Roberts and Windsor - 2019 - Innovative pain management solutions in animals ma

chunk 0 · 293 tokens

ORIGINALARTICLEInnovativepainmanagementsolutionsinanimalsmayprovideimprovedwoundpainreductionduringdebridementinhumans:AnopinioninformedbyveterinaryliteratureChristopherD.Roberts1|PeterAWindsor21ClinicalResolutions,Hessle,UK2SydneySchoolofVeterinaryScience,Sydney,AustraliaCorrespondenceChristopherD.Roberts,PhD,Principal Consultant,378,BoothferryRoad,Hessle HU130JS,UK.Email:chris@clinicalresolutions.co.ukPainfulanimalhusbandryproceduresareroutinelyperformedinarangeoflive-stockspecieswithoutanalgesia.Recently,innovativestrategieshavebeendevel-opedtoaddresswoundpainintheseanimals.Inparticular,afarmer-applied“sprayandstay”approachthatisadministereddirectlytoopenwoundswasdeveloped(Tri-Solfen®MedicalEthicsPtyLtd.,Melbourne,Victoria,Australia).Thisstrat-egyanaesthetisesthewoundsimmediatelyupontheirformation,withlong-lasting effect.Thisdevelopment,describedasa“painmanagementrevolution,”hasbecomefirmlyestablishedintheAustralianlivestockindustriesandhasglobalpotential.Thepositiveoutcomesofthisapproachprovideinsightsandhighlightpotentialbenefitsthatmaybeaccruedfromitsuseinhumanwoundcare,providingrapid-onsetwoundanalgesiaand/oranaesthetisingwoundspriortocleansingand

chunk 1 · 441 tokens

ndhighlightpotentialbenefitsthatmaybeaccruedfromitsuseinhumanwoundcare,providingrapid-onsetwoundanalgesiaand/oranaesthetisingwoundspriortocleansingand debridementprocedures.Ifthesebenefitsarerealisedfromaclinicianandpatientperspectiveforwounddebridementasaninitialindication,itcouldprovidenewhorizonsinpainmanagementforaspectrumofwound-relatedprocedures.Evi-dencefromuseinanimalhusbandrydoessupporttheconceptthatmultimodalanaesthesiaholdsgreatpotentialinthefieldofwoundmanagementacrossmanyprocedures.KEYWORDSanaesthetic,animalhusbandry,debridement,multimodal,pain1|INTRODUCTIONThepresenceofdeadornecrotictissue(includingslough)onthesurfaceofanywoundwilldelaywoundhealing.DebridementthatfacilitatestheremovalofsuchbarrierstohealingisanintegralpartofwoundbedpreparationandcomprisestheT(tissueremoval)elementintheTIMEcon-tinuumtopromotehealingendorsedbymostkeyopinion leadersandconsensusgroups.1,2Woundshealfasterwhendebridedoftenbytrainedhealthcareprofessionals.Publishedstudieshaveshownthatfasterandmorecompletehealingwasachievedwithmorefrequentdebridementregardlessofwoundtype,size,orduration.3,4Weeklyorevenmorefrequentdebridementresultedinshorterhealing timescomparedwithlessfrequentdebridement.Educationandtrainingforproperdebridementpracticesshouldnotbelimitedtophysiciansbutshouldincludegeneralstaffmem-bersinordertomaketheflowofwoundcaremoreefficient.Nearlytwiceasmanyvenousanddiabeticfootulcerswereshowntohavehealedcompletelywithfrequentdebridementcomparedwiththosetreatedlessfrequently(50%vs28%).4Theclinicalprofessionalhasarangeofoptionstoachieve Abbreviations:EMLA,eutecticmixtureoflocalanaesthetics;NHS,NationalHealthService;NSAID,non-steroidalanti-inflammatorydrugs. Received:13December2018Revised:28February2019Accepted:19March2019DOI:10.1111/iwj.13129

chunk 2 · 63 tokens

ationalHealthService;NSAID,non-steroidalanti-inflammatorydrugs. Received:13December2018Revised:28February2019Accepted:19March2019DOI:10.1111/iwj.13129 ©2019Medicalhelplines.comIncandJohnWiley&SonsLtdIntWoundJ.2019;1–6.wileyonlinelibrary.com/journal/iwj1

chunk 3 · 373 tokens

debridement,andchoicewilldependonthepainthresholdofthepatient,typeofnecrotictissue,andwherethepatient isbeingtreated.Thefastestdebridementprocedureissharpdebridementusuallyassociatedwiththeuseofascalpelorsimilarinstru-ment.Themore“patientfriendly”approaches,suchastheuseofhydrogels,maytakeweeks,withmanyvisitstofacili- tatedressingchangesforcostlyandtime-consumingre-applicationofthehydrogel.5Otherinnovativeapproachesincludetheuseofnewerpadtechnologiestocleanthe woundsurface.Forexample,monofilamentfibretechnologyisavailablethatliftsupthesloughanddebris,bindingitbetweenthefibrestofacilitateremoval.6Hydrosurgicaldebridementhasalsobeensuccessfullyusedinburnwounddebridementandcasesofchallengingwounds.7Patientswithwoundsoftenexperiencepain.However,thereisevidencethatthisisoftenunderestimatedormis-managedbyhealthprofessionals.8Inaddition,therearemanypsychologicalandemotionalfactorsassociatedwithlivingwithawoundthatcanaffectpatients'perceptionofpain,suchasanxiety,stress,fear,anddepression.9Painassociatedwithbothacuteandchronicwoundscanbeanunpleasantexperienceandcanpresentintwomain forms.Thefirstisnociceptivepainthatarisesfromdamagedtissueandisoftendescribedasachingorthrobbing.Thesec-ondtypeisneuropathicpainresultingfromdamagetoor dysfunctionofthenervoussystem.Itdiffersincharacterfromnociceptivepain,andpatientsdescribeitashavingsen-sationsofburning,tingling,orshootinginnature.10Ithasbeensuggestedthatdressingremoval,woundcleansing,debridement,andinappropriatedressingselectioncancon-

chunk 4 · 427 tokens

tionsofburning,tingling,orshootinginnature.10Ithasbeensuggestedthatdressingremoval,woundcleansing,debridement,andinappropriatedressingselectioncancon- tributetowound-relatedpain.11Asaspecificexample,ithasbeenreportedthatover70%ofpatientsexperiencepainassociatedwiththeirchroniclegwounds,rangingfrommoderatetosevere.Woundpainandintensityishighlyvariable.Itisnotanaccuratepredicatortomakeclinicalassumptionsthatspe-cificwoundtypesorwoundsizewilldefinethetypeofpain thepatientisexperiencing.Painintensitycanbestableovertime,varydaytoday,andmayincrease.12Ineffectivewoundpainmanagementcanresultindelayedhealingand lackofcompliancebythepatient.Patientswhoundergosharpdebridementmayfeelgreaterpainthanotherapproaches,andthismayimpacttheircom-pliancewithundergoingthenecessarynumberofdebride-mentstoachieveanoptimalwoundbedthatcanstartto progresstowardshealing.Inaddition,becauseofthelevelofproceduralpain,theymayaskforanimmediatecessationoftreatmentatanystageduringtheprocess.Sharpdebridement ofnon-viabletissueisafrequenttreatmentmodalityforlegulcerpatientsandhasbeensuggestedasthegold-standardapproach.13,14However,theprocedureisnotwelltolerated,andpatientswilloftenasktheclinicianstoceasebeforethedebridementiscompletedbecauseofpain.15Somepatientsmaydenyfutureconsentforthesharpdebridementifthe firstexperiencewaspainful.Thisalsoimpactstheconfi- denceoftrainedphysiciansinachievingthedepthoftissue removalnecessaryforoptimisingtheprocessofwoundbed preparation.Thisposesdifficultiesinprovidingappropriate careandinachievinghealinginatimelymanner.Delayed healingeventuallycreatesadditionalcostsanddeterioration inthepatient'squalityoflife.TheUKNationalHealthSer- vice(NHS)advocatesapatient-centredapproachthatpro-

chunk 5 · 432 tokens

ventuallycreatesadditionalcostsanddeterioration inthepatient'squalityoflife.TheUKNationalHealthSer- vice(NHS)advocatesapatient-centredapproachthatpro- motesphysicalcomfort,includingpainmanagement.16Currenttherapeuticoptionsforwoundpainreliefduringdebridementincludeuseoforalanalgesicsforminormanip- ulationstothewoundanddressingchangesifrequired. Wherethereisahighprobabilityofpaindevelopinginpro- cedures,suchassharpdebridementofthewoundsurface, drug-basedcreams(eutecticmixtureoflocalanaesthetics [EMLA]cream,AspenPharmaTradingLtd)areused,which cantakebetween30minutesand1hourstotakeeffectpriortouseofthescalpel.17,18Thiscreatesthepracticalchal-lengesofinsituretentionandpossiblere-application.Injectionoflocalanaestheticssuchaslidocainehasbeenanoptionpriortodebridement.Multiplesitesmaybe required,andtheproceduremayhavetobecarriedoutbya trained,experiencedphysician.Theonsetofactionisquick, andthedurationofactionisgenerallyupto60minutes.The anaestheticmaycauseaburningsensationwheninjected, andtimeandcareareneededtobesuccessful.Surgicalwoundinfiltrationwithlocalanaestheticshascontinuedtoincreaseinpopularitysincethemid1990s.19Itisrelativelyinexpensive,technicallynotdifficult,andmay potentiallyreducepostoperativediscomfort.Eventhough painresultsfromcomplexphysiologicalmechanismsthat involvemultiplereceptorsinboththecentralandperipheral nervoussystems,singleormonotherapywithopioidshas beenafoundationofpost-surgicalpainmanagement.Theuseofmultimodalanalgesiainvolvestheadministra-tionoftwoormoreanalgesicagentsthatactthroughdiffer- entmechanismswiththegoalofimprovingpost-surgical KeyMessages topicallyappliedTri-Solfenhasastrongevolvingevidencebasesupportingtheprovisionofpainreliefduringproceduresassociatedwithanimal

chunk 6 · 75 tokens

st-surgical KeyMessages topicallyappliedTri-Solfenhasastrongevolvingevidencebasesupportingtheprovisionofpainreliefduringproceduresassociatedwithanimal husbandry topicalmultimodalanaestheticswithadrenalineandcetrimidehavepotentialinoptimisingpainreliefduringwounddebridementinhumans 2ROBERTSANDWINDSOR

chunk 7 · 383 tokens

painmanagement.Non-opioidalternatives,forexample,non-steroidalanti-inflammatorydrugs(NSAIDs),acetamin- ophen,andlocalanaesthetics,arerecognisedaseffectivecomponentsofamultimodalpainregimenpostoperatively.20Itisproposedthatanunmetneedexiststodevelopeffectiveproductsforanaesthetisingwoundsrapidlyandeffectivelypriortocleaning,debriding,orsuturing.Ashighlightedpreviously,significantpainforpatientsundergo- ingtheseprocedurescanbepresent,creatinganeedforpain- fulinjectionsorsystemicmedications.Itcanalsoterminatetheprocedurepriortocompletionbecauseofpatientintoler-anceoftheresultingpain.2|MATERIALSANDMETHODSAsemi-systematicscopingliteraturesearchstrategyofavail-ablepeer-reviewedpublishedevidencewasconducted, includingfree-texttermstoidentifyrelevantstudiesindexedonthePubMeddatabase.Keymedicalsubjectheadingtermsincludedwounddebridement,methodsofdebridement,pain managementduringdebridement,andpatientconcordancewithdebridement.Inaddition,literatureoninnovativenewmultimodalapproachestowoundanalgesiainfarmanimals wasreviewed,includingthesafetyandefficacyofatopicallocalanaestheticandantisepticcombinationformulationandimpactonpainalleviationandwoundhealing.Theauthors acceptthattheconclusionsrelatetoasemi-systematic reviewwithanopinioncomponent,althoughthisisbasedonextensiveclinicalpublishedresearchexperience.Aswithallemergingtechnologies,researchandclinicalfindingsfrom themajorityofworkonuseofTri-Solfen(Tri-SolfenMedi-calEthicsPtyLtd.,Melbourne,Victoria,Australia)havebeencapturedcontinuouslysincetheearliestpublicationsof

chunk 8 · 412 tokens

ajorityofworkonuseofTri-Solfen(Tri-SolfenMedi-calEthicsPtyLtd.,Melbourne,Victoria,Australia)havebeencapturedcontinuouslysincetheearliestpublicationsof studiescommencedin2005.3|RESULTSWithinthefieldofanimalhusbandry,aninnovativetechnol-ogyhasemergedthathasthepotentialtocomplementthevariousapproachestohumanwounddebridement.21Itcom-prisesofa“stayandspray”approachforopenwoundsdesignedtoalleviatepain,minimisebleeding,andprovide antisepticcoverwitharapidonsetandprolongedduration.Onapplication,itformsalong-lastingbio-compatiblefilmorbarrieroverthewound,creatingitsownintrinsicanalge- sicproperties.Theformulationactsasaslow-releasecarrierfortheactives,includingthetwolocalanaesthetics,lido-cainehydrochloride(5%w/w)andbupivacainehydrochlo- ride(0.5%w/w),inadditiontothevasoconstrictor adrenalineacidtartrate(0.00451%w/w)andtheantisepticcetrimide(0.5%w/w).Theformulationkeepstheactivesincontactwith,andpromotesdiffusioninto,thewound.Thecombinedsynergiescreateaprolongationofoverallanalge-siceffectbeyondtheexpecteddurationofactives(upto 24hours)andenhancedwoundhealingofopenwoundsand/orthosethatarelikelytoremainotherwiseuntreatedforprolongedperiods.22,23Adrenalinworkssynergisticallytominimisevasodilationcausedbythelocalanaesthetics,mini-misebleeding,andpreventsystemicabsorptionandriskoftoxicity.Farmer-applied“spray-on”topicalanaesthesiaandanti-septicformulation(Tri-Solfen)wasintroducedinAustraliain2005andwasregisteredforwidespreadcommercialusein2012tomanagethepainandhastenthehealingoftheopenwoundsincurredduringthe“mulesingoperation”insheep.21,22Thisprocedureisconductedasalifetimepreven-tionagainstmyiasis(flystrike)insusceptiblesheeponmany

chunk 9 · 442 tokens

woundsincurredduringthe“mulesingoperation”insheep.21,22Thisprocedureisconductedasalifetimepreven-tionagainstmyiasis(flystrike)insusceptiblesheeponmany Australiansheepfarms,mostlyinvolvingMerinolambsathighriskoftheconditionbecauseofthepresenceof“breechwrinkle”.Theconformationoffoldedor‘wrinkle‘inthebreechareareadilyretainsurineandfaecesandprovidesanattractiveenvironmentfordepositionoftheeggsofthesheepblowflyLuciliacuprina.Followinghatching,theblowflylarvaeburrowdeeplyintoadjacenttissuestothepenetratingwoundsinafflictedanimals,rapidlycausingtheanimaltobecomemoribundbecauseofblowflystrike. Untreatedcasesusuallydie.MyiasisisoneofthemostseriouscausesofmorbidityandmortalityinAustraliansheep.Long-termgeneticbreed-ingof“fly-resistant”sheepisoccurring.However,themulesingprocedure,involvingthesurgicalremovalofskinfromeachsideofthebreechandthetailtoformasmoothscar,remainsthemosteffectivemethodtoprovidelife-timeprotectionagainstmyiasis.Previously,intheabsenceofreg-isteredpainreliefoptions,themulesingprocedurewasper-formedwithoutanalgesia,resultinginwelfareconcernsforthelambsatthetimeofsurgery.Tri-SolfenusedduringmulesingwasreadilyandwidelyadoptedbyfarmersinAustralia,enablingthesaleofwoolclassifiedas‘PR‘(painrelief)andimprovedwelfareofsheepsusceptibletoflystrikeduringtheextendedperiodrequireduntilgeneticalterationsofAustralianMerinosheepphenotypescanprogresssuffi-cientlytosuccessfullyaddresstheriskofmyiasis.Itisesti-matedthat6to7millionlambsaretreatedannually,withapproximately100millionanimalshavingnowreceivedtreatmentwithTri-Solfensincetheproductwasregistered.FollowingthefirstfieldreportsthatlambsappearedfarmoreamenabletobeingmovedaftersurgerythatincludedpainmanagementwithTri-Solfen,trialsusingavarietyofmethodstomeasurepainandwoundhealing,includingsys-

chunk 10 · 81 tokens

farmoreamenabletobeingmovedaftersurgerythatincludedpainmanagementwithTri-Solfen,trialsusingavarietyofmethodstomeasurepainandwoundhealing,includingsys- tematicbehaviouralassessments,quantitativesensorytestingofwoundswithvonFreymonofilamentsoralgometry,andphotographyoftreatedanduntreatedwounds,established ROBERTSANDWINDSOR3

chunk 11 · 590 tokens

thateffectivewoundanalgesiaoccurredforatleast24hours,withimprovedwoundhealing.22,23Plasmalocalanaestheticlevelswerewellbelowtoxicthresholds,evenwhenlargerel-ativedoseswereapplied(upto50mg/kglidocaineinlambs).Importantly,theapplicationofthecombinationtopi-calanaestheticformulationdelivereddirectlyontothewoundperi-operativelyorimmediatelypostoperativelywasimmediatelyrecognisedtohavebroaderapplicationsinlive-stockhusbandry.Followingextensiveresearchtrialsinvolv-ingmanyroutineaversivehusbandryprocedures,Tri-Solfenhasnowbeendemonstratedtobesafeandefficaciousinmanagingpainandimprovinghealingofacutesurgicalwoundsincurredduringsurgicalcastrationandtaildockingoflambs,24surgicalcastrationanddehorningofcalves,25,26andsurgicalcastrationofpiglets.27Itisalsoprovingeffec-tiveinchronicwoundconditions.AstudyindairycattleundergoingdebridementofhoofabscessinvolvingtreatmentwithTri-Solfenreportedevidenceofsignificantlyreducedpainduringtheprocedureandreducedlamenessfollowingsurgery.28Italsohaspotentialforuseforimprovingwoundmanagementintheseandinotherspecies,includingshear-ingcutsinsheep;lamenesscausedbyhoofinjuriesandabscessesinsheep;openwoundsinhorses,dogs,cats,andothercompanionanimalsandwildlife;and,potentially,forsuperficiallesionsresultingfromviralinfectiousoftheepi-dermis(PW,unpublisheddata).Importantfindingsfrompre-viousandcurrentstudiesincludeconfirmationofrapidonsetofwoundanalgesiaandpositivewelfareoutcomesforanextendedperiodwellbeyondthatexpectedwhenthedura-tionofactionoftheanaestheticactiveswasconsidered,inadditiontoimprovedpainmanagementwhenusedwithanNSAIDforpainrelief29–31and,onoccasions,improvedproductivity.32TheinclusionofanNSAIDinthepainmanagementresearchinanimalshasaimedtodevelopa“bestpractice”multimodalregimenapproachtopainmanagement,withpracticalapproachestodeliverbothblockageofnociceptionandameliorationofwoundsensitisationexamined.AmethodfororaldeliveryofNSAIDs(meloxicamasIliumBuccalgesic,TroyLaboratories,Australia)wasdevelopedinAustraliaandhasbeenshowntobeefficaciousforproce-duresinbothlambsandcalves.31,32WidespreadadoptionbyfarmersoftheadditionofanoralNSAIDtotheprocedurecurrentlyremainsuncertain.However,theuseoftopicalanaestheticformulationaccompaniedbyintramuscularinjec-tionsofNSAIDs,administeredbybeeffarmersunderveteri-naryadvice,doesappeartobeincreasinginAustralia,particularlywithrecentresearchconfirmingbothefficacy

chunk 12 · 448 tokens

tionsofNSAIDs,administeredbybeeffarmersunderveteri-naryadvice,doesappeartobeincreasinginAustralia,particularlywithrecentresearchconfirmingbothefficacy andproductivityimprovementswiththismultimodalapproachforuseinbeefcattlehusbandryprocedures.32–34TherecentdevelopmentsintheAustralianlivestockfarmingsectorindicatethatanewparadigmhasemergedinaddressingthewelfareconcernsofaversiveproceduresusedroutinelyinlivestockhusbandryforcenturies.22Thisinno-vationisincreasinglyachievinginternationalrecognition.35However,internationalproducersandconsumersoflive- stockproductsdoneedgreaterawarenessoftheimproved attitudesandpracticesofanimalwelfareonmanyAustralianfarmsthroughtheincreasingadoptionofroutinefarmanimalpainmanagementstrategies.Furthermore,thepositivelarge- scalesafetyandefficacytrialsconductedregularlyinani-malssince2005haveidentifiedthepotentialforsimilarnewinnovativetopicalanalgesicwoundmanagementstrategies foruseinacutetraumaticandchronicwoundsinhumans.4|DISCUSSIONPainelicitsawarenessofvisceralorenvironmentalinsultsandhasabroadrangeofphysiologicalandsociologicaldimensions.Woundpaininvolvesthethreestagesofnociception,sensitisation,andcentralcognition.Followinga noxiousstimulus,peripheralnociceptors,withenhancementbythereleaseofpain-sensitisingchemicalmediators,pro-duceperipheraltocentralactivationofsensoryneuronesvia theperipheralnervesandthendorsalhornofthespinalcord, stimulatingsensoryareasofthebrain,resultingincentralcognitionofpain.Aspainexpressionvariesconsiderablywithinandbetweenspecies,developingobjectiveclinicalassessmentsthatdeterminewhatanindividualanimalmaybeexperiencingischallenging,particularlyasthebehaviour of“prey”speciesistogenerallylimitthedisplayofpainincurredbyinjury.Furthermore,thewidelyheldassump-tionthatanimalsatanearlyagesufferlesspainthanthose

chunk 13 · 281 tokens

r of“prey”speciesistogenerallylimitthedisplayofpainincurredbyinjury.Furthermore,thewidelyheldassump-tionthatanimalsatanearlyagesufferlesspainthanthose thatareolderhasledtoageneralacceptancethataversive husbandryproceduresshouldroutinelybeconductedatanearlyage.Thislikelyderivesfromboththeeaseofrestraintthatcanbeappliedinyoungeranimalsandconsiderations thatananimalwithalessdevelopedcentralnervoussystem(CNS)mayexperiencelesspainthananolderanimalwheretheCNSismoremature.Thismaybeofrelevance inaltricialspeciesbutislikelytobelessrelevantinpreco-cialspecies,includingruminants,wheretheCNSissuffi-cientlyadvancedatbirthtoenableneonatestobe ambulatoryandrespondtonoxiousstimuliintheearlyneo- natalperiod.Painmanagementofruminantsasperformedroutinelybyveterinarianshasgenerallyinvolvedtheprioruseofseda- tivestoproviderestraint,oftenwithcompoundsthathavesomeanalgesicproperties(eg,xylazine,ketamine),inaddi-tiontothepriorinjectionofalocalanaestheticintothesur- gicalsiteorvicinityofalocalperipheralnervetoachieveblockageofnociception.Morerecently,NSAIDshavebeenrecruitedtoamelioratesensitisation.Thismultimodal 4ROBERTSANDWINDSOR

chunk 14 · 450 tokens

approachaimstocapturetheeffectivenessofindividualagentsinoptimaldosages,offeringtheoreticalsynergiesin acutepainprevention,potentiallyminimisingthesideeffects fromeachdrug.36However,inmanyfarmingsituations,pro-visionofpainreliefbyveterinariansisimpractical,yetfarmeradoptionofmultimodalapproachesisdifficult becauseofrestrictionsontheavailabilityofdrugsforwide- spreaduse.However,thedevelopmentofTri-Solfenhas enabledthepositivewelfareeffectsofinhibitingwound nociceptionbyspray-ontopicalanaestheticformulationbyfarmers.Importantly,Tri-Solfenhasbeenshowntobesafe,practical,effective,andispopularwithfarmers.Inclusionof afarmer-appliedNSAIDtoamelioratewoundsensitisation isconsideredalogicaladditionalstrategyandisbeing encouraged.Furthermore,thismultimodalapproachavoidstheadministrationbyfarmersofcentrallyactingdrugssuchasopiatestomodifycognition;thisisconsideredverychal- lengingandevenundesirableasitwouldrequiregreatervet- erinarysupervisionthanispracticalandpotentiallycreates foodsafetyconcerns.Intermsofwoundpaininhumans,mostoftheliteratureisfocusedongeneralpainandhowitimpactspatientwell- beingorthedetrimentaleffectsofthepresenceofpaindur- ingdressingchanges.Thishasledtoaplethoraofdressing developmentsaimedatdecreasingpainbyminimaladher- encetothewoundbed.Theimportanceofdebridementand itspotentialtoconvertachronicwoundintoamoreacute stateiswellrecognised,althoughfewpublicationsexist highlightingthespecificneedtodevelopapproachesto dampenpainduringdebridement.Anaestheticcreamscon- tainingsinglepain-relievingcompoundshaveaplace,and theiruseisevidence-based,althoughtheyhavesomedraw- backs,aslistedpreviously.Itisproposedthatatopicalfast-acting,long-lasting,easilyappliedapproachusinganaes-theticcombinationscombinedwithadrenalinetoallow targetedactionandlimitedsystemicabsorptionmaybe

chunk 15 · 425 tokens

st-acting,long-lasting,easilyappliedapproachusinganaes-theticcombinationscombinedwithadrenalinetoallow targetedactionandlimitedsystemicabsorptionmaybe safelyandeffectivelyappliedinhumansastheevidence fromnumerousstudiesinanimalssuggeststhisapproach couldpotentiallytransformthepracticeofdebridement. Fromaclinicianconfidenceandpatientacceptabilitypoint ofview,rapidoptimisationofthewoundbedbyremovalof unwantedmaterialwouldpotentiallyfacilitatefasterclosure. InnovationintranslatingwhatisknownaboutTri-Solfenin animalstothehumanwoundmodeliswellunderway.Work isongoingtodevelopuser-friendlyapplicationapproaches, andclinicaltrialsareplannedtreatingvenousulcerstodem- onstratetheanticipatedbenefitsandcreatethebeginningsofastrongevidencebase.Otherindicationsofpotentialusecouldincludeuseinsurgicalincisionspriortoclosure,lacer- ationmanagementintheemergencydepartment,open abdominalsurgery,anduseinambulancesandmilitary/mass casualtysituations.Farmer-appliedspray-onTri-Solfen,particularlyusedinamultimodalapproachwithNSAIDs,isanewparadigmfor addressingthewelfareconcernsofaversiveproceduresusedroutinelyinlivestockhusbandry.ThisapproachisbecomingfirmlyestablishedintheAustralianlivestockindustriesand potentiallyhasglobalimplications.Itissuggestedthatnotonlydointernationalconsumersofanimalproductsneedtobemadeawareoftheimprovedwelfareattitudesandprac- ticesonmanyAustralianfarms,buttheseadvancesmaybeofbenefittothewelfareofnumerousgloballivestockpopulationsforarangeofpainfulpractices.This“painman-agementrevolution”empowersfarmerstoreducethesuffer-ingexperiencedbytheiranimalsundergoingaversivehusbandryprocedures,withmarkedlyenhancedanimalwel-fare.Importantly,itaddressesconcernsraisedinactivist-led

chunk 16 · 422 tokens

gexperiencedbytheiranimalsundergoingaversivehusbandryprocedures,withmarkedlyenhancedanimalwel-fare.Importantly,itaddressesconcernsraisedinactivist-led campaignspromotingimprovedwelfareoffarmedanimalsandisanimportantmarketriskmanagementinterventionthatcouldberoutinelyadoptedinthegloballivestockindus- tries.Thisworkcouldalsoprovideinsightsintotheuseofthisapproachinhumanwoundcarethatcouldtransformexistingpracticesininterventionalpain-relieving approaches,benefitingclinicalpractitionersand,moreimportantly,theirpatients.ACKNOWLEDGEMENTSProf.WindsorandDrRobertsprovideconsultancyadvicetobothAnimalEthicsPtyLtdandMedicalEthicsPtyLtd.REFERENCES1.EuropeanWoundManagementAssociation(EWMA).PositionDocument:WoundBedPreparationinPractice.London,UK: MEPLtd.2004.2.LeaperDJ,SchultzG,CarvilleC,etal.ExtendingtheTIMEcon-cept.Whatwehavelearnedinthelast10years.IntWoundJ.2012;9(supp2):1-19.3.SteedDL,DonohoeD,WebsterMW,LindsleyL.Effectofexten-sivedebridementandtreatmentonthehealingofdiabeticfoot ulcers.DiabeticUlcerStudyGroup.JAmCollSurg.1996;183(1):61-64.4.WilcoxJR,CarterMA,CovingtonS.Frequenciesofdebridementandtimetoheal.Aretrospectivecohortstudyof312744wounds. JAMADermatol.2013;149(9):1050-1058.5.EdwardsH,GibbM,FinlaysonK,JensenR.Hydrogels.Cham-pionsforSkinIntegrity:WoundDressingGuide.Brisbane,Australia:QueenslandUniversityofTechnology;2013:16-19. ISBN:978-1-921897-79-5.6.NICEMedicalTechnologiesGuidance.TheDebrisoft™monofila-mentdebridementpadforuseinacuteorchronicwounds(MTG17).https://lohmann-rauscher.co.uk/woundcare/debrisoft/nice-guidance.2014.7.RennekampffHO,SchallerHE,WisterD,TenenhausM.Debride-mentofburnwoundswithawater-jetsurgicaltool.Burns.2006;32(1):64-69. ROBERTSANDWINDSOR5

chunk 17 · 303 tokens

8.GoldbergE,BeitzJ.Thelivedexperienceofdiverseelderswithchronicwounds.OstomyWoundManage.2010;56(11):36-46.9.VuoloJC.Wound-relatedpain:keysourcesandtriggers.BrJNurs.2009;18(15):S20-S25.10.BrownAM.Strategiestoreduceoreliminatewoundpain.NursTimes.2014;110(15):12-15.11.SolowiejK,MasonV,UptonD.Reviewoftherelationshipbetweenstressandwoundhealing:part1.JWoundCare.2009;18(9):357-366.12.FrescosN.Whatcauseswoundpain.JFootAnkleRes.2011;4(suppl1):22.13.LeaperD.Sharptechniqueforwounddebridement.WorldWideWounds.http://www.worldwidewounds.com/2002/december/ Leaper/Sharp-Debridement.html.199214.WoundsInternational.Bestpracticeguidelines:woundmanage-mentindiabeticfootulcers.www.woundsinternational.com.2013.15.RosenthalD,MurphyF,GottschalkR,BaxterM,LyckaB,NevinK.Usingatopicalanestheticcreamtoreducepainduring sharpdebridementofchroniclegulcers.JWoundCare.2001;10(1):503-505.16.NHS.NHSpapersummarizingpatientexperienceframework.Gatewayreference17273.2011.17.PurcellA,MarshallA,KingJ,BuckleyT.Eutecticmixtureoflocalanesthetics(EMLA)5%creamasaprimarydressingona painfullowerlegulcer.JWoundCare.2012;21(7):309-314.18.HanssonC,HolmJ,StefanL,SyrenA.Repeatedtreatmentwithlidocaine/prilocainecream(EMLA)asatopicalanestheticforthe

chunk 18 · 418 tokens

legulcer.JWoundCare.2012;21(7):309-314.18.HanssonC,HolmJ,StefanL,SyrenA.Repeatedtreatmentwithlidocaine/prilocainecream(EMLA)asatopicalanestheticforthe cleansingofvenouslegulcers.ActaDermVenereol.1993;73:231-233.19.JohnsonRC,HedgesAR,MorrisR,StamatakisJD.Idealpainrelieffollowinglaparoscopiccholecystectomy.IntJClinPract.1999;53:16-18.20.ChouR,GordonDB,DeLeon-CasasolaOA,etal.Guidelinesonthemanagementofpost-operativepain.JPain.2016;17(2):131-151.21.WindsorPA,LomaxS.AddressingwelfareconcernsregardingcontrolofcutaneousmyiosisinAustralia.SmallRuminRes.2013;110:165-169.22.WindsorPA,LomaxS,WhiteP.Painmanagementforimprovedsmallruminantwelfare.SmallRuminRes.2016;142:55-57.23.LomaxS,SheilM,WindsorPA.Durationofactionofatopicalanestheticformulationforpainmanagementofmulesinginsheep.AustVetJ.2013;91:160-167.24.LomaxS,DicksonH,SheilM,WindsorPA.Topicalanaesthesiaalleviatesthepainofcastrationandtaildockinginlambs.AustVetJ.2010;88:67-74.25.LomaxS,WindsorPA.Topicalanaesthesiamitigatesthepainofcastrationinbeefcalves.JAnimSci.2013;91:1-8.26.EspinozaC,LomaxS,WindsorPA.Topicalanaesthesiaprovidespainmanagementfordehorningofcalves.JDairySci.2013;96:2894-2902.27.LomaxS,HarrisC,WindsorPA,WhiteP.Topicalanaesthesiareducessensitivityofcastrationwoundsinneonatalpiglets.PLoSOne.2017;12:e0187988.28.StilwellG,FerradorAM,SantosMS,DominguesJ,CarolinoN.Useoftopicalanaesthesiatocontrolpainduringandaftertrim- minghooflesionsindairycows.The30thWorldBuiatricsCon- gress2018Sapporo(Abstract).http://hdl.handle.net/10400.5/ 1605329.PaullDR,LeeC,ColditzIG,AtkinsonSJ,FisherAD.TheeffectofatopicalAnaestheticformulation,systemicFlunixinandCarprofen,singlyorincombination,oncortisolandBehavioural

chunk 19 · 418 tokens

eC,ColditzIG,AtkinsonSJ,FisherAD.TheeffectofatopicalAnaestheticformulation,systemicFlunixinandCarprofen,singlyorincombination,oncortisolandBehavioural responsesofmerinolambstoMulesing.AustVetJ.2007;85:98-106.30.SmallAH,BelsonS,HolmM,ColditzIG.Efficacyofabuccalmeloxicamformulationforpainreliefinmerinolambsundergoing knifecastrationandtaildockinginarandomisedfieldtrial.AustVetJ.2014;92:381-388.31.SmallAH,MariniD,DyallT,PaullD,LeeC.Arandomisedfieldstudyevaluatingtheeffectivenessofbuccalmeloxicamandtopical localanaestheticformulationsadministeredsinglyorincombina- tionatimprovingwelfareoffemaleMerinolambsundergoingsur- gicalmulesingandhotknifetaildocking.ResVetSci.2018;118:305-311.32.VanderSaagD,LomaxS,WindsorPA,etal.Effectsoftopicalanaesthesiaandbuccalmeloxicamonaveragedailygain,behav- iourandinflammationofunweanedcalvesfollowingsurgicalcas- tration.Animal.2018;1:9.33.VanderSaagD,WhiteP,IngramL,etal.EffectsoftopicalAnaestheticandbuccalmeloxicamtreatmentsonconcurrentcas-trationanddehorningofbeefcalves.Animal.2018;8(35):2018.34.VanderSaagD,LomaxS,WindsorPA,TaylorC,WhitePJ.Eval-uatingtreatmentswithtopicalanaesthesiaandbuccalmeloxicam forpainandinflammationcausedbyamputationdehorningofcal- ves.PLoSOne.2018;13:e0198808.35.GrandinT.Animalwelfareandsocietyconcernsfindingthemiss-inglink.MeatSci.2014;98:461-469.36.YoungA,BuvanendranA.Recentadvancesinmultimodalanalge-sia.AnesthesiolClin.2012;30:91-100.Howtocitethisarticle:RobertsCD,WindsorPA.Innovativepainmanagementsolutionsinanimals mayprovideimprovedwoundpainreductionduringdebridementinhumans:Anopinioninformedbyveterinaryliterature.IntWoundJ.2019;1–6. https:// doi.org/10.1111/iwj.13129 6ROBERTSANDWINDSOR