Pain Management Flashcards
define pain according to the IASP definition
an unpleasant sensory and emotional experience associated with, or resembling that which is associated with, actual or potential tissue damage
what factors can the experience of pain be influenced by?
biological
psychological
social
define nociception according to the IASP definition
the neural process of encoding noxious stimuli (physiological processes)
what forms may the consequences of encoding of stimuli take?
autonomic
behavioral
is pain sensation implied when nociception occurs?
not necessarily
what is the key difference between nociception and pain?
nociception is the wiring part of the process
pain is how the patient interprets nociception
in two animals injected IM with the same technique are nociception and pain likely to be the same?
nociception is likely to be identical whereas pain, the feeling, interpretation and expression of response to nociceptive stimuli, is not.
define nociceptive pain according to the IASP definition
pain that arises from actual or threatened damage to non-neural tissues and is due to the activation of nociceptors
what is the term nociceptive pain used to describe?
pain occurring with a normally functioning somatosensory nervous system
define neuropathic pain according to the IASP definition
a lesion or disease of the somatosensory nervous system
what is the term neuropathic pain a clinical description of?
a demonstrable lesion or a disease
when is the term lesion used when discussing neuropathic pain?
when diagnostic investigations reveal an abnormality or where there was obvious trauma
when is the term disease commonly used when discussing neuropathic pain?
when the underlying cause of the lesion is known
what is the difference between nociceptive pain and neuropathic pain?
nociceptive pain arises from injury to non-neural tissue, neuropathic pain arises from damage to the somatosensory nervous system
why is it essential to avoid damaging neural tissue during elective surgical procedures?
so that neuropathic pain is is not caused alongside nociceptive
of nociceptive and neuropathic pain, which can be harder to treat?
neuropathic
what do the terms hyperalgesia and allodynia both describe?
changes in nociceptive processing that may occur in patients in an ongoing pain state
define hyperalgesia according to the IASP definition
increased pain from a stimulus that normally provokes pain (increased response at a normal threshold)
give an example of hyperalgesia
pressing on the skin can become painful if enough pressure is applied, however if the skin is bruised the pressure at which pain will be felt is much less (nociceptive threshold is lower)
define allodynia according to the IASP definition
pain due to a stimulus that does not normally produce pain
give an example of allodynia
due to underlying injury/disease a cat now finds being stroked (a non-noxious stimulus) painful
how long does acute pain last for?
a short period of time - minutes and hours to weeks
how long does chronic pain last for?
longer than a few weeks
what may happen if acute pain is not adequately treated?
may lead to a chronic pain state
what may chronic pain arise from?
chronic medical conditions such as osteoarthritis and skin disorders
is chronic pain generally protective or beneficial to the sufferer?
no it is usually detrimental
when may acute pain be productive?
can stop an animal from causing itself further damage
what can untreated or poorly treated pain lead to?
up-regulation of the pain processing system making the pain harder to treat and the establishment of pain states
what can be reduced by untreated or poorly treated chronic pain?
quality of life
why is recognition and quantification of pain so important?
if we cannot recognise pain we are unable to treat it
quantification allows categorisation of pain, assessment and judgements about quality of life to be made
what are the 3 key stages in the quantification of pain?
categorization of pain as absent, mild, moderate, severe
assess treatment efficacy
make judgements about quality of life
what does the categorization of pain as absent, mild, moderate and severe influence?
how we decide to treat the pain
how can treatment efficacy be assessed?
observing weather pain score reduces if a treatment is used
what judgements about quality of life may be made using quantification of pain?
should the animal be treated or is euthanasia a prefurrable option?
what is the key challenge of assessing pain in animals?
they cannot talk
what can be used to assess pain?
behavioural signs
physiological signs
what are the physiological signs associated with pain?
increased HR, blood pressure and body temperature
altered respiration (rate and pattern)
stress hormones increasing
EEG (electroencephalogram) activity
what is a key issue with using physiological signs to indicate pain?
they are non-specific and may increase or decrease along with things other than pain
what stress hormones could be used to indicate pain?
cortisol, noradrenaline and adrenaline
what is the difficulty of using EEG to determine presence of pain?
is this pain or nociception
are behavioural signs of pain species specific?
yes
why may behavioural signs of pain vary between individuals within a species?
depending on temperament or their response to a stressful environment which may cause them to hide pain
why do prey species tend to hide signs of pain?
so they do not stand out to a predator
what are behavioural signs associated with pain specific to?
species
individual
condition
what are the shared behavioural signs associated with pain exhibited by cats and dogs?
hunched appearance 'pain' face lack of grooming inappetance specific signs (e.g. lameness)
what are the behavioural signs associated with pain that are specific to cats?
absence of normal behavioural repertoire hide away at back of cage unwilling to relax fear-aggression resent human contact
what are the behavioural signs associated with pain that are specific to dogs?
positive behavioural signs rather than reduced repertoire
more likely to seek attention
submissive
more likely to vocalize
what are the behavioural signs associated with pain that are specific to rabbits?
immobility profound depression eyes half closed or shut not grooming avoiding attention isolating themselves from other animals bruxism abnormal body position such as a hunched posture and abdominal pressing change in temperament
when is immobility in rabbits particularly acute?
post-op or traumatic pain however they may show this behaviour in unusual environments when there is no pain at all
define bruxism
tooth grinding
what is an essential consideration when handling animals in pain?
prey animals with a strong fight or flight response which means that they can react violently to severe pain
what are the behavioural signs associated with pain that are specific to horses?
low head carriage horse at back of stable vocalisation (groaning or neighing) agitation restlessness weight-shifting tail swishing (with no flies present) lameness limb lifting abnormal distribution of weight 'tucked up' appearance looking at painful body part 'pain face' bruxism sweating muscle fasciculations
what are the main chronic pain indicators in all species?
changes in normal behaviour described by owner (may be put down to animal getting older or slowing down)
unkempt coat if grooming is difficult
loss of body condition/ weight loss due to appetite loss and/or loss of muscle tone if exercising less
slowing down/sleeping more
could also be more restless/fidgety
reluctance to move possibly described as a loss of training (e.g. peeing in the house because they can’t get outside)
difficulty in accessing higher places
what is the NRS?
numerical rating scale which requires patient to assign their pain a score from 1-10
what is VAS?
visual analogue scale which requires patient to make a mark on a line from 1-10 to demonstrate level of pain. The position of the mark on the line is then measured to assign a number
what is SDS?
simple descriptive scale where patients assign themselves a category relating to a description of a pain level that is matched to a number
what can be used to score pain in animal patients?
NRS, VAS or SDS
who awards the scores during pain assessment of animals?
caregiver
what can make pain scoring more accurate?
dynamic interaction with animal rather than just observing
what is an issue with using NRS, VAS or SDS in a veterinary environment?
interobserver variation which can be an issue in a practice where there is likely to be multiple caregivers
what is the purpose of composite pain scales?
over come some of the limitations of the VAS, NRS and SDS
how do composite pain scales work?
multiple items are assessed for each patient and given a score. These are them added to give an overall score
what must happen to composite pain scales in order for them to be useful?
must be validated which requires lots of clinical testing
what is often suggested by composite pain scales?
an intervention level/ score at which the patient should receive an intervention (analgesic medication)
what is the composite pain scale used for dogs?
SF-GCPS: glasgow composite pain scale
what is the SF-GCPS score out of if the dog cannot stand?
20
what is the SF-GCPS score out of if the dog can stand?
24
what is the intervention level of the SF-GCPS?
5/20 or 6/24
what is the drawback of the SF-GCPS?
poor differentiation between sedation and pain which is an issue immediately post-op
what is the composite pain scale used for cats?
CMPS
what is the maximum score of the CMPS?
20
what is the recommended intervention level of the CMPS?
5/20
what is essential to remember when filling in composite pain scores?
follow the order and scores on the sheet
are there composite pain scores for rabbits and horses?
not really at the moment
when may owners be helpful in filling in pain scoring?
to show pain levels over time and levels when not in the veterinary environment. Useful for post-op or chronic pain
what is involved in chronic pain assessment?
can use VAS, NRS, SDS and CPS for a snapshot of pain at a specific time but may want to include other elements such as appetite and sleep over a period of time
are there chronic pain composite pain scores available?
yes, tend to be condition and species specific used to collect data on pain and impact on life functions
with owner pain scoring of chronic pain what are the questions more often about?
quality of life as opposed to specific questions about pain at a single point in time
how does the LOAD questionnaire for OA work?
each of the mobility questions is given a score from 0-4 (not present to most severe). The LOAD score is the sum of the questions
what is another way of monitoring chronic pain?
client specific outcome measures
what is involved with client specific outcome measures?
along with owner 4 or 5 different behaviours are identified that the animal normally performs (or used to)
changes in the frequency of these behaviours or activities are recorded over time (usually from the start of analgesic therapy)
what is a key benefit of client specific outcome measures?
very specific to pet (tailored)
quick to complete
easy to track changes over time
what are the main advantages of owner questionnaires for chronic pain?
allow owner and clinician to see impact of pain on quality of life and the impact of external factors like weather and exercise on pain and quality of life
allows ongoing monitoring and assessment of interventions
what is the benefit of videos as add on or stand alone assessment?
can be shared within the team
behaviour can be shown in the animals natural environment
week on week records can help to detect changes
visible evidence of improvement may improve owner compliance with medication
owner and vet team can see how other factors affect behaviour
any species
why is assessment of health related quality of life useful?
aids decision making about requirement for analgesia or timing of euthanasia
improved patient well-being through holistic/global care
improve continuity of treatment between clinicians or treatment centres
help to build and maintain owner and veterinary professional relationships
what is involved in health-related quality of life assessment?
assessment of quality of life in relation to analgesia and chronic pain
what is preventative anaesthesia?
administration of effective analgesia before, during and after the surgery/procedure, well into the post operative recovery period
what is the aim of preventative analgesia?
prevention of upregulation of the nervous system in the presence of noxious stimuli (e.g. surgery) by administering effective analgesia
what should be seen in response to preventative analgesia?
reduction both in intensity and duration of acute pain and a reduction in persistent (chronic) pain
what is multi-modal analgesia?
using different classes of analgesic agents/techniques to attempt to over come the fact that there is no single analgesic agent that can block all nociceptive/pain pathways
what is a benefit of multi-modal analgesia?
leads to more effective analgesia often with lower doses of analgesic agents
what are the 6 main analgesic agents used in veterinary practice?
opioids NSAIDs local anaesthetics Alpha-2 agonists ketamine others/misc
what is different about alpha 2 agonists and ketamine?
alpha-2 agonists are sedatives which are analgesic
ketamine is an anaesthetic that is analgesic
rather than being only analgesics
what schedule of drugs are full opioid agonists?
schedule 2
give an example of 2 full opioid agonists
methadone and fentanyl
what schedule of controlled drugs are partial opioid agonists?
schedule 3
give an example of 2 partial opioid agonists
buprenorphine and butorphanol
what are the requirements for schedule 2 drugs?
special prescription, storage, destruction and record keeping
what are the requirements for schedule 3 drugs
special prescription and some have special storage requirements (e.g. bupe must be locked away)
where do opioids licensed for cats, dogs and horses act within the body?
endogenous opioid receptors primarily in the brain and spinal cord
what are the 3 key opioid receptors?
delta, kappa and mu
what sorts of agonists may opioids be?
full agonists, partial agonists, mixed agonist antagonist or antagonist
give an example of an opioid mixed agonist-antagonist
butorphanol
give an example of an opioid antagonist
naloxone
which type of receptor agonists are associated with analgesia?
mu
what type of agonists provide the most effective analgesia?
full mu agonists
under what circumstances are opioids used?
acute pain - preventative and part of multi-modal analgesia regimens
define potency
mg/kg of drug required to show effect
define efficacy in terms of drugs
the maximum response possible from a specific drug
why is fentanyl so dangerous?
is highly potent and efficacious - very little required to overdose
how may opioids be administered?
IV oral SC IM buccal
what opioid must not be given IV?
pethidine
what drug may not be so effective when given SC to cats?
buprenorphine
how does buccal administration differ from oral?
buccal requires transmucosal absorption by oral mucous membranes, oral medication is absorbed in the small intestine
why is there poor bio-availability of orally administered opioids?
significant first pass metabolism so they are broken down very quickly and easily by the liver
what does poor bio-availability of opioids mean for chronic pain?
limited role in management of chronic pain
give an example of a short acting mu agonist
fentanyl
when are short acting mu agonists used?
intra-operative and short term infusion
give an example of a long acting full mu agonist
methadone
when are long acting full mu agonists used?
general use for acute and pre, peri and post operative pain
how long do long acting full mu agonists tend to last?
2-4hr
give an example of a partial mu agonist
buprenorphine
when are partial mu agonists often used?
general use for acute and pre, peri and postoperative pain
how long to partial mu agonists last for?
6hrs
give an example of a K agonist and mu receptor
butorphanol
when would a mixed K agonist and mu receptor be used?
general use for acute and pre, peri and postoperative pain
how long do mixed K agonist and mu receptor drugs last for?
2hrs
what are the key side effects of opioid use at clinical doses?
respiratory depression sedation excitation minimal effect on inotropy bradycardia nausea and vomiting antitussive decrease GI motility various effects on urinary system
when are respiratory depression effects most often seen when using opioids?
dose dependent and mostly during anaesthesia
when are sedation side effects seen during opioid use?
species and dose dependant, more sedation seen in dogs
when is excitation often seen as a side effect of opioid use?
at high doses particularly in pain free animals. can cause box walking in horses and excitement in cats
what is inotropy?
force of heart contraction