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ANESTHESIA - 2 > 32 – Peri-Operative Pain Management in Large Animals > Flashcards

32 – Peri-Operative Pain Management in Large Animals Flashcards

1
Q

What are the arguments for use of analgesics in large animals?

A
  • Pain results in poor recovery from anesthesia
  • Animals are restless
  • Animals do not eat well
  • Decreased immune response due to STRESS
  • Delayed wound healing
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2
Q

What are the arguments against use of analgesics in large animals?

A
  • Over-use of injured area
  • Side effects
    o GI ulcers
    o Constipation
    o Ileus (but pain can also cause it, BALANCE)
    o Behavioural alterations
  • Masks worsening of disease process
  • Difficulty in recognizing pain
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3
Q

Head pain behaviour in horses

A
  • Shake
  • Snort
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4
Q

Jaw pain behaviour in horses

A
  • Drooling
  • Dropping food
  • Losing weight
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5
Q

Limb pain behaviour in horses

A
  • Stomp
  • Limp
  • Refusal to walk
  • Lying down
  • Abnormal stance (ex. leaning back when front limb sore)
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6
Q

Abdominal pain behaviour in horses

A
  • Kick at belly
  • Flank watch
  • Roll
  • Tail swish
  • Violent behaviour
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7
Q

‘pain face’ of a horse

A
  • Lowered ears
  • Contraction of muscles above eye
  • Tense stare
  • Dilated nostril
  • Tension of facial muscles
  • Edged shaped muzzle with lips pressed together and flattened chin
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8
Q

Pain management in horses: analgesic drugs for

A
  • Pre-medication/sedation
  • Pre-emptive pain management
  • Multi-modal analgesia
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9
Q

Pain management in horses: infusion techniques for

A
  • Intra-operative
  • Post-operative
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10
Q

Pain management in horses: epidural/spinal techniques for

A
  • Standing procedures
  • Post-operative long term pain management
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11
Q

What are the 5 ‘classes’ of analgesic drugs used in horses?

A
  1. NSAIDs
  2. Alpha-2 agonists
  3. Ketamine
  4. Opioids
  5. Local anesthetics
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12
Q

What are the benefits of NSAIDs in horses?

A
  • Analgesic
  • Anti-inflammatory
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13
Q

What are the potential harmful side effects of NSAIDs in horses?

A
  • Gastric and colonic ulceration
  • Renal tubular necrosis
  • *more with chronic use
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14
Q

What are the usages of NSAIDs in horses?

A
  • often administered PRE-OPERATIVELY anticipating inflammation that will occur during surgery
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15
Q

What are some examples of NSAIDs in horses (2)

A
  • phenylbutazone
  • flunixin meglumine
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16
Q

Phenylbutazone in horses for

A
  • musculoskeletal inflammation and pain
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17
Q

Flunixin meglumine in horses for

A
  • acute soft injury
  • endotoxemia
  • abdominal pain
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18
Q

What are the alpha-2 agonists used in horses?

A
  • Xylazine
  • Detomidine
  • Medetomidine
  • Dexmedetomidine
  • Romifidine
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19
Q

What are the usages of alpha-2 agonists in horses?

A
  • Pre-medication primarily for SEDATION
  • Intra-operatively as a CRI for analgesia
  • Post-operatively for sedation to ensure SMOOTH RECOVERIES from inhalation anesthesia
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20
Q

What are the benefits of alpha-2 agonists in horses?

A
  • ANALGESIA
  • Sedation
  • Anesthetic sparing
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21
Q

What are the potential negative side effects of alpha-2 agonists?

A
  • Bradycardia
  • Vasoconstriction and hypertension
  • Increased urine output (hyperglycemic diuresis)
  • Decreased GI motility
  • Ataxia
  • *can get excited (need to be sedated: ’nose to knees’)
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22
Q

Xylazine in horses

A
  • Used with KETAMINE and GGE (Guaifenesin) in ‘triple drip’
  • Total intravenous anesthesia (TIVA)
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23
Q

Detomidine in horses

A
  • Used for sedation and analgesia for standing procedures
  • Often combined with an OPIOID
  • Administered as an infusion (variable rate infusion (VRI))
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24
Q

Dexmedetomidine in horses

A
  • Used for invasive procedures with INHALATION ANESTHESIA (PIVA)
    o Once turn it off=it is gone (still need to SEDATE for recovery period)
  • *Ex. orthopedic surgery
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25
Q

Ketamine in horses

A
  • Used as in induction agent
  • Used in ‘triple drip’ mixture
  • *provides analgesia
    o Somatic
    o NMDA antagonism: good for chronic (‘wind-up’) pain
  • *risk of excitement: but can be controlled with sedatives
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26
Q

What are some other beneficial effects of ketamine besides analgesia?

A
  • Local anesthetic affects
  • Potent anti-inflammatory effects
  • Anesthetic sparing (decrease MAC by 37%)
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27
Q

What are the main opioids used in horses?

A
  • Morphine (mu agonist)
  • Butorphanol (kappa agonist)
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28
Q

What are opioids primarily used for in horses?

A
  • Intra-operatively
    o Not good sedative unless combined with an alpha-2 agonist
  • Appears to be effective in horses in pain OR undergoing invasive procedures=good analgesia
  • DOES NOT REDUCE ISOFLURANE REQUIREMENTS (unlike dogs and cats)
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29
Q

What are some side effects of opioids?

A
  • Excitement: control with sedatives (acepromazine, alpha-2 agonists)
    o *give them first and them first and then do opioids
  • Decreased GI motility: decreased if administered IM or not given long term
30
Q

Opioids dosage guidelines

A
  • more severe than pain=greater dose required and lower risk of excitatory side effects
  • give appropriate alpha-2 match for duration to eliminate risk of excitation
  • sedation acepromazine reduces but does not ELIMINATE risk of excitement
  • *SHOULD BE GIVEN TO EFFECT: NOT BY THE CLOK
  • Clinical signs of underdose (ie. PAIN) may MIMIC signs of overdose (EXCITEMENT)
31
Q

Morphine

A
  • Used at LOW doses for horse in pain
  • Duration: ~4hrs
  • Side effects when use repeated dosing or high dosages
  • Can enhance effects of other sedatives when used with standing sedation
  • CV stimulation when used alone
  • Can use for intra-articular analgesia (up to 24hours, less systemic side effects)
32
Q

What are some side effects when morphine is given repeatedly or at high doses?

A
  • Reduced GI motility
  • Urinary retention
  • Increased locomotor activity and ataxia
33
Q

Morphine intraoperative uses (horses)

A
  • CRI
  • Higher dosages (0.25mg/kg)
  • Clinical dosages
34
Q

Morphine CRI (intraoperative use)

A
  • Improved recovery characteristics
  • No conclusive evidence that its use increases incidence of post-anesthetic colic
35
Q

Morphine higher dosages (intraoperative use)

A
  • Used for analgesia
  • May increase isoflurane requirements
  • May result in rough recoveries
36
Q

Morphine clinical dosages (intraoperative use): recovery affect

A
  • Does not affect recovery
37
Q

Fentanyl

A
  • Use is controversial: need large doses
    o Maybe MAC reducing effect but increase in rough recoveries
  • Clinical benefit at this time: POST-OPERATIVE period via TRANSDERMAL PATCHES for pain control
38
Q

Fentanyl patches

A
  • Need 1-3 (‘for small animals’)
  • Variable results
  • May see excitement: may need acepromazine or alpha-2 sedation
  • May need to supplement with another analgesic: NSAID
  • Location may affect absorption
  • *controlled drug (don’t want abuse)
39
Q

Fentanyl patches absorption

A
  • Better absorption from thorax or groin compared to a leg
40
Q

Fentanyl patches: in foals

A
  • One 100mcg/hr patch may be used
  • Peak plasma levels after 14hrs
41
Q

Remifentanil

A
  • Used with success INTRA-OPERATIVELY
  • Good recoveries
  • Some reports of hyperthermia
  • Can ONLY be used as CRI due to SHORT-HALF LIFE
  • *Make sure analgesia is in place before turning off
42
Q

Buprenorphine

A
  • Long duration of action: up to 12hrs
  • Behavioural side effects
  • Sub-lingual administration might be useful
  • New evidence: may provide better POST-OPERATIVE analgesia than butorphanol for minimally invasive procedures (ex. castration)
  • Not really used at the school
43
Q

What are some side effects of buprenorphine?

A
  • Restlessness
  • Head shaking
  • Decreased GI motility for up to 4 hours
44
Q

Butorphanol

A
  • Can still produce excitement (delta receptors)
  • Often used INTRA-OPERATIVELY
  • Effective for VISCERAL ANALGESIA
  • Duration: 45-1hr (IV)
    o re-dosing is often necessary
  • does NOT change isoflurane requirements
  • *does provide a more ‘stable’ anesthesia
  • Post-operative usage
45
Q

Butorphanol post-operative usage (horses)

A
  • May need it IM every 3 hrs: analgesia is short last and not profound
  • Can be injected
  • Analgesia is NOT consistent as with an infusion but there is less risk of IMPACTION
46
Q

Local anesthetics: Lidocaine

A
  • As an infustion INTRA-OPERATIVELY w/o epinephrine!
  • Loading dose and CRI
  • *stop infusion at least 30 mins prior to recovery from general anesthesia: TO PREVETN ATAXIA
47
Q

What are the pharmacological benefits of lidocaine?

A
  • ANALGESIA
  • Anti-inflammatory
  • Anti-endotoxemic
  • Pro-kinetic
  • Anesthetic sparing
48
Q

Partial IV anesthesia (PIVA)

A
  • Combination of infusions (multimodal anesthesia)
  • Useful technique to reduce isoflurane requirements
  • Alpha-2 agonists, lidocaine, opioids, ketamine
49
Q

Alpha-2 agonists indications and PIVA

A
  • Invasive/painful procedures
  • Orthopedic procedures: musculoskeletal pain and inflammation
50
Q

Lidocaine indications and PIVA

A
  • Colic surgeries
51
Q

Opioids indications and PIVA

A
  • Orthopedic surgeries
52
Q

Ketamine indications and PIVA

A
  • Somatic analgesia
    o Supplement other drugs
53
Q

What are other modes of providing analgesia (4)

A
  • Epidurals
  • Epidural catheters
  • Wound/soaker catheters
  • Local blocks
54
Q

Epidurals

A
  • Good for standing procedures
  • Require sterile technique
  • Relatively easy to place in standing horse (sacrococcygeal)
  • Use preservative free drugs
  • Usually once or twice daily treatment
  • Administer drugs SLOWLY
55
Q

Epidural catheters

A
  • For LONG term pain management
  • Sterile technique for placement and management!
56
Q

Wound/soaker catheters

A
  • Can provide postoperative analgesia for 2-3 days
  • Preplace during surgery
  • Commercial kits available
  • Use LIDOCAINE infusions: 2-5ml/hr
  • Use BUPIVICAINE infusions: 2-5ml every 6-10hours
  • *maybe not used when remove a tumor?
57
Q

Local blocks

A
  • Intra-operative: anesthetic sparing:
  • Post-operative: improve recovery and minimize need for other analgesic agents
58
Q

Considerations for recovery

A
  • Must STOP ALL INFUSIONS prior to moving into recovery box
  • Give NSAIDs if warranted
  • Consider local blocks if applicale
  • Usually sedate with alpha-2 agonist
    o Xylazine
    o Romifidine
59
Q

Pain behaviour in ruminants

A
  • Abnormal stance and gait
  • Unusual resting behaviours
  • Vocalization
  • Kicking and tail swishing
  • Very subtle indicators (teeth grinding, reduced food, absence of rumination)
60
Q

What are the analgesic drugs used for ruminants (5)?

A
  • NSAID
  • Opioids
  • Ketamine
  • Lidocaine
  • Alpha-2 agoinsts
61
Q

NSAIDs: ruminants

A
  • Withdrawal times NOT well defined for meat or milk
  • Primary risk=GI ulcer formation
62
Q

What are some behavioural side effects that might be seen with opioids in ruminants and that may need to be adjusted?

A
  • Sedation
  • Dysphoria
  • Excessive locomotor activity
  • Excitement
  • *can develop INTESTINAL STASIS with long term use
63
Q

What are the 2 opioids used in ruminants?

A
  • Morphine
  • Butorphanol
64
Q

Epidural opioids: ruminants

A
  • Morphine: diluted in 10ml saline
  • *sacrococcygeal administration (‘caudal epidural’)
65
Q

In what animals can or are transdermal fentanyl patches used?

A
  • Goats and sheep
  • Llamas
  • Pigs (placed behind ear or inner thigh)
66
Q

What are the benefits of ketamine in ruminants

A
  • Anesthetic sparing
  • NMDA antagonist: good for chronic pain
  • Good for somatic analgesia
67
Q

Ketamine dosages in ruminants

A
  • Higher dosages than in small animals
68
Q

What is lidocaine used for in ruminants?

A
  • **Infusion INTRA-OPERATIVELY w/o epinephrine
  • Stop infustion at least 30 mins prior to recovery from general anesthesia to PREVENT prolonged recoveries
69
Q

What are the pharmacological benefits of lidocaine? (ruminants)

A
  • ANALGESIA
  • Anti-inflammatory
  • Anti-endotoxemic
  • Pro-kinetic: improves GI motility
  • Anesthetic sparing
70
Q

What is the dosing of lidocaine in ruminants?

A
  • Higher than HORSES and SMALL ANIMALS
71
Q

Alpha-2 agonists: ruminants

A
  • MORE SENSITIVE than horses
  • *use 1/10th dose you would use in horse
72
Q

Epidural use of alpha-2 agonists in ruminants

A
  • Use 1/10th dose of xylazine you would use in a horse

ANESTHESIA - 2 (15 decks)

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