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Essential part of every patient evaluation
Pain assessment
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Detection by the nervous system of the potential for or the actual occurrence of tissue injury
Nociception
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Protective sensation of pain that occurs when there is no or minimal tissue injury
Physiologic pain
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Pain the occurs after the tissues injury
Pathologic pain
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Nociception consist of 4 main steps
- Transduction
- Transmission
- Modulation
- Perception
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Transformation of thermal, chemical or mechanical stimuli into electrical signals called action potentials
Transduction
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Sensory impulses conducted to the spinal cord
Transmission
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Sensory nerve impulses are amplified or suppressed by other neurons
Modulation
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Impulses transmitted to the brain where they are processes an recognized
Perception
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Drugs effective in transduction phase
- NSAIDs
- Opioids
- Local anesthetics
- Corticosteroids
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Drugs effective in transmission phase
- Local anesthetics
- Alpha2- agonists
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Drugs effective in modulation phase
- Local anesthetics
- NSAIDs
- Opioids
- Alpha2-agonists
- Ketamine
- Anticonvulsants
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Drugs effective in the perception phase
- Opioids
- Sedatives
- General anesthetics
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Multimodal therapy
Using several analgesic drugs, each with different mechanisms of action
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Multimodal therapy, in regards to drug doses, results in...
Lower doses of drugs which increases safety
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5 freedoms that help to asses quality of life
- Freedom from...
- Hunger and thirst
- Discomfort
- Disease
- Injury
- Pain
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Pain related physiological changes in the cardiovascular system
- Hypertension
- Tachycardia
- Tachyarrhythmia
- Peripheral vasoconstriction
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Pain related physiological changes in the respiratory system
- Tachypnea
- Shallow breathing
- Exaggerated abdominal component
- Panting
- Open-mouth breathing
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Pain related physiological changes with the eyes
Mydriasis
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Painful medical conditions
- Arthritis
- Cancer
- Cystitis
- Pancreatitis
- Peritonitis
- Pleuritic
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Painful surgical conditions
- Spinal
- Fracture repair
- Hip replacement
- Joint
- Ear
- Dental extractions
- Sinus
- Trauma
- Eye
- Pyometra
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Preemptive analgesia
Administering analgesics before surgery decreases analgesic requirements and minimizes CNS sensation
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Examples of opioids strongest to weakest
- Fentanyl
- Oxymorphone
- Hydromorphone
- Methadone
- Morphine
- Meperidine
- Buprenorphrine
- Butorphanol
- Nalbuphine
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Examples of Alpha-2 agonists
- Xylazine
- Dexmedetomidine
- Detomidine
- Ramifidine
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Examples of NSAIDs, COX-1
- Aspirin
- Acetaminophen
- Flunixin meglumine
- Ketoprofen
- Ketorolac
- Phenylbutazone
- Piroxicam
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Examples of NSAIDs, COX-2
- Carprofen
- Meloxicam
- Etodolac
- Deracoxib
- Tepoxalin
- Firocoxib
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Examples of other analgesics
- Ketamine
- Amantadine
- Dextromethorphan
- Amitriptyline
- Tramadol
- Gabapentin
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Idiopathic pain defined as
Pain of unknown cause
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An ovariohysterectomy, which involves surgically incising the skin and abdominal wall and excising the uterus and ovaries has which components of pain
Somatic and visceral
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Where in the pain pathway does secondary sensitization of "windup" occur
Spinal cord
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Example of multimodal analgesic therapy
Dexmedetomidine, morphine and ketamine
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Example of an analgesic plan that targets three different pain receptor mechanisms
Morphine IM, Ketamine CRI and Lidocaine nerve block
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Does treating pain improve wound healing?
Yes
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Potential side effect of opioid administration in cats and dogs
Vomiting, dysphoria, respiratory depression
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Method of action of NSAIDs
Inhibit prostaglandin synthesis
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Potential side effects of NSAIDs
Liver damage, kidney damage, GI ulcers
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What to asses when indicating pain assessment scale
- Interaction level
- General appearance
- Posture
- Cardiovascular
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Muscoskeletal pain
Somatic pain
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Pain from the organs
Visceral pain
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Nerve injury pain
Neuropathic pain
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If patient is feeling mild pain then only __ location may need to be targeted
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With moderate pain may need to target ___ locations
2
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With severe pain may need to target ___ locations
3
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Locations that may need to be targeted in regards to pain
Peripheral nerves/tissues, spinal cord and brain
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Occurs when stressors like pain affect physiology and behavior
Distress
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Consequences of pain
- Catabolic state and wasting
- Suppressed immune system
- Inflammation and delayed wound healing
- Stress
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State of increased sensitivity near a site of tissue injury in which stimulation with a normally non-noxious stimulus is painful
Primary Hyperalgesia
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A state caused by constant nociceptive input from the periphery, in which neurons in the spinal cord become hyperexcitable and sensitive to low-intensity stimuli that would not normally elicit a pain response
CNS hypersensitivity AKA windup
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Project or describe animals as having human emotions/behavior
Anthropomorphize
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Behavior changes animals make when in pain
- Facial expressions (glazed/squinted eyes)
- Bruxism
- Lack of grooming
- Disinterest
- Aggression
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Pain treatment used before, during and after surgical procedure
Perioperative analgesia
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Opioids provide analgesia through which opioid receptors found where
- Spinal cord
- Brain
- Synovial membranes of joints
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C-II Opioids
- Morphine
- Oxymorphone
- Fentanyl
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Morphine causes..
Excitement in horses/cats, vomiting, histamine release if given IV rapidly
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Fentanyl
Strongest opioid, used commonly as a CRI, transdermal use as well
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Butorphanol
- Good for cough suppressant, cranial GI pain and visceral pain
- C-IV
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Buprenorphrine
- Opioid that has the longest duration
- C-III
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Adverse effects of opioids
- Dysphoria
- Respiratory depression
- Excitability (cats)
- Excessive panting
- Vomiting
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NSAID effects
- Skeletal pain
- Newer ones have somatic and visceral pain control
- 30-60 mins onset of action
- Some are antipyretic
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COX-1 controls
Homeostasis
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COX-2 controls
Inflammation
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Central and peripheral acting NSAID
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Advantages of NSAID
- Not a controlled substance
- No cardio/resp effect
- No CNS depression
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Conditions in which NSAID's shouldnt be used
- Renal disease
- Liver disease
- GI ulcers
- Hypotension
- Blood clotting disorders
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Strongest anti-inflammatory drugs
Corticosteroids
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Tramadol
- Non opiate
- Centrally acting oral pain medicine
- Inhibition of norepinephrine and serotonin reuptake
- Now a controlled substance
- Only in oral form
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Good nursing care indicates
- Clean/dry bedding
- Allowing defecation/urination
- Comfortable/quiet environment
- Regular pain assessment
- Petting/comforting patient
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Non drug therapies
- Cold/heat therapy
- Acupuncture/electro stimulation
- Therapy laser
- Physical therapy
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Two drugs that block NMDA receptors and stimulate "windup"
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Opiate absorbed mucosally in cats
Buprenorphrine
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Ideally NSAID's are __ sparing and ___ selective
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___ ___ is most important thing an anesthetist can do to prevent complications
Patient preparation
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