Pain Management in Emergency Patientscolour-2

2/15/2015
Overview
What am I treating?
How do I know if I am being
successful?
Why are emergency patients
Pain management in the different?
emergency patient Some ideas and examples
first do no harm!
Louise Clark DiplECVAA MRCVS
Louise Clark Dipl. ECVAA MRCVS

www.vetspecialists.co.uk www.vetspecialists.co.uk
What is pain? What is pain?
Important to understand what pain “is” or It is not a stimulus

“is not” It is not a defined response from the
animal
It requires that the animal is conscious
It is perceived in the higher centres
What is pain? Pain is always subjective
Pain is an unpleasant sensory and emotional

experience associated with actual or It is what the
potential tissue damage or described in patient says
terms of such damage (IASP definition) (expresses) that it
is!
“The inability to communicate verbally does
not negate the possibility that an individual
is experiencing pain and is in need of
appropriate pain-relieving treatment”
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Perception Why is pain management

perception
•End result of the neuronal activity of pain important?
Transmission occurs in transmission
three stages: •Conscious multidimensional experience
Ethical considerations
•from the site of
transduction along the Pain is a physiological stressor
nociceptor fibres to the → affects health, recovery from illness &
dorsal horn in the spinal Transduction
cord surgery
•from the spinal cord to •Nociceptors of C and
the brain stem A-delta fibres respond Severe or persistent pain can lead to
•through thalamus to to noxious stimuli maladaptive (pathological) pain
cortex and higher levels •e.g. trauma, surgery,
of the brain •Mechanical thermal
or chemical
•Somatic and visceral
transduction
central sensitisationModulation
transmission
•Changing or inhibiting transmission
•Multiple, complex pathways
•Release of inhibitory neurotransmitters
•E.g. endogenous opioids; serotonin; GABA
Pain assessment – How do I

What are the aims of pain relief?
know if my patient is painful?
Reduce neuro-endocrine stress response Medical benefits
Attenuate peripheral and central Moral and ethical obligation
sensitisation reduce chronic pain Improve animal welfare
Maintain tissue perfusion Pain assessment not easy!
Promote restful sleep Self report = Gold Standard
Improve appetite Surrogate scales with behavioural signs
Promote early mobilisation Signs of pain not consistent
Have a happy patient Differentiation between pain & anxiety
Pain assessment – what is

Behaviour
normal?
Changes in specific behaviour can be classified as:

Get to know the individual
• Posture Personality
• Gait
Before surgery
• Activity
• Facial expression Normal behaviour
• Vocalisation Difficult when patient
• Mental state presented in distress
• Evoked behaviour Like and dislikes
• Behaviour patterns
Questionnaires?
• Response to analgesics
©FAB website
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Practical assessment Pain Scales
All pain scales are subjective

Human assessor making a value judgement
Expression of abnormal behaviours
Based on previous experience of pain
Altered posture
Restlessness
Hiding (especially cats)
Inappropriate elimination,
vocalization, aggression/lack of ……
Decreased interaction (pets/family)
Altered facial expression
Factors contributing to restricted

use of analgesic agents
Poor understanding of pain
pathophysiology
Poor pain assessment
‘Pain helps to limit activity post-
operatively’
Concern about adverse effects of
analgesic agents
Dependency on clinical pain as
diagnostic aid
www.gla.ac.uk/faculties/vet/smallanimalhospital/ourservices/p
ainmanagementandacupuncture/
How do I know if I am being

Pain assessment
successful?
Vital for effective pain management
One size does not fit all
Adjust plan depending upon feedback from
the animal
Objective assessment
Subjective assessment
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Are emergency patients any Are emergency patients any

different? different?
NO YES
Requirement for analgesia
Major surgical procedures e.g. GDV More vulnerable to negative effects of drugs
Severe medical conditions e.g. trauma Care must be given to
Requirement for pain assessment • drug selection
• method of administration
• patient monitoring
Drug selection Method of administration
Knowledge of pharmacology Parenteral administration → systemic side

Side effects more pronounced where organ effects
function limited Titration to effect
• E.g. NSAIDS in renal dysfunction ± hypotension • Intravenous preferable to intramuscular
Prolonged duration of action route?
• E.g. Compromised liver function in sepsis • More rapid onset
Increased dosing interval • Less effects of hypo-perfusion
Inappropriate response/increased sensitivity Local anaesthetic techniques
• E.g. Opioids in head injury • Avoidance of systemic side effects
• Very effective analgesia
Patient monitoring Preventive analgesia
Repeated pain assessment

May demonstrate only subtle indicators of Before surgery
pain especially if very obtunded
Nursing & procedural interventions can
cause pain During surgery
More reliance on assessment of physiological
parameters over behavioural signs After surgery
More intensive monitoring of efficacy and
side effects
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2/15/2015
Pain management Nursing
Nursing Tender loving care

Feeding provides comfort
Surgical considerations Support injured limbs
Medical treatments Relieve full bladders
Restful environment
Promote sleep
Surgical considerations Analgesic Drugs
Minimise surgical trauma Non-steroidal anti-inflammatory agents

Tissue handling
Avoid nerve damage Opioids
Minimise tension in wound closure
Local anaesthetics
Alpha-2 adrenoreceptor agonists
Miscellaneous drugs with analgesic

properties…
• Ketamine, amantadine
• Gabapentin
• Tricyclic antidepressants...
Why multimodal?
Local anaesthetics, opioids,
Volatile
α2-agonists, NSAIDs, NMDA
anaesthetics
antagonists Target multiple sites in pain pathways
opioids,
Modulate Nociceptive system is “plastic” and
α2-agonists spinal pathways
Inhibit perception
ever changing
(central sensitisation)
Novel modes of action of many new
and rediscovered drugs
MULTIMODAL ANALGESIA Target therapy to the problem
Inhibit Inhibit
transmission transduction
(impulse conduction) (peripheral sensitisation)
NSAIDs
local anaesthetics
opioids
α2-agonists
local anaesthetics
opioids
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NSAIDS Opioids
Extreme care where: Two types of opioid in clinical use:

Haemorrhage • full agonists (agonists at the µ/OP3 receptor)
• partial agonists (agonists that do not give a full
Hypotension effect)
Liver dysfunction Pure or full agonists give a predictable effect
Renal dysfunction which increases as the dose increases
Coagulation (especially platelet) problems Partial agonist will have increasing effect up
to a certain dose but after that a ceiling
Avoid until patient is fully assessed and effect is produced
haemodynamically stable Side effects follow the same rules and will
increase with the dose
Opioids Pethidine
Produce analgesia for inflammatory pain Full agonist providing analgesia and
Not very effective for neuropathic pain sedation
Most cause sedation Spasmolytic properties - useful for visceral
Dysphoria occasionally with high doses or in pain
non- painful animals Short duration limits its use (max. 90
Potential for respiratory depression but minutes)
unlikely in clinical use Should not be administered intravenously as
In non-painful animals nausea can be seen this can lead to massive histamine release
Vomiting may occur with morphine Pain on intramuscular injection and also a
large volume of drug to inject
Morphine Methadone
Full agonist Synthetic opioid

Duration of action is dose Approximately equipotent to morphine
dependent Less nausea
Can be administered by Ideal for patients where vomiting needs
slow intravenous injection to be avoided after pre-medication
Safe to use in cats at Licensed in Europe cats and dogs
relevant doses
Intra-articular use
(0.1mg/kg)
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2/15/2015
Butorphanol Buprenorphine
κ agonist, can be used for mild pain Partial µ agonist - ceiling effects well
above clinically applicable doses
NOT good for severe pain
Licensed in Europe
Potent sedative
Dose 20mcg/kg in cats and dogs
Excellent sedation combined with
phenothiazines or alpha 2 agonists Slow onset time and prolonged duration
of action depending on the dose used
Buccal absorption similar to that of
intravenous injection in cats
Buccal absorption also in dogs
Multidose vials STING on injection
Drug choices – local anaesthetics perception
Use to reduce opioid

requirements
Reduce anaesthetic
requirements
“Perfect analgesics”
CNS remains naive
transduction
central sensitisation Block transmission
Drug choices – systemic lidocaine

Local Anaesthetics
Inhibition of sodium channels
routes of administration sites of action
Constant rate infusion
•Extra/epidural central Good analgesia
•Local eg intra-articular peripheral Some sedation
•Regional techniques DOGS only
•Specific nerve blocks NOT CATS
•Systemic bolus/infusion
lidocaine Mechanism not fully understood
bupivacaine
ropivacaine
Block action potential transmission in all nerve fibres,
including those transmitting nociceptive information
The “perfect analgesic”
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Drug choices – systemic lidocaine Drug choices - Paracetamol
1mg/kg IV loading dose Adjunct analgesic

Followed by 30µg/kg/min CRI use in conjunction with opioids/steroids/NSAIDS
Care - metabolism liver blood flow dependent NOT CATS
Observe for side effects Avoid where concerns about liver function
• Nausea (lick face, yawning) Useful if polyarthritis/meningitis
• Twitching 10 mg/kg bid short term
• Ultimately seizures NB: check dosing with Pardale
ONLY lidocaine
NEVER use bupivacaine
Observed cases!
Drug choices - ketamine Drug choices - ketamine
NMDA receptor antagonist Useful adjunct analgesic - reduces opioid

May reduce central sensitisation requirement
Treatment of neuropathic pain ? Doses 0.1mg/kg or 0.6mg/kg/hour reducing
to 0.3 mg/kg/hour post-operatively
Can continue dose for up to 72 hours
Limited literature!
Drug choices – α2 agonists Drug choices – α2 agonists
Potent analgesics Role for very low doses - post-operative

Significant CVS effects 1-2 mcg/kg medetomidine as single dose
Synergism with opioids Usual dose is 1-2 mcg/kg/hr medetomidine
Sedation can make pain assessment difficult Halve this for dexmedetomidine
Potentiate analgesia and sedation 0.5 -1 mcg/kg/hour dexmedetomidine
Allows normal sleep Cats 2-5 µg/kg/hr (anecdotal!)
Useful for managing difficult recoveries
Be aware of nursing issues – hypothermia etc.
Some animals become refractory to sedation
after 24-48 hours
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2/15/2015
Gunshot injury to scapula Gunshot injury to scapula
Presented “flat” Methadone 0.3mg/kg IM

Tachycardic – 230 bpm IV access obtained
ECG – sinus tachycardia Fluids bolus 10ml/kg crystalloid x 2
Minimum database - WNL Ketamine 0.25mg/kg slow IV
No CXR HR decreased to 160bpm
Received fluids at RVS Subjectively more comfortable
Dry mucous membranes GA for wound assessment and
Pale ? Vasoconstricted debridement
Methadone 0.1mg/kg at RVS Bupivacaine splash block at surgery
Ketamine CRI 5 → 2 mcg/kg/min
NSAIDS started following day
Hindlimb/inguinal crush injury Hindlimb/inguinal crush injury
Massive blunt trauma Methadone 0.3mg/kg

Transfused at RVS Still agitated and tachycardic
Surgery at RVS to pack wound Fentanyl 5mcg/kg prior to GA → relaxed
H & B – mild anaemia, CK ↑↑↑ Fentanyl 20mcg/kg/hour during GA
No IV access
Emergency surgery to assess Other options:
wound, place central line and IDUC Ketamine CRI/ Lidocaine CRI
Methylprednisolone at RVS Epidural catheter – concern re extent
necrosis
“splash block” – infected ? efficacy
NSAIDS – received steroids at RVS
Thoracotomy for lobectomy Conclusion
Opioid in pre-medication Analgesia should be:

Intercostal nerve block
NSAIDS at end of procedure Planned
Further opioids during and at end of Preventive
procedure Multi-modal
Appropriate for the procedure
Other options: Tailored to the needs of the individual
Epidural morphine? Based on the results of pain assessment
CRI ketamine/lidocaine not required
on basis of pain assessment
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2/15/2015
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2/15/2015

Louise Clark Dipl. ECVAA MRCVS

What is pain? What is pain?

Important to understand what pain “is” or It is not a stimulus

What is pain? Pain is always subjective

Pain is an unpleasant sensory and emotional

Perception Why is pain management

Pain assessment – How do I

Pain assessment – what is

Changes in specific behaviour can be classified as:

Practical assessment Pain Scales

All pain scales are subjective

Factors contributing to restricted

How do I know if I am being

Are emergency patients any Are emergency patients any

Drug selection Method of administration

Knowledge of pharmacology Parenteral administration → systemic side

Patient monitoring Preventive analgesia

Repeated pain assessment

Pain management Nursing

Nursing Tender loving care

Surgical considerations Analgesic Drugs

Minimise surgical trauma Non-steroidal anti-inflammatory agents

Alpha-2 adrenoreceptor agonists

Miscellaneous drugs with analgesic

Extreme care where: Two types of opioid in clinical use:

Full agonist Synthetic opioid

Drug choices – local anaesthetics perception

Use to reduce opioid

central sensitisation Block transmission

Drug choices – systemic lidocaine

Drug choices – systemic lidocaine Drug choices - Paracetamol

1mg/kg IV loading dose Adjunct analgesic

Drug choices - ketamine Drug choices - ketamine

NMDA receptor antagonist Useful adjunct analgesic - reduces opioid

Drug choices – α2 agonists Drug choices – α2 agonists

Potent analgesics Role for very low doses - post-operative

Gunshot injury to scapula Gunshot injury to scapula

Presented “flat” Methadone 0.3mg/kg IM

Hindlimb/inguinal crush injury Hindlimb/inguinal crush injury

Massive blunt trauma Methadone 0.3mg/kg

Thoracotomy for lobectomy Conclusion

Opioid in pre-medication Analgesia should be:

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