December 28, 2016

AVMA 2016: Anesthesia and Pain Management Tips for the Vet Tech

At the 2016 American Veterinary Medical Association conference in San Antonio, August 5-9, 2016, American Veterinarian sat down with Tasha McNerney, CVT, CVPP, anesthesia technician at the Center for Animal Referral and Emergency Services and self-proclaimed "Original Anesthesia Nerd," to discuss anesthesia and pain management resources for veterinary technicians.
By American Veterinarian Editorial Staff
At the 2016 American Veterinary Medical Association (AVMA) conference in San Antonio, August 5-9, 2016, American Veterinarian sat down with Tasha McNerney, CVT, CVPP, anesthesia technician at the Center for Animal Referral and Emergency Services and self-proclaimed "Original Anesthesia Nerd," to discuss anesthesia and pain management resources for veterinary technicians.

American Veterinarian: What are some ways to enhance pain management practices in your practice?
McNerney: When talking about pain management, there are a lot of things that a practice could do to elevate their game or get a gold standard; but one of the simplest, cheapest, cheapest, cheapest [things] for your practice [to] do, is [use] local blocks. So if you’re not doing local blocks on your patients, you really should be doing them for every surgical procedure; for anything from spays, just doing a line block along the incision, makes a huge difference. Dentistry, anytime you’re taking out teeth, or taking a biopsy of a growth in the mouth, you want to be doing a local block. It’s going to change the way that you practice anesthesia because you’re going to use less inhalant anesthetic overall, right?

We know, we get into these dentistries, and if we’re not blocking, [we] start to take the tooth out and then what happens? That patient starts [breathing heavily, and] waking up under anesthesia because those pain signals are going to the brain. Well, if we put a local block in place, we eliminate those pain signals going into the brain, [and] they’re not needing more inhalant anesthetic during the actual anesthesia. Then, if we don’t have as much inhalant anesthetic on board, we’re seeing less hypotension. In these old, decrepit cats that need 13 extractions, we don’t want them in an isoflurane level of 4 or 5%, because we know that’s detrimental. So, if we do balanced anesthesia—an opioid, plus a local block, plus a little bit of inhalant anesthetic—we can make that procedure safer for the patient overall, instead of [administering just] a whopping dose of an inhalant anesthetic.

If your practice is not doing local blocks, I would suggest getting educated on local blocks, again, there are many resources online, that will talk about different local blocks, there are a lot of good books out that will look at local blocks, [such as] Pain Management for the Veterinary Technician where Mary Allen Goldberg is the editor and Nancy Shaffran is one of the other editors, is a great resource for technicians who are interested in pain management. They have a whole chapter on local blocks with landmarks and everything, from sacrococcygeal blocks to dentistry blocks to epidurals; everything you could need local block-wise.

AV: Are there any anesthesia and pain management myths that you know are only myths? 
M: Alright, so we’re talking about anesthesia myths; there are certainly a lot out there but one I find that comes up a lot and the subject is close to my heart is the issue of dexmedetomidine. So many people use the drug dexmedetomidine simply as a sedative and they don’t think that it functions as an analgesic and that’s not true.

If you actually look at the box of Dexdomitor, it says on it: sedative and analgesic. That’s a really cool thing about this drug, not only can you use it as a sedative, but you can use it as part of your pre-med as an analgesic to help enhance the analgesic effects of [the] opioids you’re using. Unlike a drug like acepromazine, which doesn’t have analgesic effects, if you use hydromorphone plus Dexdomitor together in the pre-operative period, you’re getting great pain control and that’s really what we want, right?

[We want] really good pain control for our patients in the pre-op and in the post-op and you can use Dexdomitor for its analgesic and sedative effects in the post-op period as well. So again, it’s not sitting on your shelf just to be used as a sedative. We really want to use the drug to its full capacity, [as] a sedative and analgesic.”

AV: What are the benefits of individualized anesthesia plans?
M: When we think about what techs [can] do to make anesthesia more comfortable for them or comfortable for their patient, less chance of side effects overall, we really need to think about individualized anesthesia plans. Thinking that each patient should get a combination like butorphanol [acepromazine and glycopyrrolate] is really kind of old school thinking. Nowadays, [we] want to look at the patient, we want to look at their disease state, we want to look at how much pain is anticipated with this procedure. If we know there’s going to be a really painful procedure, a drug like butorphanol is not going to be good enough. We need to hit it with something heavy: methadone oxymorphone, a good opioid.

I think we need to look at each patient as an individual and stop thinking [that] 'well everybody that gets surgery is going to get X drug.' Well, this patient may not deal well with X drug, so then [where] can we go from there? Maybe this patient has a broken leg, but this one is just a feline castration, different levels of pain, so they need to be treated differently with different anesthetic drugs.

I think that if the technician gets some extra training in anesthesia and pain management and gets to learn the nuances of all the different drugs, that’s going to make their [lives] a lot easier. Once you learn the drugs and learn the side effects of the drugs, know how to react to those side effects, it’s going to make your job a lot easier and make your veterinarian’s job a lot easier, too. Now, they can concentrate on the surgery [and] you can concentrate on making that animal comfortable and pain-free.

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