Pain management - new ideas.

Re: Pain management - new ideas.

mariette asselbergs — Fri, 08 May 2015 15:36:39 GMT

[quote user="Louise Alexander"]

Hi Andrew I did used to substitute methadone for morphine on a like for like volume basis, but I've just ran this past an ECC specialist who suggests that methadone shouldn't be used in CRIs due to its pharmacokinetics. So I'd stick to morphine as per the protocol in Tim's article.

I agree it'd be lovely to hear what Tim is doing currently :-)

Louise

[/quote]

I have used it with methadone in stead of morphine in cats that were very painful because of a pelvic fracture and it worked a treat. Then I read that you shouldn't use lidocaine in CRIs for cats, but on the BSAVA congress the lecturer on anaesthetics (Iff) said lidocaine was fine for cats.

Mariette

Re: Pain management - new ideas.

Braden Collins — Fri, 08 May 2015 02:16:48 GMT

We use a methadone CRI but you do have to watch it if using for longer than 24 hours. It can accumulate in the system and you end up with a very sleepy dog. We initially used 0.1mg/kg/hr but find 0.05mg/kg/hr is less sedating.

Re: Pain management - new ideas.

Louise6732 — Thu, 07 May 2015 20:44:16 GMT

I agree it'd be lovely to hear what Tim is doing currently :-)

Louise

Re: Pain management - new ideas.

bob lehner — Thu, 07 May 2015 13:54:03 GMT

[quote user="Andrew Mellor"]I was wondering if anyone knows of a good all round book/source for new techniques in pain management [/quote]

The 'Dechra Academy' on the Dechra website has some good webinars on analgesia - weighted towards Methadone - but quite a lot on multi-modal analgesia.

And all free!

Re: Pain management - new ideas.

Martin Atkinson — Thu, 07 May 2015 10:31:17 GMT

[quote user="Mark Hedberg"]i think i would have wet myself if i'd come across the hooked aorta in surgery.[/quote]I had one. Unfortunately post operative analgesia wasn't something that needed consideration, it bled out during surgery. I have surgically removed a saddle thrombus from the distal aorta but clamping the thoracic aorta while it was sutured wasn't an option!!

Re: Pain management - new ideas.

Andrew Mellor — Thu, 07 May 2015 10:15:11 GMT

Hi Louise

I was wondering if you could give me your cocktail for MLK . The article by Tim in In practice is great but uses morphine and I see you use methadone. Do you replace like for like or because of the NMDA effects of both ketamine and methadone do you have to alter things at all?

I wonder if Tim still uses morphine or has changed to methadone?

Re: Pain management - new ideas.

Anthony Dennison — Wed, 06 May 2015 08:57:10 GMT

[quote user="Louise Alexander"]

Postoperative management of gastrointestinal cases: 1. Physiology and initial stabilisation, Tim Charlesworth, In Practice 2011;33:8 374-378 doi:10.1136/inp.d5011

Postoperative management of gastrointestinal cases: 2. Ongoing requirements and monitoring, Tim Charlesworth, In Practice 2011;33:9 436-440 doi:10.1136/inp.d5377

[/quote]

Those are two very good articles. I'm sure Tim might pop up and add anything that's new since he wrote them too.

Re: Pain management - new ideas.

Andrew Mellor — Wed, 06 May 2015 08:56:58 GMT

Thank you all so much for those links some excellent stuff there.

Re: Pain management - new ideas.

Mark Hedberg — Tue, 05 May 2015 22:20:45 GMT

[quote user="Andrew Mellor"]

thank you Louise I hadn't noticed anything in In practice but do tend to skim read so I will go back and have a look. and I agree with everything you said.

I am first opinion small animal 2 man practice but we do complicated surgeries PRAA last week, fish hook removal torn through oesophagus and hooked on aorta- great fun, liver lobectomy etc these need some major pain relief that a quick jab of nsaid just isn't going to touch hence why I would like to be able to offer better control of pain,

From a cost point of view ketamine and lidocaine are pence and extremely safe as long as dosages etc are right hence the question.

[/quote] i think i would have wet myself if i'd come across the hooked aorta in surgery.

Re: Pain management - new ideas.

Laura Kidd — Tue, 05 May 2015 21:44:49 GMT

I can't remember when but I think there is also a very recent In Practice article ( last year or before) on using wound splash /irrigation catheters for local analgesia.

Laura

Re: Pain management - new ideas.

John Flynn — Tue, 05 May 2015 19:31:08 GMT

[quote user="Andrew Mellor"]I am thinking of things like constant rate infusion[/quote]

Might be of interest:

http://www.vasg.org/drug_delivery_calculators.htm

Re: Pain management - new ideas.

Louise6732 — Tue, 05 May 2015 19:24:30 GMT

Glad to be of help! Those surgeries certainly sound exciting (if you enjoy that kind of thing!). From your examples of the kinds of surgeries you’re doing, these articles spring to mind from In Practice:

Postoperative management of gastrointestinal cases: 1. Physiology and initial stabilisation, Tim Charlesworth, In Practice 2011;33:8 374-378 doi:10.1136/inp.d5011

Postoperative management of gastrointestinal cases: 2. Ongoing requirements and monitoring, Tim Charlesworth, In Practice 2011;33:9 436-440 doi:10.1136/inp.d5377

The 1st article has a ‘recipe’ and information on MLK infusions specifically, but also discusses analgesia using the various drug groups. The 2^nd article discusses prokinetics and the importance of feeding amongst other things. Just an example of the variety of information the journal has.

This article has information on local analgesia, including interpleural and intercostal techniques;

Local analgesic techniques in small animals. Kate Borer. In Practice 2006;28:4 200-207 doi:10.1136/inpract.28.4.200

For the most up to date information, it’s worth checking the BSAVA Congress MP3s if you are a member (and worth becoming a member for JSAP and Congress podcasts if anything!) as there are often more ‘state of the art’ lectures on current topics and recent research, analgesia pops up quite frequently.

Enjoy!

Louise

Re: Pain management - new ideas.

Andrew Mellor — Tue, 05 May 2015 19:04:43 GMT

thank you Louise I hadn't noticed anything in In practice but do tend to skim read so I will go back and have a look. and I agree with everything you said.

From a cost point of view ketamine and lidocaine are pence and extremely safe as long as dosages etc are right hence the question.

Re: Pain management - new ideas.

Louise6732 — Tue, 05 May 2015 17:11:48 GMT

[quote user="Martin Atkinson"]

[quote user="Andrew Mellor"]I am thinking of things like constant rate infusion ketamine / lidocaine , local anaesthetic blocks/ infusions through drains [/quote]A lot of these things are a wonderful idea when administered by a specialist anaesthetist at Ivory Towers Referrals and money is no issue but unless they are going to give a dramatic improvement in recovery/safety in routine surgery, which they are not, then they are outweighed by.increased complexity, risk of complication and cost.

[/quote]

I used MLK (methadone/lidocaine/ketamine) CRIs post-surgery in first opinion practice, especially for major abdominal surgery like GDVs, foreign body removals etc. I wouldn't call that a specialist technique and they didn't add that much onto the price of the procedure. Robust analgesia helps the animal reach recovery faster, helps with healing, gets the animal eating sooner and out of the hospital. I can't see why trying to improve on this is a bad thing Martin?

I find that In Practice has up to date information all in user-friendly chunks, you do have to be a BVA member to access though, it's worth paying the membership instead of investing in a textbook as you'll have access to articles on all areas of small animal medicine not just analgesia!

Louise

Re: Pain management - new ideas.

Martin Atkinson — Tue, 05 May 2015 15:55:32 GMT

Re: Pain management - new ideas.

Fenella — Tue, 05 May 2015 15:02:36 GMT

Is this any use at all? I got a few good ideas from it.

http://www.wsava.org/sites/default/files/jsap_0.pdf

Re: Pain management - new ideas.

Anthony Dennison — Tue, 05 May 2015 14:32:52 GMT

Andrew,

I went to a talk in Chester by NW Surgeons the other week, the anaesthetist there had some very good thoughts and ideas on pain management (including the use of maropitant...). If you get nothing from here she might be able to point you in the right direction, her name is Georgie Herbert.