7. analgesia
TRANSCRIPT
1Copyright © 2011, 2003, 2000, 1994 by Mosby, Inc., an affiliate of Elsevier Inc.
Controlling Pain
Analgesia
Chapter 7
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Physiology of Pain
Nociception: detection by the nervous system for the potential for, or actual tissue injury Protects animal from painful or noxious stimuli
Physiologic pain Ouch pain Little or no tissue injury
Pathologic pain Follows tissue injury Acute or chronic
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Pathologic Pain
Classification based on mechanism Inflammatory, neuropathic, cancer, idiopathic
Classification based on origin Visceral or somatic: superficial or deep
Classification based on severity of pain None, mild, moderate, severe
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Nociception: The Pain Pathway
Step 1: transduction Transformation of stimuli into sensory electrical
signals (action potentials) Step 2: transmission
Sensory impulses conducted to spinal cord Step 3: modulation
Impulses are either amplified or suppressed Step 4: perception
Impulses are transmitted to the brain where they are processed and recognized
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Nociception: The Pain Pathway (Cont’d)
Each step has different receptors Drugs can be selected that will target specific
receptors and block a specific step Multimodal therapy: targeting two or more of the
receptors
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Consequences of Untreated Pain
Catabolism and wasting Immune system suppression Inflammation and delayed wound healing Anesthetic risk and increased anesthesia
doses Patient suffering
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Primary Hyperalgesia
Peripheral hypersensitivity Results from tissue damage and constant
stimulation of nerves Area close to the site of tissue injury
becomes painful when stimulated with non-noxious stimuli
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Secondary Hyperalgesia
Central nervous system hypersensitivity or windup
Area of hypersensitivity is further away from the site of tissue injury
Results from constant stimulation of spinal cord neurons
Neurons become hyperexcitable and sensitive
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Physiologic Changes Caused by Pain
Neuroendocrine changes: can result in a catabolic state and wasting ACTH release Elevated cortisol, norepinephrine, and epinephrine Decreased insulin
Sympathetic stimulation: can result in cardiac arrhythmias Vasoconstriction Increased myocardial work Increased myocardial oxygen consumption
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Signs of Pain in Animals
Pain elicits a stress response Stress-related pain results in “fight-or-flight”
physiological response Avoid anthropomorphosis
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Preemptive Analgesia
Administration of pain medication before the pain occurs
Commonly involves adding analgesic to premedication prior to anesthesia
Reduces overall requirement for analgesia and duration of administration
Prevents windup
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Behavioral Responses to Pain
Vary depending on species, age, breed, and temperament Young patients less tolerant Cattle very stoic Large dog breeds more stoic than small toy
breeds Cats hide; dogs seek owner comfort; herd animals
separate themselves Vary depending on nature, duration, and
severity of pain Vary on the presence or absence of humans
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Physical Evidence of Pain
Changes in gait and level of activity Evidence of arthritic pain
Reluctance to lie down or constantly shifting position Evidence of thoracic or abdominal pain
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Physical Evidence of Pain (Cont’d)
Vocalization Whine, growl, whimper, groan, snarl, bite, hiss,
grunt, or purr Emergence delirium
• Immediate postoperative vocalization Changes in facial expressions, appearance,
and attitude
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Pain Assessment Tools
Verbal rating scales Simple descriptive scales Numeric rating scales Visual analogue scales Comprehensive scales
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Pain Assessment Tools: Verbal Rating Scales and Simple Descriptive Scales
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Pain Assessment Tools: Numeric Rating Scales
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Pain Assessment Tools: Visual Analogue Scales
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Pain Assessment Tools: Comprehensive Scales
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Assessing Response to Therapy
Acute surgical pain vs. chronic pain Hourly vs. monthly With effective analgesia, pain-associated
behaviors will recede Appetite, grooming, body position or posture,
interaction with people With effective analgesia, pain assessment
scores will decrease
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Effective Postoperative Analgesia
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Perioperative Pain Management
Preemptive analgesia Begins in preoperative period with premedication May be administered as part of anesthetic
premedication Transdermal fentanyl patch NSAIDs primarily in large animals
Multimodal therapy The use of more than one drug to control pain Cover multiple receptors and mechanisms of
action Reduce dose of individual drugs and anesthetic
agent
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Pharmacologic Analgesic Therapy
Analgesia is needed at every stage of hospitalization and treatment Preanesthetic period Surgical period Immediately postoperative period Remainder of hospital stay At home
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Pharmacologic Analgesic Therapy (Cont’d)
Choice of drug depends on: Severity and type of pain Patient’s general condition Route of delivery
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Using Opioids as Analgesics
Vary in potency, duration, and adverse effects Injectable premedication
Often in combination with a tranquilizer (acepromazine or dexmedetomidine)
Diminish windup Duration of action is 2-4 hours, so not good for
postoperative pain Induce state of potent sedation
Neuroleptanalgesia Provides analgesia throughout surgery and for
some time postoperatively
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Using Opioids as Analgesics (Cont’d)
Postoperative analgesia Alone or in combination with other drugs
Sedative and antianxiety drug Excitement in awake cats and horses
Gastrointestinal effects Initial increased gastrointestinal activity: nausea,
vomiting, defecation Followed by a slow down in gastrointestinal
activity: ileus, colic, constipation Metabolized in the liver
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Opioid Agents: Morphine
Schedule II drug (United States) and narcotic (Canada)
Used for moderate to severe visceral or somatic pain Preanesthetic and analgesic Pure agonist with affinity for mu and kappa opioid
receptors May cause excitement or dysphoria in cats and
horses May cause restlessness in dogs and horses
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Opioid Agents: Morphine (Cont’d)
Administered IV, IM, SC, intraarticular, epidural, or spinal injection
Adverse side effects Initial gastrointestinal stimulation in dogs and cats Ileus and colic development in horses Excitement, miosis (dogs), mydriasis (cats),
hypothermia, hyperthermia (cats) Bradycardia, panting, increased intraocular
pressure, urinary retention Physical addiction (humans)
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Opioid Agents: Oxymorphone
Pure opioid agonist Greater analgesic potency and sedative effect
than morphine Fewer side effects and longer duration of
effect than morphine Fewer tendencies to induce vomiting Administered IV, IM, SC, or epidural
May use concurrently with a tranquilizer Expensive Schedule II drug (United States)
and narcotic (Canada)
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Opioid Agents: Hydromorphone
Opioid agonist Less potency but similar duration of effect
compared with oxymorphone Administered IV, IM, SC to dogs and cats
Used as a premedication alone or with a tranquilizer
Less expensive than oxymorphone Schedule II drug (United States) and narcotic
(Canada)
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Opioid Agents: Methadone
Synthetic opioid Characteristics similar to oxymorphone and
hydromorphone Least likely to cause vomiting in cats and
dogs Antagonist at the NMDA receptor
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Opioid Agents: Fentanyl
One of the most potent analgesics known Rapid onset (2 minutes) and short duration of
effect (20-30 minutes) when administered IV Administered by continuous IV drip,
transdermal patch, IM, SC, or epidural injection Used in combination with midazolam or diazepam
drawn into separate syringes Schedule II drug (United States) and narcotic
(Canada)
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Opioid Agents: Meperidine/Pethidine
Pure opioid agonist with less potent analgesic properties and shorter duration of action
Administered by SC injection Wide margin of safety Used mostly as a preanesthetic in combination
with atropine or acepromazine When used with a tranquilizer, it provides effective
neuroleptanalgesia in puppies Used with injectable NSAIDs to provide analgesia
before NSAIDs take effect Schedule II drug (United States) and narcotic
(Canada)
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Opioid Agents: Butorphanol
Synthetic opioid with agonist and antagonist properties Stimulates kappa receptors and blocks mu
receptors Not as effective an analgesic as a pure agonist Produces less sedation, dysphoria, and respiratory
depression Can be used to reverse the effects of morphine
and fentanyl
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Opioid Agents: Butorphanol (Cont’d)
Used as a preanesthetic, sedative, and postoperative visceral analgesic
Administered IV, IM, SC, or orally (as tablets for long-term analgesia) Constant rate infusion IV can prevent redosing
Schedule IV drug (United States) and controlled drug (Canada)
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Opioid Agents: Buprenorphine
A partial mu agonist that produces some analgesia for mild to moderate pain Used to provide postoperative analgesia to dogs and cats Can be used to reverse the effects of morphine and fentanyl
Administered IV, IM, or epidural; orally to cats Delayed onset of action and longer duration of
analgesia Used with a sedative it can prolong sleep times Expensive Schedule V drug (United States) and
unavailable in Canada
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Opioid Agents: Nalbuphine
Kappa agonist and mu antagonist with greater antagonist properties than butorphanol Weak analgesic and sedative Used as a reversal agent for opioid agonists Fewer adverse effects
Not a controlled drug in the United States
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Opioids as Postoperative Analgesics
Administered IM or SC before animal regains consciousness Injections repeated as necessary Alternative routes (IV, epidural, intraarticular,
transdermal patch) minimize adverse effects Disadvantages
Short duration of action Potential adverse reactions: respiratory depression,
bradycardia, excitement, apprehension, hypersalivation, mydriasis, excessive sedation, panting, increased sensitivity to sound, urinary retention, gastrointestinal effects
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Opioids: Intravenous Infusion
Morphine, fentanyl, oxymorphone, hydromorphone, methadone, butorphanol
Provides continuous analgesia for constant, unremitting pain
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Opioids: Intravenous Infusion (Cont’d)
Initial loading dose given to effect followed by same dose given over 4 hours through constant flow Drug may be added to a bag of fluids if an automated
infusion pump is not available Monitor patient frequently for adequate pain control,
excessive sedation, or adverse effects Adjust rate of administration according to patient response
Morphine (for example) can administered with lidocaine or lidocaine/ketamine to control severe pain
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Opioids: Intraarticular Injection
Especially useful after elbow or stifle surgery Morphine diluted in saline instilled into joint
via catheter Immediately after joint closure Can be combined with a local anesthetic
(e.g., bupivacaine) Provides 8-10 hours postoperative analgesia
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Opioids: Epidural Injection
Instillation of opioid into epidural space at lumbosacral junction To provide analgesia to hind limbs, abdomen,
caudal thorax, pelvis, tail Morphine is the most commonly used drug May be combined with an alpha2-agonist in large
animals Profound postoperative analgesia with long
duration of action
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Opioids: Epidural Injection (Cont’d)
Instillation of an opioid into the epidural space at the lumbosacral junction Administer after induction of anesthesia, but
before surgical procedure begins Onset of action: 20-60 minutes Duration of action 6-24 hours Must be supplemented with general anesthesia for
surgical procedures Reposition animals every 2-4 hours to prevent
pulmonary atelectasis or prolonged pressure on superficial nerves
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Opioids: Transdermal Use
Fentanyl transdermal patch Reservoir of fentanyl enclosed in plastic Attached to clipped skin and left in place for
several days Comes in various sizes
(25 mcg/hr; 50 mcg/hr; 75 mcg/hr; 100 mcg/hr) Large animals may require more than one patch
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Opioids: Transdermal Use (Cont’d)
Provide convenient, long-term opioid administration Similar to IM oxymorphone injection but longer
duration of action Delay of action from 4 to 12 hours (cats) or 12 to
24 hours (dogs) as drug is absorbed through the skin
Apply patch at least 6-12 hours prior to the start of surgery
Supplement with another opioid or NSAID if patch isn’t applied until after surgery
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Opioids: Fentanyl Patch
Use: Provide analgesia for postoperative pain and pain associated with trauma, burns, cancer, and painful abdominal conditions Amount of drug absorbed through skin varies
among animals Monitor for breakthrough pain and supplement as
necessary Monitor for fentanyl overdose
• Ataxia and sedation (dogs)• Dysphoria and disorientation (cats)
Remove patch if necessary
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Opioids: Fentanyl Patch (Cont’d)
Heat may increase the amount of fentanyl absorbed Avoid using in animals with fevers Avoid contact of patch with external sources of
heat (e.g., hot water bottles)
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Nonsteroidal Antiinflammatory Drugs
NSAIDs or nonsteroidal antiinflammatory analgesics (NSAAs)
Acetylsalicylic acid (aspirin) CarprofenAcetaminophen EtodolacMeloxicam Tolfenamic acidKetoprofen DeracoxibFirocoxib
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Nonsteroidal Antiinflammatory Drugs (Cont’d)
Mechanism of action Efficacy: somatic and visceral pain (varies by
drug) Onset of action: 30-60 minutes Duration of effect varies with species Toxicity varies with species Analgesic and antiinflammatory properties vary by
drug Inhibit prostaglandin synthesis by inactivating COX
isoenzymes Metabolized in the liver; eliminated by the
kidneys and the gastrointestinal tract
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Adverse Effects of NSAIDs
Prevent the production of beneficial prostaglandins along with the production of prostaglandins that mediate pain, inflammation, and fever
NSAIDs that inhibit the COX-2 enzyme but not the COX-1 enzyme produce the least adverse effects
The perfect NSAID is not available yet
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Adverse Effects of NSAIDs (Cont’d)
Adverse effects vary with drug, species, breed, and individual animals Stomach ulcers, vomiting, gastrointestinal
bleeding, lack of appetite Gastrointestinal ulceration leading to hemorrhage Renal toxicity Impaired platelet aggregation leading to prolonged
bleeding time Liver damage Antagonist to several drugs prescribed for cardiac
disease and hypertension
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Other Analgesic Agents
Opioids and NSAIDs are the most commonly used analgesics
Local anesthetics, alpha2-adrenergic agonists, and ketamine are also used as analgesics in special circumstances
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Local Anesthetics as Analgesics
Used to prevent or treat postoperative pain Sprayed or injected at the site of injury or surgical
site or infiltrated around a nerve supplying the affected area
Desensitize the entire region (epidural or IV infusion)
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Local Anesthetics as Analgesics (Cont’d)
Advantages Complete anesthesia of affected area Low toxicity Rapid onset of action
Disadvantages Short duration of action CNS and cardiac toxicity with repeated use
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Alpha2-Adrenoceptor Agonists as Analgesics
Limited use in small animals Short duration of analgesic effect Profound sedative effect Adverse effects: respiratory depression, vomiting,
bradycardia, heart block, hypotension When used in low doses may potentiate opioid
effects and increase quality of postoperative analgesia
Produce significant analgesia via the epidural route alone or with other agents
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Alpha2-Adrenoceptor Agonists as Analgesics (Cont’d)
Used in horses to provide sedation, muscle relaxation, and analgesia Xylazine, detomidine, romifidine Horses remain standing but may become ataxic Analgesia okay for moderately to severely painful
diseases or procedures Adverse effects
• Cardiovascular effects, respiratory effects, GI effects Reversal with alpha2-adrenoceptor
antagonists will also reverse sedation and analgesia
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Ketamine as an Analgesic
Used as an adjunct to more potent analgesics (opioids, local anesthetics, alpha2-agonists) Doesn’t produce analgesia by itself MLK (morphine, lidocaine, ketamine) provides
intraoperative analgesia Blocks NMDA at the level of the spinal cord to
prevent windup Use a lower dose than the one used to
induce anesthesia
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Ketamine as an Analgesic (Cont’d)
Adverse effects: dose-related effects rarely seen at analgesic levels Tachycardia Hypertension Seizures Postoperative delirium Increased intraocular and intracranial pressure Salivation
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Corticosteroids as Analgesics
Strong antiinflammatory properties Decrease prostaglandin activity such as NSAIDs Don’t use concurrently with NSAIDs
Adverse effects Ulcerogenic Immunosuppression with long-term use Hyperadrenocorticism
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Tramadol as an Analgesic
Nonopiate drug with activity at the mu receptor Also inhibits reuptake of norepinephrine and
serotonin Administered orally after patient has resumed
eating A postoperative alternative to opiates Can be administered at home
Don’t use concurrently with other norepinephrine or serotonin reuptake inhibitors (e.g., amitriptyline)
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Tranquilizers and Analgesia
Tranquilizers are not considered analgesics May potentiate effects of opioids in anxious
patients Useful in calming the excitement sometimes seen
in cats and horses following opioid administration Cannot be substituted for opioids or other
analgesic agents
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Multimodal Therapy
Use of more than one type of analgesic to relieve pain Pain is produced by several mechanisms Different drugs will target different mechanisms
along the pain pathway
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Examples of Multimodal Therapy
Acetaminophen and codeine Oral treatment for moderate to severe pain in dogs
Fentanyl and meloxicam Administered at the same time to cats to provide analgesia
until the fentanyl patch takes effect Morphine and injectable NSAID (meloxicam or
carprofen) Administered at the end of surgery followed by oral NSAID
for 3 days MLK
Administered in IV fluids during surgery, decreases amount of inhalant anesthetic needed
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Home Analgesia
Fentanyl patches Used sequentially for up to several months for
chronic pain (dogs and cats) NSAIDs
Long-term therapy of chronic painful conditions Oral morphine
Sustained-release tablet administered BID to effect
Tylenol with codeine (dogs) and butorphanol Tablet for mild-to-moderate pain
Tramadol
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Nursing Care
Relieving patient discomfort will help pain control Keep patient and cage or stall clean and dry Comfortable bedding/quiet surroundings Opportunity to urinate and defecate Comfortable position
• May have to turn every 2-3 hours Reduce anxiety with toy or blanket from home Ophthalmic ointment in unconscious patients to
prevent corneal drying Comforting reassurance through touch and talking
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Nonpharmacologic Therapies
Used in conjunction with or as an adjunct to pharmacological therapy Acupuncture Transcutaneous electric nerve stimulation Massage therapy Apply cold (acute injuries) or heat (chronic injuries) Physiotherapy Laser or magnetic therapy Homeopathic or herbal remedies