Small Animal Emergency and Critical Care Medicine: Self-Assessment Color Review, Second Edition, Q&A 17

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Student tip: This case is an approach to pain relief showing how to perform an epidural.

A 5-year-old Beagle-cross is hospitalized with a working diagnosis of acute severe pancreatitis (144). During the morning rounds: T = 39.4°C (103°F); HR = 140 bpm; RR = 20 bpm; CRT = 2 sec; MM pale pink and moist. The dog is anorexic and showing signs of nausea and severe abdominal pain. The dog is currently receiving fentanyl (5 μg/kg/min CRI IV) for analgesia but does not appear to be receiving adequate pain control.

Question	Answer		Article
What additional options for pain control may be used in this dog?	In order of preference: (a) increasing the fentanyl infusion dose (up to 10 μg/kg/min); (b) additional analgesic infusions (e.g. ketamine [0.1–1 mg/kg/hr], lidocaine [25–80 μg/kg/min] and/or dexmedetomidine [1–5 μg/kg/min]) to the fenta-nyl; (c) change the opioid (e.g. hydromorphine, methadone); (d) epidural local analgesia (0.5–2.0 mg/kg of 7.5% bupivacaine); (e) peritoneal lavage and infusion of local anesthetic. NSAIDs are rarely used in animals with pancreatitis.		Link to Article
Describe how to perform an epidural injection.	Need heavy sedation or GA. Sternal or lateral recumbency with hindlimbs ex-tended cranially. Clip and scrub the region over spinal processes of L6–S2. Ensure midline entry of needle by palpating wings of ilium; locate the space between L7 and S1. Insert a 20 or 22 gauge spinal needle directly on the midline, caudal to the dorsal process of L7, perpendicular to the spinal column. Several small ‘pops’ are felt passing through the ligamentum flavum, and a more pronounced ‘pop’ through the interarcuate ligament. Inject the drug without resistance and over 1–5 minutes.		Link to Article
What medications are commonly administered in the epidural space for pain relief?	Local anesthetics (lidocaine 2% or bupivacaine 0.5% and preservative-free morphine (0.1–0.4 mg/kg; drug volume should not exceed 6 ml).		Link to Article
What are some possible causes of the worsened nausea and abdominal pain in this dog?	Include: increasing pancreatic inflammation, peritonitis from ruptured pancreatic abscess or other cause, GI ulceration, organ torsion, dilation or ischemia, severe ileus, gallbladder distension or rupture, insufficient analgesia.		Link to Article

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