Which pain relief in pancreatitis?

Re: Which pain relief in pancreatitis?

toby travis — Wed, 21 Apr 2010 17:59:28 GMT

Have used ketamine infusions in cats twice. They seemed to work very well indeed.

Re: Which pain relief in pancreatitis?

james hunt — Tue, 13 Apr 2010 18:51:06 GMT

Thanks for your ideas Ian,

yes i think you're right managing to identify pleural space can be an issue...rightly or wrongly I tend to use a 'hanging drop' method more usually reserved for identifying epidural space to try and identify negative intrathoracic pressure.

I suppose injecting into very vascular tissue such as lung could predispose to achieving toxic plasma concentrations if bupivacaine was rapidly absorbed into circulation.

Re: Which pain relief in pancreatitis?

Ian Battersby — Mon, 12 Apr 2010 14:44:17 GMT

Hi James,

I do administer lidocaine prior to bupivicaine as I did in that patient. I think that both drugs failed to help the patient which reflect that peritoneal administration of local anaesthetics is not very effective. Which I think is reflected in the literature - you have to forgive me I am not over familiar with all the latest literature on analgesics.

Interested to read your comments about the intrapleural administration. I am a medic so I may not be as technically gifted as others , so in my hands I would be concerned that I may inject the local into the wrong space e.g. the lung parenchyma without a catheter or drain which I know is in the right space. Given the pleural cavity is small space that is moving target ( in conscious patient). I have to admit I am not sure how the systemic absorption of bupivacaine would differ in those two areas i.e. lung parenchyma versus pleural cavity.

Some of the pancreatitis cases I have seen do have pleural effusions so I guess would make this easier to do but then this introduces other factors such as drug efficacy.

From discussing this topic with our anaesethestists, the gold standard for analgesia in humans is to place a thoracic epidural catheter. The placement of subcostal catheters, to introduce local anaesthetic in a similar manner to that which you describe has been documented in people but as yet not in dogs or cats. The tricky bit with the dog is that visceral innervation is complex and may involve dermatomes up to T5, so this is a pretty big area to cover effectively and some techniques applicable to humans (bipeds) may be less applicable in quadupeds because if the effects of gravity - as yet we have no good clinical evidence - but there are several ongoing studies in the US. I would also be fairly careful with the dose of bupivacaine in cats and small dogs because of the low therapeutic incidence of bupivacaine - an absolute maximum dose of 2mg/kg for interpleural and epidural use would be sensible

Re what I wrote about cats discomfort and the comment that cats may be more painful than we may be able to appreciate it . I can't disagree with that comment at all. I guess next time I shouldn't rush my posts and expand what I am trying to say more . I guess that comment reflects that cats only very rarely present with nasty necrotizing pancreatitis, were as dogs do both necrotizing and the lower grade. The necrotizing patients are more painful.

Re incidence of pancreatitis - I suspect we under diagnosed pancreatitis ( in particular the low grade grumbly disease) in dogs and cats. It is a challenging condition to confidently diagnose in some patients ( I wont start regurging about diagnostics now). Penny watson produced some interesting data in JSAP a few years ago. She PM'd dogs that were PTS for unrelated reasons and s found evidence of pancreatitis in some, in which there was no evidence for in the clinical history

All the best - an interesting discussion

Ian

Re: Which pain relief in pancreatitis?

Michael Woodhouse — Mon, 12 Apr 2010 00:12:52 GMT

[quote user="Ian Battersby"] In cats pancreatitis tends to be a less painful disease so buprenorphine normally is sufficient. [/quote]

Or the signs of pain are just less obvious in cats?

Re: Which pain relief in pancreatitis?

Rob Loxley — Sun, 11 Apr 2010 21:17:42 GMT

[quote user="Hannah Wynne Richards"]My impression is that pancreatitis is much more common in dogs. Do the rest of you agree, or am I just not so good at diagnosing it in cats ?[/quote]

The dogs come in shouting pancreatitis whereas the cats need it looking for (i.e. less classical vomiting/cra abd pain, more frequently non-specific dullness/anorexia/wt loss) IME. In cats always consider concurrent hepatitis & IBD.

Re: Which pain relief in pancreatitis?

james hunt — Fri, 09 Apr 2010 22:44:02 GMT

[quote user="Ian Battersby"]

5- Intraperitoneal bupivicaine - only tried once in a severe necrotising pancreatitis. Patient found it very painful to administer and i didn't feel it helped. So wouldn't do it again

[/quote]

Hi Ian,

I will administer interpleural lignocaine/bupivacaine by needle in animals which don't have a chest drain as i've really seen some animals do well with this intervention (in contrast i've also seen a few it doesn't appear to have helped much) - if you use bupivacaine alone it does sting like hell for a long time so recommended to use lignocaine first to desensitise fairly quickly. I imagine similar considerations would apply to intraperitoneal?

best wishes

james

Re: Which pain relief in pancreatitis?

Hannah Wynne Richards — Fri, 09 Apr 2010 17:10:17 GMT

I've learnt from this thread (or possibly it's something I had forgotten ) that cats have a joint duct-I'll definitely only use buprenorphine in these in future.

My impression is that pancreatitis is much more common in dogs. Do the rest of you agree, or am I just not so good at diagnosing it in cats ?

Wynne

Re: Which pain relief in pancreatitis?

Ian Battersby — Fri, 09 Apr 2010 15:56:32 GMT

A variety of different option exist depending on severity of the pain.

1-Opiods; As stated above. In man opiods are a concern as the bile duct and pancreatic duct join together at the sphincter of Odi. Morphine and other opiods such as methadone and fentanyl can cause the sphincter to constrict. Were as buprenorphine seems to have a minimal effect. In dogs the pancreatic ducts are normally separate so this concern is not valid. In cats 80% have a shared exit so buprenorphine is preferable. So in dogs with severe pancreatitis I commonly uses methadone (parentally or in a constant rate infusion ) if required. Methadone is less likely to make them nauseous vs morphine.

2- NSAID ; A study in 1997 showed NSAID not to be very effective in controlling pancreatic pain and this drug group will also increase the you the risk of GI ulceration. So i would say avoid

3- Lignocaine; in a constant rate intravenous infusion. .You need to monitor closely for toxicity and is contraindicated if any concerns regarding hepatic fuinction.

4- Ketamine 1-2mg/kg s/c q4-8 hours has been described to be fairly effective. But i have no experience of this

5- Intraperitoneal bupivicaine - only tried once in a severe necrotising pancreatitis. Patient found it very painful to administer and i didn't feel it helped. So wouldn't do it again

6- lidocaine or bupivacaine administered into the thoracic cavity. The ganglia that supplies the pancreas is within the pleural cavity. Is described. But unless you have a chest drain in already , this is a clever technique but not usually practical. Certainly wouldn't justify placing a chest tube solely for this purpose. I had a dog that developed post op pancreatitis after a thoracotomy were i was able to do this.

If you are a human epidural cathers can be placed. Not very practical in our patients although described by some critical care specialists in the states.

So in summary, some of these guys particularly dogs can be pretty painful. So i usually start with methadone, move to CRI and i think some i have added in a lidocaine infusion if still painful. In cats pancreatitis tends to be a less painful disease so buprenorphine normally is sufficient.

These cases can develop ileus secondary to the local peritonitis, so given the opiods can potentiate this i invariably add in some kind of prokinectic in severe cases

All the best

Ian

Re: Which pain relief in pancreatitis?

james hunt — Thu, 08 Apr 2010 16:00:26 GMT

Interpleural lignocaine/bupivacaine can be extremely beneficial.

Re: Which pain relief in pancreatitis?

Rob Reid — Thu, 01 Apr 2010 09:31:53 GMT

[quote user="Charlotte Marshall"]

The quote says 'the bile duct and pancreatic duct enter the duodenum separately in the vast majority of dogs'. maybe your lurchers were in the minority where the ducts were co joined?

[/quote]

So if we take that to be the case (which was what I assumed in these 2 cases I had) that therefore emphasises the point that morphine, buprenorphine etc should be used with great care in these cases...

Re: Which pain relief in pancreatitis?

Charlotte Marshall — Wed, 31 Mar 2010 23:43:54 GMT

The quote says 'the bile duct and pancreatic duct enter the duodenum separately in the vast majority of dogs'. maybe your lurchers were in the minority where the ducts were co joined?

Re: Which pain relief in pancreatitis?

Rob Reid — Tue, 30 Mar 2010 21:53:47 GMT

[quote user="Hanna Bennett"]i could be being stupid, but if you struggle with pethidine due to it being short acting, how is butorphanol an improvement? I would rate it's analgesic properties as poor, and thought it's effects only lasted 60-90 mins?[/quote]

If you go on the theory it seems to suggest that duration of action is variable (from 30 minutes up to a few hours) but my experience has been that if you use a high enough dose (I tend to go at 0.4mg/kg) you get a reliable 4-6 hours of analgesia if combined with an NSAID. I also find analgesia levels are suficient if combined with an NSAID, despite what is said, though I will favour pethidene if very painful.

I am still very sceptical about buprenorphine in pancreatitis - despite what is written above. I have seen it make animals worse, so there must be some reason - differing anatomy in these specific cases maybe? Anyone care to hazard a theory, or know of any further literature that might explain...

Re: Which pain relief in pancreatitis?

Hanna Bennett — Tue, 30 Mar 2010 17:44:14 GMT

[quote user="Rob Reid"]

I have seen a couple of acute cases in dogs where buprenorphine has made the patient worse (both lurchers - has this got anything to do with it?) so I try to avoid it if possible. I find pethidene very good in very painful acute cases though obviously the major drawback with that is the short duration of action. I find most cases respond well to a combination of high dose butorphanol and an NSAID, so only need to get the pethidene for the odd case and usually then you only need a couple of doses and things are under control enough to use torb.

I have used tramadol in chronic cases with good success and no problems so far. I am a big fan of tramadol - really good for multi-modal analgesia and has made a big difference to my chronic pain managment regimes.

[/quote]

i could be being stupid, but if you struggle with pethidine due to it being short acting, how is butorphanol an improvement? I would rate it's analgesic properties as poor, and thought it's effects only lasted 60-90 mins?

I use whichever opioid is appropriate to the level of pain so buprenorphine up to morphine/ methadone dependant on how vomity they look. Chronic cases certainly seem to respond to tramadol rather than nsaids, and will admit to using preds to control the inflammation in some dogs despite the supposed contraindication - started after my addison's dog developed pancreatitis but seemed not to get worse despite his oral preds. Certainly think preds can be indicated in cats - it was all that brought my nurse's cat with necrotizing pancreatitis back from the brink.

Other thing i use is pancreatic supplementation, either for flare ups or chronically dependant on response to withdrawal.

Re: Which pain relief in pancreatitis?

Glen McIntosh — Tue, 30 Mar 2010 17:14:24 GMT

Here is some recent advice given in a CPD lecture by Derek Flaherty, specialist anesthesiologist:

"Much emphasis has been placed in the past on the most suitable opioid for use in patients with pancreatitis, with the general advice being that morphine is contraindicated. This was based entirely on the fact that, in humans, the bile duct and pancreatic duct are co-joined at the entrance to the duodenum, and, therefore stimulation of the Sphincter of Oddi by morphine could increase pressure within the pancreatic duct, leading to further damage to that organ. However, it is now recognised that the bile duct and pancreatic duct enter the duodenum separately in the vast majority of dogs, so an increase in Sphincter of Oddi tone should have no effect on the pancreas, and consequently, administration of morphine should be perfectly safe. However, around 80% of cats have co-joined ducts, and morphine should therefore be avoided if pancreatitis is suspected in this species."

I will use morphine in some dogs with acute pancreatitis, sometimes as a cri. These guys are really hurting.

Re: Which pain relief in pancreatitis?

Hannah Wynne Richards — Tue, 30 Mar 2010 12:36:37 GMT

Vetergesic-morphine if necessary-I've never knowingly had a prob with sphincter of Odi-I think it's more of a human prob, due to different anatomy. Chronic cases-codeine

Wynne

Re: Which pain relief in pancreatitis?

Helen Bowes — Tue, 30 Mar 2010 11:59:04 GMT

My own little Westie (saddly now decreased due to aggression caused by chronic pancreatitic pain) suffered with an acute bout of pancreatitis that then lead to chronic pancreatitis.

For analgesia he was on tramadol and then was also on azothiaprine so he could eat chappie as a low fat diet. He has eosinophillic gastroenteritis and true food allergy affecting his guts and skin hence why we immunosuppressed him.

Further to this we gave him pancrex powder with his food and omeprazole.

He was OK when on this combination and tramadol kept his pain under control. Unfortunately towards the end of his life he became more and more aggressive and I can only put this down to his pain becoming more. I still support use of tramadol in these cases and have put subsquent cases onto tramadol to maintain a good level of analgesia

Re: Which pain relief in pancreatitis?

Rob Reid — Mon, 29 Mar 2010 22:39:14 GMT

Re: Which pain relief in pancreatitis?

Laurence Webb — Mon, 29 Mar 2010 21:54:05 GMT

I get on well with buprenorphine (continued orally for cats). In dogs I use morphine if buprenorphine isn't effective enough then use tramadol for home treatment. I don't worry unduly about causing spasm of the Sphincter of Oddi and have always seen an improvement in following using opioids

Generally I try to avoid NSAIDs if possible, as increased gastric acid secretion and reduced bicarbonate production in the duodenum could cause increased stimulation of the pancreas although I don't know how important this is clinically and how much this is offset by anti-inflammatory benefits. I'd normally be using H2 antagonists or proton pump inhibitors at the same time anyway (dutifully following the cascade and using nothing but Zitac, of course

Re: Which pain relief in pancreatitis?

Martin Jones — Mon, 29 Mar 2010 20:59:15 GMT

It's true that opioids can - technically - cause spasm of the sphincter of oddi; but in practice, it doesn't seem to be such an issue. I remember a couple of years back reading a review paper on pain relief in (human) chronic pancreatitis, and it was concluded that out-patients on tramadol were much better off than those on NSAIDs.

Interestingly, a family friend has a primary dysfunction of the SoO, and really, really cannot have opioids at all - they cause horrible acute pancreatic flare-ups and actually increase the pain. Not to worry, though - the local PCT have a pain management specialist, and she's going to be seeing him in FORTY WEEKS. In the meantime, she can hardly eat anything without pain, so is booked to see the nutritionist in SIX MONTHS. Can you imagine what the Daily Mail would do to us if we tried that kind of approach?

I use vetergesic acutely, followed by NSAIDs. If the NSAIDs don't seem to be doing the job, then tramadol. Chronic pancreatic pain is one of the hardest things to pick up, a bit like chronic eye pain: often, it's only afterwards that the client realises how much pain the patient was in.

Martin