Week Two: Analgesia - any interesting cases or questions?

[DCLissa17]

Our weekly topic is analgesia. Please check out the reading list for
great resource material and see the quiz to see what we talked about
at group. This area is dedicated to YOU! If there were any good/
interesting/puzzling cases pertaining to anesthesia this week (or in
the past!) that you would like to go over or find out more about,
please bring them up here. Analgesia is a subject that we deal with in
the majority of our patients in the ER/ICU so how pain works, how to
recognize pain, and familiarity with the drugs and techniques utilized
in analgesia are very important. Sometimes pain control is more of an
art form than a science and sharing what has worked better or worse is
always useful in helping to deal with difficult cases and refine our
skills!

[DCLissa17]

One interesting case involving analgesia that I would like to share
was a patient that we treated last week, Kiwi. Kiwi was a 7mo DLH
kitten who had a gastrotomy performed for a foreign body retrieval.
She was also spayed and her surgery was more extensive than usually in
order to help correct a congenital deformity wherein her sternabrae
were not fused and her abdominal wall had never fully closed beneath
her skin. Her diaphragm was also very thin and lacking in muscle tone,
leading to her having compromised ability to ventilate herself. It was
imperative that Kiwi remain calm and quiet post-operatively as her
congenital deformities were such that if she pulled apart her
incisions, catastrophic damage might result.

Kiwi had been pre-medicated with Oxymorphone and received another dose
of Oxymorphone in the immediate post-operative period after
extubation. Of course, Kiwi just happened to be one of the cats who
reacts badly to Oxymorphone and becames very dysphoric. She was open-
mouth breathing and flinging herself around in her kennel. In order to
provide oxygen support and not allow her to hurt herself, she had to
be burritoed in a towel and have flow-by oxygen given. A low dose of
Acepromazine was tried first to see if some sedation would ease her
dysphoria as she was coming out of general anesthesia. No response.
The vet decided that the Oxy was doing more harm than good and opted
to reverse it. However, Kiwi had just had major surgery and would be
very painful if the Oxy was simply reversed with Naloxone. So, the
choice was made to use a low dose of Butorphanol to partially reverse
the Oxy, keeping some sedation and analgesia on board.

Within 2 minutes of the slow IV injection of Butorphanol, Kiwi relaxed
and was able to be placed back in her oxygen kennel. She seemed to be
painfree and her respiratory rate and MM color/CRT returned to normal.
4 hours after the Butorphanol was given, Kiwi was switched to
sublingual Buprenorphine TID for continued pain control, which she
tolerated very well, and she was moved out of oxygen. She had no
further complications and was released from the hospital 24 hours
after surgery.

As you can see, sometimes analgesia is not as simple as 1+1=2.
Unforeseen complications and situations can arise and it is important
that we as the nursing team not only be aware of possible
complications of procedures and drugs, but that we are aware of how
drugs work together (or against) each other. The end goal of a
painfree and calm patient can almost always be achieved with good
observations and protocols---even if those have to change a time or
two for the individual patient!