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248 Section IV: Postoperative Care and Rehabilitation

15–20 mg/kg orally every 8 hours, and in cats 61–132 mg/kg orally Antibiotics
divided every 8–12 hours [20]. The incidence of postoperative infection following spinal or intrac-
ranial surgery is low (1.3%) [32] compared with routine clean sur-
geries (2–5.8%) [33,34]. However, perioperative prophylactic
Gastroprotectants antibiotics should be used to limit incisional infections. The most
Gastric ulceration has been reported to occur at a higher incidence in commonly used prophylactic antibiotic is cefazolin, a first‐genera-
patients with neurological disease [26,27]. This can be compounded tion cephalosporin. It should be administered 30 min prior to sur-
by the use of high doses of corticosteroids that are sometimes admin- gery and then every 90 min throughout the duration of surgery at a
istered prior to referral for surgery. The development of gastric ulcera- dose of 22 mg/kg. Continuation of antibiotics following surgery is
tion following the use of corticosteroids may not be prevented by the not indicated except in cases of intracranial surgery where the fron-
use of gastroprotectants. A study evaluating the efficacy of omeprazole tal sinus has been opened or when treating traumatic contaminated
and misoprostol in dogs with naturally occurring IVD disease that wounds that involve the CNS. In cases where bone cement is used
were administered dexamethasone and prednisone revealed no differ- intraoperatively, some surgeons administer a 7–10 day postopera-
ence in the degree of gastric ulceration in either group [26]. These tive course of antibiotics as the development of infection in these
findings were similar to the study evaluating misoprostol, cimetidine cases could lead to surgical failure and would necessitate implant
and sucralfate with methylprednisolone sodium succinate [28]. removal.
There is limited information in companion animals regarding the
benefits of gastroprotectants in preventing gastric ulceration with
concurrent NSAID use, with most recommendations extrapolated Managing the Recumbent Patient
from human medicine. Misoprostol, a prostaglandin E1 agonist, has Patients with paraparesis or tetraparesis or that are unconscious
been shown to significantly decrease gastric ulceration associated (craniotomy or trauma patients) are unable to change position and
with the use of NSAIDs [29]. Misoprostol has not been shown to may be unable to ventilate appropriately. Until they become ambu-
have any advantage over other gastroprotectants in treating ulcera- latory, dry soft padded bedding should be provided to reduce the
tions not related to NSAIDs and is more expensive than other gas- risk of developing decubital ulcers (Figure 28.2). The patient should
troprotectant drugs. Misoprostol doses that have been recommended be maintained in sternal recumbency or the side of recumbency
are 2–5 μg/kg orally every 6–8 hours [20]. Gastroprotectants that should be changed every 4–6 hours depending on the size of the
have been shown to reduce gastric acidity in dogs and which may patient, always ensuring appropriate padding under bony promi-
help prevent gastric ulceration include histamine antagonists (famo- nences. If unconscious or heavily sedated, the patient’s head should
tidine, 0.5 mg/kg every 12 hours) and proton pump inhibitors (ome- be elevated 30° above the body to limit the potential for aspiration
prazole, 0.5–1.0 mg/kg orally once daily; pantoprazole, 0.5–1.0 mg/kg pneumonia and to reduce intracranial pressure [35].
intravenously once daily). If ulceration is suspected due to the
presence of melena, then sucralfate (0.5–1.0 g orally every 8 hours) Physiotherapy for the Recumbent Patient
should also be administered. In a study evaluating the effects of Passive range of motion (ROM) and muscle strengthening exercises
famotidine, ranitidine, omeprazole, and pantoprazole on gastric pH are recommended in the short‐ and long‐term postoperative neuro-
levels in normal dogs, it was found that famotidine, omeprazole, and logical patient. Passive ROM exercises should be initiated as soon as
pantoprazole significantly decreased gastric acidity compared with the patient is comfortable enough to allow it and should be per-
saline or ranitidine [30]. Oral omeprazole was also found to decrease formed three to four times daily in recumbent patients to reduce
gastric acidity faster than both famotidine and pantoprazole and for limb edema and assist in peripheral perfusion (Figure 28.3). More
longer durations throughout the day. The higher efficacy of omepra- details on rehabilitation are discussed in Chapter 29.
zole in increasing gastric pH compared with famotidine was also Thoracic percussion and neubulization as well as oral care should
found in the study by Tolbert et al. [31]. be performed three to four times daily, particularly in patients that

A B

Figure 28.2 (A) Cutaneous erosion over the left hip of a paralyzed dog. (B) Decubital ulcer over the right ischium of a paralyzed dog.