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Year 3 MOD > Anaesthesia: Management of Long Term Pain and Locoregional Anaesthesia SS > Flashcards

Anaesthesia: Management of Long Term Pain and Locoregional Anaesthesia SS Flashcards

1
Q

What is chronic pain?

A

‘whatever the animal’s behavioural changes, combined with their motivational states, tell us it is’

Pain that outlasts the original injury and expected healing time or that a specific period

Changes in central pain processing (hyperalgesia and allodynia)- Maladaptive

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2
Q

What are the different types of chronic pain?

A

Nociceptive/inflammatory

neuropathic

neoplastic

mixed

reffered

myofascial

sympathetically mediated pain?

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3
Q

What is myofascial pain?

A

Significant component of many chronic pain states- often underdiagnosed

Has myofascial trigger points- arise due to muscle ‘wear and tear’, damaged motor end plates causes acetylcholine release and therefore local sarcomere contraction leading to distinct knot or taut band

Commonly affects postural muscles- neck, shoulder, lumbar and hip

There is a specific palpation technique which gives dramatic response

May occur secondary to postural strain, blunt trauma, spinal pain

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4
Q

What are the implications of chronic pain?

A

Sensory, emotional, cognitive, motor, welfare and quality of life

‘suffering’

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5
Q

How can chronic pain be assessed?

A

Quantitative sensory testing

Force plate analysis- lameness

Validated chronic pain scales

  • e.g. - Glasgow University Vet School questionnaire (GUV-Quest)
  • Liverpool Osteoarthritis in Dogs (LOAD)
  • Canine Brief Pain Inventory (CBPI)
  • Helsinki Chronic Pain Index (HCPI)
  • Feline Musculoskeletal Pain Index (FMPI)
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6
Q

What are some common behavioural changes in dogs with chronic pain?

A
  • Reduced enthuiasm or play and initiating plah
  • Reduced excercise tollerance
  • Change in interaction with owner (more clingy)
  • Change in attitude towards other people- agressive, seperation anxiety
  • More restless
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7
Q

What are some common behavioural changes in cats with chronic pain?

A
  • Reduced enthsiasm
  • Reduced jumping to access higher areas
  • Change in interaction with owner
  • Less time spent outside
  • Change in urination behaviour
  • Reduced use of scratching post- overgrown claws
  • Appetite- increased or decreased
  • More time spent sleeping
  • Change in grooming behaviour
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8
Q

How should you approach a case of chronic pain?

A
  • Identify owners concerns and expectations
  • Identift the problem and classify the type of pain for each source
  • Identify aims of pain management
  • Devise treatment plan
  • Implement plan for review and provide clear outcome measures

PLATTER- plan, anticipate, treat, evaluate, return

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9
Q

What is the acroym for the treatment of chronic pain?

A

ABCDE

Analgesia

Body weight

Control of complications

Disease modifications

Excercise

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10
Q

What are the different ways to achieve analgesia?

A

Analgesic Drugs

Analgesic interventions- acupuncture, physiotherapy, hydrotherapy etc

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11
Q

1) What is an example of an NSAID?
2) What are there MOA?
3) What needs to be considered with long term use?
4) What are the potential side effects?

A
  1. Metacam
  2. Cox 1/2 inhibitors
  3. Serum biochemistry testing and urinalysis indicated with long term use
  4. Multiple side effects- GI, hepatic, renal, coagulation
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12
Q

1) What is grapiprant?
2) What is its marketed use?
3) What is its mode of action?
4) What are its side effects?

A
  1. Non-steroidal, non-cox inhibiting anti-inflammatory drug
  2. Marketed as first line treatment but useful if dogs cannot tolerate NSAIDs
  3. PGE2 EP4 receptor antagonist- involved in development of pain and inflammation
  4. Common side effect- mild transient vomiting
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13
Q

1) What are anti-NGF monoclonal antibodies?
2) What is the name of the canine and feline antibody products?
3) How often is it administered?
4) What are its side effects?

A
  1. Monoclonal antibodies produced against nerve growth factors that contribute to OA pain
  2. Canine- bedivetmab, Feline Frunvetmab
  3. SC injection every 4 weeks
  4. transient skin irritation

Take care- self injection can often lead to hypersensitivity

Rapid progression of OA reported with concurrent use in humans

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14
Q

For how long is paracetamol use licensed with in dogs?

What is it’s MOA?

A

Liensed for 5 days orally with codeine

MOA not fully understood

Can be used with/without NSAIDs

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15
Q

1) What class of drug is tramadol?
2) What is tramadol’s mode of action?
3) What is tramadol licensed for in dogs?

A
  1. Atypical opioid- weak mu receptor agonists
  2. Inhibits serotonin and noradrenaline reuptake- M1 metabolise has greater analgesic efficacy
  3. Licensed for acute and chronic mild soft tissue and musculoskeletal pain
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16
Q

1) How effective is tramadol in cats and dogs?
2) What can it mask when used with NSAIDs?
3) What are its side effects?

A
  1. Efficacy in dogs varies, can be effective in cats- slower clearance of M1 metabolite
  2. Can mask GI pain
  3. Side effects- salivation, vomiting, dysphoria, sedation, seizures
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17
Q

1) What are examples of NMDA antagonists?
2) How long it their onset?
3) What are their side effects?

A
  1. Ketamine, amantadine, Memantine- other 2 not licensed
  2. Slow onset 3-4 weeks
  3. Common side effects transient GI signs, may cause agitation/restlessness, may lower seizur threshold
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18
Q

1) What is the MOA of gabapentin and pregabalin?
2) What are they used to treat?
3) What are they marketed for?
4) What are their side effects?
5) What could stopping them abruptly do?

A
  1. Calcium channel antagonists
  2. Neuropathic pain
  3. If animal cannot tolerate NSAIDs
  4. Sedation, vomiting, ataxia
  5. May cause seizures

Pregabalin- oral absorption more rapid and predictable

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19
Q
A
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20
Q

1) What kind of drug is amitriptyline?
2) What chronic pain can it be used to treat?
3) What is its MOA?
4) What side effect can it cause?

A
  1. Tricyclic antidepressant- not licensed in veterinary species
  2. Neuropathic pain
  3. Central opiod receptor activity and serotonin and noradrenaline reuptake inhibitor
  4. May cause cardiac arrythmias
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21
Q

What chronic pain are bisphosphates used for?

A

Pamidronate or zoledronate for BONE PAIN

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22
Q

What is acupuncute indicated for?

A

Indicated for OA pain and central sensitisation- limited vet studys

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23
Q

What is the purpose of physiotherapy?

A

to rehabilitate, muscle strengthenin for myofascial pain, includes passage for passive movement

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24
Q

What is hydrotherapy good for with chronic pain?

A

Helps to regain fitness, strength and balence

Less pressure on joints

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25
Q

What is photobiomodulation useful for in chronic pain patients?

A

May be useful in irritable animals that won’t tolerate accupuncture

Limited evidence, riskof themral injury

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26
Q

What is TENS?

How does it work?

What are its contraindictations?

A

Transcutaneous electrical nerve stimulation

Sensory nerve depolarisation to supress pain at spinal cord, widely used in humans helps muscle strengthening

Containdications- cardiac pacemaker, seizures, abdominal area during pregnancy

27
Q

When is palliative radiotherapy often used?

A

Well recognised for palliative treatment of pain associated with oesteosarcoma in dogs

28
Q

How is body weight used to help chronic pain?

A

Obestity common

Losing weight can help by putting less pressure on joints etc

29
Q

How are is control of complications achieved?

A

Owner compliance- aware of potential side effects and complications

Involvment of owner in managment process

Common sense and comfort

Dogs- ramps, non-slip rugs, restriction of stairs, raised food/water

Cats- use of steps/ramps, provision of new hiding places, raised food/water, modification of cat flaps

30
Q

abcDe

How is Disease Modification achieved?

A

Correct diagnosis in the first place- specific medications, surgical intervention

Polysulphated GAGs, pentosan polysulphate and hyaluron injections

‘Nutraceuticals’- tumeric, omega 3, hydrolysed, collagen

31
Q

What are the options for treatment of horses with chronic pain?

A

Recognition challenging
Surgical intervention
Hollistic approach recommended
Complementary therapies
NSAIDs
Ketamine CRI sub-anaestetic dose
Paracetamol- laminitis and compartment syndrome
Gabapentin- laminitis and neuropathic pain
Tramadol
Nerve blocks

32
Q

What can be used to treat food producing with chronic pain?

A

Likely under-recognised

Limited pharmaceuticals- NSAIDs, Paracetamol, Ketamine

Consider withdrawal periods

Acupuncture

Weight managment

33
Q

Why are local blocks used in veterinary species?

A

Adjunct to sedation or general anaesthesia

Prevent nociception

Help to provide multimodal analgesia

34
Q

What areas can we block?

A

Head blocks

Limb blocks

Epidural

Line blocks

Local infiltration

Paravertebral

35
Q

How do local anaesthetics work?

A

Act by blocking sodium channels in the nerve cell membrane preventing transmission of the action potential

36
Q

What are some licensed local anaesthetics?

A

Procaine

Lidocaine

Mepivacaine

Last 1-2 hours

37
Q

What are some non-licensed but longer acting locals?

A

Bupivacaine

Ropivacaine

Last 4-8 hours

38
Q

How can locals cause neurotoxicity and cardiortoxicity?

A

Sodium channels are found in nerves of the brain and heart and therefore can cause neurotoxicity and cardiotoxicity- different locals have different toxicity profiles

39
Q

1) What can neurotoxicity cause?
2) What can cardiotoxicity cause?

A

1) Twitching, nystagmus, sedation, seizures, respiratory depression and large doses can lead to generalised CNS depression including coma and respiratory arrest
2) Can cause arrythmias, bradycardia, hypotension and in large doses cardiac arrest

40
Q

Which local is very cardiotoxic and shouldn’t be given IV?

A

Bupivacaine

41
Q

What is the treatment of suspected or known local anaestestic toxicity?

A
  • IV lipid emulsion- local anaesthetics are highly lipid soluble, 20% lipid emulsion is availible, if not propofol is 10% and can be used
  • Neurological signs- provide oxygen therapy, antiseizure medication such as diazepam or levetiracetram, may need to intubate
  • Cardiovascular signs- provide IVFT, support blood pressure with vasopressors, intropes do not use lidocaine
42
Q

What are the advantages of local anaesthetics?

A

True analgesics

Reduce or abolish stress response to anaesthesia

Anaesthetic and analgesic sparing

May reduce rate of metastasis

43
Q

What are some common equine head blocks?

A

Auriculopalpebral

Infratrochlear

Supraorbital

Zygomatic

Lacrimal

Retrobulbar

Infraorbital

Mandibular

Maxillary

Mental

Internaland greater auricular

44
Q

What nerves should be blocked for dehorning/disbudding in different species?

A

Cornual nerve- branch of lacrimal nerve

Calves- behind lateral canthus of eye, beneath temporal ridge

Adult cattle- local infiltration around horn also

Goats- horn supplied by cornual and infratrochlear

45
Q

What head blocks should be used for the muzzle such as a for a nose ring?

A

Locally infiltrate or bilateral infraorbital nerve block

46
Q
  • Where are the three main sites for providing ectra dural anesthesia?
A

Lumbo-sacral

Caudal (sacro-coccygeal or inter coccygeal)

Thoracic- small animals

47
Q

What does the drug choice for extra-durals depend on?

A

Depends on the species and the surgery

Usually: Locals, Alpha 2 agonists or opioids

48
Q

What local nerve blocks could be used for caesarean?

A

Paravertebral

Line block

Inverted L block

Local infiltration

49
Q

How is a paravertebral nerve block done in a cow?

A

Palpate cranial to tuber coxae and feel 1st palpable lumbar transverse process (L5)

Mark out other transverse process

Block T13, L1 and L2 by ‘walking’ needle off caudal border of transverse process

T13 and first 2 lumbar segments desensitised

50
Q

What does IVRA stand for?

A

Intravenous regional anaesthesia

51
Q

Where is the anaesthesia injected in IVRA?

What drug is used?

When will the anaesthesia last until?

What are the potential complications?

A

Anaesthesia distal to tourniquet

Lidocaine only

Anaesthesia will last until tourniquet is released

Complications- local anesthetic toxicity, ischaemia if long period

52
Q

How are nerves located?

A

Landmarks or palpation is used to localise the nerve- most useful are close to the surface

53
Q

How is a retrobulbar block performed?

A

Needle is advanced behind the eye to block the sensation to the eye via the trigeminal nerve

There are 5 techniques- inferior temporal is best

A curved needle in the ventral eye at orbital rim, needle advanced dorso-medially aiming for behind the globe, may feel a pop from the orbital fascia, aspirate to check not in blood

54
Q
A
55
Q

What are the potential complications of a retrobulbar block?

A

Blindness, haemorrhage, globe penetration, proptosis, stimulation of oculocardiac haemorrhage

56
Q

How is a maxillary nerve block performed?

A

Intra-oral approach- small needle inserted perpendicular to the palate behind last molar- can penetrate globe in cats

Transcutaneous- landmarksbehind the cranio-ventral border of the zygomatic arch, the cranial border of the mandibular ramus and the caudal border of the maxilla, needle withdrawn slightly and local injected

Placement of catheter into infraorbital foramen- most useful for cranial maxillay tissues

57
Q

What does the maxillary nerve supply?

What are the uses of a maxillary nerve block?

What are the potential complications?

A

Maxillaryis a branch of the trigeminal- supplies sensation to the maxillary teeth, bone and soft tissues (palate, upper lip, nose)

Oral surgery to the upper jaw

Haemorrhage, drying of the cornea

58
Q

What does the mandibular nerve supply?

A

Branch of the trigeminal enters the mandible at mandibular foramen- supplies sensation to the lower teeth, mandible and soft tissues of the lower jaw

59
Q

How is a mandibular nerve block performed and what are the potential complications?

A

Intra-oral- behind the last molar and transcutaneous where the needle is inserted ventral to the mandible

Transcutaneous where the needle is inserted ventral to mandible

In both techniques mandibular foramen palpated

Complicatoins- haemorrhage, lack of tongue sensation, stabbing yourself

60
Q

What are the three layers of meninges surrounding the spinal cord?

A

Closest is the pia mater

Sub arachnoid space filled with CSF

Enclosed by the arachnoid matter

Then the dura mater

Outside is fat containing epidural space

61
Q

How is an epidural performed in small animals?

A

Usually in the lumbosacral space- could be between any 2 vertabrae- lumbosacral is easy to palpate

Find the wings of the ilium and dorsal spinous process of L7, finger places on the wig of the ilium and first finger in the region of lumbosacral space, needle passes through the ligamentum favum ‘popping’

Hanging drop needed as pressure in the epidural space is less the atm

S1-2 in cats

62
Q

What is a nerve stimulator guided block?

A

A nerve block using a nerve stimulator for limbs by guiding you close to the nerve- femoral, sciatic, radian, ulna, median and musculocutaneous (RUMM)

63
Q

What is an alternative to nerve stimulated blocks?

A

Ultrasound guided blocks- can be used in addition

64
Q

What is local infiltration and name some common uses?

A

When local is applied directly to surgical sites to provide analgesia, may not be as effective as local nerve blocks

Topical corneal, intra-articular, incisional infiltration, splack blocks onto open areas of muscle before closing

Year 3 MOD (40 decks)

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