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Management of Pain:
A New Standard In ClinicalPractice
Suggested Guidelines for Compliancewith the New Standard & Improved
Patient Care
Pain as a Vital Sign!!!
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Why Have a Standardfor Management of Pain?
! Most patients experience acute or chronic pain atsometime during their life
! Pain is an indication of injury, pathologicconditions, or disease
! Management of pain reduces stress and providesimproved patient comfort
! Management of pain is a humane concept
! Management of pain is good medicine
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Management of Animal Pain
is a Global Concern of:! Animal Healthcare Professionals
! Animal Owners! Animal Care Providers (trainers, handlers,
ranchers, breeders " .)
! Any Concerned Humanitarians! The General Population of the World
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Stress & Pain are Multi SpeciesConcerns
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Pain assessment is considered part of every patientevaluation regardless of the presenting complaint
Step One
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! By careful examination of each patient, weare able to determine if there are any
conditions that may exist which are
painful.
! Even if it is an elective procedure, we need
to know that the patient is free of painbefore surgery or other medical
involvement takes place.
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Pain as a Vital Sign
Patient evaluation based on:
! Temperature
! Pulse (heart rate)
! Respiratory rate
! Blood pressure(in humans, but lessoften in animals)
! Pain
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! Pain assessment using a standardized scale orscoring system is recorded in the medical recordfor every patient evaluation
Pain Scores:!
Physiological parameters TPR (traditional measurements)
! Sensitivity measurements
Pain scales such as:
No Pain Mild Moderate Severe Pain
0------1------2------3------4------5------6------7------8------9------10
Step Two
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Factors Influencing Pain Scores
! Change in temperament
! Increased vocalization
! Abnormal posture
! Altered locomotion
! Other behavioralchanges
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Step Three
! Pain management is individualized for eachpatient
All patients are not alike, not even within the same species or even within the same breed nor do they respond the same.
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Threshold & Responseto Pain Varies
Species
Breed
Age
Health Status
Professional Concept: Animals have pain = Treat it
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! The practice utilizes preemptive pain management
Preemptive Medication Anesthetic Induction
Step Four
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! The practice of veterinary medicine in our clinicsand hospitals now utilizes preemptive painmanagement.
! This consists of the administration of apreanesthetic, normally a sedative or analgesicprior to induction of anesthesia for surgical andother procedures involving painful conditions.
! Utilizing preemptive measures before a painful
stimulus is elicited in the patient, will reduce theamount of medication necessary to control painby avoiding the build up of pain responses.
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! Purposeful
! Short duration
! Responsive totreatment
Acute Pain (trauma, surgery)
PNS CNS
A delta &C fibers
A : ! fibers
Acute Pain(protection)
NociousSensation
High Intensity Stimulus
Low Intensity Stimulus
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As illustrated on the previous slide Acutepain is the type that can be present either during
surgery without adequate pain management orfollowing trauma.
In the awake patient, acute pain elicits a
purposeful response which is of short duration.Whenever the pain sensation occurs, there is a high-intense stimulus which affects A-delta and C-bers inthe peripheral nervous system.
There is a related acute pain response in thecentral nervous system. The pain response to lowintensity stimulation, is to the alpha-beta bers. Werefer to this as a noxious sensation.
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! Appropriate pain management is provided for theanticipated level and duration of pain
Chronic
Step Five
Acute
vs.
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The administration of analgesics for 5 to 7
days after surgical correction in cases of injury is
usually adequate to control acute pain. The level of
pain has dropped by that time and further use of
potent analgesics is usually not needed.
In contrast, in chronic pain such as in cancer,
the level of pain may not be as immediately obvious,
but we can anticipate that it will be of long duration
and may become more severe.
As a result, extended measures for the
treatment of chronic pain are necessary.
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Treatment Related toSeverity of Animal Pain
Mild! NSAID's! Steroids! Local anesthetics
! Physical therapy
Moderate
! Opioid agonists! Opioid agonists/antagonists! Alpha 2 agonists
Severe: treatable
! Potent opioids with/withoutconcurrent medications
! Permanent nerve blocks
Neurectomies
Implantable opioid pump
Severe:uncontrollable
! Euthanasia
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There is a fourth part of the treatment ladder of mild,
moderate, severe, and severe uncontrollable pain which we
can use in veterinary medicine. This is in contrast to the
three-part ladder which is used in treatment of people. In
humans, in some cases there is severe unmanageable pain
in the patient. Quality of life for the patient is unbearable.
There is a need for further management. In
veterinary medicine; we have an answer. The use of high-
doses of analgesics with or without an anesthetic to the
point of loss of vital functions. Some may refer to it as
euthanasia. We consider this as the FINAL step in the
treatment of uncontrollable severe pain and suffering .
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Step Six
P N
! Pain management accompanies all surgicalprocedures
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Pain management should accompany all
surgical procedures from either minor to majorsurgery.
This was more obvious to us in the past, to
prevent pain during the perioperative and post-
operative periods for major surgical procedures .
We have now found that pain management for
elective procedures, thus reducing stress during
surgery and enhancing recovery of the patient to
return to normal activities.
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! Balanced perioperative management
Step Six (cont.)
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Balanced Analgesia! Similar to balanced anesthesia, also
referred to as multimodal analgesia
! Combination of complimentary methods
or drug classes! Maximize effectiveness and minimize
side effects
Analgesics Anesthetics
P N
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Step SevenThe patient is reassessed for evidence of pain throughout any
procedure that has the potential to cause patient discomfort
We are able to adjust anesthetic concentrationsand adjunct medications .
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Systems Affectedby Pain need to be evaluated
! Neurological
! Cardiovascular
! Respiratory! Skeletal
! Digestive
! Urinary
! Endocrine
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Many systems are affected by pain, they should be evaluated
during all procedures. These include:
Neurologic Skeletal
ardiovascular Digestive
Respiratory UrinaryPain or inadequate analgesia during a surgical procedure can
change heart rates and blood pressure. It can affect the
respiratory responses. Inadequate management during the
perioperative procedure may compromise the skeletal
muscles. When there are responses from inadequate
perioperative analgesia, the peripheral and central nervous
system parameters will be stimulated.
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Post-operatively, normal digestion and urinary
function will return to a stabilized levels more rapidly if we
have provided the appropriate level of pain management. Ifduring the process of painful procedures, inadequate
management of pain exists, there will be an increase in the
secretions by the endocrine system. These include:
epinephrine
norepinephrine
cortisol
The elevation of these parameters has been shown
in research to be an index of inadequate management of
painful conditions.
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! Patients with persistent or recurring conditions such asperiodontal disease, pancreatitis, neoplasia,osteoarthritis, and otitis are evaluated to determinetheir pain management needs
Step Eight
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! Non-purposeful
! Long-standing
! Less responsive to treatment
! Physiologically different
Chronic Pain(osteoarthritis, cancer, chronic otitis)
Pathological Pain:
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In chronic pain, there are certain indicators that
this is a pathological condition. These conditions maybe induced by:
Following traumatic conditions which do not
heal properly or in which there are long-term effects,chronic pain may often develop. Inammatory painwhich is not controlled will escalate into a chroniccondition. This is seen in cases of osteoarthritis.
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Chronic Pain(osteoarthritis, cancer, chronic otitis)
Pathological Pain
Mechanical Inflammatory Traumatic
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Chronic Pain(osteoarthritis, cancer, chronic otitis)
Low IntensityStimulus
Pathological Pain
Hyperalgesia
Allodynia
Tissue Damage, Inflammation
Sensitizing Soup
of Neuropeptides
Stimulation ofHigh & Low Threshold
A delta & C fibers
Transduction Sensitivity
Stimulation ofLow Threshold
A: ! fibers
Mechanical
Inflammatory
Traumatic
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As illustrated on the previous slide, in chronic pain there are
mechanical, inammatory, and traumatic pathways. When thesefactors cause a stimulation to the nervous system due to tissue
damage and inammation, we have a condition that is called
sensitizing soup of neuropeptides. This is due to stimulation of
high and low threshold A-delta and C bers. It produces a condition
of hyperalgesia. Under these conditions, the patient is extremely
distressed.
Chronic low intensity stimulation of low threshold alpha-
beta bers, causes a transduction sensitivity and a condition
referred to allodynia.
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Chronic Pain:Needs careful evaluation & extended management
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Pain Management Protocol
in Osteoarthritis! Diagnosis and evaluation of pain
! Nutrition and weight control! Exercise and physical therapy! NSAID therapy! Surgical correction
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! Analgesic therapy is used as a tool to confirm theexistence of a painful condition when pain issuspected but cannot be confirmed by other objectivemethods
Systemic
Step Nine
vs.
Regional Analgesics
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Analgesic therapy can be used as a tool to confirm
the existence of pain, when pain symptoms are observed
but cannot be confirmed by other objective methods.
This can be done systemically by evaluating the
patient for undesirable changes in the neurologic,
cardiovascular, and respiratory parameters.
Using regional analgesics, one can diagnose the
location of pain in the extremities. The patient is evaluated
for pain levels before and after joint or local nerve blocks.
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CAUTION! Pain induces neurological activity, which will
increase arterial blood pressure & heart rate
! It also creates stress &its related impact onfunction
! It causes changes intemperament
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What Is Your Diagnosis?
Intense Pain or Biting Dog!
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Step Ten! A written pain management protocol is utilized
and addresses
1) Methods for preemptive control of pain
2) Events or circumstances known to beassociated with pain
3) Means by which pain and the degree of paincan be recognized in patients
4) Names and actions of medicationsdispensed, prescribed, or administered forpain management
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Step Ten (cont.)! A written pain management protocol is utilized &
addresses
5) Side effects, complications, concurrent druginteractions, and contraindications associated with
specific analgesics and general pain management6) Ancillary methods for treating pain, such as massage
and warm or cold compresses
7) How practice team members are trained to identify
causes, level of pain, and medications and methodsto control pain
8) How clients are taught to recognize signs of pain intheir pets
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Classes of Pain Medications
! Local anesthetics
! Corticosteroids
! Non-steroidal anti-inflammatory drugs
! Alpha 2 agonists
! Opioid agonists(agonist-antagonists)
! Others including anticonvulsants
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Local Anesthetics for examplemay be used for regional analgesia
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Corticosteroidsmay be used in inflammatory mediated pain
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! Corticosteroids have been used in the pastand currently in selective conditions.
! They may be used orally, or by injection
for systemic relief of pain.
! Regional benets such as intra-articularinjections may be advantageous.
! Should not be used concurrently withNSAIDs
N S id l
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Non SteroidalAnti-Inflammatory Drugs:
Commonly used in humans
Frequently used in animals
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! Nonsteroidal anti-inflammatory drugs werecommonly used in humans for many years.
! We now have many nonsteroidal anti-inflammatory medications which have been
proven to be very effective in small and largeanimals.
! The use of these medications can be verybeneficial in both acute and chronicinflammatory pain brought on by injury orvarious disease processes.
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Available NSAIDs
! Carprofen! Deracoxib! Etodolac! Firacoxib! Mavacoxib! Meclofenamic Acid! Meloxicam! Robenacoxib! Tolfenamic Acid
Rimadyl
Deramaxx
Etogesic
Previcox or Equioxx
Trocoxil
Meclofenamic AcidMetacam
Onsior
Tolfedine
Also Known As Trade Names Generic
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Alpha 2 Agonists:use for sedation & analgesia
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! Alpha 2 agonists have been used for sedation andanalgesia in horses. In more recent years thedevelopment of xylazine, medetomidine,dexmedetomidine for sedation and/or analgesia inthe small animals was sucessful.
! They can be part of the management of the patientwhen predominantly sedation with analgesia isneeded, as premedication, or as part of post-surgicalpain management.
! The combination of the alpha2 agonist with injectable
anesthetics will reduce anesthetic dosagerequirements, can improve the quality of analgesiaand prolong the effect of the anesthetic.
O i id i i
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Opioid Agonist Antagonist:May be used in mild to moderate pain
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Currently Available Agonist-Antagonists
Butorphanol *
Pentazocine
Nalbuphine
Buprenorphine **
(partial mu agonist)
Naloxone (antagonist)
* Marketed in Europe as Butomidor ** Marketed in Europe as Bupaq
O i id Ag i t
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Opioid Agonists:Are used in moderate to severe pain
Pentobarbital may be used in conjunction with opioids in severeuntreatable pain in terminal cases.
*It is also a Schedule II substance, but not an opioid.
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! Opioid agonists are more effective for use inmoderate to severe pain than the opioidagonist-antagonist.
! Included in this group are the morphine-likeopioids and those newly developed which areeffective with less side effects.
! Either opioid agonists or agonist-antagonist
reduce anesthetic requirements for effectiveperioperative pain management.
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Currently Available Opioids *
* Will Vary By Country ** To Replace Traditional Opioids
Fentanyl Morphine
Hydrocodone Oxycodone
Hydromorphone Oxymorphone
Meperidine Remifentanil
Methadone
Sufentanil
Tramadol **
P i R d
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Patient RecordsShould Include Pain Issues
! Pain scores
! Controlled substances
! Financial
! Discharge instructions
! Signs
! Diagnosis
! Treatments
! Prognosis
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Doctor/ Staff Relationsin Pain Management
! Understanding
! Communicating
! Involving
! Supporting
K F i D l i
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You should :
! Discuss the symptoms of discomfort &pain with the staff
! Have a treatment plan to manage pain
! Involve the client in the treatment program
! Provide follow up information
Key Factors in Developinga Management Protocol
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Step Eleven! In cases where pain management is part of the
therapeutic plan, the client is effectively educated, inwriting and verbally, regarding medical issues suchas potentially beneficial and adverse effects of thetherapy ! Expected responses &
benefits! Signs of ineffective pain
management therapies
! Anticipated side effects! Client responsibilities! Follow up communication
& re-evaluation
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Buck- AdenocarcinomaA Sample Case Management Protocol
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! Labrador Retriever
! 8 year old castrated male
! Weight 45.4 kg! Vital signs normal,
no evidence of pain
! Behavior: friendly & alert
! Routine rectal exam revealed rough, palpable mass
Case Study
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! Buck was presented to the referring veterinarianfor routine physical examination and annualhealth care
! He was asymptomatic and not showing outwardsigns of pain or disease on 2/14/02
Case Study
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! 02/26/02! Colonoscopy - rectal biopsy by referring
veterinarian
! Routine recovery
Pre-Op Medication AcepromazineButorphanol
AnestheticInduction
DiazepamKetamine
AnestheticMaintenance
Isoflurane (1 hr)
Anesthetic/ Analgesic Protocol
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Histological Findings
! Path # 02-608 DB(completed UTCVM/McEntee)
! Diagnosis:Colorectal adenocarcinoma
! Comments:These tumors oftenmetastasize via thelymphatics
R di hi /
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! Ultrasonic examof abdomen
" No evidenceof metastasis
! Ultrasonic examof thorax
" No evidenceof metastasis
! Cleared for surgical removal of primary rectal tumor
Radiographic/Imaging Diagnostics
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03/20/02
EVENT DRUG/DOSE TIMEPremedication Fentanyl patch (50 g) 08:30
Acepromazine (0.01 mg/kg) 13:07
Hydromorphone (0.05 mg/kg) 13:07
Glyopyrrolate (0.01 mg/kg) 13:07
Induction Propofol (4.5 mg/kg) to effect 14:13
Maintenance Isoflurane (2.0-2.5% settings) 16:10
Perioperative AnestheticManagement for Mass Removal
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Perioperative Pain Management! Epidural Technique! Bupivicaine (0.5%) 3 cc! Morphine (1 mg/ml) 3 cc
(total volume limited to 6 cc)
S
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Heart rate, blood pressure & respiratory rate remainedwithin clinically acceptable values during the entire
procedure. The pain scores were within the desirable
range.
Surgery
P t ti P i
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EVENT DRUG DOSE(mg/kg IV )
TIME
Extubation Hydromorphone 0.05 16:45
Recovery roomanalgesics
Hydromorphone 0.05 20:00
Hydromorphone 0.05 24:00
Fentanyl patch: 50 g still in place
No further analgesics required
Postoperative PainManagement Protocol
P i Di h
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! Date: 03/23/02! 3 days post surgery
! Pain medicationdiscontinued, fentanyl patchremoved
! Buck not showing evidence
of pain! Clavamox antibiotic
15 mg/kg BID for 7 days
! Buck at release doing well
Patient Discharge
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L e t s k i c k t h e p a i n
o u t o f a c u t e a n
d
c h r o n i c
c o n d i t i o n s .
Buck!
A recoveredcancer patient!
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Management of animal pain is encouraged by theInternational Veterinary Academy of Pain
Management
Animal Pain is a GLOBAL Concern!
Provided by Charles E. Short DVM, PhD
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y ,Emeritus Professor of Anesthesiology & Pain Management,
Cornell University
Center for the Management of Animal PainUniversity of Tennessee
Prepared using the accreditation standards of the American Animal
Hospital Association, Copyright 2012