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ANESTHESIA - 2 > 32 – Peri-Operative Pain Management in Large Animals > Flashcards

32 – Peri-Operative Pain Management in Large Animals Flashcards

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1
Q

What are the arguments for use of analgesics in large animals?

A
  • Pain results in poor recovery from anesthesia
  • Animals are restless
  • Animals do not eat well
  • Decreased immune response due to STRESS
  • Delayed wound healing
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2
Q

What are the arguments against use of analgesics in large animals?

A
  • Over-use of injured area
  • Side effects
    o GI ulcers
    o Constipation
    o Ileus (but pain can also cause it, BALANCE)
    o Behavioural alterations
  • Masks worsening of disease process
  • Difficulty in recognizing pain
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3
Q

Head pain behaviour in horses

A
  • Shake
  • Snort
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4
Q

Jaw pain behaviour in horses

A
  • Drooling
  • Dropping food
  • Losing weight
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5
Q

Limb pain behaviour in horses

A
  • Stomp
  • Limp
  • Refusal to walk
  • Lying down
  • Abnormal stance (ex. leaning back when front limb sore)
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6
Q

Abdominal pain behaviour in horses

A
  • Kick at belly
  • Flank watch
  • Roll
  • Tail swish
  • Violent behaviour
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7
Q

‘pain face’ of a horse

A
  • Lowered ears
  • Contraction of muscles above eye
  • Tense stare
  • Dilated nostril
  • Tension of facial muscles
  • Edged shaped muzzle with lips pressed together and flattened chin
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8
Q

Pain management in horses: analgesic drugs for

A
  • Pre-medication/sedation
  • Pre-emptive pain management
  • Multi-modal analgesia
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9
Q

Pain management in horses: infusion techniques for

A
  • Intra-operative
  • Post-operative
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10
Q

Pain management in horses: epidural/spinal techniques for

A
  • Standing procedures
  • Post-operative long term pain management
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11
Q

What are the 5 ‘classes’ of analgesic drugs used in horses?

A
  1. NSAIDs
  2. Alpha-2 agonists
  3. Ketamine
  4. Opioids
  5. Local anesthetics
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12
Q

What are the benefits of NSAIDs in horses?

A
  • Analgesic
  • Anti-inflammatory
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13
Q

What are the potential harmful side effects of NSAIDs in horses?

A
  • Gastric and colonic ulceration
  • Renal tubular necrosis
  • *more with chronic use
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14
Q

What are the usages of NSAIDs in horses?

A
  • often administered PRE-OPERATIVELY anticipating inflammation that will occur during surgery
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15
Q

What are some examples of NSAIDs in horses (2)

A
  • phenylbutazone
  • flunixin meglumine
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16
Q

Phenylbutazone in horses for

A
  • musculoskeletal inflammation and pain
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17
Q

Flunixin meglumine in horses for

A
  • acute soft injury
  • endotoxemia
  • abdominal pain
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18
Q

What are the alpha-2 agonists used in horses?

A
  • Xylazine
  • Detomidine
  • Medetomidine
  • Dexmedetomidine
  • Romifidine
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19
Q

What are the usages of alpha-2 agonists in horses?

A
  • Pre-medication primarily for SEDATION
  • Intra-operatively as a CRI for analgesia
  • Post-operatively for sedation to ensure SMOOTH RECOVERIES from inhalation anesthesia
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20
Q

What are the benefits of alpha-2 agonists in horses?

A
  • ANALGESIA
  • Sedation
  • Anesthetic sparing
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21
Q

What are the potential negative side effects of alpha-2 agonists?

A
  • Bradycardia
  • Vasoconstriction and hypertension
  • Increased urine output (hyperglycemic diuresis)
  • Decreased GI motility
  • Ataxia
  • *can get excited (need to be sedated: ’nose to knees’)
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22
Q

Xylazine in horses

A
  • Used with KETAMINE and GGE (Guaifenesin) in ‘triple drip’
  • Total intravenous anesthesia (TIVA)
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23
Q

Detomidine in horses

A
  • Used for sedation and analgesia for standing procedures
  • Often combined with an OPIOID
  • Administered as an infusion (variable rate infusion (VRI))
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24
Q

Dexmedetomidine in horses

A
  • Used for invasive procedures with INHALATION ANESTHESIA (PIVA)
    o Once turn it off=it is gone (still need to SEDATE for recovery period)
  • *Ex. orthopedic surgery
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25
Ketamine in horses
- Used as in induction agent - Used in ‘triple drip’ mixture - *provides analgesia o Somatic o NMDA antagonism: good for chronic (‘wind-up’) pain - *risk of excitement: but can be controlled with sedatives
26
What are some other beneficial effects of ketamine besides analgesia?
- Local anesthetic affects - Potent anti-inflammatory effects - Anesthetic sparing (decrease MAC by 37%)
27
What are the main opioids used in horses?
- Morphine (mu agonist) - Butorphanol (kappa agonist)
28
What are opioids primarily used for in horses?
- Intra-operatively o Not good sedative unless combined with an alpha-2 agonist - Appears to be effective in horses in pain OR undergoing invasive procedures=good analgesia - DOES NOT REDUCE ISOFLURANE REQUIREMENTS (unlike dogs and cats)
29
What are some side effects of opioids?
- Excitement: control with sedatives (acepromazine, alpha-2 agonists) o *give them first and them first and then do opioids - Decreased GI motility: decreased if administered IM or not given long term
30
Opioids dosage guidelines
- more severe than pain=greater dose required and lower risk of excitatory side effects - give appropriate alpha-2 match for duration to eliminate risk of excitation - sedation acepromazine reduces but does not ELIMINATE risk of excitement - *SHOULD BE GIVEN TO EFFECT: NOT BY THE CLOK - Clinical signs of underdose (ie. PAIN) may MIMIC signs of overdose (EXCITEMENT)
31
Morphine
- Used at LOW doses for horse in pain - Duration: ~4hrs - Side effects when use repeated dosing or high dosages - Can enhance effects of other sedatives when used with standing sedation - CV stimulation when used alone - Can use for intra-articular analgesia (up to 24hours, less systemic side effects)
32
What are some side effects when morphine is given repeatedly or at high doses?
- Reduced GI motility - Urinary retention - Increased locomotor activity and ataxia
33
Morphine intraoperative uses (horses)
- CRI - Higher dosages (0.25mg/kg) - Clinical dosages
34
Morphine CRI (intraoperative use)
- Improved recovery characteristics - No conclusive evidence that its use increases incidence of post-anesthetic colic
35
Morphine higher dosages (intraoperative use)
- Used for analgesia - May increase isoflurane requirements - May result in rough recoveries
36
Morphine clinical dosages (intraoperative use): recovery affect
- Does not affect recovery
37
Fentanyl
- Use is controversial: need large doses o Maybe MAC reducing effect but increase in rough recoveries - Clinical benefit at this time: POST-OPERATIVE period via TRANSDERMAL PATCHES for pain control
38
Fentanyl patches
- Need 1-3 (‘for small animals’) - Variable results - May see excitement: may need acepromazine or alpha-2 sedation - May need to supplement with another analgesic: NSAID - Location may affect absorption - *controlled drug (don’t want abuse)
39
Fentanyl patches absorption
- Better absorption from thorax or groin compared to a leg
40
Fentanyl patches: in foals
- One 100mcg/hr patch may be used - Peak plasma levels after 14hrs
41
Remifentanil
- Used with success INTRA-OPERATIVELY - Good recoveries - Some reports of hyperthermia - Can ONLY be used as CRI due to SHORT-HALF LIFE - *Make sure analgesia is in place before turning off
42
Buprenorphine
- Long duration of action: up to 12hrs - Behavioural side effects - Sub-lingual administration might be useful - New evidence: may provide better POST-OPERATIVE analgesia than butorphanol for minimally invasive procedures (ex. castration) - Not really used at the school
43
What are some side effects of buprenorphine?
- Restlessness - Head shaking - Decreased GI motility for up to 4 hours
44
Butorphanol
- Can still produce excitement (delta receptors) - Often used INTRA-OPERATIVELY - Effective for VISCERAL ANALGESIA - Duration: 45-1hr (IV) o re-dosing is often necessary - does NOT change isoflurane requirements - *does provide a more ‘stable’ anesthesia - Post-operative usage
45
Butorphanol post-operative usage (horses)
- May need it IM every 3 hrs: analgesia is short last and not profound - Can be injected - Analgesia is NOT consistent as with an infusion but there is less risk of IMPACTION
46
Local anesthetics: Lidocaine
- As an infustion INTRA-OPERATIVELY w/o epinephrine! - Loading dose and CRI - *stop infusion at least 30 mins prior to recovery from general anesthesia: TO PREVETN ATAXIA
47
What are the pharmacological benefits of lidocaine?
- ANALGESIA - Anti-inflammatory - Anti-endotoxemic - Pro-kinetic - Anesthetic sparing
48
Partial IV anesthesia (PIVA)
- Combination of infusions (multimodal anesthesia) - Useful technique to reduce isoflurane requirements - Alpha-2 agonists, lidocaine, opioids, ketamine
49
Alpha-2 agonists indications and PIVA
- Invasive/painful procedures - Orthopedic procedures: musculoskeletal pain and inflammation
50
Lidocaine indications and PIVA
- Colic surgeries
51
Opioids indications and PIVA
- Orthopedic surgeries
52
Ketamine indications and PIVA
- Somatic analgesia o Supplement other drugs
53
What are other modes of providing analgesia (4)
- Epidurals - Epidural catheters - Wound/soaker catheters - Local blocks
54
Epidurals
- Good for standing procedures - Require sterile technique - Relatively easy to place in standing horse (sacrococcygeal) - Use preservative free drugs - Usually once or twice daily treatment - Administer drugs SLOWLY
55
Epidural catheters
- For LONG term pain management - Sterile technique for placement and management!
56
Wound/soaker catheters
- Can provide postoperative analgesia for 2-3 days - Preplace during surgery - Commercial kits available - Use LIDOCAINE infusions: 2-5ml/hr - Use BUPIVICAINE infusions: 2-5ml every 6-10hours - *maybe not used when remove a tumor?
57
Local blocks
- Intra-operative: anesthetic sparing: - Post-operative: improve recovery and minimize need for other analgesic agents
58
Considerations for recovery
- Must STOP ALL INFUSIONS prior to moving into recovery box - Give NSAIDs if warranted - Consider local blocks if applicale - Usually sedate with alpha-2 agonist o Xylazine o Romifidine
59
Pain behaviour in ruminants
- Abnormal stance and gait - Unusual resting behaviours - Vocalization - Kicking and tail swishing - Very subtle indicators (teeth grinding, reduced food, absence of rumination)
60
What are the analgesic drugs used for ruminants (5)?
- NSAID - Opioids - Ketamine - Lidocaine - Alpha-2 agoinsts
61
NSAIDs: ruminants
- Withdrawal times NOT well defined for meat or milk - Primary risk=GI ulcer formation
62
What are some behavioural side effects that might be seen with opioids in ruminants and that may need to be adjusted?
- Sedation - Dysphoria - Excessive locomotor activity - Excitement - *can develop INTESTINAL STASIS with long term use
63
What are the 2 opioids used in ruminants?
- Morphine - Butorphanol
64
Epidural opioids: ruminants
- Morphine: diluted in 10ml saline - *sacrococcygeal administration (‘caudal epidural’)
65
In what animals can or are transdermal fentanyl patches used?
- Goats and sheep - Llamas - Pigs (placed behind ear or inner thigh)
66
What are the benefits of ketamine in ruminants
- Anesthetic sparing - NMDA antagonist: good for chronic pain - Good for somatic analgesia
67
Ketamine dosages in ruminants
- Higher dosages than in small animals
68
What is lidocaine used for in ruminants?
- **Infusion INTRA-OPERATIVELY w/o epinephrine - Stop infustion at least 30 mins prior to recovery from general anesthesia to PREVENT prolonged recoveries
69
What are the pharmacological benefits of lidocaine? (ruminants)
- ANALGESIA - Anti-inflammatory - Anti-endotoxemic - Pro-kinetic: improves GI motility - Anesthetic sparing
70
What is the dosing of lidocaine in ruminants?
- Higher than HORSES and SMALL ANIMALS
71
Alpha-2 agonists: ruminants
- MORE SENSITIVE than horses - *use 1/10th dose you would use in horse
72
Epidural use of alpha-2 agonists in ruminants
- Use 1/10th dose of xylazine you would use in a horse

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