Pain Management for Veterinary Technicians and Nurses
Beschreibung
A practical guide for veterinary technicians and nurses on essential concepts of animal pain management
Pain management is an essential aspect of medical care, but in the field of veterinary medicine it poses unique challenges. Learning to recognize animal pain, to advocate for patient care, and to build and implement pain management protocols allows veterinary nursing teams to be more effective and vastly improves patient outcomes. Mastering this aspect of veterinary medicine means developing an understanding of pain physiology and pharmacology of pain management drugs, the necessity of various analgesics in different care environments, and how to tackle obstacles to animal pain care.
Pain Management for Veterinary Technicians and Nurses, 2nd edition provides a robust update to the only textbook on this subject directed at veterinary technicians in the US. Already a standard text for its coverage of small companion animals, this book now also covers analgesic techniques in horses, lab animals, and zoo species, making it a valuable resource for technicians in a range of professional and clinical situations. Updated to incorporate the latest evidence-based medicine, it promises to continue as the essential introduction to this oft-overlooked but critical dimension of veterinary medicine.
Pain Management for Veterinary Technicians and Nurses readers will also find:
- Multiple expanded chapters as well as a new chapter covering pain management for c-sections and neonatal care
- A new emphasis on critical thinking and a holistic approach to patient care
- Coverage of complementary and alternative therapies
- Expanded illustrations of regional analgesia techniques
Pain Management for Veterinary Technicians and Nurses is a valuable guide for veterinary technicians in both general and specialized anesthetic practice, as well as veterinary students and general veterinary practitioners.
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Stephen Niño Cital, RVT, RLAT, SRA, CVPP, VTS-LAM, is a Veterinary Technician Specialist in Research Anesthesia and Certified Veterinary Pain Practitioner. He is a Lab Manager for Howard Hughes Medical Institute at Stanford University and is an administrator for the Veterinary Anesthesia Nerds, LLC. Stephen is also a partner at Remedy Veterinary Specialists leading the pain service in the San Francisco Bay Area of California.
Tasha McNerney, CVT, CVPP, VTS, is a Veterinary Technician Specialist in Anesthesia and Analgesia and a Certified Veterinary Pain Practitioner. She is a board member of the International Academy of Pain Management and founder of Veterinary Anesthesia Nerds. She is the Training Director at a large specialty referral hospital in the Philadelphia area.
Darci Palmer, BS, LVT, VTS, is a Veterinary Technician Specialist in Anesthesia and Analgesia and a Clinical Teaching Specialist at Tuskegee University College of Veterinary Medicine. She is Executive Secretary for the Academy of Veterinary Technicians in Anesthesia and Analgesia and Administrator for Veterinary Anesthesia Nerds. She works as a private consultant, author, and lecturer in Auburn, AL.
Inhalt
List of Contributors xxiii
Foreword xxvii
Acknowledgments xxix
About the Companion Website xxxi
1 Advancing Veterinary Pain Management into a New Era 1
Mary Ellen Goldberg
1.1 Introduction 1
1.2 Brief History of Human Pain Management 1
1.3 Veterinary Pain Management Through the Centuries 3
1.4 Animal Research Contributions 3
1.5 History of Animal Nursing Staff 4
1.5.1 National Association of Veterinary Technicians in America Recognized Veterinary Technician Specialty Academies 4
1.6 Eyewitness to 50 Years of Changes for Veterinary Technicians 5
1.7 Veterinary Technician Pioneers in Pain Management 6
1.8 Future Directions for Veterinary Technician Pain Management 7
1.9 Conclusion 7
References 7
2 Careers in Animal Pain Management 9
Tasha McNerney and Stephen Niño Cital
2.1 Introduction 9
2.2 Pain Management Certifications Available for Veterinary Technicians/Nurses 9
2.2.1 Certified Veterinary Pain Practitioner (CVPP) 9
2.2.2 Veterinary Technician Specialist (Anesthesia and Analgesia), and Veterinary Technician Specialist (Laboratory Animal Medicine - Research Anesthetist) 10
2.2.3 Veterinary Technician Specialist (Physical Rehabilitation) 11
2.2.4 Surgical Research Anesthetist (SRA) 11
2.2.5 The University of Tennessee Companion Animal Pain Management Certificate Program 11
2.2.6 AAHA Pain Management Guidelines Certificate Course (AAHA Pain Management Champion) 11
2.2.7 WSAVA Certificate in Pain Management 12
2.2.8 Canine Rehabilitation Veterinary Technician Certifications 12
2.2.9 Equine Rehabilitation Veterinary Technician Certifications 12
2.2.10 Certified Equine Massage Therapist 12
2.2.11 Animal Acupressure and Massage 12
2.2.12 TCVM Veterinary Technician Programs Offered by the Chi Institute 12
2.2.13 Animal Acupuncture 13
2.2.14 Low- Stress Certifications 13
2.2.15 Veterinary Anaesthesia and Analgesia (MSc), (PgDip), (PgCert), or (PgProfDev) 13
2.2.16 Canine Arthritis Management Practitioner (CAMP) 14
2.2.17 Certified Companion Animal Rehabilitation Therapist (CCAT) 14
2.3 Leveraging Veterinary Technicians in Pain Management 14
2.4 Conclusion 15
3 Pain Physiology and Psychology 17
Stephen Niño Cital, Tasha McNerney, and Robin Saar
3.1 Introduction 17
3.2 What Is "Pain" 17
3.2.1 The Negative Effects of Pain 18
3.3 Breaking Down the Nociceptive Pathway 18
3.3.1 Transduction 18
3.3.2 Transmission 20
3.3.3 Modulation 20
3.3.4 Perception 20
3.3.5 The Dorsal Horn 21
3.3.6 Ventral Horn and Intermediate Zone 23
3.3.7 White Matter 23
3.3.8 Descending Pathways 23
3.3.9 Spinothalamic Tract 23
3.3.10 Spinoreticular Tract 24
3.3.11 Peripheral Sensitization 24
3.3.12 Central Sensitization 24
3.4 The Endocannabinoid System and Pain 27
3.5 The Gate Control Theory 28
3.6 Psychological Aspects of Pain 29
3.6.1 Personality and the Pain Experience 29
3.6.2 Stress and Anxiety on Pain 29
3.6.3 Pain Catastrophizing 29
3.6.4 Boredom and Pain 30
3.6.5 Neuroplasticity and the Memory of Pain 31
3.6.6 Caregiver Placebo 31
3.7 Types of Pain 32
3.7.1 Somatic, Visceral, and Referred Pain 32
3.7.2 Physiological/Adaptive/Acute Pain 32
3.7.3 Pathological/Maladaptive/Chronic Pain 33
3.7.4 Neuropathic Pain 33
3.7.5 Radicular Pain 34
3.7.6 Chronic/Persistent Postsurgical Pain 34
3.7.7 Complex Regional Pain Syndrome 35
3.7.8 Social Resilience and Pain 35
3.8 The Microbiome and Pain Pathophysiology 35
3.8.1 What Is a Microbiome? 36
3.8.2 Determining "Healthy" in a Microbiome 37
3.8.3 Gut Microbiome Imbalance or Dysbiosis 37
3.8.4 The Gut- Brain Axis 38
3.8.5 Microbial Derived Mediators 38
3.8.6 Pathogen- Associated Molecular Patterns (PAMPs) 38
3.8.7 Microbial- Derived Metabolites 39
3.8.8 Neurotransmitters or Neuromodulators 39
3.8.9 Endocannabinoid Axis 41
3.8.10 Pain Medication and the Microbiome 42
References 42
4 Integrating Pain Recognition and Scoring in Companion, Equine, Food and Fiber Species, and Exotic/Lab Animal Species 47
Stephen Niño Cital, Ian Kanda, Taly Reyes, Jessica Birdwell, and Mary Ellen Goldberg
4.1 Introduction 47
4.2 Pain Domains 48
4.2.1 Pain Intensity and Affect 48
4.2.2 Temporal Dimensions 48
4.2.3 Location and Bodily Distribution of Pain 48
4.3 Disposition and Personality 48
4.4 Breed or Species Bias 50
4.5 Dysphoria, Emergence Agitation, and Emergence Delirium 51
4.6 Placebo, Caregiver Placebo, and Placebo- by- Proxy 52
4.7 Non-species- specific Assessments 52
4.7.1 Quantitative Sensory Testing (QST) 52
4.7.2 Temporal Summation (TS) 53
4.7.3 Nociceptive Withdrawal Reflex (NWR) 53
4.7.4 Gait Analysis 53
4.7.5 Pain Biomarkers 53
4.7.6 Machine Learning and Artificial Intelligence (AI) 54
4.7.7 Activity Monitors (AMs) 54
4.7.8 Facial Expression or Grimace Scales 55
4.8 Clinical Pain Scoring Tools (Canine and Feline) 55
4.8.1 Canine Acute Pain Scoring 56
4.8.1.1 Glasgow Composite Measure Pain Scale - Short and Long Forms (CMPS) (Validated) 56
4.8.1.2 French Association for Animal Anesthesia and Analgesia Pain Scoring System (4A- Vet) (Validated) 58
4.8.1.3 University of Melbourne Pain Scale (UMPS) (Validated) 58
4.8.2 Canine Chronic Pain Scoring 58
4.8.2.1 Canine Brief Pain Inventory (CBPI) (Validated) 58
4.8.2.2 Helsinki Chronic Pain Index (HCPI) (Validated) 59
4.8.2.3 Liverpool Osteoarthritis in Dogs (LOAD) (Validated) 59
4.8.3 Feline Acute Pain Scoring 59
4.8.3.1 Glasgow Composite Measure Pain Scale- Short- Form (CMPS- SF) (Validated) 59
4.8.3.2 Feline Grimace Scale (FGS) (Validated) 60
4.8.4 Feline Chronic Pain Scoring 60
4.8.4.1 Client- specific Outcome Measures - Feline (CSOMf) (Validated) 60
4.8.4.2 Montreal Instrument for Cat Arthritis Testing- caretaker (MI- CAT-(c)) (Validated) 60
4.8.4.3 Feline Musculoskeletal Pain Index (FMPI) (Not Validated) 60
4.8.4.4 Oral Pain Scale - Canine/Feline (COPS-C/F) (Validated) 62
4.8.4.5 Cincinnati Orthopedic Disability Index (CODI) (Not Validated) 62
4.8.4.6 HHHHHMM Scale (Not Validated) 62
4.8.4.7 VetMetrica(TM) Health- related Quality of Life (HRQoL) (Validated) 62
4.8.4.8 Food and Fiber Species Pain Recognition and Scoring 63
4.9 Bovids 63
4.9.1 Indications of Pain in Cattle 71
4.10 Small Ruminants and Camelids 71
4.11 Swine 73
4.11.1 Normal Behavioral Observations in Swine 73
4.12 Equid Pain Recognition and Scoring 73
4.12.1 Horses 74
4.12.1.1 Appearance of the Normal Horse 74
4.12.1.2 Somatic Pain Indicators 75
4.12.1.3 Signs of Laminitis Pain Vary with the Progression of the Disease 75
4.12.1.4 Visceral Pain Indicators 75
4.12.1.5 Horse Grimace Scale 75
4.12.2 Donkeys 77
4.13 Exotic Species Pain Recognition and Scoring 77
4.13.1 Birds 77
4.13.2 Appearance of a Non- painful Bird 78
4.13.3 Appearance of a Painful Bird 78
4.13.4 Developing a Pain Score in Birds 81
4.14 Reptiles 82
4.14.1 Appearance of a Nonpainful Reptile 82
4.14.2 Appearance of a Reptile in Pain 82
4.14.3 Developing a Pain Score in Reptiles 83
4.15 Amphibians and Fish 84
4.15.1 Appearance of a Nonpainful Fish and Amphibian 84
4.15.2 Appearance of a Painful Fish and Amphibian 84
4.15.3 Developing a Pain Scoring Assessments in Fish and Amphibians 84
4.16 Small Exotic Mammals 85
4.16.1 Appearance of Nonpainful Small Exotic Mammals 85
4.16.2 Appearance of Painful Small Exotic Mammals 85
4.16.3 Developing a Pain Score in Small Exotic Mammals 85
References 89
5 Analgesia Pharmacology 95
Darci Palmer and Stephen Niño Cital
5.1 Introduction 95
5.2 Definitions 95
5.3 Analgesic Drugs 96
5.4 Opioids 97
5.4.1 Full Opioid Agonists 97
5.4.2 Individual Drug Facts 99
5.4.2.1 Morphine 99
5.4.2.2 Meperidine (Pethidine) 99
5.4.2.3 Methadone 99
5.4.2.4 Hydromorphone 100
5.4.2.5 Oxymorphone 100
5.4.2.6 Fentanyl, Remifentanil, Sufentanil, Alfentanil, Carfentanil 100
5.4.2.7 Fentanyl Patches 100
5.4.2.8 Codeine 101
5.4.2.9 Hydrocodone and Oxycodone 101
5.4.2.10 Tramadol 101
5.4.2.11 Tapentadol 102
5.4.3 Partial Agonist Opioids 102
5.4.3.1 Buprenorphine 102
5.4.3.2 Simbadol 104
5.4.3.3 Zorbium 104
5.4.3.4 Sustained or Extended Release (SR or ER) Buprenorphine 104
5.4.3.5 Buprenorphine Patches 105
5.4.4 Agonist/Antagonist Opiods: Butorphanol and Nalbuphine 105
5.4.5 Opioid Antagonists: Naloxone, Nalmefene, Naltrexone 105
5.4.6 Mixing Opioids 106
5.5 Non- steroidal Anti- inflammatory Drugs (NSAIDs) 106
5.5.1 Washout 108
5.5.2 Piprant Class 108
5.6 Corticosteroids 109
5.7 Cannabinoids 109
5.8 Local Anesthetics 110
5.8.1 Nocita 110
5.8.2 Systemic Toxicity 110
5.8.3 Lidocaine as a CRI 111
5.9 Gabapeninoids 111
5.9.1 Gabapentin 111
5.9.2 Pregabalin 112
5.10 Alpha- 2 Agonists 112
5.10.1 Xylazine, Medetomidine, Dexmedetomidine, Romifidine, Detomidine 112
5.10.2 Zenalpha® (Medetomidine and Vatinoxan) 113
5.11 N- Methyl- D- Aspartate (NMDA) Antagonists 114
5.11.1 Ketamine and Tiletamine 114
5.11.2 Precautions/Contraindications 115
5.11.3 Amantadine and Memantine 115
5.12 Neurokinin- 1 Inhibitors 115
5.13 Bisphosphonates 116
5.14 Acetaminophen (Paracetamol) 116
5.15 Frunevetmab (Solensia®) and Bedinvetmab (Librela®) 117
5.16 Polysulfated Glycosaminoglycans (PSGAGs) 117
5.17 Dipyrone (Metamizole) 117
5.18 Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin- Norepinephrine Reuptake Inhibitors (SNRIs) 118
5.19 Acepromazine 119
5.20 Trazodone 119
References 119
6 Regional Anesthesia and Local Blocks 127
Imeldo Laurel, Jeanette M. Eliason, Amy Dowling, Tasha McNerney, and Stephen Niño Cital
6.1 Introduction 127
6.2 Current Drug Options for Regional Anesthesia and Nerve Blocks 128
6.2.1 Mixing Local Anesthetics 129
6.2.2 Adjunctive Agents 129
6.2.3 Volume Expansion, Onset Time, and Buffering 129
6.2.4 Maximum Recommended Dose (MRD) 130
6.2.5 Equipment Selection 131
6.3 Dental and Facial Regional/Local Anesthesia 133
6.4 Dentistry and Facial Blocking Techniques 133
6.4.1 Inferior (Caudal) Alveolar Nerve Block (Extraoral/Intraoral) 133
6.4.2 Middle Mental Foramen Nerve Block 135
6.4.3 Infraorbital Nerve Block 136
6.4.4 Major Palatine Block: Small Animal 137
6.4.5 Caudal Maxillary Block 138
6.4.6 Auriculopalpebral Nerve Block: Motor Blockade of the Eyelid 138
6.4.7 Retrobulbar Block 140
6.4.8 Frontal Nerve (Supraorbital Foramen) Block 140
6.4.9 Auriculotemporal Block + Greater Auricular Block 142
6.5 Common Regional and Local Anesthetic Techniques: Less Specified 143
6.5.1 Intraperitoneal Lavage Technique for Dogs and Cats 143
6.5.2 Incisional Line Block 143
6.5.3 Circumferential Block 144
6.6 Regional and Local Blocks of the Thorax and Abdomen 144
6.6.1 Intercostal Blocks 144
6.6.2 Interpleural Block 146
6.6.3 Intratesticular and Spermatic Cord Block 147
6.6.4 Sacrococcygeal Block 147
6.6.5 Epidural 149
6.6.6 Spinal Anesthesia 153
6.6.7 Epidural Catheter 153
6.6.8 Erector Spinae Plane Block (ESP) 156
6.6.9 Thoracic Paravertebral Block 157
6.6.10 Transverus Abdominis Plane (TAP) Block 158
6.7 Blocks of the Limbs 160
6.7.1 Femoral- Saphenous Nerve Complex Block 160
6.7.2 Sciatic Nerve Block 162
6.7.3 Brachial Plexus Block 164
6.7.4 Radial, Ulnar, Median, and Musculocutaneous (RUMM) Nerve Blocks 166
6.8 Common Equine Techniques 167
6.8.1 Local Analgesia for Horse Castration 167
6.8.2 Caudal Epidural in the Horse 167
6.9 Common Production Animal Techniques 168
6.9.1 Analgesia for Castration 168
6.9.2 Cornual Nerve Block 170
6.9.3 Analgesia for Livestock Epidural 171
6.9.4 Local Anesthetic Blocks for Exotics and Laboratory Animals 174
References 175
7 Analgesia for Acute Pain 179
Tasha McNerney, Melissa Streicher, and Karen Maloa Roach
7.1 Introduction 179
7.2 Fear, Anxiety, and Stress in the Acute Pain Response 180
7.3 Multimodal Therapies 180
7.4 Types of Acute Pain 181
7.4.1 Surgical Pain 181
7.4.1.1 Premedication 182
7.4.1.2 Induction 183
7.4.1.3 Maintenance 183
7.4.1.4 Postoperative Analgesic Medications 183
7.4.1.5 Pain Vacation 184
7.4.1.6 Take- home Analgesics 184
7.4.1.7 Local Anesthesia Techniques 185
7.5 Creating an Effective Acute Pain Analgesic Plan 185
7.5.1 Continuous Rate Infusions 185
7.6 Analgesia Plans for Painful Procedures 186
7.6.1 Reproductive Tract Surgery 186
7.6.1.1 Premedication 187
7.6.1.2 Regional Anesthesia 187
7.6.1.3 Maintenance 187
7.6.1.4 Postoperative Analgesic Plan 187
7.6.1.5 Home Medications 187
7.6.2 Analgesia for Surgery Involving the Eye 188
7.6.2.1 Premedication 188
7.6.2.2 Regional Anesthesia 188
7.6.2.3 Maintenance 188
7.6.2.4 Postoperative Analgesic Plan 188
7.6.2.5 Home Medications 188
7.6.3 Analgesia Techniques for Surgery Involving the Ear 189
7.6.3.1 Premedication 189
7.6.3.2 Regional Anesthesia 189
7.6.3.3 Maintenance 189
7.6.3.4 Postoperative Analgesic Plan 189
7.6.3.5 Home Medications 189
7.6.4 Gastrointestinal Procedures or Acute Abdominal Pain 190
7.6.4.1 Premedication 190
7.6.4.2 Maintenance 190
7.6.4.3 Regional Anesthesia 190
7.6.4.4 Postoperative Analgesic Plan 191
7.6.4.5 Home Medications 191
7.6.5 Thoracic Procedures 191
7.6.5.1 Premedication 191
7.6.5.2 Maintenance 192
7.6.5.3 Regional Anesthesia 192
7.6.5.4 Postoperative Analgesic Plan 192
7.6.5.5 Home Medications 192
7.6.6 Protocols for Patients with Cranial Disease, Injury, or Neurosurgery 193
7.6.6.1 Premedication 194
7.6.6.2 Maintenance 194
7.6.6.3 Regional Anesthesia 194
7.6.6.4 Postoperative Analgesic Plan 194
7.6.6.5 Home Medications 194
7.6.7 Analgesia Protocols for the Patient with Urinary Disease 194
7.6.7.1 Premedication 194
7.6.7.2 Regional Anesthesia 195
7.6.7.3 Maintenance 195
7.6.7.4 Postoperative Analgesic Plan 195
7.6.7.5 Home Medications 195
7.6.8 Minimally Invasive Procedures 195
7.6.8.1 Premedication 195
7.6.8.2 Regional Analgesia 196
7.6.8.3 Maintenance 196
7.6.8.4 Postoperative Analgesic Plan 196
7.6.8.5 Home Medications 196
7.7 Orthopedic Procedures 196
7.7.1 Orthopedic Procedures of the Forelimb 196
7.7.1.1 Premedication 196
7.7.1.2 Maintenance 196
7.7.1.3 Regional Anesthesia 196
7.7.1.4 Postoperative Analgesic Plan 197
7.7.1.5 Home Medications 197
7.7.2 Hindlimb Amputation, Spinal Disease, Spinal Surgery, and Pelvic Fracture Repair 197
7.7.2.1 Premedication 198
7.7.2.2 Maintenance 198
7.7.2.3 Regional Anesthesia 198
7.7.2.4 Postoperative Analgesic Plan 198
7.7.2.5 Home Medications 198
7.7.3 Surgery of the Tail 198
7.7.4 Mandibulectomy/Maxillectomy 200
7.7.4.1 Inferior Alveolar (Mandibular) Blocks 200
7.7.4.2 Maxillary Blocks 200
7.8 Postoperative Patient Evaluation 201
7.9 Management of Painful Dermatologic Conditions 201
7.9.1 Sensory Perception in the Skin 202
7.9.2 Recognizing Cutaneous Discomfort 202
7.9.3 Painful and Pruritic Cutaneous Conditions 203
7.9.3.1 Allergic Skin Disease 204
7.9.3.2 Skin Infections 204
7.9.3.3 Autoimmune and Immune- mediated Dermatopathies 206
7.9.3.4 Cutaneous Burns 207
7.9.4 Treatment of Cutaneous Pain and Pruritus 211
7.10 Conclusion 212
References 212
8 Analgesia for the Pregnant, Neonatal, and Pediatric Patient 217
Darci Palmer and Natalie Pedraja
8.1 Introduction 217
8.1.1 Pain Management During Pregnancy 217
8.1.2 Analgesic Drugs Used During Pregnancy and C- Sections 218
8.1.2.1 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 219
8.1.2.2 Opioids 219
8.1.2.3 Alpha- 2 Agonists 221
8.1.2.4 Dissociative Agents 222
8.1.2.5 Local and Regional Blocks 222
8.2 Postoperative Analgesia 224
8.3 Anesthesia and Analgesia Case Management for a Cesarean Section 224
8.4 Pain Management for Neonates and Pediatrics 227
8.4.1 Insulting the Neonatal Pain Pathways 227
8.4.1.1 NMDA Receptors 228
8.4.1.2 Cutaneous Receptors 228
8.4.2 Treatment of Pain in Neonatal and Pediatric Patients 228
8.4.2.1 Opioids 228
8.4.2.2 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 229
8.4.2.3 Alpha- 2 Agonists 229
8.4.2.4 Local and Regional Blocks 229
References 229
9 Analgesia in the Emergency and Critical Care Setting 233
Heather Ann Scott and Rachel Stauffer
9.1 Introduction 233
9.2 Treating Pain in the Emergency and Critical Care Veterinary Patient 233
9.3 Evaluating Pain in ER and ICU Patients 234
9.4 Nursing Care and the Role of Pain Management in Kirby's Rule of 20 239
9.5 Pain and the Physiological Stress Response: A Summary 240
9.6 Sleep Deprivation 241
9.7 Windup Pain in the ER 242
9.8 Techniques and Nuances for Analgesic Delivery in the Emergency Room 242
9.8.1 Pain Vacations (Acute Pain) 243
9.8.2 Lidocaine Use in ECC 243
9.8.3 Opioid Analgesia for Emergency and Critical Care Patients 244
9.8.4 Local/Regional Analgesia in ECC 244
9.8.5 Nsaids 245
9.8.6 Maropitant 245
9.8.7 Physical Rehabilitation Methods in ECC 245
9.9 Common Painful Conditions in the ER/ICU Setting 246
9.9.1 Fractures 246
9.9.2 Acute Soft Tissue Injuries 247
9.9.3 Feline Lower Urinary Tract Obstruction 247
9.9.4 Trauma Patients 247
9.9.5 Abdominal Pain in ECC Patients 247
9.9.6 Acute Swelling and Edema 248
9.10 Conclusion 248
References 249
10 Chronic Pain Management for the Companion Animal 253
Taly Reyes, Jessica Birdwell, and Stephen Niño Cital
10.1 Introduction 253
10.2 The Complexity of Chronic Pain 253
10.3 Neuropathic Pain 255
10.4 Common Chronic Pain Conditions 255
10.4.1 Chronic Joint Pain- Osteoarthritis (OA) 255
10.4.2 Oncologic/Malignant Pain 257
10.4.3 Chiari Malformation Pain 257
10.4.4 Headaches and Migraines in Animals 259
10.4.5 Meningitis 259
10.4.6 Chronic Wounds 260
10.5 Assessing Chronic Pain 261
10.6 Goals and Modalities for Treating Chronic Pain 261
10.7 Pharmacological Interventions 261
10.7.1 Pain Vacation (Chronic Pain) 262
10.7.2 Mesotherapy 262
10.7.3 Transdermal Medications 263
10.7.4 Non- steroidal Anti- Inflammatory Drugs (NSAIDs) 264
10.7.5 Acetaminophen 265
10.7.6 Corticosteroids 265
10.7.7 Opioids 266
10.7.8 Atypical Opioids: Tramadol and Tapentadol 266
10.7.9 Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs) 267
10.7.10 Gabapentinoids: Gabapentin and Pregabalin 268
10.7.11 N- Methyl- D- Aspartate Antagonists 269
10.7.12 Neurokinin- 1 Inhibitors 269
10.7.13 Bisphosphonates 270
10.7.14 Anti- NGF, Monoclonal Antibodies 270
10.7.15 Nutraceuticals and Animal Health Supplements 270
10.8 Lifestyle Modifications 271
10.8.1 Weight Loss and Appropriate Nutrition 271
10.8.2 Routine Exercise and Physical Therapy 271
10.8.3 Thinking "Out of the Box" through Environment Modifications 271
10.9 Conclusion 271
References 272
11 Analgesia for Shelter Medicine and Trap-Neuter-Return Programs 277
Anne Marie McPartlin and Erin Spencer
11.1 Introduction 277
11.2 Multimodal Analgesia 277
11.2.1 Opioids 279
11.2.2 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 279
11.2.3 NMDA Antagonists 281
11.2.4 Alpha- 2 Adrenoceptor Agonists 282
11.2.5 Local Anesthetics 282
11.2.6 Adjunct Therapies 283
11.3 HQHVSN and TNR Programs 283
11.4 Rabbits 285
11.5 Conclusion 286
References 286
12 Pain Management in Equids 289
Molly Cripe Birt, Rebecca Johnston, Rachael Hall, and Janel Holden
12.1 Introduction 289
12.2 Pain Assessment in Horses 289
12.3 Common Analgesics and Strategies in Horses 289
12.3.1 Butorphanol 290
12.3.2 Buprenorphine 291
12.3.3 Meperidine 291
12.3.4 Tramadol 291
12.3.5 Pure Opioid Agonists 291
12.3.6 Non- steroidal Anti- inflammatories 292
12.3.7 NMDA Receptor Antagonists 293
12.3.8 Alpha- 2 Agonists 293
12.3.9 N- butylscopolammonium Bromide (NBB) 294
12.3.10 Dimethylsulfoxide (DMSO) 294
12.3.11 Prokinetics and Antispasmodics 294
12.3.12 Locoregional Anesthetics and Techniques 294
12.4 Lidocaine Use in Horses 295
12.4.1 Postoperative Period Lidocaine Use 295
12.5 Common Painful Conditions and Procedures in Horses 296
12.5.1 Surgical Pain 296
12.5.2 Gastrointestinal (Colic and Ulcers) Pain 296
12.5.3 Lameness 297
12.5.3.1 Acute Lameness 297
12.5.3.2 Chronic Lameness 298
12.5.4 Osteoarthritis 298
12.5.5 Laminitis 299
12.5.6 Pleuropneumonia 300
12.5.7 Dystocia 301
12.6 Analgesia in Foals 302
12.7 Pain Management in the Donkey 304
12.7.1 Common Painful Conditions 304
12.7.2 Pain Scoring and Behaviors 304
12.7.3 Anatomic and Physiologic Distinctions from the Horse 306
12.7.4 Analgesics in Donkeys 306
12.7.4.1 Nonsteroidal Anti- inflammatory Agents 306
12.7.4.2 Alpha- 2 Adrenoceptor Agonists 307
12.7.4.3 Opioids 307
12.7.4.4 Local Anesthesia/Analgesia Methods 307
12.8 Nonpharmacologic Approaches to Pain 308
12.9 Conclusion 308
References 308
13 Food and Fiber Species 315
Janel Holden, Rachael Hall, MegAnn Harrington, and Mary Ellen Goldberg
13.1 Introduction 315
13.2 Cattle 318
13.2.1 Bovine or Cattle Medications 318
13.2.1.1 Opioids 318
13.2.1.2 Nsaids 318
13.2.1.3 Alpha- 2- Adrenergic Agonists 319
13.2.1.4 NMDA Antagonists 319
13.2.2 Regional Anesthesia and Analgesia 319
13.2.2.1 Local Anesthetic Agents 319
13.2.2.2 Intravenous Regional Anesthesia 320
13.2.2.3 Teat Block 321
13.2.2.4 Infusion of the Teat Cistern 321
13.2.2.5 Epidural Analgesia 321
13.2.2.6 Analgesia for Dehorning 322
13.2.2.7 Spermatic Cord Block 322
13.2.3 Analgesic Adjuvants 322
13.2.3.1 Gabapentin 322
13.2.3.2 Continuous Infusion Analgesia 322
13.2.4 Withdrawal Period 324
13.3 Sheep (Ovine) and Goat (Caprine) Medications 326
13.3.1.1 Opioids 326
13.3.1.2 NSAIDs 327
13.3.1.3 Alpha- 2- Adrenergic Agonists 327
13.3.1.4 NMDA Antagonists 327
13.3.2 Regional and Local Anesthesia 327
13.3.2.1 Cornual Block 327
13.3.2.2 The Inverted L- Block or 7- Block 328
13.3.2.3 Paravertebral Nerve Block 328
13.3.2.4 Caudal Epidural 329
13.3.3 Intravenous Regional Anesthesia 329
13.3.3.1 Bier Block 329
13.3.3.2 Intratesticular Block 330
13.3.3.3 Continuous Rate Infusions 330
13.3.4 Pain Management for Pigs (Swine) 330
13.3.4.1 Opioids 332
13.3.4.2 NSAIDs 332
13.3.4.3 Alpha- 2 Adrenergic Agonists 334
13.3.4.4 NMDA Antagonists 334
13.3.4.5 Lumbosacral Epidural Block 334
13.3.4.6 Continuous Rate Infusions 335
13.4 Pain Management for Camelids 335
13.4.1 Camelid Medications 337
13.4.1.1 Opioids 337
13.4.1.2 Nsaids 338
13.4.1.3 Alpha- 2 Agonists 339
13.4.1.4 Local Anesthetics 339
13.4.1.5 NMDA Antagonists 340
13.4.1.6 CRI Techniques 340
13.4.1.7 Tramadol 342
13.4.1.8 Gabapentin 342
13.5 Conclusion 342
References 342
14 Exotic Companion Animals 347
Katrina Lafferty, Elizabeth Vetrano, Mary Ellen Goldberg, and Stephen Niño Cital
14.1 Introduction 347
14.2 Why Treat Pain? 348
14.3 Rabbits 349
14.3.1 Painful Behaviors: Rabbits 349
14.3.2 Pain Scoring: Rabbits 350
14.3.3 Nursing Care and Environmental Management: Rabbits 350
14.3.4 Common Analgesics in Rabbits 351
14.3.4.1 Opioids 352
14.3.4.2 NSAIDs 352
14.3.4.3 Regional and Local Anesthesia 352
14.3.4.4 Continuous Rate Infusions 353
14.4 Rodents and Ferrets 353
14.4.1 Mice 354
14.4.1.1 Pain Scoring: Mice 354
14.4.2 Rats and Ferrets 355
14.4.2.1 Pain Scoring: Rats and Ferrets 355
14.4.3 Gerbils 355
14.4.4 Hamsters 355
14.4.5 Guinea Pigs 356
14.4.5.1 Pain Scoring: Gerbils, Hamsters, Guinea Pigs, and Ferrets 356
14.4.5.2 Common Analgesics in Rodents 356
14.4.5.3 Opioids 356
14.4.5.4 NSAIDs 358
14.4.5.5 Regional and Local Anesthesia 358
14.5 Multimodal Analgesia: All Species 359
14.6 Avian Analgesia 359
14.6.1 Recognizing Relevant Behaviors for Each Species 360
14.6.2 Avian Pain Scoring and Management 361
14.6.3 Avian Drug Delivery 362
14.6.4 Common Analgesics in Birds 365
14.6.4.1 Nsaids 365
14.6.4.2 Opioids 365
14.6.4.3 Regional and Local Analgesia 366
14.6.4.4 Adjunctive Analgesics 366
14.7 Reptile Analgesia 367
14.7.1 Causes of Pain in Reptiles 368
14.7.2 Analgesic Medications 368
14.7.2.1 Opioids 369
14.7.2.2 NSAIDs 369
14.7.2.3 Local Anesthetics 369
14.7.2.4 Adjunctive Analgesics in Reptiles 371
14.8 Analgesia in Fish and Amphibians 371
14.8.1 Fish and Amphibian Treatment Strategies 372
14.9 Analgesia in Invertebrates 372
14.9.1 Invertebrate Analgesia Strategies 375
14.10 Conclusion 375
References 375
15 Analgesia in Zoo Animals 381
Lindsay Wesselmann, Mark Romanoski, Alison Mott, and Margot Monti
15.1 Veterinary Technicians in a Zoological Setting
1
Advancing Veterinary Pain Management into a New Era
Mary Ellen Goldberg
Independent Contractor & Mannheimer Foundation Inc., Boynton Beach, FL, USA
"The greatest evil is physical pain."
Saint Augustine of Hippo (386)
1.1 Introduction
A living being, from the moment of birth, seeks pleasure as the ultimate good while rejecting pain as the ultimate adversity and does their best to avoid it. Pain is based on an anatomical and physiological foundation. It is the intent of this chapter to historically look at human pain, proceed forth into veterinary pain, and conclude with a veterinary technician's pivotal role moving forward in pain management today.
1.2 Brief History of Human Pain Management
Western cultural identity has, in part, been influenced by ancient Greek texts such as The Iliad and The Odyssey by Homer because of the emphasis these stories placed on pain. Sophocles continues to describe pain almost as an independent being that seizes possession of the subject, invades it, and takes over. Thus, words like consuming or devouring are used to describe the ill being (Rey 1993). Galen of Pergamon was a Greek physician, surgeon, and philosopher in the Roman Empire. Galen is known today for classifying the different forms of pain which have been handed down to modern times: Pulsific or throbbing, gravative or weighty, tensive or stretching, and pungitive or lancinating (Rey 1993).
In contrast to Western medicine, which can be traced back to Hippocrates, Chinese acupuncture was fully developed by the end of the second century BCE (before the common era). Among many ancient civilizations, such as kingdoms in Africa, Sumer, China, Mesoamerica, and the Indus-Ganges, China is the only civilization where acupuncture was well documented 2000 years ago that still survives (Chiu 2014).
Before the advent of modern anesthesia, humans used diverse means to diminish pain, including pressure or ice to numb extremities. Many indigenous cultures had their own understanding of pain and often took a more holistic approach to managing discomfort, something that we see a reawakening of today. They administered herbal medicines including mandragora, hemp-marijuana, and opium. Some used fermented drinks that contained alcohol used not only for pain but also for ceremonies and recreation. The Incas, as an example, knew of the topical effects of coca/cocaine leaves, but they had no way to administer it other than placing coca-laced saliva into wounds. Hua Tuo (in the second century CE) was a Chinese physician and surgeon who is best known for his surgical operations and the use of mafeisan, an herbal anesthetic formulation made from hemp. Using a preparation of hemp and wine, he was able to make his patients insensitive to pain (Tubbs et al. 2011). Other Mesoamerican Indigenous and Aboriginal Australian people not only used herbal and mechanical means for pain relief but also incorporated ceremony, showing a deep understanding of the interconnection between physical, emotional, and spiritual health in all creatures. Unfortunately, many of these ancient herbal remedies and other culturally significant practices were banned or lost during colonization, only to be "rediscovered" in modern times by the same but very distant relatives of the original colonizers. The loss or suppression of indigenous peoples' healing practices leaves us with a "Western" or "Eurocentric" perspective in textbooks on the evolution of pain management (Eger et al. 2014; Geck et al. 2020; Quiñonez-Bastidas and Navarrete 2021; Carmona Rosales 2021; Wren et al. 2011).
René Descartes, a French scientist and philosopher, was the first recorded person to claim that pain comes from the brain. His study focused on phantom limb pain and since there was no limb to feel pain, he concluded that pain must come from the brain. Descartes opened the door to the understanding that the brain was a key component of pain, though it would be centuries before the complete connection between the brain, nervous system, and pain was made (Rey 1993).
Albrecht von Haller was interested in the reactions of fibers and how to distinguish between the irritability of muscle fiber - which he called contractibility - and the excitability of nerve fibers - which he called sensitivity (Olson 2013a).
Pierre Jean George Cabanis' work incorporated a psychophysiological approach to pain, which included the emotional component. His work led to new techniques such as using electrical stimulation for the treatment of pain.
Xavier Bichat represented a passage from organic sensitivity to animal sensitivity and the threshold concept. Bichat's contribution to pain medicine was his discovery of the importance of the sympathetic nervous system (Olson 2013a).
The early part of the nineteenth century saw the development of health clinics, which increased interest in the study of pain. Pain research at this time remained within the framework of specificity theory advanced by Johannes Müller and later Maximilian von Frey, which saw pain as an independent sensation with its own sensory apparatus. Müller proposed a theory for pain, which considered findings from physiology, historical observations, pathology, and integrated psychological dimensions of pain. He believed that pain was not imaginary - that it could occur without an external stimulus. Von Frey was trying to identify points on the skin that responded specifically to one of the four cutaneous sensations: touch, heat, cold, and pain. To accomplish this task, he invented what he called an esthesiometer, where the stimulus consisted of hair (Olson 2013b).
In 1965, Ron Melzack and Patrick Wall proposed a theory suggesting that neural mechanisms in the dorsal horn of the spinal cord could act as a "gate," increasing or decreasing the flow of nerve impulses from peripheral fibers to the spinal cord cells projecting to the brain. In other words, the spinal cord "gate" either blocks pain signals or lets them pass onto the brain (Melzack and Wall 1965). Today, the gate control theory continues to thrive and evolve despite considerable controversy. The technology of spinal cord stimulation is also based on the gate control theory where products approved by the FDA are already on the market.
In 1973, John Bonica, the founding father of the modern-day field of pain medicine and the driving force in establishing the International Association for the Study of Pain (IASP), proposed that relief of pain is a basic human right (Jackson and Norman 2014).
1.3 Veterinary Pain Management Through the Centuries
The surviving records on the advancement of veterinary medicine occurred during the Greek, Roman, and Byzantine eras. During this period, many species were investigated, with primary attention paid to the horse.
The development of nailed-on horseshoes was a major technological step that enhanced the performance of draft and cavalry horses in the Dark Ages. The Celts were first to use red hot iron to fit under the strong rim of the horse's hoof. The Islamic world chose lighter shoes that could be shaped cold (Dunlop and Williams 1996).
During the Middle Ages, mandragora (or the root of the mandrake plant) was made into an anesthetic potion administered to the patient (human or animal) before surgery or cautery (Eger et al. 2014). It induced a deep sleep likely due to the plants natural production of deliriant hallucinogenic tropane alkaloids (atropine, scopolamine, and hyoscyamine) (Roberts and Wink 1998).
In 1656, Christopher Wren (the architect for St. Paul's cathedral and a founder of the Royal Society) infused wine and ale from a syringe made of a dog's bladder, through a goose quill needle into the vein of a dog. The dog survived the experiment. Wren later gave opium intravenously via a quill to dogs, causing unconsciousness in some animals, but killing others. Wren's experiment was the first known injection to produce anesthesia (Moon 2021).
Gasses and vapors later known as anesthetics had been synthesized or isolated before (ether, nitrous oxide, and carbon dioxide) but would be more regularly synthesized from 1798 through 1846 for research and medical use. In 1798-1800, Humphry Davy used nitrous oxide for recreation and research, noting its capacity to diminish or even abolish pain. He suggested its use for surgery, but no one noticed (Ramsay et al. 2005). In 1823, Hickman used carbon dioxide to cause what he called "suspended animation," a state that permitted apparently painless surgery in animals, but no one noticed (Eger et al. 2014). In the 1840s, William Clarke, Crawford Long, and Elton Romeo Smilie each administered ether in amounts sufficient to permit surgery to be undertaken without pain. But they thought too little of what they had done, or didn't know what they had done, to request public credit for their accomplishment and no one noticed (Keys 1996).
Veterinary anesthesia/analgesia has paralleled human anesthesia/analgesia for the most part, but also still lags in many ways. The two have been intimately intertwined, each contributing to the advancement of the other. The...
