Video 16:31:  Describes the stages of anesthesia

This video is very basic to describe what happens to an animal from a physiological standpoint when is under anesthesia. It starts by defining anesthesia from the greek word “loss of sensation” which implies loss of all the senses. It explains the terms “general”, “regional”, “local”, abd ”dissociative” anesthesia. It then describes what are the conditions necessary to create a so called state of “balanced anesthesia” because no single anesthetic will do it on its own, all they do it is create a loss of conciousness; but you also need to cause a loss of pain, loss of muscle tension (myorelaxation) and inhibition of reflexes. Then, we move into explaining the 4 stages of anesthesia according to Guedel´s classification in a simple fashion with a graph that assess the depth of general anesthesia in the brain. We explain this relating then to clinical practice with typical anesthetics used in dogs and cats. Anesthetics are then grouped according to the induced stages and discussed common complications of the anesthetics are discussed. Finally, we end the presentation by discussing some protocols of anesthesia starting by the pre-anesthesia, induction, maintenance and recovery.

Video 12:50: Description of the strategy of providing pain relief to avoid or diminish ("preempt") perioperative pain.

The whole idea of this video is to illustrate the idea of preventing “central hypersensitivity” and the benefits of multimodal analgesia. It basically refers to the administration of drugs with analgesic activity before a surgical procedure to reduce pain the the postoperative period and make the recovery phase and outcome of any surgery faster and without complications. Anesthetics in general (except for a few ones like ketamine) do not provide pain relief and allow and even enhance the development of central sensitisation in which the spinal cord increases the excitability of those neurons that are receiving those painfull signals and a state of “central hypersensitivity” is created, with conditions like allodynia and hyperalgesia (pain becomes inflammatory and is not nociceptive anymore). The video provides a quick review of the pain pathway (transduction, tranmission, modulation, perception) and ways in which we can block with different drugs.

Video: 17:17:  Description of the technique of using local anesthesia to diminish the requirement for general anesthesia

The value of local anesthetics is largely underestimated as they have almost no side effects and can prevent central sensitization. The video starts by reviewing the different types of applications: infiltration, splash blocks, field blocks, topical applications, epidural and systemic infusions. It then, in journal club fashion, looks at different papers in which they use different applications for each of those compared with “gold standards” like systemic morphine. Examples of frequent surgeries like castrations and ovariohysterectomies in which they use bupivacaine in the spermatic cord or to irrigate the peritoneal cavity and both came first to the morphine in terms of providing analgesia in the post-operative period. The video ends by discussing the benefits of using lidocaine infused CRI to lower the needs for general anesthetics like isoflurane.

Video 22:46 : Discussion of the drugs given parenteral routes that are used for inducing anesthesia and providing pain relief in surgical or acute pain scenarios.

In this video, we start discussing the concept of “Total IntraVenous Anesthesia” (TIVA) which has gain momentum in recent years with the use of infusion pumps and rapidly metabolised anesthetics that can easily provide target control administrations. We list the properties of an ideal injectable anesthetic and classify the injectable anesthetics according to those that are given as either: a) “bolus injectables” (phencyclidines and barbiturates) or as b) by “constant rate infusion” (propofol, etomidate and alfaxolone). For “bolus injectables” we take a few slides to explain the mechanism of action, pharmacokinetics, and applications of the 3 main barbiturates: thiopental, pentobarbital and phenobarbital. Next, we explain the advantages and disadvantages of ketamine and tiletamine. For example, some advantages are that they can be mixed with sedatives in the same syringe and provide analgesia at 1/10 the anesthetic dose, some disavantages are bad “hangover” and it does not move that animal to a surgical plane III of anesthesia on its own. For b) “contant rate infusion” drugs again, we list the advantages such as being extremely safe with no hangover and rapid induction, and disadvantages such are potential for apnea, very short duration of action, having no analgesia (in fact they increase hypersensitivity). We end by giving examples of protocols with calculations for each of the drugs discussed to induce and maintain anesthesia and provide the references used.

Video: 16:51   Discussion of the mechanisms of action and clinical use of opioid drugs for the management of pain

This video starts by recalling the terminology of opioids. The multiple effects of opioids are emphasized for the pure agonists and that they usually go hand in hand like sedation and analgesia that can not be separated. Other opioids have unique effects and can be used for specific medical purposes like the antidiarrheals, antitussives or antiemetics. In general, the multiple effects of pure agonists are discussed by listing each organ system (respiratory, GI, body temperature, urinary) and they can be contradictory and unpredictable depending on the species and individual. Next the clinical applications are briefly discussed for both pure agonists and specific or locally acting opioids. And finally, the concept of physical dependence and tolerance is explained for the pure acting opioids with the withdrawal reactions that the individual experiences.

Video 22:30.  Detailed discussion of the mu opioid agonist fentanyl for parenteral and transdermal administration to manage pain in dogs and cats. 

In this video we discuss the different forms of delivering fentanyl in dogs: transdermal patches, topical solution (Recuvyra(R)), and constant rate infusion (CRI). All these form of delivery are posible because of the unique properties of fentanyl which are being 100x more potent than morphine and more than 1000-fold more lipophilic. We use a hydraulic model to explain how fentanyl moves through the body. The model explains why the brain fills so quickly with fentanyl, but just as quickly empties because of redistribution. We plot what happens in blood after an IV bolus is administered and explain this with pharmacokinetics parameters. We then use the transdermal patches and a graph to explain how fentanyl is being released into circulation. The graph show why a loading dose may be required. A short video clip is played to illustrate the application of the patch onto the dorsum of the neck of a dog. Next, the topical solution Recuvyra(R) is explained that overcomes some of the limitations of the patches in terms of erratic absorption and the graph clearly shows what in pharmacology is flip-flop kinetics. The next application is constant rate of infusion (CRI) that avoids “valleys” and “peaks” of bolus administrations. This is usually given in cocktails with lidocaine and ketamine and the benefits of those cocktails are explained. Next, the term context-sensitive life for fentanyl is explained, which is different from the term biological half-life. Finally, a relative of fentanyl, remifentanyl is briefly discussed because it has different kinetics (clearance and volume of distribution) in spite of having a similar half-life.

Video: 8:32 : Training video from the University of Illinois on the use of the opioid antagonist naloxone to reverse opioid toxicity in drug-sniffing dogs exposed to potent opioids while working. The principles of using an opiioid an

This video might serve as an excellent discussion point for the learners to reflect on the role of the veterinarian in helping police dog handlers to keep their canine partners safe while they work.

Video: 13:49  Common mechanisms of action and adverse effects of nonsteroidal antiinflammatory drugs (NSAIDs). 

The video starts by reviewing the process of inflammation, what creates it, what are its cardinal signs, the purposes of inflammation, its disadvantagees, and why it is occasionally important to suppress while treating its underlying cause. Then, we show where the NSAIDs work in the arachidonic acid cascade of the inflammatory process and compare it with glucocorticoids that work at an earlier step in the process of production of arachidonic acid metabolites. We talk about the prostaglandins as autacoids and their role in important housekeeping functions of the body. The types of cyclooxygenases (COXs) are discussed, along with the rationale for the strategy of suppressing COX 2, which is most involved in the inflammatory process.

Video: 8:29.  Common Traits of NSAIDs 

This video discusses some points a clinician should bear in mind when using this group of drugs. It starts by comparing the main clinical application as weak antiinflammatories compared with the glucocorticoids;  in other words, NSAIDs are mostly used for their analgesic, antipyretic and in the case of aspirin, anticoagulant effects. Then, the adverse effects should always be born in mind, particularly the ulcerogenic effect for the COX1 inhibitors. Other considerations of the group are that doses cannot be extrapolated between species, and that effects and side effects overlap and sometimes synergize with glucocorticoids.  A later video extensively discusses the evidence about how to manage switching between NSAIDs and/or glucocorticoids.

Video: 15:44 : The pharmacokinetic characteristics of most nonsteroidal antiinflammatory drugs that determine their distribution, plasma binding, and elimination.

The video will take 1 or 2 key ideas that apply to NSAIDs as a group for each step of pharmacokinetics: absorption, distribution, metabolism (biotransformation) and excretion. For example, we start by talking about the process of weak organic acids in the GI tract and how disintegration, dissolution and absorption are required, providing graphs to show what happens when this is done on an empty stomach with or without water. For distribution, we discuss the effect of protein binding on the duration of action of NSAIDs. Biotransformation accounts for the very different half-lifes between individuals within the same species and also explains why cats have very limited capacity to biotransform aromatic compounds, including the NSAIDs. Excretion involves primarily the metabolites.

Video: 22:24:   Description of the most common NSAIDs used in veterinary medicine, using aspirin as the prototype.

This video starts by listing the most commonly used nonselective (COX1/2) and selective (COX2) agents on the market. Of those, we chose to talk about aspirin and flunixin for the nonselective, and carprofen and meloxicam for the selective ones. Of interest, we include discussion of a paper entitled: Effects of flunixin meglumine in dogs following experimental induced endotoxemia. This paper is included to illustrate whether flunixin should be used in cases of endotoxemia, say in cases of puppies with parvoviral infection. Many veterinarians avoid using flunixin altogether as they consider this drug to be very ulcerogenic. This video addresses many of those questions. We also address the issue of residues in food animals with flunixin, using data from the Food Animal Residue Avoidance Databank (FARAD). For the selective COX inhibitors, with carprofen in dogs we address the issue of type B idiosynchratic reactions and single administrations in cats. Finally, for meloxicam we discuss the long-term use in both dogs and cats for osteoarthritis.  A separate video addresses meloxicam in greater detail.

Video 21:00: Specific details about meloxicam in dogs and cats.

In this video, an inflammation model in the cat is discussed in order to demonstrate how to predict the dose régimen of meloxicam necessary for managing acute inflammation. The criteria of a quality model of inflammation in experimental animals is reviewed, such as being reversible, allowing for repeat blood sampling, providing relevant clinical endpoints, being reproducible, allowing for rehabilitation (adoption), etc. The model consists of injecting an inert substance, “kaolin” in the cat´s paw that causes a sustained inflammation for 4 days and then subsides. The impact of meloxicam administration on day 2 allows evaluation of the the effect on each one of the components of inflammation: antipyretic (systemic temperature, local temperature), swelling (edema), analgesia (pain score, locomotion), and loss of function (lameness). The clinical correlates of these endpoints are shown graphically, and mathematically, and correlated with plasma profiles of meloxicam to come up with parameters of efficacy and potency.

Video 8:01:  Specific description of the use of tramadol in dogs and cats, emphasizing the importance of metabolites in the cat that lead to greater efficacy than in the dog.

Video: 6:21:  Description of gabapentin as a drug for managing chronic and neuropathic pain and evidence for efficacy in dogs and cats.

Video: 15:56: Given the increasing availability and, in some countries and U.S. states, the availability of cannabinoid (CBD) products, this is a brief introduction to the mechanisms of action and clinical utility, focusing on drugs and cats.

Video: 5:31: Drawn from TED Ed, this animated video briefly addresses the use of glucocorticoids in emergency scenarios, with a human medical focus.  Many of the principles apply to therapy in animals as well.

Video: 18:37. Part 1: Mechanisms and Therapeutic Effects.  The basic cellular and tissue mechanisms of action of glucocorticoids underlying therapeutic applications.

Video (10:59). Part 2: Side Effects, Complications and Pharmaceutics 

Discussion of the adverse effects and clinical situations which can be complicated by glucocorticoid usage.   Also, a brief discussion of the chemical modifications which impact the route of administration and duration of action (e.g. depot products).

Video (14:15) Part 3: Physiologic, Shock and Antiinflammatory Therapy

This section describes the "classes of use" of glucocorticoids, that is, what glucocorticoid preparations and their dosage is appropriate for physiological replacement therapy, shock therapy, and for antiinflammatory applications.

Video: 19:20:  Part 4: Immunosuppressive Therapy and Weaning from Therapy

This section focuses on the final "usage class", the use for immunosuppression (for example of an autoimmune condition) and ends with the rationale for alternate day therapy and weaning from therapy.

Video: 4:31 :  Intro to Dog with Orthopedic Pain Case

This video introduces a case of a dog in which pre-operative, surgical and post-operative pain management is a key feature.  The learner is challenged to prepare a case analysis addressing the questions at the end of this video.   A full multimedia writing project could be replaced by an interactive series of updates, with students being encouraged through instructor-chosen analytics. 

The suggested case analysis questions are shown in this image of the last slide:

Critical Clinical Thinking Questions for Canine Osteoarthritis Case

This case was derived from an article in Clinician's Brief which describes the rationale for therapy. Therefore, the article itself is, in effect, an "optimal answer" for the questions posed in the introductory case project challenge video.   This paper may or not be presented to the learner depending upon whether the community discussion or project analyses raises the important issues or not.

Video: 5:36 :  Introduction to a case of equine colic with moderate pain.  This case can be used for a writing project with the questions posed in the video as a starting point.  The points could also be discussed as a series of comments and updates within the community.

Critical Clinical Thinking Questions for Equine Analgesia Case

Video: 40:27:  This is a very detailed explanation of the clinical pharmacologic principles underlying the choices of drugs in this case of medically manageable equine colic with moderate pain. Alternately, this video could be used as a detailed discussion of the management of equine colic pain.   If the learners have been asked to develop detailed case analyses, with peer review and updated drafts, one might expect that this collaborative peer review product may bring and document many, if not all of the points made in Dr. Jennifer Davis' video.   As an instructor, you could also use this video for your own consumption to see how close a group of learners might come to the recommendations of an expert equine veterinary clinical pharmacologist.