PEAK Principles of Pain Management

Although veterinary practices are becoming more progressive with pain management, we still lag behind our human counterparts when it comes to adequately assessing and managing pain in our patients. Barriers exist that stand in the way of appropriate pain management, including a lack of knowledge of drugs and/or techniques available to treat pain. Here at PEAK Veterinary Anesthesia Services, we believe there are 4 primary pillars of pain management, and understanding these concepts is key to providing the best possible analgesia to our patients.

Join us in Colorado Springs on June 20 to talk about these principles in detail!

1. Pain management is good medicine.

Treating pain in our patients is not only ethical; it also makes good medical sense. Pain is a powerful physiologic stressor. Normal responses to physiologic stressors (pain, hemorrhage, shock, etc.) involve behavioral and physiological changes designed to restore homeostasis. However, if stress is severe or allowed to continue for an extended period, it produces distress and cascades of neural and endocrine responses that upset the animal’s physiologic homeostasis. Untreated or prolonged painful conditions result in extended and highly destructive behavioral, autonomic, neuroendocrine, and immunologic responses. These responses can lead to self-mutilation, immune incompetence, and gradual deterioration, potentially culminating in the death of critically ill patients.

2. Prevent windup.

Windup, also known as central neuronal hypersensitization, can occur when the dorsal horn of the spinal cord is bombarded with the constant transmission of noxious stimuli, such as that generated by trauma, chronic inflammatory pain, or surgical pain. If the noxious stimulus is not adequately managed, N-methyl-D-aspartate (NMDA) receptors within the dorsal horn are activated and amplify the signal to the brain, much like turning up the volume on a stereo. Windup can result in hyperalgesia and allodynia.

3. Provide preemptive analgesia.

Although it is not always possible to achieve, patients should receive preemptive analgesia. If we can’t provide analgesia before the primary insult (e.g., prior to injury/trauma), we should provide analgesia before the next insult (wound cleaning, surgical repair, etc.). Providing preemptive analgesia allows for lower inhalant requirements and reduces the likelihood of intraoperative breakthrough pain. Lower doses of subsequent analgesics are required to keep the patient comfortable postoperatively. Preemptive analgesia can also help prevent windup and prevent acute, adaptive pain from becoming maladaptive in nature.

4. Provide multimodal analgesia.

Nociception, the normal sensory pathway, is the physiologic process through which pain is experienced. It is made up of 4 primary steps: transduction, transmission, modulation, and perception. By using multiple drugs that affect the nociceptive pathway at different points, we are able to provide a more complete and robust pain management strategy for our patients. We have 5 primary classes of drugs that we can utilize in the perioperative period to provide multimodal analgesia: a) opioids; b) alpha-2 agonists; c) local anesthetics; d) NSAIDs; and e) NMDA receptor antagonists.

Become a better pain practitioner by remembering these 4 pillars of PEAK pain management! And don’t forget to register for our June 20 continuing education seminar where we will be talking about perioperative pain management in detail!