Clinical procedure · WET-ANLG-04 · STD-04 · In-patient hospital

Pain management — multimodal

We assess pain using structured scales and treat it in advance, combining several mechanisms of action. The patient's comfort is a clinical parameter, not a courtesy.

STD-04 · Pain management (multimodal)10 steps · 4 scales

Process owner

The veterinarian in charge of the patient

Participants

Veterinarian, anaesthetist, veterinary technician/assistant, hospital staff, the patient's owner

Purpose

Early recognition, prevention and effective treatment of acute and chronic pain, while limiting stress and minimising the risk of adverse effects

Scope

Out-patients, in-patients, peri-operative patients, patients after trauma, and patients treated for chronic pain

Location

In-patient hospital

Start

Diagnosis of a condition, injury or potentially painful procedure, or a raised score on a pain scale

End

The intended level of comfort is reached, the treatment plan is passed on to the owner, or a long-term pain control plan is established

Documents

Pain assessment record, hospitalisation record, anaesthetic record, post-operative record, treatment plan, instructions for the owner

System records

Pain scale score and time of assessment, drugs/methods used, clinical response, adverse effects, decisions to escalate or de-escalate treatment

Procedure workflow

Procedure STD-04 · ANALGESIA — Pain management: a multimodal approach, for dogs and cats. The procedure treats pain as a routinely assessed clinical parameter, and treatment covers assessment, therapy, reassessment and modification of the plan — using both pharmacological and non-pharmacological methods.

Rules that apply

Pain is treated as the “fourth vital sign” and is assessed at every examination of the patient, as well as after every procedure that may cause pain.

Treatment should not depend solely on vocalisation, heart rate, respiratory rate or blood pressure. The assessment is based chiefly on observing behaviour, movement, posture, facial expression, interaction and the response to gentle examination.

For every patient, a baseline should be established: behaviour, activity, response to touch and tolerance of handling before the onset of pain or before the procedure.

If pain is anticipated, analgesia is given pre-emptively, before the surgical stimulus or other painful event, provided the patient's clinical condition allows.

Multimodal treatment means combining methods that act through different mechanisms, tailored to the diagnosis, severity of pain, age, species, organ function, concurrent medications and the patient's risk.

Poorly controlled pain is an indication to reassess the patient and escalate treatment — not to assume that the patient “has to get through it”.

The score, the treatment given and the patient's response must be documented in the medical record.

Pain assessment always includes three elements: observation without contact, calm interaction with the patient and — where the patient's condition allows — gentle assessment of the potentially painful area.

The examination should be stopped if the patient clearly signals discomfort, fear or a defensive reaction.

Pain assessment

Behaviour in the cage or consulting room

Body position, restlessness, hiding, immobility, vocalisation, sleep, interest in the surroundings, contact with staff

Posture and movement

Lameness, reluctance to change position, stiffness, offloading of a limb, difficulty getting up, cautious movement

Facial expression and reactions

Tension in the facial muscles, ear position, narrowing of the eyelids, tension of the muzzle, attention directed at a wound, licking or biting of the painful area

Contact and palpation

Pulling away, freezing, turning the head away, lip licking, swallowing, tensing the body, growling, hissing, attempting to bite, vocalisation

Supporting parameters

Heart rate, respiratory rate, blood pressure, pupil dilation, temperature — only as supporting data, not as independent evidence of pain

Clinical context

Type of procedure, injury, location of the lesions, examination findings, stage of the disease, time since surgery, medications in use and the previous scale score

Recommended scales

Dog — acute pain, hospitalisation or the post-operative periodGlasgow Composite Measure Pain Scale – Short Form (CMPS-SF)

Cat — acute or post-operative painFeline Grimace Scale and/or UNESP-Botucatu Multidimensional Composite Pain Scale

Dog — chronic pain, e.g. osteoarthritisCanine Brief Pain Inventory (CBPI) or Liverpool Osteoarthritis in Dogs (LOAD)

Cat — suspected chronic musculoskeletal painObservational assessment, the owner's history, video recordings from home, and the quality-of-life and mobility assessment tools used by the practice

Procedure steps

Identifying the risk of pain

Assess whether the diagnosis/injury/procedure is associated with painRule: painful in humans = painful in animalsClassification: anticipated / acute / chronic / mixed / none

Initial assessment and scale score

Record the species, diagnosis, scale, score and signsInterpretation that takes stress and sedation into accountPrompt treatment and reassessment after a time appropriate to the method

Setting the treatment goal

Measurable goal: lower scale score, comfort, appetite, gaitPost-operative: comfort, not merely a lack of reactionChronic: function, activity, sleep, the owner's assessment

Pre-emptive analgesia plan

Planning before induction of anaesthesia or the stimulusCovers: intra-operative, rescue, post-operative and after dischargeConfirmation during the “Time out” in line with STD-03

Choosing multimodal treatment

At least two different mechanisms of actionCentrally acting drugs, anti-inflammatory drugs, local/regional anaesthesia, non-pharmacological methodsAvoid duplicating a mechanism; assess contraindications and interactions

Local and regional techniques

Infiltration, nerve, intra-articular, dental and epidural blocksSelection according to location, species, body weight and risk of toxicityRecords: product, dose, volume, site, time, person

Non-pharmacological methods

A calm, warm, clean, low-stress environmentSoft bedding, reduced noise, a hiding place for catsRehabilitation, cooling/warming, nutritional support

Reassessment and rescue analgesia

Assessment at a time appropriate to the route of administration and the action of the drugFor in-patients, usually every 2–4 hoursThreshold exceeded → rescue analgesia and a decision to escalate

Safety monitoring

Monitoring of sedation, vital parameters, appetite, hydration and eliminationWithhold a dose if an adverse effect is suspectedCaution: geriatric patients, kidneys, liver, clotting

Discharge and treatment at home

Confirm the pain score, wound condition, mobility and appetiteA written plan of drugs, doses and duration of treatment for the ownerWarning signs requiring urgent contact

The procedure describes the practice's standard of care; the details of the assessment of a particular patient are decided by the lead veterinarian.

Related services

Where this procedure applies

Anaesthesia · treatment

Treatment of acute and chronic pain

Pain assessment using clinical scales and a treatment plan that combines several methods — after operations, in osteoarthritis, and for cancer pain and neuropathic pain. Standard STD-04.

DogCat

In-patient hospital · treatment

Post-operative care and recovery

Supervised recovery in a heated kennel, monitoring of temperature and of pain using a scale, the first feed, and discharge with written instructions. Care from the moment the gas anaesthetic is switched off until the animal is handed back to the owner.

DogCat

In-patient hospital · treatment

Hospitalisation with an observation chart

A stay in the practice's in-patient hospital with an individual observation chart: measurements at set intervals, drips delivered by infusion pumps, oxygen, an on-site laboratory and a daily conversation with the owner.

DogCat

Anaesthesia · procedure

Local and regional anaesthesia

Nerve blocks, infiltration and epidural anaesthesia as a supplement to general anaesthesia or as stand-alone anaesthesia for minor procedures. Pain management standard STD-04.

DogCat

Orthopaedics · treatment

Treatment of osteoarthritis and chronic pain

Long-term care of a dog or cat with painful joints: diagnosis on X-ray, an individual pain management plan (medication, nutrition, activity) and regular checks of how well it is working.

DogCat

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