The Compassion Movement
December 2019
Written by
Sheilah Robertson, BVMS, PhD
Senior Medical Director
Lap of Love Veterinary Hospice
A Few of My Favorite Things:
I thought I would use the last Compassionate Movement newsletter of 2019 to share some of my favorite resources on anesthesia, acute and chronic pain with you. These are websites that I have in my favorites list on my computer because I refer to them often. I hope you find them as helpful as I do. Read on to see which ones I chose and why.

Resources for information on acute and chronic pain and anesthesia
These are the first “stand-alone” feline only anesthesia guidelines. Anesthesia for dogs and cats is often discussed together but the AAFP understands the uniqueness of cats, including their anesthesia needs. The committee that was assembled to create these guidelines included board-certified anesthesiologists in academia and general practice, feline specialists, and very importantly, a veterinary technician. The guidelines are up to date, practical, and full of good information on equipment options, suitable oxygen flow rates, a discussion on airway management, anesthesia for different disease states, and appropriate pre-anesthetic workups. One of the features of the guidelines is troubleshooting algorithms. These guide you through a specific problem (e.g. tachycardia) with simple yes/no steps to find the underlying cause and how to intervene and ameliorate the problem. These charts are available individually and can be downloaded, printed off and laminated and hung on anesthesia machines or displayed in the procedure preparation area, operating room and feline recovery room. You do not need to be a member of the AAFP to access this information, as the AAFP have a mission to improve the care of all cats and to educate caregivers on their unique needs. At the last count, the document has been downloaded over 77,000 times! 

ANESTHESIA RESOURCES
2018 American Association of Feline Practitioners (AAFP) Anesthesia Guidelines
This is a remarkable website that receives 20,000 visitors monthly. By featuring it here, I hope that number goes up, as it well worth a look and a “bookmark!” It was created by Dr. Bob Stein, a practitioner in Snyder, New York, with a passion for anesthesia and pain management. Dr. Stein has undergone extensive training in anesthesia, pain management, rehabilitation, and acupuncture. It is frequently updated – for example, there is a section on how to cope with the opioid shortage and there are video clips on certain techniques; for example how to deal with a fractious cat and how to perform a cat neuter under sedation and a local block.

One of the many “little gems” on this website is the section on drug infusions. This section explains clearly which drugs are suitable for continuous rate infusion (CRI), why they are used, and how to set them up correctly. If you do not have a syringe pump, there are excellent directions on how to perform these techniques by adding drugs or a mixture of drugs to your intravenous fluid bag. See all the options offered in the image below.

Veterinary Anesthesia & Analgesia Support Group
Downloadable excel calculators are available in a zip file. These include numerous analgesic drugs (opioids, ketamine, and lidocaine), emergency drug, and blood pressure support drugs. These can be put on your clinic desktop and I know they will get plenty of use!

The excel calculators have undergone thorough independent checking. Once downloaded, you can choose the drug you wish to use, the way you are going to set it up (IV fluid bag or syringe pump), insert the patient’s name, body weight, the rate you want, and it calculates the amount of drug you need to add, dilution factors, and administration rates, along with suggested loading doses. This can be printed off and kept with the patient during the procedure then stored in the record. It also helps you calculate the controlled drugs that have been used for documentation. The image below shows how easy it is to set up a ketamine CRI for a dog, using a 1-liter fluid bag.
If I could give a kudos award for making my life easier when it comes to setting up infusions, it would go to Dr. Bob Stein!

Recognizing and measuring acute pain is essential. If you cannot measure pain in some way, how can you be sure your intervention worked? Pain is often called the 4th vital sign in veterinary medicine, meaning that when we check a patient, we record temperature, pulse, respiration, and pain level. The Glasgow acute pain tools are validated and are simple and quick to use in a busy clinical environment. They can be downloaded as a pdf, laminated and hung on kennel or cage doors. I use a dry erase marker to check off the score for each section as I do my evaluation and record the final total score in the permanent record, then I wipe the laminated sheet, leaving it ready for the next evaluation. 
 
The Glasgow acute pain assessment tools are available for dogs and cats.

PAIN AND ANALGESIA RESOURCES
Pain Assessment
Feline Acute Pain Assessment
This is a different acute pain scoring instrument specifically for cats called the UNESP-Botucatu Multidimensional Composite Pain Scale. Currently, this scale is quite long, takes time to complete, and includes measuring blood pressure and assessing food intake. However, it is being redesigned and validated in a shorter, more user-friendly format and will be available soon, and in multiple languages, so check back at this site for those updates. One of the great features of this site is the video section. There are videos to show you the different pain behaviors they use in their assessment and you can look at videos to see how many you can spot to test yourself; they offer a score sheet completed by an expert so you can check what you saw and what you missed. This is a great site for training staff on acute pain behaviors in cats. 
RECOGNITION, ASSESSMENT, AND TREATMENT OF PAIN
World Small Animal Veterinary Association – Global Pain Council
This is an open-access site full of useful information. The Global Pain Council is comprised of members from all over the world with expertise in anesthesia, and acute and chronic pain management. The guidelines for the recognition, assessment, and treatment of pain is comprehensive and address the availability—or lack thereof—of different drugs in different parts of the world. Suggested protocols for common procedures, including neutering and C-section, are available as well. 
The section below is the only place on the internet that you can find all the different acute and chronic pain and quality of life assessment tools in one place. 
The educational “how-to” section shown below contains high-quality instructional videos with audio voice over on how to perform important local analgesic blocks. By clicking on the one you want to watch you are taken directly to the video. These are excellent for learning how to do a block and as a refresher, if you are a bit rusty on a technique. 
CARE (Canine Arthritis Resources and Education)
This is one of my new favorite sites. This site is the brainchild of Dr. Kristin Kirkby Shaw, DVM, MS, Ph.D., CCRT, DACVS, DACVSMR, a board-certified surgeon and rehabilitation guru.  

There is a section for dog owners and one for veterinarians. I highly recommend signing up for the free lifetime membership as it means you get updates in your inbox. This site has a lot of evidence-based information on drug therapy, exercise, and supplements. The case studies and videos are especially helpful.

CHRONIC PAIN RESOURCES FOR DOGS AND CATS
Canine Osteoarthritis
If you need a “one site” refresher on Omega 3 Fatty Acids for OA and how to dose, this is it.
Chronic Pain in Cats
Pain Free Cats provides information for owners and veterinarians. Currently, it is
the best site I know for explaining how to use the Feline Musculoskeletal Pain Index. This is a Clinical Metrology Instrument (CMI) which uses a questionnaire completed by cat owners and can identify cats that may have osteoarthritis. There is an excellent, engaging cartoon video aimed at owners that explains the disease and educates cat owners that young cats can have osteoarthritis and what changes in their cat’s behavior to look for and report to their veterinarian. This video strives to get the point across to owners that slowing down and acquiring mobility impairments is NOT about “just getting old” and that there is something we can do to help their cat. The video could be shown in the waiting room or a link to the video can be sent to owners along with e-mail reminders about visits. This site is still under construction, so check back often for more information as it is added.

Short cartoon for owners
Feline Osteoarthritis
Zoetis US has created a new website to raise awareness on the incidence of OA in cats and why this is a welfare issue. It contains webinars with experts such as Dr. Duncan Lascelles and Dr. Margaret Gruen, links to journal articles and new treatment possibilities, including a feline specific anti-Nerve Grown factor monoclonal antibody. There are interactive cartoons showing mobility changes in cats affected by OA which owners can use to identify if their cat might be affected.  
I find it challenging to perform a comprehensive orthopedic examination on some cats and I know I’m not the only one. The selection of feline videos is outstanding! Here you will see an expert showing how to do an orthopedic examination along with providing lots of tips on how to ensure it goes well. 
How to perform an orthopedic examination on a cat
MORE ON CATS
If you are looking for informative handouts for clients, here are two excellent options:
How do I know if my cat is in pain? (owner leaflets, free for download)
Degenerative joint disease in cats (owner information, free for download) at:

I know from CE events and treating cats with OA myself that the topic of long-term use of NSAIDs is controversial, especially because we do not currently have an NSAID that is approved for alleviating the pain related to feline chronic musculoskeletal disease in the US. Despite being 9 years old, the 2010 AAFP/ISFM guidelines still contain a lot of useful information on this topic. There is also an excellent client brochure explaining what NSAIDs are and why they are used for OA in cats, along with the pros and cons.

Long-term use of non-steroidal anti-inflammatory agents in cats
Cats, chronic kidney disease and NSAIDs
This is an even more controversial topic than long-term use of NSAIDs in cats! As many as 68% of cats diagnosed with OA have chronic kidney disease. Based on this clinical challenge, the WSAVA Global Pain Council reviewed all the information currently available on this topic and published it in a format that can be read in under 10 minutes.

An open-access article (a “clinical capsule”) in the Journal of Small Animal Practice written by members of the Global Pain Council discusses what we know about long-term use of NSAIDs in cats with chronic kidney disease.

This article has received a lot of attention, as well as a score of 14 by Altmetric; it’s among the highest-scoring articles published since May 2019.

I hope you check in on some of these websites. You won’t regret it!

Best wishes from our team to yours for the holiday season. We will be back in January with more clinic tips!

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Let's Talk About Tramadol
The Difficult Conversation
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Yunnan Baiyao, a Popular Chinese Herbal Remedy:
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