Managing Pain for Surgery Patients

Pain management is an integral part of any anesthetic or surgical plan for Westgate Pet Clinic patients undergoing invasive procedures. Studies have demonstrated the benefits relating to patient comfort and fewer post-operative complications with good pain control.

Good pain control starts at the planning stages of the procedure. Each patient is thoroughly evaluated for what they might benefit from the best. Not only the nature of the procedure involved, but also the pet’s history of anesthesia, concurrent clinical diseases present and particular anatomical variations that come with the variety of breeds we encounter in both dogs and cats are considered. For example, a Pug (a “squish nosed” breed) with kidney disease undergoing a fracture repair will be managed much differently than a young healthy Labrador Retriever undergoing a lump removal.

At Westgate Pet Clinic we practice what’s called pre-emptive analgesia that is also multimodal in nature. Pre-emptive analgesia is having the pain medications present in the patient prior to the stimulus that causes the pain being applied. The dose of medication necessary to control pain is less if it is administered before the painful stimulus is present. Rather than waiting for the pain to be evident and putting out the fire after it has started, there is clear benefit to applying pain medications beforehand.

Multimodal pain management involves the simultaneous use of multiple classes of drugs that attacks the pain process at different points along the pathway. Used alone, the dose of a pain medication needed is often significantly higher than if used in collaboration with other pain medications. Hence a big advantage of multimodal pain management is the reduced dose of drugs necessary to control pain, thereby minimizing undesirable side effects. There are some drugs that aren’t considered “pain” medications, but when used with pain medications, can potentiate (strengthen) the affect of the pain med. An example is the use of ketamine in our CRI’s that strengthen the effect of the employed narcotic in our recipe.

Pain is measured using a score based on the Hansen Pain Scale. Each patient has three variables measured on a scale of 0-4 and the three individual scores added together. The worst score would be a 12/12 (excruciating pain); with no pain being a 0/12. Our doctors and technicians are trained on recognizing and interpreting the clinical signs present in each patient. By evaluating and scoring the pain level of our patients, we can more effectively keep them comfortable and minimize postoperative complications.

After the anesthetic plan is in place, the morning of surgery our patient receives an exam and physical assessment prior to administering of medications. Most patients will receive a “pre-med” to sedate them and start the pain management. The “premed” is often a cocktail of medications mixed together that each attacks the pain pathway at a different point. For example, a young healthy patient presented for a
neuter will receive a narcotic and alpha-2 agonist mixed together. This will provide sedation and relief of anxiety to allow placement of an intravenous catheter. In addition, both medications attack the anticipated pain at different points along the pathway in preparation for the surgery.

After induction, patients might receive a Constant Rate Infusion (CRI) of pain medications. This is a mixture of medications that is administered throughout the entire procedure and post-operatively through the intravenous catheter via a fluid pump. The great advantage to a CRI is the level of pain management can be manipulated with a simple change of fluid rate. In addition, CRI recipes can be a
single drug (such as Fentanyl) or can be a mixture of drugs (such as Hydromorphone, Ketamine and/or Lidocaine) that can be individualized to each patient and their needs.

Most patients will receive a medication in the class of “Non-Steroidal Antiinflammatories” (NSAID’s). Examples often used are carprofen or meloxicam. These drugs attack the pain at the point of stimulus and inflammation. They combat the cascade of events that creates the redness and swelling at the surgical site. Another great tool is the “epidural” – this is pain medication applied along the spinal cord
that can provide analgesia to an entire region of the body. This is the same “epidural” that women often receive at birth. Multiple medications (such as Bupivacaine and/or Hydromorphone) can be used together that significantly increases the duration of the pain control. This is often used for hind limb surgeries such as fracture or stifle repair.

The application of local or regional anesthetic may be used. A common technique Westgate Pet Clinic doctors employ is called the ring block. The local anesthetic is applied in a ring fashion around the distal paw or limb. This provides analgesia to that paw for procedures such a torn nail or digit amputation. Local anesthetics can be employed in other areas too for small to medium lumps that might be removed
under sedation.

Each patient is monitored closely after surgery and the pain score recorded. Adjustments to the pain management strategy are made throughout the day based how our patient is doing. If necessary, rescue injections may be administered to bring excessive pain under control. At discharge, most patients will go home with at least one pain medication. This is often a NSAID such as carprofen or meloxicam. In addition, most are discharged with a medication called Tramadol. This reduces pain similar to what a narcotic would do and in combination with a NSAID is highly effective. Others that might be employed include gabapentin or amantadine. Some might even employ the mixture of acetaminophen and codeine.

Depending on client preference and level of pain, alternative methods might be utilized as well, though I find these are more effective for chronic conditions rather than the acute surgical pain discussed here. Rescue remedies, acupuncture, massage therapy and even chiropractic might be employed in an effort to minimize discomfort and aid recovery.

I’m proud of our pain regimen at Westgate Pet Clinic. Our doctors and technicians practice a progressive model of therapeutic pain management. I encourage you to discuss your pet’s plan with one of our veterinarians, as each pet will receive a plan tailored to their needs.