A good pain management strategy is an integral part of surgical planning. Veterinarians are advocates for their patients, ensuring their pain is well-managed and that they remain as comfortable as possible before, during, and after surgery. There are many analgesic techniques that can be used effectively, and pain management protocols vary within the same clinic, by vet and according to individual patient requirements.
Effective Surgical Pain Management for Cats: Why it Matters
Effective pain management is vital for patient comfort, but reliable analgesia also reduces the occurrence of complications post-operatively. Uncontrolled pain causes changes within the nervous system that can lead to long-term detrimental effects (1), and minimizing these changes is important. Optimal pain management also facilitates recovery after surgery (2). Such improved patient outcomes are associated with an enhanced quality of life, as well as strengthening the relationships between the veterinarian, client and patient (2).
Not all surgeries are created equal, and analgesia protocols must be customized to each individual patient and the surgery being performed. A robust surgical pain management protocol involves preventing pain whenever possible, anticipating the severity of pain, and careful monitoring and ongoing evaluation of the patient for as long as pain could be present (1-3). Protocol adaptations may be required depending on the patient’s response to intervention. Multimodal pain management is an effective means of providing analgesia and is and is an important consideration for all cats undergoing surgical procedures (2).
A multimodal approach to analgesia reduces pain by using multiple classes of pain-modifying medications, and various modalities, to target different sites on the pain pathway. These approaches work synergistically to provide more comprehensive pain relief to surgical patients, while also frequently enabling dose reduction of one or more of the drugs being used. A multimodal approach is therefore a balanced approach to analgesia, that promotes a safe pain management strategy and can reduce the risk of unwanted side effects. It usually incorporates both pharmacological and non-pharmacological approaches.
Managing Surgical Pain Utilizing a Multimodal Approach (1-4, 6-8)
The four steps of the pain pathway—transduction, transmission, modulation, and perception—can all be targeted using a multimodal pain management strategy.
- Transduction is the first step in this pathway, when a painful signal (such as a surgical incision) is transformed into an electrical signal that can be carried through the nervous system. Inflammation is generally a major component of acute pain, and inflammatory mediators sensitize nociceptive neurons. Non-steroidal anti-inflammatory medications (NSAIDs) should therefore be administered to all clinically appropriate patients.
- Transmission follows, during which pain signals are sent first to the spinal cord before being relayed to the brain. Local anesthetics can totally block nerve transmission, providing complete pain relief for as long as their effects last. They should therefore be used in all surgical procedures, where the administration of local anesthetic is possible.
- Modulation determines how intense the transmitted pain signals are. Opioids are a good example of potent, rapidly acting, important modulators of pain.
- Perception of pain can be controlled by general anesthetics as well as analgesics such as opioids and alpha-2 agonists. Alpha-2 agonists provide both sedation and analgesia benefits. They also enhance the pain-relieving properties of opioids.
When planning a balanced protocol to control pain pre-operatively, intra-operatively, and post-operatively, it is important to note that some of the classes of analgesics also individually influence more than one step in the pain pathway. Other medications (such as ketamine or gabapentin) may also be considered for inclusion in such a protocol if the development of chronic maladaptive pain is of particular concern. Non-pharmacological methods for surgical pain control, such as cold compression or laser therapy, are either already well-established multimodal options or have gained popularity in recent years.
As veterinarians become increasingly confident using and administering multiple drug classes to manage pain comprehensively and effectively in surgical patients, a multimodal approach becomes a more fundamental part of everyday veterinary procedures.
The Importance of Ongoing Patient Evaluation and Care
Cats are known to hide pain and can be difficult to evaluate, but assessing facial expressions, posture, vocalizations, and demeanor are important parameters that can suggest whether a patient is comfortable or not (9). Unfortunately, heart rate and respiratory rate are not reliable measures of pain in cats, due to the confounding effects of fear and stress (10). Frequent and ongoing monitoring for behavioral changes is vital for confirming when a pain management protocol is working, and for understanding when it isn’t so that interventions can be made. The use of validated scoring systems can help standardize the approach to patient evaluation and may also help advance behavior recognition skills. Teamwork is required to maximize recognition of pain related changes in patients (2). This includes monitoring by the wider in-clinic team, as well as feedback from the pet owner at-home.
Continuing the pain medication after discharge is essential to ensure patients stay comfortable. Animals conceal pain and owners can find it difficult to recognize pain-related changes, so treatment duration should be based on the expected duration of pain, even if pet owners report no signs of pain in their cat (3). Clear communication with clients is important in cases where ongoing pain management is needed at home, but adherence to the protocol can be challenging due to limited options. Cat owners may lack confidence or perceive difficulties when it comes to administering oral medications at home, but these challenges are minimized by prescribing medications that are highly palatable and easy to give. Long-acting surgical pain management products can be beneficial for both the client and the patient, but the availability of products approved for use in cats is currently very limited. Following up with pet owners once their cat has been discharged, can help reduce fears surrounding the surgery and recovery, and increase medication compliance.
Benefits of a Multimodal Approach for Pain Management
Benefits for the Patient
Providing appropriate analgesia and controlling inflammation in surgical patients helps manage pain, facilitates recovery from surgery, and enhances quality of life (2). Although much of the information comes from human medicine and is still to be proven in cats, the provision of comprehensive analgesia during the peri-operative period is thought to diminish the likelihood of chronic maladaptive pain developing from acute surgical pain (2, 3). Chronic maladaptive pain is complex and difficult to manage, so reducing the chance of it occurring is of benefit to the pet parent and veterinarian, as well as to the cat.
Benefits for the Pet Parent
A comfortable cat that recovers as quickly and smoothly as possible is likely to cause less worry and stress for most pet owners. Fewer post-operative complications should also equate to less follow-up visits and additional procedures, providing a significant benefit in terms of time and financial commitments.
Benefits for the Clinic
The safety of patients is of paramount importance to veterinarians, and multimodal analgesia can reduce the risk of adverse events related to surgery in several ways. The use of multiple drug classes, usually at lower doses, minimizes the potential for side effects associated with higher doses of any single drug (2). Effective analgesia also decreases the dose of inhalant drugs required for anesthesia maintenance. Adverse effects associated with inhalant drugs (such as hypotension and hypoventilation) are dose related, so decreasing the dose reduces patient risk during the operative period (3).
Uncontrolled or poorly controlled pain can negatively affect patient outcome and increase clinic workload. For example, pain can slow a patient’s gastrointestinal motility and reduce their appetite (3). Affected patients require extra nursing care and ongoing problems can delay their return home. Delayed wound healing due to poor control of pain and inflammation can cause similar problems (3), with patients requiring additional dressing changes, adjunctive medications or even follow-up surgical procedures. Pain can also cause patients to vocalize and exhibit behavioral changes, with some displaying reactive aggression. If pain is left poorly controlled, this can lead to a noisy, stressful work environment. It can also make patients difficult to handle, extend procedure times, and increase the risk of injury to clinic staff. A comprehensive approach to pain management supports comfortable patients and a calmer, less stressful work environment.
Relationship Benefits (2,3)
Effective pain management supports strong veterinarian-client-patient relationships. Clear communication with clients about multimodal pain control protocols quickly demonstrates a commitment to compassionate patient care. In addition, the inclusion of non-pharmacological techniques can help the pet parent be more involved in supporting their cat’s recovery and may even strengthen the caregiver-pet bond. The comfort of the patient post-surgery confirms the effectiveness of this balanced approach and can turn a worrying time into a positive experience underlined by quality, professional care.
A multimodal, individualized analgesia strategy will not only keep feline patients more comfortable in hospital but also enhances their recovery after surgery. By integrating multiple drug classes in each surgical protocol, clinicians can feel confident that they have applied a comprehensive approach to pain management, ensuring their patients are as comfortable as possible. Through effective communication, clinicians can educate clients on the importance of pain management at home, which can help facilitate recovery and lead to improved patient outcomes.
- Perkowski, S. Perioperative Pain Management in Dogs and Cats: An Update. NAVC Conference 2013 Small Animal. Retrieved from: https://www.vetfolio.com/learn/article/perioperative-pain-management-in-dogs-and-cats-an-update
- Epstein ME, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain management guidelines for dogs and cats. JAAHA. 2015; 51:67-84.
- Grubb, Tamara et al. “2020 AAHA Anesthesia and Monitoring Guidelines for Dogs and Cats.” Journal of the American Animal Hospital Association vol. 56,2 (2020): 59-82. doi:10.5326/JAAHA-MS-7055
- Tranquilli W. In: Pain Management for the Small Animal Practitioner, 2nd Ed, 2004:5
- Lamont LA. Multimodal pain management in veterinary medicine: the physiologic basis of pharmacologic therapies. Vet Clin North Am Small Anim Pract. 2008;38(6):1173-v. doi:10.1016/j.cvsm.2008.06.005
- Slingsby, Louisa. (2008). Multimodal analgesia for postoperative pain relief. In Practice. 30. 208-212. 10.1136/inpract.30.4.208.
- McEntire, Dan M et al. “Pain transduction: a pharmacologic perspective.” Expert review of clinical pharmacology vol. 9,8 (2016): 1069-80. doi:10.1080/17512433.2016.1183481
- Gregory, Thomas B. “Perioperative Pain Plan: Why is it Needed?” Practical Pain Management. 2013;13(9). Retrieved from: https://www.practicalpainmanagement.com/treatments/interventional/injections/perioperative-pain-plan-why-it-needed
- Mathews K, Kronen PW, Lascelles D, et al. Guidelines for recognition, assessment and treatment of pain: WSAVA Global Pain Council members and co-authors of this document:. J Small Anim Pract. 2014;55(6):E10-E68. doi:10.1111/jsap.12200
- Hoglund, O V, Dyall, B, Grasman, V. Effect of non-steroidal anti-inflammatory drugs on postoperative respiratory and heart rate in cats subjected to ovariohysterectomy. J Feline Med Surg. 2018; 20:980-984.