Chapter 193 - Pain Management in Critical Patients

Question 1

When pain is greater or lasting longer than you expected
despite attempts to treat it, there is a reason to suspect
one of several complications. What are some reasons?

Answer 1

Wound infection or dehiscence
Nerve impingement
Fracture
Ischemia
Bandage or splint pain
Gastric or esophageal ulceration
Urinary retention,
Delayed gastric emptying
Pancreatitis.

Question 2

Explain the adverse effects of opioids on body temperature in dogs and cats.

Answer 2

Dogs receiving mu-agonist opioids have altered thermoregulatory set points, leading to what is generally a non-clinically significant hypothermia of the order of 98 °F; efforts to warm dogs who are otherwise alert and stable just risks making them feel worse.

In cats, hyperthermia may occur, and hydromorphone
is particularly implicated. When cats appear
distressed, temperature monitoring and partial reversal
or a switch to buprenorphine and active cooling may be
necessary.

Question 3

Dysphoria induced with opioids?

Answer 3

The addition of tranquilizers or sedatives does not permanently resolve the condition. A dramatic response is seen following slow IV reversal of the opioid with 0.01 mg/kg naloxone or 0.1 mg/kg butorphanol. Generally within minutes, the patient becomes oriented to surroundings with more normal behavior, and does not experience more pain

Question 4

True or False?

When using buprenorphine, commonly used 0.01 mg/kg dose is thought to produce reliable analgesia as a sole analgesic.

Answer 4

Extensively studied in cats, buprenorphine is recommended to be given by the IV route when possible, and the commonly used 0.01 mg/kg dose is NOT thought to produce reliable analgesia as a sole analgesic.

Question 5

Some of the NSAIDs’ effects are not suitable in critical situations. Explain why?

Answer 5

1. The impact of NSAIDs on tissue repair (COX-2 mediated) makes them unsuitable in critical situations (e.g. compromised gastric mucosal integrity)
2. Prostaglandin inhibition is contraindicated in states of volume depletion, poor cardiac output, or with pre-existing renal compromise as the kidney relies on prostaglandins to improve renal blood flow.

Question 6

From a GI ulceration perspective, what is the washout times of NSAIDs?

Answer 6

From a GI ulceration perspective, washout times of 5–7 days between administration of different NSAIDs, with the exception of aspirin (>7 days recommended)

Question 7

Lidocaine should be used with caution and possibly lower doses in dogs with these conditions.

Answer 7

It should be used with caution and possibly lower doses in dogs with reduced serum albumin or poor cardiac output due to increased risk of toxicity.