5. Perioperative Pain Management Flashcards

1
Q
  1. Identify the 5 steps of the pain pathway and types of pain
A

transduction, transmission, modulation, projection, perception
Types: somatic v. visceral; acute v. chronic(pathologic)

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2
Q
  1. Be aware of options for assessing pain in small animals
A
  • get pre and post op pain scores
  • many systems: simple descriptive, numerical, visual analog (have the same trained observer score the pain for these 3)
  • Also glascow (multidimentional), CSU feline acute pain scale (non verified yet)
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3
Q
  1. Know common drugs and MOA used for small animal analgesia
A
  1. Opioids - (modulation, dorsal horn) full mu, partial, ag/antag
  2. NSAIDs - block COX (transduction and modulation)
  3. local anesthetics - Na channel blockers (Transmission) (Also systemically, MOA unknown)
  4. NMDA antagonists (modulation) help with chronic/neuropathic pain, and prevent windup
  5. alpha 2 agonists - (modulation) alpha 2 receptor in cord, brain, and periphery, may have local anesthetic effects
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4
Q
  1. Define Multimodal analgesia and be able to develop an analgesic plan for perioperative patient care
A

use different MOA drugs to cover multiple parts of pain pathway
- some drugs work synergistically to decrease doses, cost, drug consumption

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5
Q

side effects of full mu agonists

A

respiratory depression, bradycardia, dec. GI motility

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6
Q

partial my agonists

A

buprenorphine, tramadol, has a ceiling effect

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7
Q

agonist-antagonist opioids

A

not very effective

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8
Q

alpha 2s in small animals v. other species

A

not good enough for primary method of pain control in small animals, adjunctive only.

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9
Q

nmda antagonists

A

ketamine
amantadine - oral
methadone (nmda and full mu)

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10
Q

adjunctive agents for pain control

A
  1. gabapentin (modulation - CNS Ca channels) neuropathic/chronic pain
  2. Acetaminophen (COX3, maybe cannabinoid receptors)
    NOT IN CATS -> MetHbemia
  3. Maropitant - NK1 antag, may do some visceral analgesia
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11
Q

What happens to arachadonic acid after tissue injury?

A

broken to thromboxanes, PGFs from COX

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12
Q

COX1

A

constitutive enzyme, always there

produces PGE2, I2, TXA2 (prostanoids for homeostasis in kidneys, GI, platelets)

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13
Q

COX2

A

Inducible Enzyme, upregulated with inflammation (though technically still constitutive)
produces PGE2, PGI2, also for homeostasis (GI ulcer healing, renal BF)

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14
Q

COX constitutive enzymes?

A

Both of them!!! They’re both needed, both important for homeostasis

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15
Q

Inhibitory Ratio of nsaids

A

plasma concentration needed to inhibit Cox1:cox2

Because it was thought to minimize side effects by targeting COX2

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16
Q

Which drugs target Cox2?

A

the ones that end in -oxib are actually cox2 preferential
(carprofen only mildly cox2 preferential)
BUT THEY STILL BLOCK COX1 SOME

17
Q

Basic pharmacokinetics of NSAIDs

A
  1. good bioavailability PO, but feeding alters (give carprofen with food, robenacoxib fasted)
  2. heavily protein bound (reduce dose in hypoproteinemic)
18
Q

plasma concentration of nsaids ________ reflect analgesic property

A

do not

19
Q

GI side effects of nsaids

A

cox1 - maintains cellular integrity
cox2 - repairs GI mucosa
- inappetance, v/d, inflam, melena, ulceration, perforation
** most common reason to discontinue nsaids

20
Q

risk factors for GI injury with NSAIDs

A
  • inappropriate dosing
  • given with steroids
  • given with pre-existing GI disease
21
Q

risk factors for GI injury with NSAIDs

A
  • inappropriate dosing
  • given with steroids
  • given with pre-existing GI disease
22
Q

Tx for GI side effects nsaids?

A
  • discontinue
  • palliative (fluids, bland diet)
  • give H2 blocker/Famotidine or PPI/omeprazole, pantaprozole (if signs of ulceration, like melena)
  • misoprostol (PGE1 analog for GI integrity)
  • use different nsaid in future
  • alternative analgesia
23
Q

renal effects of nsaids

A

not directly nephrotoxic but can cause AKI. regulate BF to kidney and amount of diuresis

24
Q

use nsaid in cats with mild/mod chronic renal disease?

A

yes with oral low dose

25
Q

risk factors for causing renal injury with nsaids

A
preexisting hypovolemia, dehydration, shock
preexisting disease
inappropriate dose
steroids
general anesthesia
26
Q

hepatic effects of nsaids

A
idiosyncratic reaction (not related to dose) 
inc. enzymes, bili
27
Q

coagulation effects of nsaids

A

cox1 prod thromboxaneA2

they can affect platelet coag, but only ASPIRIN is real concern, irreversibly bind COX1, needs 7 day wash out period

28
Q

Acetaminophen

A
  • central acting cox inhibitor, no GI, kidney, platelet effect
  • bioavailability is poor, not good for analgesia
  • NOT IN CATS, they have to use sulfonidation with causes oxidative damage (toxic dose is super high in dogs however because they can do glucaronidation)
29
Q

galliprant

A

approved in dogs only
specific for EP4 receptor, does not inhibit cox/prostaglandins
high margin of safety

30
Q

When to give?

A

if preop, synergism with opiods, pre-emptive analgesia, but more adverse effects during surgery
(pro and con to both)

31
Q

should you give if post op

A

not if uncontrolled hemorrhage, intra-op hypotension, renal/GI surgery

32
Q

long term nsaids?

A

frequently recheck bloodwork and do UA before starting. discontinue if animal is not improving

33
Q

Should you change nsaids if you have adverse reaction to first?

A

yyeeaahhh

7 day waiting period (not proven, except for aspirin)