Preoperative protocol for right flank laparotomy affects postoperative serum cortisol concentrations in dairy cows

Ayano Sato Division of Farm Animal Clinical Sciences, Rakuno Gakuen University, Ebetsu, Japan

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Tomochika Sugiura Division of Farm Animal Clinical Sciences, Rakuno Gakuen University, Ebetsu, Japan

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Keigo Kosenda Division of Farm Animal Clinical Sciences, Rakuno Gakuen University, Ebetsu, Japan

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Takashi Murakami Division of Farm Animal Clinical Sciences, Rakuno Gakuen University, Ebetsu, Japan

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Abstract

OBJECTIVE

To evaluate analgesic efficacy of 3 different preoperative protocols in cows undergoing right flank laparotomy for displaced abomasum.

ANIMALS

40 cows diagnosed with displaced abomasum.

PROCEDURES

The cows were assigned by block randomization to 1 of 3 preoperative protocols: inverted L-block using 50 mL of 2% lidocaine (ILB; n = 13), ILB plus preoperative flunixin meglumine (2 mg/kg, IV; ILB-F; 13), and dorsolumbar epidural anesthesia using 2% xylazine (0.8 mL) and 2% lidocaine (4 mL; EPI; 14). Venous blood samples were collected for CBC, serum biochemistry, and cortisol preoperatively and at 0 (immediately after), 3, 17, and 48 hours postoperatively.

RESULTS

The mean (95% CI) of the serum cortisol in ILB, ILB-F, and EPI were 108.7 (66.7 to 150.7), 150.7 (116.4 to 185.0), and 139.8 (93.4 to 186.3), respectively. The serum cortisol concentrations decreased over time in all groups (ILB, P = .001; ILB-F and EPI, P < .001). In the ILB group, the cortisol concentration at 17 and 48 hours postoperatively decreased (P = .026 and P = .009, respectively), compared with that preoperatively. In the ILB-F and EPI groups, the preoperative cortisol concentration was the highest and then decreased at 0, 3, 17, and 48 hours postoperatively (ILB-F, 0 hours [P = .001] and 3, 17, and 48 hours [P < .001]; EPI, all [P < .001]).

CLINICAL RELEVANCE

ILB-F and EPI improved intraoperative and immediate postoperative indicators of pain-related stress when compared to standard ILB. EPI requires less anesthetic, which may be beneficial when in short supply.

Abstract

OBJECTIVE

To evaluate analgesic efficacy of 3 different preoperative protocols in cows undergoing right flank laparotomy for displaced abomasum.

ANIMALS

40 cows diagnosed with displaced abomasum.

PROCEDURES

The cows were assigned by block randomization to 1 of 3 preoperative protocols: inverted L-block using 50 mL of 2% lidocaine (ILB; n = 13), ILB plus preoperative flunixin meglumine (2 mg/kg, IV; ILB-F; 13), and dorsolumbar epidural anesthesia using 2% xylazine (0.8 mL) and 2% lidocaine (4 mL; EPI; 14). Venous blood samples were collected for CBC, serum biochemistry, and cortisol preoperatively and at 0 (immediately after), 3, 17, and 48 hours postoperatively.

RESULTS

The mean (95% CI) of the serum cortisol in ILB, ILB-F, and EPI were 108.7 (66.7 to 150.7), 150.7 (116.4 to 185.0), and 139.8 (93.4 to 186.3), respectively. The serum cortisol concentrations decreased over time in all groups (ILB, P = .001; ILB-F and EPI, P < .001). In the ILB group, the cortisol concentration at 17 and 48 hours postoperatively decreased (P = .026 and P = .009, respectively), compared with that preoperatively. In the ILB-F and EPI groups, the preoperative cortisol concentration was the highest and then decreased at 0, 3, 17, and 48 hours postoperatively (ILB-F, 0 hours [P = .001] and 3, 17, and 48 hours [P < .001]; EPI, all [P < .001]).

CLINICAL RELEVANCE

ILB-F and EPI improved intraoperative and immediate postoperative indicators of pain-related stress when compared to standard ILB. EPI requires less anesthetic, which may be beneficial when in short supply.

Introduction

Several techniques for anesthesia of the paralumbar fossa, including proximal paravertebral nerve block, distal paravertebral nerve block, inverted L-block (ILB), and infusion of the incision or line block, can be achieved for laparotomy in adult cows.1 These anesthetic techniques are commonly used in laparotomy, such as omentopexy, abomasopexy, rumenotomy, and cesarean section. To minimize surgical pain, sedatives, tranquilizers, narcotics, anesthetics, and the strategic use of NSAIDs are recommended.2

In the castration of calves, preoperative administration of NSAIDs and local anesthesia significantly decreases the peak serum cortisol concentration after the procedure.3 In the dehorning of calves, the use of local anesthetics, NSAIDs, and sedation has mitigated acute pain following dehorning.4,5 Cortisol concentration is an important index in pain management,3,6 but few studies have measured it for evaluating presurgical treatment, including anesthesia and preoperative analgesia, for laparotomy in adult cows.

This study aimed to evaluate the analgesic efficacy of ILB with preoperative flunixin meglumine and dorsolumbar epidural anesthesia compared to standard ILB in cows undergoing omentopexy for displaced abomasum (DA). Blood samples were collected from cows to evaluate operative stress by measuring the serum cortisol concentrations pre- and postoperatively in the 3 groups.

Materials and Methods

The study protocol was approved by the Animal Research Committee of Rakuno Gakuen University (approval No. VH18C3). Cows diagnosed with left or right DA by farm veterinarians were transported via livestock cars from the farms to the Rakuno Gakuen University Animal Medical Center (AMC). The distance from each farm to the AMC was < 35 km, and the travel time was 5 to 40 minutes. A total of 40 female Holstein dairy cows (body weight, 622.6 ± 74.6 kg; body condition score, 2.89 ± 0.24; and day in milk, 63.4 [range, 2 to 292]) were included in this study. Cows with abomasal volvulus and abomasal ulcers at the preoperative clinical examination or during surgery were excluded from the analysis. The cows were divided by block randomization into the following 3 groups: the ILB group (n = 13), ILB with preoperative IV injection of flunixin meglumine as NSAID (ILB-F) group (13), and dorsolumbar epidural anesthesia (EPI) group (14).

ILB anesthesia was administered as previously described.1 An 18-gauge, 1.5-inch needle was used to inject up to 50 mL of 2% lidocaine in multiple small injection sites into the tissues bordering the dorsocaudal aspect of the thirteenth rib and ventrolateral aspect of the transverse processes of the lumbar vertebrae. Dorsolumbar epidural anesthesia was induced as described previously.7,8 A 16-gauge disposable epidural needle (Hakko Medical Inc), which was 12 mm in length, was slowly inserted into the T13–L1 or L1–2 intervertebral space using the dorsal midline approach after skin hair clipping (Figure 1). Entrance into the epidural space was identified using the hanging drop technique. For the EPI group, the anesthetic consisted of 0.8 mL of 2% xylazine and 4 mL of 2% lidocaine. The needle bevel was directed to the right laterocranial side, and the anesthetic was administered very slowly. The needle was removed after administration.

Figure 1
Figure 1

Illustration of standard methods for dorsolumbar epidural anesthesia (EPI) in cows. A 16-gauge epidural needle, which was 12 mm in length, was slowly inserted into the T13–L1 (black arrow) or L1–2 (white arrow) intervertebral space using the dorsal midline approach. Entrance into the epidural space was identified using the hanging drop technique. The protocol was performed as previously reported.7,8 AM = Arachnoid membrane. DM = Dura mater. ES = Epidural space. S = Spinal.

Citation: Journal of the American Veterinary Medical Association 261, 9; 10.2460/javma.23.02.0062

EPI and ILB were administered 20 minutes before surgery, and the ILB-F group was injected IV with 2 mg/kg flunixin meglumine (Flunixin-chu) 15 minutes preoperatively. The mean time from arrival at the AMC to the start of surgery was 92.6 minutes. Either of the 2 experienced surgeons performed the standing right paralumbar fossa omentopexy,9,10 and the mean ± SD operative time was 50.9 ± 15.5 minutes. Abnormal intraoperative behavior data were documented in the medical chart. Postoperatively, the cows were admitted to the AMC’s single housing pen, which was 3.3 X 3.8 m so that 1 adult cow could walk free, for 18 to 24 hours before being returned to their respective farms.

Rectal temperature, pulse rate, and respiratory rate were checked preoperatively and 0 (immediately), 3, 17, and 48 hours postoperatively. Blood samples (10 or 20 mL) were collected from the jugular or caudal tail vein preoperatively and 0, 3, 17, and 48 hours postoperatively in EDTA and plain tubes. The samples collected in EDTA tubes were immediately subjected to CBC analysis using a multiparameter automated hematology analyzer for animals (pocH-100iV Diff; Sysmex Corp). Preoperative sera were measured using a clinical chemistry analyzer (Fuji Dry Chem NX500; Fujifilm) for glucose, sodium, potassium, chloride, calcium, phosphorus, magnesium, total bilirubin, glutamate-oxaloacetate transaminase, GGT, total protein, and albumin by the Daiichi Kishimoto Clinical Laboratories for nonesterified fatty acids and β-hydroxybutyric acid (Supplementary Table S1). All serum samples were frozen at −30 °C prior to the cortisol assay.

Serum cortisol was analyzed using a commercially available cortisol kit (Cortisol Enzyme Immunoassay Kit; Arbor Assays Inc) according to the manufacturer’s protocols. The serum cortisol concentrations were determined from the concentration versus absorbance relationship of the standard cortisol concentration (13.8 to 882.9 nmol/L). Assay samples below this threshold were denoted as 13.8 nmol/L. The intra- and interassay coefficients of variation were 5.7% and 6.9%, respectively.

The Kruskal-Wallis test was employed to compare the preoperative blood samples among the 3 groups. Rectal temperature, pulse rate, and respiratory rate were compared with time for each preoperative treatment at 0 hours, preoperatively, and 3, 17, and 48 hours postoperatively by the Friedman test followed by the corrected Bonferroni method. The Kruskal-Wallis test was employed to compare among the 3 groups. To evaluate whether the cortisol concentrations were variable with time, the variables were evaluated using a mixed-model ANOVA for repeated measures. The Bonferroni method was used as a post hoc test for cortisol concentrations at 0, 3, 17, and 48 hours postoperatively, which were significantly variable from the preoperative values. The area under the curve (AUC) with respect to the ground was examined to determine the magnitude and severity of the cortisol response to treatment over the 48-hour period postoperatively.11 AUC was calculated using the linear trapezoidal method for the following time intervals: preoperatively to 48 hours postoperatively, preoperatively to 0 hours postoperatively, preoperatively to 3 hours postoperatively, preoperatively to 17 hours postoperatively, and 0 to 3 hours postoperatively. The time from preoperatively to 0 hours was set to 1 hour to take the elapsed time into account. Statistical analysis was conducted using SPSS (version 27; IBM Corp), and a P value < .05 was considered statistically significant. Data are expressed as the mean and lower and upper limits of 95% CIs.

Results

All 40 cows underwent standing right paralumbar fossa omentopexy and did not have abomasal volvulus or ulcers; thus, they were all included in the study. None of the blood variables exhibited a significant difference preoperatively among the 3 groups.

Rectal temperatures changed over time in the ILB-F and EPI groups (both, P = .001; Figure 2). At 17 hours postoperatively in the ILB-F and EPI groups, they were lower than at 0 hours postoperatively (ILB-F, P = .032; EPI, P = .008). None of the pulse rates exhibited a significant difference compared to 0 hours postoperatively. Respiratory rates changed over time in all groups (ILB, P = .001; ILB-F, P = .014; ILB, P = .029; Figure 3). In the ILB group, the variables at 3 and 48 hours were lower than the variable at 0 hours postoperatively (3 hours, P = .015; 48 hours, P = .008). The rectal temperature, pulse rate, and respiratory rate did not exhibit significant differences at any points among the 3 groups.

Figure 2
Figure 2

Box plot of variations in rectal temperature of inverted L-block anesthesia (ILB; A), ILB with flunixin preoperative analgesia (ILB-F; B), and EPI (C). Boxes indicate IQRs, the middle line indicates the median value, and crosses indicate the mean value. A—No significant differences were observed to compare with the rectal temperature at 0 hours postoperatively. B—The rectal temperatures at 17 hours postoperatively decreased compared with the rectal temperatures at 0 hours postoperatively (P = .032). C—The rectal temperatures at 17 hours postoperatively decreased compared with the rectal temperatures at 0 hours postoperatively (P = .008). *P < .05. **P < .001.

Citation: Journal of the American Veterinary Medical Association 261, 9; 10.2460/javma.23.02.0062

Figure 3
Figure 3

Box plot of variations in respiratory rate of ILB (A), ILB-F (B), and EPI (C). Boxes indicate IQRs, the middle line indicates the median value, and crosses indicate the mean value. A—The rectal temperatures at 3 and 48 hours postoperatively decreased compared with the rectal temperatures at 0 hours postoperatively (3 hours, P = .015; 48 hours, P = .008). B and C—No significant differences were observed to compare with the rectal temperature 0 hours postoperatively. *P < .05 **P < .001.

Citation: Journal of the American Veterinary Medical Association 261, 9; 10.2460/javma.23.02.0062

The serum cortisol concentrations (nmol/L) changed over time in all groups (ILB, P = .001; ILB-F and EPI, P < .001; Figure 4). The mean preoperative cortisol concentration in the ILB group was 108.7 (66.7 to 150.7). At 0 hours postoperatively, it was the highest at 118.6 (64.2 to 172.9; P = 1.000) and at 3 hours, 80.1 (38.5 to 121.8; P = .388). However, at 17 and 48 hours, the mean cortisol concentrations decreased to 60.7 (35.6 to 85.8; P = .026) and 54.3 (40.0 to 68.8; P = .009), respectively. In the ILB-F group, the mean preoperative cortisol concentration was the highest at 150.7 (116.4 to 185.0) and then decreased to 93.2 (56.0 to 130.4; P = .001) at 0 hours, 52.7 (35.1 to 70.4; P < .001) at 3 hours, 46.1 (30.7 to 61.5; P < .001) at 17 hours, and 50.3 (32.6 to 68.0; P < .001) at 48 hours postoperatively. In the EPI group, the mean preoperative cortisol concentration was the highest at 139.8 (93.4 to 186.3), and it decreased to 83.4 (63.1 to 103.7; P < .001) at 0 hours, 63.8 (51.3 to 76.3; P < .001) at 3 hours, 54.0 (39.0 to 69.0; P < .001) at 17 hours, and 58.7 (37.5 to 79.9; P < .001) at 48 hours postoperatively.

Figure 4
Figure 4

Variations in serum cortisol concentration of ILB (A), ILB-F (B), and EPI (C). The thick black line indicates the mean values of each group, whiskers indicate the 95% CI, and blue lines indicate the actual measurements of individual cows. A—The cortisol concentrations at 17 and 48 hours postoperatively decreased (P = .026 and P = .009, respectively) compared with the preoperative cortisol concentrations. B—The cortisol concentrations at 0, 3, 17, and 48 hours postoperatively decreased compared with the preoperative cortisol concentrations (0 hours, P = .001; 3, 17, and 48 hours, P < .001). C—The cortisol concentrations at 0, 3, 17, and 48 hours postoperatively decreased compared with the preoperative cortisol concentrations (all, P < .001). The shaded area indicates the normal cortisol concentration range of cattle. *P < .05. **P < .001.

Citation: Journal of the American Veterinary Medical Association 261, 9; 10.2460/javma.23.02.0062

None of the AUCs in all classifications exhibited a significant difference among the 3 groups (Table 1).

Table 1

Results of area under the curve (AUC; nmol/L per mean ± standard error of the mean [SEM]) for the serum cortisol of the 3 groups: inverted L-block anesthesia group (ILB; n = 13); ILB with preoperative IV injection of flunixin group (ILB-F; 13); and dorsolumbar epidural anesthesia group (EPI; 14).

AUC ILB ILB-F EPI P value
Mean SEM Mean SEM Mean SEM
AUCpre-48h 3,180.1 511.4 2,526.9 253.7 2,904.4 321.1 .483
AUCpre-0h 113.6 19.3 122.0 14.5 111.6 14.7 .893
AUCpre-3h 411.7 82.7 340.9 47.2 332.5 30.1 .562
AUCpre-17h 1397.5 273.2 1,033.0 121.7 1,157.3 100.9 .361
AUC0h-3h 298.1 65.2 219.0 33.3 220.9 17.0 .339

No significant differences were observed between the 3 groups.

AUCpre–48h = AUC from preoperatively to 48 hours postoperatively. AUCpre–0h = AUC from preoperatively to 0 hours postoperatively. AUCpre–3h = AUC from preoperatively to 3 hours postoperatively. AUCpre–17h = AUC from preoperatively to 17 hours postoperatively. AUC0h–3h = AUC from 0 to 3 hours postoperatively.

Discussion

In this study, 40 Holstein dairy cows diagnosed with left or right DA were administered the following presurgical treatments: ILB, a simple local anesthesia; ILB-F, ILB with preoperative IV injection of NSAID; and EPI, a popular anesthesia for laparotomy of adult cows in Japan. Their serum cortisol concentrations were determined before and after performing standing right paralumbar fossa omentopexy. The results indicated significant decreases in the postoperative cortisol concentrations in all groups compared with the preoperative cortisol concentrations. Concretely, the cortisol concentrations of the ILB-F and EPI groups decreased from immediately (0 hours) to 48 hours postoperatively, whereas that of the ILB group decreased from 17 to 48 hours postoperatively. In addition, ILB-F and EPI decreased in rectal temperature at 17 hours, and ILB decreased in respiratory rate at 3 and 48 hours compared to immediately postoperatively. However, none of the rectal temperatures, pulse rates, and respiratory rates exhibited a significant difference among the 3 groups, nor the AUC for the cortisol concentration. In cattle, it was reported that dairy cows subjected to stress had increased cortisol concentrations.12 Cortisol concentration measurement was found to be a useful tool for pain and stress assessment.13,14 Surgeries cause varying degrees of pain or distress, which leads to distress in cattle.15 To summarize the results of this study, ILB-F and EPI showed equal anesthetic effects compared to ILB. However, the postoperative cortisol concentration in the ILB-F and EPI rapidly decreased compared to preoperative cortisol concentrations; thus, it was suggested that the surgical stresses were rapidly ameliorated. Regarding the reason for the delayed decrease in postoperative cortisol concentration in the ILB group, it was considered that respiratory rate at immediately after surgery in the ILB group was high, which might have been due to the severe pain associated with surgery. In previous studies on laparotomy in cattle, the plasma cortisol concentration was not reported, and studies on arthroscopic surgery or laparotomy in horses reported that the plasma cortisol concentration against baseline increased intraoperatively to 3 to 4 hours postoperatively and decreased at 6 to 24 hours postoperatively.16–18 Furthermore, because all 40 cows in this study were transported via livestock cars to the AMC for 40 minutes, they were considered to have already been stressed preoperatively due to not only the disease but also transportation. Some papers have reported that cortisol after a short trip (< 2 hours) in cattle shows a significant increase compared with pretrip levels,19 and other papers have reported that there is no significant difference between pre- and post-trip cortisol levels.20,21 The ILB-F and EPI groups had the highest preoperative mean cortisol concentrations throughout the observation period. It was difficult to rule out transportation as the reason for the high preoperative cortisol concentration; thus, we considered it one of the limitations of this study. However, all cows were transported back to their respective farms between 18 and 24 hours, and no increase in cortisol concentration was observed after 48 hours. Therefore, it was considered that the preoperative cortisol concentration strongly reflected the stress related to DA, whereas the postoperative cortisol concentration reflected the removal of the stress related to DA and postsurgical stress.

The effect of local analgesia with lidocaine starts within 15 minutes for both ILB and EPI and lasts for 60 to 90 minutes.7 No cow received additional anesthetics because almost all surgeries were performed within the effective period of the anesthetic. In the postoperative period, many cows, regardless of the group, exhibited swelling and heat at the surgical site, but the level of these symptoms was considered to be within the normal wound healing response. Although 1 cow from the ILB-F group had an infected surgical wound that required treatment later, no other problems were observed in the cows. The advantages of ILB are that it is simple to perform and does not induce gait disturbance.22 Its disadvantages include incomplete analgesia, muscle relaxation of the deeper layers of the abdominal wall, possible toxicity, and increased cost, as the technique requires larger doses.8 Lidocaine solution was used for the ILB and ILB-F groups in this study, and all 13 cows in the ILB group demonstrated intraoperative kicking and violent movement to varying degrees. Such behaviors are symptoms reflecting pain,15 which showed that the highest cortisol at 0 hours postoperatively in the ILB group occurred consequentially. In addition, this was also supported that the respiratory rate at 0 hours postoperatively in the ILB group was higher than that of the later variables. The advantages of dorsolumbar epidural anesthesia include the use of smaller amounts of sedatives, use of local anesthesia, and high efficacy of local anesthesia for standing right paralumbar fossa omentopexy.8 Some disadvantages reported include the requirement of some anesthetic experience, inability to insert the epidural needle into the intervertebral space in 12.5% to 17% of cows,1,3 and recumbency in some cattle before surgery.3 Due to the occurrence of recumbency from the previously reported doses, xylazine was reduced from 1 to 0.8 mL and lidocaine was changed from 3 to 4 mL. These changes were successful in preventing recumbency from interrupting the surgery while reducing intra- and postoperative pain. In the EPI group, some cattle demonstrated tottering steps intra- and immediately postoperatively; however, no cows had disorder in the hind limbs at 17 hours postsurgery. In Japan, there has been a shift from ILB to EPI for inducing anesthesia before laparotomy in adult cows. The results of this study were considered to support these changes.

In dogs23 and cats,24,25 preoperative pain management is more successful and optimizes animal well-being. Steroids and NSAIDs are available in clinical practice,26 and local anesthesia and NSAIDs can reduce edema, hematoma, and swelling at the surgical site.3,6 The reason for the decrease in cortisol concentration in the ILB-F group immediately after surgery (0 hours) was thought to be that the preoperatively administered flunixin reduced the pain associated with surgery. Therefore, ILB-F was considered effective in suppressing intra- and postoperative pain and the inflammatory response at the surgical site. The side effects of NSAIDs include an increased risk of abomasal ulcers and renal failure.4 The reason for choosing flunixin as the NSAID in this study was its widespread use in Japan. As flunixin was administered only once before surgery in the ILB-F group, no cow exhibited symptoms of abomasal ulcers postoperatively.

In conclusion, ILB with preoperative IV administration of flunixin and EPI was observed to have the analgesic efficacy equal to or greater than ILB and considered useful in reducing intra- and postoperative stress of omentopexy. This study had high external validity, as it used clinical cases of cows; therefore, the results indicate that this preoperative treatment for laparotomy in cows can be immediately applied to clinical practice.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org

Acknowledgments

The authors have nothing to declare.

We would like to thank Dr. Yokota and Dr. Yoshida for their cooperation in collecting data. We would like to thank Dr. Kato, Dr. Abe, and Dr. Ohtsuka for their support of our research.

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    Otto KA, Short CE. Pharmaceutical control of pain in large animals. Appl Anim Behav Sci. 1998;59(1-3):157-169. doi:10.1016/S0168-1591(98)00130-0

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