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Dr. Coates is a veterinarian based in the other “Sunshine State” – that's Colorado to the rest of you – where she lives and plays with a varied range of animals. She shares her professional and personal experiences, Monday through Friday, here on petMD's blog, the Fully Vetted. Log in for your daily dose of her insight and wisdom.

 

How to get better, safer pain relief for your pets' anesthetic procedures

January 22, 2009 / (33) comments


Your dog is all set to undergo a simple spay or—God forbid!—your kitty is scheduled for a major mass removal. You want the best kind of anesthetics and pain relievers. You may even be leery (if not downright afraid) of the anesthesia she’ll require for the procedure. But are you aware of the many choices for pain relief that can make anesthesia safer and dramatically reduce your pets’ discomfort at the same time?

Though it’s true that many savvy consumers of veterinary services (you, presumably) can be picky about the kinds of pain relief your pets get, none of you is likely to decline pain medication on principle, right? You all understand that pain relief is as indispensable to your pet’s welfare as the anesthesia itself.

On Dolitter, we’ve discussed the many ways in which anesthesia can be scary, dangerous and its risks reduced, but in the past I may have neglected to focus on how addressing anxiety and pain before, during and after the procedure can drastically improve our pets' comfort level.

Yesterday’s post on the so called, “pet centered” practice may have touched on this issue obliquely. Today we’ll examine it in more detail so that you can make better decisions about how your pet can be treated more safely and humanely than you may have thought possible…with simple techniques every vet understands and can accomplish—but which relatively few employ routinely.

Eye removal, dental extractions, onychectomy (claw removal), amputations, joint surgery, abdominal surgeries, emergency procedures. Indeed, there is NO surgical approach that cannot be enhanced with safe and powerful pain relief protocols you may not know are available.

Sure, we all know that any drug strong enough to help your pet can also hurt her. But when we tailor an anesthetic experience to your pet’s individual needs, veterinarians have found that the use of multiple drugs can reduce the overall, potentially life-threatening impact of any one of them.

In fact, this concept, referred to as “multi-modal” pain relief, typically reduces the total drug requirements for pets undergoing anesthesia and/or any potentially painful procedure.

Here’s a sampling of what this concept offers—with examples, of course:

That tail’s gotta go

A backyard stray turns up with a dangling, “dead” tail. Your vet finds a piece of fishing line wrapped midway down the appendage. He offers amputation as the only alternative to a tail that will forever be a liability.

Before anesthesia, he injects kitty with a titch of an opiate pain reliever for overall comfort and mild sedation. He uses less of the injectable anesthesia-induction drug, as a result. The gas flow he can now set at a lower level.

He then injects the tail at its base with a ring of deep injections of nerve-blocking drugs that will pre-empt the pain of removal. When the tail is sliced and diced, kitty’s heart rate does not even flicker on the monitor. He feels nothing. The nerve block’s action will linger for an hour or more. A half-dose of a kitty-approved NSAID (to last a day or two) seals the deal.

The tooth fracture

A rough game of tug-o-war with the Wuba yields one fractured canine tooth. Whether you elected the gold standard root canal approach at the veterinary dentist’s or your own vet’s careful extraction with gingival flap surgery, it’s gonna hurt some.

What better, then, than to perform a simple nerve block with an extra long-acting effect. The simple addition of ubiquitous epinephrine to the commomplace bupivicaine (local anesthetic) means this area will experience the first critical hours post-op with absolute freedom from pain. Any dental extraction can be thus treated.

Fear is NOT our friend

Is your rescue dog the most sensitive sentient on the planet? Sedatives and tranquilizers are great if they need to be at the vet’s for any length of time before the procedure. (Getting them there just before showtime may be even better.) Consider that tranquilizers reduce the amount of drugs required to induce anesthesia.

The simple spay

Ask about a "linea block" at the incision site. I use this local anesthetic approach for all my C-sections to decrease her anesthetic requirements and respiratory depression in the pups. Large dog spays and long incisions are similarly treated. (In smaller pets, the slightly higher risk of infection may not make it worthwhile.) How much better to wake up with a painless belly and later require lower doses of opiates and non-steroidals?

Visible nerves

Removing anything with a visible nerve attached (eye, limb, toe)?  Inject the nerve itself before cutting it cleanly. Human docs suggest the possibility of phantom pain is reduced as well as the post-operative pain.

***

Aside from their pain-relieving effects and the increased safety they provide, the best part of these multi-modal techniques? They can be had at any practice, not just at the specialists’ where they’re more routinely employed. Just ask…and you shall receive.

 

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COMMENTS (33)
1
by on 02/01/2009 02:39pm

Hi, I wasn't sure where to post this.. I hope this is a good spot.. I just woould like an opinion..

Jan 2 we adopted a Blk & Tak Shepard lab Mix pup 9weeks old.. It was a shelter rescue. She was in foster home for almost 3 week and was healthy when we picked her up. A typical happy healthy pup for 2 days than she spent her 2nd night at home throwing up & diarreah..
So to make a very long story short, she had parvo.. She was doing better at home (my old vet recommented home treatment with fluids)for the first 24hrs. She was actually doing better than got very, very sick.
We rushed her to animal hospital and she stayed there for 5 days.. Was making progress. After transfusions, pain killers, antibiotic, anti nausea meds, etc, she was starting to walk around and eat..
Then she developd a serious complication called interception of the intestins and surgery was the only option and she was in pain, still not over her parvo and they gave her a less than 10% chance of surviving the surgery..
We made a heart wrenching decision to put her down. We just did not want her to suffer the pain of the disease and then the surgery and then trying to recover with an incision and parvo symptoms...Her chances were slim to none.. The worst 2 weeks of our lives!
OK, so I tried to make it short but i wanted to tell all the details.. So now we get the bill.. We knew ahead of time if she stayed the 5 days what the max would be... Brand new state of the art animal hospital..4000.00 bill. So we called the shelted and explained all th details and they reimbursed us back the adoption fee plus and addiotion 1200. for a total 1500.00 plus a new pup when we are ready in months down the road.
They were very sorry for all out troube and we were very happy they offered to give us some money back...
We are still stuck with a very large balance. Several people told us they should pay for the whole thing.. Alao, WE chose to take the pup to a state of the art hospital to save her... We are torn.
Should we accept this check & I.O.U for another pup and be done with them????
Or do you or anyone reading this feel they should have done more...
Financially we could not afford the bill so we put it on credit.. We could not rescue a pup to turn around and put her down unless we tried everything possible. It was just not good enough.
Thank you for reading. I appreciate any comments or suggestions regarding the shelter...
Judith

2
by on 01/29/2009 04:28pm

My veterinarian suggestwed a pain patch for my cat after a declaw, is this safe? If so, what should I watch out for?

3
by on 01/25/2009 05:00pm

If my dog ever has to undergo surgery, I will only choose to go with Sevo and with a clinic that has used it for a longer period of time. I used to pair up with a rep that sold he and listened to him speak to vets, way back when it was newer. I am glad I was educated to know that there was something different out there. My Golden is 10 1/2 and the though of having to go under for anything scares me.

A clinic can't just special order it in not only because of the vaporizers and special equiptment, but the staff has to be properly trained on it as well. It isn't just as easy as that. I think the reason is you can go deeper just as easy as going lighter and if you go too deep, it could have life ending results. I heard a few really sad stories of vets just learning to use it and having something devastating happen. That must be scary!!

It actually isn't more expensive (may be different now than 5 years ago when I was hearing about it) and my be less to my understanging it is off patent now? The initial canister is much more expensive up front for the vet to purchase, but the clinic uses less of the gas so ultimately it is cheaper to the vet in the long run.

Thank you for the education on pain meds, I have always wondered if they gave the same thing all of the time or different things for different procedures!

4
by on 01/24/2009 08:14am

Barbara: Lots of vets had stopped using some of the common drugs (Metacam, butorphanol) because of safety reasons and duration of action, respectively. Some of us are now realizing that smaller doses of Metacam are just as appropriate and useful while a new paper just suggested that the action of butorphanol is more prolonged than we previously thought.


In any case, I believe cats should receive more locals and sedatives than dogs because the post-op drugs are so few and far between. Preempting the pain is critical to comfort since the pain mechanisms don't get all worked up to begin with if you stay ahead of them, therefore seriously diminishing post--op pain.

5
by on 01/23/2009 04:03pm

Great post. I hope you do a follow up on post surgical pain relief especially for cats. After my cats last spay I asked for pain meds when I picked her up and was told they don't give out pain meds.It never occured to me that they wouldn't or I would have gone elsewhere. I didn't even know what I oculd suggest for a medication so that maybe they would have given me something. The receptionist said that all of their post op behavior , growling or hissing, was just them coming out of the anesthesia and that they don't give out pain meds after neutering for males or females. It still makes me mad but now I know to ask before surgery and don't assume that the animal is getting any type of pain relief. It would be nice to know what is available to discuss with our vets since it seems in many cases they won't talk about it.

6
by on 01/23/2009 08:47am

PJBoosinger: I'm working on that. I had a search function on my old blog and I'm waiting for my techie to catch up with that kind of basic functionality. Alternatively, you can Google Dolittler and obesity, weight loss or Slentrol.

7
by on 01/23/2009 04:08am

Totally OT: Is there a way to search the Dolittler blog archives?  I'm looking for "dog obesity" information.  Having decent luck with my Shiba now that she's on very low dose pred but struggling with my Lab.  Found a hint at the issue at http://www.dolittler.com/2008/11/30/On-hand-fed-pets-and-the-human-role-in-pet-obesity.html "chocolate Labs with abnormal food consumption drives".  LOL, should have known.  My previous Lab was black and was tough on this issue.  This one is chocolate and it's a war.

8
by on 01/22/2009 11:41pm

Julie in OH: What screening was recommended for your Whippets? And what was done differently, taking in account for the breed's pre-disposing problem with anesthesia?


As far as pre-op bloodwork, do you think that your friend's Whippet would have had abnormal pre-screen panel?


Barb A./NH

10
by on 01/22/2009 10:58pm

Asproolee:

Fotini

11
by on 01/22/2009 10:52pm

charity:  Salukis are around, believe me.  Find your closest ASFA club, and you're on your way.


on topic:  Thanks for the timely post.  A friend's whippet just died under anesthesia for a routine dental & neuter, merely one day after 2 of our whippets had routine dental prophys.  My vet gave me the option of pain management (oh yes) and the degree of pre-screening (heck, both of them needed full panels for a good baseline anyway)... and I like to think that's what kept our 2 safe.  I have heard of other whippets dying on the table for routine dentals, and it does make me nervous.  Although not so nervous that I don't have them done when need be.  =7

12
by on 01/22/2009 10:25pm

<A HREF= "http://alabamavetwatchboard.110MB.com"></A>

13
by on 01/22/2009 10:17pm

Dr. K:


Are board-certified surgeons required to discuss anesthesia and pain management protocols with their clients prior to a major surgery such as exploratory celiotomy?  I never asked any questions about anesthesia and pain management protocols (I had no idea I could), and he never discussed any of this information with me.  He only said that there are some risks with these kind of surgeries, but he said that my companion was fairly healthy other his elevated liver enzymes as he indicated.  My companion was on Benazepril for 4 years prior to the surgery.  I believed he was referring to my companion's heart when he mentioned risks, and I asked him if his heart would be a problem.  He said that there would be no problem!  And now the rest of the story. . .he died 3 days after release from the surgeon!  Of course cause of death was Atypical Addison's disease and complications which he never mentioned prior to the surgery.


<A HREF= "http://alabamavetboardwatch.110mb.com/Asp-index.htm">Asproolee’s Story </a>

14
by on 01/22/2009 09:52pm

Always a good topic! One that still is NOT mainstream!


I very often forget to address the issue of pain---because years ago, it was NEVER considered and completely unheard of, no may=tter waht the condition.


Still "proper" or adequate pain relief is not often addressed. It didn't even 'dawn' on me for months, of how my Pocket must have suffered without prescribed pain relief with pancreatitis/peritonitis for an entire week! NOTHING, ZERO---how humane is that?


Now post-surgery & even pre- IVDD surgery, my dog felt so great on pred, that it was "murder" trying to keep her quiet & confined. Benedryl worked, I should have asked for Lunesta.


C-section: 0.5 ccIM oxymorphone, add 1.0cc prior to surgery, local lidocaine across midline, reversed 0.6 cc Naloxone----I would highly recommend it, I was THERE!
weight? maybe 20-22 lbs? No gas, no groggy pups, no groggy dam.


Barbara A. Albright/NH advocate for ethical pet med

15
by on 01/22/2009 08:35pm

Dr K-


Can you describe the "linea block" or point me to some references? I do prenatal adbominal surgeries on mice, and I'm always looking for new painkilling procedures.

16
by on 01/22/2009 07:20pm

Excellent!


We had a nurse call the clinic to schedule a neuter on her tiny 3 lb chihuahua.  She was hysterical at the thought of her tiny baby undergoing anesthesia.  She wanted us to neuter the dog under local anesthesia.  All the docs refused.  She later cancelled the surgery because she found a vet who would perform the neuter under local.  Oh my!


 


 

17
by on 01/22/2009 07:08pm

Dr. K and Barb:

thanks for the info on sevo. I will keep bugging my vets to offer it. I have read studies saying that it isn't "safer" but intuitively, it seems like it would be because of the faster recovery. I am pretty sure cost is the reason they don't offer it (they are already pretty expensive and most owners probably wouldn't be willing to pay more -- actually, most owners probably don't even inquire about anesthetic protocol. This is why the veterinary office of my "dreams" has a chinese-menu type list of options with explanations for owners . . . they would learn the difference, it would really educate clients . . . )

18
by on 01/22/2009 05:44pm

Excellent post. I'm glad you included accupuncture in your comments (I personally started accupuncture because of the amazing success stories regarding pets and accupunture).

19
by on 01/22/2009 05:33pm

Thank you for this information, my 12-yr old dog is having a mole removed from his eyelid next week and I've been wondering how much pain it's likely to cause.  I recently started him on metacam for his arthritis so I have that to give him at home.  But I need to ask the vet what they do at the time of the procedure, if any kind of nerve blocker is possible.  I'm already nervous about having him under anesthesia but it's clearly bothering his eye and it's only going to get bigger.

20
by on 01/22/2009 05:22pm

Dr. K: THANK YOU.  I'm so hoping that opionion and attitude spreads far and wide!  Are the drugs listed at http://www.ivapm.org/site/view/Dogs.pml#treatments all the ones that can be used?  These are the same ones I've seen in several places on the net and it seems like an incredibly short list of options.  I'll join Larry in asking you to do more on how drugs are approved, off label uses, risks/benefits of on and off label uses, etc., etc.  I've learned enough to stand my ground with my own human docs but I don't know how much of that would cross-over and I feel grossly under informed to stand up for my babies.

21
by on 01/22/2009 05:20pm

Sefani: On the IVAPM and its drug company sponsorships: It's hard for not-for-profits to bring these excellent sites to you without backing. I'm with the SFVMA and we're looking for sponsors, too. Trust me, we look at these things with a jaundiced eye. Really.

22
by on 01/22/2009 05:17pm

Barb: I love Sevo for its quick recovery because the patient experiences less of the stress associated with dissociation (my brain works but my body doesn't). Less of it reaches the staff for greater personnel safety. And it doesn't mean more pain as long as the pain medications are used pre and/or intra-op. It does, however, require an initial outlay in a vaporizer but the Sevo reps "pay for it." In other words, the product itself is so expensive that the company makes up for it in "razor blade" sales.

23
by on 01/22/2009 05:01pm

Of all the excellent posts you've done, this is one of the best!! Thank you - I wasn't aware of some of these options.


Stefani - the higher cost may be why some vets don't use Sevo.  Also - and I am totally not sure about this - it may require different equipment than Iso which raises the initial cost even more.


But the faster recovery time of Sevo - while I agree that's a good thing - also means the animal may actually need more pain medication post op.  In other words, the lingering pain relieving effects of the anesthetic don't "linger" so long with Sevo.

24
by on 01/22/2009 04:43pm

Re:

The International Veterinary Academy of Pain Management (IVAPM): http://www.ivapm.org


That is an interesting site. Thank you for posting. However, it definitely raises my eyebrows when I see they are sponsored by drug companies that make these drugs. i.e., Merial, Boeringer Ingelheim, Schering-Plough. I don't trust the objectivity of a professional association (veterinary or otherwise) who is sponsored by the vendors of the products for the conditions the association purports to focus on. This is what is called "Conflict of Interest."

25
by on 01/22/2009 04:36pm

I don't believe in "kitty approved" NSAIDs. My kitties will never have a "kitty approved" NSAID, including metacam.


Why don't more vets offer/use/stock Sevoflourane? I heard it has a shorter recovery time than Isoflourane. I explicitly asked for it - -and offered to pay extra for it -- at my vets, but they didn't have it even at extra cost.

26
by on 01/22/2009 04:35pm

I love posts like these. Not to replace my vet, but so I know the right questions to ask when I go in. It would be great to have a post reviewing pet pain relievers for 'ordinary' (non-surgical related) aches and pains as well.


I know Rymidal causes an upset stomach in my dog, but occasional Tramadol seems to work well when she's feeling her age. Beyond those two I don't know what else is availble, or the pros & cons of occasional or long-term use.


It's also not always easy to tell if she is in some pain. If she seems to be less active than usual sometimes I will give her something and she will really perk up. So either she was in pain or I'm slowly turning her into an addict!

27
by on 01/22/2009 04:32pm

PJBoosinger: Some still argue that pain medication is counterproductive in cases where pets (and children!) will feel so much better that they're more likely to hurt themselves. I reject that argument outright. It's a sick concept--leaving animals and kids in pain because owners/parents can't provide adequate home care. I say sedate if that's a big possibility. After all, how hard is crating. It's just that people don't want to do it. But if you explain: "Would you rather have them feel pain or be confined?", most owners will understand and comply.


And some pediatricians still fail to use [the very safe] opioids because parents fear the sedation--or because they feel children experience pain differently. Puh-lease.

28
by on 01/22/2009 03:49pm

Great pain protocols, good on you!. I believe pain management is unfortunately VASTLY underdone in animals, especially after surgeries such as you describe above. Scarily enough there are still even some vets out there who think just because an animal can't say "ouch" it doesn't feel pain. Proper pain management has a huge effect on recovery. Owners should always have the right question the vet about it, and to insist on more effective protocols if they think their pet is still in pain. I wish more would.

29
by on 01/22/2009 03:47pm

I'm so glad to see you touch on this favorite topic of mine! I am starting to gain confidence doing epidurals and am finding that it is extremely easy!! I simply ask permission to perform this procedure on pets after they are deceased and owners are very willing (so I can gain practice). I have also enjoyed becoming a member of the International Veterinary Academy of Pain Management (IVAPM): http://www.ivapm.org/

30
by on 01/22/2009 03:13pm

I believe that pain is 98% counter-productive to healing; that no patient should be left in any more pain than is perhaps appropriate to prevent the patient from doing damage by not noticing they're doing so.  It's now pretty well established that failure to treat initial pain due to injury can lead to chronic pain in humans and I believe the same to be true in animals.  I have to say I'm disturbed that most Vet patients seem to be prescribed low doses of tramadol for post op pain and it is often sadly inadequate.  Post surgery for my Shiba's knee and ACL repair, she was given tramadol.  It was grossly inadequate and that lack of post op pain care will figure into whether or not I decide to have her other knee repaired.  (And, frankly, I resent having to figure that in as a part of the equation.)


I'm not sure the medical professions are truly listening on this topic yet here in the US.  The only ones who can tell them about it are those who've experienced it.  Amongst human chronic pain sufferers, (and, yes, I am one) they are generally dismissed out of hand.  That is truly unfortunate since pets cannot speak for themselves and, so, I suspect they get "listened" to even less.

31
by on 01/22/2009 01:29pm

Nope. just a happy greyhound.

32
by on 01/22/2009 01:10pm

this is off-topic, but is that photo a Saluki? have you ever worked with that breed? I'm madly in love with them but they are so rare that I've only met one once.

33
by on 01/22/2009 12:43pm

PS: I should have mentioned acupuncture and epidurals. Some vets use acupuncture to help reduce anesthetic requirements, too (but most vets don't know how to do this). Epidurals are also less widely employed by regular vets like me (I don't do them, either) but it's worth asking your board-certified surgeon about this option.

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About fully vetted

Patty Khuly, VMD, MBA

Photo of Dr Khuly

Dr. Khuly is a former petMD blogger and small animal veterinarian in Miami, Florida, where she practices medicine at Sunset Animal Clinic and serves on the board of the South Florida Veterinary Medical Association. She is a graduate of Wellesley College, the University of Pennsylvania School of Veterinary Medicine, and The Wharton School of Business.

As a significant sideline, she writes...a lot. She authors pet health columns for USA Today, The Miami Herald and Vetstreet. She also writes a popular monthly column for Veterinary Practice News and serves as regular contributor to Veterinary Economics, The Bark, and the Veterinary News Network.

Dr. Khuly lives in South Miami with her brood of hens, goats, dogs, cats...and humans.

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