Greetings all you webinar veterinarians. Thank you for joining me for this presentation on multimodal approach to pain management in the ICU. My name is Elka Rudlof, and I'm one of the critical care specialists here at Lake Shore Veterinary Specialists in the area of Milwaukee, Wisconsin, which is just north of Chicago.

Preventing pain and providing relief from pain as well as stress-free restraint is challenging enough considering our inability to verbally communicate with critically ill animals. Analgesia is a means for treating pain as well as induce acceptance for therapeutic and diagnostic procedures. It is a common misconception that analgesia may mask physiological indicators monitored in the critical patient, such as tachycardia, hypotension, or tachypnia, but this has been refuted both in people and in veterinary patients.

Blunting pain transmission is necessary from both a humane standpoint as well as a therapeutic measure to reduce morbidity and mortality. The response to pain is highly diverse and extends beyond the nervous system. In particular, it promotes the same reflex responses associated with shock, and just as we know that circulatory shock is life threatening, so are the effects of pain.

I can't tell you about a patient where this became quite evident. A middle-aged golden retriever had just come out of surgery for a thoracotomy and pericardectomy for a chemodectoma. The dog had a wonderful anaesthetic and analgesic plan and was taking his time to be extubated.

The anaesthetist became impatient and decided to quicken the recovery process by administering naloxone, which is the reversal agent for the opioid that the patient had been given prior to and during surgery. As the full dose of naloxone was bowless, the dog acutely awoke, cried out, and went into cardiac arrest. The dog was successfully resuscitated, but that situation made it clear that pain can kill, and if you need to reverse an opioid, titrate your naloxone slowly.

And allow the patient to wake up on its own. The typical signs of pain include an elevated heart rate and respiratory rate. However, however, this can vary based on the condition.

Cats in particular might have a bradycardia and hypothermia associated with circulatory shock, which can mass a tachycardia expected with pain. Therefore, evaluation of pain requires a comprehensive assessment of the patient. This can include the patient's response to palpation, posture, and behaviour.

In addition, there are a few validated pain scoring systems available that allow quantification of a patient's behaviour, as well as a means for assessing the response to analgesic techniques. The Glasgow Composite Me pain scale is one of those systems that has both a dog and a cat scale, and this is one that we use in our ICU and it's fairly easy to, to use, and the nurses will perform a an assessment every time that they are handling the patient as well as when it is time to provide pain medication. In addition, it can tell us their response to any sort of intervention because we may start with a higher pain scale and intervene, and then we can reassess and see if that pain scale has dropped down.

In cats particular attention is paid to the ear position, the orbital tightening, muzzle tension, and whisker and head position, since they are not as obvious in their. Expression of pain. So let's take a closer look at how we might interpret the cat's facial expressions.

With this scale that you can find, it's available on the AVMA.org website. And it uses a scale of 0 to 2, but as you can see, a normal cat will have eyes facing forward, the ears are opened, the muzzle seems relaxed, the whiskers are loose and and curved or and the head is above the shoulder line.

And then as the cat experiences more pain, their ears start to pull slightly back. Their eyes are partially opened. Their muzzle starts to become tense, and then the whiskers start to curve or straighten moving forward.

And then the head starts to compress down into the shoulders. And then the cat that's very painful, as you can see here on the right side of the screen. Their ears are flattened, or rotated outward.

They're squin they may be squinting their eyes with a tense muzzle. Their whiskers may be straighter and, and pushed forward, and then they really might be tilting their head below their shoulder line. So the administration of analgesia should always be a part of the resuscitative plan, and signs of patient deterioration should not be masked with appropriate analgesia, and the cardiovascular system will still respond to Progressive hypovolemia, hypotension hypoxia, or hypercarbia despite analgesia, whereas analgesia can improve those particular parameters if they are playing a role in the clinical signs.

A number of classic analgesic drug classes exists and will briefly review their mechanisms of action, indications, and considerations for critically ill for their use in critically ill dogs and cats. And these particular agents will work in multiple areas of the pain pathways from distally. Where they might inhibit the transduction.

Then the transmission, they can modulate spinal pathways and inhibit perception. Exogenously administered opioids utilise the endogenous opioid system as their site of action. Opioid receptors are present in the periphery, the spinal cord, and the supraspinal structures.

Mew and kappa receptors, opioid receptors are the most important with respect to analgesia. Full agonists act primarily on the mereceptor. Oral opioids are difficult to dose in dogs and cats because once they are absorbed from the GI tract, they must pass through the liver, which is highly efficient at removing them, little, leaving little to circulate, which is why codeine is not.

Good for adequate analgesia. Buprenorphine is a partial mu agonist opioid, and it binds very strongly to its receptor and provides mild to moderate analgesia for the dog and moderate and a little bit has a little bit more of an effect in cats in terms of analgesia. It does bind very strongly to the Am receptor, and if you find that it's not adequately controlling in controlling pain, it may take a while before your full mu agonist will work since buprenorphine will remain on that new receptor preferentially.

Buprenorphine, however, can take more than 45 minutes to take effect and therefore for acute. Pain control. It may not be helpful unless you use it.

In conjunction with a full m agonist for immediate pain relief and then follow up with buprenorphine. Butorphrenol is a kappa agonist and a mew antagonist, and is thought to provide some mild to moderate pain control for visceral pain. And this is based on colonic balloon dilation studies done on normal beagles.

It's a great sedative to use, but if it does provide an analgesia, it will be short-lived. And, if you are using it for visceral analgesia, it would be best to try it in a continuous rate infusion. And if you do use it as a continuous rate infusion, understand that it may have a cumulative effect and as the patient becomes more sedate, you may have to reduce the dosage.

So partial mu agonist, so buprenorphine and butterphrenol are probably not the best go to medications for analgesia in the ICU and for immediate analgesia. Methadone is a synthetic opioid that, as I mentioned before, has a, is a new receptor agonist. In addition to that, it does have some effect on the NMDA receptor, as an antagonist and can reduce wind-up pain.

And it's a general observation that cats may have less of a dysphoric reaction to methadone compared to other mu agonists like hydromorphone or, or morphine. Opioids are indicated for acute inflammatory disease processes and pre-surgical preparation. Potential side effects will depend on the type and the dose of the opioid administered.

However, unlike people, dogs and cats are not as susceptible to the respiratory depressant effects at analgesic doses. Although it's rare, patients receiving opioids systemically or via epidural injection should have their urination habits and bladder size monitored for signs of urinary retention. Because opioids can affect gastrointestinal motility, once the critically ill patient is stabilised, a multimodal approach to analgesia management should be prescribed that maintains a plane of analgesia and minimises side effects by reducing the dose of any single agent.

And the next part of this talk will touch on some of those other analgesics. Local anaesthetics infiltrated near a nerve locally block fast voltage-gated sodium channels in no susceptive neurons and prevent nerve impulse transmission and no susceptor excitation. Administered IV lidocaine causes a selective central blockade of C fibre activity in addition to other mechanisms of analgesic actions, including antagonistic actions of receptors responsible for impulse transmission.

Lidocaine produces more of a cardiovascular depression in cats and is therefore used at lower doses. Buppivacaine is not administered IV because it can have some profound cardiac depressant effects. It is only meant to be administered locally or epidally.

Useful for managing hyperalgesia and neuropathic pain syndromes, lidocaine has a short latent period and a short duration of action, but does not affect GI motility. Bivvicaine has a slower onset of action, but will last longer than lidocaine, in which case some people will mix a dose of lidocaine with a dose of bupivvicaine, knowing that as the lidocaine wears off, the bivvica will still be present. If you haven't, attempted a coccygeal epidural and a black cat, I encourage you to do that.

It's, it's not a difficult procedure. This type of block will effectively anaesthetize the urethral perineal region which may reduce urethral spasms. The needle is inserted.

And the sacrococcygeal joint or the joint of C1, C2. With the cat in sternal recumbency, palpate the space between the sacrum and the first coccygeal vertebrae. Or the space between the 1st and 2nd coccygeal vertebrae, unlike the sacral crust, which is immobile, the coccygeal vertebrae will have mobility when the tail is moved.

The area is aseptically prepared, and then wearing sterile gloves, the location of the most mobile joint caudal to the sacrum is located with the non and the non-dominant index finger is used to identify the space while the dominant hand is kept sterile for handling the needle. A 25 gauge 1 inch needle is used to penetrate the skin of the midline. The needle is directed at a 30 to 45 degree.

Angle and advanced through the inner arcuate ligament and the ligament flavum. A palpable pop may be encountered when the ligament is penetrated. As the needle is advanced, there should be little resistance upon entering the epidural space.

If bone is encountered, one should establish if the needle is superficial to the spinal cord or is it down to the level of the vertebral canal. Once the needle is correctly placed, a syringe is attached and can be aspirated to confirm the absence of blood. If blood is encountered, the needle should be removed and replaced with another sterile needle.

If no blood is aspirated, 0.1 to 0.2 mL per kg of 2% lidocaine without epinephrine, it's about 0.5 mL per cat, is infused into the.

Bivvicaine liposome injectable suspension, or neceda is an extended release bivvicaine that consists of multivesicular liposomes made of non-concentric lipid bilayers resembling a honeycomb-like matrix. They're engineered to allow buppivicaine to gradually release from the vesicles. This is, has made a profound difference in our postoperative, TPLO stifle, surgery cases and, and post-amputation cases.

It pro it provides Full analgesia for a period of 1 to 2 days post infusion, and it allows the patient to become more mobile more quickly with less need for rescue analgesia. The liposomal buppivacaine is always placed following the surgical procedure so that there's no disruption of the depofoam, which can release a large volume of the bupivvica at once. You also don't want to mix lidocaine with Noceta as it can disrupt the Depophone.

It is, it is approved in the United States for cranial cruciate ligament repairs and onchiectomy surgery in cats, but our, surgical teams will use it in as many patients as they can. The shelf life, I mean, sorry, once the bottle is opened, it needs to be used within the day, and therefore, our surgical teams will often share a bottle between patients during their surgical day, to be able to use as much as they can and, and spread the cost over a couple of patients. Non-steroidal anti-inflammatory agents are used for their anti-inflammatory, antipyrectic, and analgesic effects.

They inhibit cyclooxygenase and lip oxygenase activity to prevent prostaglandin synthesis and peripheral nociceptor sensitization. Some NSAs will also act on the central spine and they'll act synergistically with other analgesic by affecting multiple sites of pain transmission. Efforts have been made to preferentially inhibit the cyclooxygenase 2 enzyme, which is the inducible form that appears and increases in concentration in response to cytokines, mitogens, and endotoxins with normal healing.

This process, with activation of the cyclooxygenase to enzyme, though the, the production of those enzymes of those. Particles will produce pain. There's a number of non-steroidal anti-inflammatory agents available.

I just listed the three that we use in, in our clinic because they come in injectable form, and then both me and in the states, the rubbena coccib is approved for use in cats, and I know that in other countries, meloxicam is as well. Now there is another cyclooxygenase enzyme, the cyclooxygenase 1, which is constitutive and part of the normal enzyme complement of the cell present in sort of level concentrations. It's part of the local prostaglandin production that serves a physiologic function to promote blood flow during low flow states to the gastric and the duodenal mucosal as well as the kidney.

It's also responsible for thromboxin production and normal function of platelets. And there may be much interaction, interactive relations between the two cycle oxygen isoforms. And unfortunately, although A manufacturer might say that their particular non-steroidal anti-inflammatory agent is specific for inhibiting the cyclooxygenase too.

Unfortunately, it, there can be crossover and the inhibition of cyclooxygenase 1 enzyme which can lead to gastrointestinal ulceration and platelet dysfunction, and this can become More of a problem when there is decreased blood flow to a particular organ, and now we've taken away that constitutive response of the local prostag glandins and inhibited them. Drugs which undergo hepatic leucuronidation will take longer to metabolise in cats. And if we look at the profile of meloxicam, this under undergoes oxidative metabolism, and that is why we can use that on a daily basis in the cat in comparison to other non-steroidal anti-inflammatory agents.

Acetaminophen is an analgesic and antipyretic, but not an anti-inflammatory medication. Although it is frequently grouped, in the class of non-steroidal anti-inflammatory agent. Its mechanism of action is unknown.

And sometimes when we can't use the classic non-steroidal anti-inflammatory agents because there is gastric ulceration or pre-existing kidney dysfunction, we, we will sometimes try acetaminophen. For postoperative pain management or severe gastrointestinal pain associated with a severe gastroenteritis. In addition, we might use it for controlling fever.

And this, of course, is only in the dog, not in the cat. Again, because of it's, their inability to, metabolise it quickly. NMDA receptor antagonists are very useful for managing hyperalgesia and neuropathic pain syndromes.

Ketamine, is the, is, is an NMDA receptor antagonist that most of us are familiar with, in addition to, being a dissociative anaesthetic, NMDA receptors, when they are blocked, they can reduce windup and spinal transmission. And ketamine itself can also have an anti-inflammatory property preventing the exacerbation of inflammation. The doses of ketamine used are quite low for their NMD receptor, NMDA receptor antagonism.

And if you have a patient with pre-existing heart disease or increased intracranial pressure, that this, the low dose of ketamine really should not affect those negatively. Amantadine is an oral form, but it can take a number of weeks before you can actually appreciate its effects. And therefore, its use in the ICU unfortunately, is, is not worth it.

So let's talk about gabapentin, and although gabapentin resembles GABA, it does not act on GABA receptors. Its primary mode of action is as an anti-convulsant, but it also has anti-nociceptive and anti-hyperalgesic properties. Gabapentin is prescribed for chronic neuropathic pain and fibromyalgia in people, and the perioperative administration of gabapentin in people is effective in reducing pain scores, opioid requirements, and opioid-related adverse effects within the 1st 24 hours after surgery.

And so, it should be an appropriate medication as an adjunctive analgesic drug. And, In, in our experience, we use it quite a bit in our ICU both as a, a potential analgesic medication in conjunction with other, other, pain medications for acute pain, but also for sedation. And many times for cats that come in quite nervous, excitable, or distressed.

We will give them a dose of gabapentin before we examine them to try to relieve some of the stress and give them a little bit of time after their ride into the clinic. That's, we'll do the same with trazodone and dogs. We'll talk about that in, in just a minute.

Now, we don't really have any studies in, in dogs or cats to really know with good pain scale comparison studies to know whether it is an adequate analgesic for soft tissue pain and inflammation or post-surgical pain. But for now, we'll make an assumption that there might be some benefit to using it and at least clinically in our ICU when we monitor pain scales using the Glasgow pain scale. We do feel like in some patients, we've got adequate analgesic control with gabapentin by itself when the patient is not able to handle opioids or non-steroidal anti-inflammatory medications.

Cannabinoids such as THC and cannabidiols, or CBD are found in the flowering tops, resin and leaves of the marijuana plant. Cannabinoids are not found in hemp. Extracts that contain more than trace amounts of cannabinoids must be from the parts of the cannabis plant that are defined as marijuana and therefore they are regulated as Schedule One controlled substances.

Cannabidiol is promoted as having anti-anxiety, antipsychotic, anti-spasmodic, and antibacterial effects. CBD is a popular phytocannabinoid, one of many that research has identified as beneficial in dogs. Retail phytocannabinoid products are allowed to put THC free on their label.

However, they can contain up to 0.3% of THC, which can be cause toxic effects in dogs. And a lot of clients, they'll go to the gas stations here or to pet stores and they will buy over the counter products that are marketed as CBD for dogs, and they might say that they're THC free, but in fact, they still can contain some THC up to 0.3% without having to declare that on their label.

In addition, if people are giving products that they are themselves taking, the THC levels can be quite high, and that is what causes the neurological signs in dogs, when we see them coming into the ER. So there are 2 companies right now in the states that are promoting CBD and other Byproducts of cannabis and marketing them as As products that can be used in dogs, and at least the one made by the LVET Sciences, you can see some data collection studies out there testing the product with some positive results and controlling pain. The veterinary recommended solution has a proprietary carrier blend that will, that binds with the phytocannabinoids within the product.

And bypasses the liver, it will go and be picked up by the lymphatic system and get dropped into the thoracic vena cava and bypass the liver and therefore be more effective than products that are picked up by the bloodstream from the GI tract and then go straight to the liver and are taken out of circulation. To have their effects be notable, 1 may need to try longer term administration for a couple of days before knowing if it works. But some of our patients are coming in already on these products and we try to continue those products in the ICU as an adjunctive to the other analgesics that the patient is on.

These products may also have added urines that work together with cannabinoids and increase the the support of the patient for calm and discomfort. So CBD1 receptors are found on the neurons and in the GI tract that cause a release of GABA and high concentration of the CBD1 receptors are present in the canine cerebellum. CB2 receptors are expressed on cells of the immune system, and then there are other non-receptor interactions that can occur with the cannabinoids and terpines.

So in addition to the medications we just talked about, that are analgesic drugs, we can enhance their actions by combining them with anxiolytics, tranquillizers, and performing therapeutic techniques. For mobilisation, we can perform both active and passive range of motion exercises to maintain the integrity of the tendon, ligaments, and articular cartilage, as well as improved lymphatic drainage and increased blood flow to joints and limbs. .

The joints of the appendicular skeleton should be placed through multiple series of gentle slow, pain-free cycles of flexion and extension, and the length of each session is variable depending on the size of the animal and the level of disability. A standard passive range of motion session for the ICU patient usually consists of manipulating each joint and with flexion and extension 10 to 15 times with the animal, relaxed and laterally recumbent. And we'll do this 3 to 4 times a day, if they're not walking or they're not using the, the particular leg.

Massage is a therapeutic manipulation of soft tissues and muscles through rubbing and kneading or tapping, and massage will increase the level of of circulation and produce nerve sedation, decreasing muscle spasms, and can attenuate edoema. Now, I have a video of this little Frenchie who's getting cookie stretches, and that's where you facilitate movement without forcing movement, and you allow the animal to do what it wants to by presenting it with some sort of a positive treat or positive action. And this is also a good way to, to try to determine if a patient has something like neck pain without causing them pain.

So you can see by her particular behaviour that she was reluctant to turn her neck and she preferred to walk to get that cookie. And that's a good indication that her, her cervical spine. Is, is hurting her.

Leg extensions are where you gently scratch over the thigh area and the hip area, and that will cause many dogs to stretch out their legs. And then tummy tickles do the same thing. And in, in providing this mobilisation, such as range of motion and massage also gives you some time with the patient to allow them some positive interaction with you and to have a greater sense of well-being.

And it allows you and the nurse to know your patient better so that you can pick up subtle signs of, of pain or other things that might be going on with the, with the patient. Space there should be minimal resistance to injection. And air is not inject injected at the site as the potential as the potential space is small and air bubbles in the region in the region may result in an incomplete plaque.

In the non-ambulatory and recumbent animal, facilitated standing and walking with a sling and a cart or a therapy ball are important components of rehabilitation. Both movements work to improve circulation and lymphatic drainage, and the physical act of standing and ambulation improves and can retain an animal's mobility and functional capacity, as well as work on their postural balance. Weak and debilitated animals also benefit from textured flooring to provide firm footing during assisted standing or walking, and bedding should be checked and changed on a regular basis to prevent complications associated with decubital ulcers, ulceration, scalding.

And promoting regional blood flow, oxygenation and ventilation, preventing lelecticis and improving mucociliary clearings. And basic cleanliness will improve the overall comfort and may reduce the anxiety of the patient as well. There's a harness system that we use in our particular facility called the Help them up, and you can, buy it for different sized animals, and it really has revolutionised the way we care for our weak and recumbent patients, particularly the big ones, and getting them up without hurting ourselves and allowing them some more normal ways to, to move around rather than trying to have them walk with a towel sling.

Once the injection is completed, the needle is withdrawn and the rectum and tail are observed for relaxation. Relaxation does not need to be complete, but some relaxation should be observed before attempting catheterization. So cryotherapy can be used throughout the rehabilitative process, to mitigate negative effects of inflammatory responses and pain from acute injury.

In response to cooling, acutely inflamed tissues exhibit a slowed metabolic rate, which will inhibit inflammatory enzymatic reactions and reduce release of histamines, as well as muscle spasms. And that limits tissue damage. Vasoconstriction with a cold application will also limit edoema formation and haemorrhage.

Cryotherapy activates menthol type receptors which are present on aferent nerve endings and that are sensitive to cold. In general, we apply cold, cool compresses for 10 to 20 minutes, 3 to 4 times a day for therapeutic benefit and The primary precautions during cryotherapy is to avoid frostbite. And so we'll use a towel between the cool pack and the ice pack, and, the skin.

You can moisten the towel, and that will allow the towel and the area to cool to a greater extent, since liquid is a better thermal conductor than air. Just monitor the colour of the skin if you can, can see it, to look, and if you use the proper temperature, frostbite really shouldn't be a problem. Locally applied superficial heating agents such as hot packs and electrical heating pads or infrared lamps, stimulate vasodilation through activation of bradykinin and nitrous oxide.

Applications of heat are, are really used more to relieve muscle spasm and to make the tissues more extensible prior to manipulation for massage or range of motion motion exercises. It is really not useful for reducing swelling. And therefore, we rarely use it for the acute care patient in our ICU.

If you are using thermal application as part of the In, in treating the patients and improving muscle mobility, be mindful, of course, that thermal burns can happen with temperatures over 60 °C. And if you use thermal heat, it's, you should avoid using moist heat because that can increase the risk of thermal burns, quite a bit more than, than dry heat. And in general, We don't wanna use it with an acute injury.

So we don't use it too much in ICU. Photobiomodulation is a process of light induced photochemical reactions in biological systems. For example, our vision is based upon light interacting with photosensitive cells in our retinas called photoreceptors, and when light is absorbed by the photoreceptors, a photochemical reaction occurs that converts the light energy into electrical signals that are transmitted to the visual processing centres.

So photobiomodulation therapy is a form of light therapy that utilises a non-ionizing form of light source, including lasers, LEDs, and broadband broadband light in the visible and the near infrared spectrums. The term laser is an acronym for the light amplification of the stimulation of the emission of radiation of radiation. Interestingly, it was also referred to as the light oscillation of the stimulation of emission of radiation, but the acronym loser was not a, not the best acronym to use and hence they changed it to the word to amplification.

Laser therapy is also commonly known as therapeutic laser, low-level laser therapy, cold laser, or just laser therapy. Photobiomodulation therapy is a non-thermal process involving the absorption of energy from photons by endogenous chromophhores. This elicits a photophysical and photochemical event at various biological scales.

The process by which photobiomodulation therapy treats pain is by altering the inflammatory response and affecting cell signalling, by increasing reactive oxygen species. Increasing ATP levels and nitric oxide. At wavelengths between 500 and 1100.

Nanometers dissociation of nitric oxide from oxygen binding sites of cytochrome Coxidase in the mitochondria increases oxygen binding, enhancing cellular respiration and metabolism. The increase in the radical oxygen species activates endogenous antioxidant systems, increased ATP supplies cells with energy for respiration, and increased nitric oxide promotes angiogenesis and modulates the inflammatory and immune response by mediating vasodilation. In addition, local beta endorphins and endogenous opioid production increases, acetylcholine releases increase and bradykinin is decreased, which are all analgesic modalities.

The cumulative effect is to accelerate wound healing and tissue regeneration and increased circulation, reducing acute inflammation, and also acute and chronic pain. Typical conditions in which photobiomodulation therapy is used in our ICU or for those patients with osteoarthritis. And even if they've had another procedure done, we will take a holistic approach to that patient and if they're getting laser therapy for their wound, they might also get it over their joints.

You can use photobiomodulation also over specific acupuncture points. If you're not trained in needle placement for acupuncture, you, you can find some laser machines that, devices that will have a pen that you can use over those acupuncture, . Photo biostimulation therapy elicits a biological response at 5 to 10 joules per centimetre squared.

Now, in terms of power, there's a, there are two therapeutic. Lasers that are typically used, 11 that are considered Class B and another that are considered class 4. Class 3B lasers are limited to powers of 500 milliwatts and under.

Class 4 therapy lasers typically enable the user to select powers anywhere from 500 to 15,000 milliwatts. The increased power enables the clinician to treat a larger area in a shorter period of time. Ultimately, this results in a therapeutic dose of joules to the target tissue.

And can take less time to reach the target than a class 3B. Due to the power differences, the treatment strategies are going to be different between class 3B and class 4 lasers. When treating with a class 4 therapy laser, the clinician, as I mentioned, will treat a much larger area.

And move the head throughout the duration of the treatment to ensure that the therapeutic energy is being delivered evenly over the entire area. The head of the laser, the probe, the Head of the laser needs to be in direct contact with the skin and in very and dogs or cats that have very thick fur, it may not be able to penetrate as well as if you trim the fur down. It is essential to wear protective eyewear, both for the person who is administering the therapy, the person who's restraining the patient and the patient themselves.

Because the, if the laser is pointed into the eye, it can cause blindness. Use caution when treating dark coloured skin or hair and move the laser over the tissues rather than leaving them in one particular spot and monitor the skin temperature with your hand throughout the treatment, because there can be some generation of heat, particularly with the C class 4. Treatment is not recommended over open fontanels or over reproductive organs.

And if the patients are on photosensitive medications, caution should be used. Remove any sort of metallic objects, jewellery leashes, and avoid using a metallic surfaces because the light will reflect and can bounce off to where somebody might inadvertently see it. Compensatory areas can be addressed as I talked about before.

So if you're treating a post-op, in a vertebral disc herniation dog with a laser, maybe they have other areas of pain and discomfort that can be addressed at the same time that you are. Applying the therapy to their back. So this particular patient on the right, it's a little difficult to see them, but the nose is on the right and the ears being held up on the left.

This patient is in our ICU receiving acupuncture for a post-op total ear canal ablation. And bula osteotomy, that suffered some cranial nerve 7 and 8 facial nerve paralysis and was having some vestibular signs. And with it, this type of patient can develop muscle spasms, because they're tilting their head constantly, as well as it can, they can develop, they, they are dizzy and can be Uncomfortable and imbalanced because of that, and acupuncture can early on can play a big role in trying to neuromodulate specific points that can ease their comfort both in stimulating trigger points where the muscles are spasming as well as trying to stimulate the nerves that are no longer functioning properly.

Acupuncture is defined as the stimulation of specific points on the surface of the body by insertion of a needle, resulting in a therapeutic or homeostatic effect. And if you are a traditional Chinese veterinary medicine proponent, then acupuncture is used to allow energy or chi to flow harmoniously. If you are a strict Western medicine practitioner, then, we think about acupuncture being used to stimulate the nervous system.

Histologically, acupuncture points are found in areas with high densities, density of mast cells, lymphatics, and, and arteriovenous plexi. In addition to regions of concentrated innervation like the Golgi tendon organs and muscle spindle cell, muscle spindle insertions. This, These areas of dense innervation contain somatic affern and efferent fibres, as well as autonomic norepinephrine, sympathetic fibres, and cholinergic acetylcholine parasympathetic fibres, with an increased ratio of myelinated to unmyelinated fibres compared to non-acupuncture points.

And acupuncture has been used effectively for the treatment of neurological disorders such as in a vertebral disc disease and spinal cord injury. And, it can also produce analgesia and other physiologic effects through neuro neurohormonal and neuromuscular mechanisms. Certain acupoints can also regulate pro-inflammatory factors, And improve microcirculation.

So stimulation of the acupoints can be achieved by inserting a fine sterile needle, and if the needle is stimulated with electricity or electroacupuncture, it can have a more profound effect, and it is used in many cases because of its rapid onset of pain relief and its ability to stimulate peripheral nerves. So upon needle insertion, there'll be micro trauma and neur and a neurovascular reaction with release of substance P and histamine. Capillaries, mast cells, and nerves involved in the reaction are involved in the reaction, and receptor activation can augment analgesia.

Unfortunately, again, there are not a tonne of studies in dogs and cats, and there are conflicting results as well. So hopefully with more practitioners being trained in acupuncture, we can start collecting more data to determine how well acupuncture works. I like to use it in in our ICU patients pretty much for any reason that they're there, whether it's the primary reason that they're there or they have comorbidities, and I enjoy it.

I do think that the, the patients have a positive response to it. But for the acute care situation, because they have such a multimodal, we have such a multimodal approach to their analgesia that it can be difficult to know for sure and to say that absolutely it makes a difference in the outcome. I can tell you though that that clients do appreciate being having that as a, as an option for their pet in ICU.

Electrical stimulation involves the application of electricity between two points, either using needles or moistened pads that are attached to the skin. And, electroacupuncture induces a modulatory effect that can activate the descending pain pathway. Pain inhibitory system, which includes opioidergic, adrenergic, and serotoninergic pathways, both in the central and the peripheral nervous system.

Both high and low frequencies are used for systemic neuromodulation. And we know that, experimentally low frequency stimulation, 2 to 4 hertz, will lead to the release of beta endorphins, encephalons, and, higher frequencies, 80 to 100 Hz, will lead to serotonin and norepinephrine releases. Patient anxiety and dysphoria can mimic as well as magnify pain.

It can also result in employee dissatisfaction with their job and disturb other patients. Opioid dose adjustments may be necessary to reduce dysphoria, but we also administration of anxiolytics and sedatives can provide a balance in the anxiety-riddled patient. So, we'll talk about trazodone here which we've really started using frequently in the last few years.

It's an oral medication that is a serotonin antagonist with weak serotonin uptake inhibition. It is a true sedative and in some cases, will also relieve anxiety and insomnia, at least in people. It is also a non-selective alpha adrenergic blocker, which can help modulate the pain responses.

It does, I gave you a reference at the bottom of the slide. Trazodone does appear to reduce stress-related signs and behaviour in hospitalised dogs, and we, encourage our surgical teams to prescribe trazodone when they've done the initial consultation with the patients so that they are actually receiving trazodone or gabapentin prior to coming into the clinic. Be aware that phenobarbital will induce the metabolism of trazodone and reduce its effectiveness, so they may need a higher dose.

And theoretically, if we use trazodone with other Tonergic medications or monoamine oxidase inhibitors, metoclopramide, or tramadol, it can result in signs of serotonin syndrome. And therefore lower incremental doses should be, should then be used if needed. So, we'll generally, once an animal has already exhibited severe signs or moderate signs of anxiety, it will, in our experience, it will take a higher dose to calm them down.

So we generally start with a 10 milligramme per kilogramme every 12 hours and go up to every 8 hours if needed. Aromazine is a phenothiazine derivative that is a dopamine receptor antagonist and produces a depressant effect on the CNS. It is a neuroleptic agent that potentiates the effects of CNS depressants with low toxicity.

It is a sedative and tranquillizer, but it is not an anxiolytic agent. It is postulated that by blocking dopaminergic receptors in the brain, the phenothiazans might increase the risk of seizures, particularly in patients that have a low seizure threshold like epileptics. But several small scale retrospective veterinary studies have not supported this claim, meaning do not hesitate to give it in a patient that is seizure prone if they need it to calm them down.

Dexametatomidine is an alpha 2 adrenergic receptor agonist that causes anxiolysis, sedation, and short-term analgesia. In people, it's used to reduce the duration of delirium, which occurs frequently in human ICUs and is a cause of adverse outcome. Dexedatomidine dosages are effective at low doses, particularly in the patient that's receiving multimodal analgesia.

Side effects can include hypertension, reflex, bradycardia, and reductions in cardiac output and stroke volume. Which makes it important to titrate the dose to the lowest dose if needed for those patients that may be cardiovascularly unstable. There does not appear to be that profound of a cardiovascular effect if the transmucosal gel is used, and if used in combination with borphenol or other opioids, it can increase the sedative effect.

Dexxedatomidine gel, or illeo as you can see the picture here on the slide is the first US FDA approved treatment for canine noise aversion, and it's supplied in a 3 millilitre multi-dose oral syringe where you dial the volume that you want and squeeze it onto the buckle mucosal surfaces. If you find that you've got a, a, pretty agitated patient in the ICU, you can test them out with a dose of dexametidomidine and whatever provides you, whatever dose provides you with the effect that you like, you can use that dose and set it up as a continuous rate infusion dose to give over the hour that you can adjust based on the patient's response. And finally, it's not uncommon for patients to experience a relapse of their pain either because they have poorly controlled pain, not adequate analgesia on board, or they have not received appropriate preemptive analgesia for a planned procedure.

We see this more commonly in patients with neurological injury, and in those cases, giving them a pain vacation seems, is in order. And what a pain vacation is, is not going to the beach. It is administering IV analgesia either as a single agent or a multimodal therapy for 4 to 12 hours just to break that cycle of pain and perhaps control the windup, so that when you reinstitute the longer term analgesic plan, they will be more receptive to it.

So, in terms of combination analgesia for moderate to severe pain in the dog, I included this particular recipe that's used fairly commonly, and it's simply adding morphine or fentanyl to a litre of crystalloid, lidocaine, and ketamine, rapidly infusing a bolus dose so that they have a therapeutic amount in their bloodstream. And then continuing this at a maintenance type rate for a continuous rate infusion. The rate can be increased or decreased as needed.

And in general, we find that after about 4 to 6 hours, we can start titrating back the rate as the patients start to become more sedate. But again, using any type of pain scale to determine when they actually need more or can go by with less as you're testing them and trying to, De-escalate their analgesia. This could be used in the cat as well, although some people might be a little nervous, leaving the lidocaine in it, which is OK.

You can take the lidocaine out if you want to or, or provide it separately at lower doses. So, I hope that I gave you some ideas of how you might be able to modulate your patient's pain for those that are staying in the hospital. And I encourage all of you to look at the International Veterinary Association of Pain Management as a resource.

In addition, because I'm the programme coordinator for the Veterinary Emergency and Critical Care Society, I wanted to make you aware of it that it's an international organisation that welcomes anyone with an interest in emergency and critical care, and I invite you to come and check us out as well. We So thank you for joining me in this presentation. If you are a fan of emergency and critical care medicine, please think about joining the Veterinary Emergency and Critical Care Society and or attending our first virtual conference this September 12th through the 14th.

As a registrant, you will have access on demand for any of those talks that will be presented at any point if you are over the pond and you're going to be sleeping through some of them. The meeting is in conjunction with our partners, which includes the American College of Veterinary Anesthesio anesthesiology and analgesia, as well as the technicians, the Academy of Veterinary Technicians and anaesthesia and analgesia. So, for those of you that are interested, this is a great meeting to in pain management, this is a great meeting to find more information on that.

I thank you and welcome you to get in touch with me if you have any questions about this presentation, and I bid you adieu. It's usually what happens happens either immediately or within a few minutes. If further confirmation of the block is required, pinch the tail or perianal region to see if you can elicit a response from the the patient.

You can give up to 2 injections, if the, you don't think that the first injection provided the effect you wanted or may not have been in the correct space.