Hello and welcome to this. Webinar on pain scoring scales. How to improve pain assessment in cats and dog and dogs.
My name is Anna Costa, and I work as anaesthesia RBN at the Queen's Mother hospital for animals at the Royal Veterinary College. So I have no, relevant financial interest. No arrangement affiliation in any company.
Apart from the P webinar, the learning outcomes for this webinar today are to recognise the physiological effects of pain, identify pain behaviours, appraise different pain scoring scales available for dogs and for cats, understand how pain scoring can be a available tool to improve pain management and to know how to implement pain scoring in the practise. So before I move on, let's have a look at the literature. So this paper came out in 2017 and evaluate the attitudes of veterinary nurses assessing pain and using pain scoring scales in the UK.
So back then, more than 500 participants were involved in these questionnaires and only 8% of the practise were using pain scoring scales at this time. About 80% of the veterinary nurses agreed that pain scoring were available to to assess pain, and more than 90% recognise that the knowledge and pain assessment could be, improved. More recently, this paper came out in 2022 and evaluate pain assessments, attitudes by veterinaries and veterinary technicians in the USA.
More than 100 participants were involved on an N 47 and when asked if they use pain scoring skills in the practise, around 47% said yes, 16.3% sometimes more in neurological pains or pains. We underwent neuro neurosurgery and orthopaedic surgery, but still 36.1% said no.
And one was reasons why not pain scoring Half of them said No training. Do you have any training? And almost another 50% said Busy, case load.
Last year, a group of, Spanish researchers, also did a questionnaire to the to veterinaries, asking about the use of pain scoring. Around 40% said yes, they used some kind of pain assessment. And they give preference to the feline Grima scale for cats and the Glasgow composite scale for dogs, which means that pain scarring scales are becoming more popular in practise and This will help us to identify pain and to treat pain, especially in our hospitalised patients.
Before we move on, we need to discuss and to talk about pain. So what? What what is pain?
So the International Association of the Study of Pain defines pain as an unpleasant sensory and emotional experience that might be associated or not with the actual or potential tissue damage. And there is an extension to this definition saying that verbal description is only one of the several ways or behaviours to express pain. Which means that humans and non human animals they are not able to verbalise not able to talk might be ex, experiencing pain.
And it's very important to also think about that. Pain is a very personal experience. We all experience pain in different ways, and animals don't have the perception that pain is temporary.
So this is even a worse experience, compared maybe to our experience is not like to be aware of what's going to happen and where this, comes from. So there are three types of pain, described in the literature. So we have the nous active and or inflammatory pain.
This is normal protective pain is a lesion in the soma visual tissue is normal. The pain that is associated to a surgery. For example, acute pain, is reversible but can be acute.
It's normally acute but can progress to chronic pain If it's not, well treated or adaptive maladaptive pain, we can also see patients with neuropathic pain. This can be acute if the primary lesion isn't in a neural, neural tissue or can be chronic if becomes from a no active inflammatory pain. That progress to chronic pain normally is reversible.
But if it's chronic, it's quite difficult to treat. And then we have what we call nosy plastic pain. This is normally a dysfunctional pain.
It's quite reported in humans is a pain with no evidence of lesion. So this comes from neuroplastic changes in the central nerve system. So this is changes in how the pain is processed.
So this becomes from an acute process, for example, that progress to chronic to neuropathic pain, and then we can have nay plastic pain. So changes in pain processing. That is going to cause the appearance of dysfunctional, pain in osteoplastic pain Quite difficult to treat and also associated with chronic pain.
So to describe pain as the fourth, vital sign. So this is some of the physiological, effects that we can have, in our animals so we can see increased catecholamine release. This has an impact, on our cardiovascular system, we can see tachycardia, hypertension, increase in respiratory rate and our effort.
We might see patients with dilated pupils as well hypersalivation nausea, stress, and then stress What's going to cause we go back in here, increase the following release tachycardia tension. So this then becomes a snowball. We can see hyperglycemia associated with stress leukocytosis cytokine pro production, immune suppression.
And this is going to lead to delayed healing, increased post op complications and increase in hospitalisation times, which is three, main, things or process that we want to avoid at all costs in our veterinary patients. And then we have the risk of developing chronic pain when acute pain is not, adequate treat. Adequately treated.
We can have, the appearance of chronic pain. Chronic pain is described as persistent pain for more than three months, but this is a definition that works for both human, medicine and veterinary medicine. And we just need to have in our minds that the lifespan of a cat or a dog is way less than our.
So maybe three months for us is a quite long period for a dog or for a cat. Let's go through some behavioural changes that we might see in dogs and cats. Aggression, fear, anxiety, stress, vocalisation or no vocalisation quite typical those cats that we say that they are very chatty and all of a sudden they stop Vocalising can be a sign of pain reluctancy to move, and or to be touched, shaking tremoring guarding behaviour at that painful area.
Very common looking, licking, biting. The painful area lethargy, hyper lip smacking is very, very common hypersalivation tail flicking this morning cats and stop grooming in cats as well. Those cats that, it's quite common when we have cats with severe osteoarthritis, they stop, grooming themselves.
We can also see behaviours, related with urination, defecation in in appropriated areas and changes in the sleeping pattern. So those animals that use it to sleep all night, and nowadays they are very restless. They don't have a position, to be laid down comfortably.
This can be also a sign of pain, some postural changes that we might see and is more focus on the hospitalised patient, statue. Like her appearance. Like this, cat over here.
This is a quite a common sign of abdominal pain. Very reluctant to lay down almost on TP toes, heads down as well. Hunched position quite evident in here.
Preposition. More common in dogs with abdominal discomfort again. Very reluctant to lay down abnormal gaits.
We see these more often neurological patients or patients with osteoarthritis. They try to compensate the gait. We can see patients with the head down with the cervical pain or with the hip pain we see that they transfer.
Try to transfer the the weight a little bit more to the four limbs so we can see abnormal gait, as well. Reluctancy to lay down restlessness again. That patient did this Mostly, or cats tend to to hide more dogs.
Might try to find a way to lay down in the kennel, to grab the bedding and then looks like, it's a mess. Inside of the kennel can be a sign of discomfort. Pain?
They don't have a position, to lay down comfortably head down again. Quite, common like in this kitty cat in over here or sign of neck pain. Hiding for more, cats and changing in facial expressions.
We'll see this a little bit later in this webinar. We can see cats are quite, expressive. We can see this picture on top.
This this cat look quite sad compared with the bottom one. Let's go through some, evidence in human medicine. Human I medicine pain is reported to be highly underestimated.
And normally is the worst, memory of patients that were hospitalised in IC U even years after the discharge. And this, pain processes are mostly associated with respiratory therapy patients that needed to be on a ventilator. Placement of nasogastric tubes, venous and bacterial catheters, placement and lack of mobilisation.
So we look at this and we can relate these procedures to our, veterinary patients as well. So we placed venous catheters, the lines, naso tubes. So these small things can also be causing discomfort and pain.
In our veterinary patients and in here, I want to highlight the lack of mobilisation. It's very important when we have a patient hospitalised dog and a cat if they don't, move themselves. It's very important to change.
We come and see to some kind of physiotherapy massages, to keep those muscles relaxed. Some pain scoring scales used in human medicine probably already came across some of those. These are uni dimensional pain scoring systems.
So basically, we have, for example, this one visual analogue scale. We have a trace, and we need to just mark if between no pain and worst pain possible where we sh we feel like we are or the typical 10 from 10. How bad is your pain or just ver verbal rating scale Non mild, moderate or severe, and then a little bit more advanced.
We have changes in, facial expressions. That we are going to use this in our, feline grimace. Scales.
These are used more in in Children, but these scales only consider the intensity of pain. So if it it's very difficult if we have a non verbal, patient, it's very difficult to use. These pains score scales, so they have.
So we have, some multidimensional scales, for patients, for example, on a ventilator. And this goes through some behavioural changes and the pain observation, too. So with these scales, we can, evaluate facial expressions if the patient is relaxed.
If it's tense, if there is movement, if coughing, against the ventilator. So these, scales are a little bit more, complex and, they evaluate behavioural changes and not just from 1 to 10. How bad is your pain?
There are some scales for premature infants as well. And if we go through here, we can see they can. It can see this, changes in physiological parameters, like heart rate, oxygen saturation.
And then again, changes in the facial expressions and behavioural state. If the baby is awake, if he's active as well, or if he's asleep and for no non verbal Children, again, we have pains, scarring, skills, evaluating behavioural changes. If the child is playful, if it's fiddly, if it's irritably cranky again, my a little bit latest is quaint in the eyes.
If it's inconsolable, sometimes we can relate this to our veterinary patients. We have a patient that is very anxious, and we're not sure. Oh, are we experiencing experiencing pain or not?
And then we just cuddle them, spend some time with them, and they, calm down so we can relate. Some behaviour changes with this, non verbal, patients as well. And then, there are some, pain scales available for patients with dementia.
And this evaluates the breathing pattern with another vocalisation. If we have hyperventilation presence or not Negative vocalisation. Normally, these patients can be, quite, quite vocal, and then all of a sudden, they cannot express themselves.
They cannot speak, change in facial expressions and body language again and again. Consol as well. So we can see that we can use other parameters.
Apart from the verbal communication to assess pain and this is what we're going to see now in our, veterinary, pain scales, available. So in veterinary medicine, pain score will always be subjective because we are reporting pain for another, and it's not another person. So it's going to be always, observational.
We can be biassed if I know that that patient had, orthopaedic procedure. I know probably is going to be, in pain. Or even if I had a condition similar the patient and and I experienced pain, I'm gonna say, Oh, this patient might be, in pain.
But if we nowadays use the multidimensional scales, in veterinary patients, they are more objective, improves consistency and reliability of the pain assessment. So nowadays, we don't use anymore the 0 to 10. How do you feel?
Which is quite difficult to and subjective to, report and assess pain in veterinary patients? In doubt. Cause these scales, as we're going to see, they can be affected by patient temperament.
And in doubt, if the patient is in pain or not, we should give a low dose of analgesia and then reassess the patient. You will see it through this webinar cause the pain scoring scales have, guidelines. And normally, when we implement this in practise, we have, to write notes on the kennel chart, and there is a pain plan agreed with the veterinary.
And normally it says if pain score higher than this, give this dose of the analgesic. If it's, equal or below this, give this dose of analgesic or do not give anything and reassess. So this is something that is agreed, with the veterinary, with the veterinarian when we implement, the pain scoring scales.
And this is a guide also for veterinary nurses, to follow, and to administer a range, of the analgesic drug. So why the pain scoring skills must be part, of the pain management plan. So this encourages frequent patient monitoring.
Normally, we do pain scores every four hours as we do our T, PR S standardise this pain assessment in the practise. So we choose one scale for dogs one scale for cats and everyone practise is trained to use those skills and assess pain in the same way. Supports clinical judgement.
Because it's very different if I go to the veteran and say, Oh, I think Bob is painful, but if I have something supporting me and say, Look, I did the pain score to Bob Pain score. Is this because this is high. This is high.
This is high. So this is a document that is going to support the clinical judgement it makes us to record trending, if our pain scoring, we can see if the analgesic plan is working if it needed to be adjust. And it's a very important piece of information to pass on on the other team members.
T night teams, day teams, it's important to record, everything. This also help us to recognise signs of pain and to quantify pain. So as much as we, use it, we are going to become a little bit of kind of experts recognising signs of pain.
And we are quite, lucky. In a way, the veterinary nurses work very closely to the hospitalised pa with the hospitalised patients. So in a way, we're going to know them a little bit better, and changes in behaviour and postures will pick up quicker.
And that might be a sign of pain again. Validate if the analgesic treatment, is working or if it needs to be adjusted and allows, ana analgesic adjustments by the veterinary nurse when the veterinary not available again. This need to be, graded, before, we implement analgesia or implement pain scarring scales and there is a plan in placement.
So I know if the pain score is this, I'm going to give this dose of an opioid, for example, And if it's below, I can decrease the dose. So this is agreed And this sign of, by the the veterinary. This is quite handy because in busy practises, we might have, the same veterinary looking after the hospitalised patients doing consults.
So having this in place just smooth a little bit the process and avoid being chasing someone that might not be able in the next hour or two to come and assess that patient and increase the analgesia. So let's see which pain scoring scales we have available for cats and for dogs. So for cats, very popular feline GMA scale, we have done But to get to a multidimensional composite pain scale, The Glasgow Composite Measure Pain scale and the Colorado State University Veterinary Medical Centre Acute pain, scale for dogs again, we have the Glasgow composite measure pain scale and the Colorado, pain scale.
As well. Just to highlight that the Colorado one is not validated for, cats. But we are going, through that one, as well, going through the feline rema scale.
So this scale, only, assesses changes in facial expressions and head position. We don't need to interact, closely with the patient so we can be outside of the canal and just observe the patient, which is quite handy. It's quite easy to use, but requires pre and post op analgesia assessment.
So we should pain for the patient if needs an AL Pia with me analgesia. Half an hour later, we should reassess the patient. The maximum score is 10 and risk analgesia.
Analgesia must be administered when a pain score is four or higher than four. It's available at the website Feline green. A scale.com.
I recommend you to visit this website. They have an app that is working, really well, nowadays, and you can do some training as well. So just to leave you with some I with an idea of the research behind it.
So, when research is, invested in this scale, they photographed and video very very many. Many, cats, and then they check the changes, and measured the distance between the ears. The whiskers as well.
The eye positioning as well. So this is quite a robust, pain scale. There is lots of evidence behind it.
So the pain, the grimace, feline scale looks like this. It's very friendly. There are some pictures and drawings as well, which facilitates the assessment, and it is quite easy to use.
There are some limitations of this, scale. It's not validated for facial pain or pain, so it might be difficult in some bronches folic breeds, to assess the facial expressions. Sometimes we have our typical British.
It has. They look happy all the time. Maybe some, per, breeds that look a little bit upset all the time.
So it might be difficult to use this, scale. And when we have, any kind of facial surgery like this, a little one here. He had a skin flap, to remove a granuloma, and you can see that the nose is also affected.
It is the whisk. It has a bit of facial paralysis because you received an axillary block. So it's quite difficult to assess pain in this little fella just based on the ears.
But I will leave you with a nice video of him. It was very comfortable, as you can see, but in this case, we could not use the feline grime scale. And we use the Glasgow, composite scale moving on to the on Boca to multidimensional composite scale.
It's a very extensive, scale evaluates again or as well, pain expressions, reaction to gentle palpation of the painful area. Psychomotor changes as poster comfort, attitude and activity, and also physiological variables as heart rate, respiratory rate and, blood pressure. Again, it's quite comprehensive.
There is a short, version of it is available in eight languages. The maximum score is 30 on the extensive, scale. The shorter version is 12.
Bre analogies must be administered if the score is eight or higher above 30 or four or higher. If we are using the shorter version, is also available on this animal pain.com dot VR website.
And it looks like this. So this is a pain score that could be very helpful to use if you have, quite significant feline case load or if you you work in a practise. There is just feline patients because it's extensive.
It means it's going to cover more aspects of pain behaviours, pain. Physiological changes so a little bit more objective. The downside is, takes a little bit of time, to go through everything because I, I will show that this has three pages.
But once you implement it and start using it, I believe this is quite you can go through it. Quite quick. Quick.
So, basically, we just need to observe the the patient, see if the cat is laid down. If it's quiet, if it's leaking the surgical area the painful area, then some gentle palpation of the womb See how the patient, react if it's vocalise vocalise. If it's, vocal, V or not, then we go post changes and then comfort a activity if the patient is eating, if it's active going to the toilet.
And some attitudes, when, contacting with the observer. So it's quite extensive, but covers many aspects of, pain behaviours, and then S some physiological changes on blood pressure and again appetite. So these are if we if we go through this thoroughly, we can see that many of these things or these steps we already do.
We already took our T PR S. We already checked the patient. It's toile thing if it's eating, so it's not like a brand new thing that we need to, insert in our practise many of these, things or tasks we already do in our daily basis when we have hospitalised patients and this is the short version of it.
We look at it, it looks a bit more friendly and quicker, but loses, some, objectivity Moving on to the Glasgow composite measure. Pain scale is available and validated for dogs and for cats. So it's based on six categories.
Behavioural assessment. Patient response to gentle palpation. It includes, section facial expression.
For cats. It's fairly easy to use the short version, but can be affected by the patient's temperaments. If we have aggressive patients or if we have fearful patients, this scale can be a little bit affected and lose.
Some objectivity. The mass score is 24 and rest. Canales must be administered when pain score is six or higher in dogs.
Five or high in cats. Because in cats is, over 20. Maximum score is 24 for dogs and 20 for cats.
And we're going to see one, in a bit. It's also available online. Pne merica.
You can print it, you can laminate it and have, in your practise. It looks like this for cats. I personally feel like these facial expressions are a little bit cartoonish.
Can be a bit more challenging to use compared with the feline, Goma scale that we have pictures. And we have, more simple drawings. Going through it.
It just, how is the patient? How is the cat? In the cage?
If it's silent, if it's growling, it looks relaxed or licking the lips. If it's ignoring the painful area or if it's trying to bite or hide the painful area. How does the cat response to to stroking if some responsive, aggressive, and how it responds when we palpate the painful area.
And this is the short form of the Glasgow pain scale for dogs. The reason why, the total score is over 24. And for cats 20 is because there is an area in here that we need to walk the dog out.
But we don't take the cat out of the kennel. So it's more or less the same. How does the dog looks?
Inside of the canal. If there is an interaction with the painful area. How is the dog when we, put the lid on and try to walk them?
If it's a normal gait, if he's laying slow or we looking to move If we had patients dead and went neuro neuro orthopaedic surgery, or if we receive any local blocks, in any limbs or, epidural, we cross this section, and how is the patient, when we, do some gentle palpation of the painful area? How his dog? Overall, he's quiet, bouncy, happy.
And if it seems comfortable or unsettled restlessness, it's quite easy and practical to use. It's just one page, so we can go through it, quite quickly moving on to the Colorado, acute pain scale. Also evaluate physiological.
Behaviours and reaction to gentle palpation of the painful area has instructions to not disturb the patient if you sleep. So the other pain scores, we might need to wake up the patients. With this one, we just delay it as practise at the G MH.
Normally, if our patients are resting, we wait, 20 minutes, half an hour. And so we don't We don't disturb them, immediately unless they require, analysis straight away. If they underwent a very painful procedure, but if they are resting, they must be, comfortable.
Enough. The only thing is, not to delay analgesia, for a very long time. Because at the time we're going to assess them.
If we delay, they might be, quite painful. The maximum score is four and rest. Kalis must be administered when pain score is, two or over two.
As you can see, comparing with the other, pain scales that we went through until now, the maximum score in this one is quite low. We're going to see it. We're going to see the pain score scale.
The form this this means that it is a little bit more subjective than the other ones. This is also available for cats again, but not, validated for the species and can be found on the that, met by yours. Sciences coloured states.
Website. It looks like this. This is for dogs.
Personally, I feel it's quite it's a bit challenging, to use because on the same, section, for example, we see zero. But in the zero, we have physiological and behavioural changes responsible P patient and body tension. So some people might argue this is more like a uni dimensional scale.
But I put it here as a multidimensional scale. The only thing that I want to point it out is, for example, I might have a dog. That is happy and content in the kennel.
But when I'm going to palpate is, it reacts to the palpation of the painful area. So I have a zero for the physiological behaviour changes. But I have, one in here and saying that we have one.
The reactive palpation. It doesn't mean that I also have one, in the psychological and behaviour, changes. OK, so this makes it, maybe a little bit more confusing to to use, and cancer.
It looks, like this as well. Again, some cat wish, images that might be a bit difficult to use, to assess, to assess pain in our in cats and dogs. Let's go through some limitation of the pains, scarring scales, and the biggest limitation report, that is time.
So I understand that sometimes we work in very busy environments, and it looks like it's another thing to do. But if we actually decided to introduce pain screening skills in practise and to choose one for cats and one for dogs And if we do this as a routine in patients that underwent surgery or might go through painful, processes, this is something that is not very difficult to introduce in practise, and it. And as you could see, many of these observational tasks we already do in our daily basis.
So, for example, if half an hour ago I took the dog out, for a walk. I already know if in half an hour is the pain score that when I put the lid, it walked fine. Or it was, a little bit lame.
So some things that we evaluate in the pain scoring scales are already part of our nursing care on a daily basis. Patient's mental state. This can be a big challenge when we use, pain scoring scales.
If you have a neurological patient, if you have a patient that suffer, head trauma, for example we might not be able to use these pains. Scarring skills. Vocalisation, again, if you have stressed patients anxious, this can be, a limitation or challenge again, we might need to sedate these patients and then assess pain, after.
But then we need to be careful or we need to consider not se sedate them too much. And we're not able to assess pain again. Stress, fear, anxiety.
Systemic disease. So we have, to have in mind that some of those, physiological changes that I mentioned before tachycardia, might be a sign. For example, hyperbole may not, pain, related, for example.
But also, systemic disease might change normal response, to pain. And we have to have We need to have that in consideration. And many of those signs, that I mentioned before might not be or they are not exclusive signs of pain.
So we need to balance that, as well. And then there is something else that is discomfort. And something that always comes to my mind is to have a patient with a full bladder.
This might not be, needed. This doesn't need analgesic treatment itself. It's a discomfort.
We just need to make sure that this patient is able to to urinate. Including this group. I also would say to have your patients hospitalised patients in a nice bed, clean bed.
Because if they are not comfortable, if they are trying to make a bed on their own, my be perceived as a sign of pain, and they are just discomfort because they don't have enough bedding or they have a full blood that I always think, in my anaesthetized patients. I always try to express the bladder before moving to recovery because I always think of myself waking up in the morning with a full bladder. I just want to run, to the toilet.
Let's go through, some cases and how we can apply some of these, pain scoring scales. So let's go through this kitty cat. This is a cat with five years old is a mal nutrient, and it's a pretty short hair, as we can see.
He underwent haimin toy at the level T nine and T 10 due to a vertebral canal stenosis. And fortunately, he had previous surgery, previous surgery one year before. A little bit more coldly.
So this patient was already on gabapentin. Long term for management of chronic pain. So he arrived to recovery after the surgery, and he was on methadone 0.1 milligrammes per kilo.
He had received the erectus spinalis plain block with BBB can two milligrammes per kilo. He was already on NSAIDs met 0.1 milligrammes per kilo that they arrived to recovery.
And they had this little face very sad little face. So I decided to assess, pain. So I used to feel angry.
My scale. So let's go through it. And see if we all agree.
So the ears are rotated down. We can see he had, Roland matoma in the past. So let's just count this little ear.
The ear is down, so I gave him a two for your position. The eyes are slightly squinted or partially squinted. I gave him a one, and there is some muscle tension as well.
It's a little bit difficult to see because he has the head down. So I gave him a two. And the whiskers are, moderately down as well.
And I gave him a one head position. Markedly, down. So, in total, I've been scoring eight.
And as you remember, above four or above, we should, adjust analgesia meth at points. We, top it up the methadone, with 0.2 milligrammes per kilo.
This after the methadone. I tried just to go. It was very, very upset.
Do you see that? The ear was up, but down is rotating down very obvious. And I try just to interact with them and didn't allow me to do any gentle palpation attach.
And it was actually, attacking. And you could see some lip smacking as well. Ok, so at this point, we started ketamine.
CR I 5 mcg, per kilo, per minute on top of the methadone, that he received 0.2 milligrammes per kilo, and it was already on 0.1.
So it was on total of 0.3 milligrammes per kilo of methadone. And this is him.
Half an hour later, we can see already some changes in the facial expressions, but let's go through our, flan grama scale the ear. It's not completely down, but it's not completely up. So I gave you my one.
The eyes are a little bit more open, but not fully so One again. Less muscle tension, but still a little bit. So give me one.
The whisk, As I can see, the whisk is already relaxed and then and down, so zero, the head is up. So at this point, I gave him a total of four. Still within that range of intervention.
So we started fentanyl CR. I 0.3 mcg per kilo per hour.
Half an hour, more or less. Half an hour later, we pain score this cat again. We can see the ear now is fully up.
The eyes are completely open. There is less muscle tension, but still a little bit. The whiskers are down and the head is up.
So total pain score was two. And it was decided to reassess this patient every two hours just because he was on a fentanyl and ketamine CR I Otherwise, if he was just on, methadone on the range between 0.1 and 0.2 we'll assess him, every four hours.
And as you can see, the progression in these pictures is quite is quite obvious. Ok, and even with some limitation with this, ear who were here, the feline grama scale was very helpful in this case to top up and escalate analgesia for this scan. And he was much happier.
And he still a little bit of sleep smacking. This was after the ketamine, but he let me touch him, and this was him Later. And cat were much happier.
OK, very different from that video from the beginning. And much happier cat. Ok, let's see another example using the Glasgow feline scale.
In K. Let me just switch off the volume here. So this cat had orthopaedic.
Intervention had a little bit of a femoral fracture over there. He was hit by a car. He had surgery on the other leg prior to to this day and you can see on the interaction is already lip smacking.
OK, when we do interaction with these patients, we should avoid go going straight forward to the painful area. So we need to make sure that they are comfortable with that, stroke them, and then palpate the area. We should palpate between one to centime 22 centimetres down in pressure.
I normally start with gentle pressure to see how they react, and then I'll go a little bit deeper if they seem comfortable to me. Something else that I would like you to see in this video, apart from the lip smacking. OK, I'm doing this and it looks to the leg again, a little bit more pressure, and it looks in this more caudal pack, and it also does a little bit of a tail flake like in here.
OK, so it's tolerating, but it's not fully happy. So going through the glass will line scale. I gave him a zero.
Because this patient was silent in the canal. Yeah. I think he, he was purring as well.
But not crying or growling, at me. I put it to, cause it was, licking the lips. When asked about, palpation of the painful area.
Sorry, in general, he was ignoring the wounds of the pain in the painful area before, I palpated, The caricatures when we go through the, facial expression is a little bit difficult because he's in lateral. But he had a bit of, rotation of the ears. And also some muscle tension.
So I gave him one for the ears and one for the muscle tension as well. And moving on to the next patient, response to to stroking, but in a in a nice way, Not, aggressive. At all.
And when palpated the painful area, he moves the tail a little bit. OK, I didn't give him a two because he didn't hiss, or cry. And the question number seven, it doesn't look happy.
Content, super happy. It's just a bit quiet, so I gave him a one. So The total score for this CATS was five.
If you remember, for the Glasgow land scale, which intervention should be, five or above five. So we top up the methadone. And this C A It had a local block, during the procedure, and we just top up the methadone when we reassess this patient half an hour later, it looked much happier.
We can see the ears are up. He actually wants some cuddles. So I gave him a one.
It was, in silent Quiet. I believe it was spurring, look more relaxed. No lip smacking.
At this time, he was ignoring the painful area and also much more comfortable. Palpation just laying down just one cuddles, facial expressions we could see at the beginning of the video. Why?
Eyes quite open ears up. No muscle tension as well. And when we move on to the next page, it responds to stroking.
But in a nice way again, there's nothing when the, be for is palpated. And it looks much happier, than before. So pain score at this stage was zero.
And it was fun to reassess every four hours and maintaining on methadone between 0.1 and 0.2 milligrammes per kilo.
Let's now see an example of a little dog using the Glasgow feline. Sorry. The Glasgow, composite, scale the short version.
So we have this little Pomeranian, he had a fracture. Repair. It looks very sad.
Just by the video, you can see it's a bit reluctant to lay down. It's very stiff on this leg. Is hyper Civ a bit might not be perceived very well, but it is.
And on genital palpation, you can see that he's already trying to guard the leg. OK, so going through the pain score, how does the patient looks? It looks quiet.
He is ignoring the painful area in a way that is not like biting looking at it, but it's holding the leg up. So this is something that is not an option in this, in this, pain scale. But we need to try and consider that it was quite reluctant to put the leg, down.
Because he had a local block and he had orthopaedic surgery. We crossed this part. We don't walk this dog.
And when the patient when the area was palpated it guarded the area. OK, that little turn, is is showing us that OK, I'm painful. I'm guarding the area overall.
This Look, this Look, look, Dog looked indifferent, a bit non responsive to surroundings. It was like, Just don't touch me and let me be, And it looked to me unsettled as well, cause he couldn't lay it down. So the total score was 6/20 it was already the borderline.
So we decided to top up the methadone with 0.2 milligrammes per kilo. And it was much happier after some of the examples that, some things that we can, perceived with analgesia is something that we call emergency delirium.
We can see euphoria can see dysphoria as well. For example, this, kitty cat, he also had spinal surgery. Is in a state of euphoria, moving to dysphoria.
So we see that we say that it enjoys seeing pink elephants. It's OK. Unless they are so active that they can hurt themselves so they start vocalising and they having dysphoric behaviour.
So in that case, we need to either sedate them on trying to antagonise partially, the opioids or the analysis they received. This dog over here, she had a labs pay, was a rescue dog. She woke up screaming.
So we we thought she had emergency delirium. She was in incubator. I just had time to wrap around the blanket, and we give her some.
We give her some sedation. She's a little bit, sedated in this picture. Also received analgesia.
But this was her half an hour later, Very happy. So we just need to have in mind that sometimes, especially in re in the recovery period, we can see emergency ium if for this for we need to sedate these animals. And together with the Allies, we can have patients, with some sedation or sedative effects or prolonged sedative effects.
And we need to monitor them until these effects were off just very briefly touching about chronic pain and that we're not going to cover in this, webinar. But I would like to share it with you. So there are some, pain scoring.
Scales that are available to evaluate, evaluate chronic pain. This is more like questionnaires for the owners and more based on quality of life. We use the canine briefings inventory in our pain clinic patients in dogs.
It's quite useful and also gives the owner an idea of, quality of life and how pain is progressing. In their, pets with, with chronic, with chronic, pain. We are, finishing this, webinar.
So just to conclude, pain cannot be adequately treated if cannot be assessed. In a way that we say an anaesthetic protocol must be tailored to the individual patient. The same, for pain treatment, the same protocol or semanal.
Its might not work for, every patient pain. I again is a very individual experience, and it's it's treatment, especially if, our patients are presenting signs of chronic pain. Again, inadequate treatment of acute pain can lead to chronic pain to these changes in the, processing, pain processing system by our, central nervous system.
And we can see, neuropathic pain. And also nay, plastic pain. As well.
The pain scoring scales. Allow us, to assess pain. And also to assess how the patient responds to analgesia.
And if the analgesia needs to be adjusted, regular training and consists of, pain scarring scales help us en enhances our ability to identify pain and contributes to a greater nursing, patient care. Thank you very much. For attention, I hope you enjoy this webinar.
