Use of multimodal analgesia in the anesthesia of a Yorkshire Terrier undergoing laparoscopic cholecystectomy - case reportABSTRACT
Multimodal analgesia combines different analgesic drugs that act on various receptors to ensure effective pain control. This paper reports on the case of a Yorkshire dog undergoing anesthesia for a laparoscopic cholecystectomy, highlighting the use of multimodal analgesia. The anesthetic protocol adopted included a combination of methadone and ketamine in the pre-anesthetic medication (PAM). Additionally, a quadratus lumborum block (QL-Block) with bupivacaine associated with dexmedetomidine and continuous infusion of sufentanil was performed. During transanesthetic monitoring, the patient developed hypotension that was unresponsive to fluid challenge and was corrected with ephedrine. In this regard, it is concluded that the multimodal approach to pain is essential for the patient's comfort, in addition to highlighting the need for continuous monitoring for early interventions, thereby reducing the risks to the patient.
Keywords:
multimodal analgesia; quadratus lumborum block; balanced anesthesia; canine
RESUMO
A analgesia multimodal combina diferentes fármacos analgésicos que atuam em diversos receptores para garantir um controle eficaz da dor. Este trabalho relata o caso de um paciente canino da raça Yorkshire submetido à anestesia para uma colecistectomia laparoscópica, destacando o uso da analgesia multimodal. O protocolo anestésico adotado incluiu, na medicação pré-anestésica (MPA), a combinação de metadona e cetamina. Além disso, foi realizado o bloqueio do quadrado lombar (QL-Block) com bupivacaína associada à dexmedetomidina e infusão contínua de sufentanil. Durante a monitoração transanestésica, o paciente desenvolveu hipotensão não responsiva à prova de carga, que foi corrigida com efedrina. Nesse sentido, conclui-se que a abordagem multimodal da dor é essencial para o conforto do paciente, além de evidenciar a necessidade de uma monitoração contínua para intervenções precoces, reduzindo os riscos ao paciente.
Palavras-chave:
anestesia multimodal; bloqueio quadrado lombar; anestesia balanceada; canino
INTRODUCTION
Multimodal analgesia is a therapeutic strategy designed for pain management, characterized by interventions on multiple receptors using a variety of pharmacological agents and different techniques. This therapeutic modality aims to provide better pain control both during the intraoperative period and postoperatively, with the goal of optimizing analgesic comfort for patients (Fossum, 2015).
Thus, this article aimed to describe the use of multimodal analgesia in a 12-year-old, 5.3 kg Yorkshire Terrier undergoing anesthesia for laparoscopic cholecystectomy, with the objective of presenting the particularities of the anesthesia used in this case and its complications during the procedure. The results of the combination of analgesic and sedative in different techniques will be presented, such as the use of locoregional anesthesia (LRA), which, according to Garbin et al. (2020), is an important tool in veterinary anesthesiology due to its proven safety and efficacy. Additionally, the drugs used and the monitoring of the patient until their anesthetic recovery will be discussed.
CASUISTRY
On March 4, 2024, the surgical team treated a 12-year-old, 5.3kg Yorkshire Terrier that had been referred from another clinic. The patient had a history of gallbladder abnormalities for approximately one year, with significant worsening in the last four months, which had led to necrosis of the gallbladder wall. The patient was being treated with ursodeoxycholic acid and bezafibrate.
Pre-anesthetic hematological and biochemical tests were performed by the surgical team. The results showed that bilirubin and glucose levels were within the reference values for the dog's age and species. However, alanine aminotransferase (ALT) and creatinine levels were elevated, with ALT reaching 385 U/L (reference range: 21 to 102U/L) and creatinine at 1.6 mg/dL (reference range: 0.5 to 1.4mg/dL). Additionally, the complete blood count revealed a slight leukocytosis due to neutrophilia.
An electrocardiogram was also conducted, revealing only sinus arrhythmia, and an echocardiogram showed mild mitral and tricuspid insufficiency, classifying the patient as a B1 cardiopath (Fig. 1). As a result, surgery was scheduled for two days after this evaluation, with the recommendation for a laparoscopic cholecystectomy.
Echocardiogram image of a canine patient, Yorkshire, 12 years old, treated on March 4, 2024, at the Clinivet Veterinary Hospital - Curitiba, PR. A- Echographic image showing mitral insufficiency. B- Echographic image showing tricuspid insufficiency.
On March 6th, the patient was admitted in the morning and taken to the surgical block. According to the owner, the dog had been fasting for 8 hours and had taken the prescribed medications only the day before the surgery. Pre-anesthetic medication was administered, including ketamine at a dose of 1 mg/kg and methadone at a dose of 0.2 mg/kg, intramuscularly. After 15 minutes, the patient showed mild sedation, venous access was established, the surgical site was shaved, and the patient was taken to the operating room.
In the operating room, a continuous infusion of sufentanil at a dose of 1 mcg/kg/h was started 5 minutes before induction with propofol. The induction was performed with propofol in a dose-response bolus of 1mg/kg, totaling 7mg/kg (3.5mL), until the patient reached the anesthetic plane with the loss of the palpebral and laryngotracheal reflexes. Endotracheal intubation was performed using a 5.0 tube with the help of a laryngoscope, followed by the administration of isoflurane through a calibrated vaporizer at 2.5% for anesthesia maintenance. Proper monitoring was established, including electrocardiogram, pulse oximetry, oscillometric blood pressure, and capnography.
After anesthetic induction, the patient was positioned for the lateral approach of the quadratus lumborum block bilaterally, using a 21G Quincke needle and a solution of bupivacaine with dexmedetomidine at a dose of 1mL/kg per point. This solution consisted of 20 mcg of dexmedetomidine in 100 mg of bupivacaine 0.5%, diluted in a 1:1 ratio with 0.9% saline solution. The needle was inserted between the quadratus lumborum muscle and the transversalis fascia, with the aid of ultrasound, which accurately guided the interfacial space, allowing the block to reach the intercostal nerves and the anterior branches of the lumbar spinal nerves (Fig. 2).
Photographic images of the quadratus lumborum locoregional block performed with ultrasound guidance in a canine patient, Yorkshire, 12 years old, operated on March 6, 2024, at Clinivet Veterinary Hospital, Curitiba - Paraná.
Subsequently, the patient was placed on pressure-controlled mechanical ventilation (PCV) with a peak pressure of 12 cmH2O, ensuring adequate pulmonary ventilation, as a pneumoperitoneum was required during this procedure to create working space.
During the surgery, vital parameters remained stable, except for the mean arterial pressure, which showed a trend of progressive decrease. Initially, a fluid challenge was performed with lactated Ringer's solution at a rate of 10ml/kg over 15 minutes, but it was not effective. As an intervention, ephedrine was administered at a dose of 0.2mg/kg intravenously, resulting in an increase in blood pressure (Fig. 3).
After gallbladder removal and completion of surgical stimulation, the dose of sufentanil was reduced to 0.5mcg/kg/h. After the videosurgery portals were removed, mechanical ventilation was changed to pressure support until the patient's spontaneous ventilation was recovered, in addition to the vaporizer being turned off. At the end of the surgery, the patient had a good recovery and was referred to the hospitalization period with postoperative monitoring and additional care.
Representative graph of the parameters observed during the various phases of anesthesia of the canine patient, Yorkshire, 12 years old, operated on March 6, 2024, at the Clinivet Veterinary Hospital, Curitiba - Paraná.
DISCUSSION
Multimodal analgesia was the technique used in the case report presented, associating analgesic drugs that act on several receptors, aiming at pain control and providing a balanced and effective anesthesia. The choice of MPA already indicates the concern with the treatment of pain in a preemptive way, using methadone, an opioid agonist μ total and antagonist of the NMDA receptor, associated with ketamine, which is also an antagonist of NMDA receptors and which acts on the opioid receptors μ, δ and κ bringing a combination of agents in MPA effective to the patient, contributing to the multimodal approach to pain. (Lumb and Jones, 2015).
In the case presented in this report, the quadratus lumborum block (QL-Block) was used, one of the important locoregional blocks, which is a locoregional anesthetic intervention with the ability to provide analgesia to both the abdominal wall and the abdominal viscera (Vieira, 2023).
In medicine, different approaches to perform this technique have been described, lateral, anterior and posterior. In the lateral approach, the needle is introduced towards the aponeurosis of the transversus abdominis muscle and the lateral border of the quadratus lumborum (QL) muscle. Local anesthetic is injected between the lateral border of the QL muscle, and the fascia transversalis (Elsharkawy, 2019). In 2020, Garbin et al. defined that the QL block by the ultrasound-guided lateral approach is a block that can be used in dogs.
The patient presented non-responsive hypotension to load test during transanesthetic monitoring, demonstrating that the origin was not due to volume and was therefore related to peripheral vasodilation, or incorrect anesthetic plan, compromising hemodynamic stability. Among the possible complications associated with the ALR technique, the migration of local anesthetics to the paravertebral space stands out, which can induce the occurrence of hypotension (Ferreira et al., 2023). However, the use of isoflurane also causes hypotension, mainly due to the reduction of systemic vascular resistance (Oliveira et al. 2014).
To correct hypotension, ephedrine was administered, a drug recognized for its prolonged duration of action compared to other vasopressor and inotropic agents, as highlighted by Lumb and Jones (2015). This characteristic is positive because it allows the administration of a single bolus dose to control hypotension, in contrast to the need to establish a continuous infusion, which would take time to prepare. However, according to the same author, it is recommended that before any medication maneuver, the patient’s anesthetics plan be corrected, in this case with the reduction of CAM and other anesthetics agents, such as Sufentanil.
In the choice of drugs used in the anesthetic protocol of the case, bupivacaine was chosen to perform locoregional blockade because it is a long-acting local anesthetic, which blocks the generation and conduction of nerve impulses in a reversible manner, preventing the rapid entry of sodium into the axons, providing analgesia. (Mombach, 2015). In addition, the addition of dexmedetomidine, an alpha-2 adrenergic agonist with analgesic properties, prolongs the duration of the block and improves pain control in the perioperative period, as described by Cervantes Zapata et al. (2023) in a study conducted in dogs with sciatic and femoral nerve blocks, ensuring analgesia in the first 24 hours.
Intraoperative use of opioids is routine practice as part of a balanced anesthetic technique. Sufentanil is an opioid analogue of fentanyl, which stands out for its 5 to 10 times higher potency, attributed to its greater affinity for opioid receptors. This compound has a faster onset of action and a longer-lasting analgesic effect when compared to fentanyl (Luz, 2015). Based on this, sufentanil was introduced into the protocol with a varied continuous infusion throughout the procedure.
The use of this drug causes respiratory depressant action, and the frequent occurrence of hypercapnia during the infusion of sufentanil in dogs anesthetized with isoflurane is common, and the use of controlled ventilation during these procedures is recommended (Carareto, 2007). In addition, laparoscopic procedures, despite being minimally invasive, require the insufflation of a gas in the abdominal cavity to induce pneumoperitoneum. However, this state of distension can cause an increase in intra-abdominal pressure (IAP), which can compromise the patient's homeostasis, especially regarding ventilatory and hemodynamic parameters, making it necessary for the animals to be placed on controlled ventilation, as in the case reported (Ido and Nunes, 2021).
CONCLUSION
The case presented here highlights the importance and efficacy of multimodal analgesia in the control of perioperative pain. The combination of quadratus lumborum block (QL-Block) and the use of intraoperative analgesic infusion proved to be a particularly effective strategy, providing comprehensive pain control both during and after the surgical procedure. The careful administration of drugs such as bupivacaine, dexmedetomidine and sufentanil contributed to safe anesthesia, minimizing the response to surgical stimulus and promoting a more comfortable postoperative recovery for the patient.
Constant monitoring is essential for early intervention in hemodynamic changes in the transanesthetic and ensures satisfactory stabilization, without harm to the patient. These results highlight the importance of the individual and multimodal approach in pain management in veterinary surgeries, highlighting its relevance as an integral part of a balanced anesthetic practice.
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