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Evaluación y tratamiento en dolor agudo en perros y gatos

Sheilah Robertson Senior Medical Director

Lap of Love Veterinary Hospice

Three questions• What is this thing called pain?

• How do we know they hurt?

• How can we help them?

We deal with pain every dayPain management involves

everyone

Veterinarians

Veterinary nurses and technicians

Other patient care staff

Client services

Owner

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In humans pain is…….

….what the patient says it is …..Pain is what we say it is

In animals…..

Is this cat normothermic? Is this cat painful?

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Is pain being assessed?

17% of veterinary practices routinely use a pain assessment tool

>80% of nurses and technicians agree that they are useful

Hunt et al 2015; Vet Rec

Coleman DL, Slingsby LS 2007; Vet Rec

What is this thing called pain?

PHYSICAL PSYCHOLOGICAL

SENSORY

DISCRIMINATIVEEMOTIONAL

AVERSIVEQUALITY

OF LIFE

What is this thing called pain?

PHYSICAL PSYCHOLOGICAL

SENSORY

DISCRIMINATIVEEMOTIONAL

AVERSIVEQUALITY

OF LIFE

HOW IT FEELSHOW IT MAKES

THEM FEEL

IASP New definition of pain

Pain is a distressing experience associated

with actual or potential tissue damage with

sensory, emotional, cognitive and social

components

International Association for the Study of Pain

Pain is always unpleasant

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… If you cannot measure it you cannot improve it...

Lord Kelvin 1824 -1907

Unidimensional pain scales

No pain 0

Mild pain 1

Moderate pain 2

Severe pain 3

Very severe pain 4

Simple Descriptive (SDS)

I I

Visual Analogue (VAS) no pain worst pain

Numerical rating (NRS)0

1

2

3

4

5

6

7

8

9

10

30-36%

Objective MeasuresQuimby, Smith and Lunn 2011

Heart rate, respiratory rate, blood pressure, temperature

HOW DO YOU

KNOW?

Me too, me

too…I want

to know too

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Normal behaviors

Loss of normal behaviors

Development of new behaviors Normal Behaviors

WHAT DO DOGS DO

WHEN THEY GET UP?

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A full body “dog shake”

Video courtesy of Dr. Alicia Karas

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VALIDATED

ASSESSMENT

TOOLS

www.newmetrica.com

English, Spanish, French,

German, Italian,

Norwegian, Swedish

CPMS-Short form for dogs

VOCALIZATION

0 - 3

ATTENTION

TO WOUND

0 - 4

MOBILITY

MOVEMENT

0 - 4

PALPATION

0 - 5

DEMEANOR

MOOD

0 - 4

POSTURE

0 - 4

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Intervention ≥ 6/24 if mobility assessed

Intervention ≥ 5/20 if not ambulatory

Vocalization

Look at dog in Kennel

Is the dog

Quiet 0

Crying / whimpering 1

Groaning 2

Screaming 3

Comfort and posture

Comfortable 0

Unsettled 1

Restless 2

Hunched or tense 3

Rigid 4

Is the dog?

Postures

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Observation alone is not enough Response to palpation

Do nothing 0

Look round 1

Flinch 2

Growl/guard 3

Snap 4

Cry 5

Response to palpation

Do nothing 0

Look round 1

Flinch 2

Growl/guard 3

Snap 4

Cry 5

Mobility

Normal 0

Lame 1

Slow or reluctant 2

Stiff 3

Refuses to move 4

Put lead on dog and lead out of the kennel

When the dog rises / walks is it?

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Sometimes it’s not clear

Lucie – implant removal

Checklist

Is this pain?

Is this separation anxiety?

Is this dysphoria?

Has she been confined before?

Is her bladder full?

Three choices

More analgesics

Sedate

Reverse opioid

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10 assessment domains

IncludesBlood pressure

Appetite

Maximum score = 30

Intervention ≥ 7

Appetite – healthy hospitalized cats

1.0

0.9

0.8

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0

Appetite

Day 1 2 3

Zeiler et al 2014

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7 Questions

Facial expression

Maximum score is 20

Suggested intervention level is > 5

Glasgow CMPS - Feline

Question 2 – is it?

Relaxed 0

Licking lips 1

Restless/cowering 2

Tense/crouched 3

Rigid/hunched 4

Posture – relaxed [0]

SprinklesCalvin

Is this pain, fear or stress?

Tensed/crouched 3

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Postures after abdominal surgery

Tucked, hunched

Abdominal surgery

Before - fearful After - painful

Glasgow CMPS

Question 3

Ignoring wound or painful area 0

Attention to wound 1

Normal grooming

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Ignoring wound or painful area 0

Attention to wound 1 Core Facial Action Units

THE “PAIN” FACE OR GRIMACE

Holden et al 2014

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0

0

Fear and stress?

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Glasgow CMPSQuestion 5

Approach the cage, call the cat by name and stroke along its back from head to tail.

Does the cat:

Respond to stroking? 0

Is it unresponsive? 1

Is it aggressive? 2

Glasgow CMPSQuestion 6

If the cat has a wound or painful area, gently apply pressure around the site

Does it:

Do nothing 0

Swish tail/flatten ears 1

Cry/hiss 2

Growl 3

Bite/lash out 4

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Glasgow CMPS

Question 7

General impression - Is the cat?

Happy and content 0

Disinterested/quiet 1

Anxious/fearful 2

Dull 3

Depressed/grumpy 4

Confounding factors

Individual temperament and personality

Fear and stress

Anesthetic drugs - ketamine

Upper respiratory tract disease

Sedation

Temperament and personality Zeiler GE et al 2014

Dem

ean

or

Score

15

10

5

0

Median; maximum, minimum

1 2 3 4 5Day

Every animal is different

Look for changes

Trust the animal and yourself not just the score

Using pain tools is not an exact science

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TREATMENT

One size does not fit all

ANTICIPATE AND PLAN

ASSESS

ALLEVIATE

HOME

PRE-OP

INDUCTION

INTRA-OP

ANESTHESIA RECOVERY

RECOVERY

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NOXIOUS

STIMULUS

NOCICEPTORS

CORTEX

PAIN

DESCENDING

INHIBITION

TRANSMISSION

DESCENDING

INHIBITION

TRANSMISSION

Anesthetized

PRIMARY

SENSITIZATION

CORTEX

DESCENDING

INHIBITION

TRANSDUCTION

TRANSMISSION

PRIMARY

SENSITIZATION

CORTEX

DESCENDING

INHIBITION

SECONDARY

SENSITIZATION

TRANSDUCTION

TRANSMISSION

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Central sensitization

Spinal cord

Activation

N-methyl-D-aspartate [NMDA] receptors

Ketamine acts hereOPIOIDS

NSAIDS

KETAMINE

LOCAL

ANESTHETICS

OPIOIDS

DESCENDING

INHIBITION

LOCAL

ANESTHETICS

NSAIDs

INITIATION REINITIATION RESOLUTION

How long do we need to treat?

TIME

TREATMENT

Severity of injury

SPONTANEOUS

ACTIVITY

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How long do we need to treat? What if we do a bad job?

Transition from acute post-operative pain to persistent pain

10-50% of human patients

Inguinal hernia repair

Breast surgery

Amputation

Persistent pain after surgery

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What’s in your analgesia toolbox?

OPIOIDS NSAIDs

LOCAL

ANESTHETICS

α2-ADRENERGIC

AGONISTS

KETAMINE OTHER?

Multimodal“balanced analgesia”

OPIOIDS

NSAIDS

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Opioids - agonists Opioids

Mixed actionsAgonist-antagonist

Vomiting Maropitant

NK-1 receptor antagonist

Effective against

Xylazine

Opioids

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Reduced from 75 to 25%

Nausea

Nausea

5HT receptor antagonist

Acupuncture PC 6

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NSAIDs

OPIOIDS

NSAIDS

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www.vasg.org

M

L

K

THINK LOCALLY

ACT GLOBALLY

wsava.org

Local anesthetics

Lidocaina Buivacaina

Local anesthetics

4 mg/kg 2 mg/kg

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Wound catheters1-3 days

Bupivacaine (0.25%) 2 mg/kg

Benito et al 2015 JFMS

GABAPENTIN

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CryotherapyPredict and plan

Assess

Intervene / treat

Reassess

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Resources – for download

EVALUACIÓN Y TRATAMIENTO EN DOLOR AGUDO EN PERROS Y GATOS

QUESTIONS?

Smokey Joe

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Intervention recommended at > 5

Smokey Joe

Crying

Rigid

Ignoring wound

Ears/muzzle

Unresponsive to stroking

Cries when palpated

Depressed

1

4

0

3

1

2

4

Total 15/20

Smokey Joe

Meowing

Licking lips

Ignoring wound

Ears/muzzle

Responds to stroking

Palpation – tensed,

flattened ears

Content

Total

0

1

0

0

0

1

0

2/20