VOLUME 24 No. 87 SEPTEMBER 2018
South Pacific Animal Welfare Refeeding syndrome Conference review Learning through feedback
PRIORITY TO URINARY SECURITY. The presence of the S/O INDEX logo on packaging indicates that this diet will help prevent the formation of the two main types of bladder stones in dogs and cats: Struvite and Calcium Oxalate. To ensure urinary security for your clients cats' and dogs', you can recommend Royal Canin diets bearing the S/O INDEX label.
NOW? K U O Y D I D th e ri sk or s in cr ea se C er ta in fa ct : ac t d is ea se of u ri n ar y tr O ve rw ei g h t al an ce M in er al im b t ie d in th e at er in ta k e L ow d ai ly w fe st yl e S ed en ta ry li ct io n s B la d d er in fe
CONTENTS
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VO LUME 24 No. 87 SEPT EM B E R 201 8
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EXECUTIVE COMMITTEE OFFICERS
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President Julie Hutt PO Box 35831 Browns Bay Auckland 0753 021 599 059 president@nzvna.org.nz
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Vice-President Amy Ross 021 852 664 vicepresident@nzvna.org.nz Treasurer & Membership Secretary Kathy Waugh 021 843 277 treasurer@nzvna.org.nz
Antoinette Ratcliffe journal@nzvna.org.nz Assistant Editor: Catherine Taylor catherine.ellen.taylor@gmail.com
EDITORIAL BOARD Exotics: Kylie Martin Equine: Lyn Hobbs Photography: Miranda Samson OSH: Libby Leader CPD: Christina Jenkins and Patricia Gleason
The New Zealand Veterinary Nursing Association would like to thank Hill’s™ Pet Nutrition NZ, our gold sponsors, for their continued support of the NZVNA and the veterinary nursing profession.
COVER:
OUR VISION
‘Working dogs’ by Miranda Samson
Caring for our community by promoting excellence in animal healthcare.
NZVNA FORMS The registration or list badge order forms, merchandise order forms and new membership forms can now all be found on the website www.nzvna.org.nz or by emailing membership@nzvna.org.nz
DISCLAIMER The New Zealand Veterinary Nursing Association Journal is published by the New Zealand Veterinary Nursing Association Incorporated (NZVNA). The views expressed in the articles and letters do not necessarily represent those of the NZVNA or the editor, and neither the NZVNA nor the editor endorse any products or services advertised. The NZVNA is not the source of the information reproduced in this publication and has not independently verified the truth of the information. It does not accept any legal responsibility for the truth or accuracy of the information contained herein. Neither the NZVNA nor the editor accepts any liability whatsoever for the contents of this publication or for any consequences which may result from the use of the information contained herein or advice given herein. The provision is intended to exclude the NZVNA, the editor and its staff from all liability whatsoever, including liability for negligence in the publication or reproduction of the materials set out herein.
CPD corner: Learning through feedback by Patricia Gleason
South Pacific Animal Welfare
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Refeeding syndrome
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Membership Secretary report by Kathy Waugh
by Courtney Spencer
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JOURNAL EDITOR
Letter from the editor by Antoinette Ratcliffe
National Secretary Luanne Corles 027 472 1072 secretary@nzvna.org.nz
Vice President’s report by Amy Ross
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by Katrina Lowe
Nutraceuticals: the basics part two by Sheree Smith
All Creatures Great and Small conference review by Lauren Prior
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Book review
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Increase your word power
by Lyn Hobbs
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NZVNA
Vice President’s report Over the last ten years, social media has become a large part of our daily lives. Facebook and Instagram are probably the most dominant platforms, but others, such as Snapchat, are becoming more popular. Not only do individuals have accounts, but so do businesses (including vet clinics). It is important to remember that if you are posting anything that is work related on your personal or business account, you need to have permission from the client and the clinic owner, even if it is in a closed Facebook group where only members of the group can see what you are posting. During our breaks and in the evenings, it is very easy to pick up our phones and scroll through our news feeds to see what is happening in the ‘world’. And as we scroll through we may see a comment that someone has made on a post in regards to animals that makes our hackles raise – don’t get me started on how many times I have seen someone say that flea treatment products from the vets are toxic, and that you should feed garlic and onions to you pets to control both fleas and intestinal worms! It is very easy to quickly make a comment to correct people about some of these misinformed facts, but it can leave you open to rebuttal comments about how the other person is correct and you are wrong. This discussion can then go around in circles as you look for a brick wall to hit your head against, so you explain that you are a qualified vet nurse and that you know what you are talking about. Unfortunately this can then lead to people saying things such as veterinary nurses are glorified cleaners and veterinarians are just after money, or worse! And of course we are going to defend ourselves, our profession and our colleagues. But as my husband likes to say, “You are only encouraging the crazies”. And while I know he is right, it is hard not to say anything. So what can we do, to not only educate people around the world about animal care but also about our profession? 4 September 2018
This October, we are replacing our annual Vet Nurse Day with Vet Nurse Awareness week, a great way to celebrate all that is good about veterinary nurses and veterinary technicians. We can bring awareness of what we do for our clients and patients by: • Becoming a registered veterinary nurse, technician or veterinary nurse assistant and promoting this to your clients, explaining that it means that not only are you qualified but that you meet the continuing education and clinical practice requirements on an annual basis. • Ask your clients (and practice owner) for consent to share your involvement with their pet’s care and what it means to you. This could be on a social media platform (owners love to see up-dates on their pets), or in a case study that is published in the New Zealand Veterinary Nurse journal. • Share all of the amazing things that you do as part of your job, including the little things that you just automatically do. This could be something as small as a head bop with a patient, to setting up to place an intravenous catheter in a patient, or something that you find not as exciting such as dispensing 100 prednisone tablets. Some parts of our job we enjoy more than others, but you will be surprised how many people will find all of these things interesting. • Ask your clinic to help showcase your team and their skills – while it is great to celebrate with cakes and lunches it is also good to show your clients what it is that you do to help care for their pets. The only way that we can change the public’s perception of our profession and help stop the ‘crazies’ is by showing them everything that we do. We may not be able to stop all of the internet trolls but we can show everyone that when we say garlic and onions are toxic to animals, that we know what we are talking about. The more that we promote our profession, the more it will become recognised and respected. Amy
NZVNA
Letter from the Editor I hope everyone enjoyed conference this year! I was particularly interested in hearing Bridey White’s talk ‘Compassion Fatigue and Burnout - can I catch it?’; it’s one thing to read about it, but another thing altogether to have an expert give a lecture that specifically relates to veterinary nurses in a room full of people who are there to support each other. Since moving back to Wellington, I managed to be a retired veterinary nurse for all of four days before popping into my new clinic to meet my colleagues. It turns out this vet nurse bug is harder to shake than I first expected, and having spoken to a few other people about it recently, I’ve found out I’m not alone. I’m not sure if I’m still contagious, but I hope the articles in this journal help to fuel your bug. This edition features Katrina Lowe’s piece on refeeding syndrome, we also get to read the second part of Sheree Smith’s nutraceuticals
article, and Lauren Prior’s conference review. Patricia Gleason talks us through learning through feedback in CPD corner, and how we can utilise it for our continued personal and professional development. If you have any ideas for an article, please contact me at antoinette.nzvna@gmail.com and I’ll send you information that will help you through the process. Antoinette
| Above: Cece relaxing after our road trip to Wellington
Membership Secretary report We are now well on the way with our sustainability plan. Renewal reminders are now being sent out by email, and invoices will only be sent on request. If you have not heard from us recently, please let me know by emailing membership@nzvna. org.nz to confirm your email address, as all future communications will be done by email.
Also, did you know that employment opportunities can be found on the website? We often send them to you by email but there may be others that you will only find on the website, so make sure you check them out at www.nzvna.org.nz. Kathy September 2018 5
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CLIENT HANDOUT
Arthritis - therapeutic exercises © Luke Feldman Group Pty Ltd All rights reserved Photograph by Miranda Samson
Therapeutic exercises can strengthen the muscles supporting the diseased joints and help maintain mobility and balance. Overview Arthritis is the irreversible and progressive deterioration of joints that causes pain and a reduction in joint motion. It affects dogs of all ages, but predominantly pets greater than 10 years of age.
Your pet must not lean to one side. Then ask them to directly stand up. Down to stand Have your pet move to a down position – “sphinx” position – and ask them to directly stand up without taking any steps forward. A treat may help them focus to stand directly upward.
When recommended by your veterinarian and in conjunction with other management techniques, therapeutic exercises can ensure your pet remains mobile and active.
Three-leg standing In a standing position, gently lift one hind limb for five seconds. Repeat three to five times a day, increasing to 30 seconds after a few weeks.
Five important therapeutic exercises Therapeutic exercises can decrease joint strain and build muscles to support joints. Swimming or walking on flat surfaces can help improve mobility.
Cross-leg standing In a standing position, gently lift one hind limb and the opposite front limb at the same time for five seconds.
The following exercises should be performed on a non-slip surface such as a rug or carpet. Sit to stand Have your pet sit normally with both hind limbs tucked against the body.
Repeat three to five times a day, increasing to 30 seconds after a few weeks. Walking Walk up and down hills or ramps gradually increasing over time to help increase the range of motion. Do not attempt these exercises if your pet appears to be in pain. Disclaimer Content is provided for informational and educational purposes only. The information is not a substitute for professional health or other advice and is in no way intended to be used or relied upon to diagnose or treat the health condition of any animal, or as a prognosis of any health condition. Always seek advice or consult a health or other appropriate professional before relying on any information provided. Source VetCheck digital pet health summaries, handouts and forms. To add your practice logo and start sharing directly to the pet owner’s mobile phone, visit www. vetcheck.it. Pet owners can now store their veterinary health record, receive pet reminders and get curated pet news at www.petcheck.it. September 2018 7
CPD CORNER
Learning through feedback By Patricia Gleason RVN, Professional Standards Committee Photograph by Miranda Samson
Feedback is any information we get about ourselves. We started receiving feedback at infancy. Throughout childhood and our school years we get feedback on assessments, from sports coaches, from our parents, siblings and friends. When we are younger, feedback directs how we learn to communicate, to develop manners, to walk, and to navigate or drive. As we get older, we get feedback from employers, potential employers, partners, customers, and, in this wonderful age of the internet, from complete strangers as well. Feedback which had previously been an innocent friend starts to be seen as a menacing foe, because it focuses on our performance and pulls into question our self-identity and self-worth. Much has been written about giving feedback, but as Stone and Heen (2014) argue, the more important part of the equation is the receiving end. The
After a career in biodiversity conservation, Patricia completed her Diploma in Veterinary Nursing (Distinction) at Massey University, and worked in veterinary clinics in the Bay of Plenty and Waikato before becoming a veterinary nurse educator. She is a founding member of the AVPRC and Chair of its Professional Standards Committee. She now works in a learning and development role coaching staff and teams in the educational sector.
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challenge with utilising feedback for our continued personal and professional development, is that we aren’t good at actually hearing and understanding the message of the giver of the feedback. We all have different triggers that put up walls, turn off our ears, and turn the volume of our internal voice up so that we block out any external input. These triggers may stem from who is giving the feedback, the timing of the feedback, feedback which casts doubt on our vision of our self, or feels untrue. Yet understanding a bit of the neuroscience behind human interactions, and focusing on our emotional intelligence (EI) and how we are responding to feedback, can allow us to focus on utilising any feedback for learning and growth. And by becoming better receivers of feedback, we will become better givers, and may teach other givers a thing or two along the way.
CPD CORNER
As human beings, we inherently know through our lived experience that the brain is a fascinating organ, which is always looking for shortcuts and ways to protect us. As trained veterinary nurses, we learn the anatomy and physiology of the brain and can make intellectual connections between the brain and behaviours we see in our patients, but how often do we stop to consider our own behaviours – how we engage with others, how we learn and grow - and their connection to our brains? Research in neuroscience has shown the human brain is a social organ, and our neurological pathways and responses are dominated by social interactions (Eisenberger & Lieberman, 2009). The beauty in the world is that we are all individuals. While you may look like or sound like others, ultimately the interpretation and response of our brain is unique and based on our own life and lived experiences. These experiences provide the frames through which we hear, interpret and respond to feedback. The other amazing thing our brain does that is particularly relevant to receiving feedback, is to process and respond to social pain – that stuff that comes from the likes of embarrassment, rejection and even perceived exclusion – the same way it does physical pain (Eisenberger & Lieberman, 2009).
differently, so we really need each other to see the whole picture that is going on around us more clearly.
Feedback comes from all around us and it can help us improve work relationships and get better at our jobs. Feedback can provide direction toward more selfawareness and a wealth of learning. Too often we seek feedback when really we want praise or recognition, so are surprised and/or upset when we receive criticism.
Each domain will have a different ranking of importance for each of us. When there is a primary threat perceived, such as in a threat to our status, the brain circuitry functions similarly as if our life were being threatened. When we experience a reward response, such as a perceived increase in fairness, the brain responds just as it would with a monetary reward. Knowing which of these domains is most important to us, and noticing our physical and emotional response when feedback relating to this domain is received, will help us stay in control.
There is an African proverb which holds important truth if we want to truly learn and grow from feedback of any type: Examine what is said and not who speaks. To become successful receivers of feedback, we have to do a few things up front: First, accept that we are all biased. None of us sees everything, and each of us has our own set of rules by which we operate that is different from others; our “blind spots” (Stone & Heen, 2014). Our different lived experiences mean we each interpret things
Second, acknowledge that givers of feedback are usually not good at it, even when they have the best of intentions (ourselves included when we are in this role). They combine appreciation, coaching and evaluation and it becomes our job to differentiate among these and separate the components (Stone & Heen, 2014). We need all of these as they each satisfy a different internal need, but separating them out helps us understand the giver’s purpose in the feedback. Third, take advantage of what we know about the brain. We know the brain works to minimise threat and maximise reward. In social interactions – where feedback happens – there are several domains that may be challenged which can trigger threat and a ‘fight or flight’ response, which Rock (2008) outlines in his SCARF model: • Status - relative importance to others • Certainty – predictability of the future • Autonomy - sense of control over work or events • Relatedness – being part of the ‘in’ group; feeling safety with others • Fairness - perception of fair exchanges between people
Once we pass this hurdle, we can start to engage with others and challenge ourselves to learn from what they are actually saying to us. Any of the experts will tell you, there is a space within this process where you can disregard someone else’s feedback, but in general, we have a
lot to learn by trying to understand others’ perspectives about how we come across and do our work, things that are important to them, and how we can reframe who we are in order to build stronger relationships that continue to help us learn and grow. As the author Aiki Flinthart wrote, “Pretty words are not always true and true words are not always pretty.” To use feedback for learning and development, we need to challenge ourselves to breathe (and maybe breathe again to keep our logical brain in charge), to grow our skills for receiving and seeking feedback and then incorporating this into our learning plans. Stone and Heen (2014) recommend becoming aware of our triggers, challenging ourselves to really hear the message, questioning to understand, looking for blind spots that are obvious to everyone else around us, and utilising specific tactics for managing the feedback conversations. When we are ready to try a new way of being or doing, they say experiment and start small. Don’t try to change 10 things at once; find the one or two things that would really make a difference to those we work (or live) with and focus on those first. Eventually, spotting the differences in how we see things from those around us will become second nature, and drive a curiosity towards broadening our lived experience and thus not only our ideas and opinions, but also our behaviours and identity. Just like we are always trying to find more data to guide our decisions around patient care, seeking more data about others’ perspectives through feedback can inform our behaviours and continued learning. References Boyatzis, R. and Jack, I. (2018). The neuroscience of coaching. Consulting Psychology Journal: Practice and Research, 70 (1), 11–27. Eisenberger, N. and Lieberman, M. (2009). The pains and pleasures of social life. Science, 323 (5916), 890-891. Rock, D. (2008). SCARF: A brain-based model for collaborating with and influencing others. Neuroleadership Journal, 1 (1), 44. Stone, D. and Heen, S. (2014). Thanks for the Feedback: The science and art of receiving feedback well. Penguin Group LLC. September 2018 9
SPAW
South Pacific Animal Welfare By Courtney Spencer RVN, Vetcare Glen Innes
South Pacific Animal Welfare (SPAW) is a New Zealand charity that runs temporary veterinary clinics on several islands in the South Pacific, including Tonga. In December 2017, SPAW, in conjunction with Unitec Institute of Technology, ran a week-long clinic in Nuku’alofa, Tonga. The clinic provides services including desexing, parasite control and vaccinations. The team consisted of fourteen Diploma in Veterinary Nursing students, four veterinarians and four support staff (three Unitec lecturers and one veterinary nurse). Our team departed Auckland on Friday morning. It was an early start, but we were all so excited and couldn’t wait to get to Tonga. Once we arrived, we went to our accommodation and spent the rest of the day settling in. On Saturday we spent the morning at the local markets, then headed off to the clinic after lunch to set up. As the clinic is only used a few times a year, a good clean out was required before we set up our equipment. For several Diploma students, including myself, this was the second combined SPAW and Unitec trip we had
Courtney is a registered veterinary nurse currently employed at a small animal practice in Auckland. She graduated with a Diploma in Veterinary Nursing at Unitec in 2014 and also completed a Bachelor of Applied Science in Animal Management and Welfare in 2018.
10 September 2018
participated in, so we already knew what to expect. For those who hadn’t been, this was the first time they were able to see the environment we would be working in. The clinic consists of two surgery rooms - one had proper (but old) surgery tables, so this was our main surgery room. Our second room was for surgery, drug storage and cleaning surgical equipment. In here, we had two fold-up tables on bricks to make them the right height for the veterinarians. The hospital area was outside. This outside area was multipurpose and would be used for treating sick patients, administering vaccinations and parasite treatments, and would also be where patients were recovered post operatively. The equipment available was also very limited; kits were basic and in short supply, and we had no diagnostic equipment. There was no anaesthetic machine, instead we used total intravenous anaesthesia (TIVA). We were lucky to have an autoclave, however, we would also be utilising cold sterilisation. Setting up the clinic was definitely an eye-opener for the students,
| Above: (from left to right) Sandra Gensch, Dr Geoff Neal and Courtney Spencer with their patient after a successful amputation surgery
SPAW
it was clear that this would not be a standard week’s work! In the evening we had a run through of the plan for the week. Students were separated into groups on a rotating roster for the week: hospital, surgery and field visits, allowing everyone to have a turn in each area. We went over the drug procedures and the tasks that each role required. The hospital nurses would greet incoming clients and establish why they were there. Hospital cases primarily involve providing parasite treatment to patients, treating sick animals, vaccinating, and educating clients on animal care. Surgery cases were primarily for desexing. The surgery nurse was responsible for caring for their patient from admit to discharge. This involved tasks that would not normally be performed by a student, such as intubation and intravenous (IV) catheterisation. On Tuesday through to Thursday we ran field visits, where a vet and three to four nurses went to various locations to set up a temporary clinic for the day, or visit farms to check livestock. Sunday is a religious day so everything on the island shuts down - we were fortunate to be able to catch the ferry over to Pangaimotu Island and spend some time there. A nice relaxing day before the busy week ahead! On Monday we were all up early and rearing to go. We arrived at the clinic and set up for the day. It wasn’t long before our first patients started arriving. Students who had been last year paired up with the new
student volunteers to walk them through their first few patients, allowing the start of the day to flow well. The day passed by rather quickly as there was a constant stream of patients, and by the end of the day everyone had gotten into a rhythm. Monday was a big learning curve, as for most of the students it was the first time they had done tasks such as intubating and placing IV catheters. After a long day at clinic, we headed back to our accommodation and relaxed. After dinner, we had a meeting to discuss the day’s events and allow anyone to ask any questions they had after their first clinic day, allowing any kinks to be sorted for the rest of the week. Tuesday to Thursday breezed by. With the field clinics operating on these days, it meant that we were down a vet and several student nurses at the clinic. Although we were busy, everyone was working well together, allowing us to get through each day efficiently. Field visits were a bit of a mixed bag; some days were non-stop for them at a temporary clinic that had been set up in a hall, others were at a bit of a slower pace with the team visiting farms, however it gave students the opportunity to see things they normally wouldn’t in a clinic. On Wednesday evening we were lucky to be treated to a cultural show and dinner by the Ministry of Agriculture, Forestry, Food and Fisheries, and on Thursday we went to a local beach for an afternoon swim. Friday was our last full day at the clinic, however as field clinics were not operating
| Above: (from left to right) Tamara Thompson and Sarah Hailwood with puppies brought into the clinic
that day we had our full team ready for the anticipated busy day. As predicted, it was a rather busy day in both the surgery and hospital areas. Towards the end of the day we had a dog brought in that had been missing for a week. The owner advised us that she had possibly been hit by a car, resulting in a leg wound with an exposed femur. We amputated the leg and sent her home with pain relief and antibiotics. On Friday evening we went to Oholei Beach Resort for a cultural show and dinner to celebrate a successful week. We were leaving on Saturday evening, so only had a morning clinic for any lastminute patients. We had some desexing surgeries and a few hospital cases needing parasite treatments. Our amputation case from the night before came back for a recheck. It was great to see she was running around, especially as we were all aware that her outcome would have been very different had we not had our clinic operating that week. After our last patient left, we cleaned and packed down the clinic leaving it ready for the next group. We all then went back to our accommodation, packed up and then left for the airport. Overall, we a had a long but rewarding week. Being able to learn things like intubation and IV catheter placement was a massive opportunity, and at the end of the week we were all confident in these tasks. It also gave us a chance to see cases we wouldn’t normally see in a standard clinic, and to hone our skills. Over the five and a half days we were able to see 398 animals; 156 were surgical cases including spey and
| Above: (from left to right) Ruth Scheurich and Courtney Spencer intubating a patient
September 2018 11
SPAW
neuter surgeries and amputations, and 242 hospital cases including health checks, vaccinations, treating sick animals and attending to livestock. Last year, SPAW ran a total of four volunteer clinics spread throughout the year in Tonga. Despite having several clinics
| Above: Outside the clinic
throughout the year, their services are still in high demand. Tonga does not have the luxury of having access to vet clinics every day like we do – if they require treatment for their pets or livestock, they must wait for one of the SPAW clinics. At the start of the year, Tonga was devastated by
Cyclone Gita. Tonga was hit particularly hard, and SPAW would appreciate help such as volunteer veterinarians and veterinary nurses, and both monetary and supply donations. If you can help in any way, please contact SPAW or visit their website: http://spaw.org.nz.
| Above: The amputee patient visiting the clinic the morning after the surgery
TIME TO START PLANNING HOW YOU’LL BE CELEBRATING
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REFEEDING SYNDROME
Refeeding Syndrome By Katrina Lowe RVN, After Hours Veterinary Centre, Christchurch Photograph by Miranda Samson
Katrina graduated with a Diploma in Veterinary Nursing from Ara Institute of Canterbury. She is employed at the Christchurch After Hours Veterinary Centre caring for emergency and critical care patients. She is interested in animal behaviour, nutrition, and enjoys teaching puppy classes.
14 September 2018
Introduction Refeeding syndrome is a secondary condition that can occur when nutrition is reintroduced (enteral or parenteral) to patients that are severely malnourished, starved, or metabolically stressed due to severe illness or injury. This results in metabolic disturbances, which usually occur within the first three to seven days of nutrition being reinstated. It can be seen in people with cancer, anorexia nervosa, and in our animals with hepatic lipidosis and diabetic ketoacidosis. Refeeding syndrome is believed to be a rare condition with only a few cases in veterinary practice. The reintroduction of food creates a redistribution of electrolytes and fluids, which are unable to be accommodated and result in a compromised cardiovascular system. Water is imperative for survival, and death can occur within a few days of deprivation. Animals are able to survive for longer periods of time without food, but regular nutrition is critical for health, longevity and disease prevention. When nutritional requirements are compromised, withheld or not adequately met, the body’s ability to heal, defend (immunity) and maintain cardiac and respiratory functions is compromised. Adaptive biochemical and physiological changes occur with a severe calorific deficiency. Metabolism is reduced as a coping response to the lack of food, and a prolonged state can cause permanent organ damage and death. When nutrition is reintroduced, the increase in insulin creates a cascade of electrolyte disturbances, as the body struggles to handle the influx of nutrients after a calorie deficit, and the result can be fatal. The primary disturbances associated with refeeding syndrome are hypokalaemia, hypomagnesemia and severe hypophosphatemia Physiology/pathophysiology In a healthy state, during the initial stages of fasting, the glycogen stores are primarily used for energy. Cats as strict carnivores have their glycogen stores
depleted quickly and are more susceptible than dogs to refeeding syndrome. Within a few days, a metabolic shift occurs and fat stores will be used by the body for energy. A continued lack of nutrition will see further changes by the body and energy will predominantly be derived from accelerated proteolysis, the breakdown of proteins or peptides into amino acids by the action of enzymes. The process continues and the carbohydrate, fat and protein stores will become depleted in the body. Skeletal muscles will be utilized for energy and muscle wasting will result. The body will produce ketones, insulin secretion will decrease, and a decrease in the metabolic rate will occur. The body will be attempting to balance energy intake against energy use, and potassium, magnesium and phosphorus levels will become depleted (Chan, 2012). The shift from a catabolic state where protein is the primary energy source, to an anabolic state where carbohydrates are the energy source can lead to refeeding syndrome. When a malnourished patient is fed aggressively (particularly carbohydrates) this stimulates a release of insulin, metabolically inactive cells are triggered, and this begins the intracellular shift of potassium, phosphate and glucose, which results in hypokalaemia and hypophosphatemia. Hypophosphatemia Hypophosphatemia is the most significant electrolyte disturbance with refeeding syndrome. The reintroduction of amino acids and energy, particularly carbohydrates, creates a significant shift in electrolytes from extracellular to intracellular compartments. The majority of the body’s phosphorus is located in bones (80%), with the remainder involved in major body functions e.g. carbohydrate metabolism, the storage, release and transfer of energy, and the composition of physiologically important substances, for example nucleic acids and phospholipids (Sirois, 2015). Most of the
REFEEDING SYNDROME
Figure 1: Progression to Refeeding Syndrome (source: Lowe, K. 2016)
K4
Refeeding syndrome
Insulin
Food
PO4
K4
Hypocalcaemia Hypomagnesemia Hypophosphatemia
PO4
5–7 days
Figure 2: Pathophysiology of Refeeding Syndrome (source: Walmsely, R. S., 2013) Homeostasis – electrolytes, vitamins, insulin and extra and intracellular fluids are in balance. Starvation – insulin levels fall, slowly intracellular stores, cofactors and electrolytes fall. RS (Refeeding syndrome) – with provision of nutrition (especially carbohydrates) a surge in insulin results in increased metabolic activity with intracellular movement of electrolytes, water and utilisation of cofactors for enzymatic process.
phosphorus in whole blood is found within the erythrocytes as organic phosphorus, inorganic phosphorus is in plasma and serum - this is what is analysed in laboratories. A high demand for phosphorus by the cells removes phosphate from the blood; this occurs irrespective of the route of nutrition (enteral or parenteral). Haemolytic anaemia can result due to hypophosphatemia. Red blood cells require phosphorus to maintain shape; insufficient levels disrupt the red blood cells’ integrity and causes them to burst. Rhabdomyolysis can also occur in severely affected cats due to the rapid shift of electrolytes. Hemolyzed blood samples should not be used as the ruptured erythrocytes may be hydrolysed due to inorganic phosphorus, which will result in an inaccurate elevation of phosphorus. The blood cells, plasma and serum should be separated as soon as possible, it is suggested within one hour after collection and before storage (Wortinger, 2011). The level of inorganic phosphorus provides a good indication to a patient’s total phosphorus level. Phosphorus and calcium concentrations in plasma and serum are inversely related – as phosphorus decreases, calcium increases (Sirois, 2015). Serum concentrations of electrolytes may appear normal in a starved state, due to the renal excretion rates of electrolytes (Geol, 2015). Hypomagnesemia Hypomagnesemia is another electrolyte complication that occurs with refeeding
syndrome – it increases urinary excretion of potassium, which exacerbates hypokalaemia. It makes successful treatment of the hypokalaemia difficult until the hypomagnesemia is corrected. Hypomagnesemia may result in a patient becoming irritable or aggressive. Secondary hypocalcaemia can occur as a result of hypomagnesemia; this will be resistant until the magnesium deficit is corrected. This is due to the parathyroid hormone (PTH) being unable to elicit calcium from bones (Wortinger, 2011). Thiamine Deficiency A thiamine deficiency could occur due to atrophied villi and can be exacerbated by the feeding of carbohydrates. This deficiency may result in Wernicke’s Syndrome, a severe acute deficiency in thiamine. Dogs may show neurologic or cardiac signs. Cats are more susceptible and may present with ventral neck flexion, sluggish demeanour, ataxia, coma, ocular disturbances such as dilated, poorly responsive pupils, and nystagmus. Patients that are at risk of developing refeeding syndrome include: • animals with a poor body score condition (severe malnutrition / starvation) • an animal that has been fasted for more than five to ten days regardless of bod condition • an animal which has lost less than ten percent of body weight in less than two months
• an animal that has suffered burns • an animal suffering with a chronic disease such as cancer, cardiac cachexia, renal failure or hepatic dysfunction, hepatic lipidosis • animals with diabetic ketoacidosis (phosphorus depletion can occur in the absence of hypophosphatemia) • animals with eclampsia • animals in certain life stages (gestation, lactation or growth) • animals with certain endocrine diseases (hyperaldosteronism, hyperadrenocoticism, hyperthyroidism and hyperparathyroidism) • animals mounting a metabolic response to illness or severe injury may be at higher risk of developing of malnutrition • animals with respiratory alkalosis or metabolic acidosis • older cats with gastrointestinal disease (inflammatory bowel disease) • an animal on certain medications (phosphate binders, diuretics and glucocorticoids may lower serum phosphorus levels) • an animal with a critical illness may escalate the time frame • an underlying renal failure patient that is malnourished may become a ‘late re-feeder’ (late development of refeeding syndrome). The renal failure may slow the electrolyte clearance rate with elevated serum electrolyte (Cloete, 2013) An owner may observe weight loss, lethargy, nausea, vomiting, diarrhoea, anorexia, weakness, pigmenturia, restlessness, seizures, coma and death (from decreased cardiac and respiratory function). Obesity puts cats at risk of developing feline hepatic lipidosis, which occurs when a cat has become inappetent and the liver is forced to convert body fat September 2018 15
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into usable energy. A physical examination may indicate poor body condition but this may not be evident in all patients. A history of recent weight loss may be a stronger indicator of refeeding syndrome. A patient with hypophosphatemia may have pale mucous membranes (MM) related to anaemia, a bounding pulse, and may be experiencing tachycardia, tachypnoea and lethargy. Dogs may have a prolonged buccal mucosa bleed time (BMBT) of less than four minutes due to platelet dysfunction and/or a left ventricular systolic dysfunction. Parameters to monitor in at-risk patients include: • Biochemistry and electrolyte levels: monitor daily serum potassium, phosphate and magnesium or more frequently if receiving supplementation. Monitoring needs to begin within 12 hours of refeeding (Wortinger, 2011) • Blood glucose levels (hyperglycaemia is rarely present in dogs) (Lippo, 2008) • Packed cell volume (PCV) for anaemia and serum for haemolysis. Serum chemistry, PCV, total solid, and complete blood count need to be rechecked five to six days after discharge and again at 21 to 28 days • Neurologic signs: muscle weakness, tremors, paraesthesia and seizures (Cloete, 2013) • Electrocardiogram and blood pressure: these patients have the potential for heart failure • Nutrition: what, route and volume a patient is being fed • Outputs: any vomiting, urination and defecation volumes and appearance • Accurate weight, and daily re-weighing: weight gain could indicate fluid retention or fluid overload and the patient should be monitored for any oedema and congestive heart failure. When a patient’s body weight is less than fifty percent of its normal body weight, the prognosis is poor • Temperature: patients that have sustained a period of calorie deficit will have limited resources to adequately maintain a normothermic temperature. A hypothermic patient should be re-warmed gradually, 16 September 2018
current recommendations are to use the human guidelines at 1°C per hour as rapid rewarming can cause further complications (Cloete, 2013) • Infection status: with compromised immunity we need to protect these patients so barrier nursing procedures should be used. Regular monitoring of intravenous catheter sites, open wounds, surgical sites, and feeding tubes is vital to reduce the risk of sepsis. Vaccinations should not be administered during illness • Evidence of parasites: any parasite infection should be attended to if required Actively identifying and anticipating a patient that has the potential to develop refeeding syndrome may help in prevention. Treatment A nutritional assessment will assist decisions around tailoring a feeding plan. The urgency of nutritional support may influence the route of nutrition administration. The route chosen may be influenced by disease or injury, length of intended use, a patient’s stability to undergo anaesthesia and expected tolerance to a tube. Commonly used feeding tubes include nasoesophageal, esophagostomy, gastrostomy and jejunostomy. ‘If the gut works, use it’ is the preferred option as it is cheaper, poses fewer complications and has beneficial effects on the gastrointestinal tract. Syringe feeding can lead to food aversion and some patients are very resistant and do not tolerate this well, which can be counterproductive when trying to encourage patients to eat. Specific veterinary products are available that are suitable to use with feeding tubes. Depending on the size of the tube some may require blending or diluting to enable administration with narrower tubes. The advantage to using these is that it may eliminate a diet change as the patient begins to eat. Other wet foods can be blended but may require straining to enable administration through a feeding tube. When water is used to dilute food this does alter the kcal/mL and this needs to be taken into account when calculating
patients resting energy requirement (RER). Calculation for Resting Energy Requirement (RER) >2kg RER (kcal) = (30 x Bodyweight) + 70 <2kg RER (kcal) = (70 x (BW)0.75) It is recommended that no animal go longer than five days without food, and this should be calculated as the total number of days, not just hospitalized days (Wortinger, 2011). Documentation has shown that metabolic changes that are consistent with starvation in humans are present in canines that have been anorexic for three days. After four days of acute starvation, immune function impairment can be detected in (previously healthy) felines, therefore nutritional support should be considered in any ill cat that has not eaten adequately for more than three days. At day five the lack of nutrition becomes more urgent as metabolic and immune function changes are detectable, which are directly linked to a prolonged period of inadequate nutrition (Chan, 2012). It is critical to get our patients eating and prevent further delays in administration of nutrition. Recommendations to re-establish RER The nutritional support should aim to meet the full RER over three or five days, but may alter depending on the number of days the animal has been anorexic. A reduction in the feeding rate, changing food to a low carbohydrate food, and supplementation of phosphorus, magnesium and potassium should be considered. Feeding should be divided into several meals throughout the day, or if a patient is not tolerating the food, it can be introduced as a constant rate infusion using a syringe driver (depending on route of administration). Care should be taken to avoid food aversion and aspiration. Food should ideally be at room temperature or warmed for eating. Before beginning nutritional support, the patient’s hydration, electrolyte and acid base status, along with cardiovascular instability, should be addressed. Phosphorus, magnesium and potassium
REFEEDING SYNDROME
levels will need to be monitored with potential refeeding syndrome patients. If the electrolyte levels drop by less than twenty percent after the introduction of nutrition, refeeding syndrome should be included on the differential diagnosis. Electrolyte and glucose levels should continue to be monitored every four to six hours during supplementation until they are stable. During supplementation, trends should be taken into account rather than individual values. Heart rate, rhythm and blood pressure should also be closely monitored during administration of supplementation. A PCV is also recommended as haemolytic anaemia can occur due to hypophosphatemia. As the electrolyte levels improve, nutrition can slowly be increased (Sumner, n.d). Choosing the correct nutrition (low carbohydrate, high fat food) could make all the difference for a patient that is at risk of developing refeeding syndrome. The canine and feline charts (Figure 3) show the breakdown of different veterinary foods that we may consider feeding a patient that has been anorexic or is recovering after an illness or injury. Ways to avoid food aversion • Removal of unwanted food from the cage, leaving water accessible • Warming food rather than feeding straight from the fridge • Trying different bowls – patient may be
• • • •
more likely to eat from a bowl that is similar to what they have at home e.g. metal vs plastic Keeping facial area clean of food or blood (facial trauma) Hand feeding Spending time with a patient before feeding e.g. petting / grooming Changing the patient’s environment: they may prefer somewhere quieter. Our hospital environment can be frightening, for example if a dog may never eat inside at home
A patient may experience gastrointestinal irritation, which can present as nausea, vomiting, signs of reflux, abdominal pain, early satiety and/or diarrhoea. The gastrointestinal villi during starvation will atrophy which can cause diarrhoea or delays in gastric emptying. Medication may be required for a patient to help with any gastrointestinal irritation. Ensuring that our patients remain clean and dry will assist in avoiding faecal or urine scalding, and prevent additional strain on the body’s compromised immunity. Summary Refeeding syndrome involves a combination of abnormalities in fluid balance, vitamin deficiency, metabolism, glucose, hypophosphatemia, hypomagnesemia and hypokalemia. This condition occurs after a period of calorific deficiency as patients begin
receiving enteral or parenteral nutrition. Hypophosphatemia is the most severe complication of refeeding syndrome. With a limited number of reported cases in veterinary patients, it does not mean this does not occur. It is unclear why refeeding syndrome affects some patients and not others. The prognosis for simple starvation malnutrition in patients that do not develop hypophosphatemia or anaemia is favourable. Patients that have a concurrent illness or injury area at greater risk of developing this condition. The prognosis for a patient that is critical or is experiencing a chronic illness that develops hypophosphatemia and has evidence of haemolytic anaemia is guarded (Lippo, 2008). Cats with severe hypophosphatemia and haemolytic anaemia have died within 12 to 72 hours of refeeding (Hand, 1998). Veterinary nurses play a crucial role in providing nutrition. We are every patient’s advocate and should incorporate a nutrition plan for every animal that is admitted to hospital / clinic. Nutrition dramatically influences a patient’s recovery from illness, injury or elective surgery: planning nutrition on day one will help recuperation. Feeding plans for the starved patient will need to be reassessed frequently as the patient status will change throughout the feeding period.
Figure 3: Breakdown of veterinary foods Canine per 100g
Royal Canin Canine Recovery
Hill’s a/d
Hill’s i/d
Royal Canin Canine Sensitivity (wet)
Carbohydrate
2.6
3.7
5.3
9.5
Fat Content
6.2
7.3
2.7
6
Protein
14
10.6
9.2
8.5
Phosphorus
0.29
0.24
0.25
0.3
Potassium
0.21
0.22
0.16
0.23
per 100g
Royal Canin Feline Recovery
Hill’s a/d
Royal Canin Feline Renal (Tuna, wet) Royal Canin Feline Sensitivity (wet)
Carbohydrate
2.2
3.68
4.8
4.5
Fat Content
5.1
7.24
5.5
5.5
Protein
11.6
10.58
8.2
8
Phosphorus
0.24
0.24
0.14
0.35
Potassium
0.17
0.22
0.19
0.17
Feline
Sources: Royal Canin®, Hill’s Pet Nutrition®
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Refeeding syndrome has the potential to occur in many of our hospital patients - identifying and anticipating at risk patients is the first step in preventing and avoiding refeeding syndrome in veterinary practice. References Chan, D. (2012). Nutritional requirements in critical illness. In J. M. Creedon and H. Davis (Eds.), Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care (pp. 477-484). Arnes, USA: Wiley-Blackwell. Cloete, A S. (2013.) Recognition and Treatment of Refeeding Syndrome in Animals. Retrieved from https:// www.wcea.education/app/ vettech-cva/elearning/veterinarytechnician-veterinary-nurse/ commonwealth-veterinary-associationtech/152321/refeeding-syndrome Geol, A. (2015). Refeeding Syndrome. Retrieved from http://slideplayer.com/ slide/3453149/. Hand, M., Thatcher, C., Remillard, R., & Roudebush, P. (Eds.) (1998). Small Animal Clinical Nutrition 4th Edition. Missouri, USA :Walsworth Publishing Company. Hill’s Pet Nutrition. (2017). Hill’s Key to Nutrition: Dietary Management with Hill’s. Retrieved from https://www. hillsvet.ca/en-ca/practice-management/ hills-key-to-clinical-nutrition 18 September 2018
Lippo, N., & Byers, C. (2008). Hypophosphatemia and Refeeding Syndrome. Retrieved from http:// d1uhp0uy75me04.cloudfront.net/mmah/ bb/7506daecc94dd79f76cf29cb60b931/ fileSOC_10_04_6.pdf. Royal Canin. (2010). Royal Canin Health Nutrition for Cats & Dogs Product Book. Retrieved from http://www.royalcanin. in/products/products/vet-products/ vet-product-book Sirois, M. (2015). Laboratory Procedures for Veterinary Technicians (6th ed.). St. Louis, USA: Elsevier Saunders. Sumner, C. (n.d.) Refeeding Syndrome. Retrieved from https://www.mspca.org/ angell_services/refeeding-syndrome/ Wortinger, A. (2011). Refeeding Syndrome: When Good Food Goes Bad. Retrieved from http://wendyblount.com/taca4/ Refeeding.pdf Further reading: Bassett, J., & Thomas, J. (Eds.), (2014). McCurnin’s Clinical Textbook for Veterinary Technicians(8th ed.). Philadelphia, USA: Elsevier Saunders. Cooper, B., Mullineaux, E., Turner, L., & Greet, T. (Ed.). (2011). BSAVA Textbook of Veterinary Nursing (5th ed.). Quedgeley, United Kingdom: British Small Animal Veterinary Association. Crook, A., Hally, V., & Panteli, J. (2001). The Importance of the Refeeding Syndrome. Retrieved from: http://www. hopkinsmedicine.org/gim/_pdf/consult/
refeeding_syndrome.pdf Donohoe, C. (2012). Fluid Therapy for Veterinary Technicians and Nurses. United States:Wiley-Blackwell. Gas Exchange. (2016). Carbohydrate, Protein and Lipid Metabolism Notes. Retrieved from http://gasexchange.com/ notes/metabolism/. Lane, D., Guthie, S., & Griffith, S. (2008). Dictionary of Veterinary Nursing (3rd ed.). United Kingdom: Butterworth Heinemann. Mehanna, H., Moledina, J., & Travis, J. (2008). Refeeding Syndrome : what it is, and how to prevent and treat it. Retrieved from https://www.ncbi.nlm. nih.gov/pmc/articles/PMC2440847/ Stanga, Z., Brunner, A., Leuenberger, M., Grimble, R., Shenkin, A., Allison, S., & Lobo, D. (2007). Nutrition in Clinical Practice - the refeeding syndrome: illustrative cases and guidelines for prevention and treatment. Retrieved from http://www.nature.com/ejcn/ journal/v62/n6/full/1602854a.html Thomovsky, E., Backus, R., Reniker, A., Mann, F., & Dodam, J. (2007.) Parenteral Nutrition: Formulation, Monitoring, and Complications. Retrieved from https:// www.ncbi.nlm.nih.gov/pubmed/17727159. Walmsley, R., (2013). Refeeding Syndrome: Screening, incidence and treatment during parenteral nutrition. Journal of Gastroenterology and Hepatology, 4:1137. https://doi.org/10.1111/jgh.12345
NUTRACEUTICALS
Nutraceuticals: The basics – part two By Sheree Smith RVN, UKRVN, Dip Hydrotherapy Owner and Director of Kinesis Veterinary Ltd Photograph by Miranda Samson
Introduction The purpose of the second part of this article is to discuss how nutraceuticals can help treat anxiety and manage stress, support a patient’s bladder and help with managing skin conditions. It also discusses how nutraceuticals can benefit your practice, how they can benefit your patients, and allow you to gain the confidence of your clients to begin to use them in your patient’s treatment and/or care plans. Before drugs were developed as they are now, they all started off in nature. Nutraceuticals are a pure form of a natural product that, to be more effective, is in high concentration. Many nutraceutical ingredients have come to be accepted by mainstream medicine for their proven therapeutic benefits, such as: glucosamine, boswellia, omega 3 fatty acids, and antioxidants. There is a huge array of other ingredients that are lesser known to the public, but can be very effective in helping to benefit patients’ health and quality of life. This can be increased further if used in combination with other nutraceuticals to enable faster action, better absorption or to counteract contraindications.
Sheree Smith is a widely experienced veterinary nurse, hydro therapist, pain management and rehabilitation practitioner. She graduated in 2002 from Unitec Institute of Technology and has also studied hydrotherapy and pain management in the UK. Sheree has worked as a veterinary nurse in New Zealand, Australia and Europe, spending an extended period working at a cutting edge referral centre in the UK called The Willows.
Thankfully, there are some superb products available in the veterinary market today, many of which have undergone scientific trials or proven their value in case studies. However, make sure you read more into these studies and find out where it was carried out, with how many sources and who it was funded by. You may be interested to find that some companies fund their own trials and of course these have yielded brilliant outcomes for their products. There has been acceptance among veterinarians that many of these products will benefit animal health if used sensibly and intelligently. The following continues the brief discussion of some of the more popular categories of pet dietary supplements.
Anxiety and stress management Lives have become busier and more complicated, resulting in increased levels of stress and anxiety. Often pets’ personalities and behaviours are reflective of their owners’ inability to cope with a frantic lifestyle, as well as the amount of time many pets spend alone. Dogs are pack animals and easily affected with separation anxiety, signs of which include chewing or tearing furniture or other objects, excessive salivation and inappropriate urination and defecation. Cats and dogs are also easily stressed with travel, boarding, grooming and visits to the veterinarian. Sedatives and calming drugs like fluoxetine tend to produce sleepy, lethargic pets. Supplements containing blends of natural herbs or mixtures of chamomile, ginger and tryptophan help reduce anxiety without causing sluggishness and disorientation. There are many situations that pets can find stressful or develop phobias to, such as new homes or pets, new babies, fireworks and separation anxiety. With stress, anxiety and phobias, the excitatory chemicals (neurotransmitters) that get the body in readiness for ‘fight or flight’ have gone into overdrive. The calming inhibitory neurotransmitters can’t keep up to balance them out and return the body to a calm state. These chemicals are manufactured in the brain so with nutraceuticals we are giving the body the amino acid building blocks to manufacture them with a combination of fast and slow acting ingredients. Improved products have very high levels of: L-Tryptophan: the precursor to serotonin (the ‘happiness hormone’). This high strength formula has also been shown to help with territorial aggression. GABA (Gamma Amino Butylic Acid): termed the body’s natural valium, calming and relaxing while also shown to be September 2018 19
NUTRACEUTICALS
beneficial in senility dementia cases. L-Theanine boosts dopamine production (Inagawa et al., 2005). All have calming properties that have a sustained effect. (Uetake et al., 2012). Lastly, passiflora incarnata, which is a passion flower extract. This has its own relaxing properties, relieves tension, and boosts the GABA production in the brain. Passiflora has been used very successfully in humans with General Anxiety Disorder (GAD). Passiflora also works very quickly, used on average about an hour before the perceived stressful event. Very helpful for those clients that wait until the night before an event to remember that their dog is terrified of fireworks! Ideally a dose should be given the day before the stressful event, if possible, while the pet is calm to maximize efficacy as it is a very complex chemical process in the brain. Ideal products work within one to two hours and can be used with patients prior to coming into veterinary clinics that are nervous, or anxious (Lakhan & Vieira, 2010). Nutraceuticals can be used in conjunction with other multimodal calming agents such as animal pheromones used to reduce anxiety in cats and dogs. Thunder jackets can also help an anxious patient. Bladder support Conditions involving the bladder often are a result of stress or a stressful event. A common example in veterinary medicine, with stress being a contributing factor, is the occurrence of Feline Idiopathic Cystitis (FIC). Look for products with ingredients with L-Tryptophan, a ‘de-stressing agent’, and N-acetyl D-glucosamine. N-acetyl D-glucosamine: supports the mucoid Glucosaminoglycan (GAG) layer within the bladder. This has been shown to be deficient in the layers of the bladder of patients with FIC. Quercetin: cystitis is an inflammatory condition and the nutraceutical should have a three-staged attack - relieving stress, reducing inflammation and supporting the GAG layer. Quercetin is a flavonoid, found naturally occurring in things like broccoli, green tea and cranberries. It is an antioxidant but also 20 September 2018
has an anti-inflammatory action that works in the urinary tract area to support urinary tract health. Although it is an active ingredient, quercetin is also very palatable to cats! Client feedback shows that cats have been seen licking this off their food and leaving the food. L-Theanine: used in some bladder supports as it’s an anti-stress agent. L-theanine is beneficial for relaxation and sleep; it is calming, but not sedating (Hofve, 2015). Most importantly it gives the client some things they can do at home to help manage the condition, because treating FIC is all about the management at home. Allergies and skin dysfunctions The skin is the body’s largest organ system. It acts to protect an animal from injury and infection, helps control internal temperature, and serves as a storage tank for certain nutrients. The coat insulates the body and shields the skin from injury due to sunlight, heat and irritants. The physical condition of this important organ is vital to the health of animals, and supplements containing omega fatty acids are commonly used by pet owners to maintain skin health and promote a radiant, healthy coat. Omega 3 fatty acids are derived mainly from flaxseed oil and fish oil in the diet.
Unlike the omega 6 fatty acids, they are used preferentially for select functions, such as proper brain development and reduced inflammatory response. The use of omega 3 fatty acids in pet foods and supplements may help reduce the signs of allergies and other skin inflammatory dysfunctions, such as itching and reddening. Veterinarians often advocate the use of omega 3 fatty acids as routine supplements for dogs or cats with nonspecific skin problems, although a proper diagnosis often requires an expensive in-depth diagnostic work-up. The ratios of omega 3 to omega 6 fatty acids and the total amount of fat intake affect response, and their inclusion in the diet must be carefully balanced. Most animals receive enough omega 6 from their diets; it’s the omega 3 that is usually lacking in some patients. Also, there are great trials out there that show omega 3s help look after joint care also. So, they are a good combination to use with joint supports. A deficiency in omega 6 can cause a skin problem. That is why skin supplements historically contained omega 6 to make sure pets had enough. Cereal based diets with added vegetable oils contain a lot of omega 6, and when this accumulates they can be pro-inflammatory, especially if they are not counterbalanced by the antiinflammatory omega 3s. That is why we should look out for a skin supplement with omega 3s only and no added omega 6, as supplementing with even more omega 6 isn’t as beneficial as was first thought. It’s also important to look at where those omega 3s are being sourced coming from. Traditionally plant-based omega 3s have been used, such as linseed or flax oil, evening primrose, borage or starflower, for example. Yes, they contain omega 3s, but the body can’t synthesize them as effectively, extending the chains in the liver; it’s not a very efficient process and cats can’t do it at all. They also produce nothing in the way of EPA or DHA. EPA and DHA are the ‘active fatty acids’ within omega 3s. These are the key components for skin within that omega 3 bracket. Saying something has omega 3s in it is like saying it contains vegetables, but what we need to know is how many
NUTRACEUTICALS
carrots and how many peas! Some omega 3s are sourced from sardines which is a much better utilised source within the body (ideally from a sustainable fishery). This oily fish produces elevated levels of EPA and DHA (note EPA and DHA only occur in fish oil sources of omega 3). Oils go through a six stage refinement process to filter out ALL omega 6 and other impurities such as heavy metals. Biotin (a B vitamin sometimes called vitamin H) helps the body to synthesise omega 3s and helps improve coat condition and hair growth, as well as natural vitamin E which is recycled in the tissues much better than the cheaper synthetic ones - it boosts the immune system and helps it fight inflammation. Omega 3s are very susceptible to oxidisation, which is why they should be encapsulated. The capsules themselves are made of fish gelatine usually, so again try and avoid land animal sources as many dermatitis cases can be attributed to allergies to land animal sources. They can be given whole or can be cut open, or pierced, and the jellified liquid squeezed out onto the food. That will then stick to the top of the food and not just sink to the bottom of the bowl leaving an oily mess uneaten. There are many trigger factors for skin conditions, and nutraceuticals will help with your atopy cases, your flea allergy cases, cracking/flaking dry nails (German Shepherds), those dry flaky skin cases and seborrheic cases as well. Most skin nutraceuticals take a good four weeks to see any changes; skin conditions don’t change overnight unfortunately. How can nutraceuticals benefit your practice? Nutraceuticals appear to be of benefit in both the treatment and prevention of disease (Khan et al., 2014). By using nutraceuticals, you may be able to reduce or eliminate the need for conventional medications, reducing the chances of any adverse side effects. Nutraceuticals often possess unique chemical actions that are unavailable in pharmaceuticals. Examples include the ability of silymarin in milk thistle to protect liver cells from
damage, and quercetin (found in a variety of plants) to stabilize certain cells of the immune system (mast cells) to avoid allergic reactions. Look for a company that sells only to veterinary practices; this ensures that the clients receive the best possible products and clients are provided with high quality long-term care, under your veterinary clinic. This then keeps the profits back in the practice. Unfortunately, with today’s online savvy world a lot of products are getting purchased online, usually much cheaper than your practice can supply them for as well. Your clients then continue to come back regularly and build a good rapport with you. You also get a chance to have a four to six monthly check up with a nurse or veterinarian as this gives the client an added level of support. Conclusions There is no doubt that nutraceuticals are changing the face of pet health care. Companies that add nutraceutical-type ingredients such as joint support nutrients, antioxidants or digestive aids must make sure that these ingredients are not inactivated during processing or storage and are present quantitatively in the product at the time of consumption, not just noted qualitatively as ingredients on the label. Furthermore, pet owners and vets who recommend products should research the active ingredients in supplements and foods to ensure their animals receive the same quality they expect for themselves. Although there is increased interest in specific nutrients or nutrient combinations, veterinarians have not routinely embraced supplements for animals. Nevertheless, nutraceuticals, supplements and additives will play an increasingly key role in preventing and managing animal diseases. As this happens, nutraceutical companies must commit to providing solid evidence of safety and efficacy as well as dosages that ensure benefit.
Having nutraceuticals in your veterinary practice can be very rewarding, as the clients will gain trust and a better relationship with you, as you have given them options. You will be more informed now knowing what to look out for in a good nutraceutical product and will retain profits in your practice where they are needed to help you grow. References Inagawa, K., Seki, S., Bannai, M., Takeuchi, Y., Mori, Y., & Takahashi, M. (2005). Alleviative Effects of Y-Aminobutyric ACID (GABA) on behavioural Abnormalities in Ages dogs. Retrieved from: https://www. ncbi.nlm.nih.gov/pubmed/16276066 Khan, R., Elhassan, G., & Qureshi, K. (2014). Nutraceuticals: In the treatment & prevention of diseases – an overview. Retrieved from: https://pdfs.semanticscholar. org/7c10/2dd74abdb56856db47472987191 4582f3d4f.pdf Lakhan, S., & Vieira, K. (2010). Nutritional and herbal supplements for anxiety and anxiety-related disorders: systematic review. Nutrition Journal (9)42. DOI: 10.1186/1475-2891-9-42 Lerman, A., & Lockwood, B. (2007). Nutraceuticals in veterinary medicine. Retrieved from: https:// www.pharmaceutical-journal. com/news-and-analysis/news/ nutraceuticals-in-veterinarymedicine/10003000.article Schneider, L. (2013). Nutraceuticals and their use in veterinary practice. The New Zealand Veterinary Nurse, (19)65, 8-11, Uketake, K., Okumoto, A., Tani, N., Goto, A., & Tanaka, T. (2012) Calming effect of orally administered g-aminobutyric acid in Shih Tzu dogs. Animal Science Journal, 83, 796–798. Correction to Nutraceuticals – the basics part one: Probiotics are microorganisms that are beneficial to the body, and prebiotics are the food the probiotics feed on (usually cellulose, the indigestible part of the plants, and FOS/inulin). September 2018 21
CONFERENCE
‘All Creatures Great and Small’ New Zealand Veterinary Association Conference review By Lauren Prior RVN, NZVNA Executive Committee member
I had the absolute privilege of attending the 2018 New Zealand Veterinary Association (NZVA) Mega-Conference at the Claudelands Event Centre in Hamilton, as an Executive Committee member of the New Zealand Veterinary Nursing Association (NZVNA). This year’s conference was a combined event organised by the NZVA and NZVNA, bringing together eight special interest branches to celebrate unity within our profession. After a chilly early morning start on the 19th June, veterinary nurse delegates piled into the Claudelands Event Centre to receive their conference satchels packed full of information, freebies, and ID lanyards. The veterinary nursing stream began with a lecture from our talented international keynote speaker, Amy Newfield. Amy is a Veterinary Technician Specialist in Emergency and Critical Care and works as a Technician Training Manager in the USA. It was apparent from the get-go that Amy was a highly skilled, engaging and vibrant speaker, and a natural teacher.
Lauren has a Bachelor of Science in Biology from The University of Auckland and a Diploma in Veterinary Nursing from Unitec Institute of Technology. She has worked as a veterinary nurse for five years, first in small animal general practice, then a specialist surgical and imaging referral practice. Lauren is now a lecturer at Unitec Institute of Technology, teaching the next generation of veterinary nurses and is hoping to continue into postgraduate study.
22 September 2018
Amy Newfield’s lecture ‘Caring for the Critical Pet’ was one of my favourite talks of the conference. I truly appreciated the way that Amy highlighted the need for evidence based medicine and practice in our field, suggesting veterinary nurses need to be advocating for our own research instead of relying on that of our human nursing counterparts. Amy’s response to the question we all face, “Why don’t you want to be a veterinarian someday?”, struck a chord with many in the room. She went on to discuss how we want and crave that interaction with the animals, we want to be the ‘doers’ and be the people who make a difference to our patients treatment.
Morning tea time presented delicious snacks from the catering team and opened up the exhibition hall to the delegates. And wow! What a vibrant array of industry representatives and stands available. It was inspiring to walk around in the break times and converse with peers, learn about new products and, of course, one cannot forget the conference goodies! This year, personally I would like to acknowledge the beginning of a plastic and waste conscience that echoed around the exhibition hall. Most companies were doing their best to provide reusable and recyclable gifts and giveaways, which was refreshing to see. Personal favourite stand shout-outs would go to Bayer for their amazing minigolf game and KeepCup prize, and REM Systems for their solid conference giveaway of a Bluetooth Speaker! And also Hill’s for bringing the little cat pens into my life. The NZVNA stand looked brilliant – it was a joy to have veterinary nurses come by over the two days to collect their certificate and let us know how much they were enjoying conference. Our next speaker after morning tea was Dr Angus Fechney, inspiring all of us on the subject of animal dentistry and what lies beneath the plaque! It was great to have a veterinarian, who is so passionate about his subject, lecture to a room full of eager veterinary nurses. He recognised the need for nurses to be advocates when it comes to dental health in our patients and that we are the ones more likely to really get behind dental hygiene, rather than the veterinarians. His take home message was that if a problem in the mouth seems like it would be painful – then it probably is! I also loved his quote, “Call me geeky, but the pellicle is a fascinating surface!” – a great example to me of someone who is passionate and loves what they do.
CONFERENCE
| Above: NZVNA stand
The NZVNA Annual General Meeting was up next, with reports from President Julie Hutt and Vice President Amy Ross. The Treasurer’s report and Financial Statements were read by Julie Hutt on behalf of Treasurer and Membership Secretary Kathy Waugh (absent). Fiona Hastie presented her HR report reminding everyone about the support networks available for NZVNA members. Laura Harvey gave her portfolio reports on Health and Safety, NZCAHF, and gave the good news that we will be extending Vet Nurse Day to Vet Nurse Awareness week. Christina Searle presented her Professional Advancement portfolio and Antoinette Ratcliffe presented the Journal portfolio report. Changes to the NZVNA Executive Committee include Fiona Hastie’s resignation from her position as National Secretary, and Antoinette Ratcliffe’s resignation from the Executive Committee. Luanne Corles was elected in as the new National Secretary, and Antoinette will continue to edit the New Zealand Veterinary Nurse journal. An overview was then given by Jennifer Hamlin on what the Regulation Committee has been achieving. After another wonderful lecture with Amy Newfield on Fluid Therapy, it was then time to learn about Emergency Anaesthesia with the very knowledgeable Marcia Fletcher from Massey University.
This was another personal favourite lecture of mine, and it is clear that Marcia is a very skilled and experienced teacher. A take home message from Marcia would be “fail to prepare, prepare to fail” – which resonates very true when it comes to emergency medicine. As day one lectures came to a close, I was reminded by my body how little I actually sit down in my day to day veterinary nursing job! My legs were restless and I needed a good walk around Claudelands Showgrounds to recover. The NZVNA dinner was held this year at SkyCity Hamilton. It was amazing to see all of the veterinary nurses dressed beautifully, and ready for some good food and dancing. Each of the tables had been dressed by a different sponsor with themed goodies for the people sitting at the table. Royal Canin outdid themselves with a French theme, kitted out with a mini Eiffel Tower, berets and fairy lights. After an absolutely stunning dinner of pasta, beef, salad, chicken and ham on the bone, the dancing began and the DJ played throwback songs that were sure to get people up dancing. I left for bed at 10pm (late for me because I am old before my time), but people were still dancing their hearts out to Abba as I left the venue. Day two’s lectures included fantastic and informative lectures from Amy Newfield on pneumonia, reperfusion injury and the
| Above: Robyn Taylor and Libby Leader at the vet nurse dinner
upper-airway patient, Marcia Fletcher giving us an overview on the CPR Recover Guidelines, and speaker Bridey White, who delved into the subject of the humananimal bond and compassion fatigue. It was refreshing and inspiring to see a full lecture hall, and even quite a few veterinarians stop by for her talks. Both emotional and necessary, this is a subject we as veterinary nurses cannot ignore. We were also excited to present 2017’s Vet Nurse of the Year award winner, Alice Gasnier, with a beautiful bouquet of flowers before the afternoon lectures began. A massive congratulations to Alice on behalf of the NZVNA Executive Committee! Overall I thoroughly enjoyed this year’s conference, and commend the organisers on their spectacular efforts in making this a fun and motivating environment in which to learn. On behalf of the NZVNA executive committee, I would like to thank the wonderful speakers, sponsors and delegates for a fabulous two days of learning – we are proud to be advocating for such a supportive and inspiring profession. September 2018 23
ADVERTORIAL
Pyoderm® S Staphylococcus and Malassezia update By Simon Clark BVSc MVM Virbac Technical Product Manager - Companion Animal & Equine
Many people ask me about the use of Pyoderm® S¹ for Malassezia overgrowth syndrome. It seems a strange choice to use a shampoo without an anti-fungal like miconazole or ketoconazole. But chlorhexidine is an effective antifungal treatment and can be used to manage yeast populations very well. Malassezia overgrowth can be enormously frustrating for pets, pet owners and the veterinary staff trying to help them. It can be secondary to atopic dermatitis, flea allergy dermatitis or other allergic skin diseases, or can be a primary disease in its own right, usually seen in exotic breeds of cats like Devon Rex and Sphynx. There are several studies that compare Pyoderm S with other shampoos for managing Malassezia and other microorganisms that infect the skin and these studies demonstrate that Pyoderm S is just as effective. Pyoderm S also comes with some interesting features and benefits that could make it the best option for your client. Lloyd and Lamport² demonstrated that Pyoderm S is equally as effective as Malaseb®³ at killing Staphylococcus intermedius and Malassezia pachydermatis in vitro. With both of these medicated shampoos there were no Malassezia pachydermatis surviving after eight minutes of contact time, even at a dilution of 1/25.
| Above: Spherulite
24 September 2018
There are several studies that compare Pyoderm S with other shampoos for managing Malassezia and other microorganisms that infect the skin and these studies demonstrate that Pyoderm S is just as effective. Pyoderm S also comes with some interesting features and benefits that could make it the best option for your client. Lloyd and Lamport² demonstrated that Pyoderm S is equally as effective as Malaseb³ at killing Staphylococcus intermedius and Malassezia pachydermatis in vitro. With
both of these medicated shampoos there were no Malassezia pachydermatis surviving after eight minutes of contact time, even at a dilution of 1/25. Lloyd, Lamport, Gatto and Rème4 did a similar study comparing Pyoderm S, Malaseb and Chlorhex 3%5 and found that Pyoderm S and Malaseb were both superior to Chlorhex 3%. This shows that it is not only the ingredients that count, but also the formulation. All of the ingredients work together to help the treatment. And the pH is formulated for cat and dog skin at 7.5, not pH 5.5 which is appropriate for human skin and would be quite harmful to dogs and cats. The other significant active ingredient in Pyoderm S is Chitosanide. Chitosanide is derived from chitin, the protein that provides the strength in crustacean shells. Once processed, Chitosanide exists as a polysaccharide of glucosamine units and has incredible properties. It forms a film over the hair, moisturising the skin and helping skin healing and regeneration6. Chitosanide also has several interesting uses in human medicine including treating skin burns and corneal lesions, surgical suture and for encapsulating slow release medication. Chitosanide is also cationic, which enhances the adhesion and durability of Spherulites. These concentric spheres of phospholipid bilayers, unique to Pyoderm S amongst the chlorhexidine shampoos, allow the slow release of active ingredients in the shampoo, leading to improved efficacy. The studies so far have been in vitro. Jasmin, Schroder, Briggs, Last and Sanquer7 performed an in vivo assessment of Pyoderm S in twenty-eight dogs with Malassezia dermatitis. They found Pyoderm S to be highly effective and well tolerated. The treatment protocol of twice weekly shampooing for three weeks led to not only eliminating
ADVERTORIAL
Malassezia in 93% of the dogs, but also greatly improved pruritis, excoriations, erythaema, exudation and other lesions. A more in-depth study was conducted by Maynard, Rème and Viaud8 where they compared Pyoderm S with an unnamed 2% miconazole and 2% chlorhexidine shampoo in the treatment of Malassezia overgrowth in fifty-four dogs. There was no significant difference between the treatment groups in yeast count reductions and both groups had significant reductions in their lesion scores. The authors concluded that the two shampoos were each as clinically effective as the other. Pyoderm S is also effective in treating Juvenile Impetigo. Rème, Schroeder and Briggs9 demonstrated its use in 15 puppies, twice a week for three weeks, without any other therapy such as systemic or topical antimicrobials. 12 out of 15 dogs were cured and two were markedly improved on this treatment and no adverse effects were reported. Pyoderm S has also been demonstrated to be effective against Methicillin Resistant Staphylococcus pseudintermedius (MRSP) in an in vitro study by Young, Buckley and McEwan10. They found that chlorhexidine was the most effective of the biocides they assessed, and that the MRSP isolate they investigated was just as sensitive to chlorhexidine as was an antibioticsensitive isolate of the same organism. With antibiotic resistance becoming an ever-increasing concern, chlorhexidine shampoos will be a useful tool to augment and supplement antibiotic courses, reduce the frequency and duration of systemic antibiotic treatment, or replace the need for systemic antibiotics in some cases. And, as Pyoderm S does not contain miconazole, it is able to be sold without a prescription label. Pyoderm S is a safe and effective over the counter shampoo for managing the skin of dogs and cats who are prone to overgrowth of Staphylococcus and Malassezia. Even though these infections are usually secondary to some other underlying skin disorder, managing their secondary infections can often lead to
dramatic, if not complete, control of clinical symptoms. ¹ Pyoderm® S is Registered Pursuant to the ACVM Act 1997. ACVM # A9396 ² Lloyd, H., & Lamport, A. I. (1999). Activity of chlorhexidine shampoos in vitro against Staphylococcus intermedius, Pseudomonas aeruginosa and Malassezia pachydermatis. ³ Trade name: Dermcare Malaseb® Medicated Shampoo. Malaseb is a registered trademark of Dermcare-Vet (NZ) Pty Ltd. Registered Pursuant to the ACVM Act 1997. ACVM #A7641. Malaseb is a Restricted Veterinary Medicine and is only available under Veterinary Authorisation. 4 BSAVA Congress 2003 Scientific Proceedings 5 Product of Dechra. Not currently available in New Zealand. 6 OKAMOTO, Y., SHIBAZAKI, K., MINAMI, S., MATSUHASHI, A., TANIOKA, S. I., & SHIGEMASA, Y. (1995). Evaluation of chitin and chitosan on open wound healing in dogs. Journal of Veterinary
Medical Science, 57(5), 851-854. Jasmin, P., Schroeder, H., Briggs, M., Last, R., & Sanquer, A. (2003). Assessment of the efficacy of a 3% chlorhexidine shampoo in the control of elevated cutaneous Malassezia populations and associated clinical signs (Malassezia dermatitis) in dogs. In Proceedings of the 19th Annual Congress of the ESVD ECVD, Tenerife (Vol. 170). 8 Maynard, L., Rème, C. A., & Viaud, S. (2011). Comparison of two shampoos for the treatment of canine Malassezia dermatitis: a randomised controlled trial. Journal of Small Animal Practice, 52(11), 566-572. 9 Reme, C. A., Schroeder, H., & Briggs, M. (2005). Efficacy of a 3% chlorhexidine shampoo for the resolution of canine juvenile impetigo. Vet Dermatol, 16, 358. 10 Young, R., Buckley, L., McEwan, N., & Nuttall, T. (2012). Comparative in vitro efficacy of antimicrobial shampoos: a pilot study. Veterinary dermatology, 23(1), 36-e8. 7
| Above: Spherulites SEM
| Above: Erythaema
September 2018 25
BOOK REVIEW
Atlas Of Clinical Imaging And Anatomy Of The Equine Head Reviewed by Lyn Hobbs CVN, CRAT, NZVNA Executive Committee member
Written by Larry Kimberlin, Alex zur Linden and Lynn Ruoff Published: 2017 Publisher: John Wiley & Sons. Inc 154 pages (hardcover) $82.31 (Amazon, June 2018) This book is an in depth look into imaging of the horse head. In the mere six pages of written content, the authors discuss what computed tomography (CT) and magnetic resonance imaging (MRI) are and how they work. The also discuss why a CT scan may be performed over an MRI, however radiographic imaging is not discussed in this edition. Three chapters cover the different aspects of imaging, with the first one covering the transverse sections of the head, working from the lips right back to the poll. This chapter comprises 37 images in total with dissection photos, and are numbered and labelled with the corresponding anatomy. The next chapter covers the sagittal
planes, working from left to right across the head. There are 13 images in this chapter, again numbered and labelled. The last chapter covers the dorsal sections of the head, working from the front/ top of the head to the bottom. There are 13 images in this chapter all numbered and labelled. The included glossary is very handy to refer to in regards to the directional, anatomical and imaging terms used. The images are of high quality making it easy to identify all the anatomical points referred to. I found this textbook interesting and it gave me a better understanding of the anatomy of the horseâ&#x20AC;&#x2122;s head. Not much reading per se but there is plenty of information on the images and this is a must in an equine clinicâ&#x20AC;&#x2122;s library. I would recommend this book to veterinary nurses who work in equine practice or have an interest in diagnostic imaging of horses and want to learn more about their anatomy.
Increase your word power All definitions are from the Dictionary of Veterinary Nursing (2nd edition), D.R. Lane and S. Guthrie
Agglutination
Grouping together or clumping of cells, widely used in antibody-antigen measurements and blood typing
Haemoglobinuria Colouration of the urine caused by the presence of haemoglobin; indicates severe blood haemolysis Hypocalcaemia Low level of blood calcium, most likely to occur in the nursing animal Hyperglycaemia Raised blood sugar level, one possible sign of diabetes Hypokalaemia Abnormally low levels of potassium in the blood, often associated with renal disease and polyuria Hypomagnesaemia Low magnesium levels in the blood, causes muscle twitching and tetany Rhabdomyolysis Condition found in racing greyhounds and other dogs with vigorous activity. The signs after exercise are of painful back muscles and dark yellow to brown urine 26 September 2018
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