Patient Care 1

 

County Seat Animal Hospital Pain Control Protocol

 

Goal: County Seat Animal Hospital has created a protocol with the intent to prevent, recognize, and minimize pain of patients.

Oversight Responsibility: Attending veterinarian, veterinary technician, and veterinary assistant.

Performance Responsibility: Attending veterinarian, veterinary technician, and veterinary assistant.

Methods for preemptive control of pain:

■ Oral Analgesics

" Injectable analgesics

• Transdermal analgesics

• Local and regional analgesics

• Adjunct analgesics

• Environmental support (warmth, comfort, and a stress free environment)

Events or circumstances known to be associated with pain:

***Severe to Excruciating

* Neuropathic pain ( e.g., cervical intervertebral disk rupture, nerve entrapment

* Extensive inflammation (e.g., peritonitis)

* Necrotizing pancreatitis

* Bone Cancer

*** Moderate to Severe

*Osteoarthritis

* Fracture Repair

*Onychectomy

*Peritonitis

*Torsion

D Trauma (e.g., orthopedic, extensive soft tissue, head

* Neoplasian Corneal ulceration

***Moderate
* Cruciate repair
* Laparotomy
* Inguinal hernia repair
* Uretheral repair
* Ovariohysterectomy
* Enucleation
* Some dental procedures

***Mild to Moderate

* Lump removal

* Cystitis

* Otitis

 

Means by which pain and the degree of pain can be recognized in patients:

1  Physiologic signs of acute pain include increased blood pressure, heart rate, and peripheral vasoconstriction that manifests itself as blanched mucus membranes. Respiratory rate often increases and muscle splinting may occur if pain is localized within the thorax.

■ stress leukogram is often evident and catabolic processes predominate.

Responses to pain vary among species, but a variety of behaviors and signs are consistent with ongoing painful conditions. Alterations in normal vocalization patterns and attention-seeking behaviors are common. Dogs often whine or whimper while cats groom, growl, or purr. Dogs can become either timid or aggressive toward human interactive behavior. Cats often try to hide when in pain. Facial expressions and body posture can be quite revealing as dogs may have a fixed stare and arching posture whereas cats may squint their eyes and refuse to move. Dogs and cats both demonstrate guarding behaviors of injured or painful tissues by biting or scratching when palpated and often lick, chew, or paw at the site of pain. Some dogs become restless while cats often refuse to interact or change body positions.

• can reduce appetite and food intake, alter voiding behaviors, and reduce grooming behaviors so that the patient appears disheveled.

• the complexity of pain perception, behavioral signs of pain are unique for each animal and may be best identified by the animal's owner. It is unlikely that a single reliable objective measure of pain exists, and few correlations between subjective and objective measures of pain severity have been documented.

" there is a likelihood of experiencing postoperative pain, analgesics should be used regardless of an animal's outward behavior. Generally the benefits of pain management outweigh the risks associated with analgesic drug administration

Pain Assessment

• practitioner should become familiar with the patient's normal and/or presenting physiologic values and behaviors by assessing these parameters at admission.

• Pain Evaluation Charts Will be used Post Op

• thorough pain assessment should include both a non-interactive evaluation carried out from a distance, and an interactive evaluation that encourages a response from the patient.

• series of assessments should be made and recorded in the medical record at appropriate intervals to document changes in pain status and response to therapy. It is recommended that serial pain assessments be made by the same observer, if possible, to reduce inter-observer differences.

• simple pain assessment tools have been used clinically to evaluate pain and distress in veterinary patients. These include the visual analog scale (VAS) and the numerical rating scale (NRS).

• VAS is comprised of a line of a standard length, usually 10 cm, upon which a mark is made to indicate the observer's impression of the intensity of pain the patient is experiencing. The distance from the end to the mark is measured and recorded as the pain score. It is important for all users to understand the meaning of the end point of the line (e.g., worst pain imaginable or worst pain possible for a particular condition). Inter-observer variation will occur, but can be minimized by training users. This tool can be used rapidly and in many different clinical situations.

• NRS is similar to the VAS in that it is a line of standard length; however, the line is divided at regular Intervals by numbers that usually range from 0 to 10. Some scales add descriptions of the expected behaviors at points on the line to aid in assessment. The NRS is usually more repeatable when used by multiple observers.Animals that are ill or in pain tend not to do the normal things that cats and dogs do.

 

• Younger animals are much less tolerant of pain.

• Cats and geriatrics tend to withdraw or become stole when in pain.

• Pain is usually enhanced in the presence of inflammation; during stretching/distention of

viscera; during tissue handling.

■ Heart-rate- especially after analgesic administration- is frequently an insensitive indicator of

pain.

■ Respiratory rate, pupillary dilation, systolic hypertension may be correlated more closely with

pain.

■ Familiarity with the personality of the animal is Important when assessing pain- the pet owner

may be the best person to evaluate the level of anxiety or pain that the patient may be experiencing- treating anxiety tends to improve the patient discomfort.

We will also use the Glascow standard for pain assessment. Any score of 2 or higher will recieve analgesic

 

 

Names and actions of medications dispensed, prescribed, or administered for pain management:

"  Morphine: Injectable: pure-mu agonist, receptors present in peripheral tissues/ joint

capsule/ dorsal horn of spinal cord/ brain, binding increases potassium conductance which causes hyperpolarization and decreases neurotransmitters such as acetylcholine/substance P/dopamine/ norepinephrine.

"   Buprenorphine Injectable: Partial mu agonist/antagonist, strong affinity for mu

receptors, has kappa antagonist properties, hard to reverse the effects.

"  Butorphanol Injectable: Kappa agonist/mu antagonist, as dose is increased antagonist properties may reverse some of the agonist activity, 7-10 times the receptor binding potency of morphine but less effective as analgesic with severe pain.

Hydromorphone Hydrochloride (Schedule II) - same as morphine

Trade Name: Dilaudid □     Concentration: 2 mg/ mL D     Supplied as: 20 mL/vial

D     Company: Knoll Pharmaceutical Company, Mount Olive, NJ 07828 □     Website: http://www.basf.com/knoll/index2.html

Medetomidine-Domitor Injectable: Alpha2 agonists- binds to presynaptic alpha2 receptors at locus ceruleus in the brain/dorsal horn of the spinal cord/ sympathetic nerve endings, binding of presynaptic receptors causes a decrease in norepinephrine release which results in decreased pain conduction/ decreased arousal/ increased parasympathetic tone, treats anxiety/dysphoria.

■ Tramadol Oral Tablets: Mild mu action, metabolite has 200 times opioid binding affinity,

inhibition or norepinephrine and serotonin reuptake.

■ Lidocaine and Bupivacaine Injectable: Decrease neuronal conduction by inhibiting sodium

influx and stopping propagation if action potential.

"  Carprofen and Meloxicam: NSAID-attenuate anti-inflammatory response, inhibit COX 1 and COX 2 (cyclo-oxygenase) enzymes that catalyze formation of prostaglandins/thromboxane/prostacylines from arachidonic acid.

■ Deramaxx: A coxib-class NSAID, believed to predominately inhibit cyclooxygenase-2 (COX-2)

and spare COX-1 at therapeutic doses. Theoretically this would inhibit production of prostaglandins that contribute to pain and inflammation (COX-2) and spare those that maintain normal gastrointestinal and renal function (COX-1).

■ Acepromazine-Phenothiazine: Tranquilizer, antagonizes dopamine receptors, potentiates

analgesic duration of opioids.

"  Naloxone: Pure opioid antagonist, used competitively to displace the agonist, in high doses can antagonize central effects of opioid agonist, short half-life in brain/ only provides antagonism for about one hour.

■ Atipamezole-Antisedan: Competitively inhibits alpha2- adrenergic receptors, thereby acting

as a reversal agent for alpha2- adrenergic agonists (e.g., medetomidine).

*  Opioid Analgesics and Non-steroidal Anti-inflammatory Analgesics, Mathews, Karol A., The Veterinary Clinics of North America, July 2000. p759-763,783-784.

• Analgesic Drugs, Posner, Lysa P., Clinicians Brief, May 2008 Vol 6 No. 5.p.l3-14

• Deracoxib, Donald C. Plumb, Plumb's Veterinary Drug Handbook, 5th edition, 2005. p223.

• Atipamezole HCL, Donald C. Plumb, Plumb's Veterinary Drug Handbook, 5th edition, 2005.

p69.

Pharmaceutical manufacturers' presentations at practice team meetings Pharmaceutical manufacturers supply current resources on pain management Literature review of current periodicals and books Internet access to structured courses Learning from other team members

Veterinarian overseeing patient and accountability for the case Time sensitive review for entire practice team (as often as applicable) How clients are taught to recognize signs of pain in their pets

Handouts on procedures to be performed/recognizing signs of pain and review of handouts Discussion of all procedures performed, anticipated associated pain, way pain will be

Written^oral triggers to seek vetennary care if they suspect that their pet is in pain - Contact person/emergency clinic after hours for assistance/treatment if necessary performance- ^Management win constantly be assessed and adapted based on peer-reviewed and evidence-based medicine. Overset, The attending veterinarians have oversight responsibilities

County Seat Animal Hospital, LLC Pain Control Protocol

 

Ancillary methods for treating pain, such as massage and warm/cold compresses

• American Veterinary Guidelines

• Physical therapy (ex. Massage, exercise, hydrotherapy)

0 We look forward to adding these services in thfuture.

■ Nutriceuticals are considered as an alternative or in addition to conventional therapies.

• Theraputic Laser

• Chiropractic

• Accupuncture

*

How practice team members are trained to identify causes, level of pain, and medications and methods to control pain

1 Pharmaceutical manufacturers' presentations at practice team meetings

• Pharmaceutical manufacturers supply current resources on pain management

• Literature review of current periodicals and books

• Internet access to structured courses

• Learning from other team members

• Veterinarian overseeing patient and accountability for the case

• Time sensitive review for entire practice team (as often as applicable) How clients are taught to recognize signs of pain in their pets

• Handouts on procedures to be performed/recognizing signs of pain and review of handouts

  • • • • Discussion of all procedures performed, anticipated associated pain, way pain will be

addressed

■ Written and oral triggers to seek veterinary care if they suspect that their pet is in pain                   ■ Contact person/emergency clinic after hours for assistance/treatment if necessary

Performance: Pain Management will constantly be assessed and adapted based on peer-reviewed and evidence-based medicine.

Oversight: The attending veterinarians have oversight responsibilities