The use of multimodal analgesia in the management of suspected extremity compartment syndrome in the pelvic limb of a horse

Abstract

Summary A 12‐year‐old Thoroughbred cross Dartmoor mare was referred to the clinic with marked lameness and swelling involving the left stifle region. There was poor initial response to medical management and arthroscopic examination of the stifle joint was performed under general anaesthesia. Following surgery, the lameness and swelling worsened and extremity compartment syndrome was suspected. A multimodal analgesia protocol was instigated to provide adequate analgesia and improved mobility, aiding the use of physical therapy in resolving the swelling. This report demonstrates the successful combination of nonsteroidal anti‐inflammatories, paracetamol, ketamine infusion and epidural opioid administration to manage the clinical signs. The mare was discharged from hospital after 15 days and at short‐term follow‐up (3 months), there was no reported residual swelling or lameness.

Update in advances in pain management for the equine practitioner

“…The case report by Bruniges et al . (), and the accompanying clinical commentary (van Loon ) illustrate both ‘new ways to use old drugs’, and also introduce some ‘newer’ drugs.…”

“…Ketamine should not be used as a sole analgesic but is most effective as part of a multimodal analgesic plan, particularly where the pain is thought to have a neuropathic component e.g. laminitis (Guedes et al 2012;Bruniges et al 2019 both 'new ways to use old drugs', and also introduce some 'newer' drugs.…”

“…Four articles published in this issue of EVE demonstrate recent advances in equine pain management; they also highlight some issues around these developments (Bruniges et al . ; Hopster and van Eps ; McFadzean and Love ; van Loon ). This editorial aims to summarise these advances and enlarge on the practical implications for the equine clinician.…”

“…These equine advances fall into three categories: increasing evidence of the benefits of multimodal analgesia (Bruniges et al . ; Hopster and van Eps ; van Loon ), the use of ‘new’ analgesic agents (Bruniges et al . ; Hopster and van Eps ; McFadzean and Love ; van Loon ) and the development of pain scoring systems (Hopster and van Eps ; McFadzean and Love ; van Loon ).…”

Multimodal analgesia, a fashionable term or evidence‐based medicine?

“…Bruniges et al . () present a horse with suspected extremity compartment syndrome in the pelvic limb and the use of a multimodal analgesic protocol in the current issue of Equine Veterinary Education. They describe the combination of nonsteroidal anti‐inflammatory drugs (phenylbutazone) with constant rate infusion (CRI) of ketamine, epidurally applied morphine and methadone and orally administered paracetamol.…”