multimodal analgesia protocol for perioperative pain in dogs, what agents to combine?

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The core perioperative multimodal analgesic protocol for dogs combines an opioid, a nonsteroidal anti-inflammatory drug (NSAID), and a local anesthetic, with adjuncts added based on procedure type and patient comorbidities. This combination targets different points in the nociceptive pathway, allowing lower doses of each agent and reducing adverse effects. 111 Pre-emptive administration — giving analgesics before the surgical insult — is a foundational principle. Analgesic therapies should be initiated prior to surgery or as early as possible, as this approach has demonstrated benefit in dogs. Analgesia should be continuous and overlapping, extending into the early at-home period, and matched in intensity to the degree of surgical trauma. 11 Opioids are the first-line perioperative analgesic for moderate-to-severe pain. Methadone provides superior pain control compared to tramadol, particularly when administered preoperatively or intraoperatively. 2 Oral tramadol has not been shown to be effective postoperatively in dogs, and injectable tramadol shows mixed efficacy for surgical pain in dogs. 11 NSAIDs are a core component of the multimodal plan. Pre-emptive meloxicam reduces postoperative cardiovascular changes without affecting renal function in dogs undergoing mastectomy. When meloxicam is combined with gabapentin, the need for rescue opioid analgesia is reduced, with robenacoxib producing similar results. 2 Tramadol's analgesic effect appears enhanced when combined with meloxicam or dipyrone compared to tramadol alone. 2 Local anesthetics are the third pillar. Lidocaine provides blockade for 1 to 2 hours, while bupivacaine and ropivacaine typically last 4 to 6 hours. 7 Local infiltration with lidocaine or bupivacaine provides effective wound-site pain control. 2 Ropivacaine carries less risk of cardiac and systemic toxicity than bupivacaine, which is relevant when larger volumes are used. 9 Intraperitoneal ropivacaine at 3 mg/kg has been used in canine ovariohys