LITMIR.BIZ

Скачать книгу

we can't improve that.

      This type of introductory language can help to move the conversation, exam, and management choices forward, which can subsequently have a significant positive impact on patient quality (and perhaps length) of life. It can be initiated by front desk personnel taking calls and watching pets in reception area, technicians and veterinary assistants escorting to the exam room and talking to owners, and animal caretakers interacting with the patients under their care.

      In the absence of vocalizing, lameness, and other obvious signs of pain, the veterinary team can be mindful of the following observable changes in body conformation and mobility.

       Visible conformation: high body condition score (BCS); kyphosis (bowing up) of back, diminished angle to stifle and hock, obvious muscle atrophy (denotes a patient that has been shifting weight forward for considerable time); cow‐hock, base narrow or wide, chondrodyplasia – all evident at a glance.

       Dog sitting “square” or cheating on one hip (likely stifle pain)?

       When stands from a lying position, should be all four legs simultaneously versus rising up first on forelimbs followed by hoisting up the rear quarters.

       Gait if possible – stilted or fluid? Lameness: look for a “quick step” which suggests the contralateral limb is affected; look for classic “wiggle” of rear quarters seen as the dog rotates its pelvis to reduce painful extension of the hip.

       Jumping up or standing on back legs easily, partially, or unable/unwilling?

      Several clinical metrology instruments (CMIs) are validated for both dogs and cats to assign scores for acute postsurgical pain (examples: Glasgow Composite Measure Pain Scale for dogs and cats, UNESP‐Botucatu Multidimensional Composite Pain Scale for cats). They utilize the domains of observing the patient without interaction (with focus on position in cage, posture, behavior, facial expression), then with interaction (willingness to interact and move), then palpating the incision site. A nonvalidated but simple tool is to apply a global 0–10 score of those domains taken together, whereby 0 is no pain at all and 10 is the worst possible pain for that procedure; this is a so‐called dynamic interactive visual analog scale (DIVAS) and can be quickly and easily deployed in any practice setting. It can be argued that the most important of those domains is palpation of the surgical site, and if so the simplest assessment method of all would be to assign a 0–4 score based on this maneuver alone.

      Several CMIs also exist for chronic OA‐related pain and disability in dogs (e.g., Canine Brief Pain Inventory, Liverpool OA in Dogs, Canine OA Staging Tool in Dogs) and cats (e.g., Feline Musculoskeletal Pain Index, Montreal Instrument for Cat Arthritis). These assess various domains of owner‐ (not veterinarian) observed signs of discomfort and limitations on activities of daily living.

      2.16.3 Prevention and Treatment of Pain

      Industry guidelines and consensus statements have been published on the highest, wisest, and safest use of modalities to prevent and control surgical and OA‐related pain [3, 4]. Additional discussions are available elsewhere (see 6.14 Pain Prevention, Management, and Conditioning, and 8.13 Team Approach to Pain Management). High‐level concepts include the following.

      2.16.3.1 Acute Postsurgical Pain

      1 Anxiolysis, to include both pharmacological and nonpharmacological measures.Anxiolytics such as trazodone and gabapentin administered the morning of surgery, even by the owner at home prior to transport to the hospital.Fear‐free experience, low‐stress handling, pheromone therapy, comfortable species‐specific housing (see 6.6 Fear Free Concepts).Anxiolytic administered as part of in‐hospital premedication, e.g., midazolam, dexmedetomidine, acepromazine (when administered with opioids).

      2 Opioid – while this remains the most effective drug class for acute pain, veterinary clinicians are advised [5] to follow the shift in human medicine to use fewer opioids, lower doses, shorter frequency, and insofar as possible shift from full mu agonists (morphine, hydromorphone, fentanyl) to partial mu agonists (e.g., buprenorphine) and mu antagonists, kappa‐agonist (e.g., butorphanol). Consensus statements support the aggressive use of opioid‐sparing strategies (the other modalities discussed in this section), and reserving full mu agonists for the prospectively more painful procedures and patients.

      3 Nonsteroidal antiinflammatory drugs (NSAIDs).

      4 Local and locoregional anesthetics and techniques – the “missing ingredient” for many if not most surgical procedures in small animal medicine (but not in large animal or in human medicine); nevertheless industry guidelines stipulate that local anesthetics should be utilized with every surgical procedure (even if just an incisional block but there are dozens of local and locoregional techniques within the scope of any veterinarian – and veterinary technician – to master).

      5 Adjunctive pain‐modifying medications and modalities: these are deployed with patients undergoing predictably more painful procedures and/or are at higher risk for maladaptive pain, e.g. those with nerve injury, severe trauma (preexisting or surgical, soft tissue or orthopedic), or with long‐standing previous pain and inflammation. These include but are not limited to constant‐rate infusions of ketamine, systemic lidocaine, dexmedetomidine, oral gabapentin, amantadine, and others.

      6 Nonpharmacological interventions such as cold compression, physical rehabilitation, possibly acupuncture, and energy‐based modalities such as therapeutic laser, pulsed electromagnetic field, and others.

      2.16.3.2 Chronic OA Pain

      There are a variety of options for managing the chronic pain of OA (see also 8.20 Team Strategies for Arthritis).

       Weight optimization

       Antiinflammatory agents (NSAIDs and prostaglandin receptor antagonists, PRA)

       Eicosapentaenoic acid‐rich (dog), docosahexaenoic acid‐rich (cats) diets

       Therapeutic exercise

       Polysulfated glycosaminoglycan and nutritional supplements

       Adjunctive pain‐modifying medications (e.g., gabapentin, amantadine)

       Intraarticular (IA) agents such as biologics (stem cells, platelet‐rich plasma) and others

       Anti‐nerve growth factor (NGF) monoclonal antibody (mAb)

      2.16.3.3 Non‐OA Chronic Pain

      Neoplastic pain, especially osteosarcoma (OSA) and any tumor metastasizing to bone, is generally considered to include a neuropathic component facilitated in part by osteoclastic activity. In palliative care circumstances (e.g., limb‐sparing OSA), multiple modalities should be deployed since undercontrolled pain will predicate the decision for humane euthanasia. As cyclooxygenase (COX) enzymes are greatly upregulated in OSA, NSAIDs are appropriate medications to deploy, along with one (or more) adjunctive pain‐modifying oral medications (among the higher effectiveness:safety ratios in human cancer‐related pain are anticonvulsants like gabapentin). Oral acetaminophen and opioids are frequently deployed in humans with chronic cancer pain, and can be utilized judiciously in dogs (not cats), but the bioavailability and clinic impact of these drugs have been questioned. Long‐acting (days, not weeks) parenteral opioid medications are available for off‐label use in dogs and cats. Uniquely in cancer pain, bisphosphonate (pamidronate, zolendronate) infusions freeze osteoclast activity and can elicit durable (approximately one month) improvement in a majority of dogs [6].

      Nonneoplastic maladaptive and/or neuropathic pain syndromes described in dogs and cats often have an identifiable cause, but not always; it may be associated with identifiable inflammation, but not always. If an underlying condition is identifiable, it should be managed accordingly. To treat pain directly, if there is a grossly

Скачать книгу