We have all heard some of the reasons onychectomy is evil: • It as a barbaric as cutting people’s knuckles off. Cats end up miserably painful and unable to walk and jump for the rest of their lives. • No reasonable cat would willingly choose to have the procedure done. • Vets have only gone to school for, like, 20 years or so, and are obviously incapable of making intelligent decisions. Plus, they’re in it for the money. Therefore, politicians, lobbyists and activists should make sound decisions for them. Some of the grounds to allow vets to do declaws include: • It is a surgical procedure, performed under general anesthesia, which should only be offered after discussing the pros and cons with the owner--just like any other surgery. • Declawing should not be a convenience or an automatic procedure. It should be chosen as a last resort, when other recognized, established options (regular nail trimming, training, glued-on plastic nail caps, etc.) have failed. • Scratching babies, kids, grandmas, chemo patients, AIDS patients and furniture is not always easy to prevent. In selected cases, declawing may then be an alternative to relinquishment or euthanasia. • Forbidding vets to perform declaws may lead to “backyard declaws,” with or without anesthesia. And with or without pain relief. Of course, there are other reasons. But one small detail always seems to be missing from this debate: appropriate pain management. We perform surgeries that are far more traumatic and painful that onychectomies. If we can repair bilateral radius/ulna fractures with plates and screws, amputate a leg, perform spinal surgery or do a combined thoracotomy and laparotomy, and send a comfortable (and ambulatory) kitty home after one or a few days in the hospital, then surely we should be able to make a declaw a humane procedure. That’s the missing detail nobody seems to talk about. Here is one anesthetic protocol that has been shown to provide excellent analgesia. It is borrowed from colleagues--general practitioners--who have used it successfully for years. 1. Application of a 12.5 microgram fentanyl “pain patch” the night before. The patch kicks in after 12-24 hours. The owner could be given the option of overnight hospitalization or bringing the cat back the next day. 2. Before surgery, local anesthesia is provided in the form of a “ring block” 3. Before surgery, an injectable nonsteroidal anti-inflammatory drug (NSAID) such as meloxicam (for example at 0.15 mg/kg) is given. 4. Before surgery, injectable morphine is administered. 5. After surgery, the injectable NSAID is continued once daily and the morphine every 6-8 hours or as needed. 6. To go home, the NSAID is continued by mouth for five days. Just be aware that this is an off-label use, so your clients should be perfectly informed of the possible side-effects, including renal toxicity. 7. The fentanyl patch can be removed three to five days after application. Don’t like morphine? “You could use injectable and then oral buprenorphine,” explains Kurt Grimm, DVM, MS, Ph.D., a diplomate of the American College of Veterinary Anesthesiology and of the American College of Veterinary Clinical Pharmacology. Dr. Grimm, anesthesiologist at Veterinary Specialist Services in Conifer, Colo., explains: “Some colleagues are hesitant to use a fentanyl patch with buprenorphine, but I think that the antagonistic clinical interactions between opioid agonists may have been over-extrapolated from in vitro data. “The net analgesic effect in any individual depends on many factors such as the relative doses, timing of administration, and individual responses to opioid administration. What matters clinically is whether the patient appears comfortable without significant adverse drug effects. “Alternatively, if the patch doesn’t seem to be effective or needs to be removed because of adverse effects such as sedation, dysphoria, anorexia, hyperthermia or urinary retention, you could consider oral tramadol, either in a tablet form or compounded into syrup (often 12.5 mg per cat three or four times daily),” he continues. Dr. Grimm reminds us that every patient is different and that it is imperative to periodically assess the effectiveness of the analgesia protocol and to adjust it to meet individual needs, rather than to blindly follow a recipe. Other recommendations include very strict confinement and wearing an Elizabethan collar for two weeks, as well as being home-bound for life. Ultimately, whether declawing is a humane procedure is a personal decision. However, improper analgesia is inhumane, period. We have made tremendous progress in pain management. There are journals, books, short courses, associations, symposia and a whole specialty college dedicated to that subject. Let’s apply this knowledge to our patients! The AVMA position statement confirms: “If onychectomy is performed, appropriate use of safe and effective anesthetic agents and the use of safe peri-operative analgesics for an appropriate length of time are imperative.” You may be concerned that following the above protocol is cost prohibitive. First, the colleagues who use it would strongly disagree. Their clients are happy to provide such a high level of care once they are educated about what declawing entails and what the consequences are. Second, if your clients can’t afford appropriate analgesia, then this debate is not at all about ethics or morality or being heartless. Turns out, it may become a financial discussion. Oh, I almost forgot. I don’t perform declaws. As a surgeon, I tend to do fancier procedures, also with appropriate analgesia. How to perform a ring block A ring block is an easy procedure that can provide excellent preoperative pain relief to the distal front limb. “It is ideal to use a 50/50 mixture of two local anesthetics: a short-acting one such as 2 percent lidocaine or 2 percent mepivacaine and a longer-acting drug such as 0.5 percent bupivacaine,” Dr. Kurt Grimm says. “It often takes 15 to 30 minutes for bupivacaine to have a complete anesthetic effect. If you use bupivacaine alone, surgery will likely start before the block is effective,” he says. “By combining both drugs, you get rapid onset and longer duration of action.” It is important to make sure the drugs do not contain epinephrine. A total of 0.1 to 0.3 ml of the mixture can be injected using a 22 G needle at each site. The goal is to block distal branches of the radial, ulnar and median nerves.* • Radial nerve branches can be palpated on the dorso-medial of the proximal carpus. • Ulnar nerve branches are palpable proximally and laterally to the accessory carpal bone. • Median nerve branches can be palpated proximally to the median carpal foot pad (digit 1). Alternatively and more simply, a four-point nerve block can be performed. To perform either block, the hair is clipped around the carpus and the skin is scrubbed thoroughly. It is important to note that local anesthesia may cause vasodilatation and therefore increased bleeding, which should, however, be short-lived. Overall, the procedure can easily be included in an anesthetic protocol for a declaw procedure. *Reference: RT Skarda and WJ Tranquilli “Local and regional anesthetic and analgesic techniques: cats.” In: WJ Tranquilli, JC Thurmon and KA Grimm. Lumb and Jones’ Veterinary Anesthesia and Analgesia, 4th edition. Blackwell Publishing, 2007. Dr. Phil Zeltzman is a small-animal board-certified surgeon at Valley Central Veterinary Referral Center in Whitehall, Pa. His website is www.DrPhilZeltzman.com. <HOME>
