So thank you for joining us for the analgesia for the dental patient lecture. We're all doing a lot of dentistry in first opinion, and I think there's some room for improvement sometimes with how well our patients are controlled with their pain management. So hopefully this will give you an insight of anything we could be doing differently and sort of open up different thought processes and conversations we could be having in practise as to how we manage the pain control for our dental patients.

So we'll get started. My name's Stacey. I know it's a bit odd as we can't see one another.

I qualified as an RVN in 2014, completed my feline nursing certificate and my MCAT in anaesthesia and dentistry. I've worked in first opinion practise, and then a combination of first opinion emergency and referral all bundled into one. And now I am a referral anaesthesia and dental nurse at Perry Referrals specialist veterinary dentistry and oral surgery.

That's me on the right at the front, that's Rachel Perry, who I work with, she's a European dental and oral surgery specialist. And we also provide in-house CPD. So as I said, we work as Perry referrals and we primarily at the moment work out of North Down specialist referrals, which is a multidisciplinary centre in Bletchingley in Surrey.

So the objectives for this lecture is what is pain and why should we avoid it. Different drug choices that might be available to us, different side effects for each of those drugs, and what doses we could look at using. Now the doses I'm speaking about are often less than the formulary.

They're doses for dentistry, for other surgeries, different doses may be appropriate. And they're doses that we would recommend using for our own patients. So there was always going to be room for manoeuvre with drug doses.

Don't get too hung up on them. This is just an example of what we use should we use those drugs. Let you know the routes of administration for those drugs, and we'll also talk about local nerve blocks, which is something that nurses can do if we're trained appropriately.

And we mustn't forget that the pain and the whole procedure doesn't stop when we turn off the gas and all the sutures are in. We then need to manage them in the hospital post-op and once they've gone home. So we'll cover on all of those points today.

So pain is an unpleasant sensory and emotional experience. I imagine that unfortunately all of us have been in some sort of pain. It could be minor when we get a paper cut.

It could be huge and we've had some sort of trauma or we've broken a limb or a bone in our body, and we all know it's not pleasant, and we can't explain to them either what's happening. And I think with human patients we can. Know what's happening, know it can be managed, but I think it's quite scary for the patients, or the animals that are our patients and the clients, the owners of those patients.

They're also likely to be suffering chronic pain by the time we've recommended a dental surgery that the owner has accepted the fact that they need a dental, and when we've been there to book them in, particularly at the moment, I think we're all quite overbooked. So by the time we see them, we may also have to deal with chronic pain, so we're already on the back foot. And what causes pain in dentistry?

Well, loose teeth are painful if you've ever had one, it's not nice, resorptive lesions, tooth fractures, jaw fractures, any tumours or masses in the mouth. Scaling, I don't know if you've ever had it done at the dentist is quite sensitive, and that's in the mouth that we clean 2 to 3 times a day. So you imagine the work that's needed in these patients that we see when they're not cleaning their teeth every day.

Mentioned fractured already, abscesses are very uncomfortable as well. They feel quite pressurised and tender. Exposed roots from periodontal disease, root planing, and dental extractions are all uncomfortable and are causing pain to alleviate pain sometimes.

So we need to alleviate this pain, there's chronic pain, there's surgical pain, there's post-op pain as it delays healing, it's emotionally distressing. It can cause self trauma, if something's hurting, they keep trying to rub at it. They could then have the inability to eat, or they remember that when they went to eat, it hurt and then they don't want to do it anymore.

And all of that really lowers the quality of life, and the whole point of us being there is to improve the quality of life for our patients. So signs of dental pain that they might. Talk to you about in a nurse consultation or for a dental check?

Are they favouring one side when they eat? Do they have a buildup of calculus on one side? Are they hyper salivating, or is there a change of smell or texture to the, the saliva they're producing?

They've got really bad breath. Do they go to eat and they look hungry and excited and then think, oh, no, I can't, it hurts, or do they pick a bit up and drop it? Often with cats, they will eat very fast, no chewing, throw it to the back and then vomit it up very shortly, and that's actually a sign that there could be some dental pain there.

And we find that some cats with mild dental disease may have removed one or two teeth due to absorption. The owners said that, yeah, they used to eat really fast and throw it all up on the carpet, and postoperatively, they'd actually stopped doing that. They took their time and they chewed their food and they didn't rush it.

They didn't try and get a painful. Experience over quickly because they were no longer in pain. They might not be moving around as much, not playing as much.

They could be pouring at their face. There could be a real change in character. And sometimes it's absolutely no sign because they're worried that they'll be seen as weak.

There's that pack mentality in some animals still. And the only difference is noted postoperatively when the owner goes, My God, I hadn't realised. The difference in my animal until you've treated the pain of the teeth.

And that's always lovely to hear that we've done a good job, but it's quite sad to think that they've been suffering in silence for a while because they just weren't telling us. Really important to pain score our patients. We pain score all of our patients, postoperatively before they're allowed to go home and we'll top up their analgesia prior to discharge if possible.

There's some different ways of pain scoring. We quite like the pictorial ones that gives you a number, and if you're over a certain number, we administer more pain relief. They're available for dogs and cats.

Cats, the new one is really good, because they're talking about their ear placement and how they're holding their face and their whiskers. And we had this poor chap come in the other day, he's got really sore, gingivar dermatitis, and this was him on the table, just for his pre-op check. And we hadn't met him before, he wasn't on any pain relief, and you can see he's really not happy, he's really scrunched up, his thigh isn't the best condition, his ears are completely flat and he's holding his whiskers in real tight.

He's he's not a happy boy. So we've talked about the fact that we need to alleviate the pain, but what, what drugs should I use? So we're gonna go through the more regular drugs that I feel people may have in practise.

And obviously I won't say it for every drug, but some of them are scheduled and controlled drugs, so we need to be careful how we're storing them, dispensing them, logging them. And also it is the veterinary surgeon's place to prescribe and choose the drugs that we're giving, how we're giving them and the dose. But then why do nurses need to know about it, but they feel it's super important to know what to expect from your drugs, to be able to have that team communication about what might be appropriate pain relief for your patient and have an understanding of how that drug works, side effects to look out for.

And it's often us that has to administer the drug, so we should know the best way of doing that. So I think that's why it's important we educate ourselves as much as possible about these drugs that are going into the patients that we're monitoring together with the vet. And as I said, I reiterate, before we talk about drugs, it is the registered veterinary surgeon's place to prescribe and choose the doses and routes.

So we do need to go by what they say. So after the agonists, you might think is a bit strange because we're talking about analgesia and not sedation, but they do hold a degree of analgesia, and they do hold a good level of sedation, as we know. We use much lower doses than the formulary, and we have really good, sedative effects with it, and we have very smooth anesthesias.

And that's meatomidine or Dexedatomidine or Dexomidor. And one note, if you're ever administering an alpha 2 agonist, please always draw up the antecedent at the same time and keep it with you. Probably won't need it because you've got it ready, but always have it with you.

You do not want to be trying to find that, should you need it in an emergency, it should be right there. So medicamidine I've focused on, we use it the most at the moment. It holds holds a dose dependent sedation, really good muscle relaxation, and as I said, it does have that element of analgesia.

There will be improved levels of sedation and analgesia when combined with an opioid, and we will talk about the opioids next. Cats, we will offer a 2 to 5 mcg, so that's micrograms per kilo ivy, and dogs 1 to 3 mcg per kg IV. Now you may be reaching for your appetites more when you have a frac patient that you cannot place an IV in.

So yes, higher doses will be required. For us, we normally have an IV catheter in thankfully, and therefore they are the doses that we will use as a premedication leading up to induction. The duration of the drug is dose dependent, a higher dose will last longer.

So if you're used to using much higher doses that's suffering the cardiovascular effects of that, if you change to lower doses, that's great, you'll have a much nicer ride, but bear in mind you may need to top it up if you're using a smaller dose. And once they're under anaesthesia we very, very rarely would give more than 1 or 2 mcg per kilo IV once they're under the anaesthetic, and we would give that incredibly slowly. And ensure that we're reducing our gas, our IO or CO once we've administered that.

Potential side effects of course bradycardia, reduced cardiac outputs, but it is incredibly max vaing, which is a good thing. But by up to 70%, which is a huge amount. So if you're using an alpha 2 but not reducing your usual levels that you might normally need for ISO or Sio.

Then you could be producing too deep anaesthesia. So although it's not a side effect, it's definitely a fact to be aware of. It's not recommended in some cardiovascular disease or diabetics, it changes the production of insulin, not recommended for the pregnant patients or patients that you do not wish to vomit.

It can make them vomit. We don't wish that, for example, in head trauma. If they do vomit, and they don't seem that sedated yet, that's OK.

It's, it's a sign that it's on the way to the brain, so hopefully they're not too distressed to clean it up, work their face and they should drift off into the sedation if you're giving it IM and that's what you're waiting for. And the big question we always get asked is, do you reverse it? If we do, we don't reverse it, Ivy.

We also have to remember that we are reversing the analgesia as well as the sedation. There's normally a good reason that you gave an alpha 2, so remember that you would then have an unsedated patient on the table, so you'll need more of your indolence. And you may be having a more rocky recovery.

So we'd only really reverse it in an emergency or if the procedure was far, far shorter than we thought, and we switched off the gas and our patient is still fast asleep than we would normally, half reverse IM to see what happened there. As long as there's appropriate analgesia on board and we're comfortable that that's not gonna enter them into a rocky recovery. So as promised we'll move on to the opioids and we'll talk about new agonists and that's class in different opioids.

And what does this even mean? It means it has a, the mu agonist is a high affinity and intrinsic activity for m receptors, but that's fine, but what does that mean? Affinity is the extent to which the drug will bind to its receptors, so a high affinity is good.

Intrinsic activity is the ability of the drug receptor to produce a maximum response. So again, having a high intrinsic activity is good. So a mew agonist is very good and a pure mew opposed to a partial is the better.

Methadone is a PMU agonist. I think it's something that a lot of us in the UK have in stock. It's appropriate for moderate to severe pain, so we use it on all of our dentistries, I would say, as a blanket statement.

Dogs and cats between 0.1 to 0.3.

Normally we start at 0.1 in cats, 0.2 in dogs, if we're giving it intravenously, if it's going IM we give 0.2, unless they're very fractious, then we might go up to 0.3 to have the increased sedative effect IM.

And then it's every 3 to 4 hours, and once I've administered methadone, I would always write on the hospital form 3 to 4 hours later I will pop them down with a highlighted square to have a pain score. Potential side effects, respiratory depression and bradycardia, particularly when you're giving it once they're already under the anaesthetic, so give it slowly, dilute it if you're worried, and then you can monitor the effect and slow it down or stop if you're seeing an effect that you're not comfortable with. I find with dogs, because it changes their thermoregulation and makes them think that they're actually really hot, they do start panting when they're conscious.

So if I'm using meatomidine with methadone, I will give them meatomidine first to try and sedate them prior to them feeling like they're panting, because that can be a bit stressful, I think. Morphine. Not something that we use, to be honest, because we have the methadone.

I'm also a new agonist and appropriate for moderate to severe pain. Dogs, 0.1 to 0.3 mg per gig, very slow IV.

Otherwise, if it's given too quickly, you can have a histamine release. Or you can give it IM every 2 hours, but that's also, as we said, depending on the pain score. Everyone is individual.

Caps slightly lower, 0.1 to 0.2, we picking IV or IM again very slowly IV every 3 to 4 hours, but again depending on the pain score.

It can offer respiratory depression, but we can manage that by IPPV and monitoring it. The big thing with morphine is it can make them sick, and I think it makes them vomit far more than methadone, which is why it's not a drug that we would reach for as our first choice. It can also cause a reduction in GI motility if it's used over a longer duration, and a prolonged effect if impaired liver function on your patients.

So just be careful if you've got any liver disease patients. Fentanyl. Now this is a PMU agonist as well.

It's 50 times more potent than morphine, so you don't need as much. Every drop is stronger. Provides a profound intraoperative analgesia and has a very rapid onset, but a very short duration, for up to about 20 minutes.

Now again, because it's every drop is very strong, we're talking low doses, so we're back to the micrograms. Dogs and cats, 1 to 5 mcg per kilo IV every 20 minutes. Or, because that's not appropriate to keep having to give that, you can put them on a constant rate infusion, which we'll talk about in a moment.

There's also transdermal patches available. I mean I've seen them used quite often. It's not something I'd put on and anticipate them to be completely comfortable with that because the uptake can be varied, but it's something to be aware of during surgery as if you're placing anything particularly warm like a heat pad or, or the bear hugger particularly near there, or any other heating devices, it can cause vasodilation, which means, that it could be absorbed quicker.

So potentially they could be getting a bit of an overdose. So something to be aware of. So fentanyl at a constant rate infusion, we call them a CRI.

You must do that with a syringe pump so that you can offer it in an accurate manner and also not waste a load of fentanyl by drawing up into a whole bag of fluids. Loading dose again, it's micrograms, 1 to 5 mcg per kilo, and that's IV. And then to maintain them at 6 to 10 mcg per kg per hour IV and reduce that down to 1 to 5 mcg per kg per hour IV for the post-op period.

Potential side effects, respiratory depression, we can handle that with IPPV bradycardia. We can handle that with an anti-cholonic, or even some very rare cases of asystole on rapid IV administration. So like everything you're given intravenously, give it slowly, we can then titrate it, we can give it to effect and we're far less likely to see any reactions.

And if it's a tiny dose and you're struggling to give that loading dose slowly, dilute it. So buprenorphine is a partial new agonist and is appropriate for mild to moderate pain. We don't use it for surgery, due to its high affinity, we cannot use a pure mew after its administration and expect to see the full effect of that pure muse.

So that means we can't top it up. So if the buprenorphine wasn't enough, it's kind of game over for the opioid choice, not a position you want to be in. But the doses that we use, when we're giving it, if we're just taking X-rays and absolutely not taking any teeth out, and also postoperative, we find it's really good, pain relief, particularly for cats.

It's 0.02 m per kg IV IM or subcu, and transmucosal is really good in cats. Even in dentistry, because it is a liquid, it's not a tablet.

It's just twice a day and we tend to suggest it for 3 days after surgery. It can last between 6 and 12 hours. I think you all agree it's quite patient dependent.

Some cats can be quite sleepy with it, and they really don't need it until 12 hours, and some are uncomfortable at 6 or 8. Patient dependent, surgery dependent, so tailor it to your, your patient's needs. It does have an onset time of 40 minutes though, so you cannot start if you are only using that for extractions and you're unable to offer any better pain relief, then remember, you do need to allow the time to go by.

Potential side effects, I think the multi-dose vials sting on injection and don't taste nice. We use the, the single vials, and it can cause mild sedation in cats. So ketamine is a dissociative anaesthesia.

It can cause profound visceral and somatic analgesia. And remember we're talking about analgesia doses here. I'm aware that ketamine is very good.

For disassociative anaesthesia and sedation, but we're talking about pain here. So, a bolus dose at 0.3 to 0.5 mg per kg IV.

Higher doses are used if you're doing a complete coinduction with propofol, but that's not what we're talking about. We're talking about an analgesia dose. That will last you around 30 to 40 minutes.

Potential side effects are apnea, particularly if you give it quite quickly IV again, dilute it if you feel you can't give a small dose slowly and keep an eye out for that and we can support them with IPPV. It's usually very transient between 5 and 15 minutes. Again, it's max Being.

Be careful with how high you've got your inhalant. You can see some rare cardiovascular effects. So keep an eye out on your ECG and listen to the chest.

You can see dysphoria or excitement on recovery and muscle rigidity. It's not appropriate for patients who may have raised intraocular pressure. So just make sure you've got a good sedative on board in your pre-meds and that enough time has passed before you're waking them up.

So they're not waking up with solely the ketamine left on board. Otherwise you will be in for a stormy recovery. It's a drug that I really do like using, if I'm worried that the local nerve blocks aren't going to work due to the amount of infection or inflammation or the.

Deformity of the skull, then we'll include this in the induction, and it really is lovely. Yes, we see a bit of apnea, but we can manage that, but they have a really smooth anaesthetic from a pain relief point of view if ketamine is appropriate for that patient. We can give it as a CRI too for our long procedures.

0.3 to 0.5 me per gig is the loading dose, and 2.5 to 10 mcg per kilo per minute intravenously as a CRI reducing to 2.5 mcg per kilo per minute for recovery.

Women not causing the pain anymore, the surgical stimulus, they don't need as much, but if you suddenly stop it, they're gonna become very uncomfortable, so gently release it. So NSAIDs, non-steroidal anti-inflammatory drugs. There's different brands available, particularly at the moment, it really seems to be what you can get your hands on.

We're really keen on using liquid form because we don't want owners having to put hands in mouths or pill poppers in cats or shoving hard tablets in mouth after we've just done some gentle oral surgery. Some benefits are that it's got a long duration of effect. It's often given just once a day.

It is an anti-inflammatory and we can cause a lot of inflammatory of the tissue when we're extracting teeth and creating flaps. There's no behaviour modification, there's no respiratory or cardiovascular side effects. As I said, the liquid formula is ideal for post-operative care for dentistry.

Easy for the owners to administer. Definitely do not use it in combination with steroids, and if you're moving between one non-steroidal, there is a washout time which will vary between different non-steroidals, so make sure you're aware of that. There is the potential for gastrointestinal side effects, and we must be careful with patients in renal disease.

It might be that we don't give it to those guys. Avoiding patients who have been in shock, might have a coagulopathy, risk of haemorrhage, dehydration or hypovolemia. And have they had a negative reaction in the past?

I read all the history for our patients a week or so before because we know who we've got quite far in advance, and I look into their anaesthesia form and how the anaesthetic went, what they went home with, if their post-op checks said that they had an upset tummy or were vomiting, then we will try and avoid the, the same non-steroidal in the hope that that won't happen. Paracetamol, not something I'd heard of until I entered a more referral setting for animals. The dose is 10 meg per gig every 8 to 12 hours, and we give it IV perioperatively.

There's a nice liquid formula that can just be put on their dinner, and smaller strength tablets are available for smaller dogs too. But to be honest, if it's a smaller dog, we tend to just give them the liquid because it's easier to put on the food, or if they won't eat, you can just gently put it in their mouth. And again, we like to avoid.

Tablets when we've performed oral surgery. It's very cheap, so it's not expensive to the practise or for the owner. You do need to be careful if they do have liver disease, though.

It must never, ever, ever be administered to cats. They cannot metabolise it, so it will poison them. So do not use it in cats.

And when we, prescribe it to dog owners, we put on the label, never administered to cats in case they think, Oh, well, my dog had paracetamol, and that was fine. It would be fine for my cat and that would just be terrible. If the owner says I'm I'm not paying for the paracetamol and no thank you, I've got some at home.

That's fine as long as you're very clear and you get written instructions and your practise is happy with that, but ensure that they don't have any additives in that, such as codeine or caffeine or anything else that might be. And also let them know that ibuprofen is not appropriate for our patients. Tramadol, there's mixed reviews about how well tramadol actually works.

It is a weak new agonist for mild to moderate pain. Dosages for dogs are 2 to 5 mg per kg every 8 hours, and cats 2 to 4 mg per kg every 8 hours. But they don't feel like cats tolerate it very well.

It's very bitter, and again, we're back to the tablet situation. Potential side effects are vomiting and dysphoria in cats, sedation, and we have to be careful if they're epileptic. And care using alongside trazodone, buprenorphine, fentanyl.

Amitriptyline, it can cause a serotonin syndrome, which can cause potential seizures, which could lead to death. So it's always worth looking at your drug interactions, what you can and can't give together. Gabapentin has really picked up speeds of being used recently.

It's really good for neuropathic a cat that's had lots of dental extractions, or maybe you've gone near a nerve, or perhaps you've done surgery where unfortunately, lots of roots have been left behind previously and you've had to rummage to go and and get them after you've found them on the radiographs. And I know that gabapentin is used for pre-op checks. And given preoperatively for cats.

But we are talking about a pain relief level here. So dosages for dogs are 10 to 160 mg per kg every 8 to 12 hours, and cats, 5 to 10 mg per kg, and this is obviously peros every 8 to 12 hours. And as I said, higher doses are used to sedate the cats and to alleviate their stress coming into the clinic.

Potential side effects at high doses in particular, sedation, ataxia, and the absorption of gabapentin is actually affected by antacids, so dose this 2 hours after you've given the antacid, if they're on that too. Brophenol, I'm not a fan. It's poor analgesia.

It's good if they've got a cough, but if they're coming in for dentistry, I'm not that worried about their cough, I'm worried about the pain that we're giving to them. It is a good sedation in combination with an alpha 2, but it's actually a new antagonist, not. Very good for your dental surgery as it will reduce the efficacy of your pure new opioids, and we've discussed why they're so good.

So I don't know why we would want to give them something that would reduce the efficacy of that. We're never entirely sure what we're going to be doing when we start a dental surgery. And you might think, oh, I just take some reds.

Oh, there's just one loose incisor. I just get that why I'm here. That's going to be uncomfortable because you haven't given them any analgesia if you've just used buorphennil.

So I don't recommend its use personally. The local nerve blocks, something that is the gold standard, happens a lot for human dentistry, which is why we don't have to go under anaesthesia. But it's so lovely working with a vet who will supply local nerve blocks.

You know, they're not always successful for whatever reason, so we do have to be prepared, which is why we need to learn about all the drugs we've just discussed together. But local nerve blocks will give you the best time for your patients, and we'll discuss them in more detail. The benefits that it will block the transmission of the oxygen stimuli before incision.

It is max sparing. One study found that to be at least 23% when using bupa the cane, so that's reducing the amount of inhalant that you need. It will give you a smoother anaesthetic because they can't fill the area that's had the surgery.

Therefore, a better recovery. This is a good multimodal approach, and it will reduce your other drug dosages requirements as well. But there's a good reason that people are worried about them and want to be fully educated before they give them, and that's that there's damage to other tissues such as globe perforation.

Inadvertent numbing of the tongue, and the animal then can't feel its tongue and causes significant trauma in recovery. Cardiovascular effects if inadvertently administered into the arteries or veins. We can cause a hematoma, which is quite uncomfortable.

Damage to neurovascular tissue and if not calculated correctly, we can give them an overdose. So, we can try and eliminate some of those risks by always aspirating back and check there's no blood prior to administration. Calculate your dose for all patients, and that is your overall dose for the entire mouth.

Consider the length of the canal for all patients and keep a wide range of length and width needles for dentistry, local nerve blocks. Always label the syringe, always, always, always, always for all drugs, the last thing you want to be doing. If it's the end of the day and we've got another dental to do, you know you've got all the cleaning to do and, you know, there's lots of distractions, is someone to reach for the lidocaine or buppivocaine and to give that IV instead of another drug at induction or pre-medication time.

So please label your syringe. And allow time for it to onset as well. You can't just give a local block and expect a half a minute later to start making an incision and it not be painful.

So there's different nerve blocks that we can use. We tend to do infraorbital and in. Alveolia.

I'll start that again because my cat jumped away, sorry. Did what had happened there. Yeah, if you could that'd be great.

Yeah, it's fine, sorry, he, he lives with a rabbit and then he, they scared each other. No problem, sorry, so. What nerve blocks can we use?

We tend to use infraorbital and inferior alveolar blocks. The infraorbital block will desensitise all dental structures of the maxilla, but be careful with caps and brachycephalics as you are quite near the globe of the eye. It may not reach M1 and M2 in the dog, however, in the larger dogs.

The inferior alveola will desensitise hard and soft tissues of the mandible, and the maxillary will desensitise all dental structures of the maxilla, plus the soft and hard palate. So when might the blocks not work, if they've got a very deformed skull like the brachycephalic or teacup breeds, if their tissues are very infected or inflamed, if they have an oral tumour that might be blocking the pathway. Recent trauma, lots of swelling.

Not placed correctly, therefore might not work. And you can always think about trying a local infiltration or a splash block if one of those reasons above is preventing you from placing a local nerve block. Now volume wise is different to dose.

So cats and small dogs, up to about 6 kg, we would say 0.1 mL per site. Dogs 6 to 25, 0.3 to 0.6 mL per site, and larger dogs above 25 kgs, 0.5 to 0.8 mL per site.

As long as that meal per site does not exceed your total, the maximum meg per kg, so you do have to do some calculations to make sure we're not giving them an overdose. Now, you can use lidocaine. Maximum total dose 2 meg per gig.

Very quick onset, which is good, but the duration is only 30 to 120 minutes, so it's not gonna last as long into the recovery, or if it's a very long procedure, perhaps it's not even gonna last the duration of your procedure. Potential side effects are CNS effects hematoma, and obviously if you inadvertently give it intravenously in a cat, we could be heading into trouble too. This is why you always draw back and make sure there's no blood.

Buppica nerve blocks, maximum total dose that we use is lower than other literature would say, 0.75 mg per gig in cats to avoid any cardiovascular effects or any toxic effects, 2 mg per gig in dogs. The onset, in the literature is 6 to 10 minutes.

Honestly, I think from an anecdotal personal experience, I think it's nearer 20 minutes. Duration is better, 4 to 6 hours, and I have seen it last up to 12 hours. It's, it's all patient dependent.

Potential side effects is the inadvertent intravascular injection which can cause severe cardiac arrhythmias that are refractory to treatment, meaning they won't resolve by treatment and we can cause death, which is why we must label everything. People often ask, what if I mix the two? Will it work quickly but last longer?

What if I put adrenaline? Will it last, stay in the local area more? What if I put buprenorphine?

Does that make it work better? What if I put an alpha 2 in? From what I've established from talking to anaesthetists and dental specialists, and looking at literature, there's currently no studies yet to significantly prove that mixing two local nerve agents or adding in the buprenorphine or in alpha 2 have any.

Superior benefits. It would be lovely if there's something we could do to improve, to make it work quicker and last longer and just to be better if that's an improvement out there, that would be great. But as far as I'm aware at the moment, there's nothing confirmed.

As I have said, always label all your drugs. We've spoken about a lot of drugs and some patients, as you can see on the left, that was for one patient, have a lot of drugs. Particularly if they have a lot of other disease processes we're managing or we have concerns, or we're performing some big surgery that's going to be incredibly painful, they're all labelled.

Now you can have fancy labels that it's printed on, like the colourful ones. You can have a plain one and you've filled it in yourself. Or if you can't find that and you don't want to leave your patient and you've had to draw up a drug, that's just the back of a rectal thermometer probe.

It's better than nothing, so make sure it is always labelled with something. I don't put the label on the needle cap because that needle cap could fall off, and if it's a clear liquid, we're not gonna have a clue what it is. And what if it's flush or what if it's meatomidine?

We could be in a right pickle. So I don't care what it's labelled with, label it please. What drugs used for dentistry and anaesthesia are not an analgesic.

Your inhalant certainly isn't, so just being told to turn up the gas because then they won't feel it is not true. They just won't be telling you as much, but their blood pressure will be having a dreadful time. So the inhalant does not offer any analgesia, certainly not with iso and civo.

Propofol and nalfaxolone, your induction drugs do not. ACP, one of your pre-medication drugs does not. Midazolam does not either.

And steroids, they do not provide post-op analgesia, so we do not offer them for analgesia at all. So you've used your usual drugs, but my patient is still painful. I'm not having a nice anaesthetic, what can I do?

If we haven't done a nerve block, could we? Have we suddenly realised we started on a side, we hadn't realised we'd be working on and we hadn't blocked. It's never too late, pop it in.

Do we need to top up the analgesia? Did we start with 0.1 mg per gig of methadone and actually there's much more work than we needed, and I have done a block but it wasn't overly successful, so maybe we need to give another 0.1 meg per gig of methadone.

Don't just keep giving the same drug with a higher and higher dose if it's not working, you'll end up with a very dysphoric dog and you're potentially going to have more side effects by using a higher dose of one drug. Try a different drug. If one drug doesn't get you anywhere, the opioid isn't doing anything, the local block, you haven't done it or you did, and it just doesn't seem to be working.

Maybe reach some ketamine if it's appropriate. Surgical technique, we can't control that, I know, but there is a vast difference for a surgeon that operates very gently opposed to one that does not, and that's often to do with the tools that they have as well. And as nurses, we are in a place to look after the equipment.

And there is another lecture of the role of the RBN in dentistry that you could watch if you'd like that will help you to prepare everything so that everything runs as smoothly as possible. And are they in pain or has your pre-medication sedative just worn off? Did you use a very low dose of meatomidine, which had a beautiful effect, but after an hour it's kind of worn off, your heart rate's back up, and I feel like they're not very well sedated.

I'm needing more iso, my blood pressure's dropping a little. It might be that you need to top up their sedation if you've been there for a while. Patient positioning as well, are they arthritic?

Have you twisted them a little bit abnormally? Do they need some padding under their spine between their legs? Do they have a full bladder?

Are they trying to go for a toilet? And do they have any other problem areas? It's nothing to do with dentistry.

Do they have arthritis? Have they got a wound somewhere else or is somewhere else particularly tender? So we just need to take in.

Into account the entire patient, not just the mouth. So, for example, for cats, 5 year old cats who's had multiple extractions, postoperatively, this is what we're talking about now when they're going home, what could I send them home with? Well this little chap on the right, Simba, his pre-op bloods were unremarkable.

His clinical exam was very clear. He had a very steady anaesthesia, he remained normotensive and I'm very happy with him. So here we go home on a non-steroidal ideally in liquid form.

We don't give our non-steroidals until postoperatively as it can interfere with your blood pressure and you're more likely to control levels of hypertension without having a non-steroidal on board. We would then give them injectable loxicon, for example, post-op meloxicam, and then let the owner know to start it. The next evening, so 24 hours later.

We'd add in buprenorphine if we thought the cat would tolerate it, and if they wouldn't, we would perhaps look at gabapentin if we've done multiple extractions. So we've got multimodal analgesia, not just in the hospital, but at home. This little fellow, 3 year old dog, he had a car natural extracted because it was fractured and it had a nasty tooth throat abscess.

So this is just the analgesia that we're talking about to go home with, again, a non-steroidal, ideally a liquid. I don't want to be put in a tablet and potentially disturbing those sutures if we can help it, and if they can tolerate the liquid form. And we also send our dogs patients that have had extractions home on paracetamol, whether that's liquid or tablets.

The tablets are quite small, they're normally capsules you can hide them in food. Or if you're worried, and it's not a huge amount. So if that's sort of 8 kg and under the liquid, you can dispense for them.

And they can normally start it that night if you've used an injectable form. It's 8 to 12 hours between each dose. And remember, no paracetamol for cats.

And sometimes they just want a hug. They've woken up, they've got all the pain relief on board, and they're scared and they're used to being carried around or being in their bed at home. So this little guy on the left would always just completely relax when he had a cuddle.

He was a happy, happy boy. He had a fractured jaw. He'd been through a lot.

He'd had his eye removed. He had a feeding tube in place, but if you cuddled him, he was purring and he was happy, and he'd even start licking a little bit of food. And this guy on the right, he just wanted to be snuggled up in a big soft bed.

He's obviously a skinny little boy, and that was what made him the most comfortable. So think outside of the drugs and and the holistic care, as well as the medication that we can offer. And then discharge instructions.

We need to give really clear medication guidance. We might be really bored with all the drugs that we use on a daily basis, and it becomes obvious to us how to give it and why you would give it that way. Well, the owner doesn't know, they're not medically trained.

This is all brand new to them. They may never have medicated their animal before. And they're gonna be worried as it is, the baby has had surgery.

To guide them with a discharge instruction in written form and speak them through the main aspects of that for the correct care. This will help calm the owner. Tell them when to start each medication, what each medication will do.

So this is anti-sickness, this is for pain relief, this is another pain relief, this is an antibiotic. I think if they understand why they're giving it. They're more likely to give it appropriately and tell them how to give each one.

Can it go on food? Doesn't need to be on an empty tummy. Can you syringe it straight into the mouth?

And when we're dispensing meloxicam, physically show them that syringe. Show them where they need to draw it up to, because I think we've probably all seen the patients that have come in. Having 3 syringes instead of 3 kg dose for a cat and then have to have, you know, treatment for a meloxicam overdose.

So I think we must show them. Even if they've had it before, at the minute, there's a big shortage of different non-steroidals, so always tell them, only use this syringe in this box, and this is how you use it, and that prevents any inadvertent owner overdosing. And where possible, follow up these guys, if, if someone can call them the next day.

Or maybe the, the following 2 days, 2 days after. How are you doing? Are they eating?

Are they comfortable? Do you, are you happy with them? How are you finding the pain relief?

Because sometimes they say, oh, I couldn't give it. And then you can think of something that they might be able to come and collect instead, instead of just being painful at home, or you can suggest a way of how to give that trans mucosal buprenorphine if they haven't been able to achieve it on their own. So there's some literature available on ECGs and hypertension and catnography, and I'm very passionate about keeping my patients warm, so if you're interested, you can take a look there.

And thank you for listening to this analgesia talk. I hope it's been helpful, and there's some tips, that you can take back to practise to talk about together, and you're more aware of what your drugs that you're being asked to give do achieve and how to look after patients that are being administered them. So thank you very much and thank you to the webinar vet for having me.

If you have any questions, if I haven't been clear, or you'd like to discuss something, I'm always up for a chat, so my work mobile number is on there, you can send a text or a WhatsApp or feel free to email me as well. Thank you very much.