The finding of this study should be considered when planning postoperative analgesia in dogs undergoing elective orthopaedic procedures and in which a PNB has been performed.

Article by
Dr. Dan Cripwell
BSc (Hons) BVSc CertAVP (EM) PgCert (VPS) MRCVS

Veterinary Technical Advisor UK
RCVS Recognised Advanced Veterinary Practitioner

Originally published: Wednesday, 9th January 2019

References

Pascoe, P.J., 2000. Opioid analgesics. Veterinary Clinics: Small Animal Practice30(4): 757-772.

Reid, J., Nolan, A.M., Hughes, J.M.L., Lascelles, D., Pawson, P., Scott, E.M. 2007. Development of the short-form Glasgow Composite Measure Pain Scale (CMPS-SF) and derivation of an analgesic intervention score. Animal Welfare16: 97-104.

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