Innovative pain management solutions in animals may provide improved wound pain reduction during debridement in humans: An opinion informed by veterinary literature

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Received: 13 December 2018 Revised: 28 February 2019 Accepted: 19 March 2019 DOI: 10.1111/iwj.13129 ORIGINAL ARTICLE Innovative pain management solutions in animals may provide improved wound pain reduction during debridement in humans: An opinion informed by veterinary literature Christopher D. Roberts1 | Peter A Windsor2 1 Clinical Resolutions, Hessle, UK 2 Sydney School of Veterinary Science, Painful animal husbandry procedures are routinely performed in a range of live- Sydney, Australia stock species without analgesia. Recently, innovative strategies have been devel- oped to address wound pain in these animals. In particular, a farmer-applied “spray Correspondence Christopher D. Roberts, PhD, Principal and stay” approach that is administered directly to open wounds was developed Consultant, 378, Boothferry Road, Hessle (Tri-Solfen® Medical Ethics Pty Ltd., Melbourne, Victoria, Australia). This strat- HU13 0JS, UK. egy anaesthetises the wounds immediately upon their formation, with long-lasting Email: chris@clinicalresolutions.co.uk effect. This development, described as a “pain management revolution,” has become firmly established in the Australian livestock industries and has global potential. The positive outcomes of this approach provide insights and highlight potential benefits that may be accrued from its use in human wound care, providing rapid-onset wound analgesia and/or anaesthetising wounds prior to cleansing and debridement procedures. If these benefits are realised from a clinician and patient perspective for wound debridement as an initial indication, it could provide new horizons in pain management for a spectrum of wound-related procedures. Evi- dence from use in animal husbandry does support the concept that multimodal anaesthesia holds

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agement for a spectrum of wound-related procedures. Evi- dence from use in animal husbandry does support the concept that multimodal anaesthesia holds great potential in the field of wound management across many procedures. KEYWORDS anaesthetic, animal husbandry, debridement, multimodal, pain 1 | INTRODUCTION Published studies have shown that faster and more complete healing was achieved with more frequent debridement The presence of dead or necrotic tissue (including slough) regardless of wound type, size, or duration.3,4 Weekly or on the surface of any wound will delay wound healing. even more frequent debridement resulted in shorter healing Debridement that facilitates the removal of such barriers to times compared with less frequent debridement. Education healing is an integral part of wound bed preparation and and training for proper debridement practices should not be comprises the T (tissue removal) element in the TIME con- limited to physicians but should include general staff mem- tinuum to promote healing endorsed by most key opinion bers in order to make the flow of wound care more efficient. leaders and consensus groups.1,2 Wounds heal faster when Nearly twice as many venous and diabetic foot ulcers were debrided often by trained health care professionals. shown to have healed completely with frequent debridement Abbreviations: EMLA, eutectic mixture of local anaesthetics; NHS, compared with those treated less frequently (50% vs 28%).4 National Health Service; NSAID, non-steroidal anti-inflammatory drugs. The clinical professional has a range of options to achieve © 2019 Medicalhelplines.com Inc and John Wiley & Sons Ltd Int Wound J. 2019;1–6. wileyonlinelibrary.com/journal/iwj 1 2 ROBERTS AND WINDSOR debridement, and choice will depend on the pain

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ohn Wiley & Sons Ltd Int Wound J. 2019;1–6. wileyonlinelibrary.com/journal/iwj 1 2 ROBERTS AND WINDSOR debridement, and choice will depend on the pain threshold of the patient, type of necrotic tissue, and where the patient Key Messages is being treated. • topically applied Tri-Solfen has a strong evolving The fastest debridement procedure is sharp debridement evidence base supporting the provision of pain usually associated with the use of a scalpel or similar instru- relief during procedures associated with animal ment. The more “patient friendly” approaches, such as the husbandry use of hydrogels, may take weeks, with many visits to facili- • topical multimodal anaesthetics with adrenaline tate dressing changes for costly and time-consuming re- and cetrimide have potential in optimising pain application of the hydrogel.5 Other innovative approaches relief during wound debridement in humans include the use of newer pad technologies to clean the wound surface. For example, monofilament fibre technology is available that lifts up the slough and debris, binding it between the fibres to facilitate removal.6 Hydrosurgical and patients will often ask the clinicians to cease before the debridement has also been successfully used in burn wound debridement is completed because of pain.15 Some patients debridement and cases of challenging wounds.7 may deny future consent for the sharp debridement if the Patients with wounds often experience pain. However, first experience was painful. This also impacts the confi- there is evidence that this is often underestimated or mis- dence of trained physicians in achieving the depth of tissue managed by health professionals.8 In addition, there are removal necessary for optimising the process of wound bed many psychological and

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th of tissue managed by health professionals.8 In addition, there are removal necessary for optimising the process of wound bed many psychological and emotional factors associated with preparation. This poses difficulties in providing appropriate living with a wound that can affect patients' perception of care and in achieving healing in a timely manner. Delayed pain, such as anxiety, stress, fear, and depression.9 healing eventually creates additional costs and deterioration Pain associated with both acute and chronic wounds can in the patient's quality of life. The UK National Health Ser- be an unpleasant experience and can present in two main vice (NHS) advocates a patient-centred approach that pro- forms. The first is nociceptive pain that arises from damaged motes physical comfort, including pain management.16 tissue and is often described as aching or throbbing. The sec- Current therapeutic options for wound pain relief during ond type is neuropathic pain resulting from damage to or debridement include use of oral analgesics for minor manip- dysfunction of the nervous system. It differs in character ulations to the wound and dressing changes if required. from nociceptive pain, and patients describe it as having sen- Where there is a high probability of pain developing in pro- sations of burning, tingling, or shooting in nature.10 It has cedures, such as sharp debridement of the wound surface, been suggested that dressing removal, wound cleansing, drug-based creams (eutectic mixture of local anaesthetics debridement, and inappropriate dressing selection can con- [EMLA] cream, Aspen Pharma Trading Ltd) are used, which tribute to wound-related pain.11 can take between 30 minutes and 1 hours to take effect prior As a specific example, it has been reported that over

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ch tribute to wound-related pain.11 can take between 30 minutes and 1 hours to take effect prior As a specific example, it has been reported that over 70% to use of the scalpel.17,18 This creates the practical chal- of patients experience pain associated with their chronic leg lenges of in situ retention and possible re-application. wounds, ranging from moderate to severe. Injection of local anaesthetics such as lidocaine has been Wound pain and intensity is highly variable. It is not an an option prior to debridement. Multiple sites may be accurate predicator to make clinical assumptions that spe- required, and the procedure may have to be carried out by a cific wound types or wound size will define the type of pain trained, experienced physician. The onset of action is quick, the patient is experiencing. Pain intensity can be stable over and the duration of action is generally up to 60 minutes. The time, vary day to day, and may increase.12 Ineffective anaesthetic may cause a burning sensation when injected, wound pain management can result in delayed healing and and time and care are needed to be successful. lack of compliance by the patient. Surgical wound infiltration with local anaesthetics has Patients who undergo sharp debridement may feel greater continued to increase in popularity since the mid 1990s.19 It pain than other approaches, and this may impact their com- is relatively inexpensive, technically not difficult, and may pliance with undergoing the necessary number of debride- potentially reduce postoperative discomfort. Even though ments to achieve an optimal wound bed that can start to pain results from complex physiological mechanisms that progress towards healing. In addition, because of the level of involve multiple receptors in both the central and

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omplex physiological mechanisms that progress towards healing. In addition, because of the level of involve multiple receptors in both the central and peripheral procedural pain, they may ask for an immediate cessation of nervous systems, single or monotherapy with opioids has treatment at any stage during the process. Sharp debridement been a foundation of post-surgical pain management. of non-viable tissue is a frequent treatment modality for leg The use of multimodal analgesia involves the administra- ulcer patients and has been suggested as the gold-standard tion of two or more analgesic agents that act through differ- approach.13,14 However, the procedure is not well tolerated, ent mechanisms with the goal of improving post-surgical ROBERTS AND WINDSOR 3 pain management. Non-opioid alternatives, for example, contact with, and promotes diffusion into, the wound. The non-steroidal anti-inflammatory drugs (NSAIDs), acetamin- combined synergies create a prolongation of overall analge- ophen, and local anaesthetics, are recognised as effective sic effect beyond the expected duration of actives (up to components of a multimodal pain regimen postoperatively.20 24 hours) and enhanced wound healing of open wounds It is proposed that an unmet need exists to develop and/or those that are likely to remain otherwise untreated for effective products for anaesthetising wounds rapidly and prolonged periods.22,23 Adrenalin works synergistically to effectively prior to cleaning, debriding, or suturing. As minimise vasodilation caused by the local anaesthetics, mini- highlighted previously, significant pain for patients undergo- mise bleeding, and prevent systemic absorption and risk of ing these procedures can be present, creating a need for pain- toxicity. ful injections or

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mise bleeding, and prevent systemic absorption and risk of ing these procedures can be present, creating a need for pain- toxicity. ful injections or systemic medications. It can also terminate Farmer-applied “spray-on” topical anaesthesia and anti- the procedure prior to completion because of patient intoler- septic formulation (Tri-Solfen) was introduced in Australia ance of the resulting pain. in 2005 and was registered for widespread commercial use in 2012 to manage the pain and hasten the healing of the open wounds incurred during the “mulesing operation” in 2 | MATERIALS AND METHODS sheep.21,22 This procedure is conducted as a lifetime preven- tion against myiasis (flystrike) in susceptible sheep on many A semi-systematic scoping literature search strategy of avail- Australian sheep farms, mostly involving Merino lambs at able peer-reviewed published evidence was conducted, high risk of the condition because of the presence of “breech including free-text terms to identify relevant studies indexed wrinkle”. The conformation of folded or ‘wrinkle‘ in the on the PubMed database. Key medical subject heading terms breech area readily retains urine and faeces and provides an included wound debridement, methods of debridement, pain attractive environment for deposition of the eggs of management during debridement, and patient concordance the sheep blowfly Lucilia cuprina. Following hatching, the with debridement. In addition, literature on innovative new blowfly larvae burrow deeply into adjacent tissues to the multimodal approaches to wound analgesia in farm animals penetrating wounds in afflicted animals, rapidly causing was reviewed, including the safety and efficacy of a topical the animal to become moribund because of blowfly strike. local

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d animals, rapidly causing was reviewed, including the safety and efficacy of a topical the animal to become moribund because of blowfly strike. local anaesthetic and antiseptic combination formulation and Untreated cases usually die. impact on pain alleviation and wound healing. The authors Myiasis is one of the most serious causes of morbidity accept that the conclusions relate to a semi-systematic and mortality in Australian sheep. Long-term genetic breed- review with an opinion component, although this is based on ing of “fly-resistant” sheep is occurring. However, the extensive clinical published research experience. As with all mulesing procedure, involving the surgical removal of skin emerging technologies, research and clinical findings from from each side of the breech and the tail to form a smooth the majority of work on use of Tri-Solfen (Tri-Solfen Medi- scar, remains the most effective method to provide life-time cal Ethics Pty Ltd., Melbourne, Victoria, Australia) have protection against myiasis. Previously, in the absence of reg- been captured continuously since the earliest publications of istered pain relief options, the mulesing procedure was per- studies commenced in 2005. formed without analgesia, resulting in welfare concerns for the lambs at the time of surgery. Tri-Solfen used during 3 | RESULTS mulesing was readily and widely adopted by farmers in Australia, enabling the sale of wool classified as ‘PR‘(pain Within the field of animal husbandry, an innovative technol- relief) and improved welfare of sheep susceptible to flystrike ogy has emerged that has the potential to complement the during the extended period required until genetic alterations various approaches to human wound debridement.21 It com- of Australian Merino sheep

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the during the extended period required until genetic alterations various approaches to human wound debridement.21 It com- of Australian Merino sheep phenotypes can progress suffi- prises of a “stay and spray” approach for open wounds ciently to successfully address the risk of myiasis. It is esti- designed to alleviate pain, minimise bleeding, and provide mated that 6 to 7 million lambs are treated annually, with antiseptic cover with a rapid onset and prolonged duration. approximately 100 million animals having now received On application, it forms a long-lasting bio-compatible film treatment with Tri-Solfen since the product was registered. or barrier over the wound, creating its own intrinsic analge- Following the first field reports that lambs appeared far sic properties. The formulation acts as a slow-release carrier more amenable to being moved after surgery that included for the actives, including the two local anaesthetics, lido- pain management with Tri-Solfen, trials using a variety of caine hydrochloride (5% w/w) and bupivacaine hydrochlo- methods to measure pain and wound healing, including sys- ride (0.5% w/w), in addition to the vasoconstrictor tematic behavioural assessments, quantitative sensory testing adrenaline acid tartrate (0.00451% w/w) and the antiseptic of wounds with von Frey monofilaments or algometry, and cetrimide (0.5% w/w). The formulation keeps the actives in photography of treated and untreated wounds, established 4 ROBERTS AND WINDSOR that effective wound analgesia occurred for at least 24 hours, addressing the welfare concerns of aversive procedures used with improved wound healing.22,23 Plasma local anaesthetic routinely in livestock husbandry for centuries.22 This inno- levels were well below toxic thresholds, even when large

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g.22,23 Plasma local anaesthetic routinely in livestock husbandry for centuries.22 This inno- levels were well below toxic thresholds, even when large rel- vation is increasingly achieving international recognition.35 ative doses were applied (up to 50 mg/kg lidocaine in However, international producers and consumers of live- lambs). Importantly, the application of the combination topi- stock products do need greater awareness of the improved cal anaesthetic formulation delivered directly onto the attitudes and practices of animal welfare on many Australian wound peri-operatively or immediately postoperatively was farms through the increasing adoption of routine farm animal immediately recognised to have broader applications in live- pain management strategies. Furthermore, the positive large- stock husbandry. Following extensive research trials involv- scale safety and efficacy trials conducted regularly in ani- ing many routine aversive husbandry procedures, Tri-Solfen mals since 2005 have identified the potential for similar new has now been demonstrated to be safe and efficacious in innovative topical analgesic wound management strategies managing pain and improving healing of acute surgical for use in acute traumatic and chronic wounds in humans. wounds incurred during surgical castration and tail docking of lambs,24 surgical castration and dehorning of calves,25,26 4 | DISCUSSION and surgical castration of piglets.27 It is also proving effec- tive in chronic wound conditions. A study in dairy cattle Pain elicits awareness of visceral or environmental insults undergoing debridement of hoof abscess involving treatment and has a broad range of physiological and sociological with Tri-Solfen reported evidence of significantly reduced dimensions. Wound pain involves

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ent and has a broad range of physiological and sociological with Tri-Solfen reported evidence of significantly reduced dimensions. Wound pain involves the three stages of pain during the procedure and reduced lameness following nociception, sensitisation, and central cognition. Following a surgery.28 It also has potential for use for improving wound noxious stimulus, peripheral nociceptors, with enhancement management in these and in other species, including shear- by the release of pain-sensitising chemical mediators, pro- ing cuts in sheep; lameness caused by hoof injuries and duce peripheral to central activation of sensory neurones via abscesses in sheep; open wounds in horses, dogs, cats, and the peripheral nerves and then dorsal horn of the spinal cord, other companion animals and wildlife; and, potentially, for stimulating sensory areas of the brain, resulting in central superficial lesions resulting from viral infectious of the epi- cognition of pain. dermis (PW, unpublished data). Important findings from pre- As pain expression varies considerably within and vious and current studies include confirmation of rapid onset between species, developing objective clinical assessments of wound analgesia and positive welfare outcomes for an that determine what an individual animal may be extended period well beyond that expected when the dura- experiencing is challenging, particularly as the behaviour tion of action of the anaesthetic actives was considered, in of “prey” species is to generally limit the display of pain addition to improved pain management when used with an incurred by injury. Furthermore, the widely held assump- NSAID for pain relief29–31 and, on occasions, improved tion that animals at an early age suffer less pain than those productivity.32

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dely held assump- NSAID for pain relief29–31 and, on occasions, improved tion that animals at an early age suffer less pain than those productivity.32 that are older has led to a general acceptance that aversive The inclusion of an NSAID in the pain management husbandry procedures should routinely be conducted at an research in animals has aimed to develop a “best practice” early age. This likely derives from both the ease of restraint multimodal regimen approach to pain management, with that can be applied in younger animals and considerations practical approaches to deliver both blockage of nociception that an animal with a less developed central nervous system and amelioration of wound sensitisation examined. A (CNS) may experience less pain than an older animal method for oral delivery of NSAIDs (meloxicam as Ilium where the CNS is more mature. This may be of relevance Buccalgesic, Troy Laboratories, Australia) was developed in in altricial species but is likely to be less relevant in preco- Australia and has been shown to be efficacious for proce- cial species, including ruminants, where the CNS is suffi- dures in both lambs and calves.31,32 Widespread adoption by ciently advanced at birth to enable neonates to be farmers of the addition of an oral NSAID to the procedure ambulatory and respond to noxious stimuli in the early neo- currently remains uncertain. However, the use of topical natal period. anaesthetic formulation accompanied by intramuscular injec- Pain management of ruminants as performed routinely by tions of NSAIDs, administered by beef farmers under veteri- veterinarians has generally involved the prior use of seda- nary advice, does appear to be increasing in Australia, tives to provide restraint, often with compounds that have particularly

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the prior use of seda- nary advice, does appear to be increasing in Australia, tives to provide restraint, often with compounds that have particularly with recent research confirming both efficacy some analgesic properties (eg, xylazine, ketamine), in addi- and productivity improvements with this multimodal tion to the prior injection of a local anaesthetic into the sur- approach for use in beef cattle husbandry procedures.32–34 gical site or vicinity of a local peripheral nerve to achieve The recent developments in the Australian livestock blockage of nociception. More recently, NSAIDs have been farming sector indicate that a new paradigm has emerged in recruited to ameliorate sensitisation. This multimodal ROBERTS AND WINDSOR 5 approach aims to capture the effectiveness of individual Farmer-applied spray-on Tri-Solfen, particularly used in agents in optimal dosages, offering theoretical synergies in a multimodal approach with NSAIDs, is a new paradigm for acute pain prevention, potentially minimising the side effects addressing the welfare concerns of aversive procedures used from each drug.36 However, in many farming situations, pro- routinely in livestock husbandry. This approach is becoming vision of pain relief by veterinarians is impractical, yet firmly established in the Australian livestock industries and farmer adoption of multimodal approaches is difficult potentially has global implications. It is suggested that not because of restrictions on the availability of drugs for wide- only do international consumers of animal products need to spread use. However, the development of Tri-Solfen has be made aware of the improved welfare attitudes and prac- enabled the positive welfare effects of inhibiting wound tices on many Australian farms, but these advances

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f the improved welfare attitudes and prac- enabled the positive welfare effects of inhibiting wound tices on many Australian farms, but these advances may be nociception by spray-on topical anaesthetic formulation by of benefit to the welfare of numerous global livestock farmers. Importantly, Tri-Solfen has been shown to be safe, populations for a range of painful practices. This “pain man- practical, effective, and is popular with farmers. Inclusion of agement revolution” empowers farmers to reduce the suffer- ing experienced by their animals undergoing aversive a farmer-applied NSAID to ameliorate wound sensitisation husbandry procedures, with markedly enhanced animal wel- is considered a logical additional strategy and is being fare. Importantly, it addresses concerns raised in activist-led encouraged. Furthermore, this multimodal approach avoids campaigns promoting improved welfare of farmed animals the administration by farmers of centrally acting drugs such and is an important market risk management intervention as opiates to modify cognition; this is considered very chal- that could be routinely adopted in the global livestock indus- lenging and even undesirable as it would require greater vet- tries. This work could also provide insights into the use of erinary supervision than is practical and potentially creates this approach in human wound care that could transform food safety concerns. existing practices in interventional pain-relieving In terms of wound pain in humans, most of the literature approaches, benefiting clinical practitioners and, more is focused on general pain and how it impacts patient well- importantly, their patients. being or the detrimental effects of the presence of pain dur- ing dressing changes. This has led to a plethora of

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t well- importantly, their patients. being or the detrimental effects of the presence of pain dur- ing dressing changes. This has led to a plethora of dressing developments aimed at decreasing pain by minimal adher- A C KN O W L E D G E M E N T S ence to the wound bed. The importance of debridement and Prof. Windsor and Dr Roberts provide consultancy advice to its potential to convert a chronic wound into a more acute both Animal Ethics Pty Ltd and Medical Ethics Pty Ltd. state is well recognised, although few publications exist highlighting the specific need to develop approaches to dampen pain during debridement. Anaesthetic creams con- REF ER ENC ES taining single pain-relieving compounds have a place, and their use is evidence-based, although they have some draw- 1. European Wound Management Association (EWMA). Position backs, as listed previously. It is proposed that a topical fast- Document: Wound Bed Preparation in Practice. London, UK: MEP Ltd. 2004. acting, long-lasting, easily applied approach using anaes- 2. Leaper DJ, Schultz G, Carville C, et al. Extending the TIME con- thetic combinations combined with adrenaline to allow cept. What we have learned in the last 10 years. Int Wound J. targeted action and limited systemic absorption may be 2012;9(supp 2):1-19. safely and effectively applied in humans as the evidence 3. Steed DL, Donohoe D, Webster MW, Lindsley L. Effect of exten- from numerous studies in animals suggests this approach sive debridement and treatment on the healing of diabetic foot could potentially transform the practice of debridement. ulcers. Diabetic Ulcer Study Group. J Am Coll Surg. 1996;183(1): From a clinician confidence and patient acceptability point 61-64. 4. Wilcox JR, Carter MA, Covington S. Frequencies of debridement of view,

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6;183(1): From a clinician confidence and patient acceptability point 61-64. 4. Wilcox JR, Carter MA, Covington S. Frequencies of debridement of view, rapid optimisation of the wound bed by removal of and time to heal. A retrospective cohort study of 312744 wounds. unwanted material would potentially facilitate faster closure. JAMA Dermatol. 2013;149(9):1050-1058. Innovation in translating what is known about Tri-Solfen in 5. Edwards H, Gibb M, Finlayson K, Jensen R. Hydrogels. Cham- animals to the human wound model is well underway. Work pions for Skin Integrity: Wound Dressing Guide. Brisbane, is ongoing to develop user-friendly application approaches, Australia: Queensland University of Technology; 2013:16-19. and clinical trials are planned treating venous ulcers to dem- ISBN:978-1-921897-79-5. onstrate the anticipated benefits and create the beginnings of 6. NICE Medical Technologies Guidance. The Debrisoft™ monofila- ment debridement pad for use in acute or chronic wounds a strong evidence base. Other indications of potential use (MTG 17). https://lohmann-rauscher.co.uk/woundcare/debrisoft/nice- could include use in surgical incisions prior to closure, lacer- guidance. 2014. ation management in the emergency department, open 7. Rennekampff HO, Schaller HE, Wister D, Tenenhaus M. Debride- abdominal surgery, and use in ambulances and military/mass ment of burn wounds with a water-jet surgical tool. Burns. 2006; casualty situations. 32(1):64-69. 6 ROBERTS AND WINDSOR 8. Goldberg E, Beitz J. The lived experience of diverse elders with 27. Lomax S, Harris C, Windsor PA, White P. Topical anaesthesia chronic wounds. Ostomy Wound Manage. 2010;56(11):36-46. reduces sensitivity of castration wounds in neonatal piglets. PLoS 9. Vuolo JC. Wound-related pain: key sources

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stomy Wound Manage. 2010;56(11):36-46. reduces sensitivity of castration wounds in neonatal piglets. PLoS 9. Vuolo JC. Wound-related pain: key sources and triggers. Br J One. 2017;12:e0187988. Nurs. 2009;18(15):S20-S25. 28. Stilwell G, Ferrador AM, Santos MS, Domingues J, Carolino N. 10. Brown AM. Strategies to reduce or eliminate wound pain. Nurs Use of topical anaesthesia to control pain during and after trim- Times. 2014;110(15):12-15. ming hoof lesions in dairy cows. The 30th World Buiatrics Con- 11. Solowiej K, Mason V, Upton D. Review of the relationship gress 2018 Sapporo (Abstract). http://hdl.handle.net/10400.5/ between stress and wound healing: part 1. J Wound Care. 2009;18 16053 (9):357-366. 29. Paull DR, Lee C, Colditz IG, Atkinson SJ, Fisher AD. The effect 12. Frescos N. What causes wound pain. J Foot Ankle Res. 2011;4 of a topical Anaesthetic formulation, systemic Flunixin and (suppl 1):22. Carprofen, singly or in combination, on cortisol and Behavioural 13. Leaper D. Sharp technique for wound debridement. World Wide responses of merino lambs to Mulesing. Aust Vet J. 2007;85: Wounds. http://www.worldwidewounds.com/2002/december/ 98-106. Leaper/Sharp-Debridement.html. 1992 30. Small AH, Belson S, Holm M, Colditz IG. Efficacy of a buccal 14. Wounds International. Best practice guidelines: wound manage- meloxicam formulation for pain relief in merino lambs undergoing ment in diabetic foot ulcers. www.woundsinternational.com. 2013. knife castration and tail docking in a randomised field trial. Aust 15. Rosenthal D, Murphy F, Gottschalk R, Baxter M, Lycka B, Vet J. 2014;92:381-388. Nevin K. Using a topical anesthetic cream to reduce pain during 31. Small AH, Marini D, Dyall T, Paull D, Lee C. A randomised field sharp debridement of chronic leg ulcers. J Wound

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hetic cream to reduce pain during 31. Small AH, Marini D, Dyall T, Paull D, Lee C. A randomised field sharp debridement of chronic leg ulcers. J Wound Care. 2001;10 study evaluating the effectiveness of buccal meloxicam and topical (1):503-505. local anaesthetic formulations administered singly or in combina- 16. NHS. NHS paper summarizing patient experience framework. tion at improving welfare of female Merino lambs undergoing sur- Gateway reference 17273. 2011. gical mulesing and hot knife tail docking. Res Vet Sci. 2018;118: 17. Purcell A, Marshall A, King J, Buckley T. Eutectic mixture of 305-311. local anesthetics (EMLA) 5% cream as a primary dressing on a 32. Van der Saag D, Lomax S, Windsor PA, et al. Effects of topical painful lower leg ulcer. J Wound Care. 2012;21(7):309-314. anaesthesia and buccal meloxicam on average daily gain, behav- 18. Hansson C, Holm J, Stefan L, Syren A. Repeated treatment with iour and inflammation of unweaned calves following surgical cas- lidocaine/prilocaine cream (EMLA) as a topical anesthetic for the tration. Animal. 2018;1:9. cleansing of venous leg ulcers. Acta Derm Venereol. 1993;73: 33. Van der Saag D, White P, Ingram L, et al. Effects of topical 231-233. Anaesthetic and buccal meloxicam treatments on concurrent cas- 19. Johnson RC, Hedges AR, Morris R, Stamatakis JD. Ideal pain tration and dehorning of beef calves. Animal. 2018;8(35):2018. relief following laparoscopic cholecystectomy. Int J Clin Pract. 34. Van der Saag D, Lomax S, Windsor PA, Taylor C, White PJ. Eval- 1999;53:16-18. uating treatments with topical anaesthesia and buccal meloxicam 20. Chou R, Gordon DB, De Leon-Casasola OA, et al. Guidelines on for pain and inflammation caused by amputation dehorning of cal- the management of post-operative pain. J Pain.

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Leon-Casasola OA, et al. Guidelines on for pain and inflammation caused by amputation dehorning of cal- the management of post-operative pain. J Pain. 2016;17(2):131-151. ves. PLoS One. 2018;13:e0198808. 21. Windsor PA, Lomax S. Addressing welfare concerns regarding 35. Grandin T. Animal welfare and society concerns finding the miss- control of cutaneous myiosis in Australia. Small Rumin Res. 2013; ing link. Meat Sci. 2014;98:461-469. 110:165-169. 36. Young A, Buvanendran A. Recent advances in multimodal analge- 22. Windsor PA, Lomax S, White P. Pain management for improved sia. Anesthesiol Clin. 2012;30:91-100. small ruminant welfare. Small Rumin Res. 2016;142:55-57. 23. Lomax S, Sheil M, Windsor PA. Duration of action of a topical anesthetic formulation for pain management of mulesing in sheep. Aust Vet J. 2013;91:160-167. How to cite this article: Roberts CD, Windsor PA. 24. Lomax S, Dickson H, Sheil M, Windsor PA. Topical anaesthesia Innovative pain management solutions in animals alleviates the pain of castration and tail docking in lambs. Aust Vet may provide improved wound pain reduction during J. 2010;88:67-74. debridement in humans: An opinion informed by 25. Lomax S, Windsor PA. Topical anaesthesia mitigates the pain of veterinary literature. Int Wound J. 2019;1–6. https:// castration in beef calves. J Anim Sci. 2013;91:1-8. 26. Espinoza C, Lomax S, Windsor PA. Topical anaesthesia provides doi.org/10.1111/iwj.13129 pain management for dehorning of calves. J Dairy Sci. 2013;96: 2894-2902.