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Please see the “AAHA/AAFP Pain Management Guidelines for Dogs and Cats” for pain management details and a list of resources. Q: Is giving buprenorphine orally effective in dogs? Buprenorphine injectable can be delivered transmucosally in the cat and the ferret. This is NOT oral delivery. ORAL delivery inactivates the medication. The injectable solution is absorbed across the mucus membrane of the cheek pouch or under the tongue in the cat and the ferret. This delivery does NOT work in the dog. Q: How is transmucosal buprenorphine applied in cats or ferrets? The injectable buprenorphine is delivered using a TB syringe with NO NEEDLE into the cheek pouch or under the tongue in the cat and the ferret. Q: How long should pain management continue after surgery? Pain management should continue after a surgery for a length of time determined by the invasiveness and magnitude of the surgery. Examples: 3 days of post-op pain medications for uncomplicated, pre-pubescent canine 5 days of post-op pain medications for uncomplicated pre-pubescent canine 7 – 14 days of post-op medications for dental interventions that require Up to several weeks post-op for orthopedic surgeries, depending upon the Q: Is it always appropriate to use local anesthetics (lidocaine, etc.), in addition to systemic pain medications, before any elective surgery? It is always appropriate to use local anesthetic blocks (combination of lidocaine and bupivacaine) in addition to systemic pain medications, infused before the incision is made to block pain signals from getting to the spinal cord. Q: What is an example of a pain management protocol for an animal with kidney or liver disease? Please see the references. For both chronic and acute pain in patients with kidney or liver failure, we would exclude the use of NSAIDs. However, there are excellent options for control of both chronic and acute pain that do NOT include NSAIDs. Q: Do you prefer buprenorphine or hydromorphone as pre-op medication? For pre-meds we use a pure mu-agonist along with very low-dose acepromazine - - this means either morphine or hydromorphone (in our practice we use morphine in dogs and hydromorphone in cats). The acepromazine potentiates the effects of the mu-agonist, Be aware that hydromorphone used post-op at analgesic doses causes hyperthermia in a majority of cats. Consequently, we use hydromorphone in our feline patients for pre- meds, then we transition to buprenorphine post-op. Q: Is it better to attack pain from many angles—for example, using systemic and local analgesics—to lower their dosages? It is always better to use a multi-modal approach to pain management - - both acute and chronic - - so that you may use lower doses of each agent you have chosen for your pain management protocol. Q: Do you have information on using continuous flow pain management, calculating appropriate amounts used, etc.? Any formulary has the appropriate information for CRI (constant rate infusion). I recommend creating Excel spread sheets so that the calculations are already done for you. I will happily send our Excel CRI files if you request them via email. Be sure to identify that you are requesting them following the MerialEDU/Firstline webinar. My email is: drrobin@windsorvet.com . Q: Can you repost the website for AAHA pain info? www.aahanet.org - - you will need to search the site for the pain management guidelines. Q: How beneficial is applying ice/heat in pain management? The application of ice in the immediate post-operative or post-injury time is exceptionally beneficial. We typically use ice packs for the first 72 hours or so following surgery or an injury. Then we switch to heat therapy to increase circulation. Q: Other than less jumping, what are other common signs for osteoarthritis (OA) in cats? Other signs of OA (or pain) in the cat include: Not wanting to be petted Vocalizing or biting when handled Q: What do you recommend using for cats that are in pain? My choice of pain management in cats depends entirely on the diagnosis. Why is the cat painful? I generally choose among the following medications (and often combine some The choice(s) of medication(s) must be driven by the patient, the diagnosis, the level of pain, etc. And these cats must be reassessed very regularly so that their pain management strategies can be appropriately revised. Q: What is a good pain management protocol for an elective surgery in a cat? In our hospital, for an elective surgery in a cat, we pre-medicate with hydromorphone and acepromazine. We induce with propofol and midazolam. We follow surgery with buprenorphine and meloxicam. We typically send both medications home post-op. Q: Can you recommend affordable pain management for cats post-operatively or is buprenorphine the end-all and be-all? First of all, all the pain management techniques about which I spoke during the webinar are quite affordable - - for both the practice and for the pet owner. Depending upon the cat and the procedure, we use a combination of meloxicam and buprenorphine. Buprenorphine is now available as a generic, meaning you can’t afford not to have it available for cats. Q: What do you recommend to manage feline patients in pain with saddle thrombus? Saddle thrombus cats would be hospitalized in our practice and would receive fentanyl and ketamine CRI to attempt to control their pain long enough to see if they will be able to recover. All the usual techniques and procedures to make a complete diagnosis as well as to work toward resolution of the thrombus should be taken (e.g. conferring with an internist as well as ultrasonographer for an echocardiogram of the heart). Q: If we use lidocaine SQ for declaw, will it affect the heart? In cats that must be subjected to declaw surgery, a combination of lidocaine (with NO epinephrine) and bupivicaine should be used as a “ring block”. At the appropriate doses, there are no cardiac side effects. Q: How do you convince a doctor who has "old school" ideas to treat with more pain medication—especially when the entire staff feels an animal is in pain? First of all, realize that there has now been a test case where a veterinarian in Minnesota has lost his license for not treating surgical patients with pain medications. That should motivate any veterinarian to get serious about pain management. The “AAHA/AAFP Pain Management Guidelines for Dogs and Cats” is probably the easiest place to start. Then it is time to add textbook references to the practice’s library. The most important of these is Handbook of Veterinary Pain Management, second edition by Drs. Gaynor and Muir. It is a Mosby publication, released just a few months ago. Worst case scenario - - find another job. Q: I have been using tramadol at 1-2 mg/kg BID the past few months and I am getting reports from clients that the patients are not eating or wanting to get up. The tramadol is usually being given with an NSAID or prednisone. The emergency clinic is using this as a sole source of pain meds. What is your experience with tramadol? What side effects have you seen with tramadol in dogs or cats? Tramadol has an exceptionally short half-life in the dog (1.7 hours) making it pretty useless unless it is given at least TID. It is not a good choice as the “sole source of pain meds”. It is quite good when it is used alongside an NSAID or in conjunction with gabapentin. The most common side effect of tramadol is sedation, which can be profound. Also, tramadol is extremely bitter. So, if a patient actually tastes it while they are being medicated, they may refuse to eat anything at all. Q: Where could we reference pain management protocols to use in surgical anesthesia and pain management for our post-op patients? The Handbook of Veterinary Pain Management, second edition by Drs. Gaynor and Muir. It is a Mosby publication, released just a few months ago is a great place to start. Also, joining the International Veterinary Academy of Pain Management (www.ivapm.org) will give you access to all the postings from members about various pain management protocols. Another great resource is the Veterinary Anaethesia and Analgesia Support Group website (www.vasg.org). Q: Do you believe in giving NSAIDS prior to healthy elective surgeries? We never give NSAIDs before any surgery. We always deliver our NSAID after surgery (if NSAIDs are appropriate for the patient). This way we do not take the chance that a patient could have an issue with renal perfusion during anesthesia, leading to adverse effects of the NSAID. There is no scientific evidence that it is better to give the NSAID before surgery. Q: Do you offer pain medication as an option in your treatment plans, or do you automatically include it in your treatment plan? There is no excuse for allowing pain medications to be “optional” under any circumstances. Using appropriate pain management is scientifically proven to be beneficial to the patient. Using pain medication is a medical decision. Veterinarians who ask lay people (meaning pet owners) to make medical decisions, are opening themselves up for accusations of malpractice. Q: In canine osteoarthritis, do you recommend continuous use of NSAIDS or as needed? Is it important to elevate food and water bowls with this disease and what is the right type of diet? Canine patients with OA often need ongoing NSAIDs. That said, we attempt to titrate their dosing to the lowest effective dose over a period of weeks to months. It is VERY important to manage the home environment of a dog with OA. This means raising the food and water dishes to elbow height, carpeting all surfaces the dog walks on (including the area where they eat and drink), providing a ramp for getting in and out of the car, etc. If the dog is overweight when we diagnose OA, we MUST achieve weight loss. Maintenance or “light” foods WILL NOT WORK!!! We use Hills’ Prescription Diet r/d® Canine to achieve weight loss, and then we transition to Hill’s Prescription Diet j/d® Canine - - the “joint diet” - - for maintenance. If the dog has a co-morbidity like chronic renal failure, we manage the most important problem nutritionally - - in this case the renal disease. Q: Is that "emla" cream? EMLA is a brand name - - we use the generic equivalent. It is lidocaine and prilocaine cream, 2.5%/2.5%. Q: In emergency medicine, we tend to get cases where the pet is "shocky" and we need to get an IV catheter, etc. in ASAP. Does the state of shock affect the pain receptors? Is there anything we can do that will take effect quickly prior to certain emergency procedures? If your patient is critical and shocky, get a catheter in as quickly as possible. If your patient is sick and needs fluids and is NOT shocky, take the time to EMLA the leg to numb the site of the catheter placement. Q: I have two questions. What about morphine use in cats? And butorphanol vs buprenorphine—which do you feel is better? Morphine is a great drug in cats. We start with 0.5 mg/kg and increase from there as needed to control pain. Butorphanol is only active for about 30 minutes making it a less useful drug for pain management in dogs and cats. Buprenorphine in cats is a great choice - - it should be given IV if possible, or transmucosally if you do not have an IV catheter in place. Buprenorphine is NOT absorbed well from a SQ injection site, so do not deliver it that way. Q: What is your experience with opioids like morphine, fentanyl, etc.? How do you avoid secondary effects? I have had only EXCELLENT experience with opioids. Opioids are to be given to effect to take care of the pain. If the dose is titrated appropriately to take care of the pain, the patient does not develop adverse effects. Q: If you were choosing between hydromorphone and morphine as your in-clinic opiate injectable, what would you view as the pros/cons and which would you prefer? In this choice, morphine wins hands down… It is more cost-effective, it does not cause hyperthermia in cats at analgesic doses, it can be used as a single injection and as CRIs. While there are other narcotics that are more POTENT than morphine (meaning you can use a smaller dose) there are NO narcotics that are BETTER than morphine. It remains

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