Techniques in Perioperative Pain Management for Small Animals

- Emphasis on Clinical Use of Local and Regional Anesthetics

Ralph C. Harvey, DVM, MS, Diplomate ACVA
University of Tennessee College of Veterinary Medicine
Small Animal Clinical Sciences
C247 Veterinary Teaching Hospital
Knoxville, TN 37996-4544


Techniques for use of local and regional anesthetics in small animal patients are
easily learned and applied to substantially reduce the doses of other anesthetics and
analgesics needed. These techniques are very cost-effective and greatly improve patient
care. These anesthetic/analgesic procedures contribute to "balanced analgesia" in
combinations with other strategies for preventing and relieving clinical pain.


Epidural Injection

Landmarks: Iliac crests, dorsal midline, and dorsal lumbar vertebral spinous processes
Preservative-free morphine (e.g. Duramorph), designed for epidural use, is the best-
recommended product. With the preservative-free morphine preparation, cost is
substantially greater. We currently do use the preservative-free morphine, usually in
combination with either saline or 0.5% bupivacaine. The Duramorph preparation is at a
concentration of 1.0 mg/ml. We administer 1 cc Duramorph per 10 kg body weight (0.1
cc/kg) mixed with either saline or bupivacaine, also at 1 cc per 10 kg, for a total volume
of 2 cc per 10 kg.








Brachial Plexus Nerve Block

Produces anesthesia / analgesia distal to the and including the elbow
Bupivacaine at 0.2 ml/kg (0.1 ml/lb)
22 ga. 1.5-3.5 inch needle
insert long needle between shoulder joint and ribs, parallel to vertebrae
aspirate, inject 0.2cc, withdraw slightly, repeat to distribute Bupivacaine
Keys to success: distribute drug, aspirate to avoid IV injection and toxicity, minimize
volume at each injection site to avoid nerve damage





Lidocaine CRI (constant rate infusion)

Analgesic contribution and reduction in anesthetic requirements (reduced inhalant
anesthetic requirement improves blood pressures) and prokinetic. Possible anti-
inflammatory contribution. Very cost-effective analgesic contribution to opioid analgesics.

Loading dose 1-2 mg/kg by slow IV injection over three minutes. Constant Rate Infusion
at 50-100 micrograms/kg/minute (0.05-0.1 mg/kg/min) by syringe pump or by controlled
drip.

Easy set-up method: 68 cc of 2% lidocaine added to liter bag of IV fluid, administered at
1cc/pound/hour will provide 50 micrograms/kg/min. Reduce or discontinue if clinical
signs of intolerance or overdose occur: nausea, CNS stimulation (twitching or seizures).

Other CRI options for analgesia:
Low-dose ketamine
Fentanyl
Morphine
Combinations of analgesics - One of our favorites is lidocaine and fentanyl (1:1
mixture) adjusting rate as needed.


Maxillary Nerve Block

Maxillary Nerve
Maxilla, upper teeth, lip, nose
Insert needle toward the
pterygopalatine fossa from
ventral margin of zygomatic
arch, 0.5 cm lateral to lateral
canthus of the eye. Aspirate, deposit drug at surface
of bone.
Dose: 0.1-1.0 ml bupivacaine or Septocaine (preferred)


Mandibular Nerve Block

Mandibular Nerve
(Inferior Alveolar Branch)
Mandible, lower teeth, lip
Insert needle at lower angle of
jaw, rostral to angular process,
advance dorsally to mid-portion on medial aspect
Aspirate, deposit drug at surface of bone.
Dose: 0.1-1.0 ml bupivacaine or Septocaine (preferred)


The mandibular nerve block is very easy to perform and very inexpensive. The
mandibular foramen is located on the medial aspect of the mandible, at the transition
from the vertical portion to the horizontal portion of the mandible. We slide the needle,
usually a 22ga. 1.5 inch needle, along the interior aspect (medial or oral surface) of the
mandible to a site about 1/2 way across that surface (easy to see the foramen on a skull
or in a textbook figure). The block can be performed either from inside or outside the oral
cavity. I usually prefer to make the injection from outside the mouth. Obviously, this
nerve block should be performed AFTER induction of anesthesia, but should be done
BEFORE surgery is begun.


Contact Septodont
245C Quigley Blvd.
New Castle, DE 19720
(800) 872-8305 phone
(302) 328-5653 fax






Distal Limb Blocks (declaw analgesia)

Superficial Radial Nerve
dorsomedial carpus
Ulnar N. (branches)
lateral carpus
Median N. Ulnar N. (branch)
palmar carpus adjacent to
the accessory carpal pad

0.1-0.3 ml Bupivacaine 0.5% at each site
Note: Never use locals containing epinephrine (e.g. Septocaine or lidocaine with epi) for any extremities!















Intra-Articular Stifle Block

1" 22g needle. In lateral recumbency with the affected limb uppermost, flex the stifle
and apply digital pressure to the medial side of the straight patellar ligament. Insert
the needle on the opposite side of the straight patellar ligament midway between the
patella and the tibial tuberosity and direct it obliquely and distally toward the
intercondylar space of the tibia.

Distention of the joint with long-lasting local anesthetic
Bupivacaine 0.5%
3-6+ hours duration
dose 0.2 ml/kg (0.1 ml/lb)
Injection pre-op and post-op for best effect




SELECTED REFERENCES:

Local and regional anesthesia and analgesia, P. Pascoe, in Seminars in Veterinary
Medicine and Surgery (Small Animal) 1997; 12(2): 435.

Veterinary Anesthesia and Pain Management Secrets, S. A. Greene, (ed.), Hanley and
Belfus, Philadelphia, 2002.

Pain Management for the Small Animal Practitioner, W. J. Tranquilli, K. A. Grimm and L.
A. Lamont, 2000, Newton NewMedia.

Perioperative pain management, Pascoe, P., Veterinary Clinics of North America, Small
Animal Practice 30(4): 899-919, 2000.

Analgesics and pain, Carroll, G., Veterinary Clinics of North America, Small Animal
Practice 29(3): 701-717, 1999.

Analgesia after intercostal thoracotomy: A comparison of morphine, intercostal
nerve block, and interpleural analgesia, Thompson, S.E., and Johnson, J.M.,
Veterinary Surgery, 20(1): 73-77, 1991.

Analgesia after lateral thoracotomy in dogs. Epidural morphine vs. intercostal
bupivacaine, Pascoe, P.J., and Dyson, D.H., Veterinary Surgery. 22:141-147, 1993.

Local and Regional Anesthetic and Analgesic Techniques, Skarda, Roman T., in Lumb
and Jones Veterinary Anesthesia, 3
rd
edition. John C. Thurman, et al., Williams and
Wilkens, Baltimore, 1996.