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Acute and chronic pain in cats, part two

Mathews KA, Kronen PW et al.  WSAVA guidelnes for recognition, assessment, and treatment of pain. Journal of Small Animal Practice 2014;55:E10-68.

This is a summary of Section 2 (“Pain management”) and Section 3 (“Pain Management Protocols”) of this document as it pertains to the cat.  The document is the work of the World Small Animal Veterinary Association’s (WSAVAC)  Global Pain Council (GPC), an international consortium of specialists whose goal is to help the veterinary profession identify pain as the fourth vital sign and minimize pain prevalence in and impact on small animal patients.  

Section 2 (“Pain management”) discusses general approaches to the treatment of acute, perioperative, and chronic pain, and then discusses in detail the many pharmaceutical and non-pharmaceutical  options for the management of pain in small animals.  The authors recommend that particularly in all chronic pain patients, non-drug treatment modalities should be used alongside pharmaceutical treatments.  The various drugs available to treat small animal pain are discussed in detail in this section of the document, and differences between dogs and cats with respect to the pharmacokinetics, pharmacodynamics, side effects, indications, and contraindications for the use of the drugs in each class are discussed.  Tables of suggested indications, contraindications, and dosages for dogs and cats are provided in the sections discussing opioids, non-steroidal anti-inflammatory drugs (NSAIDs), local anesthetics.

Other sections in this part of the document discuss the use of alpha-2 adrenoreceptor agonists, adjunctive medications such as NMDA receptor antagonists (ketamine and amantadine), gabapentin, tricyclic antidepressants (imipramine and amitryptyline), and non-analgesic drugs such as glucocorticoids, maropitant, and acepromazine in the management of the painful patient.  As these guidelines were prepared for the global veterinary community, not all medications listed are available in all countries, and approved feline dosing guidelines for NSAIDs in particular may vary from country to country.  This section also includes information regarding analgesic delivery techniques and tools, including sustained release delivery systems, continuous rate infusions, wound infusion catheters, electrical nerve locators, and epidural catheters; physical rehabilitation; diet and supplements;  nursing and supportive care; acupuncture; medical massage; and salvage surgical procedures.

“Pain management protocols”, Section 3 of the document, outlines suggested pain management protocols for common procedures and situations involving small animal patients.  The first subsection offers specific guidelines for feline orchiectomy (castration) and ovariohysterectomy/ovariectomy.  A separate subsection discusses protocols for canine patients undergoing these procedures.  As many gonadectomy procedures in small animals may be performed in settings in which there is limited drug availability, alternative protocols using no controlled substances and for situations in which there is limited availablity of analgesic drugs are also outlined.  Two other subsections discussing common surgical procedures review protocols for orthopedic surgery and soft tissue surgery, and an example of a relevant  feline protocol is provided in each category.

Detailed subsections with illustrations of many useful loco-regional anesthetic techniques, including intratesticular blocks, limb nerve blocks, digital nerve blocks, wound soaker catheters, epidural blocks (showing differences in needle placement between dogs and cats), and dental nerve blocks, are provided.  Additional subsections discuss analgesia for ophthalmic procedures, emergency and critical care patients, pregnant or lactating patients (including caesarian section), neonatal and pediatric patients, and management of acute medical pain (pain not primarily associated with surgery or trauma).

The document concludes with subsections discussing neuropathic pain, degenerative joint disease, oncologic pain, and a brief overview of humane euthanasia.  This comprehensive review is a useful guide to the many options available for pain management in small animals in a wide variety of clinical situations, and does not focus principally on dogs; ample attention is paid to the cat, and this should provide the feline practitioner with some new ideas as to how to manage painful patients.  [PJS]

See also:

Gruen ME, Griffith E, et al. Detection of clinically relevant pain relief in cats with degenerative joint disease associated pain. J Vet Intern Med. 2014 Mar-Apr; 28(2):346-350.