Pain Management in Small Mammals, Birds and...
Transcript of Pain Management in Small Mammals, Birds and...
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Pain Management in Small Mammals, Birds and Reptiles
Marion Desmarchelier, DVM, IPSAV, DES, MSc
Diplomate of the American College of Zoological Medicine
Animal Welfare in Practice - September 18th 2010
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Introduction
• More and more exotic pets…
• More and more analgesics used in domestic animals…
• But lack of knowledge in exotic pet analgesia
• “First do no harm.” => No pain medication!?!?
• Of course, all vertebrate animals can feel pain…
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Plan
• Why treat pain in exotic pets?
• How to recognize pain in exotic pets?
• What we can use (or not) to manage their pain?
• In Practice… A few clinical cases.
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Before starting…
• Literature not extensive!!!
Based on clinical experience
Controversial subject / Various opinions
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Why treat pain?
• Moral and ethical obligation
• But much more…
“Pain is good, it keeps them quiet…”
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Why treat pain?
• Same reasons as in other species
• Risks of gastrointestinal stasis in herbivores
• Risks of hypoglycemia in small species
• Risks of automutilation
• Post-surgery complications
• Delayed healing
• Risks of diseases secondary to immune system suppression
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PAIN
ANOREXIA
GASTROINTESTINAL STASIS
HYPOGLYCEMIA
ENTEROTOXEMIA
DEATH
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How to recognize pain?
• What would be painful for us (or cats and dogs) should be considered painful in
exotics too (even reptiles!!!).
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Recognizing pain inSmall mammals
• Immobility
• Lethargy
• Isolation
• Aggression in normally docile animal
• Half-closed or dull, unfocused eyes
• Pushing abdomen on the floor
• Production of fewer, smaller or no fecal pellets
• Chewing at affected site / Overgrooming
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Recognizing pain inSmall mammals
• Lack of grooming
• Vocalization
• Stretching with back arched
• Flinching on palpation
• Hunched posture
• Teeth grinding
• Reluctance to curl when sleeping (ferrets)
• Strained facial expression, bulging eyes
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Recognizing pain inSmall mammals
• Increased frequency and depth of respirations or rapid shallow breathing
• Lameness
• Anorexia
• Head extended and elevated (rabbits)
• Piloerection (guinea pigs)
• Porphyrin secretion in rats (stress)
• Squinting (especially ferrets)
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Recognizing pain in Birds
• Feather picking, biting or scratching area
• � Aggression in normally passive animal
• � Striking out to avoid being handled
• � Lameness/Wing droop
• � Vocalization
• � Closed eyes
• � Overgrooming or lack of grooming
• � Ruffled feathers
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Recognizing pain in Birds
• Increased respiration/Open-beak breathing
• Immobility/Lethargy/Isolation
• Anorexia
• Reluctance to perch
• Absence of normal behaviors
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Recognizing pain in Reptiles
• Anorexia
• � Hunched posture, remain standing
• � Scratching or flicking foot at affected area
• � Aggression in normally passive animal
• � Flinching on palpation
• � Closed eyes
• � Head elevated and extended
• � Color changes
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• Immobility
• Lethargy
• Lameness
• Absence of normal behaviors
• Intermittently pulling head into shell and then extending the neck out and up
Recognizing pain in Reptiles
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How to treat pain?
• Opioids
• NSAIDs
• Local analgesia
• Ketamine (and other anesthetics)
• Gabapentin
• Other drugs…
• Environment
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Opioids
Advantages Drawbacks
Good analgesia
μ-opioids > κ-opioids in mammals?κ-opioids > μ-opioids in birds?μ-opioids > κ-opioids in reptiles?
InjectableOral form: tramadolPatches
Can be reversed if needed.
Can cause severe respiratory depression (++ ferrets, rats).May cause digestive hypomotility.
Most are short-acting.
Controlled drugs.Most are injectable only.Patches can be ingested!!!
Sedative effects.
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Non-Steroidal Anti-Inflammatory Drugs
Advantages Drawbacks
Good analgesiaInjectable and oral forms
Meloxicam: liquid form, tastes good, PK in rabbits, studied in birds.
Newer drugs less side-effects.
May cause renal failure in dehydrated or hypotensive animals.
May cause gastroduodenal ulcerations (ferrets, guinea pigs ++).
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Local Anesthesia
• Lidocaine < 2 mg/kg total
• Bupivacaine < 2 mg/kg total
• Same principles as for cats and dogs
• Epidural analgesia
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From Exotic DVM Vol. 4.3 July 2002
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Other analgesic agents
• Ketamine
• Medetomidine
• Gabapentin
• Amitryptilline
• …
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***Environment***
• A good environment is essential to improve the welfare of exotic pets when they are hospitalized.
• Diet (Favorite food?)
• Comfortable cage (Shredded paper…)
• Stress-free environment
• Tender Loving Care
• Social interaction
• Bandages…
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In Practice…
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Case #1• 6-month old male dwarf rabbit
• Castration
• Preoperatively: -opioid
(butorphanol 0.2-0.3 mg/kg IM)
• Postoperatively: NSAID + -opioid
(meloxicam 0.3 mg/kg SC + butorphanol 0.1-0.2 mg/kg SC)
• Following days: NSAID
(meloxicam 0.3 mg/kg PO q12h for 3-5 days
• Avoid GI stasis (no stress, food, activity…)
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Case #2• 3 year-old female dwarf lop rabbit
• Femur fracture => Orthopedic surgery (IM pins)
• Preoperatively: -opioid (+ ketamine in the protocol)
(hydromorphone 0.2 mg/kg IM)
• Postoperatively: NSAID + -opioid
(meloxicam 0.5 mg/kg SC + hydromorphone 0.1-0.2 mg/kg SC q4-6h)
• Following days: NSAID +/- hydromorphone as needed
(meloxicam 0.5 mg/kg PO q12h for 10 days)
• Avoid GI stasis (no stress, food…)
• Choose a good surgeon (check the bandage, wound…)
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Case #3
• 6-month old male ferret
• Enterotomy (Foreign body removal)
• Preoperatively: -opioid
(hydromorphone 0.1 mg/kg IM)
• +/- Intraoperatively: ketamine CRI
• Postoperatively: NSAID + -opioid
(meloxicam 0.1 mg/kg SC + hydromorphone 0.05-0.1 mg/kg SC q4-6h)
• Following days: NSAID
(meloxicam 0.1 mg/kg PO q24h for 3 days)
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Case # 4• 3-year old male ferret
• Pelvic limb amputation
• Preoperatively: -opioid + epidural
(hydromorphone 0.1 mg/kg IM + morphine 0.1 mg/kg epidurally + bupivacaine 1.1 mg/kg epidurally)
• Intraoperatively: nerve local anesthesia + CRI
(lidocaine diluted + ketamine 10 g/kg/min IV)
• Postoperatively: -opioid + NSAID
(meloxicam 0.1 mg/kg SC + hydromorphone 0.05-0.1 mg/kg SC q4-6h)
• Following days: NSAID +/- -opioid
(meloxicam 0.1 mg/kg PO q24h for 7 days)
• Environment
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Birds…
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Case # 5
• 3-year old male African Grey Parrot
• Primary feather bleeding
Needs to be extracted.
• General anesthesia with isoflurane
• Local anesthesia (lidocaine diluted)
• +/- NSAID?
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Case # 6
• 8-year old female Blue-fronted Amazon Parrot
• Tibiotarsal fracture => Orthopedic surgery (IM pin)
• Preoperatively: -opioid
(butorphanol 1 mg/kg IM)
• Postoperatively: -opioid + NSAID(butorphanol 0.5 mg/kg IM q2-4h + meloxicam 0.5-1 mg/kg IM)
• Following days: NSAID(meloxicam 1-2 mg/kg PO q12h)
• Environment
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Case # 7
• 4-year old male Senegal Parrot
• Self-mutilation
• Acute phase: -opioid + NSAID
(butorphanol 1-2 mg/kg IM q2-6h + meloxicam 0.5 mg/kg IM q12h)
+ topical treatment + E-collar
• Chronic phase: NSAID + gabapentin(meloxicam 0.5-1 mg/kg PO q12h + gabapentin 5-10 mg/kg PO q8h)
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Reptiles…
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Case # 8• 5-year old female water dragon
(Physignathus cocincinus)
• Ovariosalpyngectomy
• Preoperatively: -opioid(hydromorphone 0.2 mg/kg IM ???)
• Postoperatively: -opioid + NSAID(hydromorphone 0.2 mg/kg IM ??? + meloxicam 0.1 mg/kg IM ???)
• Following days: NSAID (meloxicam 0.1 mg/kg PO q24h ???)
• Environment
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Wild and Zoo Animals
• Hard to recognize pain (They hide it!)
• Stress plays a major role.
• Not easy to handle or examine.
• Pharmacokinetics of drugs?
• Efficacy of drugs?
• Toxicity of drugs??????
• Higher risks of GI ulcers because of chronic stress in some species?
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Case # 9
• 16-year old male Amur Tiger
(Panthera tigris altaica)
• Right front limb chronic severe lameness
• NSAIDs (meloxicam 0.05 mg/kg q24-48h PO)
• Glycosaminoglycanes (PO, IM and IA)
• Corticosteroids (PO, periarticular)
• -opioid (tramadol PO)
• Gabapentin (PO)
• Amitryptilline (PO)
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Conclusion
• Still a lot to discover!
• Difficult to assess pain
• Limited side-effects at recommended dosages
• To be continued!
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Thanks for your attention!
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Questions ?