Financial'Disclosure 3/22/18. Reducing)Fear,)Stress,)&)Pain)in) Anesthesia)Benefits)Everyone. Reduce&Fear& Pain Stress

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1 Reducing)Fear,)Stress,)&)Pain)in) Anesthesia)Benefits)Everyone Ralph&Harvey,&DVM,&MS,&Diplomate&ACVAA Associate&Professor&of&Anesthesiology University&of&Tennessee& Financial'Disclosure I'have'commercial'relationships'with:'Aratana Therapeutics,'Elanco,'Merck'Animal'Health,' BI>Merial,'Sentier,'and'Zoetis'companies,'but'I'do' not'believe'that'these'influence'my'presentations. Reduce&Fear& Pain Stress A# Big#Idea # Emphasis#across#our#industry Benefits#for#All#Involved 1

2 BAYER&VETERINARY&CARE&USAGE& STUDY 58.2! Sedation'can'allow'for' less'stress'to'patient Thinking'About Visit'is'Stressful Dog 37.5 Pet'Hates Going'to'Vet Cats! Pet'owner'appreciate' compassionate' treatment Less'stress'to'pet' and'pet'owner Better'overall' experience von'simson C,'Volk'J,'Felsted'KE.'(2011). Updated'2014.'Presented'AVMA'Annual'Convention,'July'2011S'St.'Louis,'MO.' MultiAModal'or'Balanced Analgesia! Thorough'Nursing'Care! Alteration'of'the'Environment! Distraction'and'Relaxation! Opioids! Local'or'Regional'Anesthesia! Rehabilitative'medicine,'PT! AlphaA2'Agonist' Dexmedetomidine! NSAIDs! Adjunctive'Agents:! gabapentin,'amantadine,'ketamine,'tramadol'(snri),'acupuncture,' trazadone (SaRI),'fluoxetine (SSRI),'amitriptyline (TCA),'maropitant, etc.'! Excellent'adjuvants'A Not sole'agents Gentle&Handling&Refined: AAFP$/$ISFM$Feline-Friendly$Handling$Guidelines Respect,$admiration,$&$thanks$to$ Dr.$Sophia$Yin$and$Dr.$Temple$Grandin Fear$- Stress$- Aggression Separated$Areas$for$Cats$or$Feline$Only$Facilities$ Pheromone$spray Towel$wraps$ Remove$the$top$and$work$in$the$cat$carrier Avoid$/$Minimize$ scruffing $or$excessive$stretching$$ Gentle$technique,$Less$is$More doi: /j.jfms Rodan,$et$al.$Journal$of$Feline$Medicine$and$Surgery.$May$2011 vol.$13 no.$ Yin$S. Low$Stress$Handling,$Restraint$and$Behavior$Modification$of$Dogs$&$Cats. Cattle$Dog$Publishing.$

3 SEDATION)IS)PREFERRED TO)CHAMBER)INDUCTION Risk)Factor)Associated)with) Chamber)Induction 1)! Increase#the#stress#of the#patient! What#is#the#actual# Inhalant#dose# %#MAC! Delay#ability#to#gain airway#control,#monitor#! Increases#personnel# exposure#to#inhalant#gas 1)#Bednarski#R#et#al.#AHHA#Anesthesia#Guidelines#for#dogs#and#cats.#J"AM"Anim Hosp Assoc.#47:#377>385#2011. GOALS&OF&SEDATION Relieve'patient'anxiety Muscle'relaxation Provide'analgesia'if' required Patient'is'unaware'of' surroundings,'but'can' respond'to'noxious' stimuli Pharmacological+Intervention? Does%This%Look%Familiar? 3

4 Win$/$Win$/$Win Introduce$clients$ to$these$modern$ medical$miracles: Peanut$Butter$ and$spray$cheese Modified'Basket'Muzzles' for'recovery Reduce'conflict Improve'safety Facilitate'handling''''' during'recovery'from' anesthesia Who$wins? Increased)stress)for)patient)and)personnel Increased)risk)of)serious)injury )to)all)involved 4

5 PATIENT'BENEFITS:'SEDATION'IS'PREFERRED TO'EXCESSIVE'MANUAL'RESTRAINT! Excessive#manual#restraint# can#be#stressful#to#the#patient 1! Struggling#causes#stress# hyperglycemia,#elevated lactate#and#norepinephrine 2! The#patient#may#injure itself#or#staff An'Overall'Negative'Experience' for'everyone 1)#K#Moffat.#Addressing#Canine#and#Feline#Aggression#in#the#Veterinary#Clinic.#VCNA%Small%Animal%38(5)#2008,# )#Rand#J#et#al.#Acute#Stress#Hyperglycemia#in#Cats#is#Associated#with#Struggling#and#increased#Lactate#and#Norepinephrine.#J%VIM 2002M#16:#123P132. WHAT%IF%THIS%CAT%HAD ASYMPTOMATIC%HCM?%HARDS? Prevalence*of*subclinical*cardiomyopathy*is*16% 1 Number*of*cats*with*asymptomatic*heartworm* disease*is? Would*you*put*this*cat*in*a*chamber? Would*you*manually*restrain*this*case? How*can*you*reduce*the*stress? Paige*CF,*Abbott*JA,*Elvinger*F,*et*al*Prevalence*of*cardiomyopathy*in*apparently*healthy*cats.* JAVMA. 234:*1398M1403O*2009.* Stress&reduction&for&all&critical&patients Deleterious+stress+and+stress/associated+responses,+ particularly+disadvantageous+for+compromised+ patients.+ Blunting+stress+response+is+increasingly+recognized+ as+a+desirable+medical+goal.+ Sympatholytic+contribution+of+dexmedetomidine+ (lower+doses)+credited+with+beneficial+effects.+ Reduction+in+catecholamine+release+and+stress+ responses+benefits+ brittle +or+ fragile +patients. 5

6 WHY2DO2YOU2SEDATE2PATIENTS? Patient Benefits! Less$ Physiological$ Stress! Less Risk$of$ Physical$Harm! Better Experience Healthcare Team Benefits! Less$Risk$of$ Injury! Decreased Radiation$ Exposure! Less stress,$ greater$job$ satisfactions Clinic Benefits! Fewer personnel to$complete$the$ procedure! Less$time$ required$to$ complete$the$ procedures! More$efficient without$loss of$quality Pet2Owner Benefits! Decrease$their own$anxiety about$vet$visit! Improve$ perception$ regarding their$ pet's$levels$of$ comfort and$anxiety! Demonstrate$ compassionate$ treatment of$pet NAVTA%Survey%Results:% When%to%Sedate: Why%Sedate: Industry%News,%The%NAVTA%Journal.%Oct/Nov%2015 HEALTH&CARE&TEAM&BENEFITS: IMPROVED&SAFETY&AND&DECREASED& STRESS 53%%of%bite%and%82%%of% Workman s&compensation 1 scratch%wounds%by%cats% %&Claims 100% 80% 60% 40% 20% 0% 50% Injury%from Cats 42% Injury%from Dogs 90% Bite Wounds 1)%PHLIT%Newsletter% )%PV%Scrivani,%est%asR%Restraint%methods%for%radiography%in%dogs%and%cats.%Comp%Contin%Edu.18:%899U917R% )%Karas%AZ%sedation%and%chemical%restraint%in%the%dog%and%cat.%Clin%Techni%Small%Anim%Pract.%14:%15U26R1999. Average%loss%per%claim:% $1, Preclude%injury:% appropriate%training%and% use%of%chemical%restraint% Reduce%Personnel% Exposure%Radiation 2 Veterinary&Health&Care&Team&Experiences&Less& Stress&When&Working&with&Calm&Patients 3 6

7 Updated'and'Expanded'2015' AAHA'AAFP'Pain'Management'Guidelines Pharmacologic,and,non/pharmacologic, modalities Evidence/based,or,consensus,of,expert,opinion, Behavioral,changes, Validated,pain,scales Post/surgical,pain,is,predictable, Strategies,mitigate,adaptive,& maladaptive,pain Chronic,pain, DJD predominates Prevalent,,Under/diagnosed,,Ubiquitous,,Progressive, Evidence/based,strategies,emerging,in,cats 2015,AAHA/AAFP. Pain Management Guidelines for,dogs,and Cats, J,Am,Anim Hosp Assoc 2015P,51:67 84.,DOI, /JAAHA/MS/7331 Epstein,.,J Feline Med,Surg MarP17(3):251/72.,doi:, / X %AAHA%AAFP%Pain%Management%Guidelines Less&is&More For&everyone. involved Best%use%of%Opioids: Morphine Oxymophone Hydromorphone Fentanyl3(Duragesic,3Recuvyra) Remifentanil3(Ultiva) Butorphanol (Torbutrol,3Torbugesic,3Stadol) Buprenorphine (Buprenex,3Temgesic,3Simbadol) Tramadol3(Mu3agonist3plus3SNRI3F inhibits3reuptake3of3serotonin3and3 norepinephrine) Common%adjuvants: F Maropitant3F eliminates3vomiting,33returns3spontaneous3feeding3 F (B3Kraus,3June32014) F Metoclopramide3F gastro3prokinetic,3antiemetic,3tighten3les F Famotidine3or3ranitidine33F protect3the3gut Dr.3Ralph3Harvey 7

8 Buprenorphine! Buprenex Oral,Trans,Mucosal Nasal,Trans,Mucosal Buprenorphine*SR-(compounded,,not,FDA,approved) Simbadol a,concentrated,buprenorphine FDA,Approved,for,24,hour,analgesia,in,cats,,repeat,for,72hr, total Effective,and,safe,analgesic,for,cats Our,first,24,hour,duration,opioid,analgesic,for,cats Shafford 2013,Proceedings,NAVC,Small,Animal One$Anesthesia$+ Sedation Newer%generation%agents%include%dexmedetomidine,% the%dextrorotary%s7enantiomer%of%medetomidine Detomidine 7 horses Romifidine dogs Dexmedetomidine% humans,%dogs,%cats,%etc. Precedex Dexdomitor Dexdomitor%0.1!!2#AGONIST#HEMODYNAMIC#EFFECTS Bind#to#!!2#Receptors#on# Peripheral#Blood#Vessels Peripheral# Vasoconstriction! CNS# Norepinephrine Hypertension Parasympathetic# Override Baroreceptor Response! Cardiac Output Decreased Maintains Reflex Heart Bradycardia Rate Blood#Flow# Redistributed#to# Vital#Organs! Peripheral# Perfusion# Pale Mucous Membranes Sedation#or# Anesthesia Decreased# Metabolic#Rate Perfusion#in# Excess#of#O2# Demand 8

9 Cardiac'output'is'decreased' Blood'flow'is'redirected Core'organ'perfusion'is'preserved Species(differences(in(hemodynamics Dose(related(changes(at(high(doses No(decrease(in(ventricular(function(when(separated(from( increased(afterload Supply'meets'O 2 demand Isolated(Canine(Heart=Lung(Prep: DM(caused(no(myocardial(depressant(effect(in(the(isolated,(blood=perfused(canine HLP,(decreases(in(cardiac(function(seen(after(this(drug(is(given(to(intact(and autonomically denervated dogs(must(be(due(to(factor(s)(other(than(a(direct(action on(the(myocardium Flacke,(et(al.,(J(Cardiothorac Vasc Anesth.(1992(AugR6(4):418=23. WHAT%IS%A% NORMAL %HEART%RATE?% WITH%BRADYCARDIA,%THE%HEART%SPENDS% MORE%TIME%IN%DIASTOLE Diastole! Heart(is(relaxed! Heart(fills(with(blood! Workload(is(low! Coronary(Blood(vessels( are(dilated,(allows(for( cardiac(perfusion Systole! Heart(is(contracted! Pumps(blood(to(body(! Heart(workload(is( increased! Coronary(vasoconstrict,( decreasing(cardiac( perfusion Bradycardia%May%Be%Advantageous%During%Anesthesia,%Provided( That(Tissue(Perfusion(of(the(Vital(Organs(Meets(Oxygen(Demand 9

10 WHAT%HAPPENS%WHEN%ATROPINE%IS% ADMINISTERED%WITH%!/2%AGONISTS?! Heart%Rate Possible%! Blood% Pressure Minimal%Improvement in%cardiac%output! Workload%of%Heart,% Decreases%Perfusion! Arrhythmias death Dr.%Jeff%Ko teaches%us:%if%hr%is%too%low,%check%apb If%aBP is%high,%use%atipamezol (Antisedan), titrate%carefully If%aBP is%low,%use%atropine,%titrate%carefully 1)#Bloor#BX#et#al.#J"Pharm"Exper"Therapeut,#263:# # )#DEXDOMITOR#Freedom#of#information#summary,#NADA# ,#Dec#1,#2006. DEXDOMITOR:*PROGRESSIVE*IMPROVEMENT* IN*! 2 1AGONIST*DEVELOPMENT*!12*Agonist!12*Selectivity*(Affinity*!12:!1* Receptor) 1,2 Dexmedetomidine/Medetomidine 1620 Xylazine 160! DEXDOMITOR*is*a*full*agonist*of*the*!12*adrenoceptor 6! A*greater*degree*of*!12*selectivity*provides#more#predictable# sedation,#analgesia,#and#muscle#relaxation 3!82#adrenoceptor#agonist#have#a#inhibitory#effect#on#level#of# consciousness!81#adrenoceptor#agonist#have#a#stimulatory#effect#on#the#cns! Reversal*agents*selectively#antagonize#the#!82#agonist 4,5,#!81# agonist#activity#can#continue#after#reversal# 1)#Savola#JM,#Virtanen#R.#European)Journal)of)Pharmacology,#195:# # )#Virtanen#R*,#Savola#J8M,#et#al#European)Journal)of)Pharmacology,#150:#9814:# )#Guo#TZ,#Tinklenberg#J,#Oliker#r#et#al.#Anesthesiology9#71:#758799# )#Shepperson#N#B,#Duval#N,.#Massingham#R#et#al.#J)Pharmaco)&)Experimental)Therapeu.#219:# :# )#Virtanen#R.#Savola#JM.#Saano#V.#Arch)Intern)Pharmacodynamie)Therapie.#297: ,#1989#Jan8Feb. 6)#Scheinin#H,#Virtanen#R,#MacDonald#E#et#al.#Prog)Neuropsycopharma)Biol)Psychiatry,#13:# # Noise&Phobias& Noise&Aversion At&least&one?third&of&dogs&in&the& United&States&suffer&from&noise& aversion.& This&fear&and&anxiety&condition&leads& to&distress&and&suffering. Harris&Poll,&November&2013,784&dog&owners. Shull?Selcer EA,&Vet$Clin North$Am$Small$Anim Pract. 1991D21(2):353?367. Sherman&BL,&Vet$Clin North$Am$Small$Anim Pract. 2008D38(5):1081?

11 Treatment:8Multimodal8Approach 1 Environment Behavior-Modification 5 Pharmacologic-Agents Avoid8stimulus Provide8safe8haven Mask8Noise 2 Pheromones 3 Scents 4 Wearables Counterconditionin g Systematic8 Desensitization Benzodiazepines6 Serotonergic8 Agents AlphaS28agonist 7 Other Nutraceuticals 8,9 Homeopathics 10 Evidence-is-Lacking-for-Some;-None-Are-FDA-Approved-for-Canine- Noise-Aversion 1)8Sherman8BL,8Mills8DS )8Levine8ED,8Ramos8D,8Mills8DS )8Wells8DL,8Graham8L,8Hepper PG )8CrowellSDavis8SL,8Seibert8LM,8Sung8W,8et8al.8 3)8Frank8D,8Beauchamp8G,8Palestrinin C.8JAVMA JAVMA )8Ogata8N,8Dodman8N.8J%Vet%Behav, )8Graham8L,8Wells8DL,8Hepper PG, )8Pike8AL,8Horwitz8DF,8Loprise H.8J%Vet%Behav, )8DePorter TL8et8al.8JVB )8Cracknell,8NR,8Mills8DS.8The%Vet%J Sileo :(FDA(Approved(for(the(Treatment(of( Noise(Aversion(in(Dogs 0.1(mg/mL(of(dexmedetomidine(hydrochloride(in( a(tasteless(gel(formulation Comes(in(carton(w/(a(HDPE((high(density( polyethylene)(3(ml(dosing(syringe(and( Prescribing(Information(leaflet Dosage:(125(mcg/m 2 Administered(between( cheek(and(gum Oral(transmucosal( absorption 32 Sedation)to)prevent)or)treat)post. operative)delirium)or)agitation) Out%patient+anesthesia+techniques+in+human+and+ veterinary+anesthesia+have+improved+the+quality+ of+care+and+are+usually+credited+with+improved+ patient+outcomes+as+well+as+reduced+medical+ costs.+ As+rapid+recovery+from+anesthetic+agents+has+ become+possible,+sedation+to+prevent+or+treat+ post%operative+delirium+or+agitation+has+become+ increasingly+important.+ 11

12 Happy%at%work Sedation)for)the)transition)from) Anesthesia)to)Recovery Lessons'from'equine'anesthesia'strongly' support'the'role'of'!52'ar'agonists'(xylazine,' etc.)'to'improve'the'transition'from'inhalant' anesthesia'to'standing'recovery.' Lower'doses'of'dexmedetomidine,'0.5'to'1.0' mcg/kg,'have'been'similarly'useful'to'reduce' agitation'and'delirium'in'dogs'and'in'humans' recovering'from'general'anesthesia.' National(Dog(Bite( Prevention(Week Third(week(of(May( Educating(people(= Preventing(dog(bites 12

13 Reduce&the&Conflict Reduce&Fear,&Pain,&and&Stress Embrace(Sedation(and(Analgesia To(Reduce(Fear( Pain Stress Big%Ideas %, Major%Goals Emphasized%across%Veterinary%Medicine Benefits%for%All%Involved Strengthen(the( Human-Animal(Bond Suggested Reading,and,References: AAHA/AAFP Pain Management Guidelines for,dogs,and Cats, J,Am,Anim Hosp Assoc 2015C,51:67 84.,DOI, /JAAHAMMSM7331 Golden,,A.,L.,,Bright,,J.,M.,,Daniel,,G.,B.,,FeFee,,D.,,Schmidt,,D.,,Harvey,,R.C.,(1998),Cardiovascular,Effects,of,the,AlphaM2, Agonist,Medetomidine in,clinically, Normal,Cats,Anesthetized,with,Isoflurane American)Journal)of)Veterinary) Research 59:,509M513. Daniel,,G.,B.,,Golden,,A.L.,,Fefee,,D.,,Young,,K.,,Schmidt,,D.,,Harvey,,R.C.,(1997),The,Effects,of,Medetomidine on,cardiac, Function,in,Normal,Cats,Measured, by,radionuclide,ventriculography" Veterinary)Anaesthesia and)analgesia 24(2):, 12M 16. Flacke,,WE,,Flacke,,JW,,Blow,,KD,,McIntee,,DF,,Bloor,,BC,(1992),Effect,of,dexmedetomidine,,an,alpha,2Madrenergic,agonist,,in, the,isolated,heart. J, Cardiothorac Vasc Anesth,,6(4),,418M423. Lamont,,L.A.,,Bulmer,,B.J.,,Sisson,,D.D.,,Grimm,,K.A.,,Tranquilli,,W.J.(2002),Doppler,echocardiographic,effects,of,medetomidine on,dynamic,left,ventricular,outflow,tract,obstruction,in,cats.,j,am,vet,med,assoc,,221:, Lamont,,L.A.,,Bulmer,,B.J.,,Grimm,,K.A.,,Tranquilli,,W.J.,,Sisson,,D.D.,(2001).,Cardiopulmonary,evaluation,of,the,use,of, medetomidine hydrochloride,in,cats. American)Journal)of)Veterinary)Research, 62(11),, Mahmoud,,M.,,Mason,,K.P.,(2015) Dexmedetomidine:,review,,update,,and,future,considerations,of,paediatric perioperative,and, periprocedural applications,and,limitations Br.,J.,Anaesth. (2015) 115 (2): 171M182 doi: /bja/aev226., Naaz,,S.,,Ozair,,E.,(2014),Dexmedetomidine,in,Current,Anaesthesia Practice,M A,Review. Journal,of,Clinical,and,Diagnostic, Research, 8(10),,GE01 GE04.,doi: /JCDR/2014/ Pypendop,,B.,,Verstegen,,J.,,(1994),A,comparison,of,the,sedative,and,analgesic,effects,of,buprenorphine,in,combination,with, acepromazine,,midazolam,or,medetomidine in,dogs.,vet,anaesth Analg 21,, ISFM,and,AAFP,Consensus,Guidelines:,LongMTerm,use,of,NSAIDs,in,Cats Journal,of,Feline,Medicine,and,Surgery July,2010 vol.,12 no.,7 521M538.,doi: /j.jfms Robinson,and,Lascalles.,2010.,JFMS.,doi: /j.jfms Simbadol (buprenorphine,injection),freedom,of,information,summary,,nada,141m434c,july,18,,2014 Sherman,BL,,Mills,DS.,Canine,anxieties,and,phobias:,an,update,on,separation,anxiety,and,noise,aversions.,Vet)Clin North)Am) Small)Anim Pract. 2008C38(5):1081M1106. ShullMSelcer EA,,Stagg,W.,Advances,in,the,understanding,and,treatment,of,noise,phobias.,Vet)Clin North)Am)Small)Anim Pract. 1991C21(2):353M367. Yin,S. Low,Stress,Handling,,Restraint,and,Behavior,Modification,of,Dogs,&,Cats. Cattle,Dog,Publishing.,2009.,doi: /j.jfms