For this latest blog post I wanted to basically draw your attention to the WSAVA Global Pain Council Pain Management Protocols that have recently been made freely available online. This is an excellent vetFOAMed resource for which they are clearly to be commended.
I also especially like how the WSAVA has tried to suggest guidelines based on the recognition that facilities, resources, experience and expertise vary widely across the world. They write:
“The Global Pain Treatise is a downloadable, practical resource to assist practitioners around the world by providing guidance in recognizing and assessing pain accompanied by management protocols for a wide range of painful conditions. Because it also provides guidance on scenarios where analgesic agents are limited, it helps to empower veterinarians in these countries to recognize and treat pain, regardless of their limitations.”
In terms of specific pain management protocols you can download PDFs for the following:
Of special interest to Emergency and Critical Care practitioners:
Emergency and critical care
Neonatal and pediatric patients
Pregnant or lactating patients
But clearly we are very interested in all of the others too:
Cancer related pain
Castration and ovariohysterectomy/ovariectomy in Cats
Castration and ovariohysterectomy/ovariectomy in Dogs
Degenerative joint disease
Soft tissue surgery
Emergency and Critical Care Pain Management Protocol:
I am not going to dissect what they have written in detail but I did want to just pick out a few things to list here by way of emphasising their importance:
“individual drug selection, and dosing to effect is essential, rather than considering a standard regimen for all patients.”
“Where blood or ¬fluid loss may be present or suspected, fl¬uid therapy is commenced prior to careful titration of the opioid to avoid potential adverse effects with standard dosing”.
I would like to comment on this. I see the point that they are making and it is true that aggressive pure opioid administration could potentially cause some reduction in blood pressure (e.g. by vasodilation or by reducing cardiac output, potentially from a sympatholytic effect) depending to an extent on the individual agent in question. However the risk of clinically significant adverse effects on cardiovascular status in conscious painful patients dosed appropriately is in my experience very low indeed and easy to over-emphasise. There is an argument that says that when the patient is painful their sympathetic tone will also be helping to support their cardiovascular status; hence relieving pain without taking measures to support cardiovascular status – typically fluid therapy in the first instance – could trigger cardiovascular deterioration. This is the point I think the protocol is trying to make and is fair enough…however it should not be interpreted as a reason to withhold opioid analgesia over concerns of cardiovascular status (please don’t do that!); just dose conservatively and titrate up to effect and simultaneously take steps to support the cardiovascular system. Interestingly there is some discussion about the use of ketamine in a scenario like this as being a sympathomimetic agent it may help to support cardiovascular status while alleviating pain; but it needs to be used with another agent, never alone as it can do some crazy things used on its own!
“use of NSAIDs in the emergency patient should be withheld until the volume, cardiovascular and renal status of patients is determined to be within normal limits and with no potential for deterioration. NSAIDs should never be administered to patients with evidence of/potential hemorrhage.”
“Analgesia and the induction of restful sleep is the goal. Continuous rate infusions are useful to achieve this”.
They also make a comment about not using lidocaine infusions in cats which is the traditional recommendation. However its evidence base is poor; there are certainly some practitioners who have used lidocaine infusions in cats for analgesic purposes for quite some time without having recognised any clinically significant adverse effects. I will write a blog post on this in the future to go into more detail. I guess for now you should adhere to the traditional recommendations or take steps yourself to investigate the evidence base and the experience of others before considering changing practice.
I am also glad that they mention at the end about the importance of non-pharmacological measures in pain management and are open-minded enough to mention acupuncture!
Any comments, as always, do let me know.