|
D
1)
DERACOXIB
a)
Classification
i)
A coxib class COX2 selective NSAID
b)
General Information
i)
Effective anti-inflammatory/analgesic generally free of significant
GI side effects
c)
Advantages/Recommended use
i)
Short term use for acute pain
ii)
Long term use in chronic pain for tolerant patients
d)
Cautionary Information
i)
As with any NSAID, GI side-effects can be substantial
(1)
Discontinue use if GI signs develop
ii)
Avoid use in:
(1)
Combination with
corticosteroids
(a)
Potentially increased ulcerogenic effect
(2)
Renal compromised patients, dehydrated or hypotensive patients,
patients with hepatic disease, pregnancy, patients with pre-existing GI
disease, coagulopathies
iii)
Monitor liver enzymes of canine patients on chronic therapy
e)
Dosage Information
i)
Dogs – 1 to 2 mg/kg PO SID for general pain management
(1)
3 to 4 mg/kg PO SID for up to 7 days for acute surgical pain
ii)
Cats – use of deracoxib is not
recommended at this time
f)
Cost
i)
Moderately high
2)
DEXTROMETHORPHAN
a)
Classification
i)
An antitussive drug and an NMDA antagonist
b)
General Information
i)
Developed initially
as a human cough suppressant
ii)
An oral prescription medication capable of NMDA antagonism useful
in managing the central sensitization component of chronic pain management
c)
Advantages/Recommended use
i)
Chronic pain management
d)
Cautionary Information
i)
Reduce dose or discontinue in patients with hepatic dysfunction
e)
Dosage Information
i)
Dogs & Cats
(1)
0.5 to 2.0 mg/kg (0.25 to 1.0 mg/lb) TID to QID PO
ii)
Robitussin CoughGelsÒ
are an OTC gelcap that contains 15 mg dextromethorphan per capsule and no
other drugs. Vicks Formula 44 Cough ReliefÒ
is a dextromethorphan only liquid OTC product that contains 2 mg/ml and
comes in 118 ml bottles.
f)
Cost
i)
Moderate
3)
DIAZEPAM
a)
Classification
i)
A benzodiazepine hypnotic sedative agent
b)
General Information
i)
Usually combined with ketamine or an opioid
c)
Advantages/Recommended use
i)
Combined with ketamine for:
(1)
Older patients
(2)
Some cardiac patients
ii)
Combined with oxymorphone for:
(1)
Debilitated patients
(2)
Geriatric patients
iii)
Cats
(1)
Several hour duration makes it suitable for short term sedation in
the cat
iv)
Spinal surgery cases
(1)
Give at extubation for muscle relaxation (decreases pain)
v)
Diazepam is reversible using flumazenil
d)
Cautionary Information
i)
Propylene glycol base makes diazepam somewhat painful and less
predictably absorbed than midazolam when given IM
(1)
Propylene glycol has potential to cause hemolysis and vasodilation
if given in sufficient quantity
ii)
Rapid IV administration may lead to short term arrhythmia
iii)
Dogs
(1)
Extremely short duration makes it unsuitable for sedation as sole
agent in the dog
e)
Dosage Information
i)
Dogs & Cats
(1)
Generally dose – 0.2 mg/kg to 0.4 mg/kg (0.1 to 0.2 mg/lb) IV, IM
(2)
IV induction #1 - combined with equal volume of Ketamine
(a)
Draw up 1cc of total mixture per 10 kg (20lb)
(i)
Give ½ initially, then to effect
(ii)
Reduce dose by 30% - 50% if depressed or heavily sedated by
pre-meds
(3)
IV induction #2 - combined with fentanyl, hydromorphone, or
oxymorphone – most useful for dogs
(i)
See Diazepam & an Opioid section under Induction Protocols for
details
(ii)
Cats would need low dose Ketamine (1 to 5 mg/lb) or Propofol (0.5
to 2 mg/lb) to facilitate intubation
(4)
IV maintenance – most useful for dogs
(a)
See Diazepam & an Opioid section under Maintenance Protocols
for details
(i)
Main indication would be canine patient with difficult to manage
hypotension while on inhalant agent
f)
Cost
i)
Low
4)
DOBUTAMINE
a)
Classification
i)
Positive inotropic agent related to dopamine
ii)
Primarily a direct beta1-adrenergic agonist with mild
beta2- and alpha1-adrenergic effects
b)
General Information
i)
Used to help increase blood pressure in hypotensive patients
ii)
Compatible with most of the commonly used IV fluids including D5W,
saline, and LRS
(1)
The initial vial and the diluted drug is stable for 24 hours
c)
Advantages/Recommended use
i)
Used to increase blood pressure when an anesthetic reduction, IV
fluids, and colloids are inadequate
d)
Cautionary Information
i)
This drug must be diluted before administration
(1)
Final drug concentration must be no greater than 5.0 mg/ml
ii)
Use open vial and diluted drug for no longer than 24 hours
iii)
Use caution when mixing with other drugs
(1)
Confirm compatibility before doing so
iv)
Discontinue if significant increase in heart rate or if any
arrhythmia develops
(1)
Arrhythmias are much less likely at dose rates below 0.008
mg/kg/min (0.004 mg/lb/min)
e)
Dosage Information
i)
Dog – 0.001 to 0.010 mg/kg/min (0.0005 to 0.005 mg/lb/min)
ii)
Cats - use low end of dog dose range
iii)
Recipe for 0.002 mg/kg/min (0.001 mg/lb/min) dose
(1)
4.8 ml @ 12.5 mg/ml = 60 mg
(2)
Add to 250 ml 0.9% saline for 0.24 mg/ml
(3)
Give 0.5 ml/kg/hour
f)
Cost
i)
Low
5)
DOMITOR
a)
Pfizer’s brand name for medetomidine
i)
See medetomidine
6)
DOPAMINE
a)
Classification
i)
Positive inotropic agent
ii)
Precursor to norepinephrine and epinephrine
iii)
Primarily beta1-adrenergic effects at therapeutic doses
with alpha1-adrenergic effect at higher dose rates
b)
General Information
i)
Used to help increase blood pressure in hypotensive patients
ii)
Compatible with many of the commonly used IV fluids including D5W,
saline, and LRS
(1)
Diluted drug is stable for 24 hours
c)
Advantages/Recommended use
i)
Used to increase blood pressure when an anesthetic reduction, IV
fluids, and colloids are inadequate
d)
Cautionary Information
i)
This drug should be diluted before administration
ii)
This drug is available in many different strengths – adjust
recipes accordingly
iii)
Use open vial and diluted drug for no longer than 24 hours
iv)
Protect from light
v)
Use caution when mixing with other drugs
(1)
Confirm compatibility before doing so
vi)
Discontinue if significant increase in heart rate or if any
arrhythmia develops
(1)
Arrhythmias are much less likely at dose rates below 0.020
mg/kg/min (0.010 mg/lb/min)
e)
Dosage Information
i)
Dog – 0.002 to 0.010 mg/kg/min (0.001 to 0.005 mg/lb/min)
ii)
Cats - use low end of dog dose range
iii)
Recipe for 0.002 mg/kg/min (0.001 mg/lb/min) dose
(1)
1.5 ml @ 40 mg/ml = 60 mg
(2)
Add to 250 ml 0.9% saline for 0.24 mg/ml
(3)
Give 0.5 ml/kg/hour
f)
Cost
i)
Low
7)
DURAMORPH
a)
Classification
i)
Preservative free morphine
ii)
Pure mu opioid agonist
b)
General Information
i)
A specific preparation for epidural use
c)
Advantages/Recommended use
i)
Epidural analgesia
d)
Cautionary Information
i)
Single use 10 mg (10 ml) vials and 2 mg (2ml) vials - do not save
residual meds
e)
Dosage Information
i)
Epidural use
(1)
Dog & Cat - 0.1 mg/kg (0.045 mg/lb.)
(a)
1 cc per 10 kg
f)
Cost
i)
Moderately high – significant wastage
E
1)
EPINEPHRINE
a)
Classification
i)
Endogenous adrenergic agent with Alpha and Beta properties causing
increased contractility and increased blood pressure
b)
General Information
i)
An emergency medication
c)
Advantages/Recommended use
i)
Anaphylactic allergic reactions
ii)
Cardiac resuscitation (asystole)
d)
Cautionary Information
i)
Store in refrigerator
e)
Dosage Information
i)
Dogs
(1)
Cardiac resuscitation - 1 ml per 10 kg (20 lb) IV (1:1000 dilution)
(2)
Anaphylaxis – 0.010 to 0.20 mg/kg (0.005 to 0.10 mg/lb) IV
ii)
Cats
(1)
Cardiac Resuscitation - 1 ml per 10 kg (20 lb) IV (1:1000 dilution)
(2)
Anaphylaxis – 0.010 to 0.20 mg/kg (0.005 to 0.10 mg/lb) IV
(3)
Feline asthma - 0.1 ml SQ or IV (1:1000 dilution)
f)
Cost
i)
Very low
2)
ETODOLAC
a)
Classification
i)
A COX2 selective NSAID
b)
General Information
i)
Effective anti-inflammatory/analgesic generally free of significant
GI side effects
c)
Advantages/Recommended use
i)
Short term use for acute pain
ii)
Long term use in chronic pain for tolerant patients
d)
Cautionary Information
i)
As with any NSAID, GI side-effects can be substantial
(1)
Discontinue use if GI signs develop
ii)
Avoid use in:
(1)
Combination with
corticosteroids
(a)
Potentially increased ulcerogenic effect
(2)
Renal compromised patients, dehydrated or hypotensive patients,
patients with hepatic disease, pregnancy, patients with pre-existing GI
disease, coagulopathies
iii)
Monitor liver enzymes of canine patients on chronic therapy
e)
Dosage Information
i)
Dogs – 10 to 15 mg/kg (4.8 TO 6.8 mg/lb) PO SID
ii)
Cats – use of etodolac is not recommended
at this time
f)
Cost
i)
Moderately low
3) ETOMIDATE
a)
Classification
i)
An imidazole
b)
General Information
i)
Considered the best induction agent for dilated cardiomyopathy
ii)
Comes in two forms
(1)
Standard USA product in propylene glycol vehicle
(2)
European lipuro form in hyperlipid emulsion similar to propofol
c)
Advantages/Recommended use
i)
For serious cardiac cases including cardiomyopathy cases
d)
Cautionary Information
i)
May cause myoclonus, retching, or excitement during induction or
recovery – this is uncommon if patient is adequately sedate from the
premeds or is clinically depressed
(1)
Premed with one of the following:
(a)
Oxymorphone 0.05 mg/kg (0.025 mg/lb) IM and midazolam 0.1 mg/kg
(0.05 mg/lb) IM
(b)
Hydromorphone 0.1 mg/kg (0.05 mg/lb) IM and midazolam 0.1 mg/kg
(0.05 mg/lb) IM
(c)
Butorphanol 0.2 mg/kg (0.1 mg/lb) IM and midazolam 0.1 mg/kg (0.05
mg/lb) IM
ii)
Does suppress adrenocortical function for 3 hours after
administration
(1)
This effect can be overcome by corticosteroid administration if
there is an existing adrenal concern
(a)
Some believe this lack of a “stress response” may actually
reduce patient morbidity
iii)
The propylene glycol containing etomidate can trigger hemolysis
that some consider a potential for renal stress
(1)
Effect of possible pigment overload
(2)
For renal or anemic patients use etomidate-lipuro
iv)
Unused etomidate-lipuro should be discarded if not used that day
e)
Dosage Information
i)
Routine induction
(1)
Dogs - 0.5 to 3.0 mg/kg (0.25 to 1.5 mg/lb) IV
(a)
If patient is not already depressed or is not reasonably sedate
from premeds, precede etomidate with 0.2 to 0.4 mg/kg (0.1 to 0.2 mg/lb)
diazepam IV
(2)
Cats – 0.5 to 2.0 mg/kg (0.25 to 1.0 mg/lb) IV
(a)
If patient is not already depressed or is not reasonably sedate
from premeds, precede etomidate with 0.2 to 0.4 mg/kg (0.1 to 0.2 mg/lb)
diazepam IV
ii)
Give the propylene glycol containing etomidate with IV fluids to
minimize pain on injection and hemolysis
(1)
This concern is due to the propylene glycol content of this
preparation
f)
Cost
i)
Very high
F
1)
FENTANYL
a)
Classification
i)
A pure mu agonist
b)
General Information
i)
Duration of effect is 30 to 45 minutes
c)
Advantages/Recommended use
i)
Short-term analgesia
(1)
Excellent as an intra-operative “top up” analgesic
ii)
Induction agent when combined with a benzodiazepine
iii)
CRI analgesic use
d)
Cautionary Information
i)
May see panting and muscle rigidity
e)
Dosage Information
i)
Induction
(1)
See Diazepam & an Opioid section under Induction protocols for
details
ii)
Analgesia
(1)
Bolus – 0.002 mg/kg (0.001 mg/lb)
(2)
CRI – 0.001 to 0.004 mg/kg/hr (0.005 to 0.002 mg/lb/hr)
(3)
Duragesic patch – based upon weight
|
Patient
|
Dose
|
Fentanyl Content
|
|
Small
Dogs ** (<5kg) & Cats
|
25
mcg/hr
|
2.5
mg
|
|
Dogs:
5-10 kg
|
25
mcg/hr
|
2.5
mg
|
|
Dogs:
10-20 kg
|
50
mcg/hr
|
5
mg
|
|
Dogs:
20-30 kg
|
75
mcg/hr
|
7.5
mg
|
|
Dogs:
>30 kg
|
2
x 50
mcg/hr
|
10
mg
|
(a)
Small
dogs and cats, use the 25 mcg/hr patch but only expose ½ of the patch
(b)
For
even smaller cats consider exposing ¼ of the patch
(c)
Never
cut the patch
(d)
Clip
hair as closely as possible at planned patch site without irritating the
skin. Gently wipe area once or twice with slightly dampened gauze to
remove loose hair. Let area dry. Warm patch to body temperature. Remove
backing and apply patch to skin. Hold firmly against skin with hand for 2
full minutes. White tape and Kling gauze are used to cover and support the
patch when possible.
(e)
For dogs greater than 30 kg, two 50 mcg patches will likely provide better
drug delivery than one 100 mcg patch.
f)
Cost
i)
Low per IV use
ii)
High per patch
2)
FLUMAZENIL
(ROMAZICON(R))
a)
Classification
i)
Benzodiazepine antagonist
b)
General Information
i)
Reversal agent for diazepam and midazolam
c)
Advantages/Recommended use
i)
To reverse any undesirable effects resulting from diazepam or
midazolam use
d)
Cautionary Information
i)
None
e)
Dosage Information
i)
Dogs – 0.02 to 0.1 mg/kg (0.01 to 0.05 mg/lb) IV
ii)
Cats – 0.02 to 0.1 mg/kg (0.01 to 0.05 mg/lb) IV
f)
Cost
i)
Very high |
