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Post by Meg & Dexter on Jul 15, 2017 15:38:58 GMT -7
Hi all, my 7 year old dachshund Dexter is one week post op after a ventral slot surgery for a rupture at C2-3. He has been back and forth to the emergency vet twice since surgery for pain management. They kept him about 48 hours post op as well. Every time he goes back they say he is comfortable on his pain regimen but when we get him home we has these horrible bouts of pain with yelping in pain. This last admit they placed a fentanyl patch with the plan for more consistent pain management
He is currently on (he is about 17#)
-fentanyl patch placed about 36 hours ago
-gabapentin 100mg every 8 hours
-methocarbamol 1/2 of a 750mg tablet every 8 hours
-tramadol 25 mg every 8 hours
-omeprazole 10mg every 12 hours
-starting prednisone Monday morning. He was getting carprofen prior to this admission and the doc wanted to switch to pred but wanted the carprofen fully out of his system before starting.
[Moderator's note: please do not modify
17 lbs
carprofen stopped 7/7
Prednisone after days of washout on 7/17: ?mgs ?x/day
fentanyl patch as of 7/13
methocarbamol 375mgs 3x/day
gabapentin 100mg 3x/day
tramadol 25mgs 3x/day
omeprazole 10 mgs 2x/day]
We are currently staggering pain meds by giving gabapentin and methocarbamol together and then 4 hours later doing the tramadol. He is also on crate rest as well and only out to potty
He had very little neurologic deficit prior to surgery but with intense pain unable to be managed conservatively. He is still walking well with no neuro decline we have seen. He eats unless he is having an active episode of pain and pees and poops without issue.
He seems to have episodes of pain related to spasm as we have seen the muscles in his neck twitching during pain episodes. We continue to call the vet when it happens but they are rarely helpful.
The plan is to try and get him through at least a few days of the prednisone and then consider reimaging
I am heart broken and it makes me physically ill when he goes through these episodes. Is there anything I could be doing different? Are his pain meds dosed accurately?
I need some hope because at this point we are asking ourselves how much we put our sweet boy through. Is this normal at this point??
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PaulaM
Moderator. 
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,792
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Post by PaulaM on Jul 15, 2017 19:02:52 GMT -7
Welcome to the Forum and so sorry to hear that Dexter is being undermedicated for pain. You have an emergency to make a phone call to get this resolved asap. Here are things you can discuss with the vets who have already seen him thus will be able to prescribe over the phone. ~~ Why the surgeon did no continue with the NSAID post post, is a mystery as no washout would be needed! So you can advocate for getting the same NSAID (not a different brand!) as before surgery back on board now. OR if there is some good reason to move to the most powerful of the anti-inflammatory drugs, the steroid class, then when it is an emergency of pain a vet can so deem it and NOT do the washout. Because there would be double jeopardy with no washout, then double stomach protection is a must. Not only would Omeprazole be on board but a 2nd called SUCRALFATE. As usual know about all drugs that go in your dog's mouth: marvistavet.com/sucralfate.pml~~ FYI on Fentanyl patches: Michael Richards, D.V.M.: "Fentanyl Patch It is important to recognize that there is a delayed onset of effect when using the patches. In dogs it takes about 12 hours to achieve good pain relieving dosages and in cats it takes a minimum of five hours. The effective life of the patch is about 3 days in dogs and up to 5 days in cats. The pain relief from these patches is considered to be moderate, especially in dogs. For this reason it is often necessary to use them as a constant provider of pain control but to supplement them as necessary with a compatible narcotic or an NSAID." www.vetinfo.com/dpain.html~~ Tramadol, a narcotic, is being way undermedicated for a 17 pound dog! The two references below are not for you to self prescribe but to be able to advocate on Dexter's behalf: The usual in controlling pain is to Rx at the higher end of the mg range AND promptly every 8 hours. ~~ Advocate for Gabapentin to be Rx'd for evert 8 hours as this drug has a short half life. What are the credentials of the surgeon--- a neuro (ACVIM) or a orth (ACVS)? Has the surgeon every been contacted about the pain and getting the pain meds adjusted-- he really, really, needs to be alerted about his patient? What is the name of the hospital where the surgery was performed? Are the "vets" you mention general DVM vets or specialist (neuro or ortho)? |
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Post by Julie & Perry on Jul 15, 2017 19:58:37 GMT -7
Hi Meg, my dog had a hard time getting her pain meds right too. I also wondered if I was being fair. However, I kept pushing and asking questions until it was finally right. For some reason, many doctors underprescribe pain meds for IVDD dogs. Maybe they don't realize how painful it is or aren't up on the right combination of meds. Once Dexter gets the right combination of meds and the right dose you'll see a big difference. Keep advocating strongly for Dexter. Hang in there, you're doing great.
I'm not a vet, but my dog takes tramadol and gabapentin for pain and I know they work best together.
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Post by Meg & Dexter on Jul 15, 2017 20:49:39 GMT -7
The surgeon who performed the procedure was a neuro specialist and the surgery was done at the Charleston Veterinary Referral Center. The [neuro specialist] surgeon has been in touch with us and has re-examined dexter twice since surgery.
The issue is that when he is there, they claim they see no signs of pain and he is always "comfortable" or "resting comfortably" when we call to check on him.
Then we get him home and the cycle seems to start all over again with them saying the only option is to bring him in.
He actually just had another spasm attack about an hour before his tramadol dose was due so we called to keep them informed of each attack he has. I specifically asked about increasing any of the med doses and all they said was we could start giving them all every 7 hours instead of every 8
Each time this happens we see the neck muscles twitching so we are fairly confident it is muscle spasms but no idea why he is still having them, why they are so severe, and how they claim he had nothing like this while admitted
Is there ever any indication for them to do methocarbamol and Valium together and off set the two? I asked about more or different muscle relaxers and they said methocarbamol is the best.
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Post by Pauliana on Jul 15, 2017 21:52:46 GMT -7
Meg, I am sorry that you aren't getting any help when you call the surgeon's office. Dogs are very stoic while at the Vet office.. they don't like to show they are in pain while there because they are afraid they will have to stay so they become actors...pretending all is well, then when they get home where they feel safe, their true pain shows up.. This happens with my Tyler too. He is quite the actor until he gets home.. Tramadol and Gabapentin work very well together and enhance each other so they should be given at the same time.. The Tramadol dose that is being given is so low that it is like not giving him any.. That is the dose for a much smaller dog. If the Methocarbamol is not working for Dexter they should try another muscle relaxer.. Not every drug will work the same on every dog.. If they won't help you, I think a second opinion is called for.. I know they did his surgery but you need a Vet that will work with you in helping Dexter.. Try taking a video of Dexter having the attack and make sure the surgeon sees it..Maybe that will get your message across! I can understand your upset and frustration.. Once his spasms are under control it will make all the difference in his recovery.. These are the special things you can do for neck disc episode: Raise food and water bowls to head height to avoid bending down to eat and drink. dodgerslist.com/literature/cratesupplies/bowlHLDR.jpgIf you feed kibble, moisten each meal with equal parts water and kibble and allow to hydrate in the fridge overnight. Then warm slightly in microwave, just to take the chill off, before serving. This will eliminate pain from crunching kibble. No chew treats or kongs during recovery. Chewing on those makes the head and neck move a lot and can deter healing and cause more pain. Snuggle Safe is a commercial product that will keep warm the whole night. Wrap in a towel, piece of fleece fabric as a soft place for your dog to choose to rest the head or snuggle with. WARNING: only used with adog that still has feeling. As a dog can feel if it's too hot for them and move away from it. Snuggle Safe is available at pet shops or on-line. Raise the crate up on a table so there is no need for your dog to to raise the head to look at you or watch the world from the crate. |
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Post by Meg & Dexter on Jul 16, 2017 4:55:51 GMT -7
Thank you all so much for taking time to give advice. It's heart breaking that we are talking about how much pain is fair to put him through and at what point we say enough is enough and end the suffering. The surgeon keeps saying she doesn't think we are headed down that path but she is not at home with us when we see him like this.
I'm definitely going to push the tramadol dosing, I feel like the vet on call overnight was reluctant to change dosing without the surgeon being present but his spasms seem to come on about an hour before his tramadol dose is due so it would seem to make sense to me that more tramadol could help.
At one point he was also on trazadone but the vet discontinued it because he was too sedate in combination with tramadol. But this was the only time he actually seemed comfortable. Is it ever ok for these drugs to be given together? I know the risk is seretonin syndrome and I've read mixed reviews on how high that risk is.
We have an appointment with the neurologist Monday at 1 so I'm trying to get all my concerns organized before then. There is another specialty vet in Charleston and if they don't address his pain better on Monday then I'm ready to go for a second opinion at this point. Everyone has been very nice at our vet but the action to remedy his pain is just not there. The suggestion they have is to medically board him until his pain is adequately controlled, which is on the list of possibilities but would warrant us going much further into credit card debt than we already are with this ordeal.
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,792
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Post by PaulaM on Jul 16, 2017 8:24:16 GMT -7
Meg, waiting to get pain relief until Monday is way too long a time! What can you do to use your best of advocating skills today, Sunday? Is there another ACVIM (neuro) on call at Charleston Veterinary Referral who you can talk about pain management to opposed to a general DVM vet? Be polite, but be a squeaky wheel! There are many reasons this could be for the why of the pain ~~ The surgeon was not able to get all the disc material removed, may not not have seen some of it. This can happen ~~ The same or another disc in the neck has had escape of disc material. That too has happened. Some have had a 2nd surgery but many have just done conservative treatment to let the disc heal. So until you have something that says this is not another disc episode (the same one or a new disc, make sure you are doing VERY STRICT rest. 100% STRICT rest 24/7 only out for a very, very few footsteps at potty time. Movement of the the vertebrae in the neck can worsen a "suspected bad disc" Limited movement is the focus when treating a disc episode with conservative treatment (meds, strict rest) The bottom line is he IS currently being under mediicated for pain because he clearly IS in pain. ~~ trazadone is not a pain reliever, it can relieve anxiety, it can sedate. but it does not mask pain. ~~ Methocarbamol: ~~ Do what you can over the phone to very strongly advocate for getting pain managed today, Sunday. It is very clear from the references provided above that the dose of 25mgs tramadol being given is almost like not giving any tramadol at all. Advocate for the maximum analgesic dose of tramadol at " 10 mg/kg every 8 hours" ~~ Find out why the exact same NSAID prior to surgery can't be continued with now, today as that needs no washout? Why is it necessary to do a washout and a switch to the other class of anti-inflammatory drugs, a steroid? There may be a good reason or not. Understanding the treatment is your right and the responsibility of the vet to explain to you. ~~ One source of pain is not being addressed...nerve pain. Gabapentin 3x/day is what to advocate for. --Because pain has gone so long not in control, it may be worthwhile to bring out all the guns and an Rx for Amantadine to try and get pain back in control. Amantadine when combined with other pain relievers, adds an extra dimension of pain relief. We see more neuros using this drug now post op. Please read about this drug so you can best advocate for it: marvistavet.com/amantadine.pml It is totally inhumane to allow pain, when there can be an easy adjustment to pain-masking pain meds. When the proper pain med regimen is on board, you would expect full pain control in one hour. The pain would stay in control right up to the next dose of pain meds. WHY PAIN CONTROL is a MUST There is a need to get the pain under control as fast as possible; the longer you wait the harder it is to control the pain. Delays in getting full pain control can cause any future pain to be more intense and severe. "There is now a vast literature showing the uncontrolled pain is a major stressor, retarding healing and increasing the likelihood of infection." Gaynor JS. In Gaynor JS, Muir WW III (eds): Handbook of Veterinary Pain Management, 2nd ed—St. Louis: Mosby Elsevier, 2009, pp 10. Treating pain early usually brings quicker and better results. Healing occurs faster when pain is under control. Pain affects blood pressure, heart rate, appetite, and general mood. Until all the swelling is resolved on the inside via surgery or conventional medical treatment, there will still be a source of pain. Herniated discs, damaged spinal cord require a significant amount of time to heal. New tissue must be generated. Swelling must have time to subside. "Pain is so important to the overall well-being of a patient that it has become the 5th cardinal sign of human assessment." (Philips DM. JCAHO pain management standards are unveiled. J.Am Med Association 284(4):428-429, 2000) Institutions can risk their federal funding if they do not routinely assess for pain. Robin Downing, DVM, CVA, DAAPM is one of only four veterinarians in the world to hold the Diplomate credential in the American Academy of Pain Management - the largest interdisciplinary pain management organization in human medicine said: "Pain control is never a "one size fits all" prescription, and there are dozens of drugs that can be used alone and with other medications to relieve all but the most extreme pain in animals.
Animals can feel all the same aches and pains that we can because they share the same physiologic structures.
Treating pain doesn't just make the hurting stop: It also promotes healthy healing. Untreated pain slows healing time, interferes with sleep and depresses the immune system."www.florida-weekly.com/news/2007/1101/Top_News/022.htmlPlease let us know when you have successfully advocated and what changes to the med have been made. |
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Post by Meg & Dexter on Jul 19, 2017 15:18:37 GMT -7
Sorry for the delay in posting. We finally have some good news. I spent the better part of Sunday calling the vet over and over but they would not increase any medications and despite all of the references they claimed that the tramadol was at the max dose they were comfortable with.
We made it to Monday morning and had our follow up with the surgeon. Dexter continue to exhibit not pain on her exam at the vet which was so frustrating but she added in ✚Valium due to our reports of ongoing muscle spasms. By this time he had his first dose of ✚prednisone (1.5 tablets at 5mg each on a slow taper). We got home Monday and he has not had a single episode of pain since then!
He is still on tramadol, gabapentin, methocarbamol and omeprazole but we are planning to take the ▼tramadol back out to every 8 hours instead of every 6.
The steroids have literally given us out dog back. He is so much more himself and we are having to hold him back from wanting to do stuff. We are still being strict with crate rest for the full recovery.
My concern is with how much pain he had, I wonder if that means the odds of a relapse after weaning medications and tapering steroids is greater than average.
The surgeon would not give me any indication of what she thought might happen. She said dexters recovery has been so much not what she anticipated that she was reluctant to set any expectations. Any info on the odds or relapse?? She said his disc was very lateralized where it was ruptured and she had poor visibility meaning there very well could be some residual disc but she was hopeful even if that is case that we could keep dexter comfortable. Any thoughts?
I'm trying not to be too picky because I am happy to jus finally have a glimpse of my buddy back.
[Moderator's note: please do not modify
17 lbs
carprofen stopped 7/7
✚Prednisone 5mg tabs as of 7/17: 7.5mgs ?x/day for how many day? before test-for-pain taper?
methocarbamol 375mgs 3x/day
gabapentin 100mg 3x/day
▼tramadol 25mgs 3x/day
omeprazole 10 mgs 2x/day
✚Valium 3mg 1x/day.]
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Post by Pauliana on Jul 19, 2017 22:06:05 GMT -7
Great news that Dexter is pain free.. Major victory. I am glad you were able to get Valium on board.. What is the dosage and how many times a day? How many times a day is the Prednisone to be given and what are the tapering instructions?
Every dog with IVDD is different so there aren't any written odds of relapsing. There are some dogs who only have one episode in their lifetime but others have multiple episodes like my Tyler.. That has never stopped him from recovering each time and going back to our new normal.. They are born with this disease but the symptoms don't typically show up until they are between 3 and 7 years old although some present earlier or later..
All neck disc episodes are very painful even more than the back disc episodes.. That is why pain meds need to be aggressive in most cases. The fact that neck discs are more painful doesn't mean there won't be a recovery from this episode.. Rest assured you and Dexter will have your good life back! Now that he is pain free, he can heal in comfort and there will be a lot less stress and upset for you!
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Post by Meg & Dexter on Jul 20, 2017 18:33:25 GMT -7
Dexter is on a prednisone taper that is 1.5 tablets (5mg each) for 5 days, 1 tablet for the following 5 days, then a half tablet for 5 days and then a half tablet every other day until gone.
The Valium dosage I believe is 3mg up to every 6 hours as needed. The vet told us this was a fairly low dose and that it could be increased if we needed but thankfully as of now we have not needed to increase the dose and have only used it at bedtime to assist with getting dexter to wind down and relax in his crate.
Tomorrow is the last day of the highest dose of prednisone so I'm nervous about that. I'm also nervous about taking him off tramadol this weekend as well but I understand they don't want dexter on opioids for longer than necessary.
Any happy thoughts for this weekend would be appreciated. My husband and I also have to go back to work full time next week and will have to alternate coming home at lunch for med administration every day. On top of everything I am going to be 38 weeks pregnant on Monday so as you can imagine, this has been a rather stressful few weeks.
Keeping our hopes up for no setbacks but if he has residual disc material we are aware this is a possibility. Keeping all our paws crossed for good luck though!
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PaulaM
Moderator.
Member since 2007: surgery, conservative . Montana, USA
Posts: 19,792
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Post by PaulaM on Jul 21, 2017 9:12:43 GMT -7
Meg, just to clarify about prednisone.
Currently Dexter is on a 5 days course of pred: 1.5mg tab for how many times a day right now? Then there will be a taper that is 1/2 tab for 5 days, etc. to conclusion.
With a reduction in pred scheduled to begin on Sunday when the vet is not open, you would then want to have a plan B with your vet in place today. Should the test for pain pred taper reveal pain, then what do you do til he reopens. Do you have enough pills on hand to go back up to the original dose OR an Rx you could fill at a local 24hr pharmacy? A plan B is free.....a Sunday ER visit can be expensive should pain resurface.
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