Last week’s webinar, led by Elke Rudolf DVM DACVECC CVMA, offers a useful overview of the many aspects of pain management within the intensive care setting. I would like to think I’m fairly experienced in providing adequate pain relief to the emergency patient, with fast-acting opiates such as methadone being my drug of choice. However, I could do with extending my knowledge in terms of a multimodal approach where using individual drugs such as opiates are not adequate and this webinar provides exactly what is neede
Opiates are, without doubt, the drug of choice for pain relief in the ICU setting under most circumstances but offering additional methods of pain relief can also be really useful. For example, Elke suggests using local anaesthetic techniques such as a coccygeal epidural for our blocked toms as it completely anaesthetises the urethral and perineal region offering real benefits to these patients. The technique for this procedure was outlined in the webinar. Elke also discussed liposomal bupivicaine which is an extended-release bupivicaine and can provide good analgesia for up to 72 hours after infusion. It can be really useful for use post surgical procedures such as TTAs and TPLOs and can be used either as a local or regional infusion.
Elke also discussed the use of NSAIDs which are really useful for post op pain, inflammatory conditions, and chronic conditions such as OA and cancer. Their use can however have detrimental effects on renal function, and can cause GI ulceration, hepatotoxicity and prolonged bleeding. These complications are usually associated with patients suffering from pre existing conditions and/or poor perfusion. Paracetamol can be a really useful alternative as an analgesic and antipyretic to NSAIDs where their use is inappropriate. The use of paracetamol is however strictly contraindicated in the cat due to their inability to metabolise it.
Other drugs discussed by Elke included gabapentin and the cannabinoids. Gabapentin can be really useful for neuropathic pain and helps prevent hyperalgesia and central sensitisation. Elke not only uses it for acute pain management but she also finds it very useful as a sedative especially in the fractious cat. Elke uses gabapentin at a dose rate of 10-20mg/kg every 6-8hrs. In terms of the cannabinoids there is now increasing evidence that these substances can have positive effects controlling pain in dogs. It is however important to be aware that cannabinoid products contains THC ( the psychoactive chemical) are not appropriate for pets as they are very sensitive to its effects even in products just containing 0.3% of THC which is a level that does not have to be stated on the label.
Physical therapies can also be really useful in the ICU setting and this is certainly an area that I don’t always consider when providing analgesia for my patients. Mobilisation techniques such as mobilising joints 15-20 x per joint 3-4 times a day can aid in increasing blood flow and circulation in the non ambulatory patient. Even tickling the tummy of a patient can encourage them to move. Not only are these techniques crucial for reducing muscle spasm and decreasing oedema, they also offer some invaluable time interacting with the patient. Other techniques discussed included cryotherapy, photobiomodulation ( i.e. laser therapy)and acupuncture which has been shown to provide analgesia, decrease reactive oxygen species, increase blood flow and modulate immune functions.
Elke provided even further information on the use of a variety of drugs to reduce anxiety and dysphoria including trazodone, ACP and dexmedetomidine. There was no shortage of information within this webinar and it has certainly refreshed and extended my knowledge on the multimodal approach to pain relief in the ICU patient. There was one more point that Elke was very keen to make at the start of this webinar and which I have left till the end of this blog. Always remember that patient deterioration will not be masked by analgesia and without analgesia, these patients will suffer from the same effects of shock. Therefore it is imperative we do all we can to manage these patients effectively and watching this webinar is certainly a step in the right direction.