Pain Management for Veterinary Technicians and Nurses, 2nd Edition

List of Contributors xxiii

Foreword xxvii

Acknowledgments xxix

About the Companion Website xxxi

1 Advancing Veterinary Pain Management into a New Era 1
Mary Ellen Goldberg

1.1 Introduction 1

1.2 Brief History of Human Pain Management 1

1.3 Veterinary Pain Management Through the Centuries 3

1.4 Animal Research Contributions 3

1.5 History of Animal Nursing Staff 4

1.5.1 National Association of Veterinary Technicians in America Recognized Veterinary Technician Specialty Academies 4

1.6 Eyewitness to 50 Years of Changes for Veterinary Technicians 5

1.7 Veterinary Technician Pioneers in Pain Management 6

1.8 Future Directions for Veterinary Technician Pain Management 7

1.9 Conclusion 7

References 7

2 Careers in Animal Pain Management 9
Tasha McNerney and Stephen Niño Cital

2.1 Introduction 9

2.2 Pain Management Certifications Available for Veterinary Technicians/Nurses 9

2.2.1 Certified Veterinary Pain Practitioner (CVPP) 9

2.2.2 Veterinary Technician Specialist (Anesthesia and Analgesia), and Veterinary Technician Specialist (Laboratory Animal Medicine – Research Anesthetist) 10

2.2.3 Veterinary Technician Specialist (Physical Rehabilitation) 11

2.2.4 Surgical Research Anesthetist (SRA) 11

2.2.5 The University of Tennessee Companion Animal Pain Management Certificate Program 11

2.2.6 AAHA Pain Management Guidelines Certificate Course (AAHA Pain Management Champion) 11

2.2.7 WSAVA Certificate in Pain Management 12

2.2.8 Canine Rehabilitation Veterinary Technician Certifications 12

2.2.9 Equine Rehabilitation Veterinary Technician Certifications 12

2.2.10 Certified Equine Massage Therapist 12

2.2.11 Animal Acupressure and Massage 12

2.2.12 TCVM Veterinary Technician Programs Offered by the Chi Institute 12

2.2.13 Animal Acupuncture 13

2.2.14 Low- Stress Certifications 13

2.2.15 Veterinary Anaesthesia and Analgesia (MSc), (PgDip), (PgCert), or (PgProfDev) 13

2.2.16 Canine Arthritis Management Practitioner (CAMP) 14

2.2.17 Certified Companion Animal Rehabilitation Therapist (CCAT) 14

2.3 Leveraging Veterinary Technicians in Pain Management 14

2.4 Conclusion 15

3 Pain Physiology and Psychology 17
Stephen Niño Cital, Tasha McNerney, and Robin Saar

3.1 Introduction 17

3.2 What Is “Pain” 17

3.2.1 The Negative Effects of Pain 18

3.3 Breaking Down the Nociceptive Pathway 18

3.3.1 Transduction 18

3.3.2 Transmission 20

3.3.3 Modulation 20

3.3.4 Perception 20

3.3.5 The Dorsal Horn 21

3.3.6 Ventral Horn and Intermediate Zone 23

3.3.7 White Matter 23

3.3.8 Descending Pathways 23

3.3.9 Spinothalamic Tract 23

3.3.10 Spinoreticular Tract 24

3.3.11 Peripheral Sensitization 24

3.3.12 Central Sensitization 24

3.4 The Endocannabinoid System and Pain 27

3.5 The Gate Control Theory 28

3.6 Psychological Aspects of Pain 29

3.6.1 Personality and the Pain Experience 29

3.6.2 Stress and Anxiety on Pain 29

3.6.3 Pain Catastrophizing 29

3.6.4 Boredom and Pain 30

3.6.5 Neuroplasticity and the Memory of Pain 31

3.6.6 Caregiver Placebo 31

3.7 Types of Pain 32

3.7.1 Somatic, Visceral, and Referred Pain 32

3.7.2 Physiological/Adaptive/Acute Pain 32

3.7.3 Pathological/Maladaptive/Chronic Pain 33

3.7.4 Neuropathic Pain 33

3.7.5 Radicular Pain 34

3.7.6 Chronic/Persistent Postsurgical Pain 34

3.7.7 Complex Regional Pain Syndrome 35

3.7.8 Social Resilience and Pain 35

3.8 The Microbiome and Pain Pathophysiology 35

3.8.1 What Is a Microbiome? 36

3.8.2 Determining “Healthy” in a Microbiome 37

3.8.3 Gut Microbiome Imbalance or Dysbiosis 37

3.8.4 The Gut- Brain Axis 38

3.8.5 Microbial Derived Mediators 38

3.8.6 Pathogen- Associated Molecular Patterns (PAMPs) 38

3.8.7 Microbial- Derived Metabolites 39

3.8.8 Neurotransmitters or Neuromodulators 39

3.8.9 Endocannabinoid Axis 41

3.8.10 Pain Medication and the Microbiome 42

References 42

4 Integrating Pain Recognition and Scoring in Companion, Equine, Food and Fiber Species, and Exotic/Lab Animal Species 47
Stephen Niño Cital, Ian Kanda, Taly Reyes, Jessica Birdwell, and Mary Ellen Goldberg

4.1 Introduction 47

4.2 Pain Domains 48

4.2.1 Pain Intensity and Affect 48

4.2.2 Temporal Dimensions 48

4.2.3 Location and Bodily Distribution of Pain 48

4.3 Disposition and Personality 48

4.4 Breed or Species Bias 50

4.5 Dysphoria, Emergence Agitation, and Emergence Delirium 51

4.6 Placebo, Caregiver Placebo, and Placebo- by- Proxy 52

4.7 Non–species- specific Assessments 52

4.7.1 Quantitative Sensory Testing (QST) 52

4.7.2 Temporal Summation (TS) 53

4.7.3 Nociceptive Withdrawal Reflex (NWR) 53

4.7.4 Gait Analysis 53

4.7.5 Pain Biomarkers 53

4.7.6 Machine Learning and Artificial Intelligence (AI) 54

4.7.7 Activity Monitors (AMs) 54

4.7.8 Facial Expression or Grimace Scales 55

4.8 Clinical Pain Scoring Tools (Canine and Feline) 55

4.8.1 Canine Acute Pain Scoring 56

4.8.1.1 Glasgow Composite Measure Pain Scale – Short and Long Forms (CMPS) (Validated) 56

4.8.1.2 French Association for Animal Anesthesia and Analgesia Pain Scoring System (4A- Vet) (Validated) 58

4.8.1.3 University of Melbourne Pain Scale (UMPS) (Validated) 58

4.8.2 Canine Chronic Pain Scoring 58

4.8.2.1 Canine Brief Pain Inventory (CBPI) (Validated) 58

4.8.2.2 Helsinki Chronic Pain Index (HCPI) (Validated) 59

4.8.2.3 Liverpool Osteoarthritis in Dogs (LOAD) (Validated) 59

4.8.3 Feline Acute Pain Scoring 59

4.8.3.1 Glasgow Composite Measure Pain Scale- Short- Form (CMPS- SF) (Validated) 59

4.8.3.2 Feline Grimace Scale (FGS) (Validated) 60

4.8.4 Feline Chronic Pain Scoring 60

4.8.4.1 Client- specific Outcome Measures – Feline (CSOMf) (Validated) 60

4.8.4.2 Montreal Instrument for Cat Arthritis Testing- caretaker (MI- CAT-(c)) (Validated) 60

4.8.4.3 Feline Musculoskeletal Pain Index (FMPI) (Not Validated) 60

4.8.4.4 Oral Pain Scale – Canine/Feline (COPS–C/F) (Validated) 62

4.8.4.5 Cincinnati Orthopedic Disability Index (CODI) (Not Validated) 62

4.8.4.6 HHHHHMM Scale (Not Validated) 62

4.8.4.7 VetMetrica™ Health- related Quality of Life (HRQoL) (Validated) 62

4.8.4.8 Food and Fiber Species Pain Recognition and Scoring 63

4.9 Bovids 63

4.9.1 Indications of Pain in Cattle 71

4.10 Small Ruminants and Camelids 71

4.11 Swine 73

4.11.1 Normal Behavioral Observations in Swine 73

4.12 Equid Pain Recognition and Scoring 73

4.12.1 Horses 74

4.12.1.1 Appearance of the Normal Horse 74

4.12.1.2 Somatic Pain Indicators 75

4.12.1.3 Signs of Laminitis Pain Vary with the Progression of the Disease 75

4.12.1.4 Visceral Pain Indicators 75

4.12.1.5 Horse Grimace Scale 75

4.12.2 Donkeys 77

4.13 Exotic Species Pain Recognition and Scoring 77

4.13.1 Birds 77

4.13.2 Appearance of a Non- painful Bird 78

4.13.3 Appearance of a Painful Bird 78

4.13.4 Developing a Pain Score in Birds 81

4.14 Reptiles 82

4.14.1 Appearance of a Nonpainful Reptile 82

4.14.2 Appearance of a Reptile in Pain 82

4.14.3 Developing a Pain Score in Reptiles 83

4.15 Amphibians and Fish 84

4.15.1 Appearance of a Nonpainful Fish and Amphibian 84

4.15.2 Appearance of a Painful Fish and Amphibian 84

4.15.3 Developing a Pain Scoring Assessments in Fish and Amphibians 84

4.16 Small Exotic Mammals 85

4.16.1 Appearance of Nonpainful Small Exotic Mammals 85

4.16.2 Appearance of Painful Small Exotic Mammals 85

4.16.3 Developing a Pain Score in Small Exotic Mammals 85

References 89

5 Analgesia Pharmacology 95
Darci Palmer and Stephen Niño Cital

5.1 Introduction 95

5.2 Definitions 95

5.3 Analgesic Drugs 96

5.4 Opioids 97

5.4.1 Full Opioid Agonists 97

5.4.2 Individual Drug Facts 99

5.4.2.1 Morphine 99

5.4.2.2 Meperidine (Pethidine) 99

5.4.2.3 Methadone 99

5.4.2.4 Hydromorphone 100

5.4.2.5 Oxymorphone 100

5.4.2.6 Fentanyl, Remifentanil, Sufentanil, Alfentanil, Carfentanil 100

5.4.2.7 Fentanyl Patches 100

5.4.2.8 Codeine 101

5.4.2.9 Hydrocodone and Oxycodone 101

5.4.2.10 Tramadol 101

5.4.2.11 Tapentadol 102

5.4.3 Partial Agonist Opioids 102

5.4.3.1 Buprenorphine 102

5.4.3.2 Simbadol 104

5.4.3.3 Zorbium 104

5.4.3.4 Sustained or Extended Release (SR or ER) Buprenorphine 104

5.4.3.5 Buprenorphine Patches 105

5.4.4 Agonist/Antagonist Opiods: Butorphanol and Nalbuphine 105

5.4.5 Opioid Antagonists: Naloxone, Nalmefene, Naltrexone 105

5.4.6 Mixing Opioids 106

5.5 Non- steroidal Anti- inflammatory Drugs (NSAIDs) 106

5.5.1 Washout 108

5.5.2 Piprant Class 108

5.6 Corticosteroids 109

5.7 Cannabinoids 109

5.8 Local Anesthetics 110

5.8.1 Nocita 110

5.8.2 Systemic Toxicity 110

5.8.3 Lidocaine as a CRI 111

5.9 Gabapeninoids 111

5.9.1 Gabapentin 111

5.9.2 Pregabalin 112

5.10 Alpha- 2 Agonists 112

5.10.1 Xylazine, Medetomidine, Dexmedetomidine, Romifidine, Detomidine 112

5.10.2 Zenalpha® (Medetomidine and Vatinoxan) 113

5.11 N- Methyl- D- Aspartate (NMDA) Antagonists 114

5.11.1 Ketamine and Tiletamine 114

5.11.2 Precautions/Contraindications 115

5.11.3 Amantadine and Memantine 115

5.12 Neurokinin- 1 Inhibitors 115

5.13 Bisphosphonates 116

5.14 Acetaminophen (Paracetamol) 116

5.15 Frunevetmab (Solensia®) and Bedinvetmab (Librela®) 117

5.16 Polysulfated Glycosaminoglycans (PSGAGs) 117

5.17 Dipyrone (Metamizole) 117

5.18 Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin– Norepinephrine Reuptake Inhibitors (SNRIs) 118

5.19 Acepromazine 119

5.20 Trazodone 119

References 119

6 Regional Anesthesia and Local Blocks 127
Imeldo Laurel, Jeanette M. Eliason, Amy Dowling, Tasha McNerney, and Stephen Niño Cital

6.1 Introduction 127

6.2 Current Drug Options for Regional Anesthesia and Nerve Blocks 128

6.2.1 Mixing Local Anesthetics 129

6.2.2 Adjunctive Agents 129

6.2.3 Volume Expansion, Onset Time, and Buffering 129

6.2.4 Maximum Recommended Dose (MRD) 130

6.2.5 Equipment Selection 131

6.3 Dental and Facial Regional/Local Anesthesia 133

6.4 Dentistry and Facial Blocking Techniques 133

6.4.1 Inferior (Caudal) Alveolar Nerve Block (Extraoral/Intraoral) 133

6.4.2 Middle Mental Foramen Nerve Block 135

6.4.3 Infraorbital Nerve Block 136

6.4.4 Major Palatine Block: Small Animal 137

6.4.5 Caudal Maxillary Block 138

6.4.6 Auriculopalpebral Nerve Block: Motor Blockade of the Eyelid 138

6.4.7 Retrobulbar Block 140

6.4.8 Frontal Nerve (Supraorbital Foramen) Block 140

6.4.9 Auriculotemporal Block + Greater Auricular Block 142

6.5 Common Regional and Local Anesthetic Techniques: Less Specified 143

6.5.1 Intraperitoneal Lavage Technique for Dogs and Cats 143

6.5.2 Incisional Line Block 143

6.5.3 Circumferential Block 144

6.6 Regional and Local Blocks of the Thorax and Abdomen 144

6.6.1 Intercostal Blocks 144

6.6.2 Interpleural Block 146

6.6.3 Intratesticular and Spermatic Cord Block 147

6.6.4 Sacrococcygeal Block 147

6.6.5 Epidural 149

6.6.6 Spinal Anesthesia 153

6.6.7 Epidural Catheter 153

6.6.8 Erector Spinae Plane Block (ESP) 156

6.6.9 Thoracic Paravertebral Block 157

6.6.10 Transverus Abdominis Plane (TAP) Block 158

6.7 Blocks of the Limbs 160

6.7.1 Femoral- Saphenous Nerve Complex Block 160

6.7.2 Sciatic Nerve Block 162

6.7.3 Brachial Plexus Block 164

6.7.4 Radial, Ulnar, Median, and Musculocutaneous (RUMM) Nerve Blocks 166

6.8 Common Equine Techniques 167

6.8.1 Local Analgesia for Horse Castration 167

6.8.2 Caudal Epidural in the Horse 167

6.9 Common Production Animal Techniques 168

6.9.1 Analgesia for Castration 168

6.9.2 Cornual Nerve Block 170

6.9.3 Analgesia for Livestock Epidural 171

6.9.4 Local Anesthetic Blocks for Exotics and Laboratory Animals 174

References 175

7 Analgesia for Acute Pain 179
Tasha McNerney, Melissa Streicher, and Karen Maloa Roach

7.1 Introduction 179

7.2 Fear, Anxiety, and Stress in the Acute Pain Response 180

7.3 Multimodal Therapies 180

7.4 Types of Acute Pain 181

7.4.1 Surgical Pain 181

7.4.1.1 Premedication 182

7.4.1.2 Induction 183

7.4.1.3 Maintenance 183

7.4.1.4 Postoperative Analgesic Medications 183

7.4.1.5 Pain Vacation 184

7.4.1.6 Take- home Analgesics 184

7.4.1.7 Local Anesthesia Techniques 185

7.5 Creating an Effective Acute Pain Analgesic Plan 185

7.5.1 Continuous Rate Infusions 185

7.6 Analgesia Plans for Painful Procedures 186

7.6.1 Reproductive Tract Surgery 186

7.6.1.1 Premedication 187

7.6.1.2 Regional Anesthesia 187

7.6.1.3 Maintenance 187

7.6.1.4 Postoperative Analgesic Plan 187

7.6.1.5 Home Medications 187

7.6.2 Analgesia for Surgery Involving the Eye 188

7.6.2.1 Premedication 188

7.6.2.2 Regional Anesthesia 188

7.6.2.3 Maintenance 188

7.6.2.4 Postoperative Analgesic Plan 188

7.6.2.5 Home Medications 188

7.6.3 Analgesia Techniques for Surgery Involving the Ear 189

7.6.3.1 Premedication 189

7.6.3.2 Regional Anesthesia 189

7.6.3.3 Maintenance 189

7.6.3.4 Postoperative Analgesic Plan 189

7.6.3.5 Home Medications 189

7.6.4 Gastrointestinal Procedures or Acute Abdominal Pain 190

7.6.4.1 Premedication 190

7.6.4.2 Maintenance 190

7.6.4.3 Regional Anesthesia 190

7.6.4.4 Postoperative Analgesic Plan 191

7.6.4.5 Home Medications 191

7.6.5 Thoracic Procedures 191

7.6.5.1 Premedication 191

7.6.5.2 Maintenance 192

7.6.5.3 Regional Anesthesia 192

7.6.5.4 Postoperative Analgesic Plan 192

7.6.5.5 Home Medications 192

7.6.6 Protocols for Patients with Cranial Disease, Injury, or Neurosurgery 193

7.6.6.1 Premedication 194

7.6.6.2 Maintenance 194

7.6.6.3 Regional Anesthesia 194

7.6.6.4 Postoperative Analgesic Plan 194

7.6.6.5 Home Medications 194

7.6.7 Analgesia Protocols for the Patient with Urinary Disease 194

7.6.7.1 Premedication 194

7.6.7.2 Regional Anesthesia 195

7.6.7.3 Maintenance 195

7.6.7.4 Postoperative Analgesic Plan 195

7.6.7.5 Home Medications 195

7.6.8 Minimally Invasive Procedures 195

7.6.8.1 Premedication 195

7.6.8.2 Regional Analgesia 196

7.6.8.3 Maintenance 196

7.6.8.4 Postoperative Analgesic Plan 196

7.6.8.5 Home Medications 196

7.7 Orthopedic Procedures 196

7.7.1 Orthopedic Procedures of the Forelimb 196

7.7.1.1 Premedication 196

7.7.1.2 Maintenance 196

7.7.1.3 Regional Anesthesia 196

7.7.1.4 Postoperative Analgesic Plan 197

7.7.1.5 Home Medications 197

7.7.2 Hindlimb Amputation, Spinal Disease, Spinal Surgery, and Pelvic Fracture Repair 197

7.7.2.1 Premedication 198

7.7.2.2 Maintenance 198

7.7.2.3 Regional Anesthesia 198

7.7.2.4 Postoperative Analgesic Plan 198

7.7.2.5 Home Medications 198

7.7.3 Surgery of the Tail 198

7.7.4 Mandibulectomy/Maxillectomy 200

7.7.4.1 Inferior Alveolar (Mandibular) Blocks 200

7.7.4.2 Maxillary Blocks 200

7.8 Postoperative Patient Evaluation 201

7.9 Management of Painful Dermatologic Conditions 201

7.9.1 Sensory Perception in the Skin 202

7.9.2 Recognizing Cutaneous Discomfort 202

7.9.3 Painful and Pruritic Cutaneous Conditions 203

7.9.3.1 Allergic Skin Disease 204

7.9.3.2 Skin Infections 204

7.9.3.3 Autoimmune and Immune- mediated Dermatopathies 206

7.9.3.4 Cutaneous Burns 207

7.9.4 Treatment of Cutaneous Pain and Pruritus 211

7.10 Conclusion 212

References 212

8 Analgesia for the Pregnant, Neonatal, and Pediatric Patient 217
Darci Palmer and Natalie Pedraja

8.1 Introduction 217

8.1.1 Pain Management During Pregnancy 217

8.1.2 Analgesic Drugs Used During Pregnancy and C- Sections 218

8.1.2.1 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 219

8.1.2.2 Opioids 219

8.1.2.3 Alpha- 2 Agonists 221

8.1.2.4 Dissociative Agents 222

8.1.2.5 Local and Regional Blocks 222

8.2 Postoperative Analgesia 224

8.3 Anesthesia and Analgesia Case Management for a Cesarean Section 224

8.4 Pain Management for Neonates and Pediatrics 227

8.4.1 Insulting the Neonatal Pain Pathways 227

8.4.1.1 NMDA Receptors 228

8.4.1.2 Cutaneous Receptors 228

8.4.2 Treatment of Pain in Neonatal and Pediatric Patients 228

8.4.2.1 Opioids 228

8.4.2.2 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 229

8.4.2.3 Alpha- 2 Agonists 229

8.4.2.4 Local and Regional Blocks 229

References 229

9 Analgesia in the Emergency and Critical Care Setting 233
Heather Ann Scott and Rachel Stauffer

9.1 Introduction 233

9.2 Treating Pain in the Emergency and Critical Care Veterinary Patient 233

9.3 Evaluating Pain in ER and ICU Patients 234

9.4 Nursing Care and the Role of Pain Management in Kirby’s Rule of 20 239

9.5 Pain and the Physiological Stress Response: A Summary 240

9.6 Sleep Deprivation 241

9.7 Windup Pain in the ER 242

9.8 Techniques and Nuances for Analgesic Delivery in the Emergency Room 242

9.8.1 Pain Vacations (Acute Pain) 243

9.8.2 Lidocaine Use in ECC 243

9.8.3 Opioid Analgesia for Emergency and Critical Care Patients 244

9.8.4 Local/Regional Analgesia in ECC 244

9.8.5 Nsaids 245

9.8.6 Maropitant 245

9.8.7 Physical Rehabilitation Methods in ECC 245

9.9 Common Painful Conditions in the ER/ICU Setting 246

9.9.1 Fractures 246

9.9.2 Acute Soft Tissue Injuries 247

9.9.3 Feline Lower Urinary Tract Obstruction 247

9.9.4 Trauma Patients 247

9.9.5 Abdominal Pain in ECC Patients 247

9.9.6 Acute Swelling and Edema 248

9.10 Conclusion 248

References 249

10 Chronic Pain Management for the Companion Animal 253
Taly Reyes, Jessica Birdwell, and Stephen Niño Cital

10.1 Introduction 253

10.2 The Complexity of Chronic Pain 253

10.3 Neuropathic Pain 255

10.4 Common Chronic Pain Conditions 255

10.4.1 Chronic Joint Pain- Osteoarthritis (OA) 255

10.4.2 Oncologic/Malignant Pain 257

10.4.3 Chiari Malformation Pain 257

10.4.4 Headaches and Migraines in Animals 259

10.4.5 Meningitis 259

10.4.6 Chronic Wounds 260

10.5 Assessing Chronic Pain 261

10.6 Goals and Modalities for Treating Chronic Pain 261

10.7 Pharmacological Interventions 261

10.7.1 Pain Vacation (Chronic Pain) 262

10.7.2 Mesotherapy 262

10.7.3 Transdermal Medications 263

10.7.4 Non- steroidal Anti- Inflammatory Drugs (NSAIDs) 264

10.7.5 Acetaminophen 265

10.7.6 Corticosteroids 265

10.7.7 Opioids 266

10.7.8 Atypical Opioids: Tramadol and Tapentadol 266

10.7.9 Tricyclic Antidepressants (TCAs), Selective Serotonin Reuptake Inhibitors (SSRIs), and Serotonin–Norepinephrine Reuptake Inhibitors (SNRIs) 267

10.7.10 Gabapentinoids: Gabapentin and Pregabalin 268

10.7.11 N- Methyl- D- Aspartate Antagonists 269

10.7.12 Neurokinin- 1 Inhibitors 269

10.7.13 Bisphosphonates 270

10.7.14 Anti- NGF, Monoclonal Antibodies 270

10.7.15 Nutraceuticals and Animal Health Supplements 270

10.8 Lifestyle Modifications 271

10.8.1 Weight Loss and Appropriate Nutrition 271

10.8.2 Routine Exercise and Physical Therapy 271

10.8.3 Thinking “Out of the Box” through Environment Modifications 271

10.9 Conclusion 271

References 272

11 Analgesia for Shelter Medicine and Trap–Neuter–Return Programs 277
Anne Marie McPartlin and Erin Spencer

11.1 Introduction 277

11.2 Multimodal Analgesia 277

11.2.1 Opioids 279

11.2.2 Nonsteroidal Anti- inflammatory Drugs (NSAIDs) 279

11.2.3 NMDA Antagonists 281

11.2.4 Alpha- 2 Adrenoceptor Agonists 282

11.2.5 Local Anesthetics 282

11.2.6 Adjunct Therapies 283

11.3 HQHVSN and TNR Programs 283

11.4 Rabbits 285

11.5 Conclusion 286

References 286

12 Pain Management in Equids 289
Molly Cripe Birt, Rebecca Johnston, Rachael Hall, and Janel Holden

12.1 Introduction 289

12.2 Pain Assessment in Horses 289

12.3 Common Analgesics and Strategies in Horses 289

12.3.1 Butorphanol 290

12.3.2 Buprenorphine 291

12.3.3 Meperidine 291

12.3.4 Tramadol 291

12.3.5 Pure Opioid Agonists 291

12.3.6 Non- steroidal Anti- inflammatories 292

12.3.7 NMDA Receptor Antagonists 293

12.3.8 Alpha- 2 Agonists 293

12.3.9 N- butylscopolammonium Bromide (NBB) 294

12.3.10 Dimethylsulfoxide (DMSO) 294

12.3.11 Prokinetics and Antispasmodics 294

12.3.12 Locoregional Anesthetics and Techniques 294

12.4 Lidocaine Use in Horses 295

12.4.1 Postoperative Period Lidocaine Use 295

12.5 Common Painful Conditions and Procedures in Horses 296

12.5.1 Surgical Pain 296

12.5.2 Gastrointestinal (Colic and Ulcers) Pain 296

12.5.3 Lameness 297

12.5.3.1 Acute Lameness 297

12.5.3.2 Chronic Lameness 298

12.5.4 Osteoarthritis 298

12.5.5 Laminitis 299

12.5.6 Pleuropneumonia 300

12.5.7 Dystocia 301

12.6 Analgesia in Foals 302

12.7 Pain Management in the Donkey 304

12.7.1 Common Painful Conditions 304

12.7.2 Pain Scoring and Behaviors 304

12.7.3 Anatomic and Physiologic Distinctions from the Horse 306

12.7.4 Analgesics in Donkeys 306

12.7.4.1 Nonsteroidal Anti- inflammatory Agents 306

12.7.4.2 Alpha- 2 Adrenoceptor Agonists 307

12.7.4.3 Opioids 307

12.7.4.4 Local Anesthesia/Analgesia Methods 307

12.8 Nonpharmacologic Approaches to Pain 308

12.9 Conclusion 308

References 308

13 Food and Fiber Species 315
Janel Holden, Rachael Hall, MegAnn Harrington, and Mary Ellen Goldberg

13.1 Introduction 315

13.2 Cattle 318

13.2.1 Bovine or Cattle Medications 318

13.2.1.1 Opioids 318

13.2.1.2 Nsaids 318

13.2.1.3 Alpha- 2- Adrenergic Agonists 319

13.2.1.4 NMDA Antagonists 319

13.2.2 Regional Anesthesia and Analgesia 319

13.2.2.1 Local Anesthetic Agents 319

13.2.2.2 Intravenous Regional Anesthesia 320

13.2.2.3 Teat Block 321

13.2.2.4 Infusion of the Teat Cistern 321

13.2.2.5 Epidural Analgesia 321

13.2.2.6 Analgesia for Dehorning 322

13.2.2.7 Spermatic Cord Block 322

13.2.3 Analgesic Adjuvants 322

13.2.3.1 Gabapentin 322

13.2.3.2 Continuous Infusion Analgesia 322

13.2.4 Withdrawal Period 324

13.3 Sheep (Ovine) and Goat (Caprine) Medications 326

13.3.1.1 Opioids 326

13.3.1.2 NSAIDs 327

13.3.1.3 Alpha- 2- Adrenergic Agonists 327

13.3.1.4 NMDA Antagonists 327

13.3.2 Regional and Local Anesthesia 327

13.3.2.1 Cornual Block 327

13.3.2.2 The Inverted L- Block or 7- Block 328

13.3.2.3 Paravertebral Nerve Block 328

13.3.2.4 Caudal Epidural 329

13.3.3 Intravenous Regional Anesthesia 329

13.3.3.1 Bier Block 329

13.3.3.2 Intratesticular Block 330

13.3.3.3 Continuous Rate Infusions 330

13.3.4 Pain Management for Pigs (Swine) 330

13.3.4.1 Opioids 332

13.3.4.2 NSAIDs 332

13.3.4.3 Alpha- 2 Adrenergic Agonists 334

13.3.4.4 NMDA Antagonists 334

13.3.4.5 Lumbosacral Epidural Block 334

13.3.4.6 Continuous Rate Infusions 335

13.4 Pain Management for Camelids 335

13.4.1 Camelid Medications 337

13.4.1.1 Opioids 337

13.4.1.2 Nsaids 338

13.4.1.3 Alpha- 2 Agonists 339

13.4.1.4 Local Anesthetics 339

13.4.1.5 NMDA Antagonists 340

13.4.1.6 CRI Techniques 340

13.4.1.7 Tramadol 342

13.4.1.8 Gabapentin 342

13.5 Conclusion 342

References 342

14 Exotic Companion Animals 347
Katrina Lafferty, Elizabeth Vetrano, Mary Ellen Goldberg, and Stephen Niño Cital

14.1 Introduction 347

14.2 Why Treat Pain? 348

14.3 Rabbits 349

14.3.1 Painful Behaviors: Rabbits 349

14.3.2 Pain Scoring: Rabbits 350

14.3.3 Nursing Care and Environmental Management: Rabbits 350

14.3.4 Common Analgesics in Rabbits 351

14.3.4.1 Opioids 352

14.3.4.2 NSAIDs 352

14.3.4.3 Regional and Local Anesthesia 352

14.3.4.4 Continuous Rate Infusions 353

14.4 Rodents and Ferrets 353

14.4.1 Mice 354

14.4.1.1 Pain Scoring: Mice 354

14.4.2 Rats and Ferrets 355

14.4.2.1 Pain Scoring: Rats and Ferrets 355

14.4.3 Gerbils 355

14.4.4 Hamsters 355

14.4.5 Guinea Pigs 356

14.4.5.1 Pain Scoring: Gerbils, Hamsters, Guinea Pigs, and Ferrets 356

14.4.5.2 Common Analgesics in Rodents 356

14.4.5.3 Opioids 356

14.4.5.4 NSAIDs 358

14.4.5.5 Regional and Local Anesthesia 358

14.5 Multimodal Analgesia: All Species 359

14.6 Avian Analgesia 359

14.6.1 Recognizing Relevant Behaviors for Each Species 360

14.6.2 Avian Pain Scoring and Management 361

14.6.3 Avian Drug Delivery 362

14.6.4 Common Analgesics in Birds 365

14.6.4.1 Nsaids 365

14.6.4.2 Opioids 365

14.6.4.3 Regional and Local Analgesia 366

14.6.4.4 Adjunctive Analgesics 366

14.7 Reptile Analgesia 367

14.7.1 Causes of Pain in Reptiles 368

14.7.2 Analgesic Medications 368

14.7.2.1 Opioids 369

14.7.2.2 NSAIDs 369

14.7.2.3 Local Anesthetics 369

14.7.2.4 Adjunctive Analgesics in Reptiles 371

14.8 Analgesia in Fish and Amphibians 371

14.8.1 Fish and Amphibian Treatment Strategies 372

14.9 Analgesia in Invertebrates 372

14.9.1 Invertebrate Analgesia Strategies 375

14.10 Conclusion 375

References 375

15 Analgesia in Zoo Animals 381
Lindsay Wesselmann, Mark Romanoski, Alison Mott, and Margot Monti

15.1 Veterinary Technicians in a Zoological Setting 381

15.1.1 Types of Questions to Ask Keepers Include 381

15.2 Recognizing Pain in Non- domestic Animals 382

15.2.1 Scoring Pain and Discomfort 384

15.3 Treatment 385

15.4 Medication Administration 385

15.5 Adjunctive Therapies 388

15.6 Choosing a Pain Regimen 389

15.7 Taxon- specific Considerations 389

15.7.1 Elephants 389

15.7.1.1 Pain Interpretation 394

15.7.1.2 Treatment 395

15.7.2 Great Apes 398

15.7.3 Old World and New World Non- human Primates (NHP) 399

15.7.3.1 Signs of Pain or Distress in Nonhuman Primates 401

15.7.3.2 Local and Regional Anesthetics 401

15.7.4 Exotic Ungulates 402

15.7.4.1 Nonruminant Ungulates 403

15.7.4.2 Ruminant Ungulates 404

15.7.5 Swine 405

15.7.6 Wildlife 406

15.8 Conclusion 407

References 407

16 Physical Rehabilitation 411
Kristen Hagler, Wendy Davies, and Lis Conarton

16.1 Scope of Training for the Team 411

16.1.1 Team Approach to Care 413

16.1.2 Applications in Veterinary Medicine 413

16.2 The Veterinary Technician and Physical Rehabilitation 413

16.2.1 Common Conditions and Therapeutic Modalities 413

16.2.2 General Wound Healing 415

16.2.3 Bone 415

16.2.4 Muscle 415

16.2.5 Tendons and Ligaments 416

16.2.6 Articular Cartilage 417

16.3 Client Communication and Activity Modification 417

16.4 Patient Assessment 418

16.4.1 Veterinary Diagnosis – The Rehabilitation Team 418

16.4.2 Objective Outcomes: Goniometry and Muscle Girth 419

16.4.3 Pain and Disability Scoring – Methodology in Pain Scoring and Assessment 420

16.4.4 The Musculoskeletal System 422

16.4.5 Structural and Postural Evaluation 424

16.4.6 Gait Analysis and Movement 425

16.4.7 Lameness 425

16.4.8 The Aging Patient 427

16.5 Patient Management 427

16.5.1 Assistive Devices: Mobility Wheelchairs, Harnesses, and Footwear 427

16.5.2 Bracing, Splinting, and Prosthesis 429

16.5.3 Kinesio Taping 430

16.5.4 Environmental Modifications 430

16.6 Therapeutic Modalities and Emerging Treatments 431

16.6.1 Superficial Thermal Therapies 431

16.6.2 Photobiomodulation (Therapeutic Laser) 433

16.6.3 Electrical Stimulation 434

16.6.4 Extracorporeal Shock Wave Therapy (ESWT) 435

16.6.5 Therapeutic Ultrasound (ThUS) 435

16.6.6 Electro- Magnetic Therapy 436

16.7 Manual Therapy and Myofascial Trigger Points 436

16.7.1 Myofascial Trigger Points 436

16.7.2 Joint Mobilizations and Chiropractic 437

16.7.3 Joint Range of Motion – Passive 438

16.7.4 Therapeutic Massage 438

16.8 Emerging Therapeutic Medical Interventions 439

16.8.1 Regenerative Medicine and Biological Treatments 439

16.8.2 Corticosteroids and Hyaluronic Acid 440

16.8.3 Stem Cells 440

16.8.4 Platelet Rich Plasma (PRP) 440

16.8.5 Interleukin- 1 Receptor Antagonist Protein (IRAP) 440

16.8.6 Prolotherapy 441

16.8.7 Emerging Technologies: Radiosynoviorthesis (Conversion Electron Therapy) 441

16.8.8 Emerging Technologies: Viscoelastic Therapies – Injectable Hydrogel Microparticles and Polyacrylamide Gels 441

16.9 Therapeutic Exercise and Aquatic Therapy 442

16.9.1 Therapeutic Exercise Principles and Application 442

16.9.2 Land Treadmills 443

16.9.3 Hydrotherapy or Aquatic Therapy 444

Appendix 16.A Obtaining Goniometric Measurements in the Canine Patient 446

Appendix 16.B Limb Circumference 447

Appendix 16.C Postural Compensations and Associated Medical Conditions 447

Appendix 16.D Photobiomodulation Example Protocols Adapted from (Monici et al. 2019) 448

Appendix 16.E Electrical Stimulation Example Protocols (Armitage 2019) 448

Appendix 16.F Myofascial Trigger Point (MTrP) and Myofascial Pain Syndrome (MPS) Terminology 449

Appendix 16.G Myofascial Trigger Point Examination Techniques 449

Appendix 16.H Techniques Addressing Myofascial Trigger Points 450

Appendix 16.I Joint Mobilizations 450

Appendix 16.J Passive Range of Motion 451

Appendix 16.K Therapeutic Massage Techniques 452

Appendix 16.L Therapeutic Exercises for Early Rehabilitation 453

Appendix 16.M Sample Guidelines 454

References 459

17 Nutrition and Integrative Medicine 465
Robin Saar, Jaime Brassard, and Stephen Niño Cital

17.1 Nutrition – The 5th Vital Assessment 465

17.1.1 Components of a Nutrition Assessment 466

17.1.1.1 Pet- Related Components 466

17.1.1.2 Diet- Related Components 466

17.1.1.3 Feeding Management 466

17.1.2 Nutrition Plan 467

17.1.3 Complete and Balanced Nutrition 467

17.1.4 Obesity’s Role in Inflammation and Pain 468

17.1.5 Key Nutritional Factors 468

17.1.6 Macronutrients and Micronutrients 470

17.1.7 Antioxidants 471

17.1.8 Nutrient- Focused Diets 471

17.2 Microbiota Health 471

17.2.1 Prebiotics 471

17.2.2 Probiotics 471

17.2.3 Fecal Microbial Transplant (FMT) 472

17.2.4 Postbiotics 472

17.3 Cannabinoid Medicine 473

17.3.1 History of Cannabis 473

17.3.2 Cannabis Potential in Veterinary Medicine 474

17.4 The Endocannabinoid System (ECS) and Endocannabinoidome (eCBome) 475

17.4.1 Primary Cannabinoid Receptors 475

17.4.2 Endocannabinoids 476

17.4.3 Retrograde Signaling 477

17.4.4 Exogenous Cannabinoids 477

17.4.5 Major Cannabinoids 478

17.4.6 Minor Cannabinoids 478

17.4.7 Terpenoids and Flavonoids 479

17.4.8 Entourage Effect and Synergy 480

17.5 Cannabinoid Role in Pain Management 480

17.5.1 Acute Pain 480

17.5.2 Chronic Pain 481

17.5.3 G- Coupled Protein Receptors (GPR) 481

17.5.4 Glycine Receptors (GlyR) 481

17.5.5 N- Methyl- d- Aspartate (NMDA) Receptor 481

17.5.6 Peroxisome Proliferator- activated Receptors (PPAR) 482

17.5.7 Serotonin Receptors (5- HT) 482

17.5.8 Transient Receptor Potential (TRP) Cation Channel Superfamily 482

17.5.9 Opioids and Opioid Receptors (OPD1, OPK1, OPM1) 482

17.5.10 Acetaminophen and the ECS 483

17.5.11 Gabapentinoids 483

17.6 Cannabis Safety and the Veterinary Technicians Role in Client Education 483

17.7 Harm Reduction Education (HRE) 485

17.7.1 THC Intoxication 485

17.7.2 Cognitive Perception Modulation 486

17.7.3 Product Guidance 486

17.7.4 Dosing 487

17.7.5 Monitoring 488

17.8 Acupuncture 488

17.9 Supplements for Pain Management 489

17.9.1 Omega- 3 Fatty Acids 489

17.9.2 Palmitoylethanolamide (PEA) 490

17.9.3 Turmeric (Curcumin) 490

17.9.4 Glucosamine/Chondroitin and Undenatured Collagen- based Supplements 491

17.9.5 Kratum 491

17.9.6 Magnesium 491

17.9.7 Green Lipped Mussel Extract 492

17.9.8 Passion Fruit Peel Extract 492

17.9.9 Avocado/Soybean Unsaponifiables (ASU) 492

17.9.10 Yucca Schidigera 493

17.9.11 Melatonin 493

17.10 Conclusion 493

References 494

18 Pain Management for End- of- Life Care 507
Brooke Quesnell and Danielle DeCormier

18.1 Hospice and Palliative Care 507

18.1.1 Veterinary Staff in the Hospice and Palliative Care Environment 508

18.1.2 Work Areas 508

18.2 Technicians’ Roles in a Hospice and Palliative Care Practice 509

18.2.1 Patient Presentation and Evaluation 509

18.2.2 Planning of Care 509

18.2.3 Delivery of Care 509

18.2.4 Caregiver Education and Training 510

18.2.5 Setting Up the Physical Environment 510

18.2.6 Social Environment 510

18.2.7 Support for the Family 510

18.2.8 Pain Recognition and Management 511

18.2.8.1 Neoplasia 511

18.2.8.2 Osteoarthritis 511

18.2.8.3 Analgesia for Specific Procedures and Special Problems 511

18.2.9 Advocacy 512

18.3 Euthanasia and Analgesia for the Dying Patient 512

18.3.1 Euthanasia 513

18.3.2 Natural Death 514

18.3.3 Pain Management for the Dying Animal 514

18.4 Support for the Family of the Dying Patient 515

18.5 Conclusion 515

References 516

19 Selected Case Studies in Analgesia 517
Tasha McNerney, Darci Palmer, and Stephen Niño Cital

Index 529

Stephen Niño Cital, RVT, RLAT, SRA, CVPP, VTS-LAM

Is a Veterinary Technician Specialist in Research Anesthesia and Certified Veterinary Pain Practitioner. He is a Lab Manager for Howard Hughes Medical Institute at Stanford University and is an administrator for the Veterinary Anesthesia Nerds, LLC. Stephen is also a partner at Remedy Veterinary Specialists leading the pain service in the San Francisco Bay Area of California.

Tasha McNerney, CVT, CVPP, VTS

Is a Veterinary Technician Specialist in Anesthesia and Analgesia and a Certified Veterinary Pain Practitioner. She is a board member of the International Academy of Pain Management and founder of Veterinary Anesthesia Nerds. She is the Training Director at a large specialty referral hospital in the Philadelphia area.

Darci Palmer, BS, LVT, VTS

Is a Veterinary Technician Specialist in Anesthesia and Analgesia and a Clinical Teaching Specialist at Tuskegee University College of Veterinary Medicine. She is Executive Secretary for the Academy of Veterinary Technicians in Anesthesia and Analgesia and Administrator for Veterinary Anesthesia Nerds. She works as a private consultant, author, and lecturer in Auburn, AL.