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Unveiling Nocita: A Breakthrough in Post-operative Pain Relief with Dr. Tammy Grubb - Ep. 10
335 Plays1 year ago
Here on the NAVAS podcast, we are recognizing and honoring September as Animal Pain Awareness Month by giving our listeners a small taste of a larger episode on pain assessment that will come out later this month with Dr. Tammy Grubb. As a board-certified veterinary anesthesiologist who is an expert in companion animal pain management and an intense fan of local anesthetic agents, Dr. Grubb provides her incite and expertise on the groundbreaking drug, Nocita. Together with host, Dr. Bonnie Gatson, they will dive into Nocita’s mechanism of action, address safety concerns, discuss its use in various clinical circumstances, and touch on some of the controversies of its use as part of an analgesic plan. We hope you have 15 minutes to spare to learn how to incorporate Nocita into your daily anesthetic practice.
Learn more about Nocita.
Learn more about Animal Pain Awareness Month.
We invite our listeners to check out articles mentioned in today’s episode, including this manuscript comparing the use of Nocita to bupivacaine for dental blocks and a two-part review article authored by Dr. Grubb about the use of local anesthetics in dogs and cats.
Part 1 and Part 2
If you like what you hear, we have a couple of favors to ask of you:
- Subscribe to the North American Veterinary Anesthesia Society (NAVAS) for access to more anesthesia and analgesia educational and RACE-approved CE content.
- Spread the word. Share our FB or IG posts, re-tweet, post something on a network or a discussion forum, or tell a friend over lunch. 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.
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 if you want to suggest topics for future episodes, please reach out to the producers of this podcast at education@mynavas.org. Please consider subscribing, liking, leaving this podcast a review, or even telling your friends to give this podcast a listen. We appreciate any and all listener support!
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.
The NAVAS Podcast is published monthly on or near the 15th of the month.
Special thanks to Chris Webster of Chris Webster Productions for editing, producer Maria Bridges, and Saul Jimenez for IT support in making this podcast a reality.
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Transcript
Introduction to the NABAS Podcast
00:00:06
Speaker
Hello, gas passers. Welcome to a special episode of the NABAS Podcast, where our goal is to help veterinary professionals and caregivers advance and improve the safe administration of anesthesia and analgesia to all animals.
Preview: Animal Pain Awareness Month
00:00:22
Speaker
September has been designated by the International Veterinary Academy of Pain Management, or IPOPAM for short, as Animal Pain Awareness Month.
00:00:32
Speaker
And in honor of this important event, we are releasing a special mini episode as a little taste of a larger and more comprehensive episode we plan on bringing to all of you later on in the month.
Interview with Dr. Tammy Grubb on Local Anesthetics
00:00:48
Speaker
For this shorter episode, we are going to be speaking with the president elect of Ivapam, Dr. Tammy Grubb. She is a world-renowned expert
00:00:59
Speaker
for her knowledge in pain management in companion animals. We have an entire episode coming up with Dr. Grubb about pain recognition, but in this shorter episode, we are going to focus on a powerful class of drugs that provides profound pain relief for our four-legged friends, local anesthetics.
00:01:20
Speaker
We haven't had an episode on local anesthetics yet on this podcast, so I'm really excited to introduce this topic with this particular guest. In our conversation, Dr. Grubb confessed to me that she is a huge fan of local anesthetics.
00:01:37
Speaker
and I wanted to hear her opinion about a specific local anesthetic drug called Nocida. This local anesthetic agent has been out in the market for a few years now and I wanted her to explain more about how the drug works and I wanted to get her hot take on some of the unique and dare I say off-label uses of this newer local anesthetic agent.
00:02:02
Speaker
So, without further ado, I hope you enjoy this condensed but informative discussion on NOCEDA with Dr. Tammy Grubb right here on the NavAss Podcast.
The Advantages of Nocita
00:02:18
Speaker
I want to talk about NOCEDA. It's a drug that has been out there for a little while. And I know you are somebody who is a strong advocate for NOCEDA. For our listeners, what is NOCEDA and how is it licensed to be used currently?
00:02:34
Speaker
Now CETA is liposome encapsulated bupivacaine. So we all know and love bupivacaine. And now by putting it in little liposomes, it becomes a long duration drug because those liposomes degrade after they're injected into the tissue. They degrade over 72 hours, releasing little bits of
00:02:57
Speaker
bupivacaine right wherever you injected those liposomes for that 72 hours. So we get this long duration of analgesia from a drug that we know, bupivacaine. He asked me what it's licensed to be used for. It's licensed to be used for injection into an incision in dogs or peripheral nerve blocks in cats, specifically the peripheral nerve block for desensitizing the paw.
00:03:26
Speaker
Right, so are there any benefits of using NOCEDA over a traditional nerve block with a local anesthetic? So for example, a line block with just like regular bupivacaine as opposed to using NOCEDA?
00:03:45
Speaker
Absolutely. That long duration is almost miraculous. And I think as we see newer drugs being developed, whether it's acute or chronic pain, one thing we're seeing is the development of more longer duration drugs.
00:04:00
Speaker
so that we can be more consistent with treating that post-operative pain or that chronic pain and also decrease the caregiver burden. If we give a longer duration drug, then that means there's less for that pet parent to have to do at home, which means there's better compliance because we did it. So that long duration to me is huge. And not only do we get this longer duration analgesia, but because it's a local anesthetic, again, it has such a power,
00:04:28
Speaker
to decrease the amount of pain that's getting to the central nervous system where wind up or central sensitization occurs and where the affective components of pain occur. We have a decrease in that. We also have a decrease in the need for drugs like opioids that can cause some, opioids are great and they're great pain relievers, but of course they can also cause nausea and vomiting and
00:04:50
Speaker
constipation if we keep giving them and we don't like to send a lot of opioids home with owners to give because pet parents to give because they're controlled drugs.
00:04:58
Speaker
And so we get fewer adverse effects, again, decreased caregiver burden. And also what we're seeing is quicker discharge from the hospital. And again, because either they're not getting a big dose of opioids, so they go home, they're awake faster, they're not nauseous, they're ready to go home, or because they don't need constant rate infusion. So they don't need to stay in the hospital for more infusions. Because that is a tough one, isn't it? When they're really painful and they need something like infusions, but they're really ready to go home, what do
Dr. Grubb's Experiences with Off-label Nocita Uses
00:05:27
Speaker
you do?
00:05:27
Speaker
well, then we can use this longer duration in local aesthetics, or specifically nocita. And it probably decreases the incidence of chronic post-surgical pain too, or CPSP, which is really well-identified in humans. And we're starting to see that, yes, animals have that as well. And a big contributor to CPSP is the amount of pain in recovery. And when I say recovery, I don't mean recovery from anesthesia. I mean tissue recovery. So that 72 hours is an important timeframe.
00:05:56
Speaker
I just wanted to clarify a little bit about the license used for NOCEDA, and if I am wrong about this, please correct me. From my understanding, NOCEDA is licensed to be used for incisional blocks, for dogs, post TPLO, or knee surgeries.
00:06:14
Speaker
and in cats it's licensed to be used as a local block for the paw and specifically it's supposed to be licensed for use for like declawing procedures. Is that correct? You're totally correct and you're way more precise so good for you. Yes, exactly right.
00:06:32
Speaker
So it's injected just before closure so that when you make the incision, you don't go through all those liposomes because you might lice some of them, right? And that doesn't create a toxic situation, but it may not last for 72 hours in if you lice it with your scalpel blade.
00:06:47
Speaker
So specifically at closure for TPLO surgery is what's approval for dogs. And then you're right, cats specifically for peripheral nerve locks, for D-claw. And the reason D-claw, nobody's advocating that, but it is the orthopedic surgery that the FDA recognizes as painful in cats. And so it's unfortunately used for a lot of analgesic drugs.
00:07:09
Speaker
but nobody's advocating it. They're just trying to get the drug approved so that we use it. Now you can probably guess in both species, I use it pretty much for almost every block, completely off label, but anytime we're going through the skin, the skin is highly innervated. I love to block the skin with no seed at enclosure.
00:07:27
Speaker
peripheral nerve blocks in both dogs and cats. I think it's very smart to get the drug approved for skin in one species and then for peripheral nerve blocks in the other species, knowing that as vets we're going to cross over. So I use it for almost all blocks. Now the caveat to that is back to how it works. So those liposomes releasing that little bit of bupivacaine at a time,
00:07:53
Speaker
You need to put them where you want them. So on either side of that incision, for instance, or right over a nerve, for instance, because when we inject regular bupivacaine, it diffuses in a fairly large area.
00:08:08
Speaker
where these liposomes are not, and it's just tiny, tiny bits of bupivacaine. So if it's something like an intraperitoneal lavage, this is not the right drug because those liposomes are going to be floating around the abdomen.
Nocita vs. Traditional Methods
00:08:21
Speaker
I don't know where, but they won't be right at where we caused pain, right? So it needs to be something a little bit
00:08:27
Speaker
specific for us so we can inject that drug where we want it. And I'm going to say something back to the 72 hours right quick. Yes, it's more expensive than the regular local anesthetics. I can't give you anything cheaper than lidocaine, really, but it lasts 72 hours. I had to come back to that, sorry, because everybody always says it's expensive. Yeah, 72 hours.
00:08:48
Speaker
So from what I'm hearing from you, you are using it off label in both species for either incisional blocks where you've created tissue damage with a scalpel and you're closing the wound and you're using it as an incisional block in that area. Or you're also using it as a peripheral nerve block, is that correct?
00:09:10
Speaker
That is correct. Obviously, off-label is very important to note. Which nerve blocks are using Nocita for, like, pretty regularly?
00:09:19
Speaker
You know, really, gosh, pretty much all of them. So we do a lot of blocks for things that happen on the foot that aren't declaws, right? So using that same block that it's approved for, for any surgery on the foot, using it for dentistry. I'm trying to think of a nerve block. I don't use it for, I guess I wouldn't use it if there's the chance to block some
00:09:43
Speaker
big motor nerves. Like I haven't used it for the sciatic block yet. I bet other people have, but I haven't yet. We don't want to block the motor nerves, but of course motor nerves are big and less likely to be desensitized. Would you use it in a tap block? Because I personally do a lot of tap blocks and I'm curious if you have any experience or know of anyone who's done it for that.
00:10:05
Speaker
Yes, I have not done it yet, but yes, I do know some of our colleagues are doing it for a TAP block. So I'm a little curious about this because, so this might shock you Dr. Grove, but I actually don't use Nocida very much. And I do a lot of local regional anesthesia.
00:10:24
Speaker
in my practice. And I oftentimes am using a combination of bupivacaine, not liposomal, not nocida, just bupivacaine with some added dexametomidine in it. And I recently came across a study, I think it's about a year old now, where they were comparing long-term pain scoring in animals that had either nocida or the bupivacaine with dexametomidine for dental nerve blocks.
00:10:54
Speaker
and pain scoring these animals long-term. And they were really seeing no significant difference between the two groups, if I remember correctly. And if you were familiar with that study, or if you can comment on maybe some of the results that were found in that study.
00:11:08
Speaker
Yeah, great question, and I vaguely remember that study, so I can't comment directly, but just to say that I think you and I both probably try to keep up with the literature, and you and I both know, and everybody knows, for every paper that shows something doesn't work, then there's a paper that shows it does, right?
00:11:28
Speaker
Now, the body of literature shows that we have good long-term analgesia with the no-CEDA. But like you said, there's some other ways too. Adding in an alpha 2 we know prolongs the duration of the local blocks. And so there's definitely, as long as people are doing local blocks, I'm super happy however they're doing them. And I love your idea of trying to prolong it in some way because we know we want that long duration blockade.
Engagement with NAVAS and Community
00:11:52
Speaker
Obviously the way you're doing it is a really good choice too. And you know, that's something people could start tomorrow. If they don't have no seed in their practice, they probably have it out, but they probably have dexametomidine and elopein, bupivacane. So start tomorrow. Yeah. And people always ask me for a dose, but I usually recommend as far as mixing dexametomidine in with bupivacane. And again, not no seeders. Like I don't mix dexametomidine and no seeders. If you have just regular bupivacane or ropivacane, this works for either one.
00:12:21
Speaker
I usually do a microgram of dexamadonine per mil of bupivacaine. So what I used to like to do is to get like a 50 mil bottle of bupivacaine that's a multi-dose vial. And then I would put 50 micrograms of dexamadonine into that vial, shake it up and label it as like, this is for our local anesthetics. And I would just do all my local blocks with that bottle of bupivacaine or ropivacaine.
00:12:48
Speaker
Oh, I love that. And that makes it easy for everybody. And of course, since we were already talking off-label, it's okay that we're also giving compounding advice, right? Because this is real life. This is how we work. I love that. That's a great way to do it because then people don't have to remember to add it or don't have to do the dose every time. Like it's already there in the bottle. The bottle's labeled. It has got dexametatomidine in it. And that's a great idea.
00:13:12
Speaker
Well, you know, I want to thank you so much because we talked today about something that I'm passionate about and it sounds like you're also very passionate about. Thank you for having me. It was great fun. I appreciate it too. I really appreciate Navas and all the education Navas is doing and the forum to reach people. We haven't had that in the past.
00:13:37
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 Borden anesthesiologists, as well as specialty technicians, and just so much more.
Acknowledgments and Closing Remarks
00:14:02
Speaker
visit www.mynavass.org to advance your anesthesia journey today. If you have been listening and enjoying this podcast, I would sincerely appreciate it if you could give us a like or subscribe to our podcast, write a review, or simply just tell a friend about this podcast.
00:14:28
Speaker
We appreciate any and all listener support. If you have any questions about this week's episode or the NavAss podcast in general, or if you want to suggest topics you would like for us to discuss in future episodes, please reach out to us at education at mynavass.org. We would love to hear from all of you.
00:14:47
Speaker
Also, a huge thank you to our sponsor, Decra, without whom this podcast would not be possible. Visit their website, www.decra-us.com to learn more about their line of veterinary anesthesia products. This podcast was produced and edited by Chris Webster of Chris Webster Productions. Learn how to get your podcast edited and produced by going to propodcastnow.com.
00:15:15
Speaker
I want to thank our guest, Dr. Tammy Grubb, for this insightful discussion on Nocita. If you are interested in learning more about pain management and recognition in animals, please check out the IVAPAM website at IVAPM.
00:15:32
Speaker
And a huge thank you to all the gas passers out there who choose to spend their time with me today on the NABAS podcast. Becoming a skilled anesthetist is a lifelong journey of learning and self-discovery, so I hope you consider listening in the future. Until next time, I am your host, Dr. Bonnie Gatson, and thank you for listening. I hope you consider joining us later on this month for our in-depth discussion on pain recognition in companion animals.