Old girl

Re: Old girl

Stephen Courtney — Sun, 24 Jul 2011 11:32:42 GMT

Use what fits/ works. Having a dogmatic approach doesn't work, and yes using opiods for end stage DJD is often a desperate act, when the only alternative is a euthanasia.Incidentally these animals are usually getting opiods as well as nsaids. Use what works.

I have several knackered old dogs doing suddenly much better because of tramadol. I have one doing suddenly much better because he's getting some PLT ( Steroids !) and I have a couple getting rimadyl and low dose preds. I've also put a few to sleep lately.

I would agree that poor response to 'reasonable ' pain medication is suggestive of an underlying nasty situation.. But many owners are reluctant to embark on a' cancer hunt' just for an excuse to put an animal to sleep. if you can buy some time with drugs so much the better - assuming that's what people want. you'll always get someone wanting a pts because their elderly dog needs permanent medication and they 'don't want him to suffer'

You can't always get to diagnose - or cure- the source of the pain. The issue is effective treatment of symptoms, if possible. If you cannot control pain, then euthanasia looms large.

Re: Old girl

Julian Earl — Sun, 24 Jul 2011 09:39:41 GMT

[quote user="Stephen Courtney"]

I don't why nsaids should be the main thrust of analgesia. at all. Opiods are far superior as analgesics. Obviously they have no anti inflammatory component, but i would not leave an animal in pain for weeks on end .

...Nsaids are great, if tolerated, but are only a part of the whole thing. i'd take a pretty dim view if all I got after my cruciate surgery was a couple of aspirins. Pain should be assessed carefully, and animals should be given the benefit of the doubt - try empathise with what is wrong with them, and make decisions on analgesia based on a proper assessment.

[/quote]

Opioids for chronic joint pain are not always very effective. In fact, IME, rarely effective. Both degenerative and inflammatory arthritis respond better to NSAIDs (or steroids for the latter) and opioids are a desperate measure on my part. I would have thought that adding paracetamol to the NSAIDs is more likely to be beneficial, as it can be extremely potent even following major invasive procedures such as thoracic surgery - it's not just for headaches!

Also, as Andrew Kent says, a poor response to NSAIDs or other pain killers can be very suggestive of a tumour so that could be the problem, i.e. the problem is the source of the pain not the choice of analgesic IYSWIM.

Re: Old girl

Stephen Courtney — Sat, 23 Jul 2011 16:41:36 GMT

There is a massive difference between acute and chronic pain management. Chronic pain and hypersensitisation issues are one thing, good multimodal post op pain relief quite another.

If you are perceptive enough to realise the need for good pain relief you should also be perceptive enough to realise if there is a problem with the meds. not everyone will tolerate opiods, not everyone will tolerate nsaids. I'm quite fond of lidocaine CRI's weaned off over 12-24 hours. the difference in patient demeanor is staggering.

Re: Old girl

Bob Russell — Sat, 23 Jul 2011 11:10:38 GMT

The vetsurgeon chronic pain link is brilliant. I have been reassessing pain relief protocols over the last year or so and this has some really useful information!

Re: Old girl

Andrew Kent — Fri, 22 Jul 2011 17:13:27 GMT

How was the arthritis diagnosed? Where is the possible tumour?

I have had dogs with bone tumours that can be so painful that eventually you cannot control that pain. What analgesics has she had - she needs multi-modal NSAID plus opioid plus something else if needed (gabapentin, fossamax, ketamine)

Andy

Re: Old girl

CatherineThomas — Fri, 22 Jul 2011 16:47:11 GMT

I've had cruciate surgery too and I was in a lot of pain when I woke up, despite having had morphine. I was also quite painful for several days after the surgery despite being on ibuprofen, codeine and tramadol.

Re: Old girl

Arlo Guthrie — Fri, 22 Jul 2011 10:00:04 GMT

[quote user="Anthony Todd"] Ahha Arlo, found you at last.[/quote]

Was it difficult?! If in doubt, you can always click my name next to any of the stories in the news section. Then send me a private message.

[quote user="Anthony Todd"]Can you make it so I can remain logged in on my computer.[/quote]

Actually, this kind of thing is usually best done by private message, and I have replied to you via PM

Re: Old girl

Martin Atkinson — Fri, 22 Jul 2011 09:25:43 GMT

[quote user="Stephen Courtney"]

In human medicine the measurement of pain, and the treatment approach , is based on patient perception of that pain. we have to rely on clinical signs and owner perceptions. Nsaids are great, if tolerated, but are only a part of the whole thing. i'd take a pretty dim view if all I got after my cruciate surgery was a couple of aspirins.

[/quote]

Absolutely true Stephen but you shouldn't preconceive what others require based on you own experiences. My own take based on my cruciate surgery was that after previous experience of being given opioids following orthopaedic surgery I felt so ill from the drugs that I prefer to put up with the pain and expressly told the anaesthetist not to given me any. I would have had nothing except the orthopod suggested that while I might like to think I'm a hard man and could tolerate pain, the anti-inflammatory effect of NSAIDs would speed my recovery so I took them for that purpose. Maybe I'm a masochist (you have to be to be a racing cyclist) or have a naturally high pain threshold but I can make that choice, we cannot ask our patients what their choice would be and owner perception is clouded by the same logic. We can evaluate need on patient reaction but how do we really know they wouldn't rather put up with some pain than risk the side effects of say shoving in corticoids and NSAIDs together if they knew what they were. Maybe we play God too often. Interesting philosophical argument or me talking out of my anal sphincter (again)?

Re: Old girl

Anthony Todd — Fri, 22 Jul 2011 09:24:47 GMT

Ahha Arlo, found you at last.

Can you make it so I can remain logged in on my computer.

I have enough trouble remembering my log in name let alone a password...

I promise never to be rude again if you do this for me....

Re: Old girl

Alan Tevendale — Fri, 22 Jul 2011 08:14:12 GMT

I remember years ago an old lecturer telling me that you never give antibiotics without good reason and always give analgesics unless you find a reason not to. In other words if you think an animal might be painful give it some pain relief and if you think it's still painful give it some more.

Re: Old girl

Arlo Guthrie — Fri, 22 Jul 2011 08:10:35 GMT

Not sure if this is relevant, but think it might be. We have a new blog on www.vetsurgeon.org on the subject of chronic pain in the dog, with some pretty illustrious contributors!

If you want to be alerted when there is a new post on the blog, click the email notification link on the right. It's prefilled with your VetSurgeon registered email address, but if you want it sent elsewhere, you can overwrite it.

http://www.vetsurgeon.org/blogs/chronic-pain/default.aspx

Re: Old girl

Stephen Courtney — Thu, 21 Jul 2011 23:12:48 GMT

In human medicine the measurement of pain, and the treatment approach , is based on patient perception of that pain. we have to rely on clinical signs and owner perceptions. but the principle is the same. the more the pain receptors are stimulated, the less stimulus is required to produce the pain. As time goes by less and less stimulus will cause more and more pain, and in fact non painful stimuli begin to be perceived as painful. Preventing this sensitisation is important, and this is where long courses of analgesia come in, I agree totally. BUT - you don't have to wait 4 weeks to see if a dog or cat needs something more than a bit of your favourite nsaid!

Nsaids are great, if tolerated, but are only a part of the whole thing. i'd take a pretty dim view if all I got after my cruciate surgery was a couple of aspirins. Pain should be assessed carefully, and animals should be given the benefit of the doubt - try empathise with what is wrong with them, and make decisions on analgesia based on a proper assessment.

Re: Old girl

Vet2Vet — Thu, 21 Jul 2011 21:36:43 GMT

I was at CPD recently about this topic and it appears that you should not give up on your first choice too soon , i.e. 3 -4 weeks at the CORRECT dose , NO titrating unless Side Effects , then move to another NSAID for similar length of time , and then a 3rd choice , tramadol may be given as an adjunct but NSAIDs main thrust of analgaesic treatment

Re: Old girl

Stephen Courtney — Thu, 21 Jul 2011 21:27:00 GMT

^^ What he said!

If no funds for investigations then analgesia can be improved with gabapentin and also tramadol. Steroids plus nsaids can help, but is specifically advised against in all data sheets. It is a last resort, informed consent type of action. Having said that i have done it, but not since tramadol appeared in my professional life!

Re: Old girl

Martin Atkinson — Thu, 21 Jul 2011 16:18:43 GMT

Allodynia? - dose of pain relief too low before so dog is now hypersensitised. Don't like the idea of steroids and NSAIDS together. Also sounds it needs a good work up before ploughing on with more analgesia.