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63 Cards in this Set
- Front
- Back
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Some people claim that if pain is removed in an injured body part then the animal will over-use that body part and cause further damage. What do you think about this?
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Inhumane and a horse in pain often becomes agitated and may actually cause more damage than a calm, relaxed animal with good analgesia and physical support of the injured body part.
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Some people think that providing analgesia will mask a disease condition, what doy you have to say to this?
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Generally as long as the overall condition of the horse is taken into account, the progress of disease is not misdiagnosed as treatment progresses.
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The initial pain impulse is called a '____________' response and it is a normal process designed for protection.
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physiologic response
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When does a physiologic response to pain become a pathologic response?
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Once a painful stimulus has ceased to serve a purpose, can result in peripheral and central sensitization
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When does peripheral sensitization occur?
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When chemicals like cytokines, kinins and arachidonic acid derivatives (leukotrienes and prostaglandins) are released from damaged tissues
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What is the result of peripheral sensitization?
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Chemicals cause an increase in the sensitivity of the nerve endings and cause damage to tissues on the periphery of the lesion, thereby increasing pain intensity and spreading size of the painful area
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When does central sensitization occur?
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When components of the pain pathway located within the CNS become 'upregulated' on exposure to prolonged or repetitive pain stimulus
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What is the result of central sensitization?
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Upregulation results in an exaggerated painful response to stimuli that should be only minimally painful or not painful at all
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True or false. Central sensitization can be treated with preepmtive analgesia.
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True
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What is the body's physiologic response to pain?
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initiates a fairly profound stress response (cortisol release) and a sympathetic overdrive; also increases energy requirements which may lead to a negative nitrogen balance
-Cortisol & negative nitrogen balance both impair healing |
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What is the cascade of effects stimulated by the stress and autonomic imbalance caused by pain?
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Includes GI ileus, GI ulceration, clotting dysfunction, hypertension, tachycardia, and tachyarrhythmias
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What are the 2 benefits of analgesia that were proved in human patients?
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1) Experienced fewer complications including decreases in
-GI dysfunction (indigestion, ileus, ulceration) -Clotting dysfunction (hypercoagulability, emboli) -Pulmonary dysfunction (atelectasis & pneumonia) 2) Healed faster and had better long term results -Decreased cortisol release |
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What are the 3 basic tenets of pain management?
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1) Analgesic drugs should be administered preemptively
2) Multimodal analgesia should be used whenever pain is moderate to severe 3) Analgesia should continue as long as pain is present |
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Why is it important to give analgesia prior to the pain stimulus?
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More effective because it prevents or alleviates the hypersensitization of the pain pathways, resulting in overall decrease in the intensity of the pain sensation and increase effectiveness of analgesia drugs.
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Why do we like to use multimodal analgesia?
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capitalizes on the additive or synergistic effects of analgesic drugs and all provide analgesia that is more intense and of longer duration than analgesia provided when drugs are used alone.
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Why is it so important to provide analgesia for the duration of the pain?
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Untreated pain can contribute to both peripheral & central hypersensitization, which can set the patient up for long-term pathologic pain
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What are 5 classes of drugs used for analgesia?
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1) NSAIDs
2) Opioids 3) Local anesthetics 4) Alpha-2-agonists 5) NMDA receptor antagonists |
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_______ are the most commonly prescribed analgesic agents in all mammals.
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NSAIDs
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NSAIDs are among the only drugs that treat not only the pain itself, but also ________.
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The source of pain
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We now know that COX-2 is not only inducible but constitutive in what 3 tissues?
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1) Kidneys
2) CNS 3) Stomach |
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Why can COX-2 specific NSAIDs cause side effects similar to those caused by less specific NSAIDs?
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Because COX-2 is not only inducible, but has constitutive release in some tissues
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When should NSAID use be considered?
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anytime pain of inflammation is present
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What are 2 newer NSAIDs used in horses?
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1) Oral Eqioxx (firocoxib)
2) Topical Surpass (diclofenac sodium) |
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Why are opioids underused analgesics?
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because of perceived side effects, there is a narrow margin b/w analgesia and behavior changes (primarily excitement) in horses than in some other species, but margin is wider in painful horses
-opioids combined w/ sedatives (like alpha-2 agonists) provide moderate to profound analgesia w/ minimal occurrence of excitement |
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________ class of drugs includes the most potent analgesic agents available to use.
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opiods, but if not used properly can cause excitement and decreased GI motility
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Why don't we worry about the excitement and GI motility decrease with opioid use in painful horses?
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Excitement less common in horses in pain and pain may decrease GI motility more than the opioids.
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What are 5 opioids used for analgesia in horses?
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1) Butorphanol
2) Morphine 3) Buprenorphine 4) Fentanyl patches 5) Tramadol |
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What is the most widely used opioid in horses? What's its mechanism of action?
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Butorphanol, an opioid agonist-antagonist
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What dose of butorphanol is used for analgesia in horses?
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b/w 0.02 mg/kg (what we use) and .2mg/kg (what provides most analgesia)
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What is the benefit of combining opioids with alpha-2-agonists?
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Both the analgesic and sedative effects of these two drug classes are additive or synergistic
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Morphine can cause profound excitement, even in painful horses. How can we minimize this?
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Morphine + alpha-2 agonist is quite useful for controlling moderate to severe pain and for analgesia for standing surgery
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How is butorphanol administered?
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can be used as CRI
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How is morphine administered?
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Generally IM, but can be IV (slow to prevent histamine release) and can be used in epidural and articular spaces
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What are the affects of morphine administered in the epidural space?
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provides up to 24 hours of analgesia with no systemic effects and no ataxia or motor dysfunction, have been used to treat acute & chronic pain
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What is the mechanism of action of intraarticular morphine injections?
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binds to synovial opioid receptors
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How is morphine administered for standing surgeries?
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a morphine/detomidine combo, administered SLOWLY IV
-repeat detomidine dose if more sedation is needed |
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Why isn't buprenorphine/ alpha-2 agonists given more often for analgesia in horses?
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Buprenorphine is expensive for adult horses but could be appropriate for foals or miniature horses
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Are fentanyl patches used very often for analgesia in adult horses?
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Provide analgesia w/ no or minimal side effects, but somewhat expensive, but provide analgesia for 48-72 hours so cost should be divided by duration of analgesia
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What is the mechanism of action of tramadol?
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'opioid-like' analgesic drug whose MOA is partly mediated by the opioid pathway and in part by other mechanisms (SSRI)
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Why does tramadol have limited use in horses?
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Half life is short after IV administration and the bioavailability is low after oral administration
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What is the most underutilized analgesia in veterinary medicine?
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Local anesthetics
-highly effective, extremely easy to use and amazingly inexpensive |
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What is the mechanism of action of local anesthetics?
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Block sensory input to the dorsal horn neurons in spinal cord, thereby decreasing likelihood of hypersensitivity and decreasing the overall intensity of pain experienced by the patient
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What are 3 routes of administration of local anesthetics used for analgesia?
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1) Local tissue infiltration
2) CRI -lidocaine 3) Long-term perineural blockade |
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What anesthetic is administered via local tissue infiltration for short duration analgesia? Intermediate duration? Long duration?
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Short: lidocaine (60-90 m)
Intermediate: carbocaine (2-3 h) Long: bupivicaine (4-6 h) |
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Why is lidocaine CRI advantageous?
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Can provide long duration pain relief w/o sedation or decreased GI function
-easy to use, safe, inexpensive |
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How do you perform a long-term perineural blockade?
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Utilizes indwelling catheters for long-term blockade of peripheral nerves
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When are alpha-2 agonists an excellent choice for analgesia?
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treating acute pain and associated excitement or distress bc provide sedation & analgesia
-also synergistic w/ opioids |
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What's 'old' about alpha-2 agonists?
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Effective for sedation
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What is something 'new' about alpha-2 agonists?
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A growing realizaiton of the role of these drugs in our efforts to achieve MULTIMODAL analgesia
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What are 3 alpha-2 agonists used as a bolus dose to provide analgesia?
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1) Xylazine
2) Romifidine 3) Detomidine |
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When do we use xylazine as a bolus dose?
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Used as a short-acting drug when break-through pain needs to be assessed (e.g. re-assessing colic patients)
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When do we use detomidine as a bolus dose?
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When pain needs to be controlled for a longer duration
e.g. during a long procedure or in colic patients being shipped to distant sites or when surgery is not an option |
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What alpha-2 agonist can be used for standing surgeries?
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Detomidine CRI can be used for sedation & analgesia
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Explain how you would go about administering a detomidine CRI.
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Remove 5 ml of fluid from a 500-ml bag of NaCl and add 5 ml of 10 mg/ml detomidine (for a final concentration of 100 microg/ml of detomidine). Give 8.4 microg/kg detomidine IV as a bolus and then start the drip
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Why can ataxia and excessive head dropping occur with detomidine CRI?
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Causes muscle relaxation
-horse should be supported in stocks and head should be elevated w/ cross-ties |
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What receptors are extremely active in the process of central hypersensitization?
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N-methyl-D-aspartate (NMDA) receptors in the dorsal horse of the spinal cord
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What is the mechanism of action of NMDA receptor antagonists?
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Not true analgesic drugs, but do play a role in pain management by decreasing hypersensitization thereby allowing other analgesics to control the patient's pain better
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What are 2 NMDA receptor antagonists that can be used as an 'analgesic'?
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1. Ketamine
2. Amantadine |
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How is ketamine administered for 'analgesia'? When is ketamine used?
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NMDA receptor antagonist at sub-anesthetic dosages and is generally administered as CRI for acute pain
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How is Amantadine administered? When is it used?
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Orally administered NMDA receptor antagonist that has been used for chronic pain in other species but use not reported inhorses
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What is Gabapentin? What's it used for?
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An anti-seizure drug that has a role in management of 'neuropathic' pain e.g. spinal cord trauma, especially when used in conjunction with other drugs
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What are some joint health modifiers?
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Polysulfated glycosaminoglycans and hyaluronic acid
-have a role in pain management and control of inflammation |
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What are some non-pharmacologic options used for horse analgeisa?
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Acupuncture, chiropractics, massage, low-level laser therapy, electrical nerve stimulation, extracorporeal shock wave therapy, stem cell therapy, ice wounds, stabilize areas of instability
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