Cats, NSAIDs and acute renal failure

Re: Cats, NSAIDs and acute renal failure

Michael Woodhouse — Tue, 03 Jun 2014 01:59:41 GMT

[quote user="Rebekah Robinson"]Michael, I'd like to hear more on your experiences with using Metacam in cats with CRF. I always steer well away from them but after another recent case and reading the current ICC reconmmendation, I'm still undecided. Can you elaborate more on how you use it. Also, how do you discuss the pros/cons with owners? I end up talking owners and myself out of using them!![/quote]

I'm doing very little small animal work these days, so no expert.

I put it to the owners simply that the cat is in pain. There is some medicine that will really help with that pain, but it can have negative effects on the kidneys. Cats are particularly prone to kidney problems - kidney failure is one of the most common causes of death in cats. Given the choice I'd rather live a shorter pain free life than live longer in agony. I explain there is a risk, but that risk, in my opinion, is worth taking.

I would always recommend bleeding the cat if I intended to put it on long term meds, and would like to check after a month (or sooner if any changes in drinking/urination/demeanour), A reasonable chunk of owners decline bloods.

I've never had a cat made worse. Many occasions the cat is happier and brighter and more active a month later. The kidney parameters in these cats have always improved (to the best of my recollection). Put one cat on Loxicom with azotaemia and it was doing well 2 years later when I left the practice. The datasheet does say not to use if renal disease.

Be honest and discuss it with the owner. You will be surprised.

(the only real negative I've found is some cats start to vomit after a while)

Re: Cats, NSAIDs and acute renal failure

Rebekah Robinson — Mon, 02 Jun 2014 23:09:17 GMT

[quote user="Michael Woodhouse"]

[quote user="Martin Atkinson"]The questions here are: is that quoted incidence of 25% over-dramatic or is it realistic?[/quote]

Sometimes I wonder what planet these guys in referral centres come from. I am absolutely sure that a quarter of cats getting NSAIDS do NOT go azotaemic. I've put cats with known kidney disease on long term NSAIDs and had kidney parameters improve in many cases. The reduction in pain, increased appetite and activity seem to really help. I used to be very nervous of putting these cats on NSAIDs but I'm now quite brave (although I like to keep a close eye on the kidneys to start with, warn re changes in drinking etc).

I disagree that the pain is good. I'd rather relieve 200 cats of pain, and one get a bit of a kidney problem, than leave 200 cats in pain.

I suspect pre-op bloods would have been normal.

We give old cats subcut fluids, but I wouldn't in such a young animal.

This falls under the rare but possible risk of harm from a GA. I suspect the cat has a natural susceptibility, given the history. Don't let it change your practice too much. Don't over-react and get all scared of NSAIDs.

[/quote] Michael, I'd like to hear more on your experiences with using Metacam in cats with CRF. I always steer well away from them but after another recent case and reading the current ICC reconmmendation, I'm still undecided. Can you elaborate more on how you use it. Also, how do you discuss the pros/cons with owners? I end up talking owners and myself out of using them!!

Re: Cats, NSAIDs and acute renal failure

Rebekah Robinson — Mon, 02 Jun 2014 22:57:07 GMT

[quote user="Bob Russell"]

Having been 'taught' to give pre-emptive NSAI's as part of the pre-med for a long time, I went to a talk that Kit Sturgess gave on the subject of post-operative ARF. Since then we have given the injection during the recovery period.

Total balls to suggest 25% of cats go into renal failure. Total balls to suggest no pain relief should be given for a patient having his 'pockets picked'. All surgery is painful and it is appropriate and professional to minimise this.

I suspect there was a drop in blood pressure at some stage sufficient to reduce renal perfusion to the point that the NSAI became a problem.

[/quote] Bob, out of interest what Kit have to say about this? In Australia, NSAIDs are always given on recovery, while here in the UK typically right after induction. I still feel on recovery makes more sense, but have adopted the UK way for the past 5 years without any problems.

Re: Cats, NSAIDs and acute renal failure

Gillian Mostyn — Mon, 02 Jun 2014 15:35:14 GMT

[quote user="David Mills"]As for medetomidine, it retains central pressure - and in some cases increases it - and so is highly unlikely to cause renal failure even in the dehydrated. [/quote]

I agree that the medetomidine is very unlikely to cause ARF directly ... but I do feel that if it isn't reversed then the animal certainly stays sedated for longer than necessary, which in some cats seems to be hours! It is also a diuretic. This will mean that animals, especially cats, can become significantly dehydrated with NSAIDS on board.... not ideal!

Re: Cats, NSAIDs and acute renal failure

Braden Collins — Mon, 02 Jun 2014 12:51:04 GMT

[quote user="Malcolm Ness"]

[quote user="Braden Collins"]Watch the Tour de France when one of those blokes fall off. They jump back on and ride like there's nothing wrong but you can bet they're hurting like hell.[/quote]

And, of course, they are all completely free of drugs!!

[/quote]

Possibly not the best example I could have come up with, but they're probably a better example than football players for not showing pain. Maybe I should have used rugby or Aussie Rules players for the example.

Re: Cats, NSAIDs and acute renal failure

Malcolm Ness — Mon, 02 Jun 2014 12:39:38 GMT

[quote user="Braden Collins"]Watch the Tour de France when one of those blokes fall off. They jump back on and ride like there's nothing wrong but you can bet they're hurting like hell.[/quote]

And, of course, they are all completely free of drugs!!

Re: Cats, NSAIDs and acute renal failure

Braden Collins — Mon, 02 Jun 2014 12:17:49 GMT

[quote user="Anthony Todd"]

[quote user="ruths"]Pain relief doesn't have to always involve NSAIDs. And I think I'd rather be proved worng having given pain relief to animals hat didn't need it than to face the realisation that animals did need pain relief and I withheld it.

[/quote]

I don't dispute that at all and I agree with the logic.

All I have ever been saying is that sometimes, if not often, after some routine surgical procedures like spays and castrations there may be no post op pain judged only by the animals normal behaviour and not by our assumptions.

This includes equine castration, which I find hard to believe, but their post op behaviour supports me.

[/quote] If we look at behaviour and pain it doesn't always correlate. Lambs being mulsed will behave normally, but give them some analgesia they gain weight better so there does appear to be some pain despite the outward behaviour. You can see it in people too. Watch the Tour de France when one of those blokes fall off. They jump back on and ride like there's nothing wrong but you can bet they're hurting like hell.

Re: Cats, NSAIDs and acute renal failure

David Mills — Sun, 01 Jun 2014 23:43:19 GMT

[quote user="Braden Collins"] I think this is probably a cat that has a particular reaction to NSAIDs[/quote]

There is a gradually emerging field called pharmacogenetics, wherein people (and animals, one presumes) are genetically likely to process drugs differently. Just as some people (and animals) are allergic to some drugs, so people will process drugs differently, with different effects.

An example. Beagles process nsaids more slowly than other breeds of dog, so that the common nsaids last longer in their systems and so there is a real danger of overdose.

I very much suspect in this case that, unfortunately, the pharamcogenetic makeup of this cat was such that it handled nsaids incredibly poorly.

To extrapolate from this that animals shouldn't be given nsaids because surgery doesn't cause pain - based on some rose-tinted biased anecdotal mis-recall of a long-retired vet who qualified before many of us were born - well it's as ridiculous as that sentence reads.

As for medetomidine, it retains central pressure - and in some cases increases it - and so is highly unlikely to cause renal failure even in the dehydrated. It remains one of the most poorly understood drugs by vets, mainly, I think, because nurses seem to hate it because it makes the gums a bit pale.

Re: Cats, NSAIDs and acute renal failure

Shona Haydon — Sun, 01 Jun 2014 21:04:28 GMT

Re: Cats, NSAIDs and acute renal failure

ruths — Sun, 01 Jun 2014 19:40:21 GMT

Sheesh- -)) I don't always use NSAIDs - I use differe t techniques and different drugs in different cases. And I said up thread that my belief is that there is likely a Multifsctorial problem here. I'm not sure what else to say so I shan't reply further. It's not that you have 'won', it's just I am not minded to spend any more time on this. I do hope the cat is feeling better and showing signs of recovery

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sun, 01 Jun 2014 18:08:26 GMT

[quote user="ruths"]Anthony you may be right But what if you are wrong?

[/quote]

Sure, routine analgesia if you like but don't say "because they are" say "because they might be" in pain.

No argument with that as I've said but if you're risking ARF and they may not be in any pain what then?

And someone please please explain the horses castrated with no anaesthetic at all [suxa isn't!] and their immediate post-op behaviour.

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sun, 01 Jun 2014 18:03:28 GMT

[quote user="Braden Collins"]Just a couple of thoughts on the OP.[/quote]

Why on earth would this sensible reasoned useful post by someone without an ax to grind get a bloody red star.

Arlo, red stars should be abolished! Criticise for sure but a cowardly anonymous irrational red-star; no!

I'm still trying to see anything to justify it in this post

PSit's now 5 gold, go figure!!

Re: Cats, NSAIDs and acute renal failure

Braden Collins — Sun, 01 Jun 2014 13:28:28 GMT

Just a couple of thoughts on the OP. I think this is probably a cat that has a particular reaction to NSAIDs. I think the previous history coupled with this episode probably indicates a problem specific to this cat, rather than your treatment. With the recent study showing the safety of oral meloxicam even in cats with quite advanced CRF I think for this cat to have had the reaction to 5 days of meloxicam it has to be the cat that is the problem.

Our standard premed includes methadone for almost everything, intraoperative fentanyl where needed, and NSAID on recovery if indicated. We use bupivacaine nerve blocks for dentals too so can keep anaesthetics very light in most cases. Blood pressure is monitored throughout and everything undergoing GA goes onto IV fluids (even cat castrates). They certainly wake up better and recover faster with IV fluids.

I've only ever seen one animal experience catastrophic renal failure due to NSAIDs. Bloods were run before starting it on Previcox (for arthritis so no anaesthetic involved) and it was dead a week later from acute renal failure. Everything done right and by the book, just the dog seemed to react to the drug.

Re: Cats, NSAIDs and acute renal failure

ruths — Sun, 01 Jun 2014 10:55:32 GMT

Anthony you may be right But what if you are wrong?

Re: Cats, NSAIDs and acute renal failure

Ceri Gruffudd Jones — Sun, 01 Jun 2014 10:10:37 GMT

In simple terms, I've seen many animals re-presented post op for additional analgesia, I've seen one or two develop ARF post GA/NSAID in 11 years of 1st opinion general practice. In my mind it's very justified. There is also huge variation in individual tolerance of and response to tissue trauma / pain, which cannot always be predicted on the basis of a 10 minute check over before admitting an animal for surgery.

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sun, 01 Jun 2014 10:04:57 GMT

[quote user="Will McMullan"]you wouldn't feel any pain or discomfort afterwards? [/quote]

I'd say there are loads of examples where humans have major wounds, particularly sharp knife wounds and do not notice them ie suffer no immediate pain and, in fact, only notice the wound by it's appearance and/or blood etc, and [see below] by what pain is assumed.

This is the only quote I can find which expresses this:

The frequency of pain severe enough to require a narcotic was studied in 150 male civilian patients and contrasted with similar data from a study of wartime casualties. Efforts were made to have the two groups comparable in essential respects and to make sure that existing differences, such as age and past illness, between the two groups did not influence the results. The group of soldiers had very extensive wounds, were clear mentally, and were not in shock; many had had no morphine at all, yet less than one-fourth said, on being questioned, that they had enough pain to want anything done about it. The percentages of patients desiring narcotics were 32 and 83 for the military and the civilian groups respectively.

There was no dependable relation between the extent of a pathological wound and the pain experienced. No significant difference was found between the pain of sudden injury and that of chronic illness. The intensity of suffering is largely determined by what the pain means to the patient. This emphasizes the impossibility of appraising, by current experimental techniques at least, the power of analgesic agents in man. It also means that the indiscriminate administration of powerful analgesics to all injured individuals is unsound.

fromHenry K. Beecher, M.D.JAMA. 1956;161(17):1609-1613. doi:10.1001/jama.1956.02970170005002

We've all cut ourselves or damaged ourselves and been unaware until we see it and it is this that I am trying to explain.

Be interesting to hear Martin Atkinson's take on the point as he's suffered all sorts of accidents. I know when I dropped a boiler on my anterior tibia there was no pain at the time; it did come later! There was minimum tissue trauma, just a clean cut.

Of course this is only in the immediate post event period but it may be that animals, sometimes, with a "sympathetic" wound, ie a sharp cut with no tissue trauma, [and, at the time there isn't any yet] actually suffer no immediate post-event pain.

That's all I'm suggesting, and, as yet no one has suggested an explanation for the post-castration horse behaviour,and it may be that their post pain perception is absent. Similarly with the cat castration under GA; post-op pain is nil, or perceived as nil.

It certainly appeared that way to me.

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sun, 01 Jun 2014 00:56:54 GMT

Reduction of pain and swelling by a corticosteroid injected 3 hours after surgery

P Skjelbred, P Løkken - European journal of clinical pharmacology, 1982 - Springer

It would be me wouldn't it

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sun, 01 Jun 2014 00:47:58 GMT

[/quote]

I don't dispute that at all and I agree with the logic.

This includes equine castration, which I find hard to believe, but their post op behaviour supports me.

Re: Cats, NSAIDs and acute renal failure

ruths — Sat, 31 May 2014 21:02:30 GMT

Pain relief doesn't have to always involve NSAIDs. And I think I'd rather be proved worng having given pain relief to animals hat didn't need it than to face the realisation that animals did need pain relief and I withheld it.

Re: Cats, NSAIDs and acute renal failure

Michael Woodhouse — Sat, 31 May 2014 17:19:32 GMT

[quote user="Anthony Todd"]I'm just saying I and other dinosaurs don't believe they show any signs of pain postop and, if they do there's another reason for it ie infection, tissue trauma tight sutures etc.[/quote]

I'm not sure we should even need to discuss whether surgery is painful. What we don't know is what the dog feels, but we have to err very much on the safe side.

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sat, 31 May 2014 17:03:53 GMT

[quote user="Elizabeth Billimore"]The "humpy" or "squinty face" or "flat out and unresponsive" cat can be showing signs of pain.[/quote]

Most cats show one or more of these these signs most of the time; are they in pain most of the time.....?

Being serious though, most of you are saying you expect the cat spay or cast to be in pain rather than you are sure they are.

I'm just saying I and other dinosaurs don't believe they show any signs of pain postop and, if they do there's another reason for it ie infection, tissue trauma tight sutures etc.

I'll get my coat.

Re: Cats, NSAIDs and acute renal failure

Bibs — Sat, 31 May 2014 16:54:34 GMT

They don't show pain in way that's always obvious. The "humpy" or "squinty face" or "flat out and unresponsive" cat can be showing signs of pain. Not everyone is going to be looking for this and not every nurse knows to look for these signs.

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sat, 31 May 2014 16:47:38 GMT

[quote user="Will McMullan"]I expect your friend had an epidural prior to her hysterectomy? [/quote]

Um, no actually, even I realise that an epidural acts as an anaesthetic.

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sat, 31 May 2014 16:45:14 GMT

[quote user="Marie Kubiak"]an animal trying to maintain a facade of health [/quote]

Oh come on, are you suggesting the animal puts on a brave face? Animals don't hide pain unless they are in a stressful situation ie being attacked or pursued.

[quote user="Marie Kubiak"]p.s, I red-starred you for insinuating I am a 'mature woman', I find that incredibly offensive [/quote]

I'm between the devil and the deep blue sea! I can't call you "mature" and recently "girl" is deemed discriminatory.......

Re: Cats, NSAIDs and acute renal failure

Anthony Todd — Sat, 31 May 2014 16:28:06 GMT

[quote user="ruths"] I just felt the need to say something in response to your post.[/quote]

Fair enough and thank you. My points were not to allow pain or to condone no pain relief but to query whether pain actually occurs at all in some procedures.

I just can't equate a horse, just having been castrated with no anaesthetic at all rising and immediately eating grass and, to all extent and appearance, being totally unconcerned.

Compare that to a horse with colic; they certainly know how to exhibit symptoms of pain!

If there is actually no pain following a cat castration and analgesia can result in ARF then it might be worth considering it's use, particularly if the pain is assumed rather than real.

If you were to say that "I give analgesia in case there is pain" I wouldn't argue at all. If you say, though, "I give pain relief because I know there is pain" I would say, in some obvious cases, there doesn't seem, to me and others, any signs of it.