Perioperative

Analgesia
“What if YOU were
being neutered?
Would you want
analgesia?”
Learning Objectives
1. Discuss why pain management is
so important.
2. List the principles of good pain
management protocols and
understand why they work.
3. Review analgesic drugs and know
which drugs should be included in
perioperative pain management.
4. Design basic pain management
protocols.
Why Do We Care About
Analgesia?
“Being admitted to the profession of
veterinary medicine, I solemnly swear to
use my scientifc knowledge and skills for
the beneft of society through the
protection of animal health and welfare,
the prevention and relief of animal
sufering, the conservation of animal
resources, the promotion of public health,
and the advancement of medical
knowledge.”
◦ The veterinarian’s oath, adopted by the
AVMA in August, 1969, revised 2010.
Medical Benefts of
Analgesia
Painis a medical condition that
causes side efects
◦ Cortisol release – delayed healing
◦ Cardiovascular efects – tachycardia,
hypertension
◦ Gastrointestinal efects – ulceration,
ileus
◦ Etc…
Morbidity of Pain
Patients that received adequate analgesia:
◦ experienced fewer complications
 GI dysfunction (indigestion, ileus,
ulceration)
 Clotting dysfunction (hypercoaguability,
emboli)
 Pulmonary dysfunction (atelectasis &
pneumonia)
◦ healed faster, better long term results
 Decreased cortisol release
Persistent pain following
knee arthroplasty. Puolakka
PA, Rorarius MG, Roviola M, Puolakka TJ,
Nordhausen K, Lindgren L. Eur J Anaesthesiol.
2010;27(5):455-60.

The degree of early postoperative pain

was the strongest risk factor.
If the degree of pain during the frst
postoperative week was from moderate
to intolerable, the risk for the
development of persistent pain was three
to 10 times higher compared with
patients complaining of mild pain.
Long duration of pre-operative pain was
also a risk factor.
Why Do We Care About
Perioperative Analgesia?

 Professional commitment
 Patients that receive adequate
analgesia:
1. Heal faster with fewer complications.
2. Can be maintained at a lighter
anesthetic plane, thus improving
anesthetic safety.
3. Are less likely to develop chronic
pain.
Confronting the Myths

Animals do not
feel pain.

◦ Physiologically,
animals have the
same pain pathway
that human beings
have
Quick Review – Pain
Pathway
Allmammals
have the same
pain pathway:
◦ Transduction
◦ Transmission
◦ Modulation
◦ Perception
Confronting the Myths
Pain is benefcial in
limiting a
recovering animal’s
activity.
◦ Animals are more
likely to move and
aggravate surgical
sites if they are
painful
PAIN IS A PATHOLOGY
Pathology of Pain
• Cardiovascular System
• Respiratory System
• Gastrointestnal System
• Renal System
• Endocrine System
• Immune System
• Metabolism
• Behavior
Pain is Benefcial????
 Tachycardia
Animal doesn’t
 Hypertension
 Arrhythmias
move
 Atelectasis
 Acid-Base Imbalance
 Decreased RBF, GFR
 GI ulcers
 Ileus
 Impaired clotting
 Increased cortisol
concentrations
 Delayed wound
healing
 Etc…
Will Pain Keep this Patient
Still?

Dailymail.com.uk
Confronting the Myths
Animals tolerate
pain better than
people do.
◦ Animals tend to
communicate
pain through
changes in body
language
◦ We must learn to
interpret their
expressions
How do you
assess pain
relief in a
nonverbal
species?
Assessing Pain
‘Absence of evidence is not
evidence of absence’ Carl Sagan
USE PAIN SCORING SYSTEMS
They aren’t perfect – but they
make us LOOK at the patient
Pain
Assessment
Example
Pain
The inability to communicate in no way
negates the possibility that an individual
is experiencing pain and is in need of
appropriate pain relieving treatment.
— International Association
for the Study of Pain
… animal pain and sufering are clinically
important conditions that adversely afect
an animal’s quality of life.
— American Veterinary
Medical Association
Treating Perioperative Pain: The
Principles of Analgesia
Pre-emptive Analgesia
◦ Better to prevent than to treat
Multimodal Analgesia
◦ Efects of Analgesic drugs are
generally additive or synergistic
Don’t quit!
◦ Pain doesn’t end when the vaporizer
is turned of or when the patient
walks out the practice door
Why Preemptive
Analgesia?
Receptors in dorsal horn
of spinal cord actually
become ‘upregulated’
or ‘hypersensitized’
from painful impulses
‘central sensitization’
Preemptive analgesia
decreases input to
these receptors, or
decreases the response
of the receptors
Multimodal Analgesia
Multimodal drug
administration
‘blocks’ pain
pathway at
diferent sites
Allows efects of
analgesic drugs
to be additive or
synergistic
Analgesic Drugs
Opioids

NSAIDs

Local Anesthetics

Adjunctive Drugs
◦ Alpha-2 Agonists
◦ Ketamine
Opioids
Most potent class of analgesic drugs
Should be considered anytime that pain
occurs, especially when pain is moderate to
severe
◦ This includes surgical, medical and traumatic pain
whether acute or chronic
MINIMAL SIDE EFFECTS – high safety margin
◦ ‘Respiratory depression’ is more of a human
problem
◦ Minimal to no cardiovascular efects
◦ REVERSIBLE!!
Relativelyshort acting when compared
to the duration of pain
Which opioids?
Morphine, hydromorphone, fentanyl
◦ Most potent opioids due to receptor
binding
◦ Moderate duration, moderate to good
sedation (depending on species, age,
health)
Buprenorphine

◦ Moderately potent, longer duration of

analgesia, minimally sedating
Butorphanol

◦ Moderately potent, short duration

of action, excellent sedative
Tramadol: Bioavailability
Good MULTIMODAL drug
◦ Bioavailability in the dog:
65 +/- 38%
◦ Little to no production of active
intermediate metabolite
◦ Rapid elimination
◦ Recommended dosing Pharmacokinetics of
tramadol and the metabolite
from this study: O-desmethyl tramadol
5 mg/kg every 6 h in dogs
or 2.5 mg/kg
KuKanich B, Papich MG
every 4 h
J Vet Pharmacol Ther. 2004
Aug;27(4):239-46.
Which cases?
ANY PATIENT with moderate to
severe pain
◦ Acute or chronic pain
◦ Surgical, medical or trauma pain
◦ Decrease dose in aged or
debilitated patients – but don’t
omit
Any patient going to surgery
◦ As a premedicant – decreases dose

of induction & maintenance drugs

Contraindications?
◦ None
NSAIDs
Anti-
infammatory,
thus, treats
not only the
pain but the
source of the
pain
Long duration
of action
Easy to
administer,
non-sedating,
not controlled
Local Anesthetic Drugs
The most under-utilized class of
analgesic drugs
◦ Efective, easy to use,
inexpensive
Blockade of painful impulses to
dorsal horn neurons of spinal
cord
◦ Total pain relief from blocked
nerves for duration of block
◦ Overall decreased sensation of
pain once block has worn of
 Intensity of nerve ‘fring’
wanes over time
Which Local Anesthetic
Drugs?
Lidocaine

◦ Very fast onset (2 mins), 90 minute

duration
Bupivcaine

◦ Fairly fast onset (5 mins), 4 hour

duration
Combo of the two

◦ May have benefts

Newer agents?

◦ Ropivicaine, articaine
◦ Not yet in veterinary medicine
Other Drugs
Alpha-2 agonists
◦ Domitor & Dexdomitor
◦ Short duration analgesia with
sedation
◦ Excellent component of multi-modal
analgesia
◦ Reversible
Spay/Neuter Pain Management
Oral Rimadyl 2 hours before surgery or
Injectable Rimadyl 1 hour before surgery
Pre-medicate 15 minutes before surgery
with (acepromazine & torbutrol) or with
(dexdomitor & torbutrol) & buprinorphine
Induce with valium & ketamine & intubate
Local skin block of surgery site
lidocaine/marcaine
Maintain on isofourane/oxygen
Post operative oral Rimadyl/carprofen to
go home for 4 days
SUMMARY – and
QUESTIONS
There are medical consequences
to untreated pain, including
impaired patient healing.
Utilize preemptive, multimodal
analgesia for greatest pain relief
and safest anesthetic period.
Utilize all of the drug classes – in
the appropriate patients, of
course.
Case Examples
If time permits, or questions arise
Perioperative Analgesia
Henry
6-month old
Beagle dog for
routine neuter
What
analgesic
protocol “What if YOU
should you were being
use?
neutered?”
Perioperative Analgesia
Pre-emptive, multi-modal
◦ Hydromorphone or morphine
◦ NSAID?
◦ Alpha-2 agonist?
Intraoperative

◦ Testicular block with local

anesthetics
Postoperative

◦ NSAIDs post-operative and for

discharge
Miss Kitty – Dental
Extractions
 Usethe same principles and same drug
classes used in dogs
Preemptive/Multimodal
◦ Hydromorphone or morphine
or buprenorphine
◦ Alpha-2 agonist?
◦ NSAIDs?
Intraoperative
Local anesthetic blockade
Postoperative/Discharge
◦ Buprenorphine transmucosal
BID or TID and/or NSAIDs?