Perioperative Pain Management

Question 1

Analgesic plan

Answer 1

-preventative
-multimodal (max analgesia, minimize side effects)
-flexible

Question 2

Multimodal analgesic

Answer 2

1. Opioid
2. NSAID
3. Local anesthetic
4. alpha 2 agonist
5. Analgesic adjuncts (ketamine, lidocaine, gabapentin) if needed
6. Use nonpharmacologic techniques to minimize pain

Question 3

Other conditions that may interfere with pain score

Answer 3

-emergence delirium
-dysphoria
-anxiety

Question 4

How to determine pain?

Answer 4

-animals can be temporarily distracted
-calmed by interaction and will resume behaviour when left alone
-source of pain can be ID’d
-opioids improve situation

Question 5

How to determine emergence delirium?

Answer 5

-anesthesia related behaviour… residual inhalant anesthesia
-only in immediate recovery period (after intubation)
-self limiting and resolves in several mins

*sometimes need sedation

Question 6

How to determine dysphoria?

Answer 6

-Rxn of overdose of opioids
-animals difficult to distract or calm by interaction
-dont respond to light palpation of area

Question 7

Treatment of Dysphoria

Answer 7

1.Sedation- low dose acepromazine, dexmedetomidine

2. Partial opioid reversal (careful titration)
   -Butorphanol (mu antagonist, kappa agonist)- keep pain and reverse negative effects of mu
   -Naloxon (mu antagonist)

Question 8

How to determine Anxiety?

Answer 8

-Animals can be temporarily distracted
-calmed by interaction but will resume when left alone
-no source of pain can be ID’d
-fear and anxiety can affect how pain is experienced

-animals responsive to TLC, anxiety drugs (traz, gaba, acepromazine), sedation
-limit time in hospital

Question 9

Mu opioids

Answer 9

Analgesia, sedation, vomiting, bradycardia, resp depression

Reversible with Naloxone
-IV slow, short duration-side effects: hypertension, tachycardia, CNS stimulation

Question 10

Hydromorphone side effects

Answer 10

-panting in dogs
-nausea and vomiting
-dysphoria, hyperthermia in cats
-respiratory depression, bradycardia
-urine retention, GI ileus

Question 11

Buprenorphine

Answer 11

-partial mu agonist
-popular in cats
-slow onset time
-rarely causes vomiting or dysphoria
-euphoria in cats
-mild to moderate pain

AVOID if using pure mu agonist in near future

Question 12

Butorphanol

Answer 12

-kappa agonist
-can reverse mu opioid agonist
-30-90mins
-weak analgesic
-mild sedation
-potent antitussive
-does not cause panting in dogs

Question 13

CRI of opioids

Answer 13

-consistent levels of analgesia
-adverse effects minimized
-less drug used overall

-Fentanyl

Question 14

Fentanyl

Answer 14

-low dose in awake patients
-high does intraoperatively
-bolus: onset 1-2mins, duration 20-30mins

-analgesia, sedative, respiratory depression