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Dr. Melina Zimmerman on Postoperative Pain Control at Home - Part 2
376 Plays7 months ago
Are you having a BRAT summer, because we sure are here on the NAVAS podcast! By BRAT, we mean Best Remedies for Analgesic Therapy! We’re excited to continue our discussion on post-operative pain control for dogs and cats. If you haven’t listened to part one of this conversation, please go back and listen before diving into this episode. We’re going to finish up our conversation on surgical pain management by discussing the nuances of NSAID use in cats, confronting some controversial opinions on Gabapentin, rave about local anesthetic agents, and introduce some pharmacologic and non-pharmacological therapies to help tackle acute pain for our patients. Joining us again is Dr. Melina Zimmerman, veterinary anesthesiologist and owner of The Doggy Gym, where she provides pain management therapies for all kinds of species. Pain management is so much more than “set and forget”, and we hope to convince you of that right here on the NAVAS podcast.
References are made to the following resources in the episode:
Our previous short episode on Nocita with Dr. Tammy Grubb.
2022 ISFM consensus guidelines on managing acute pain in cats that has been endorsed by the American Association of Feline Practitioners (AAFP):
2024 ISFM & AAPF consensus guidelines on long-term NSAID use in cats
Buprenorphine as an additive agent with bupivacaine for certain dental blocks in dogs
If you like what you hear, we have a couple of favors to ask of you:
Become a member of NAVAS for access to more anesthesia and analgesia educational and RACE-approved CE content.
Spread the word. Share our podcast on your socials or a discussion forum. That would really help us achieve our mission: Reduce mortality and morbidity in veterinary patients undergoing sedation, anesthesia, and analgesia through high-quality, peer-reviewed education.
As a reminder, the ACVAA Annual Meeting is happening in Denver, CO from September 25-27 later this year. Registration rates are discounted for NAVAS members. We hope to see you there! Sign up today!
Thank you to our sponsor, Dechra - learn more about the pharmaceutical products Dechra has to offer veterinary professionals, such as Zenalpha.
If you have questions about this episode or want to suggest topics for future episodes, reach out to the producers at education@mynavas.org.
All opinions stated by the host and their guests are theirs alone and do not represent the thoughts or opinions of any corporation, university, or other business or governmental entity.
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Transcript
Introduction and Podcast Goals
00:00:07
Speaker
Hello to all my fellow gas passers. Thanks for joining me on the North American Veterinary Anesthesia Society podcast. I'm your host and proud gas passer myself, Dr. Bonnie Gatson. In case you are new here or you're joining us for the first time, hello and welcome. Our mission with this podcast is to help veterinary professionals and caregivers like you advance and improve the safe administration of anesthesia and analgesia to all animals.
00:00:38
Speaker
And if
Post-Operative Pain Management Overview
00:00:39
Speaker
you're here today, it's hopefully in anticipation and sheer excitement to dive deep into part two of post-operative pain management in dogs and cats. If you haven't listened to last month's episode, please pause this episode right now, go back so you can be all caught up. A link to part one will be provided in the show notes for you gas passers.
00:01:04
Speaker
As usual, we will start with our housekeeping items. First and foremost, I'm giving a big shout out to our sponsor, Decra. We could not make this podcast without them as they have a shared mission with us to ensure that there are excellent resources for continuing education out there. And we are very grateful that they donate their efforts to that cause.
00:01:27
Speaker
They have a great line of veterinary anesthesia products, including zenalfa, which we have an entire episode on in our archives to check out. Visit www
Veterinary Anesthesia Meeting Announcement
00:01:38
Speaker
.decra-us.com and see what DECRA can do to help your clinic optimize anesthesia and sedation at your practice.
00:01:47
Speaker
Second, I can't wait to meet up with all my fellow gas pastors at the American College of Veterinary Anesthesia and Analgesia annual meeting taking place in Denver this year from September 25th to the 27th. If you want to learn that most up-to-date information on anesthesia while getting those much needed CE credits, visit www.acvaa.org and register for the conference today.
00:02:16
Speaker
NavVis members get a discount on registration, so don't delay. All right, so back to the episode. We are continuing our conversation with Dr. Zimmerman from our last episode about providing pain relief to dogs and cats in the days following a surgical procedure. In that
Pain Relief Options: Pharmaceuticals and Beyond
00:02:33
Speaker
last episode, we focused mostly on opioids and NSA therapy for acute pain, so please check back to our last episode if you want more information on those classes of drugs, as I mentioned earlier.
00:02:45
Speaker
In this episode, we are going to focus on some other oral analgesics for acute pain, as well as some non-pharmaceutical modalities. Should Gabapentin be getting all the hype it's currently getting? Should your hospital consider investing in the long-acting local anesthetic agent, Nocita?
00:03:09
Speaker
What kinds of non-pharmaceutical options have actual evidence supporting their use for post-operative pain control? If you're interested in any of these questions, then I'm so pleased to let you guys know that joining us again is friend of the North American Veterinary Anesthesia Society and the International Veterinary Academy of Pain Management, Dr. Melina Zimmerman.
00:03:33
Speaker
As a reminder, she is a veterinary anesthesiologist and the brilliant mind behind the pain management rehabilitation clinic, the doggy gym. So even though I hate to end this amazing conversation with her, let's wrap up this discussion on what we can do to keep our dog and cat friends comfortable at home after surgery right here on the NavAss podcast with Dr. Melina
Focus on Meloxicam Use in Cats
00:03:57
Speaker
Zimmerman.
00:04:02
Speaker
Welcome back, Dr. Zimmerman. Thank you so much for coming back on the NAVAS podcast so we can chat more about acute pain management in the post-operative period. Well, thank you so much for having me back. I had a lovely time chatting last time and I'm excited to continue talking. I think we're going to start with just wrapping up some points about using NSAIDs, specifically in cats, because I think there's a little bit more to be said about that.
00:04:30
Speaker
And then we're going to talk about some other pharmaceutical agents. Mostly we're going to be focusing on gabapentin because it's been used so widely, I think recently in veterinary medicine, especially for pain management. So we'll spend some time chatting about that. And we're going to bring in our local anesthetics a bit and talk about maybe why they're a nice addition to our pain management arsenal for our acute pain management patients.
00:04:59
Speaker
And then we'll kind of follow up the discussion at the end, chatting about maybe some non-pharmaceutical options we have for post-operative pain. But let's jump a little bit back into NSAIDs and CATS. And I wanted to point out to our listeners that there is a consensus statement on acute pain management in CATS that was published in 2022 by ISFM and also they were endorsed by the AFP. So we are going to put a link in the show notes for our listeners if you want to follow up with that. But I guess my question for you Dr. Zimmerman or if you want to just
00:05:42
Speaker
kind of interject your opinion on all this as it comes, has to do with the black box warning on Meloxicam that was put out by the FDA in 2010 and it still exists on the label today. I don't know if you want to chat about like what that black box warning says and what that means for our feline patients, at least for acute pain management when we're using Meloxicam.
00:06:06
Speaker
I mean, I think, you know, I'm definitely a rabbinicoxib fan for cats, personally, just because I really like it. I think, though, when it comes to oral dosing or if I'm going to, if they don't have rabbinicoxib, I have no qualms about using meloxicam in cats or dogs.
00:06:25
Speaker
To be honest, you know, I think that I definitely have other NSAIDs that I prefer just from preference choice. But I think one thing about the black box warning and, you know, just with any kind of like, this is like ace promazine and boxers kind of in my opinion, right? It's not that this is something that's going to happen in every single cat. And I think with an NSAID being out as long as Meloxicam's been out. Once Rabinococcov has been out for a period of time, I bet there's going to be some warnings that equal you know to like the warnings about Meloxicam. So I think it's one of those things that you know we just need to know that it's out there, you know educate owners about it. If we are using
NSAIDs and Gabapentin in Pain Management
00:07:10
Speaker
it in our practice, like knowing that this does exist and this is something that owners might ask you about kind of thing. But I think just using it
00:07:19
Speaker
in a manner that you're comfortable using it in, that based on scientific studies can be efficacious using it. Like I'm not like a use 0.2 makes per cake of Miloxicam every 24 hours kind of doctor. So I think that we can definitely use it at lower doses and have it be not only an effective form of pain management, but a safe way of pain management for cats.
00:07:46
Speaker
I guess that's my opinion on it, but do you want to elaborate on the black box warning? So the black box warning from Boringer, Engelheim, and also the FDA states that repeated administration of Miloxacam has an association with acute renal failure and death in cats.
00:08:08
Speaker
And I think it has made a lot of veterinary practitioners and owners as well, I think rightly so, concerned about using Meloxicam in this species. I think the important thing to note, though, is number one, the labeled dose, at least for the United States,
00:08:27
Speaker
is 0.3 mixed per cu sub-q one time for the inductable. Probably repeated use of that particular dose might actually have a greater association with acute renal failure compared to some of the lower doses. And that is kind of what the implication is in that 2022 consensus statement about QP management is in cats is that at lower doses, one of the published doses that has been used, which is actually the one that I use most commonly, is 0.2 mix-per-kig sub-q for 24 hours of acute pain management, followed by 0.05 mix-per-kig by mouth for up to four additional days. And at that dose, if as long as your patient doesn't have underlying renal disease and they are uvolemic, and they didn't have hypotension under anesthesia, I think that the actual risk of that patient developing acute renal failure from that dose of Meloxicam is probably fairly low. But I guess the point being is like use Meloxicam efficaciously, be aware of the black box warning and be aware that the dose that is recommended by the manufacturer is probably a little bit higher than at least what I think most people do clinically.
00:09:47
Speaker
Yeah, I think that's super fair too. And I think that client education is so important when it comes to using chinseds in any species, right? So even though we might use things off-label like you just talked about with Meloxicam, like I talked about with Rabinococcib, I'll use that off-label for long-term use, you know, in cats.
00:10:05
Speaker
Even for acute pain management, I think going beyond that initial four or five days of NSAID, a lot of the times ends up being a necessary thing, especially for you know procedures with a lot of soft tissue manipulation, inflammatory type pain.
00:10:21
Speaker
You know, I think that that's one thing to consider is that a lot of the times we're needing to use these things off label anyway. And even with chronic use of NSAIDs, like we do have that study out of Kansas State that looked at those chronic kidney patients with, you know, cats with stage two or three chronic kidney disease.
00:10:40
Speaker
looking at lower doses of meloxicam, that 0.02 makes per keg every 24 hours, and they did that for six months and found that you know their renal excretory function didn't decline. Now, you know they did have a little worsening in proteinuria, but again, the risk of that black box warning of the acute kidney injury, I think, is when used at appropriate clinical doses is a very minimal thing in cats.
00:11:08
Speaker
But noted. Yeah, I would agree with that. And you know, chronic use of NSAIDs for long term pain management is probably outside the scope of this discussion. But for our listeners, if you are interested in learning more about that, the ISFM and as well as the AFP put out a consensus statement on long-term use of NSAIDs in cats and they did that this year so I would like to just direct our listeners to look for that study and will again put that one in the show notes for those of you who are interested in reviewing that.
00:11:39
Speaker
One more comment on NSAIDs because I think, you know, before we move on to other adjuncts for this acute, you know, post-operative type pain is that we do need to remember probably the best evidence we have for acute pain management in our dogs and cats and all veterinary species is going to be NSAIDs, right? And I think that having post-surgical chronic pain syndromes, we know that in people like this is such an important thing. And I really do, you know, now running a pain management practice, I really do see these chronic postoperative, you know, pain syndromes in dogs, cats, bunnies, you know, ferrets, all kinds of species. And I wonder if it all goes back to us maybe not utilizing NSAIDs for long enough in these patients and appropriately in these patients. So, you know, as much as we've kind of hit in that NSAIDs can have these side effects and, you know, all of these things, I think it's so important to remember that these are the drugs that we 1000% should be relying on for inflammatory and soft tissue type pain.
00:12:49
Speaker
Yeah, and I think it's a really good segue into Gabapentin because I'm very excited to talk about Gabapentin because I think veterinarians are a little put off by some of the side effects that come with NSAIDs. So Gabapentin doesn't have the same adverse side effect profile as NSAIDs are also thought of to be a little safer, especially for older patients. So I think gabapentin is being reached for very frequently for all sorts and types of pain management. So let's just start with what is the mechanism of action of gabapentin? How does gabapentin address painful conditions in animals?
00:13:34
Speaker
Yeah, so gabapentin is a gabapentinoid, right? So, you know, especially as tramadol has now fallen out of favor, I think that, you know, gabapentin has become something that veterinarians are reaching for. So as a gabapentinoid, gabapentin was initially developed as an anticonvulsant.
00:13:54
Speaker
So, we know now that gabapentin binds to the alpha-2 delta subunit of voltage-gated calcium channels, and what that does is it creates a presynaptic decrease release of more excitatory neurotransmitters.
00:14:09
Speaker
We know that it does increase GABA and glutamate within the CNS, probably either via increased synthesis, increased release, decreased metabolism. We're not really sure exactly how that mechanism works. You know, I think as we learn more and more about drugs like gabapentin, you know, amantadine, which we'll talk about in a little bit,
00:14:28
Speaker
We know that there probably are other mechanisms of these drugs. And for gabapentin specifically, there's been some evidence to show maybe it blocks sodium channels. So maybe it has some effect you know of blocking that transmission and transduction of the pain signal. So there's lots of different ways that gabapentin effectively can work on you know treating pain. And like you said, it is very safe, right? The major side effects of gabapentin being a CNS relaxant, basically, is just sedation. So does gabapentin work to create this analgesic response for acute postoperative pain? I think that the jury's still a little bit out on that one, right? We are lucky that we're getting a little bit more evidence kind of coming in through the pipelines on gabapentin. But that being said, you know, for the amount that gabapentin is used in now,
00:15:23
Speaker
I don't think we have quite the evidence like we have for NSAIDs to support its use as a single agent analgesic for post-operative acute pain. How often does it need to be administered to be effective? And I think that's a really important question because oftentimes I think owners are probably maxed out on being able to administer gabapentin twice a day.
00:15:47
Speaker
And like, is that going to be generating enough of a positive concentration to have any analgesic effect? Yeah, I think that you know what we know about gabapentin is that it does have a pretty high bioavailability, so around like 40%, which is pretty good for an oral analgesic. That being said, because it does have a shorter half-life, ideally we're dosing gabapentin every eight, potentially depending on the dose that you're using, every six hours to have it have effective plasma levels.
00:16:20
Speaker
So yeah, I think the twice a day gabapentin is one of those things that unless you're using very high doses, probably not going to be very effective for that kind of middle of the day acute pain management, which is another big reason why you know we don't want to be using it as a sole analgesic for that purpose.
00:16:39
Speaker
Let's briefly discuss pre-gabalin because I know this drug not too long ago it just came off patent, so I think there has been some interest in this particular drug as well. yeah How is pre-gabalin different from gabapentin?
00:16:58
Speaker
So pre-gabalin is a little bit different in just that it's a different gabapentinoid. You know, the bioavailability is pretty similar with pre-gabalin to gabapentin. The half-life though tends to be a little bit longer than that with gabapentin. So here's where with pre-gabalin now we can use it at that Q12 hour dosing.
00:17:17
Speaker
maybe Q8 hour dosing, especially you know in dogs or with lower doses. But with a head-to-head study that recently came out looking at gabapentin versus pre-gabalin for sedation in cats, like pre-anesthetic sedation in cats, they found that there was really no difference between the two drugs. Now again, we don't have any evidence telling us that for acute post-operative pain, this is going to be an effective pain reliever.
00:17:44
Speaker
But at least for the sedative properties of it, which is how we think the actual analgesic effects happen, head to head with gabapentin, it produces similar results, just needing a little bit increased of a dosing interval. So meaning we can dose pre-gabalin at that Q12 hour mark, whereas gabapentin, really that Q8 hour mark.
00:18:05
Speaker
Yeah, I was kind of excited about pre gabalin when I first heard about it because there was a study that came out in for King Cavalier, Charles Spaniels. Yes. ring myallia yeah And that pre gabalin seemed to have a really nice analgesic effect for the particular subpopulation. yeah So I was a little excited about pre-gabalin, but I don't really know if there's been any good studies showing its efficacy for like acute surgical pain. There's not any to my knowledge. so The jury is out still. The jury is still out. But you know again, I consider gabapentin as one of what I would consider an adjunct analgesic for acute postoperative pain.
00:18:48
Speaker
So it's not that you can't use it. It's not that it might not be beneficial and be aiding in the analgesic relief. But
Local Anesthetics and Techniques
00:18:56
Speaker
I don't think personally it should be used as a sole agent analgesic.
00:19:00
Speaker
Alright, so let's jump now to a different class of pharmaceutical agents. And we're going to focus on long acting local anesthetic agents, because in my opinion, I feel very strongly that local anesthetics should be used as often as possible for like any surgical case that you do because they are so beneficial at attacking the transduction of signals that probably more efficacious than most of our other drugs that we use. So incorporating them in a multimodal pay management plan is like key, in my opinion. I completely agree. just as Just as much of a soapbox I get up on NSAIDs about, I have the same one for local anesthetics. So I completely agree. However, whenever we can incorporate local anesthetics into our surgical practice, 1000% we should be doing so. Yeah, not only that, but let's say you don't have a long acting local anesthetic in your practice, like bupivacaine or something.
00:20:06
Speaker
There's so many studies showing that even if you're doing like short-term local aesthetics that it just decreases your opioid consumption post-operatively and that's true in animals and it's true in humans. It's been shown to multiple species. Yes. We have so much evidence in animals that this aids in their analgesic protocols post-operatively.
00:20:28
Speaker
Let's just start with how do local anesthetics work. So local anesthetics, you know, are sodium channel blockers. So they're working to deactivate sodium channels within the nerve membrane on the nerve membrane. And what that does is it prevents depolarization of that cell membrane. So it inhibits generation and propagation of the initial nerve impulse from a noxious stimuli.
00:20:53
Speaker
Right. So when I think of like long-acting local anesthetics or applying local anesthetics into like the post-operative period, really, I think of like three options or so. The first one is going to be just utilizing a long-acting local anesthetic agent. like bu pain or rope hivikine, which should last about six to eight hours postoperatively. Depending on how you're injecting it, especially if you're doing like a targeted nerve block, sometimes the analgesic efficacy of those can last like 12 hours or so, even longer, despite like what we know about the half-life of those particular drugs. But as you mentioned earlier, we can add some adjuvant agents.
00:21:38
Speaker
So is that something that you do or you commonly adding adjuvant agents? And if you are, which ones are you mixing in to your local anesthetics to make them last a little bit longer?
00:21:50
Speaker
I do typically use adjuncts to local anesthetics. I personally will either use something like dexmedetomidine as an alpha-2 agonist, you know, peripherally vasoconstricting to overall decrease absorption and increase the duration of the blockade of the long-acting local anesthetic that I'm using.
00:22:09
Speaker
or I'll utilize something like buprenorphine, which as a partial mu opioid agonist, also has some sodium channel blockade properties and can extend that duration. And, you know, either dexmenetomine or buprenorphine, I'm usually not mixing the two together with a long acting local anesthetic, but like you said, it can really extend the duration of that block, like maybe from that like six to eight hour mark for bupivacaine up to like 18 to 20 hours, right? So depending on where you're using it,
00:22:38
Speaker
It can really extend the duration of that block. Right. So in my practice, I commonly use dexametomidine. Actually, I mix it into the bottle of bupivacaine. Yeah. And then if I do that, that will be the bottle that I'll use for all my local blocks. Yeah.
00:22:59
Speaker
And I find it to be really efficacious and I use it at a dose of like one microgram per mil of local anesthetic. So for example, if I have like a 50 mil vial of bupivacaine, I'll add in 50 micrograms of dexamatone into the whole bottle and like shake it up and that will be like my local anesthetic vial. So that's how I do it.
00:23:24
Speaker
Yeah. And then just out of curiosity, do you know off top of your head, like what your dose of adding buprenorphine is into your local anesthetic? Yeah. So I do the same exact thing for dexmenetomidine, make it the one microgram per mil dexmenetomidine vial. And I really like that for more peripheral nerve blocks. So for ephemeral sciatic blocks, brachial plexus blocks, you know things like that. But then when I do dental blocks, a lot of the times I will use buprenorphine just because I think dexmenetomine with the amount of vasoconstriction that goes on, you know it's it's usually just not my go-to for dental blocks. Not that there's anything wrong with using it for that, just my personal opinion. I like buprenorphine for my dental blocks. So for that, I make it a solution of either like five to 10 micrograms per mil of buprenorphine.
00:24:11
Speaker
So for that 10 mic per mil buprenorphine, I put 0.17 mils of 0.3 mic per mil buprenorphine into 10 mils of like a 5 mic per mil bupivacaine to make that solution. And then like you said, now I have that 10 mil vial that all day long, you know, for every dental procedure or whatever procedure we're using, I can just use that vial.
00:24:34
Speaker
Yeah, I find that, well, first of all, there is that study about buprenorphine in dental blocks. So we'll link that into the show notes too. So if you want to review it, you can totally look at it for our listeners. But I usually only utilize buprenorphine for dental blocks when I know we're going to do like lots of very extensive work. But I, you know, I don't think there is a reason you can do it for like all your blocks, really.
00:25:01
Speaker
Absolutely. You know, I think it's one of those things, you know, and and sometimes I'm a little, you know, controversial for saying this, but I tend to anthropomorphize for my patients. And I know when I go to the dentist, if I'm just getting a cavity filled, if I'm like, you know, whatever, I don't like chewing on my tongue all day, right? So especially I don't like my lip being numb all day. So, you know, especially if it's like a very simple type of dental thing. So if it's like,
00:25:30
Speaker
you know, oh, they're, you know, just sensitive from the cleaning, we're pulling an incisor that's already loose and falling out, you know, something very simple. I'll usually just utilize lidocaine for those procedures. But if it's now, you know, a tooth extraction, you know, especially like upper fourth premolars, you know, bottom molars, you know, things that there's going to be a lot of now soft tissue and extensive like inflammatory work going on.
00:25:57
Speaker
Or if it's like a cat with horrible gingivitis, you know, whatever, then absolutely, I think making that block last longer is completely appropriate. So,
Nocita for Postoperative Pain Control
00:26:07
Speaker
you know, just kind of utilizing and picking the drugs that you're using for local blocks, depending on The ultimate, like not only duration that you want, but the ultimate amount of pain and discomfort you feel like that patient's going to be in post-operatively, I think is very appropriate. So the other way that I can think of that we can extend our duration of blockade kind of farther into the post-operative period using adjuvants is going to be using
00:26:34
Speaker
a drug like Nocida. So we do have an entire like little mini episode on Nocida with Dr. Grubb. So I'm going to reference that in our show notes and just have our listeners kind of go back if they want to hear a little bit more about Nocida. So no, we're not going to go into like the mechanism of Nocida and things like that, but I'm just curious if you have used a lot of Nocida and like what your thoughts are on this particular drug.
00:27:03
Speaker
I love Nosita. I think Dr. Grubb is on the same exact page as us that she loves using local blocks. I highly encourage your listeners to listen to that you know short podcast on Nosita because it is a really cool drug and the whole mechanism, the way it's you know been made and the way that it works,
00:27:21
Speaker
They really, you know, hit it out of the park and did a very good job with Nocita. So yeah, I've definitely used Nocita a lot. I think that initially, you know, we utilized it a lot more how it was labeled dosed for dogs, especially for orthopedic procedures for that infiltration postoperatively.
00:27:39
Speaker
But then you know we found that as we were opening this bottle, and then I started playing around with it for a lot of things. And I think where I really like Nocita the best is for skin incisions. So I think that you know it really just helps because what we know about skin incisions in people is that this is where a lot of the post-operative pain comes from, right is the actual skin incision. So if we can provide something in there to help that longer acting block, you know This can last up to like three days, which is pretty cool. So if you now have something that's a constant release of this local anesthetic around that incision, that's probably where I like using it the most.
00:28:18
Speaker
just to give a personal experience I have with Nocita. So I didn't use a lot of Nocita until like recently. okay And we had a cat that was getting like a very large sarcoma removed from its flank. And normally for those cases, because my training was really heavy into just doing like Local nerve blocks typically I was using like intercostal blocks for those types of procedures and I was feeling like I was getting kind of like mixed results like some animals would be really comfortable, but I think it also depends sometimes on like if you were really effective at getting infiltration into all those intercostal nerves across like all of those ribs segments and making sure that you actually spread, the like you you covered enough ribs as well like segments and when I was doing flank procedures. And I had a case recently where we were just like running out of time. We had to kind of go quickly. So we decided to use Nocita post-op instead of going forward and and doing the intercostal blocks preoperatively.
00:29:25
Speaker
Right. And so and we just managed that patient's pain during the procedure with just injectables. And then postoperatively, we just did a skin incision with Nocida. And man, that cat was like the most comfortable cat I've ever seen after a flank procedure. Like that cat was eating. it was We could like pet it. We was like walking around. I mean, it was, we excavated the cat and it was just like walking around the cage. Like I didn't even know it had this major surgery.
00:29:52
Speaker
ah So yeah, it really was eye-opening for me and it has made me appreciate different off-label uses of Nocita. That being said, just like you you mentioned, it's really expensive. And I also think right now there's a shortage of Nocita. And I don't know when that shortage is going to go away, but I know a lot of people are having a hard time getting it right now.
00:30:14
Speaker
Just like any other drug that goes through its phases, you know, it's it's nice thing to stock up on when you can. And yeah, I think that the important thing to remember practically and clinically is that if you're going to open a bottle, make sure you have other things you can use it on, not just one case. It's okay. Okay, especially if it's a cat, like you were saying, 1000%, that would be a fantastic reason to open the bottle of Nocita. But then utilize it in other things, you know utilize it for those skin incisions, even for spays and neuters, right? It's one of those things that incisional pain for this acute post-operative setting, such a huge deal. So you know any kind of mass removals, like you were just talking about, you know utilizing it not just over as a line block, but coming up and doing those intercostal blocks.
00:30:59
Speaker
I think one thing to really remember though is because it lasts up to three days, anytime you're doing it around something that has a motor nerve attached to it, just be extremely considerate about that. So you know I think that you know more more than not, it's not going to be a major issue. but especially when it's if it was a bilateral paravertebral block for thoracotomy or for sternotomy or something like that. you know Definitely be considerate because i've I've definitely heard some stories of patients that ended up on ventilators or had other motor issues that persisted for a little bit longer than they expected. so As amazing of a drug as it is, again, it all comes down to case and patient selection for sure.
00:31:43
Speaker
The last method I
Wound Soaker Catheters and Their Benefits
00:31:45
Speaker
can think of off the top of my head of utilizing local anesthetics into the postoperative period is going to be using wound soaker catheters, which I don't think are used very commonly anymore, but I use them a lot in my early part of my career. So I was going to ask you if you could just describe what a wound soaker catheter is and how they work.
00:32:09
Speaker
Yeah, so we do, you know, like like you said, i I don't think these are extremely popular anymore. I think a lot of fears and people, you know, that I think there were a couple case reports that showed, you know, some infections that occurred and things like that. You know, one nice thing to know is that wound soaker catheters are available commercially. So Myla makes a fantastic one. You can make them yourselves and sterilize them, but they always should be obviously a sterile catheter.
00:32:38
Speaker
that has a portion outside of the patient and a portion inside of the patient's wound that has multiple areas of exit to it. Like I use them during my residency for amputations, right? So if it was an amputation, you know, there might be like 50 to 70 different holes coming out on the patient end of it, and then a port at the out-of-patient end that you can inject local anesthetic to basically be infused into the wound bed area at whatever intervals you need to do so. So if you're using a drug like Bupivacaine, maybe every like six to eight hours, infusing that drug into the wound catheter so that it disperses through that wound bed.
00:33:24
Speaker
You know, I think that we've done such a good job advancing local blocks now. And I think we also know now that we have things like Nocita and we know that the evidence for like splash blocks makes such a big difference and, you know, things like that. I think the wound soaker has fallen a little bit out of favor, but at the same time, you know, if you're doing a lot of things, especially like amputations and you don't have, you know, the ability or the knowledge to do brachial plexus blocks or, you know, blocks like that.
00:33:54
Speaker
But wound catheters can be fantastic options for these stills. So I think that they definitely have a place still in medicine, but you know are definitely less commonly used. Yeah, and they are much cheaper than Nocita. Yeah, that's very true. It is is much cheaper than Nocita. Wound soaker catheters, and then even if you just have a sterile catheter,
00:34:15
Speaker
into the abdomen for you know a post-op gallbladder case or a post-op chest case that you can literally just be infusing and doing intraperitoneal blocks for those patients post-operatively in very similar fashion to a wound soaker catheter. you know I think that's another good way for local anesthetics to be utilized, you know especially when you don't have drugs like Nocita and you don't have the option to do you know nerve blocks and things like that.
00:34:42
Speaker
Yeah, I am a really big fan of wound soakers. I don't use them, I think as much as I used to, just because of kind of all the things that you already mentioned. But we also, we keep them in for like two or three days. And this was also before NOCEDA really, but Those animals were just so comfortable, especially amputations. I was very impressed with how the wound soaker catheter operated. I also really, we use them a lot for like very large reconstructive surgeries. So if we had to do like flaps or anything like that, because we took off like a large mass, we would use them a lot for that. And I was very, very pleased with the level of pain management that we could be providing up to like two days. Wow. And also, you know, we could really get those patients off
00:35:31
Speaker
fentanyl, for example, a lot sooner. as So those animals were like walking and eating a lot faster. So I've always been really pleased with them. In theory, yeah I guess you could send an owner home with one, but i I mean, you need to be very careful about selecting those types of patients that are you're going to do that for.
00:35:51
Speaker
Yeah I agree with that. Do you prefer making your own or do you like using like commercially available ones? I think you could very easily make them. I've made them before with like a red rubber and then you know maybe I'll decide like how big my wound is or my incision.
00:36:08
Speaker
like we think it's going to be. Yeah. And then we actually mark it with like a Sharpie kind of up from the distal edge all the way up approximately so we'll mark it with a Sharpie and then everything below that we just poke it with a 25 gauge needle like all the way down. Yeah, absolutely. And then you sterilize it and you're ready to go. Yeah, no, I love it. I think that's great. Yeah. And again, I think local anesthetics, you know, and and even longer acting, you know, for this acute post-operative pain period, whether it's dental blocks, whether it's, you know, utilizing nosita, whether it's using these wound soakers,
00:36:40
Speaker
whether it's doing the intercostal nerve blocks, you know, doing retrobobar blocks or splash blocks for in nucleations, right? I think epidurals are something that shouldn't be not mentioned because they can be used for so many different procedures, right? And now with caudal epidurals, so with that being so popular, you know, such an easy thing for you to learn how to utilize in private practice. So we can put links to
Adjunct Agents in Pain Management
00:37:06
Speaker
articles on all of these different things, you know, of of how we can incorporate these blocks into practice. But, you know, last last moment on the local anesthetic soapbox, I totally think that these should be utilized in pretty much every single procedure that we use, right? And we didn't even mention testicular blocks.
00:37:24
Speaker
mesovarian blocks, these are all just such easy things to incorporate in for that acute post-operative pain that makes such a huge difference and we have scientific evidence showing that it makes a difference you know in our veterinary patients.
00:37:39
Speaker
Yeah, I could probably have a whole episode on like easy local blocks that you could do in practice. And I'm sure, I'm sure that will come up at some point. That being said, I think it's so important just to emphasize like, even if you're using lidocaine, which is a short-acting low-clinsetic block, the act of doing the block during the surgery makes a humongous difference for your patient two, three days out.
00:38:05
Speaker
Absolutely. There's lots of evidence to show that. Absolutely. So, two local blocks. Yes. Even for, like, Duclav removals, you know, all, like, ah tail amputations, like, it's so important, you know, for that patient postoperatively. So, a thousand percent. We're on the same page with that.
00:38:23
Speaker
So let's move on to some other adjuvunct agents that we can use. We talked about gabapentin and you mentioned amantadine earlier. These were drugs that have classically been used for chronic pain, but I'm curious if they have a role to play for acute pain. And we could start with amantadine and maybe like what is amantadine and does it have a role to play in acute postoperative pain?
00:38:51
Speaker
Yeah, so amantadine is an NMDA receptor antagonist, which is how, you know, we think with chronic pain, it helps to create these like anti-hyperalgesic effects, right? So very similar to how ketamine works. But like I mentioned with gabapentin, you know, the more we find out about amantadine and there actually is a new study that looked at like all of the unique mechanisms of amantadine. So, you know, amantadine was initially made as an antiviral drug, so we know it has like M2 protein inhibition, but it also can increase the release and decrease the reuptake of dopamine and serotonin. It has neuroprotective effects, so there's lots of different things that amantadine, especially for chronic pain, can be a huge help with. That being said, you know, now when we have a surgical procedure that's creating a degree of neuropathic pain, right? So if we have an amputation and, you know, back surgery and orthopedic surgery, even dental procedures, um you could argue, and I'd love to see some evidence that comes out, you know, to help us to to support some of these things. But by preemptively utilizing a drug like Amantadine, You know, we may have beneficial or kind of additive synergistic effects, prevention of those chronic post-operative pain syndromes, things like that that I was talking about. You know, we do have evidence that with chronic pain, a mantadine can kind of potentiate the effect of NSAIDs in chronic arthritis patients.
00:40:28
Speaker
But again, for that acute post-operative surgical pain, I usually will recommend and utilize a mantadine for a short period of time, typically like a 20 to 30 day period in patients that have a significant degree of a neuropathic pain component to things.
00:40:44
Speaker
I think there was a study
Non-Pharmaceutical Pain Relief Methods
00:40:46
Speaker
that was looking at i think like a preemptive ketamine infusion before like surgery to see if it reduced postoperative opioid consumption. It might have been something like that or some other marker of analgesia. and I don't know if it was opioid consumption or pain scores or like what it was, but there seemed to be some evidence that by providing like some of these NMDA antagonists, prior to even like surgical pain, that it might have been effective at improving pain relief in the post-operative period. There's actually been a few studies that shown that it not only decreases opioid use intra-op, but also post-op. So, you know, I think that ketamine, it's along those same lines as what I was saying with amantadine, that preemptive, like if there is a high neuropathic component,
00:41:43
Speaker
You know, we know ketamine CRIs and I know we're not talking about, you know, CRIs and things like that during this podcast. But that being said, you know, ketamine CRIs can make a huge difference in anesthetic management for so many different reasons. But I think especially for that reason you just mentioned for, you know, that reduction in just that you know post-operative need for opioids, just the whole perception of pain in that acute post-operative period. CRIs, especially with things like ketamine, you know make a huge, huge role in that.
00:42:16
Speaker
so Just like the evidence we have for ketamine CRIs, I'd love to get some, now for amantadine, looking at that in the acute post-operative period as well, you know for a drug that can be combined with something, again, as an adjunct analgesic, but that can potentiate and you know decrease the need for other types of drugs too.
00:42:36
Speaker
Yeah, I utilize a lot of ketamine for dental patients. I've been very happy with the way patients, because most of the time for dental patients, at least for the ones I'm working with, we're doing fairly extensive procedures. And for the animals that are receiving a ketamine CRI, and then maybe they're going home on an NSAID,
00:42:59
Speaker
I've been very pleased, I would say, for the majority of my patients with how they're looking as far as pain management is concerned when they walk out the door. so Yeah, absolutely. And especially since those patients tend to be a little bit more rocky under anesthesia right and then have blood pressure issues, you know things like that, ketamine can really just balance out the anesthesia part of it while providing that fantastic pain relief that, like you said, translates into that post-operative patient. so Super cool drugs. Yeah, I think that's important. and we We harped on that last time we spoke, which is that the protocol that you choose to use intraoperatively can affect how your patient is doing when it leaves the hospital. Yes. And ketamine is one of those drugs that will affect it. Absolutely. I hate to pick favorites, but ketamine rotates as one of my top favorite analgesic drugs of all times.
00:43:56
Speaker
Let's talk now about the power of using non-pharmaceutical agents to produce post-operative pain relief at home. So what are some standard non-pharmaceutical options you regularly incorporate when managing acute surgical pain?
00:44:17
Speaker
I think photobiomodulation is probably by far the easiest thing to incorporate into absolutely everyday practice for every single acute post-operative surgical type pain.
00:44:31
Speaker
so you know I think that's probably my number one when we're talking, you know, other modalities. Things like cryotherapy, thermotherapy, right? Even things like electrical stimulation, post-electromagnetic therapy, acupuncture, ultrasound, like these are all things that can be used. But I think a super easy thing to incorporate in is going to be laser therapy, right? Or photobiomodulation.
00:44:57
Speaker
So when do you start lasering those patients when they're coming out of the OR? So immediately, right? You can actually, a lot of practices that I've been at will just incorporate it in while they're actually still in the ah OR. So as you're discontinuing your gas anesthetic, you're cleaning up the patient, getting them you know unhooked and ready for the recovery process, just doing a photobiomodulation, or I'm just going to say laser therapy,
00:45:24
Speaker
doing a laser therapy over their incision wherever it may be, right? So if it's on their ventral abdomen, if it's a dental procedure and now you're doing it inside their mouth, you know, on the gingiva, you know, the only caveat being if we've done a mass removal on some sort of cancer, you know, neoplasia If you have maybe like an open fracture you just repaired, maybe be a little bit more considerate about where you're placing the laser. Not saying it can't be used anywhere on their body, but not directly over those sites is a smart, you know, clinical tip to go along with that. But immediately post-operatively. And then are you doing it, how often, kind of into the recovery phase after that?
00:46:06
Speaker
So then it's one of those things that we know that even one laser therapy is going to produce decreased inflammation, improve wound healing, decrease edema formation, decrease bruising. So usually it's something that you can incorporate once to twice a day in those post-operative patients depending on what else you're doing with them.
00:46:27
Speaker
You know, once a day is absolutely appropriate and fine, you know, until they're discharged. If it's a same day discharge and you want to do one more before they go home that day, it wouldn't be wrong necessarily to do another session before they went home that day as well. Yeah, I think it's important to note as far as lasers concern, most of the lasers that we have out now, either Class 3 or Class 4 lasers, they usually have pre-programmed settings. So it's very easy, in my opinion, to just like quickly put on a pain management setting or a moon setting anything and then you just let it let it go and do its thing.
00:47:04
Speaker
Absolutely. You know, they really make it so easy. And this is something that doesn't even tie up, you know, necessarily the doctor 1000%. You can teach your veterinary nurses how to use the laser safely and appropriately. You do
Therapies for Post-Op Recovery
00:47:18
Speaker
want to make sure if you are using it in the OR and you have something like a class three or class four laser,
00:47:24
Speaker
that you have signage on the doors that you have windows you know that aren't directly into another area that if you shine that laser light you know someone not wearing goggles is going to be affected so just being considerate of where you're using it and you know the surrounding environment to it but yeah like it's totally a set and forget you know easy thing And even if you do have to manually enter things in, it's something that can be extremely easily calculated and, you know, taught, you know, just having like a sheet that has, you know, based on their skin type, the depth of tissue that you're using, you know, this is what we do for wounds in a white dog, you know, between this way and this way. This is what we do in a cat with black fur from this way to this way, you know, that kind of thing. So, you know, yeah, super easy to use. And I think, you know, there's such a varied application list of ways you can use laser therapy. And I think for that acute post-operative pain, it's a no-brainer. This is a great way to get it into your practice and use it every single day.
00:48:27
Speaker
Let's talk about like cold therapy versus heat therapy. so I think many people have gotten a little bit confused. When is it better to use cold and when is it better to use heat? When do you put the ice pack on versus like a warm pack? so Do you have any basic recommendations for when do you use cold, like an ice pack, and when do you use like a little bit of warmth?
00:48:52
Speaker
Yes. So cold therapy, and you know usually this is something for that acute post-operative period that we're utilizing over incisions, right? Any area where there's an acute inflammatory process, that's where I will incorporate cold therapy.
00:49:08
Speaker
And it's not just cold therapy, right? It's good to have, you know, the ice pack, you know, things like that. But using some compression with it is where in studies we actually show that it is a little bit more effective and analgesic. So having some compression on that. So if you just lay a cold pack, you know, over an incision and walk away from it, having somebody actually put a little bit of pressure on that, you know, for about a 15 minute period is going to be a little more beneficial than just laying it on top.
00:49:35
Speaker
You know, and cold therapy on incisions just to before we get off that topic, I'll do like for that like 15 minute, you know, somewhere between 10 and 20 minutes up to like three to four times a day, right? So this is something so easy to tell an owner to be doing at home, especially when we're sending patients home same day, you know, with nothing but an NSAID or you know, what whatever we might be sending them home with.
00:49:58
Speaker
So now with thermotherapy, this is where I think more for like those chronic type of conditions or when they have strains, sprains, like muscle tightness, things like that, where we need to loosen tissue, that's where I'll now use the warm compression. So, you know, I think especially if you're now going to be doing any kind of like physical activity, so let's say they've had a TPLO, they go home, and the owner is going to start walking them or doing range of motion with them you know the following day. Prior to range of motion, that's where I'll grab the thermo-therapy, lay it on top of the thigh, maybe not directly over the incision or over the stifle, but up on the thigh and hip, then do some good massage, good stretching, good range of motion, and then post that activity, now we've created this acute inflammatory pain.
00:50:49
Speaker
that's where that cold compression then goes onto that stifle post that activity. So you mentioned massage, passive range of motion, things like that. Normally I think about those things for like orthopedic conditions. Do you ever incorporate it for like non-orthopedic conditions?
00:51:06
Speaker
Yeah, absolutely. You know, I think that, you know, massage therapy is one of those things that, again, just as easy as laser therapy, if you don't have a laser in your practice, you have a heating pad, you know, you have the cold packs, you have your hands, right? So using your hands and doing massage work on these patients,
00:51:25
Speaker
is so analgesic for them. So especially in that acute post-operative phase, coming in and releasing tension, releasing trigger points, you know, massage itself increases limb flow, increases blood lactate clearance, prevents fibrosis from forming, improves the immune system, so decreases the risk of infection. And, you know, we know that that pain pathway modulation is such a big part, you know, if anyone's gotten a massage and they leave and they feel fantastic, right?
00:51:54
Speaker
We know that massage can be so pain relieving. So even in that acute post-operative phase, 1000%. So if they've had an abdominal procedure and now, you know, they're tensing up their muscles of their abdomen, you coming in and relaxing that or preventing them from doing that muscle spasm and tension is huge, right? And exercise we know is actually hypoalgesic in and of itself.
00:52:20
Speaker
So we have studies and evidence that shows us that just the form of active motion is such a hypoalgesic thing. So same thing, absolutely we think about it for things like orthopedics, but even for soft tissue procedures, just doing, you know, some passive range of motion or as they can active range of motion will help to improve their overall recovery process in that acute post-operative phase.
00:52:45
Speaker
Yeah, I think if I have, you know, like my ideal, like abdominal procedure, you know, maybe that patient gets a local block during the spay or abdominal explore, foreign body procedure, whatever. And we do like a splash block or a tap block or something on that incision so that with some kind of long acting local anesthetic, so that maybe, you know, four to eight in that range, hours after we get out of the OR, that patient's going outside and going for a walk and like using the restroom. And absolutely the local block is helping that patient to be able to like walk around. And I do feel like those patients that are up and moving around earlier look a lot more comfortable in the postoperative in general. And I don't know if it's just because they're analgesias well managed, so they are walking. I don't know if it's correlated or not, but I do feel like the patients that are able to get up and move around, they do look a lot more comfortable. Yeah, absolutely. You know, we talk about recovery optimization, right? And so, you know, we know that in people, recovery optimization from an anesthesia standpoint, you know, makes such a gigantic difference in their pain management, in their opioid consumption, in their return to normal function, in their exit from the hospital, right? I think that in veterinary medicine, sometimes we get into these little routines, okay, well, they're going to be here overnight, they go home the next day, you know, it's like a routine that we do. But recovery optimization, getting them up and moving faster, we know, you know, these patients are more comfortable, like you said,
00:54:17
Speaker
So you know whatever we can do to make that happen, and I think especially things like local blocks, NSAIDs, the CRIs we were talking about, the ketamine CRIs, and now physical medicine, right? Physical medicine, the goal is to maximize the function. So we want to get them up and moving. We want to make sure that they're comfortable.
00:54:38
Speaker
So utilizing this physical medicine now in incorporation with the pharmaceutical type of medicine is going to make a huge difference for our patients when we combine them together. You know, we used to
Enhancing Post-Operative Comfort
00:54:50
Speaker
talk about multimodal pain management, right? And that usually included an NSAID and an opioid and a local block and maybe a CRI, right?
00:54:58
Speaker
Multimodal pain management should include both pharmacologic and non-pharmacologic methods. So we definitely are evolving that we have evidence that shows us now that both of these methods together are doing so much more for our patient's comfort.
00:55:15
Speaker
Yeah, I also think very strongly that we need to consider using anti-emetics even in the post-operative phase. And even though those are not directly have analgesic properties, they help to make patients so much more comfortable. And in human medicine, we know that nausea and vomiting post-operatively just so negatively impacts patient's experience in the post-operative phase. And it must also happen for dogs and cats.
00:55:42
Speaker
yeah So thinking about maybe setting that dog home with like Reglen or Serenia or Zofran or something like that to help control post-operative nausea and get that patient back to eating. I just feel so strongly about that and I think it's like really underutilized. Yes.
00:56:00
Speaker
I totally agree. It's not just nausea and vomiting, right? It's fear and anxiety. So for me, pre-medications for acute surgical procedures, you know, elective procedures starts at home. So I want those pre-medications to start at home. I want them to be getting anti-anxiety, you know, anxiolytic type drugs. but I want them to be getting their anti-nausea drugs either at home or I totally agree in that pre-med or intraoperative or recovery period.
00:56:30
Speaker
You know, but ideally using these things like antiemetics and anxiolytics preemptively before just like with opioids, right? We use these before we're creating the noxious stimuli, local blocks before we're creating the noxious stimuli.
00:56:45
Speaker
So if we can curb nausea and anxiety before they start occurring in our patients, that's going to lead to those better outcomes. The more comfortable patients, the association between behavior and pain is such a big one. you know In my practice, I see chronic pain patients you know all the times. So many of those patients, I work very closely with a few different behaviorists because pain and behavior you know are just intertwined.
00:57:15
Speaker
And we know that anxiety and fear you know has such a big component in pain response as well. So if we're already at this heightened level, you know that's going to lead to us having more of, like I talked about, those chronic post-operative syndrome type complications.
00:57:32
Speaker
That's a really excellent point. Incorporating non-pharmaceutical agents, things like massage, passive range of motion, icing, things like that, this is a way that you can help tighten or strengthen the owner you know animal bonds because these are things you can teach your owners to do at home with their patients and make them feel like they are a part of the treatment plan and helping to make their patient feel better. I do have some owners that are like really scared of doing passive range of motion because they're worried they're going to hurt their animal more and that's totally fair, but I do feel like you have this other subsection of of owners that like really want to be involved and they want to feel like they're helping in some way to make their animal feel better. And I think by teaching people how to do these things, it can help strengthen even the bond that they have with their own pets.
00:58:30
Speaker
Yeah, listen, the human-animal bond is not controversial. This is scientific things that we know about as well, right? So I completely agree with you. I think that that's a huge part to all of it. And giving them
Conclusion and Future Topics
00:58:42
Speaker
something that not only brings them closer to their patient, but also can help us identify areas of discomfort and continued pain that the animal is feeling.
00:58:53
Speaker
so that we can continue pain therapy. you know If they just go home and they're laying on the pillow on the couch right for five days and they're not being touched, they're not being palpated, you know teaching owners how to do pain scores at home, you know things like that I think is important as well to all of this acute post-operative pain management. Any other soap boxes you feel like jumping on? Man, I feel like you know my legs are tired. That was a lot of soap boxes today.
00:59:18
Speaker
but I think there's not a set and forget with this acute post-operative pain management. I think that's what we've highlighted in this podcast and the one before, right? It's really about choosing that right multimodal pain management, but I think we've both kind of highlighted the importance of using that opioid, using the local blocks, using the NSAIDs, and then all of these other things are like icing on the cake, right? So we're just creating this huge, beautiful cake and we're plopping the icing on top and, you know,
00:59:49
Speaker
until those birthday candles are on and they're lit. you know We want to make sure we get every component of that cake up and functional. And I think that acute post-operative pain management is that birthday cake, right? We need to make sure we get all of the components on there so that we have the best outcome in our patients.
01:00:07
Speaker
Well, thank you so much for talking to me not once, but twice about really big and important question, which is making sure that we keep our patients comfortable.
01:00:19
Speaker
after they have surgery. So thank you so much for chatting with me about that. Well, thank you for having me. And honestly, thank you for doing this podcast. It's really awesome. And I think that, you know, NavVis is one of those organizations that is huge. It's so great to have for our veterinary community. And what you do is awesome.
01:00:43
Speaker
If you like what you heard today, I encourage you to check out NavAss and consider becoming a member. As a member of the North American Veterinary Anesthesia Society, you get tons of benefits, including access to CE events, focusing on anesthesia and pain management, blog posts, fireside chats with bored anesthesiologists, as well as specialty technicians, and just so much more. Visit www.mynavass.org to advance your anesthesia journey today.
01:01:12
Speaker
If you have been enjoying the content of this podcast, I would sincerely appreciate it if you would give us a like or subscribe to our podcast, write a review or simply spread the word about this podcast to your friends and coworkers. We appreciate any and all listener support. If you have any questions about this week's episode or the Navas podcast in general, or if you want to suggest topics for future discussion, please reach out to us at education at mynavas.org. We would love to hear from all of you.
01:01:42
Speaker
Also, a huge thank you to our sponsor, Decra, without whom this podcast would not be possible. Visit their website, www.decra-us dot.com to learn more about their line of veterinary anesthesia products. This podcast was produced by Maria Bridges, edited by Chris Webster of Chris Webster Productions, and technical support was provided by Saul Humminess.
01:02:06
Speaker
I want to thank our guest, Dr. Melina Zimmerman, for this wonderful discussion on postoperative pain management. And lastly, a huge thank you to all the gas pastors out there who choose to spend their time with me today on the North American Veterinary Anesthesia Society podcast. Becoming a skilled anesthetist is a lifelong journey of learning and self-discovery, so I hope you consider listening in the future. I'm your host, so Dr. Bonnie Gatson, and thank you for listening. See you next month with another episode of the NavAss Podcast.