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Clinical Pain!End it Now !
End it for Good !
Ralph Harvey, DVM, MS, Diplomate ACVA University of Tennessee College of Veterinary Medicine
Pain management is individualized for each patient
Leader Dogs for the Blind, Rochester, Michigan
Pain is an unpleasant sensory and emotional experience with actual or potential tissue damage. (Merskey 1979)
This definition of pain is also applied to the animal patient.
Clinical Pain:
1. Acute Pain Operative and Trauma Care
2. Chronic Pain Arthritic Pain Cancer Pain
3. Critical Care Analgesia
1. Acute Pain and Perioperative Pain Management:
Perioperative and Trauma Care
The first area of marked improvement
2. Chronic Pain, Arthritic Pain, and Cancer Pain
For our clients, the most obvious improvements in veterinary pain management.
For example, have you heard of “Rimadyl”? (>8M dogs in US alone)
2
3. Critical Care Analgesia:
Advantages are well defined.
Mechanisms are documented.
Tools are available.
Application of these too often lags. Same is unfortunately true in human medicine.
8
Benefits of Pain/Stress Management
Reduced sympathetic stimulation Better control of cardiovascular function Reduced neurologic stimluation (maladaptive neuro-endocrine response)
Improved eating & drinking
Improved general well being
Reduced morbidity and mortality
Pre Medication
Post Medication
Pain as a Vital Sign
AAHA PM Standards: “Pain assessment using a standardized scale or scoring
system is recorded in the medical record for every patient evaluation”
Pain scales…
Pain Evaluation in our Patients
3
Options for Evaluation
1. Simple Descriptive Scale
2. Numerical Rating Scale
3. Composite Scale
4. Interactive Visual Analog Scale
Measurement of stress: neuroendocrine catecholamines electrical impedance/conductance
Measurement of pain: Intraspinal c-fos
Behavioral signs… Severe Pain
--10
Many Factors Influence Pain Scores
Temperament
Vocalization
Posture
Locomotion
Other behavioral changes
There are species-specific variations in the
reliability of the behaviors or indicators of pain
Behavioral differences may be observed when
the patient is removed from its normal
environment
Client / owner input should be considered
Reassessment after treatment should be made
by the same individual
Species-specific responses to chronic pain:
Dogs - eating behavior is rarely affected
Cats - isolation from others in the household, decreased grooming, and cessation of eating
Horses - inappetance, severe weight loss, dull expression, glazed eyes, and basewide stance
Ruminants - weight loss and isolation from the herd
Pigs - reluctance to rise, reduced social interaction, and little appetite change
4
Behaviors as potential indicators of pain in the dog:
Hunched or prayer position Glazed facial expression Attention-seeking and whining Licking the painful area Not hiding the painful body part
Behaviors as potential indicators of pain in the cat:
Poor or lack of grooming Hissing or aggression if the painful part is
manipulated Tendency to hide the painful part and
look normal Dissociation from the environment Vocalization is rare
Common behaviors associated with chronic pain:
Temperament - dull, grouchy, and grumpy.
Posture and locomotion - limited ambulation, altered gait, overt lameness, reluctance to move, difficulty rising, and reduced play behavior.
Grooming - alteration in or lack of grooming, grooming of specific parts, and licking of painful parts.
Reduction of activity level. Reduction of food and water consumption.
Inappropriate urination and defecation.
Human sensitivity to vocalization and extreme behaviors.
Lameness evaluation:
Affected by joint
Severely subject to observer bias
Owner evaluation subject to placebo effect
Caretaker expectation of perceived pain
Documented Observation Biases:
Sudden Changes in Behavior:
Non-responsive:
Hiding, motionless, silent
Vocalization:
Crying, barking, hissing
Aggression:
Biting, kicking, pawing, scratching, …Caution!
CAUTION Pain induces neurological activity, which will increase
arterial blood pressure & heart rate
It also creates stress & its related impact on function
It causes changes in temperament
5
Pain Posture and Attitude Pain Behavior
Scales for Evaluation of Pain:
1. Simple Descriptive Scale
2. Composite Scale
3. Interactive Visual Analog Scale
4. Numerical Rating Scale (Interactive, 0-10)
(Repeated evaluations by owners, veterinarians & staff)
Our choice for evaluation of clinical pain.
Other pain scales have been developed and should be considered
Pain Scales: Simple Descriptive Scale Modified Verbal Rating Scale
Adapted from Jensen & Karoly, 1992
Subjective based on simple observations & conclusions
No Pain Mild Pain Discomforting Distressing Intense Excruciating
(Scale as Used in Human Pain Scoring)
The use of pain scores in animals is more
complex than in humans. The use of single
signs of pain such as facial expressions may
lead to erroneous conclusions.
No Pain Mild Pain Discomforting Distressing Intense Excruciating
( Same Scale as Used in Animal Pain Scoring? ) Additional behavioral information is required
for complete assessment.
Scale of 0-10 based on 0 is no pain and 10 is worst possible pain
1 2 3 4 5 6 7 8 9 10
Pain Scales: Numerical Rating Scale (NRS)
0
6
Pain Scales: Visual Analog Scale (VAS)
Use of the VAS to evaluate pain management Scale of no pain to worst pain ever, 0-100 mm
100 0
100 0
Pain Scales: Visual Analog Scale (VAS)
10 20 30 40 50 60 70 80 90
77 Animal with pain requiring treatment
100 0
Pain Scales: Visual Analog Scale (VAS)
10 20 30 40 50 60 70 80 90
16 Evaluation after treatment
100 0
Pain Scales: Visual Analog Scale (VAS)
10 20 30 40 50 60 70 80 90
43 Post-treatment. Pain is returning, TIME TO REDOSE.
Interactive Scale of 0-10 Based on 0 as no pain and 10 as the worst possible
pain for that condition
1 2 3 4 5 6 7 8 9 10
Pain Scales: Numerical Rating Scale (NRS)
0
Numerical Rating Scale
Scale of 0-10 “0” as no pain “10” as the worst possible pain for that condition
Based on behavioral signs Interactive
Approach, engage, physically contact, elicit responses
Repeated evaluations by owners, veterinarians & staff Evaluations before and after analgesic interventions Individualize interactions and evaluations to patient needs Pain score recorded for every patient evaluation
7
Application of Pain Scales in our Patient Care: Interactive Numerical Rating Scale
Evaluations are conducted by owners, veterinarians & staff.
All evaluations should be interactive with the patient.
RESUSCITATION CODE: GREEN • YELLOW • RED
Protocol Approved by: Patient ID Verified by: Technician Initials:
DATE TIME SCHED. CAGE/STALL SURGEON ASSISTANT
PRE-OP DIAGNOSIS
PROPOSED OPERATION
BODY WT. TEMP. PULSE RESP. M.M. CRT PRE-OP RADS
FASTED YES NO
P.C.V. TPP BUN CREAT. Hb URINE S/G OTHER
Physical Status: 1 2 3 4 5 E Interactive Pain Score: (0-10) ______
ANESTHESIA RECORD
University of Tennessee, W.W. Armistead Veterinary Teaching Hospital
ANESTHESIA RECORD
Date: __________________________ Anesthetist: ________________________________ Anesthesiologist: ____________________________________________ VMRS-003
Pre-Anesthetic Drugs Anesthetic InductionDrug Cont # mg DOSE (mL) Route Time PRE-MED Result Drug Cont # mg DOSE (mL) Route Time
! None! Slight ! Moderate! Profound! Adverse
BLOOD/PLASMA Donor name Donor, PCV/TPRATE gtt/sec
I.V. SOLN 1RATE CRI rate
I.V. SOLN 2RATE CRI rate
I.V. SOLN 3RATE CRI rate
O2 Flow L/m
AG
EN
TS
Isoflurane
ET Iso ( )
Sevoflurane
ET Sevo ( )
___________
___________
8.0
7.0
6.0
5.0
4.0
3.0
2.5
2.0
1.5
1.0
TIME 0100-2400
340
320
280
START ANES. A 260
240
START OPER. O 220
200
END ANES. A 180
END OPER. X 160
B.P.SYST MEAN DIAS.
V X
140
120
C.V.P. (x10) "100
SpO2 !80
ETCO2 "60
55
PULSE !50
45
RESP. "40
35
SPON:30
o-o S 25
CONT20
o-o C 15
10
5
COMMENTS:
TOTAL FLUIDS
Plasma __________ mls Blood ___________ mls
Fluids 1 _________ mls Fluids 2 _________ mls
MONITORING
Blood Pressure Blood Gases
Esophageal Steth Doppler Temp
ECG CVP SpO2 ETCO2
MAINT OF AIRWAY
Mask ET Tube Size _______________
Armoured Murphy Cuffed
Difficulty _______________________________
BODY POSITION
Lateral L R Sternal Dorsal
Head-Up Head-Down
ANESTHESIA SYSTEM
Semi-Closed Bain Ventilator
REGIONAL ANESTH
Epidural Regional Local
Site ___________________________________
Agent # 1 _______________________________
Cont # ________________ Amount _________
Agent # 2 _______________________________
Cont # ________________ Amount _________
CRI
Agent # 1 _______________________________
Cont # ________________ Amount _________
Agent # 2 _______________________________
Cont # ________________ Amount _________
ADDITIONAL MEDS
Agent # 1 _______________________________
Cont # ________________ Amount _________
Agent # 2 _______________________________
Cont # ________________ Amount _________
Total Anesthesia Time _____________________
Anesthesia Base Charge ___________________
Anesthesia ______________________________
Epidural _______ Doppler _______ CVP ______
Misc. drugs ___________ Bair Hugger ________
Wt. 60# ______________ Blood, Plasma ______
CRI Meds _____________ CRI Base __________
Nerve Block ___________ Ventilator _________
ASA III ________ ASA IV _______ ASA V ______
Jugular Catheter 1 2 3 4 _____________
Arterial Line Monitoring ____________________
TOTAL COST:
V
RESUSCITATION CODE: GREEN • YELLOW • RED
Protocol Approved by: Patient ID Verified by: Technician Initials:
DATE TIME SCHED. CAGE/STALL SURGEON ASSISTANT
PRE-OP DIAGNOSIS
PROPOSED OPERATION
BODY WT. TEMP. PULSE RESP. M.M. CRT PRE-OP RADS
FASTED YES NO
P.C.V. TPP HB CREAT. BUN URINE S/G OTHER
Physical Status: 1 2 3 4 5 E Interactive Pain Score: (0-10) ______
University of Tennessee, W.W. Armistead Veterinary Teaching HospitalRECOVERY ROOM RECORD
Date: __________________________ Anesthetist: ________________________________ Anesthesiologist: _____________________________________________ VMR-055
RECO
VERY
ROO
M
Time of Arrival: Release Status: ! Alive ! Dead ! Euthanatized
Time Released: Release To: ! Ward ! ICU Cage/Stall# _________
Total Time: Signature: ! Owner ! Path
CLINICIAN’S RECOVERY ROOM ORDERS:
SPECIAL OBSERAVTIONS REQUIRED: CONTINGENCY ORDERS: (Anticipated problems & what to do, who to call)
CONTROLLED SUBSTANCES: Agent: Total Agent Drawn: mis. Control No. Total Agent Given: mis.
TIME TEMP. PULSE RESP. B.P. M.M. CRT REFLEX U/BM Pain Score Comments & Medications Initials
ANESTHESIA SUMMARY:
RECOVERY ROOM RECORD
Principles in Pain Management
1. Preemptive analgesia
2. Balanced analgesia
3. Dose to effect
Thorough Nursing Care Alter the Environment Distraction / Relaxation Opioids Loco-Regional Anesthesia Alpha-2 Agonists Adjunctive Analgesics
tramadol, gabapentin, amantadine, ketamine, acupuncture, etc.
Balanced or Multi-modal Analgesia:
Make best use of Opioids:
Morphine Oxymorphone Hydromorphone Fentanyl (Duragesic) Remifentanil (Ultiva) Butorphanol
(Torbutrol, Torbugesic, Stadol)
Buprenorphine (Buprenex, Temgesic)
Tramadol (Mu agonist plus inhibits reuptake of NE & 5-HT) 42
Powerful and sustained analgesia
Effective throughout the body
Technically easy Cost effective Numerous benefits
Epidural Opioids +/- Locals
8
Neuroaxial Analgesia:
12-24 hours of substantial analgesia
Decreased “Stress response”
Epidural Morphine Duramorph (preservative free)
Morphine USP
Bupivacaine or Lidocaine (with volume expansion)
Fentanyl (Duragesic) Patches
Consistent (basal) level of strong opioid analgesia (3-5 days)
Many veterinary applications
Strictly “off-label”
Limitations / precautions
Alternatives: CRI fentanyl, oral SR morphine, oral buprenorphine, oral codeine
45
Success with Local Anesthetics:
Drugs used: Lidocaine Bupivicaine, Ropivicaine Articaine
Applications: Regional, Specific Nerve Blocks, Infiltration Neuroaxial
Epidural, Spinal
Intravenous (Lidocaine C.R.I.)
Locals are very cheap and very effective!
Make best use of NSAID’s:
Ketoprofen Carprofen Etodolac Deracoxib Meloxicam Firocoxib Other NSAID’s (Acetaminophen)
Recognition of additional actions…
Recognize tremendous individual patient variability in efficacy and safety of various NSAID’s, and it changes!
Skill in application and management Management of toxicities
Cox-2 selectivity/specificity Constituitive Cox-1 and Cox-2 Cytoprotective measures Dual pathway Cox/Lox
Several paradigm shifts regarding NSAID toxicities
Which NSAID?
48
Principles in Pain Management
1. Preemptive analgesia
2. Balanced analgesia
3. Dose to effect
plan a “wet lab”…
9
49
Case Studies
Fan-belt Trauma
Case Studies
Thermal Burns - dog or cat
Case Studies
Thoracotomy
Case Studies
Evisceration – Gored by a “Pet” Boar!
Massive trauma, sepsis, shock
Case Studies
Total Ear Canal Ablation
10
55
Case Studies
Polytrauma Multiple Fractures, etc.
56 Thank you for participating in these sessions!
Dr. Ralph Harvey
How to Manage Clinical Pain