Epidural Administration of Tramadol as an Analgesic Technique in Dogs Submitted to Stifle Surgery
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Epidural Administration of
Tramadol as an Analgesic
Technique in Dogs Submitted to
Stifle Surgery
Alonso G.P. Guedes, DVM, MS1
Cláudio C. Natalini, DVM, MS, PhD2
Elaine P. Robinson, BVetMed, MVSc1
Simone D.L. Alves, DVM3
Simone T. Oliveira, DVM3
1 3
Department of Small Animal Clinical Science Departamento de Clinica de Pequenos Animais
College of Veterinary Medicine Universidade Federal de Santa Maria
University of Minnesota Santa Maria, RS, Brazil
St Paul, Minnesota
2
Veterinary Clinical Sciences
School of Veterinary Medicine
Louisiana State University
Baton Rouge, Louisiana
KEY WORDS: tramadol, epidural analge- respiratory rates, systolic, mean, and dias-
sia, orthopedic tolic arterial blood pressure, and pulse
oximetry were measured before premedica-
ABSTRACT tion (baseline), and at fixed intervals after
Tramadol is a centrally acting analgesic anesthesia induction. Arterial partial pres-
with µ-opioid, monoaminergic, and local sures of oxygen and carbon dioxide, oxy-
anesthetic effects. In view of the involve- gen-hemoglobin saturation, pH, and plasma
ment of the opioid and monoaminergic sys- bicarbonate concentration were measured at
tems in pain pathways, the study was baseline, immediately before the epidural,
conducted to evaluate tramadol as an and at 60, 120, 240, and 360 minutes there-
epidural analgesic in dogs. Ten healthy after. Post-operative analgesia was evaluat-
adult dogs (mean ± SEM body weight = ed for 4 hours using a scoring system.
17.3 ± 3.8 kg) were premedicated with ace- Statistically significant decrease in arterial
promazine (0.05 mg/kg, IM), induced with blood pressure was observed following
thiopental (10 mg/kg, IV), and maintained anesthetic induction, although hypotension
under anesthesia with halothane in oxygen. was not observed. Partial pressure of carbon
Twenty minutes after starting halothane dioxide in arterial blood increased signifi-
anesthesia, tramadol (1.0 mg/kg in 0.22 cantly from baseline at 60 minutes after
mL/kg of sterile water) was administered epidural tramadol. The remaining variables
epidurally at the lumbo-sacral space. were not significantly different from base-
Surgery began 15 minutes later. Pulse and line values. No variables were significantly
Intern J Appl Res Vet Med • Vol. 3, No. 4, 2005 351different from values obtained immediately pharmacological profile of tramadol makes
before tramadol administration. Intra- it an attractive drug for epidural administra-
operative antinociception was considered tion as an analgesic technique for surgeries
adequate, with satisfactory post-operative in the hind limbs of dogs. Activation of opi-
analgesia for 4 hours. In conclusion, epidur- oid receptors, inhibition of the monoaminer-
al tramadol seems to produce satisfactory gic system, and local anesthetic effects4,9,12
antinociception and analgesia without caus- are likely to decrease transmission and
ing clinically significant hemodynamic and improve modulation of afferent nociceptive
respiratory depression in healthy dogs signals, resulting in significant analgesia.
undergoing stifle surgery. These possibilities along with a shortage of
information on the epidural use of tramadol
INTRODUCTION in the veterinary literature motivated this
Tramadol is a centrally acting analgesic that study. Therefore, the pre-operative epidural
was introduced in Germany in the late administration of tramadol was evaluated as
1970s for use in human medicine, and has an analgesic technique in dogs submitted to
been used in the United Kingdom for stifle surgery.
approximately 8 years.1,2 In the United
States the U.S. Food and Drug MATERIAL AND METHOD
Administration approved its oral form for The study was approved by the Scientific
use in humans in 1999.3 It is a µ-opioid Committee at the Office of Projects of the
receptor agonist with an analgesic potency Rural Sciences Center of the Universidade
equal to meperidine and 5- to 10-times less Federal de Santa Maria, RS, Brazil. Ten
than morphine in humans.4 Further examina- adult, clinically healthy, mixed breed dogs,
tions of the neurochemical profile of tra- 6 male and 4 female, weighing 17.3 ± 3.8
madol revealed that it inhibits the neuronal kg (mean ± SEM; range, 12−23 kg) were
uptake of norepinephrine and serotonin.5−7 studied. The dogs were fasted for 12 hours
More recent studies have shown that tra- and deprived of water for 2 hours preopera-
madol also has local anesthetic action either tively. The surgical procedure consisted of
by producing analgesia after intradermal experimental excision and replacement of
injection,8,9 or by reducing pain associated the cranial cruciate ligament in the right
with propofol administration.10,11 limb of each dog.
Tramadol consists of a racemic mixture Acepromazine (Acepran 1%,
of 2 enantiomers, (+) tramadol and (−) tra- Andrômaco, São Paulo, SP, Brazil) was
madol.2 Racemic tramadol inhibits the given intramuscularly as premedication
synaptosomal uptake of norepinephrine and (0.05 mg/kg), with the induction of anesthe-
serotonin with about equal potency.12 The sia performed 15 minutes later with thiopen-
(+) enantiomer is the most potent inhibitor tal (10 mg/kg; Thionembutal, Abbott, São
of serotonin uptake, enhances serotonin Paulo, SP, Brazil) given intravenously
release and has modest affinity for µ-opioid through a catheter previously placed in the
receptors. The (−) enantiomer is the most cephalic vein. Following tracheal intubation,
potent inhibitor of norepinephrine uptake halothane (Fluothane, Wellcome-Zeneca,
and has the same affinity as the racemate Cotia, SP, Brazil) was delivered in 100%
for µ-opioid receptors. The monoaminergic oxygen for anesthetic maintenance, using a
effects of the 2 enantiomers are more potent semi-closed circle system with a fresh gas
than the opioid action. They also interact in flow rate of 30 mL/kg/min. The animals
a complementary and synergistic manner to were allowed to breathe spontaneously, and
produce antinociception, but do not sum- body temperature was maintained in the
mate to increase side effects, such as consti- physiological normal range with the use of
pation and respiratory depression.12 The an electric warm blanket.
352 Intern J Appl Res Vet Med • Vol. 3, No. 4, 2005Twenty minutes following anesthetic ured before premedication (baseline), imme-
induction, 1.0 mg/kg of tramadol (Tramal diately before the epidural administration of
50, Carlo Erba, Duque de Caxias, RJ, tramadol (before epidural), and then 60,
Brazil), diluted in distilled water to a final 120, 240, and 360 minutes after the epidural
volume of 0.22 mL/kg, was administered procedure. Blood from the femoral artery
epidurally at the lumbo-sacral space. The was collected anaerobically and immediate-
dosage rate of tramadol chosen was deter- ly stored in ice water, with the evaluation
mined as 1/10 of the systemic dosage used carried out within a period of 1 hour (AVL
in humans.5 The technique was performed AG900, Biomedical Instruments,
using a 22-gauge, 3.75-cm spinal needle. Switzerland).
Correct placement of the spinal needle in The vaporizer settings were adjusted to
the epidural space was confirmed by the provide an adequate depth of surgical anes-
hanging drop technique and by the lack of thesia. Presence or absence of limb move-
resistance to administration of 1 mL of air. ment, palpebral reflex and any detectable
The dogs remained laterally recumbent with response to surgical stimulation were among
the surgical side down for 10 minutes the clinical parameters used to assess the
before being positioned dorsally for surgery. depth of anesthesia. Based on this evalua-
Lactate Ringer’s solution was used intra- tion, dogs were allowed to be as lightly
operatively at a rate of 20 mL/kg/h for the anesthetized as possible during the surgical
first hour and 10 mL/kg/h thereafter. procedures. Fentanyl (2.5 µg/kg IV) was
Arterial blood pressure (systolic, mean, reserved for intra-operative administration
and diastolic), pulse rate, respiratory rate, to improve antinociception if necessary. The
arterial blood oxygen saturation, and arterial criteria for administration was based on an
blood gases were evaluated. These measure- increase in pulse rate, mean arterial blood
ments were taken in the conscious dog pressure, and/or respiratory rate equal or
before any drug administration (baseline) higher than 15% of the previous value after
and after anesthetic induction at 5, 10, 20, the start of surgery, in the presence of an
30, 40, 50, 60, 70, 80, 90, 100, and 110 adequate depth of anesthesia. At the end of
minutes. Arterial blood pressure was meas- the anesthesia, duration of anesthetic recov-
ured non-invasively by oscillometry ery was measured from the time that the
(Dinamap-Critikon, Tampa, FL, USA), with vaporizer was turned off to the moment that
an appropriate cuff (width approximately the dog assumed sternal position.
equal to 40% of the limb circumference) Post-operative analgesia was evaluated
positioned proximally to the carpus. Pulse by an investigator (SA) unaware of the drug
rate and arterial blood oxygen saturation used epidurally, with the use of a scoring
were obtained with a pulse oximeter system designed for this study (Appendix
(Nellcor N-200, Nellcor Inc., Pleasanton, A). Baseline assessments for pulse rate, res-
CA, USA). The oximeter probe was placed piratory rate, levels of vocalization, activity,
on the lip, vulva, or prepuce for the base- posture, and color of mucous membranes
line, and on the tongue for intra-operative were performed in each dog before the
measurements. Respiratory rate and vaporiz- administration of any drug. These assess-
er settings (after anesthetic induction) were ments were repeated in the post-operative
assessed at these same intervals. period at 60, 120, and 240 minutes. A 50%
Blood gas analyses were carried out to increase in pulse or respiratory rate over
determine arterial pH, arterial partial pres- baseline and/or a total score of subjective
sures of oxygen (PaO2) and carbon dioxide assessments ≥3 points was assumed to be
(PaCO2), oxygen-hemoglobin saturation indicative of pain that should be treated
(SaO2), and plasma bicarbonate concentra- with additional analgesics (morphine 0.5
tion (HCO3−). These parameters were meas- mg/kg IM, repeated after 20 minutes as
Intern J Appl Res Vet Med • Vol. 3, No. 4, 2005 353RESULTS
Duration of anesthesia
and surgery were 100.2 ±
11.2 and 77.5 ± 7.5 min-
utes, respectively.
Duration of anesthetic
recovery was 81.1 ± 21.7
minutes. The surgical con-
ditions were considered
very good, with good
muscle relaxation, and no
excessive bleeding. Intra-
Figure 1. Intra-operative halothane vaporizer settings in dogs (n = 10) operative use of fentanyl
given epidural tramadol (1.0 mg/kg) and submitted to stifle surgery.
was not necessary based
on the chosen criteria.
Vaporizer settings were
needed). After this 4-hour period, all dogs significantly decreased over time (Figure 1).
received 1.0 mg/kg of flunixin meglumine Values for pulse and respiratory rates, sys-
IV, which was continued for 2 additional tolic, mean, and diastolic arterial blood pres-
days, administered subcutaneously every 24 sure, and pulse oximetry are shown
hours. graphically in Figure 2. Induction of general
Statistical analysis was performed using anesthesia produced a statistically significant
repeated measures analysis of variance to decrease in arterial blood pressure although
assess changes over time, followed by hypotension (mean arterial blood pressure
Bonferroni multiple comparison test when avascular and respiratory
variables measured were
changed with the epidural
administration of tramadol.
The post-operative pain
assessment showed that the
dogs were apparently com-
fortable; these data are dis-
played on Table 1. In the
subjective evaluation, all
dogs showed no vocaliza-
tion, were inactive or sleep-
ing, and presented normal
mucous membrane col-
oration throughout 4 hours
of evaluation. For posture,
Figure 2. Mean values of pulse rate (PR), systolic arterial blood
most of the dogs were pressure (SAP), mean arterial blood pressure (MAP), diastolic arte-
recumbent in the first hour, rial blood pressure (DAP), pulse oximetry (SpO2), and respiratory
while in the second and rate (ƒ) in dogs (n = 10) administered epidural tramadol (1.0
mg/kg) undergoing stifle surgery.
fourth hours most of them
were standing spontaneous-
ly, although not weight
bearing on the operated
limb. None of the dogs had
a 50% increase in heart or
respiratory rate over base-
line nor received a total
score ≥3 points, and there-
fore no additional analgesics
were used during the 4
hours of evaluation.
DISCUSSION
In humans, tramadol has
been used epidurally for
many years,13−1 6 but in vet-
erinary medicine the
epidural administration was
Figure 3. Mean values for pH, arterial partial pressures of oxygen
studied only recently in (PaO2) and carbon dioxide (PaCO2), oxygen-hemoglobin satura-
horses, where tramadol was tion (SaO2), and plasma bicarbonate concentration (HCO ) in 3
-
found to be 10-times less dogs (n = 10) administered epidural tramadol (1.0 mg/kg) under-
going stifle surgery.
potent than morphine. To17
date, there are no reports
on the epidural administration of tramadol in tered at a dose of 1.0 mg/kg.17 Also, as tra-
dogs. Therefore the dose chosen for this madol was 10-times less potent than mor-
study was based on human literature, where phine,17 the use of 1.0 mg/kg in the present
tramadol was used epidurally in children at study is likely to be equipotent with the dose
doses of 1.0 to 2.0 mg/kg,16,18 and from the of 0.1 mg/kg of morphine commonly used
study done in horses where it was adminis- epidurally in dogs.
Intern J Appl Res Vet Med • Vol. 3, No. 4, 2005 355In this study, a decrease in arterial blood of the spinal cord, and can modulate affer-
pressure, mild hypoventilation, and decrease ent pain signals at this level.26,27 Opioids,
in respiratory rate were observed with the noradrenergic, and serotonergic drugs can
institution of general anesthesia compared interact with these systems to produce
with the baseline values in the conscious ani- antinociception,27 and the use of these drugs
mals. This is expected to happen with all the in combination significantly improves anal-
commonly used inhalant anesthetics, as they gesia.28−30 This may explain the antinocicep-
cause dose-dependent cardiovascular and res- tion obtained with the use of epidural
piratory depression.19,20 Tramadol was given tramadol as its opioid and monoaminergic
epidurally after 20 minutes of general anesthe- actions interact at the level of the spinal
sia, and no changes in arterial blood pressure, cord to produce antinociception.6,12
pulse and respiratory rates, pulse oximetry, The opioid and monoaminergic actions
and arterial blood gases were noticed. Similar of tramadol are well recognized, and local
results have been observed in anesthetized anesthetic effects also have been demonstrat-
humans14,15,17,21 and in unanesthetized horses18 ed more recently. The intravenous regional
after epidural administration of tramadol. administration of tramadol was shown to
Additionally, intravenous doses up to 2.0 reduce the incidence of the painful sensation
mg/kg in conscious humans, and up to 10 associated with intravenous administration
mg/kg in awake or anesthetized dogs had no of propofol in humans.10,11 Also in humans,
significant adverse cardiovascular effects.22,23 intradermal injection of tramadol produced
While inhalant anesthetics cause uncon- loss of sensation to pin prick, light touch,
sciousness and the patient does not experi- and cold in one study8 and surgical analgesia
ence pain, even profound planes of similar to prilocaine in another.9 Local anes-
anesthesia may not block nociception and thetic effects, combined with the opioid and
many of the autonomic responses related to monoaminergic actions, support the findings
surgical stimulation.24 Although clinical of satisfactory antinociception obtained in
evaluation of adequate intra-operative the present study.
antinociception may be difficult, tachypnea, The use of scores to evaluate the anal-
tachycardia, and hypertension may be gesic status of animals may not be accurate in
observed in anesthetized animals in some occasions due to the subjective and
response to surgical stimulation.25 Attempts complex nature of pain.31 However, pale
to block these responses by increasing the mucous membranes due to peripheral vaso-
volatile anesthetic concentration will result constriction, tachypnea, and tachycardia may
in severe respiratory depression.24 None of occur as a sympathetic response to pain in
these changes were observed in the present conscious animals.25,31 Changes in respiratory
study. The anesthetic depth was maintained rate are good physiologic indicators of pain
as light as possible, with most dogs showing with a high correlation with subjective meth-
palpebral reflexes and some degree of shiv- ods of evaluation.31 Furthermore, a patient
ering in the second half of the anesthetic who is pain free will be calm, quiet, and will
procedure, yet surgical conditions were often sleep.31 In the present study, respiratory
good. Vaporizer settings remained below rate during the post-operative period remained
1.0% for the surgical period 30 minutes similar or lower than baseline, and the ani-
after epidural administration of tramadol to mals were quiet, calm, or asleep, indicating
the end of anesthesia, in the present study, satisfactory post-operative analgesia. Several
with values similar or even lower than the reports from the human literature have shown
reported minimum alveolar concentration of effective postoperative analgesia after epidur-
0.87% for halothane in dogs.19 al administration of tramadol.14,15,18,32,33 In addi-
Noradrenergic descending pathways and tion, complete analgesia in the perineal and
the serotonergic system innervate all levels sacral areas for 4 hours has been reported in
356 Intern J Appl Res Vet Med • Vol. 3, No. 4, 2005horses given tramadol epidurally.17 Our study Complementary and synergistic antinociceptive
interaction between the enantiomers of tramadol.
suggests that the epidural administration of J Pharmacol Exp Ther 1993;267:331−340.
tramadol may produce at least approximately
13. Chrubasik J, Warth L, Wüst H, Bretschneider H,
5.5 hours of analgesia in dogs. Schulte-Mönting J: Untersuchung zur analgetis-
chen Wirksamkeit peridural applizierten tra-
CONCLUSION madols bei der behandlung von schmerzen nach
abdominalchirurgischen Eingriffen. Schmerz
Epidural tramadol produces satisfactory intra- Pain Douleur 1988;9:12−18.
operative antinociception and post-operative 14. Baraka A, Jabbour S, Ghabash M, Nader A,
analgesia without causing clinically signifi- Khoury G, Sibai A: A comparison of epidural
cant hemodynamic and respiratory depression tramadol and epidural morphine for postopera-
tive analgesia. Can J Anaesth 1993;40:308−313.
in healthy dogs undergoing stifle surgery.
15. Wilder-Smith CH, Wilder-Smith OHG,
Farschtschian M, Naji P: Preoperative adjuvant
REFERENCES epidural tramadol: the effect of different doses
on postoperative analgesia and pain processing.
1. Besson JM, Vickers MD: Tramadol analgesia:
synergy in research and therapy. Drugs Acta Anaesthesiol Scand 1998;42:299−305.
1994;47:1−2. 16. Batra YK, Prasad MK, Arya VK, Chari P,
2. Eggers KA, Power I: Tramadol. Br J Anaesth Yaddanapudi LN: Comparison of caudal tra-
1995;74:247−249. madol vs bupivacaine for post-operative analge-
sia in children undergoing hypospadias surgery.
3. US Food and Drug Administration. CDER New J Clin Pharmacol Ther 1999;37:238−242.
and Generic Drug Approvals: 1998-2004.
Available at: http://www.fda.gov/cder/approval/ 17. Natalini CC, Robinson EP: Evaluation of the
index.htm. analgesic effects of epidurally administered mor-
phine, alfentanil, butorphanol, tramadol and
4. Collart L, Luthy C, Dayer P: Multimodal anal- U50488H in horses. Am J Vet Res
gesic effect of tramadol. Clin Pharmacol Ther 2000;61:1579−1586.
1993;53:223.
18. Senel AC, Akyol A, Dohman D, Solak M:
5. Driessen B, Reimann W: Interaction of the cen- Caudal bupivacaine-tramadol combination for
tral analgesic, tramadol, with the uptake and postoperative analgesia in pediatric herniorrha-
release of 5-hydroxytryptamine in the rat brain in phy. Acta Anaesthesiol Scand 2001;45:786−789.
vitro. Br J Pharmacol 1992;105:147−151.
19. Steffey EP, Gillespie JR, Berry JD, Eger EI 2nd,
6. Raffa RB, Riderichs E, Reimann W, Shank RP, Rhode EA: Circulatory effects of halothane and
Codd EE, Vaught JL: Opioid and non-opioid halothane-nitrous oxide anesthesia in the dog:
components independently contribute to the spontaneous ventilation. Am J Vet Res
mechanism of action of tramadol: an ‘atypical’ 1975;36:197−200.
opioid analgesic. J Pharmacol Exp Ther
20. Thurmon JC, Benson GJ: Pharmacologic consid-
1992;260:275−285.
eration in selection of anesthetics for animals. J
7. Driessen B, Reimann W, Giertz H: Effects of the Am Vet Med Assoc 1987;191:1245−1251.
central analgesic tramadol on the uptake and
21. Houmes RJM, Voets MA, Verkaaik A, Erdmann
release of noradrenaline and dopamine in vitro.
Br J Anaesth 1993;108:806−811. W, Lachmann B: Efficacy and safety of tramadol
versus morphine for moderate and severe postop-
8. Pang WW, Mok MS, Chang DP, Huang MH: erative pain with special regard to respiratory
Local anesthetic effect of tramadol, metoclo- depression. Anesth Analg 1992;74:510−514.
pramide, and lidocaine following intradermal
injection. Reg Anesth Pain Med 1998;23:580−583. 22. Osterloh G, Friederichs E, Felgenhauer F, et al:
General pharmacological studies on tramadol, a
9. Altunkaya H, Ozer Y, Kargi E, Babuccu O: potent analgesic agent. Arzneimittelforschung
Comparison of local anaesthetic effects of tra- 1978;28:135−151.
madol with prilocaine for minor surgical proce-
dures. Br J Anaesth 2003;90:320−322. 23. Lee CR, McTavish K, Sorkin EM: Tramadol: a
preliminary review of its pharmacology and
10. Pang WW, Huang PY, Chang DP, Huang MH: The pharmacokinetic properties, and therapeutic
peripheral analgesic effect of tramadol in reducing potential in acute and chronic pain states. Drugs
propofol injection pain: a comparison with lido- 1993;46:314−340.
caine. Reg Anesth Pain Med 1999;24:246−249.
24. Ilkiw JE: Balanced anesthetic techniques in dogs
11. Wong WH, Cheong KF: Role of tramadol in and cats. Clin Tech Small Anim Pract
reducing pain on propofol injection. Singapore 1999;14:27−37.
Med J 2001;42:193−195.
25. Hellyer PW, Gaynor JS: Acute postsurgical pain
12. Raffa RB, Friederichs E, Reimann W, et al: in dogs and cats. Compend Contin Educ Pract
Intern J Appl Res Vet Med • Vol. 3, No. 4, 2005 357Vet 1998;20:140−153. 30. Coda BA, Hill HF, Schaffer RL, Luger TJ,
Jacobson RC, Chapman CR: Enhancement of
26. Sawynok J: The role of ascending and descend-
morphine analgesia by fenfluramine in subjects
ing noradrenergic and serotonergic pathways in
receiving tailored opioid infusions. Pain
opioid and non-opioid antinociception as
revealed by lesion studies. Can J Physiol 1993;52:85−91.
Pharmacol 1989;67:975−988. 31. Mathews KA: Pain assessment and general
27. Yaksh TL, Wilson PR: Spinal serotonin terminal approach to management. Vet Clin North Am
system mediates antinociception. J Pharmacol Small Anim Pract 2000;30:729−755.
Exp Ther 1979;208:446−453. 32. Paddleford RR Analgesia and pain management.
28. Gordon NC, Heller PH, Levine JD: Enhancement In: Manual of Small Animal Anesthesia. 2nd edi-
of pentazocine analgesia by clonidine. Pain tion. WB Saunders: Philadelphia, PA; 1999:
1992;48:167−169. 227−2 4 6 .
29. Branson KR, Ko JCH, Tranquilli WJ, Benson J, 33. Ozcengiz D, Gunduz M, Ozbek H, Isik G:
Thurmon JC: Duration of analgesia induced by Comparison of caudal morphine and tramadol for
epidurally administered morphine and medetomi- postoperative pain control in children undergoing
dine in dogs. J Vet Pharmacol Ther inguinal herniorrhaphy. Paediatr Anaesth
1993;16:369−372. 2001;11:459−464.
358 Intern J Appl Res Vet Med • Vol. 3, No. 4, 2005Appendix A. Scoring System Used to Subjectively Evaluate Post-Operative Analgesia Through
Assessments of Vocalization, Agitation, and Mucous Membrane Coloration of Dogs Submitted
to Orthopedic Surgery and Epidural Administration of Tramadol (1.0 mg/kg).
Clinical Sign Score and Patient Criteria
Vocalization 0 = None
1 = Present, easily controllable by talking to the animal with a calm voice.
2 = Present, controllable with gentle touch and calm voice
3 = Present, not controllable with gentle touch and calm voice
Level of activity 0 = Asleep, inactive, or calm
1 = Uncomfortable, changing position constantly
2 = Agitated, constantly standing up and laying down
3 = Thrashing and destructive behavior
Posture 0 = Standing spontaneously, weight bearing
1 = Standing spontaneously, but non-weight bearing
2 = Recumbent, but able to stand with verbal stimulation, with or without
minimal help
3 = Recumbent, refuse to stand with verbal stimulation or minimal help
Mucous membrane 0 = Normal coloration
coloration 1 = Pale mucous membrane
Total Score Possible 10 points
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