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Difficulty with pain meds post amputation
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22 December 2018 - 8:13 pm
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I was hoping for some advice/reassurance for my 5 year old staffy cross (‘Jynx’), now 10 days post right forelimb amputation for osteosarcoma of the distal radius. I am having some trouble with her pain meds, and may need to end up seeing a pain specialist, but her surgical team is away for 2 weeks over Christmas, and so we only have the emergency vets to help for the time being.

I am a human doctor (paediatrics) and caught in that horrible place of a little knowledge is a dangerous thing. I visited her local vet 4 times before she was finally diagnosed, as I felt something was up, but she is normally a stoic dog that was still doing zoomies despite a sizeable tumour in her leg – so I am now a fairly anxious dog mum on very little sleep, and need some objective opinions and advice from those that have been through a similar situation! I know some of my concerns only a vet will likely be able to address, but thought it was worth an ask, as I am panicking.

Jynx had her amputation Thurs 13 Dec and came home day 1 post-op, and was doing suprisingly well for the first few days – she is about 24kg and discharged home only on the anti-inflammatory carprofen 50mg twice daily. I was having to encourage her to rest, and restrict her from mobilising too much.

A few days in she developed lots of swelling, and then pain, and was having trouble mobilising. We saw the surgical team day 4 post-op Mon 17 Dec, and of course the adrenaline rush meant she was then mobilising okay and even jumped up onto her hindlimbs to give the surgeon a hug! So they were not concerned and sent us home with a pressure bandage, gabapentin 200mg twice daily, and tramadol 75mg 2-3 times a day as required.

She was quite sedated on the gabapentin and tramadol, still eating during her alert periods although appeared depressed, but I had increasing difficulty getting her outside to the toilet, and she ended up wetting the bed a few times as she was unable to get up. There were some occasions where I wasn’t sure if she was in pain or having med side effects (panting, trembling, tail always between legs etc). However, she was oversedated despite us withholding the tramadol for a day, and so I called the surgical team Wed 19 Dec and they advised ceasing all meds, and only giving a lower dose of tramadol the next day if I needed to.

Of course by the next day Thurs 20 Dec she was yelping in pain, and I added the tramadol back at 50mg 3 times that day which she tolerated well, as well as carprofen 50mg in the morning. By that night she was still in pain, so we ended up presenting to the emergency vet (same centre as her surgeon and oncologist) and again she was then mobilising fine, appeared pain free and looking good. They appreciated that the dog they were seeing at the vet was NOT the same dog I had at home, so they gave her a subcutaneous injection of buprenorphine and sent us home again, as we had a surgical review in the morning.

After the buprenorphine she slept a few hours at home, then I got up in the morning to get her outside for the toilet and she appeared to be a little confused as she RAN outside like she still had 4 legs – I got her back in, and she stood there trembling, tail between legs and cried for the next 3 hours straight. 

By the time we saw the surgical team later that morning she had settled, easily got up the few steps into the building, and appeared to have tenderness at the surgical site, but nil other concerns (other than her being anxious, which she always is at the vet). The surgeon gave me a bit of a talk about Jynx and I feeding off each other’s anxiety, and I do appreciate his comment that I am ‘chasing shadows’. He sent us home with tramadol 50-75mg 2-3 times a day, as well as diazepam 5-10mg as required.

She was wonderful for the remainder of the day, only appearing to be in pain in the afternoon, so I perhaps stupidly gave her both tramadol and diazepam at the same time, and then was subjected to hours of crying and agitation. She eventually slept during the night but woke up yesterday Sat 22 Dec in significant pain, not even able to stand up to greet my mother and niece who she loves. 

She had only tramadol and carprofen yesterday, and was sedated but still uncomfortable. She managed a few mins at the local park (on leash) and appeared to perk up, and mobilised well. She also jumped into the ute before I could stop her (honestly, I have been restricting her movement but she is sneaky with wanting to be her usual athletic self – and seems depressed if I don’t get her out and sniffing for a few minutes). 

As she tolerated the tramadol and carprofen well, I eventually gave her a half dose of gabapentin (100mg) late last night and this morning. She is sedated but nothing like on the 200mg dose when I was having to check she was still breathing. However, she is now agitated and whimpering which I feel is medication-related rather than pain, as she is doing silly things like trying to slide under the dining room chairs on her tummy. 

So I don’t know what to do anymore. She starts chemo tomorrow as they don’t feel she is unwell, but I was hoping she would be more comfortable and stable on pain meds by now (or not needing them anymore!).

I’m sorry for such a long post, but I wanted all the details to be there. I appreciate any reassurance/advice anyone can give. In summary:

– I am surprised she tolerates the tramadol, as this is the med I thought dogs seem to have the most trouble with?

– I really would like her to tolerate the gabapentin, as I feel this is better for her pain than the tramadol, especially if she is having issues with neuropathic pain, or needs something long-term. Should I persist, and see if the side effects settle?

– I am concerned that she seems to not tolerate so many medications in terms of her being distressed (whether it is nausea, anxiety, confusion, or other) – gabapentin, buprenorphine and diazepam. I feel other options like fentanyl patches are not going to be any different.

– I am also concerned that she has progressive difficulty with her right hindlimb and she is trying to mobilise on just her 2 left legs which is not possible (I understand she needs to adapt to a different gait, and new muscle/joint strain, but this seems to be getting worse despite minimal mobilising) – I can’t localise an area where it is sore, but does have some new ‘clickyness’ in the joints in that leg.

– She has been on the carprofen for almost 3 weeks now (with a few days off in those weeks) – how long can she continue this without having gastrointestinal/renal side effects? I can hear her tummy gurgling, and she did having some raised creatinine pre-op which they think was dehydration-related, but it does concern me with all her meds.

– I am worried her pain doesn’t seem to be improving 10 days post-op, despite her looking fine whenever we are at the vet.

Livermore, CA
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22 December 2018 - 10:34 pm
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Hello and welcome.

I’m sorry you are on such a roller coaster with Jinx! 

My initial (non-vet) take is that the inconsistency with pain meds is a problem.  And the fact that they sent you home right after surgery without pain meds is not acceptable.  A major surgery like an amputation without pain meds? Once the pain gets a hold it is much harder to get it back under control and keep it under control.  It also sounds like she might be a bit too active.  Our surgeon told us that only short, leashed potty breaks for the first two weeks post surgery.

I know you are doing your best- I’m not criticizing you or your care of Jinx. You are following instructions the best you can- it’s just that to me the instructions are not great.  You did a good job getting her back in and getting pain meds.

My Pug Maggie did not handle tramadol well- after one dose once she didn’t sleep for 12 hours. And here in the US (sounds like you are in the UK?) there is some discussion about how effective tramadol is.  My experience with it in my quad Pug Obie’s two knee surgeries was that it worked fine and he tolerated it without side effects. 

My quad Pug Tani took carprofen for a couple years to help with her arthritis without any issues.

With gabapentin some have seen it be more effective when started at a lower dose then increase.  When I first started it with Tani (again for arthritis)  there was some sedation but that resolved after time.

Are you giving all the meds at one time?  It might help to give the tramadol and gabapentin at different times to there is always something in her system.  Most pups here are on pain meds for at least two weeks post op, some go into week three.

You might also try some massage for Jynx- you are right that she has to get used to her new gait, and she will need to build strength and endurance again.  Here are some blog posts on massage.

Hang in there!  You are doing your best and are being a good advocate for your girl.  Keep after the vets to get her pain managed and if you have to see another vet.  If you don’t feel comfortable starting chemo then ask for a week or two delay.  While the majority of dogs don’t have any side effects from chemo you do want to have confidence that your girl is ready.

Also- please consider registering as a member.  That way you can take advantage of everything on this site and your posts won’t have to wait to be approved.

Karen and the Spirit Pug Girls

Tri-pug Maggie survived a 4.5 year mast cell cancer battle only to be lost to oral melanoma.

1999 to 2010

 

              Maggie's Story                  Amputation and Chemo

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22 December 2018 - 11:19 pm
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Thank you for your reply and advice. I’m in Australia so some of the names/terms I’ve used may be different!

I agree that inconsistency with her pain meds has been a problem. She seems settled and sleeping now after having 100mg gabapentin 6 hours ago and spending an hour or so agitated, so my feeling is to try that again this evening with her carprofen and only add the tramadol if she still seems uncomfortable and not too sedated. I had heard about tramadol perhaps not being effective for pain by itself for dogs, so although she tolerates that far better than the gabapentin, I am keen to try and get her on the gabapentin if possible (which is why we are trying the 100mg rather than 200mg doses initially).

She was initially discharged with carprofen for pain but nothing else – it is reassuring to hear that she can probably remain on this for more than a few weeks though. And reassuring that the sedation (and perhaps other side effects) of gabapentin may settle. I haven’t really given her tramadol and gabapentin at the same time due to the oversedation she had with the 200mg gabapentin.

In terms of her mobilising too much, this is probably the case, but I think my post makes it sound like she is mobilising more than she actually is (she spends the vast majority of the time sedated and sleeping, or agitated and crying). There have been just a couple of occasions where she unfortunately has suddenly decided to jump or run unexpectedly, but generally she has only been allowed out for toilet breaks or in/out for vet visits. (Letting her sniff at the local park has been for toilet stops on the way to the vet, and we’ve only been just outside the car for a few mins).

I’ve been massaging her remaining limbs, and contacted a vet rehab to see when we can get her in for some more formal treatment. (Thank you for the link to blog posts).

I am keen to go ahead with chemo tomorrow anyway, but had just hoped we’d be in a better place with pain and meds by now.

Here and Now

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23 December 2018 - 11:37 am
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becandjynx said
just hoped we’d be in a better place with pain and meds by now…

Welcome and best wishes for Jynx! Don’t miss the many helpful pain management articles, podcasts and video interviews in the Tripawds News blog .

While you wait for comments from others, use the Advanced Search above to refine your forum search results with specific phrases, and you’re sure to find lots of helpful feedback. You can also search all blogs here . Or, consider downloading the Tripawds e-books for fast answers to common concerns.

Please keep us posted. Your future forum posts will not require moderation. Meanwhile, start here for help finding all the helpful Tripawds resources and assistance programs.

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23 December 2018 - 9:09 pm
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You’ve gotten good insight  from Karen and you are doing an excellent job of advocating  for Jinx.

The inconsistency  with the pain meds, as well as the Surgeon not sending you home with proper pain management , gave her a pretty shaky start.  And it is hard to distinguish  between pain symp6 and meds sone effects.  Regardless though, it is important to keep the pain managed.   And it does take some tweaking to find the right balance for each  individual  dog.

And absolutely,  we see  a bit more delay in the chemo until the dogs are stronger quite often.  My Happy Hannah waited three weeks as I didn’t  feel like she was in a good enough place to take that on.  She sailed through all four treatments. .  Had she  done it at the two week mark  (and you’re talking the eleven day mark), I don’t know if she would have handled it so well.  Of course, whatever you decide with your Onco is the right choice for Jinx.  

And good for you for getting  a Rehab Specialist  to assess her.  They are so good at identifying  issues and how to correct them. 

It is still VERY early on recovering  from MAJOR surgery, all while adjusting not three legs.   Hopefully  you can get  the pain meds sorted out, as well as when it’s best to start the chemo.

Ipdate is when you can.  And try and get some rest yourself!  Recover6nis exhausting  fot hoomans as well as the furbabies!

Extra higs

Sally and Alumni Happy Hannah and Merry Myrtle and Frankie too!

Happy Hannah had a glorious additional bonus time of over one yr & two months after amp for osteo! She made me laugh everyday! Joined April's Angels after send off meal of steak, ice cream, M&Ms & deer poop!

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23 December 2018 - 11:41 pm
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Thank you all. That is an excellent point about it being harder to get on top of pain that is already there than to prevent it in the first place, and something I had forgotten in my sleep-deprived panic!

I am surprised she wasn’t discharged on appropriate pain relief from the start, especially given she attends a specialist veterinary hospital. Her pre-op surgeon had mentioned there would be other drugs on discharge, but it was a different surgeon actually performing the surgery and on the day of discharge. I thought it was odd at the time, but assumed she must have been given sufficient intraop meds if they weren’t sending her home in anything other than carprofen, so I didn’t question it (silly me).

There was an unexpected screaming episode lasting 10-15 seconds which freaked us both out last night. She was stepping onto her bed and seemed reluctant, so I went to push her butt a bit as I thought she was too drowsy, and she started screaming (I was nowhere near her surgical site or moving her in any way that would normally cause her pain). Afterwards she was fine and I couldn’t reproduce the pain by moving her, and her surgical site was non-tender. I searched the forums, and I’m now wondering if this was nerve/phantom pain that others have mentioned. I think I really need to push the gabapentin despite her alternating between heavily sedated/depressed and agitated/confused.

I’m of course still panicking about something else going on, given I had 4 visits to the vet with me insisting therecwas something wrong before she was eventually diagnosed.

We went ahead with chemo today, but I begged them to do everything they could to prevent nausea as I didn’t need another issue affecting her recovery (I’m about to pick her up).

The oncology nurse asked about her appetite and I had said she needed me to hand feed her last night and this morning, although it could be that she is so sedated (she’s previously been keen to get up for food despite her pain). He suggested that o needed to find that happy place between pain management and not being so sedated that she isn’t keen on eating. But she still had her tail between her legs from the moment she stands to the moment she lies down again, so clearly she is uncomfortable, and I don’t see how I can back off on the meds at all.

However, I gave her tramadol 50mg at 4am and then gabapentin 100mg and carprofen 50mg at 6am with her breakfast… she would normally be agitated about 2 hours post gabapentin but slept through today. Whether that is because I gave her tramadol beforehand or she is starting to tolerate the gabapentin better I’m not sure, but was nice to see!

The aim is to give her 3 doses of 100mg gabapentin today and see how she goes.

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24 December 2018 - 8:34 am
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It is really good to see that you are working so hard on Jynx pain medication plan. Many have to space out the meds just the right way to get positive effects and it is tricky sometimes. 

Huckleberry is a cat, but it took several doses and consistency before he stopped getting sleepy and acting like he was “drugged”. After the first week, I gave him his meds and he continued to act like himself. Of course, lots of sleep right now is important to the healing process so I would not be concerned with that. 

The drugs can also get them a little off in the appetite department. This is usually the time that we do whatever we can to keep them eating and drinking. Scrambled eggs, hamburger, rotisserie chicken either added to the food or given by itself usually helps to keep them eating.

I hope she did ok with her first chemo. Hang in there, you are doing a great job of advocating for your girl. 

Jackie and Huckleberry heart

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Jackie, David, Mitchell, Andy Oscar, and the coolest feral tripawd kitty Huckleberry

http://paws120......pawds.com/

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24 December 2018 - 9:10 pm
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And ditto Jackie!!  And try to get her to eat anything at this point!  

Since she was off appetite before chemo, did the Onco give you any Cerenia  in case she gets nauseous?   

Really hoping things start to get better for you.  It’s so hard to be patient,  but just remember, recovery  doesn’t  last furever…just seems like it!

Hugs

Sally and Alumni Happy Hannah and Merry Myrtle and Frankie too!

Happy Hannah had a glorious additional bonus time of over one yr & two months after amp for osteo! She made me laugh everyday! Joined April's Angels after send off meal of steak, ice cream, M&Ms & deer poop!

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24 December 2018 - 10:06 pm
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She has had a good morning post her first chemo – we spent Christmas Eve night and a Christmas morning at my sisters, and whether or not it was the new environment, she seemed far more settled and happier. Stood up and wagged her tail when she heard a knock at the door which was great to see!

Less sedated despite increased number of doses of gabapentin yesterday (now having 100mg every 8 hours), and her tail isn’t permanently in between her legs! Still had the odd whimper/yelp, but her right hindlimb seems to be causing her the most discomfort at the moment (this is getting worse and worse). The vet yesterday was great, and really made me feel like he took my concerns seriously. He advised a second opinion if her pain control was still an issue after Christmas, and re-examined her – he felt she has arthritis in her hindlimbs.

Her appetite is changed – doesn’t want her usual food, but happy to eat some lean pork and a sausage, so I’m happy with that for now. And didn’t have to be hand fed. Back to drinking some water, although I have made her some chicken broth too. Keeping up with her anti-nausea drugs!

She’s now having a sleep post Christmas morning excitement. Thank you all for your wonderful support. 🙂

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25 December 2018 - 6:51 am
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That is great news! Eating and drinking, taking meds and alert, YAY! Hopefully she can rest that sore leg, if it is arthritic and she is getting used to a different gait it could def be putting a different strain on it. 

Merry Christmas!

Jackie and Huck 💖

Hugs,

Jackie, David, Mitchell, Andy Oscar, and the coolest feral tripawd kitty Huckleberry

http://paws120......pawds.com/

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25 December 2018 - 7:55 am
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So happy to read this…tail wags and all!!!😁😀   

It is amazing  how a change of scenery can lift the spirits of dogs (and hoomans too)!! The recovery  routine can be stressful for both of you.

Yeah, sometimes an arthritic leg isn’t  as noticeable on four.  Now that she’s  using it to help support three, it’s  feeling it a bit more.  You can ask about Dasuquin,  Adequan injections, Rimadyl  and other options for helping  arthritis.   For now, sloooow and easy as her muscles adjust.  A Rehab Specialist  can help too.

Thanks for sharing the great news!  She’s  a RockStar!!!

Hugs

Sally and Alumni Happy Hannah and Merry Myrtle and Frankie too!

Happy Hannah had a glorious additional bonus time of over one yr & two months after amp for osteo! She made me laugh everyday! Joined April's Angels after send off meal of steak, ice cream, M&Ms & deer poop!

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25 December 2018 - 3:48 pm
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I’m so happy to hear that you all had a good pawliday and she’s engaging and getting some sparkle back. She’s got a strong appetite? And alert to visitors? Sounds pretty good to me!

And that’s really cool that the vet is encouraging another look at her pain issues if she doesn’t seem more at ease. We hope you don’t need to go see another vet but do keep us posted if you need to.

Pretty good progress considering where she started, so yey! Hoppy holidays to you both!

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25 December 2018 - 9:06 pm
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Day 13 post op today. I’m cautiously optimistic (she did well before and then declined) – but I really think it’s the gabapentin that’s made the difference! I’m glad I pushed through with it despite the side effects.

She’s still lethargic, fussy with food (though happy to eat if I find something she likes and bring it to her), occasionally in pain with a yelp first thing in morning and odd tail tuck, and walking VERY stiffly, but is worlds better than a few days ago! And is day 2 post chemo, so is probably also feeling a bit off because of that anyway.

Showing some interest in what’s going on around her (sniffing etc). And I’ve removed 10 of her 14 stitches – thank goodness the surgeon was happy for me to do that myself at home. The wound itself looks great, and I’m gently massaging the area as she has been getting muscle spasms.

Back to work for me tomorrow, so will trial her at home alone today. 😬

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25 December 2018 - 9:22 pm
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You’re doing a great job of monitoring  every little improvement (ie HUGE improvement) and tracking when she has those yelps.  

Keep trying  any yummy food she’ll eat, yeah, even if it means hand feeding!  She has you well trained!.  And yeah, hard to say if the lethargy is from chemo  since she was that way before.  But seeing her being  engaged and alert….YAAAAAAAAY!!!

Give her a big smooch for us!  And YAY for stitch  removal…or at least almost!

Hugs

Sally and Alumni Happy Hannah and Merry Myrtle and Frankie too!

Happy Hannah had a glorious additional bonus time of over one yr & two months after amp for osteo! She made me laugh everyday! Joined April's Angels after send off meal of steak, ice cream, M&Ms & deer poop!

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25 December 2018 - 10:40 pm
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You’re a real rock star! I love how you are monitoring her so closely and keeping watch. Great job! Hopefully the appetite issues will subside this week.

I hope your first day back at work is uneventful and she does well. Bet she’ll be sleeping all day 🙂 Keep us posted.

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