Week 4 - pain management

Question 1

The pain response is unique to each individual and involves two components:

Answer 1

(1) the sensory component is nociception, which is the neural processing of noxious stimuli

(2) the affective component is pain perception, which is the unpleasant sensory and motional experience associated with either actual or potential tissue damage.

Question 2

Acute pain vs chronic

Answer 2

Acute pain has been defined as pain that exists during the expected time of inflammation and healing after injury (up to 3 mo)

Chronic pain is defined as that which exists beyond the expected duration associated with acute pain
(pain that persists beyond the normal healing time or pain that persists in conditions where healing has not or will not occur)

Question 3

The PLATTER Approach to Pain Management

Answer 3

PLan
Anticipate
TreaT
Evaluate
Return

Question 4

Non-pharmacologic pain management examples (at least 3)

Answer 4

cold compression
acupuncture
physical rehabilitation/ therapy
therapeutic laser/ laser therapy

Question 5

What is considered the ‘‘fourth vital sign,’’ after temperature, pulse, and respiration

Answer 5

a pain score

Question 6

Chronic Pain: Characteristics

Answer 6

• Diminished exercise tolerance and general activity
• Difficulty standing, walking, taking stairs, jumping, or getting up
• Decreased grooming (cats especially)
• Changes in either urination or defecation habits

Question 7

Chronic Pain -> Causes

Answer 7

Under-recognized and undermanaged chronic pain can result in premature euthanasia.

Proper recognition and management of chronic pain can be as life preserving as any other medical treatment in veterinary medicine

Question 8

Butorphanol in dogs , what can be different about its analgesia?

Answer 8

In dogs, the l antagonist/ j agonist butorphanol in particular appears to have limited somatic analgesia and very short duration of visceral analgesia

Question 9

Opioids should be used as a routine —– medicant ?

Answer 9

Opioids should be used as a routine preoperative medicant, preferentially in combination with a tranquilizer/sedative

Question 10

buprenorphine is preferred over butorphanol in cats, why?

Answer 10

buprenorphine administered before surgery and during wound closure provided adequate analgesia for 6 hr following ovariohysterectomy in cats, whereas butorphanol did not

Question 11

What is the preferred method for administering opioids in cats?

Answer 11

In cats, the subcutaneous route of opioid administration is not recommended.

IM and IV routes are preferred both pre- and postoperatively.

The oral transmucosal or buccal route of administration for buprenorphine may also have clinical efficacy as well

Question 12

Opioids are what with a-2 adrenergic agonists?

Answer 12

Opioids are synergistic with a-2 adrenergic agonists

Question 13

Opioids and patients undergoing major surgery..

Answer 13

• Periodic readministration of parenteral opioids.
• Constant or variable rate infusion. Calculators can be found online.

*Long-acting formulations and technologies (transdermal fentanyl product in dogs or concentrated injectable buprenorphine product for cats).

*Oral opioids (No comparable studies exist for cats).

Question 14

NSAID - why use them

Answer 14

The majority of conditions that cause pain have an inflammatory component. Nonsteroidal anti-inflammatory drugs (NSAIDs) are a mainstay for management of chronic pain as well as for perioperative use

Question 15

Non-approved NSAIDs (4)

Answer 15

aspirin,
ibuprofen,
naproxen
meloxicam for human use

Question 16

Risks of Nonsteroidal Anti-Inflammatory Drugs

Answer 16

• gastrointestinal (GI) toxicity- vomiting, diarrhea, and inappetence
• erosions and ulcers
• nephrotoxicity - importance of maintaining a normotensive state during anesthesia
• hepatocellular necrosis
• delayed bone healing in rabbit and rodent

Question 17

Nine Ways to Minimize the Risks of Nonsteroidal Anti-Inflammatory Drugs (NSAIDs)

Answer 17

1. Obtain a complete medication history.
2. Be discriminating in patient selection.
3. Provide verbal and written client instructions
4. Recognize the earliest signs of adverse events
5. Perform laboratory monitoring.
6. Utilize a balanced, integrated analgesic approach as part of NSAID-sparing strategies.
7. Consider washout periods.
   Based on pharmacokinetics, practitioners who wish to err on the side of caution may want to withhold meloxicam for 5 days and other NSAIDs or short-acting corticosteroids for 7 days prior to initiating treatment with another NSAID.
8. Use gastroprotectants
9. Dose optimization.

Question 18

Only class of drug that renders complete analgesia?

Answer 18

local anaesthetics (LAs)

Question 19

a-2 Adrenergic Agonists …

Answer 19

a-2 Adrenergic receptors are located with opioid receptors.
Thus, the two drug classes used together are highly synergistic for sedation and analgesia

Question 20

Ketamine …

Answer 20

• dissociative anesthetic
• Ketamine is particularly useful in veterinary practice for the following reasons:

1. Anesthetic Induction
2. Sedation and Restraint:
3. Pain Management: Ketamine has analgesic properties, making it effective for controlling moderate to severe pain, especially in surgical or traumatic conditions.

Subanesthetic ketamine constant rate infusion (CRI) prevents pain and has antihyperalgesic, and antiallodynic effects

Question 21

Systemic Lidocaine

Answer 21

• local and topical anaesthesia

Various formulations for a combination of orphine, lidocaine, and ketamine CRIs have been described in dogs

Question 22

Tramadol …

Answer 22

• opiate analgesic
• use oral tramadol in a flavored compounded form (the drug is otherwise quite bitter)

Question 23

Gabapentin

Answer 23

• is an anticonvulsant with analgesic properties
• Cats with Degenerative joint disease (DJD) and of chronic musculoskeletal pain
• Dogs with Degenerative joint disease (DJD)
• 8–12 hr dosing interval has been suggested

Question 24

Adverse effect of Gabapentin in dogs?

Answer 24

somnolence

Question 25

Bisphosphonates …

Answer 25

pain relief in dogs with bone cancer (IV infusion)

Question 26

Corticosteroids …

Answer 26

• anti-inflammatory and immunosuppressive agents
• not primarily analgesic drugs,
• may exert a pain-modifying effect by reducing inflammation

Question 27

Pain management for dogs and catsundergoing a surgical procedure include the following …(3)

Answer 27

1. a preoperative opioid plus a tranquilliser / sedative
   (eg. acepromazine & midazolam OR diazepam & dexmedotomidine)
2. Administration of NSAID either pre or postoperatively based on patient risk factors and clinician preference
3. A LA

Question 28

For patients undergoing procedures with risk, thefollowing interventions or drugs should be strongly considered (6)

Answer 28

• cold compression
• a-2 adrenergic agonist
• ketamine CRI
• lidocaine CRI
• gabapentin
• epidural anesthetic

Question 29

Canine DJD: Therapeutic Considerations

Answer 29

weight loss

NSAID administration (Some dogs may require several weeks of NSAID treatment before clinical improvement is noted)

PSGAGs are more likely to have a beneficial effect when given early in the disease process (Polysulfated Glycosaminoglycans)

therapeutic exercise

Question 30

Feline DJD: Therapeutic Considerations

Answer 30

Treatment of DJD in cats should focus on environmental modification in addition to pharmacologic therapy.

NSAIDs are the mainstay of pharmacologic treatment for DJD in other species, and there is considerable evidence to support their effectiveness in cats as well

(Low-dose meloxicam (i.e., 0.01–0.03 mg/kg per os q 24 hr) is effective in treating arthritic cats and is well-tolerated even in cats with chronic kidney disease (CKD) provided their clinical status is stable.)