/// QUARTERLY BEAT / APRIL 2022
QUARTERLY BEAT / APRIL 2022 ///
NOCITA ® (bupivacaine liposome injectable suspension) 13.3 mg/mL For local infiltration injection in dogs only For use as a peripheral nerve block in cats only Local anesthetic Single use vial Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Before using this product, please consult the Product Insert, a summary of which follows: DOG Indication: For single-dose infiltration into the surgical site to provide local postoperative analgesia for cranial cruciate ligament surgery in dogs. CAT Indication: For use as a peripheral nerve block to provide regional postoperative analgesia following onychectomy in cats. DOG Dosage and Administration: NOCITA is for single dose administration only. A dose of 5.3 mg/kg (0.4 mL/kg) is administered by infiltration injection into the tissue layers at the time of incisional closure for dogs. A single dose administered during surgical closure may provide up to 72 hours of pain control. CAT Dosage and Administration: NOCITA is for administration only once prior to surgery. Administer 5.3 mg/kg per forelimb (0.4 mL/kg per forelimb, for a total dose of 10.6 mg/kg/cat) as a 4-point nerve block prior to onychectomy. Administration prior to surgery may provide up to 72 hours of pain control. Contraindications: Do not administer by intravenous or intra-arterial injection. If accidental intravascular administration occurs, monitor for cardiovascular (dysrhythmias, hypotension, hypertension) and neurologic (tremors, ataxia, seizures) adverse reactions. Do not use for intra-articular injection. In humans, local anesthetics administered into a joint may cause chondrolysis. Warnings: Not for use in humans. Keep out of reach of children. NOCITA is an amide local anesthetic. In case of accidental injection or accidental topical exposure, contact a physician and seek medical attention immediately. Wear gloves when handling vials to prevent accidental topical exposure. Precautions: Do not administer concurrently with bupivacaine HCl, lidocaine or other amide local anesthetics. A safe interval from time of bupivacaine HCl, lidocaine or other amide local anesthetic administration to time of NOCITA administration has not been determined. The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to toxicity. The safe use of NOCITA in dogs or cats with cardiac disease has not been evaluated. The safe use of NOCITA in dogs or cats with hepatic or renal impairment has not been evaluated. NOCITA is metabolized by the liver and excreted by the kidneys. The ability of NOCITA to achieve effective anesthesia has not been studied. Therefore, NOCITA is not indicated for pre-incisional or pre-procedural loco-regional anesthetic techniques that require deep and complete sensory block in the area of administration. The safe use of NOCITA in dogs for surgical procedures other than cranial cruciate ligament surgery has not been evaluated. The safe use of NOCITA in cats for surgical procedures other than onychectomy has not been evaluated. The safe use of NOCITA has not been evaluated in dogs or cats younger than 5 months old. The safe use of NOCITA has not been evaluated in dogs or cats that are pregnant, lactating or intended for breeding. DOG Adverse Reactions: Field safety was evaluated in 123 NOCITA treated dogs. The most common adverse reactions were discharge from incision (3.3%), incisional inflammation (2.4%), and vomiting (2.4%). CAT Adverse Reactions: Field safety was evaluated in 120 NOCITA treated cats. The most common adverse reactions were elevated body temperature (6.7%), surgical site infection (3.3%), and chewing/licking of the surgical site (2.5%). Storage Conditions: Unopened vials should be stored refrigerated between 36° F to 46° F (2° C to 8° C) NOCITA may be held at a controlled room temperature of 68° F to 77° F (20° C to 25° C) for up to 30 days in sealed, intact (unopened) vials. Do not re-refrigerate. Do Not Freeze. How Supplied: 13.3 mg/mL bupivacaine liposome injectable suspension in 10 mL or 20 mL single use vial. 10 mL supplied in 4-vial carton. 20 mL supplied in a single vial carton and 4-vial carton. NADA 141-461, Approved by the FDA US Patent: 8,182,835; 8,834,921; 9,205,052 4 Most of the commonly used blocks in veterinary practice (e.g., incisional, oral/dental, manus/pedus, intraperitoneal, testicular, etc.) can be done with knowledge of anatomy and the ability to palpate anatomical landmarks. Easy-to- follow, detailed, open-access resources that describe the anatomy relevant to the blocks are available 3,4 and should be downloaded and placed in the work area where the blocks are done. There are also advanced techniques that are most effectively done using nerve finders or ultrasound guidance if you want to expand your power. 5 If nothing else, block the incision or traumatic injury site. The skin is highly innervated and a major source of pain.
1 General anesthesia and local anesthetic blockade are completely different. Only perception is blocked with general inhalant anesthesia while the rest of the pain (or nociceptive) pathway is fully functional. Whether the patient is awake or anesthetized, the pathophysiologic adverse effects of pain are still occurring. This can be demonstrated by the fact that physiologic markers, like changes in heart rate, blood pressure, serum cortisol concentrations, etc., are used as pain (nociceptive) indicators in research studies on anesthetized patients undergoing painful procedures. Clinically, pain can make maintenance of the patient at an appropriate plane of anesthesia more difficult, while local blockade allows a lower dose of inhalant anesthetic, which improves dose-dependent anesthetic safety. 2 As with all drugs, the adverse effects of local anesthetics are uncommon when the drug is administered at the correct dose using proper technique. Adverse effects are most likely to occur when supra-clinical doses are administered IV, 1 which is not the injection site for local/regional blocks. Carefully calculate the dose and use good injection technique, meaning gentle insertion of the needle into tissue and aspiration prior to injection every single time a local anesthetic (or any other drug) is injected into the tissue. 3 To make your superpower a habit, put ‘local/regional block’ on a checklist (Figure 2) of analgesic drugs/procedures that the patient needs. Increasing awareness that a block should be used will increase the likelihood that doing the blocks will become habit. Date Preanesthesia (fill in drug name) Dose/Route/Time Administered Opioid: Analgesic Protocol For Procedure
SPONSORED ARTICLE
What if Your Superpower was the Ability to Stop Acute Pain?
TAMARA GRUBB , DVM, PHD, DACVAA, PRESIDENT-ELECT IVAPM Adjunct Professor at Washington State University; Founder of VetAACE.com; Consultant
Imagine, a room full of patients that have suffered trauma or have undergone surgery and are in pain, suffering, probably in silence and trying to hide their misery. The pain is causing adverse health effects (e.g., tachycardia, hypertension), behavior (e.g., anxiety, aggression) and welfare/quality of life issues (e.g., anorexia, insomnia). And in you step, with the super powerful class of drugs - the local anesthetics – to use your superpower of stopping acute pain.
Pain is most effectively controlled when a multimodal protocol is used with drugs chosen based on their mechanism and location of action in the pain pathway. For acute pain, opioids, non-steroidal anti-inflammatory drugs (NSAIDs) and local anesthetics are the most potent drugs included in the protocol. As a quick review of the pain pathway and where drugs work (Figure 1), NSAIDs work primarily in the transduction phase of the pathway, opioids in modulation and perception, and local
mediated in the brain. A recent review paper described the powerful impact of local anesthetics: decreased nociceptive responses intraoperatively; lower inhalant doses for anesthetic maintenance; lower postoperative pain scores overall, even when used alone (which isn’t the goal); decreased need for rescue analgesia, like opioids, so decreased opioid-mediated sedation and gastrointestinal effects; and potential prevention of chronic pain from the acute pain source. 1 So given this superpower, wouldn’t local anesthetics be used for every patient undergoing every painful procedure? Unfortunately, and inexplicably, no. In a recent veterinary
anesthetics in transmission. All of these are very potent drugs and are effective at their site of action, but the site of action itself can be quite complicated as there are numerous pain generators and propagators in most phases and the drugs acting there may not control all of them. The exception is transmission. In transmission, the pain (or nociceptive) impulse is propagated from the periphery to the central nervous system
Alpha-2 agonist:
survey, local anesthetic blocks were used in only 0.17%, 0.24% and 0.23% of cats undergoing ovariohysterectomy or castration, major soft tissue surgery, or orthopedic surgery, respectively. 2 Yes, that abysmally low number is correct. In addition, veterinarians indicated that, if they were to use
NSAID:
Other: INTRAOPERATIVE Drug bolus:
Figure 1: The pain pathway and site of action of various drugs/ treatments for acute pain
Local/regional block:
Infusion:
by the one way that any other nerve signal is propagated, the opening of voltage-gated sodium channels with subsequent nerve depolarization. Our superpower is the ability to use local anesthetics to block the pain by blocking sodium channels. This has a unique and profound effect on the pain pathway. Opioids modulate, i.e., decrease pain once it reaches the central nervous system (CNS), while local anesthetics prevent the pain impulse from reaching the CNS. The power of this is not only decreased pain itself, but also decreased behavioral and effective components of pain since those are
opioids more, they would use local anesthetics even less, which is not capitalizing on the superpower – or on multimodal analgesia. Why is this happening? Why isn’t every veterinarian using their superpower? In an informal survey by the author, veterinarians stated these reasons for not routinely using local anesthetics: 1) no perceived need for local anesthesia if the patient is under general anesthesia; 2) fear of adverse effects; 3) use of blocks ‘not a habit’ so often forgotten; 3) uncertain which drug to use and 4) unsure of the proper local/regional blockade technique. Let’s clear out the kryptonite and start using our superpower!
Other: RECOVERY/DISCHARGE Bolus:
Infusion:
Manufactured for: Aratana Therapeutics, Inc., Leawood, KS 66211 Additional Information is available at www.aratana.com or by calling Aratana Therapeutics at 1-844-272-8262. NOCITA is a registered trademark of Aratana Therapeutics, Inc. © Aratana Therapeutics, Inc. NOC-0088-2 August 2018
NSAID:
Other:
Figure 2: An example of a patient checklist that includes the use of local/ regional blocks. Not all drugs listed are appropriate for all patients
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