Top 5 Drugs For Perianesthetic Analgesia

2/8/24, 11:09 AM Top 5 Drugs for Perianesthetic Analgesia
Drugs & Therapeutics Anesthesiology & Pain Management
Top 5 Drugs for Perianesthetic Analgesia in Cats

Tamara Grubb, DVM, PhD, DACVAA, Washington State University
ARTICLE LAST UPDATED MARCH 2021 10 MIN READ PEER REVIEWED
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For effective control of surgical pain, analgesic drugs should be included in the preanesthesia,
maintenance (intra- anesthesia), and recovery (postanesthesia) phases of the anesthetic
protocol.1-6 Drugs should be chosen based on their mechanism of action in the pain pathway
(Figure 1). Drugs approved for the species being treated should be used whenever possible.
https://www.cliniciansbrief.com/article/top-5-drugs-perianesthetic-analgesia?utm_medium=email&utm_source=newsletter&utm_campaign=Online+2… 1/17
FIGURE 1 Sites of action of select analgesic drugs and techniques in the mammalian pain pathway
Following are the author’s top 5 analgesic drugs/drug classes used in surgical pain protocols
in cats (also see Tables).
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1. Gabapentin (preanesthesia, potentially

postanesthesia)
Fearful/anxious or fractious cats may benefit from receiving gabapentin, an anxiolytic, prior to
travel to the clinic.7 Although the efficacy of gabapentin for acute pain relief is undetermined,
decreased anxiety alleviates the intensity of pain in humans,8 and this same anxiety–pain
relationship is thought to apply to cats because of the commonality of human and animal
pain/fear/anxiety pathways. There are several case reports and one study involving use of
gabapentin for control of acute pain in cats.9 Gabapentin may be more effective in patients
with chronic, particularly neuropathic, pain.10 Patients undergoing anesthesia for treatment
of chronic pain conditions and/or patients with pre-existing chronic pain undergoing
anesthesia for other conditions could potentially benefit from gabapentin.10
*This discussion primarily applies to healthy cats but, depending on the disease and the drug
dose, all or most of these drugs are appropriate for diseased cats. More information
describing clinical use of these drugs in patients with comorbidities is available (see
Suggested Reading). This list of drugs is a generalization, and sources of variability (eg,
procedure, patient, surgeon, disease) should be considered for individual patients.
Although not all of the drug classes discussed need to be used in all patients, the author
commonly uses all 5 together, especially for treatment of moderate to severe pain. No drug–
drug interactions using these combinations have been experienced by the author, but, of
note, interactions can occur anytime drugs are coadministered. In addition, all drugs can have
adverse effects. These topics are outside the scope of this article. Major concerns are included
in this discussion, and references have been included for further reading. However, this is not
an exhaustive review of the literature on this topic, and many other references are available.
Table 1: Pre-, Intra-, & Postoperative Analgesic Drug Dosages for

Acute Pain Relief in Cats
View all table fields by scrolling horizontally and vertically.
Drug Dosage Author’s When not Used

Recommended Use by the Author
Gabapentin Preanesthesia at Preanesthesia for No patient

home: 50-200 mg/cat administration at limitations, but,
PO; administered 2 home in to avoid
hours before leaving anxious/fearful cats exaggerated
home and potentially and generally effects from
the night prior to continued decreased
anesthesia (for cats postoperatively, if clearance, the
with high fear or needed for control of low end of dose
anxiety and fractious anxiety, for 2-3 days should be used
cats) if the patient has
Preoperative for hepatic or renal
After discharge for potential analgesia in disease.
neuropathic pain: 10 patients with pre-
mg/kg PO every 8-12 existing pain (eg, from
hours (author’s dose); an injury, periodontal
other doses are disease, or
listed.9 osteoarthritis).
Postoperative for
neuropathic pain; not
effective for pain of
inflammation
Morphine 0.1-0.3 mg/kg IM or As premedication, No patient

slowly IV intraoperatively (as limitations. Low
boluses or infusions), end of dose
and postoperatively. should be used
Postoperative doses in patients with
are generally the profound
same as the disease and in
preoperative dose but true geriatric
could be lower (eg, patients (ie,
one-half dose) with those with age-
effective multimodal related
analgesia. physiologic
changes).
Hydromorphone 0.1 mg/kg IM or IV As premedication, No patient

intraoperatively (as limitations. Low
boluses or infusions), end of dose
and postoperatively. should be used
changes).
Methadone 0.2-0.4 mg/kg IV; 0.2- As premedication, No patient

0.6 mg/kg IM; 0.6 intraoperatively (as limitations. Low
mg/kg oral boluses or infusions), end of dose

transmucosal (OTM) and postoperatively. should be used
changes).
Buprenorphine Anesthesia: 0.01-0.03 As premedication and No patient

(0.3 mg/mL mg/kg IM or IV; very postoperatively. limitations
concentration) low bioavailability if Postoperative doses
administered SC are generally the
same as the
After discharge: 0.03- preoperative dose.
0.05 mg/kg OTM every OTM uptake is not as
6-12 hours robust as IV/IM uptake
so OTM
administration should
be reserved for at-
home use. Dose is
higher than injection
dose because of the
lower uptake.
Buprenorphine 0.24 mg/kg SC As premedication or No patient

(1.8 mg/mL (labeled dose) once postoperatively limitations.
concentration) daily; 0.12-0.18 mg/kg (duration of action, 24 Lower dose
SC (author's dose) in hours); lower dose should be used
patients with used by author has in patients with
impaired not been shown to mild pain and/or
metabolism/clearance have a 24-hour as effective
(eg, geriatric cats, cats duration, but slowed multimodal

with hepatic disease) clearance in those analgesia (0.18
patients with mg/kg) and in
impaired patients with
metabolism/clearance profound
is predicted to provide disease or true
long duration even at geriatric
low dose. patients (0.12
mg/kg).
Butorphanol 0.2-0.4 mg/kg IM or IV Primarily used as a No limitations

sedative both pre-
and postoperatively
Dexmedetomidine 0.004-0.030 mg/kg IM As premedication and Most cats with

or IV (author’s most postoperatively. cardiac disease,
common dose for Postoperative doses except those
healthy cats is 0.008 are generally one- with left
mg/kg) quarter to one-half ventricular
the preoperative outflow tract
dose. The author’s disease, and
most common only if needed.
postoperative Cats with
drug/dose is comorbidities
dexmedetomidine causing
(0.001-0.003 mg/kg IM systemic disease
or IV). to the point the
cat does not
need a potent
sedative
Medetomidine 0.015-0.050 mg/kg IM As premedication and Most cats with

or IV (author’s most postoperatively. cardiac disease,
common dose for Postoperative doses except those
are generally one- with left
healthy cats is 0.015 quarter to one-half ventricular

mg/kg) the preoperative outflow tract
dose. The author’s disease, and
most common only if needed.
postoperative Cats with
drug/dose is comorbidities
dexmedetomidine causing
(0.001-0.003 mg/kg IM systemic disease
or IV). to the point the
cat does not
need a potent
sedative
Ketamine 0.5 mg/kg IV loading Intraoperative No limitations.

dose; 2-10 infusion in patients Subanesthetic
µg/kg/minute CRI with severe or dose is safe,
prolonged pain that is even in cats with
likely to lead to comorbidities
central sensitization. such as renal
Started preoperatively failure or
and continued cardiac disease.
postoperatively for
patients with severe
pain
2. Opioid/α2 Agonist Combination (preanesthesia,

commonly postanesthesia)
Using opioids in combination with α2 agonists can provide analgesia of greater intensity
and/or longer duration, generally allowing a lower dose of each drug class.11 Opioids
commonly used in cats include morphine, methadone, hydromorphone, fentanyl, and
buprenorphine. Butorphanol is an effective sedative in most cats, but the duration of
analgesia is extremely short (≈90 minutes)12 and, as with most opioids, is variable among
individual patients.5,12-14 A feline-specific, FDA-approved formulation of buprenorphine
provides 24 hours of analgesia with a single SC injection.15 Although opioids are not needed
in every procedure, it is the opinion of the author and pain experts that opioids should be
used for surgical pain, especially if pain is expected to be moderate to severe.1-6 If opioids are
not available, multimodal analgesic options should be emphasized and the α2 agonist dose
can be increased (using the high end of the dose range). Opioid-mediated hyperthermia can
occur in cats and is most often related to hydromorphone.4,5
α2 agonists (eg, medetomidine, dexmedetomidine) are classified as sedative-analgesic drugs,

and dexmedetomidine is FDA-approved for use in cats.16 The reversible effects of α2 agonists
can provide benefits of both safety and convenience. Because α2 agonists are effectively
administered IM, cats can be sedated without the undue stress of restraint that is often
necessary for IV injection. Although α2 agonists should not be administered to most cats with
clinical cardiac disease, α2-mediated bradycardia may be beneficial in some cats with left
ventricular outflow obstruction.17 Other comorbidities may need to be considered but are not
necessarily contraindications. More information is available for the clinical use of α2 agonists
in cats with comorbidities (see Suggested Reading). If α2 agonists are not available, the high
end of the opioid dose should be considered and other sedatives added, if needed.
3. Local Anesthetic Blocks (intra-anesthesia,

effects last into postanesthesia)
Local/regional anesthesia should be considered as part of a multimodal protocol for pain
relief after every surgery and traumatic injury.1-5,18,19 Local anesthetic drugs block pain
transmission to the CNS, making them highly effective analgesics.18 Most of these drugs are
inexpensive and most blocks are relatively easy to administer.1-5,18,19 In most patients, local
anesthetic blockade provides profound pain relief (block-, drug-, and procedure-specific)
both during the procedure and into recovery, beyond the drug’s expected duration of
action.20-22 This is an important mechanism because it can be complicated to treat pain
during recovery in some patients due to limited options and potential drug contraindications
with specific diseases (eg, NSAIDs in most patients with renal disease). Local/regional
blockade also decreases surgery-related chronic pain development in humans,23 and due to
the commonality of the mammalian pain pathway, this effect is predicted to occur in cats.
Lidocaine, bupivacaine, and ropivacaine are commonly used local anesthetics in cats.
Liposome-encapsulated bupivacaine provides analgesia for 72 hours, is FDA-approved for use
in cats for peripheral nerve blocks,24 and is commonly used for other blocks.18,19 Local and
regional techniques for cats include oral blocks,1-5,18-20,25 coccygeal epidurals,1-5,18,19,26,27

lumbosacral epidurals,1-5,18,19,28 testicular blocks,1-5,18,19,29,30 and uterine/ovarian blocks or
peritoneal lavage (Figure 2).1-5,18,19,21,22,31-33
FIGURE 2 Local anesthetic drugs are instilled into the abdomen through the open incision for postanesthetic relief of
pain following ovariohysterectomy and other abdominal procedures.
4. Ketamine Infusion (intra-anesthesia,

potentially pre- and/or postanesthesia)
Ketamine is an N-methyl-D-aspartate (NMDA)-receptor antagonist that has a well-
documented role in both acute34 and chronic35 pain control in humans through prevention
and treatment of central sensitization, which is an amplification of the pain stimulus primarily
due to activation of the normally inactive NMDA receptors. Ketamine is administered at a
subanesthetic dose to directly antagonize NMDA receptors. This is a unique mechanism of
action as compared with other analgesic drugs. Research in veterinary patients is limited but
promising.9 Ketamine infusions are commonly administered to cats, easy to make/administer,
and inexpensive.1-5,9,10 Adverse effects with the subanesthetic infusion dose are uncommon,
even in patients that have comorbidities.1-5,9,10
Table 2: Local Anesthetic† Drug Dosages, Time to Onset, &

Duration of Action for Acute Pain Relief in Cats
Drug Dose Onset Duration
Lidocaine 2-4 mg/kg <5 minutes 1-2 hours
Bupivacaine 0.5-1 mg/kg 5-10 minutes 4-6 hours
Ropivacaine 0.5-1 mg/kg 5-10 minutes 4-6 hours
Mepivacaine 2-3 mg/kg 2-5 minutes 2-3 hours
Liposome- 5.3 mg/kg/thoracic 2-5 minutes (human 72 hours

encapsulated limb or 10.6 mg/kg data; not studied in
bupivacaine total cat veterinary patients)
†All drugs in this chart can be used for tissue infiltration and perineural injection. Lidocaine,
bupivacaine, ropivacaine and mepivacaine can also be injected epidurally.
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5. NSAIDs (postanesthesia, potentially

preanesthesia)
The main source of surgical pain is inflammation; thus, NSAIDs are a crucial component of
effective analgesia. NSAID administration can be initiated pre- instead of postanesthesia,
depending on the likelihood the patient will develop hypotension or hypovolemia during
surgery.1-6,36 If used postanesthesia, an injectable NSAID is recommended by the author to
enable pain relief prior to return to swallowing, at which point administration of oral
medication is deemed safe. NSAIDs should be dispensed for administration at home, with the
treatment duration dependent on the expected duration of pain. Both meloxicam (single
dose) and robenacoxib (3 daily doses) are approved for treatment of acute pain in cats in the
United States37,38; however, the clinically recommended meloxicam dose (0.1 mg/kg) is lower
than the labeled dose (0.3 mg/kg).36 In many countries outside the United States, both drugs
are approved as long as pain is present.39,40 For more effective pain control, opioids can be
used when pain cannot be controlled by NSAIDs alone and in patients in which NSAIDs are not
appropriate.41 Buprenorphine can be administered oral transmucosally, although the uptake
is not as predictable as once thought, and is likely to produce a varied response5,12-14; this
dose may need to be higher (0.01-0.05 mg/kg) than the injectable dose.14 Federal and state
laws should be followed when dispensing opioids.
Conclusion
For any painful procedure, regardless of the perceived efficacy of the analgesic protocol,
assessment of pain—and pain relief following analgesic administration—is a critical
component of appropriate patient care. Validated pain scoring systems for acute pain
assessment in cats are available.40-46
References
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preanaesthetic medication in cats. J Small Anim Pract. 2009;50(2):73-81.
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antinociceptive effects of butorphanol in cats. Am J Vet Res. 2004;65(8):1085-1089.
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buprenorphine in cats. J Vet Intern Med. 2014;28(3):762-770.
15. Simbadol (buprenorphine injection) [package insert]. Kalamazoo, MI: Zoetis;

2017.
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https://www.zoetisus.com/products/dogs/dexdomitor-01/doc/dex_dex-
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17. Lamont LA, Bulmer BJ, Sisson DD, Grimm KA, Tranquilli WJ. Doppler
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18. Grubb T, Lobprise H. Local and regional anaesthesia in dogs and cats: overview of
concepts and drugs (part 1). Vet Med Sci. 2020;6(2):209-217.
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and inferior alveolar nerve blocks in cats undergoing dental extractions. J Feline
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administration of bupivacaine in cats. J Feline Med Surg. 2016;18(11):906-912.
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KS: Aratana Therapeutics; 2018.
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extractions. Accessed December 11, 2020.
26. American Animal Hospital Association. Local anesthetic techniques for perineal
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Pharmacokinetics of bupivacaine after intraperitoneal administration to cats
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ovariohysterectomies. AAHA website. https://www.aaha.org/aaha-
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feline.pdf. Published 2006. Accessed December 20, 2020.
Suggested Reading
Grubb TL, Albi M, Ensign S, Holden J, Meyer S, Valdez N. Anesthesia & Pain
Management for Veterinary Nurses and Technicians. Teton New Media; 2020.
Mathews KA, Sinclair M, Steele AM, Grubb T. Analgesia and Anesthesia for the Ill or
Injured Dog and Cat. Wiley-Blackwell; 2018.
Snyder LBC, Johnson RA, eds. Canine and Feline Anesthesia and Co-Existing Disease.
Wiley-Blackwell; 2014.
Steagall P, Robertson S, Taylor P, eds. Feline Anesthesia and Pain Management. Wiley
& Sons; 2018.
About the Authors
Tamara Grubb, DVM, PhD, DACVAA

Washington State University
Tamara Grubb, DVM, PhD, DACVAA, is an adjunct professor of

veterinary anesthesia and analgesia at Washington State University.
She also serves as an anesthesia/analgesia consultant in small and
large animal practices and is a certified acupuncturist. Dr. Grubb is
coauthor of Anesthesia & Pain Management for Veterinary Nurses and
Technicians and Analgesia and Anesthesia for the Ill or Injured Dog
and Cat. Her clinical interest and research focus is pain management,
and she is a member of the International Veterinary Academy of Pain
Management. Dr. Grubb has received the Carl J. Norden Distinguished
Teaching Award from students at 2 universities.
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2/8/24, 11:09 AM Top 5 Drugs for Perianesthetic Analgesia

Drugs & Therapeutics Anesthesiology & Pain Management

Top 5 Drugs for Perianesthetic Analgesia in Cats

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1. Gabapentin (preanesthesia, potentially

Table 1: Pre-, Intra-, & Postoperative Analgesic Drug Dosages for

Drug Dosage Author’s When not Used

Gabapentin Preanesthesia at Preanesthesia for No patient

Morphine 0.1-0.3 mg/kg IM or As premedication, No patient

Hydromorphone 0.1 mg/kg IM or IV As premedication, No patient

Methadone 0.2-0.4 mg/kg IV; 0.2- As premedication, No patient

mg/kg oral boluses or infusions), end of dose

Buprenorphine Anesthesia: 0.01-0.03 As premedication and No patient

Buprenorphine 0.24 mg/kg SC As premedication or No patient

(eg, geriatric cats, cats duration, but slowed multimodal

Butorphanol 0.2-0.4 mg/kg IM or IV Primarily used as a No limitations

Dexmedetomidine 0.004-0.030 mg/kg IM As premedication and Most cats with

Medetomidine 0.015-0.050 mg/kg IM As premedication and Most cats with

healthy cats is 0.015 quarter to one-half ventricular

Ketamine 0.5 mg/kg IV loading Intraoperative No limitations.

2. Opioid/α2 Agonist Combination (preanesthesia,

α2 agonists (eg, medetomidine, dexmedetomidine) are classified as sedative-analgesic drugs,

3. Local Anesthetic Blocks (intra-anesthesia,

regional techniques for cats include oral blocks,1-5,18-20,25 coccygeal epidurals,1-5,18,19,26,27

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4. Ketamine Infusion (intra-anesthesia,

Table 2: Local Anesthetic† Drug Dosages, Time to Onset, &

Drug Dose Onset Duration

Lidocaine 2-4 mg/kg <5 minutes 1-2 hours

Bupivacaine 0.5-1 mg/kg 5-10 minutes 4-6 hours

Ropivacaine 0.5-1 mg/kg 5-10 minutes 4-6 hours

Mepivacaine 2-3 mg/kg 2-5 minutes 2-3 hours

Liposome- 5.3 mg/kg/thoracic 2-5 minutes (human 72 hours

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40. Onsior UK product information. MyElanco website.

About the Authors

Tamara Grubb, DVM, PhD, DACVAA

Tamara Grubb, DVM, PhD, DACVAA, is an adjunct professor of

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