VOL UME 37 I S S UE 2
CANADIAN VETERINARY TECHNICIANS
A NATIONAL JOURNAL PUBLISHED BY THE ONTARIO ASSOCIATION OF VETERINARY TECHNICIANS
D E D I C AT E D TO PROFESSIONALISM
CONTINUING EDUCATION • What the Heck is a COHAT • Nursing Care for the Septic Patient • The “How To” on End Tidal CO2
PUBLICATION MAIL AGREEMENT NUMBER 40034241 • PUBLISHED Plus: BY THE OAVT • Return Canadian undeliverable address to: TECHNEWS | VOLUME 37 ISSUE 2 OAVT, 100 Stone Rd W., Suite 104 Guelph, ON N1G 5L3
Three Steps to Finding your Veterinary Technician Specialty; Vet Team in Nunavut; 1 Anesthesia for the cat with a Heart Murmur; Volunteer Abroad with Animal Experience International, Furosemide; The Trouble with Gloves, and more...
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TECHNEWS | VOLUME 37 ISSUE 2
2013 Platinum Sponsors Making continuing education better & more accessible across Canada Bayer HealthCare Animal Health Division
Three Steps to Finding your Veterinary Technician Specialty ............................................................6 Vet Team in Nunavut........................................................................................................................8 Anesthesia Column: Anesthesia for the Cat with a Heart Murmur..................................................10
Hill’s Pet Nutrition Canada, Inc. Royal Canin Medi Cal
Tech Tips and Tidbits......................................................................................................................11 Pharmacology Column: Furosemide................................................................................................12
CE Article #1: What the Heck is a COHAT?.........................................................................14 Zoetis These companies are generously supporting a series of outstanding learning opportunities for registered veterinary technicians through OAVT.
Safety Column: The Trouble with Gloves........................................................................................17 Apps, Blogs & Websites to Watch.............................................................................................. 18 CE Article #2: Nursing Care for the Septic Patient...................................................................20 RVTs On-Site: Sharing Our Strengths.............................................................................................24 Submitting Articles to TECHNEWS..............................................................................................25
Behaviour Column: Nutraceuticals & Veterinary Care - Show me the evidence....................... 26 The 36th Annual OAVT Conference
CE Article #3: The “How To” on End Tidal CO2.................................................................. 28
& Trade Show has been confirmed
TECHNEWS Winter 2014 CE Quizzes.................................................................................31
for February 27-March 1, 2014 at the
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Volunteer Abroad with Animal Experience International.................................................................35 Poisoning Column: Canine Toxins Lurking in the Equine Tack Trunk............................................36
TECHNEWS The quarterly national publication with three CE articles in each issue delivered directly to
Global News...................................................................................................................................38 Puzzle..............................................................................................................................................38 Did You Know?...............................................................................................................................39
your door! Making information, education, industry news and career opportunities available to technicians - everyday and everywhere! www.oavt.org
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TECHNEWS Information > Next Issue: Spring 2014 Deadline for Material: February 1, 2014 Distribution Date: March 15, 2014 TECHNEWS is a quarterly publication published by the OAVT. • Technical Editor - Shirley Inglis, AHT, RVT (Shirley@oavt.org)
The opinions expressed in this publication do not necessarily reflect the opinion of the Board of Directors nor the members of the Association.
TECHNEWS TECHNEWS | VOLUME | VOLUME 37 ISSUE 37 ISSUE 2 2
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TECHNEWS | VOLUME 37 ISSUE 2
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It’s time to rethink your approach. www.pgpetwellness.com • 1.800.535.VETS (8387)
Jessica McKellar, RVT
Darci Burtch, RVT
Jessica McKellar, RVT
Andrea McNeely, RVT
Jamie Bond, RVT
Sarah Junea, RVT
Jessica McKellar, RVT
JoAnne Kennedy, RVT
Samantha Ferguson, RVT
Jamie Bond, RVT
Crystal Brear, RVT
Samantha Ferguson, RVT
Jamie Bond, RVT
Diane McGill, RVT
Crystal Brear, RVT
Andrea Howland, RVT
Adrienne Nieman, RVT
Melanie Holding, RVT
Diane McGill, RVT
Darci Burtch, RVT
Angela Rideout, RVT
Samantha Ferguson, RVT
Darci Burtch, RVT
Angela Misasi, RVT
RVTs showed their pride and submitted photos of the RVT Crest on display. Here are just some of the entries that were entered into a draw for free lunch for their establishment. One RVT from each winning establishment won full registration to the 2014 OAVT Conference and Trade Show and one complimentary awards banquet guest ticket.
Three Steps to Finding your Veterinary Technician Specialty Rebecca Rose, CVT, Catalyst Veterinary Practice Consultants, LLC email@example.com, www.catalystvetpc.com You take your career seriously. You offer valuable services to your patients and their dedicated owners. How can you offer advanced care AND improve your career? The answer is simple; become a Veterinary Technician Specialist (VTS). For those who have already earned a VTS, they have achieved a great goal and deserve a round of applause! You too can create a plan, establish deadlines, set goals and test your knowledge to become a VTS. There are currently eleven Academies recognized by the National Association of Veterinary Technicians in America (NAVTA, www.navta.net) with more petitions on the way. The following is the current list: • Academy of Veterinary Emergency and Critical Care Technicians (AVECCT) • Academy of Veterinary Technician Anesthetists (AVTA) • Academy of Veterinary Dental Technicians (AVDT) • Academy of Internal Medicine for Veterinary Technicians (AIMVT) • Academy of Veterinary Behaviour Technicians (AVBT) • Academy of Equine Veterinary Nursing Technicians (AEVNT) • Academy of Veterinary Zoological Medicine Technicians (AVZMT) • Academy of Veterinary Surgical Technicians (AVST) • Academy of Veterinary Technicians in Clinical Practice (AVTCP) • Academy of Veterinary Nutrition Technicians (AVNT) • Academy of Veterinary Clinical Pathology Technicians (AVCPT)
STEP 1: Identify which academy appeals to you. Where to begin? How do you take the initial steps? Identify what you are passionate about! Do you currently enjoy anesthesia monitoring? Are you already consulting with clients about the adoption of a new dog or cat? How often are you involved in dental procedures and assuring proper care and follow up? Does your heart race when you hear a critical case is arriving in 10 minutes? How often are you educating clients on pet nutrition and feeding? Do you work in an equine veterinary hospital and ready to research VTS?
STEP 2: Review the academy’s website to determine their application requirements. How many case studies are required? Is there a mentor to assist you through the process? How will you be supported by the Academy and current members to assure success? What is the application fee and the cost to sit for the test? You work in a general practice and wonder how you will fulfill the requirements if you are not meeting the caseload requirements? How long will it take to complete the requirements? Is there a nearby VTS or Veterinary Diplomate available for questions or shadowing?
STEP 3: Know what research and reading materials are needed. Objectively create an outline that takes you through the process, from the beginning to the end. • Starting date • Mentors • Application requirements and fees • Case Histories • Defined requirements specific to that specialty (i.e., x-rays, written materials, presentations) • Continuing education • Reading materials • Travel time • Certification date and fees • Celebration of success • Offering of new service, VTS • How to implement your goal in your veterinary hospital • Completion date Keep in mind, this is a general outline. Your outline may be far more indepth and detailed. Create whatever you need to make this a successful journey. Consider interviewing a VTS in your chosen area of expertise. Find out their obstacles, challenges and rewards. Once you have researched your VTS options, will you be able to commit to the two year (or longer) process? Will you be supported in the certification? (This may include taking extra time off and absorbing financial considerations from your current management and team.) If you are prepared to make the commitment, then take your idea to your supervisor, manager or
Ms. Rose currently owns her own business, Catalyst Veterinary Practice Consultants, LLC. She graduated from Colorado Mountain College in 1987 with an AAS in veterinary technology and became credentialed as a certified veterinary technician in the same year. AAHA Press recently updated her book, Career Choices for VeterinaryTechnicians; Opportunities for Animal Lovers.This one project opened up many opportunities. Over the years Rebecca has been honoured with many veterinary industry and academic awards. Rebecca’s diverse career includes working as a veterinary technician in a mixed animal practice, offering relief services throughout Colorado, being the first paid administrator to the Colorado Association of Certified Veterinary Technicians, managing two AAHA veterinary practices, and working with various industry leaders in an array of areas. She invites you to join her on her Facebook business page, Catalyst Veterinary Practice Consultants, LLC. You will see Rebecca finds great joy helping teams succeed.
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veterinarian. Set up a time to discuss all the pros and cons, to include the benefit to the patient, owner, veterinary hospital and for your professional development. Be prepared to review your realistic outline to include SMART goals (Specific, Measurable, Realistic, and Timely). Anticipate their questions, concerns and seek their support. Consider using the included Career Road Map. (See right.) Your presentation to management is crucial. Explain your desire to take your career to the next level by increasing your knowledge, skills, and professionalism. Show how the shared support will increase job satisfaction, increase revenue within the hospital, and improve care to the patients your veterinary hospital serves. You have the passion, you have the tools to succeed, now create your career as a VTS. “Do not let anything get in your way. If you have the motivation and interest, start your journey! If there is something you are passionate about and there is not a VTS in that area – start one! We currently have eleven NAVTA recognized specialties. Chances are, if you are passionate about something, you will have colleagues that have similar interests. Contact NAVTA and let them know. NAVTA can put all interested parties in touch with each other and a new specialty just might be born,” encourages Kara Burns, MS, MEd, LVT, Past Chair of the Committee on Veterinary Technician Specialties and current NAVTA Interim Communications Director.
What is the benefit? In my research over the years, it has been difficult to pinpoint the financial advantages for a veterinary technician becoming a VTS. In the past, the benefits came from speaking engagements, writing peer reviewed articles and passive income opportunities. In a recent survey generated by the Veterinary Hospital Managers Association (VHMA), we are able to glean a new perspective. In their 2009 Compensation and Benefits Report they show veterinary technicians who are VTSs making an average of $3.30 more an hour than other credentialed veterinary technicians. That equates to approximately $6,600 more a year. This may also be part of your conversation with your management team. Conveying to management how having a VTS on the team is best for the patients and their owners, the veterinary team and for you, personally. If you have any questions about growing your career, in any capacity, feel free to contact me. I look forward to helping you succeed. Wishing you great success!
For more information visit: Career Opportunities for RVTs: www.oavt.org/about/about-careers.php Salaries for veterinary technicians: www.healthcaresalarycanada.com/ veterinary_tech_salary.html
CATALYST Career Road Map: Professional Development Name:
Vision of the Future What it is I want to be doing in my career? How long will it take me to get there? Obstacles I need to overcome? Those supporting me in my professional development/mentors? 1.
Benefit to the pet: Benefit to the owner: Benefit to the veterinary practice: Benefit to me, once I achieve my professional goal:
SMART Goal Specific (give it a title)
Measured (what does the outcome look like) Attainable (brainstorm all aspects to completion, equipment needed, financial cost) Realistic (skills needed to achieve goal, classes required) Timely (beginning, middle and end time line) Date started:
Middle Review (1)
Middle Review (2)
CELEBRATE Achievement (e.g., throw a party)
TECHNEWS Travels Stacey Huneke, RVT, recently sent in a great suggestion for a new column for TECHNEWS, i.e. a place for our members to send photos of them enjoying TECHNEWS while traveling the globe. Brilliant! Stacey has started the ball rolling with the pictures of her summer trip to Iceland. We’re really looking forward to seeing what everyone can come up with on their travels! So, please forward photos of you and your TECHNEWS to firstname.lastname@example.org, and we’ll be happy to include as many as we can. Enjoy!
NAVTA’s Specialties: www.navta.net/specialties/specialties
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Vet Team in Nunavut By Christine Robinson, RVT Executive Director,The Canadian Animal AssistanceTeam
and dewormed has made them healthier and they were able to keep weight on them through the harsh winters. Deworming alone can make the difference between getting through the winter or not. Some of our team members have been going on the annual projects in Baker Lake throughout the five years. They also observed that the dogs were generally healthier and in much better body condition than before the program started. A truly unanticipated response came from one of the sled dog team owners. He expressed his change of attitude freely with the team. The first two years that we were in the hamlet, he felt that sterilization of his sled dogs was going to make them less driven, lazy, less effective sled dogs. Through discussions with our veterinarians and technicians over the years, he decided in the third year to start to sterilize and by this year, all but two of his team are sterilized. He is selectively breeding his dogs. His observations were that the sterilized dogs were more focused on their jobs, less likely to fight, and much more effective workers. He admitted that this was a surprise to him and he was very glad that he made the decision to have the surgeries performed. As our team of veterinarians and veterinary technicians bumped and jostled across the tundra on borrowed ATV’s, it was clear to us that this was not an average day. It was cold, windy and snowy, but back home (in Ontario and BC) we knew that we were missing an incredible September “heat wave.” Every one of us had a huge smile on our faces. You could see wide open tundra for miles in every direction as we stopped for lunch, built a small fire for warmth and watched a herd of muskox meander by. We knew we were experiencing something special and rare. In 2008, organizers of a local animal welfare group, the “Buddy Fund,” headed by Susan MacIsaac, asked for assistance with overpopulation and animal health issues in their community. Baker Lake is an Inuit hamlet located inland from the coast of Hudson Bay in the territory of Nunavut. In September 2009, CAAT began a pilot project in Baker Lake, committing to five years of animal health care work by holding an annual animal health care clinic. Our CAAT team completed our final annual visit to Baker Lake in September 2013. The team focused strongly on vaccinations, deworming and education during this visit. We were able to provide services for all the sled dog teams as well as go door to door and cover the entire hamlet while there. Owners also brought in their dogs and cats for sterilization surgeries as needed. Door to door work was invaluable not only in providing services but also in receiving direct feedback from the community members. Many dog owners commented that having their dogs vaccinated
Each year, CAAT’s Dog Bite Prevention Program for the children in the community has been an important part of the project. For 2013, we took a full time educator who worked with smaller groups in the elementary and high school in every single classroom. In the older grade levels, the children were telling our educator how to be safe! They remembered what they had been taught in past years and were eager to share the knowledge. This was very encouraging and afforded us the opportunity to spend time talking about how dogs feel, what their basic needs are and to give the children confidence to be teachers of others. The objectives of the five-year project were: 1. To successfully introduce veterinary services to a place that previously had none and thus improve the general health and welfare of the animals in the community - Community members went from wondering why the vets were there to eagerly awaiting their return each year. - The general body condition of most of the dogs in the community has improved. - There are fewer dogs that are kept outside than previously. Many community members have started to experiment with having some dogs inside the home. 2. To reduce the overpopulation of the dogs and cats to a level that would be sustainable with occasional visits from a small veterinary team
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- Statistics show that we have reached that level. A large veterinary team is no longer needed annually. The statistics from 2009 to 2013 show a trend of decreasing demand for sterilization surgeries, and an initial rise then steady demand for vaccinations. 3. To raise awareness of basic animal needs with community members Our CAAT team members connected with owners through door to door vaccination programs, dog sled teams, and our sterilization program. The feedback was consistent: - The majority of owners understand the importance and the difference that routine vaccinations have made for the health of their dogs - Owners who have had their dogs sterilized see the difference sterilization has made to their dogs’ health - Community members, both those that own dogs and those that don’t, have seen a dramatic reduction in puppies being born and the number of dogs in the community - Many more dogs are allowed indoors than previously. Baker Lake will continue to need veterinary services annually, however, the need for a large team of veterinarians and technicians to travel to the community no longer exists. The community plans to have one veterinarian come once a year to do the smaller amount of surgery work needed and to hold a vaccination clinic in the community. CAAT has provided the humane education initiative program material and activities to the local library and schools so the information will continue to be shared as in the past five years. Working in the community of Baker Lake has been a true commitment for CAAT and many team members. Several of our
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team members returned more than once to assist on these projects. The provision of annual clinics had its share of challenges as well as truly wonderful accomplishments. Each team member that has been a part of this journey:
“Our CAAT team members connected with owners through door to door vaccination programs, dog sled teams, and our sterilization program.” - Showed dedication and a tremendous work ethic to accomplish what is needed, without complaint - Showed a strong sense of teamwork and created, in each project’s first day, a cohesive, effective, efficient team - Showed commitment to help the animals and the people who care for them, adapting their perspectives to the realities of the community itself and educating owners in the care of their animals In the communities we serve, there will always be some community members you just don’t reach (not unlike regular practice!). However, in every community, we are able to improve the lives of many dogs and cats in need and reduce the population growth rate. Just as importantly, our team shared animal health care knowledge with a great number of owners and children -- and that plants the seed of change.
For the Cat with a Heart Murmur By Nancy Brock, DVM, Dip ACVA In a previous article, we looked at safe anesthesia delivery to dogs with heart murmurs caused by mitral valve dysfunction. We’re going to continue in the theme of heart disease and focus on feline patients with heart murmurs. Cats, like dogs, can have heart murmurs caused by mitral valve dysfunction and essentially their anesthesia management should be the same as for dogs. But as we all know, a cat is not a dog. So, unfortunately navigating the feline heart murmur “waters” is a bit more treacherous than for our canine patients. The problems in this regard are that: 1. Cats can hide the severity of their condition by virtue of the fact that they sleep 20 hours a day. So, inquiring about exercise tolerance in a cat is somewhat un-enlightening. 2. Cats on the verge of heart failure do not develop a cough. We cannot use inquiries about the presence or absence of a cough to help us determine the severity of the heart compromise. 3. There is a disturbingly high incidence of occult heart disease in the overtly healthy cat population. Below is an excerpt from a 2009 study into the incidence of hypertrophic cardiomyopathy in domestic cats reported as follows: Of 103 apparently healthy cats screened for heart disease with the use of ultrasound: “Heart murmurs were detected in 16 cats; of these, 5 had cardiomyopathy. Cardiomyopathy was also identified in 16 cats [without detectable heart murmurs]; 15 had hypertrophic cardiomyopathy (HCM), and 1 had arrhythmogenic right ventricular cardiomyopathy...”
CONCLUSIONS AND CLINICAL RELEVANCE: Cardiomyopathy was common in the healthy cats evaluated in this study. In apparently healthy cats, detection of a heart murmur is not a reliable indicator of cardiomyopathy.” Paige CF, Abbott JA, Elvinger F, Pyle RL.J Am Vet Med Assoc. 2009 Jun 1;234(11):1398-403. So, what should you do? Here are a few suggestions about screening cats with heart murmurs before they undergo anesthesia: 1. Ideally, owners of cats with newly diagnosed heart murmurs should be offered the opportunity and encouraged to pursue ultrasound evaluation even if only once, to determine whether there is a condition that is likely to progress to something serious. 2. If the owners decline the offer, or if ultrasound evaluation is not available in your community, take lateral and ventral dorsal view chest X-rays to evaluate cardiac silhouette shape and the state of
the pulmonary veins. Note that a cat with clinically significant heart disease can have a normal chest appearance on X-ray. But X-ray screening is inexpensive and readily accessible. It will assist you in identifying patients with obvious problems and change the nature of any discussion you might have about anesthesia risk: If the cardiac silhouette or pulmonary vein size are abnormal, then in the absence of a diagnosis, assume the patient has serious heart disease and “err on the side of safety”. 3. Use chest X-rays as a monitoring tool for cats with undiagnosed heart murmurs to track for changes in their condition over time while recognizing the diagnostic limitations of chest X-rays in cats - a cat can have serious heart disease and a normal cardiac silhouette. Evaluation of the change in size and prominence of pulmonary veins can be helpful in tracking changes over the long term. 4. Have the owners of cats with heart murmurs track and record resting respiratory rates (RR) for their cats at home when they are sitting quietly or sleeping. A RR that is rising or a RR above 20/minute suggests that the risk of pulmonary congestion is higher. This does not give you a diagnosis as to the nature of the underlying problem but it warns you that your patient may have reduced cardiac reserve. And as with chest X-rays, this information allows you to have a frank and meaningful discussion with a cat’s owner about anesthesia risk. 5. If the patient is a senior when the murmur is first detected, the likelihood is that the disease is not HCM and is more likely secondary to hyperthyroidism or hypertension both of which can be screened for. 6. If a murmur is detected in a juvenile cat, assume that a congenital defect is present. Unfortunately, without an ultrasound evaluation, the details about the nature of the heart anomaly cannot be known and thus the anesthesia risk evaluation is not possible. 7. Certain breeds are more likely than others to develop HCM and this fact too should be considered. Maine Coon, British and American Shorthair and Persian breeds have a higher incidence of HCM than other breeds. What about the scary incidence of undetectable HCM in the apparently healthy cat population? My stance on this this is a bit controversial since there are no published studies to back up my recommendations. But I believe that one of the most powerful ways we can make our anesthesia protocols safer for this cat population is to reduce our reliance on ketamine as a primary anesthetic induction agent. I am not advocating eliminating the use of ketamine completely. Ketamine is a valuable tool. Rather, I am suggesting a reduction in the total dose of ketamine that a cat receives. This entails doing away with ketamine and diazepam anesthetic inductions as well as cocktails such as “Kitty Magic” which are combinations of ketamine, opioids and alpha 2 agents administered intramuscularly at relatively high doses. I have altered my approach to feline anesthesia to incorporate these changes and have not found it difficult to do
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so. There are plenty of alternatives. And, NO I am not advocating resorting to mask inductions as this approach brings along its own set of headaches. Here are a few suggestions for how to reduce the amount of ketamine you administer to cats: Premedicate all feline patients. Premedicate fractious cats at home with oral phenobarbital 10 mg/ kg about 2 hours before they travel to your hospital. If you need to administer ketamine for intramuscular chemical restraint, do so at the lowest possible dose by combining it with alfaxalone, midazolam and an opioid. Often a dose as low as 10 mg ketamine per cat is sufficient to obtain the chemical restraint you need. Switch to intravenous (IV) propofol or IV Alfaxan-based induction protocols. A few words on troubleshooting during anesthesia for the cat with an undiagnosed heart murmur.: Be conservative with your fluid therapy, administering 3 mL/kg/ hour IV as anesthesia maintenance fluids and limiting your IV fluid boluses to a maximum of 2 bolus doses of 5 mL/kg to address hypotension. If the hypotension does not resolve, then consider a more balanced anesthesia approach that reduces your dependence of inhalant agents. This can take many forms: You can administer a dose of IV buprenorphine or you can initiate a constant rate infusion of fentanyl. Use as much regional anesthesia as possible. Every surgical procedure presents an opportunity for local anesthesia infiltration or specific nerve blocks for enhanced analgesia. Inhalants are NOT good analgesic agents. Lastly, you may have noticed that I am not providing specific anesthesia drug protocols for cats with heart murmurs. It is not possible to do so. The specifics of a case are so important when selecting anesthesia drugs for cats with heart murmurs that a generic protocol would not go very far in making anesthesia safer for the cat with heart disease. If you screen your patient as well as you can based on the guidelines I have provided, if you minimize the stress of handling and if you are judicious in your use of ketamine, you will go a long way in improving anesthesia safety for the cat with a heart murmur as well as the cat with heart disease but no heart murmur.
Dr. Nancy Brock obtained her DVM degree from the University of Guelph in 1982. She practiced at Picton Animal Hospital until 1984 and the London (Ontario) Emergency Clinic until 1985. She completed a residency in anesthesia and critical care at the University of California, Davis in 1988. In 1995, she became certified as a veterinary anesthesia specialist and is a Diplomate of the American College of Veterinary Anesthesiologists. Based in Vancouver, BC, Dr. Brock is a regular contributor and consultant for the VIN (Veterinary Anesthesia Network) and is also a clinical instructor at Douglas College’s AHT program in Coquitlam, BC. As part of her anesthesia referral practice, Dr Brock provides veterinarians and their nursing staff with anesthesia assistance and expertise via telephone consultation, the in-clinic delivery of anesthesia to high risk or fragile patients and the training of veterinarians and technicians in advanced anesthesia techniques.
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HERE ARE A FEW POINTERS TO USE WHEN DISCUSSING WITH CLIENTS WHETHER OR NOT TO BREED THEIR DOGS:
For People Who Want to Breed Dogs Factors to Consider: • Will your dog contribute excellent health, temperament, working ability or conformity to the breed standard? • Do you understand that spaying and neutering will prevent some health problems that you risk by keeping your dog intact? • Are you aware of any and all health and temperament problems in your dog’s pedigree, looking at both depth and breadth of pedigree? • Are you willing to search for the best dog to breed your dog to, even if you have to travel out of province? • Do you have carefully screened buyers and deposits for all the puppies you may produce? • Do you have money set aside in case the dam or puppies need emergency care? • Can you or another responsible adult be present 24 hours a day for the first 3 weeks in case hand feeding is needed? • Have you read about what to prepare and expect for canine pregnancy, whelping and puppy rearing? (resource: Canine Reproduction: A Breeder’s Guide 3rd Edition, Phyllis Holst) • Are you willing to keep and properly socialize all the puppies until good homes are found? • Are you willing to take back any or all puppies any time in their lives if they may no longer be wanted? • Are you willing to serve as a lifetime resource for the buyers of your puppies? Pre-Breeding Procedures: • Annual CERF eye certification. • Wait until 2 years of age before breeding, then have OFA hip and elbow certification performed. • Have all breed-specific health clearances performed check with veterinarian and national breed club (may include heart, thyroid, genetic testing, many others). • Have Brucella canis test performed 1 month in advance. • Have a complete physical examination performed on your dog prior to breeding. - This should include a digital vaginal exam to check for vaginal band/stricture. by Joni L. Freshman DVM, MS, DACVIM (Veterinary Partner Client Information Sheets)
P H A R M AC O L O G Y C O L U M N
by Dr. Wendy Brooks, DVM, DipABVP (Educational Director, Veterinary Partner.com)
Available in 8 or 10 mg/ml oral solution; 12.5 mg, 20 mg, 40 mg, 50 mg & 80 mg tablets; and injectable Background The kidney is one of the most complicated organs of the body. It is responsible for maintaining electrolyte balance, blood pressure, and fluid/hydration status through its elaborate filtration and excretion systems. It is not our intention to review a system as complex as this here; with regard to furosemide, what is important to know is that it acts on the kidney to increase the body’s loss of water and assorted minerals and electrolytes (salt, potassium, calcium, magnesium, bicarbonate, hydrogen, and ammonium).
How This Medication is Used Because furosemide leads to water loss via increased urine production it is classified as a diuretic. This makes it a useful medication in conditions where the removal of excessive fluids would be beneficial. Such conditions include: Congestive Heart Failure By definition, congestive heart failure involves fluid congestion or accumulation somewhere where there should not be excess fluids. This accumulation is usually in the belly or chest cavity or actually within the lung tissue (pulmonary edema). Furosemide causes an increase in urine production, thus shifting the equilibrium away from the accumulation of fluid in tissue. Injectable furosemide is needed during acute heart failure crisis but oral is generally adequate for continued management after stabilization. Edema Furosemide can also be used to remove fluid from body cavities or peripheral tissues even when the cause is not heart failure. Swellings due to fluid accumulation can be reduced through using this medication. False Pregnancy False pregnancy can be quite a nuisance for a female dog. The excess mammary tissue can be reduced in some cases with furosemide. Usually in this condition, simply waiting for the hormones to normalize is adequate but furosemide administration would represent a conservative treatment course. Chronic Bronchitis Furosemide can act as a respiratory airway dilator. Dilation is not only beneficial for patients coughing from congestive heart failure/ pulmonary edema but also for patients coughing for other reasons. Dogs with chronic bronchitis can get relief from furosemide via airway dilation, which is completely independent of furosemide’s diuretic effect. 12
Another important reason to stimulate urine production could be acute kidney failure where the kidney is trying to shut down urine production permanently and fatally. Obviously this is a dire emergency and frequently a combination of diuretics is needed for treatment. Furosemide can be used to reduce excessive blood calcium levels that are inherently dangerous to the kidneys. Calcium is one of the minerals furosemide encourages the body to lose. Often prednisone is used with furosemide for this use as it too encourages calcium excretion. Furosemide can also be helpful in reducing dangerously high potassium blood levels and it has been used in horses to treat exercise induced pulmonary hemorrhage (nose bleeds). Side Effects Inherent to all diuretics, including furosemide, are the following side effects: - Increased thirst - Increased urination Furosemide is associated with an increase in blood sugar levels. This is not a problem for most patients but a different diuretic may be a better choice for a diabetic patient. Hearing loss has been reported, especially in cats, when large amounts of injectable furosemide have been used in a crisis. Urination is usually seen within 30 minutes of the administration of an oral dose of furosemide. The drug peaks in strength after 1 to 2 hours after it is given orally. Interactions with other Drugs One of the most common drug interactions to be aware of is the interaction between furosemide and vasodilating heart medications (especially the angiotensin converting enzyme inhibitors such as enalapril, benazepril, and lisinopril). Furosemide will decrease circulating blood volume as it causes depletion in body water. This means that the kidney (and most other organs) will have a reduced blood flow to them. The patient’s kidney and electrolyte balance must stabilize before a vasodilator is added in. If the vasodilator is added too soon, it too will reduce blood flow to the kidney and the kidney will fail, possibly permanently. These two types of medications are frequently used together in heart failure patients. To avoid problems, the patient should be assessed biochemically with a blood test prior to the addition of the vasodilator. If all is normal, the vasodilator may be started and renal blood parameters should be rechecked 3 to 5 days later. If they are still normal, then the above kidney issues should not be a problem; however, should another heart failure crisis arise and large doses of injectable furosemide be required to resolve it, kidney values should again be checked 3 to 5 days later. The airway dilator theophylline may be able to reach higher blood levels when used in conjunction with furosemide. This means that the theophylline dose may need to be reduced. Furosemide is often used concurrently with digitalis derivatives. If
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furosemide leads to a significant drop in blood potassium levels, this can increase the risk of heart rhythms disturbances and other signs of digitalis toxicity. Furosemide is often used in combination with prednisone to reduce serum calcium levels. It is possible for this combination of medication to lead to a reduction in potassium level significant enough to require potassium supplementation. Aminoglycoside antibiotics (amikacin, gentamicin, etc.) have properties that make them toxic to the ear and kidney. These properties increase with accompanying use of furosemide. Concerns and Cautions Obviously it is best not to use this medication in a dehydrated patient if water is being restricted. Weakness or lethargy could be an indicator that blood potassium has dropped too low. Be sure to inform your veterinarian if your pet seems listless. Because of the increased calcium excretion brought on by furosemide (i.e., an increase in urinary calcium levels), there could be a problem using this medication in patients with a history of calcium oxalate bladder stone formation. It is extremely difficult to overdose with this medication. Toxic doses reported are over 100 times a typical oral dose of medication. It is important to realize that in the treatment of heart failure, which is this drug’s primary use, a crisis can arise at any time. Often giving an extra dose of oral medication can be a life-saving procedure. Be sure you understand what signs you are to watch for to determine if an extra dose or two should be administered and when you should definitely rush to the vet’s office. The loss of water-soluble vitamins or urine can be a problem for patients receiving diuretics. Prescription diets for heart and kidney disease are vitamin-fortified with these extra losses in mind. Patients that refuse to eat such prescription diets should probably receive a vitamin supplement.
© 2014 Dr Wendy Brooks, DVM, DipABVP and VIN, All rights reserved. Editor’s Note: Reprinted courtesy of Veterinary Information Network (VIN). VIN (www.vin.com) is the largest online veterinary community, information source and CE provider. The VIN community is the online home for over 30,000 colleagues worldwide. VIN supports the Veterinary Support Personnel Network (VSPN. org); a FREE online community, information source for veterinary support staff. VSPN offers a wide range of interactive practical CE courses for veterinary support staff -- for a small fee. Visit www. vspn.org for more information
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CE Article #1 What the Heck is a COHAT? Fraser Hale, D.V.M., FAVD, DAVDC
COHAT stands for Comprehensive Oral Health Assessment and Treatment. This is a term that was born on the dental discussion board of www.vin.com (Veterinary Information Network) through a discussion regarding ‘What the heck to call what we do?’ The discussion arose out of frustration with the common habit of using terms such as “a dental” or “routine prophy.” We were looking for a term that more accurately conveys the truth of the matter in a way that clients could understand and would also be simple to write in the appointment book/medical record. What is wrong with using the term “a dental?” Plenty. For one thing, the word dental is an adjective as in dental disease, dental pain, dental school, dental instrument. It is not a noun. You cannot do “a dental” any more than you can do “a surgical.” Even if we use dental as an adjective and said the patient was being admitted for a dental procedure, this title is still too vague. It would be like scheduling a patient for a surgical procedure (is it a spay, a limb amputation, a bowel resection…?). In order to proceed with any treatment, we need informed owner consent. To acquire informed consent from the owner, the owner needs to be informed. The term ‘a dental’ under-informs and suggests that all dental patients have the same issues and require the same care. This simply is not true.
When discussing any dental issue or procedure, it would likely be best to avoid the use of the term routine. A castration can be routine, a cutaneous lumpectomy can be routine, even a cystotomy can be routine, because there few variables and most cases are very similar in presentation, technique and outcome. In dentistry however, there are a huge number of variables, a vast number of combinations and permutations of findings and so every case is unique. A simple case that requires just a straightforward oral hygiene procedure is such a rare occurrence (when you know what to look for and take the time to look) that they are far from the routine and are the exception. By suggesting to the client or to yourself that the patient just needs a routine dental procedure you are setting yourself up for trouble.
Using the term routine tells you and your staff that you do not expect to find anything interesting and so you are less likely to go looking for problems. Since most dental disease is well hidden, if you do not go looking, you will not find it and if you do not find it, you cannot treat it. Using the term routine with the client tells them that they should expect no surprises either. There is only one way to go from here. By suggesting the (very rare) best case scenario, in most cases you will have to contact the owner intra-op to give them unexpected and bad news that things are far worse than they were prepared for. This makes effective communication and informed consent much more difficult. Owners may feel you have pulled a “bait-and-switch” on them and that is no way to build trust. The term prophy is short for prophylaxis
Dr. Fraser Hale graduated from OntarioVeterinary College in 1984 and took an associate position at an American Animal Hospital Association practice in Toronto, ON. During five years there, he developed a special interest in dentistry. Later after moving to Fergus, ON he began the Companion Animal Dental Certificate Series and left general practice to begin a mobile veterinary dental referral service. In 1997, he became a Diplomate of the American Veterinary Dental College (the first in Ontario and the third in Canada to become board certified). In 2003, Dr. Hale opened Canada’s first dental-only veterinary facility. As well as being busy with his referral practice, Dr. Hale frequently speaks to veterinary and technician groups and presents at national and international conferences. He offers a wide range of continuing education programs at his practice, and he has published several articles and case reports in journals as well as textbook chapters. He is also a consultant on the Veterinary Information Network dental board.
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which means prevention. In the great majority of our patients, there is already established dental disease by the time they are presented for treatment. Therefore, to suggest what we are doing is preventative is misleading and undervalues the work; undervalues it not only in the client’s mind but in ours and our staffs’. This again discourages those involved to look for problems and to be aggressive in treating them. Comprehensive Oral Health Assessment and Treatment, while a real mouthful, is far more descriptive of what each and every dental patient requires. By using the term Comprehensive, we are telling ourselves and our clients that we are going to do a very thorough oral/dental examination and make sure that if there is trouble anywhere, we are going to find it. Oral Health Assessment indicates that we are not just going to look at the teeth. We are going to examine all the hard and soft tissues that make up and surround the oral cavity. To do such a complete assessment is going to take time and by acknowledging this to ourselves, we will be encouraged to schedule enough time to do this properly. After the comprehensive assessment, we then need to do comprehensive Treatment TECHNEWS | VOLUME 37 ISSUE 2
of all problems found. That is also going to take time. By knowing this going in, we are less likely to get ourselves in a time-bind by scheduling too little time. Comprehensive Oral Health Assessment and Treatment takes longer to say than a dental or a prophy and it is a term your clients may not be familiar with. Therefore, it encourages us to slow down and communicate more completely with our clients regarding what is going to be involved in the assessment phase and what may be involved in the treatment phase. Without this communication, we cannot obtain informed consent. In time, your clients will get to know what COHAT means and what they can expect from such a procedure. Until then, use the term as a jumping off point for a discussion regarding dental and oral health. The next question is, “What is really involved in a COHAT?” As discussed, since every dental case is unique, it follows that every COHAT has unique aspects. However, there are components that will be common to all. Note that some of the components can be the responsibility of support staff and other components must be performed by a licensed veterinarian. This means a team approach for every COHAT, for every dental patient.
An excellent resource with targets to aim for is the 2013 AAHA Dental Care Guidelines for Dogs and Cats. I have posted the entire document on the front page of my website (www.toothvet.ca) and I would encourage all readers to download and print this and make serious efforts to adopt all of its recommendations. This document is intended as a blueprint for every general practice that offers dental services. It is not ‘Ivory-Tower Pie-inthe-Sky’ stuff. In short, the Guidelines provide information on the following subjects: A list of the equipment, instruments and materials every clinic should have on hand to be able to provide basic dental care. A discussion on personal protection for the dental team. • Pre-operative assessment of the patient. • Pre-op client communication and education. • Treatment planning and patient monitoring. • The dental procedures themselves. • Post-operative management. • Client education and short-term follow-up. • On-going follow-up plans. • Nutrition.
COHAT involves a thorough review of patient history and signalment, including a review of diet, chewing habits, and the home care strategies currently in place. Back to a step-by-step discussion of a COHAT: COHAT involves a thorough review of patient history and signalment, including a review of diet, chewing habits, and the home care strategies currently in place. 1. Thorough general physical examination. 2. Pre-anesthetic diagnostics (blood, urine, ECG, chest radiographs - as indicated by history and health status). 3. As thorough an oral examination as the patient will allow in the front office (wear a head light and magnifying loupes) to develop a tentative problem list. 4. An unhurried discussion with the owner, aided by dental models, clinical and radiographic images to illustrate the issues identified, or that you suspect are awaiting detection. This interview also illustrates the ownerâ€™s commitment and expectations. 5. Once the patient is anesthetized, connected to monitors and stable, a much more detailed oral examination is performed. Again, with head light and magnification, all hard and soft tissues of the oral cavity and oropharynx are examined; accurately record findings in the patient file. Digital photography greatly enhances recording of findings and communication with owners. 6. A preparatory flush of the mouth with a chlorhexidine solution is often a good idea at this point. 7. Gross calculus removal with forceps or a mechanical scaling aide may be appropriate at this point to facilitate the following steps. 16
8. Probing depths are taken at several points around every tooth to look for periodontal pockets and abnormal depths are recorded on the dental chart. 9. Crowns are examined and explored for damage (abrasive wear, fractures, discolouration, etc.) and findings recorded on the chart. 10. Whole-mouth intra-oral dental radiographs are taken at this point. This is NOT an optional extra and is NOT open for debate. Virtually all dental patients require whole mouth intra-oral dental radiographs to allow assessment of the 60% of each tooth that is hidden from view as well as the surrounding bone. I promise you that if you are not doing whole-mouth intra-oral dental radiographs on all your dental patients, you are dramatically under-diagnosing dental pathology and your patients are receiving sub-optimal dental care. 11. Following the more detailed clinical and radiographic examination, the treatment plan is re-evaluated (as is the estimate). New findings and treatment options are communicated to the owner to obtain informed consent for the new plan and estimate. 12. All teeth are scaled above and below the gum line to remove all mineralized deposits (calculus, tartar). 13. Other oral surgical procedures are now performed as indicated and agreed upon with the owner (periodontal surgery, extractions/wound closure, restorative work, endodontic treatments, biopsy/ mass removal, etc.) with appropriate intra- and post-operative radiographs and photographs. 14. Remaining teeth are polished above and below the gum line. 15. The oral cavity and gingival sulci are rinsed/flushed to remove all debris (blood, calculus, polishing paste, etc.) and inspected to ensure no foreign material is left behind (gauze sponges, fragments of extracted teeth, tags of suture material, etc.). 16. Various final steps (depending on opinion, the specifics of the case, availability) may include a fluoride treatment or a rinse with a chlorhexidine solution. 17. Recover the patient from anesthesia. Pay
close attention to this period. Many anesthetic deaths occur during the recovery, possibly because attention has shifted away from the recovering patient to preparing the next patient for its procedure. 18. Record final notes on the detailed dental chart. 19. Write up the discharge statement with explicit instructions for the owner regarding medications, diet, activity, home care, follow-up visits, etc. 20. At discharge, show client photographs and radiographs, review the pathology found and the treatments performed. Review the discharge statement and instructions and answer any questions. Make sure the owner fully understands their part in the ongoing management and maintenance of optimal oral health for their pet. 21. Ten to 14 days post procedure, have the patient back for a follow-up visit to assess healing. If all is well, reinforce the recommendations and instructions regarding daily dental home care (plaque control). Review what is and is not appropriate in the way of chewing behaviour to reduce the risk of dental fractures. If all is not â€œall wellâ€?, the situation (whatever is still wrong) needs to be thoroughly assessed and addressed by going back to the beginning. 22. Outline plans for the next COHAT and ensure that the patient is entered in the recall schedule to be called at an appropriate time interval. What is an appropriate time interval? There in no one answer for that as different patients will have different needs/risks but a convenient default approach is to repeat COHATs on an annual basis. If your current dental procedures do not include all of these steps, then they are not COHATs, but rather POHATs (partial oral health assessment and treatment). Based on my observations, several of the above steps are frequently missed or glossed over in many general practices. While the term COHAT is gaining wider acceptance and usage, you should not use it in your practice unless you truly are doing a comprehensive oral health assessment and treatment. If you want to use the term, you need to provide the service.
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The Trouble with Gloves Excerpted from the Worms and Germs Blog by Dr Maureen Anderson, October 24, 2013
When it comes to hand hygiene, there is an unfortunately all-too-common misconception that wearing gloves makes hand washing or using alcohol-based hand rub unnecessary. In veterinary and human medicine, gloves, like hand hygiene, are typically used for two reasons: to prevent spread of germs or chemicals from a patient/person/object/surface to a person’s hands, and/or to prevent the spread of germs or chemicals from a person’s hands to a patient/person/object/surface. However, gloves are not the infallible barrier to germs that many people would like to think they are. Here are a few reasons why: Even new gloves can have holes in them: The accepted quality control limit for defects in medical gloves large enough to leak water is 1.5%. That may seem relatively low, but when you consider the hundreds of gloves that may be used over time in a veterinary (or human) clinic, that can add up to a lot of potential hand-to-patient or patient-to-hand pathogen transmission. Gloves can be damaged during use: Glove tears or punctures during use can be extremely common, particularly for certain procedures involving anything pointy or sharp (e.g. equipment, teeth, claws) or long procedures. Studies have shown that glove punctures that may occur during surgical procedures are frequently undetected by the person wearing the gloves. Even though gloves may provide an added layer of protection for a time, proper hand hygiene before and after glove use helps reduce the risk of transmission when that barrier breaks down. Bacteria can multiply under gloves: Anyone who has ever had to wear any kind of rubber, latex or vinyl gloves for more than 5-10 minutes knows how sweaty and hot it can make your hands, so you can imagine the kind of sweaty soup that can accumulate when gloves need to be worn for even longer than this. That’s why hand hygiene before putting on gloves is so important for “clean” procedures like surgery, because it helps
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decrease the number of bacteria on the hands to start, and ultimately the amount that will grow back by the time the procedure is done. Hand hygiene after glove removal is important so the “soup” isn’t being spread to the next patient, person or object. We use gloves for the highest-risk procedures: Glove use is typically recommended for the cleanest procedures (i.e. surgery) and the dirtiest procedures (i.e. things with a high “ick” factor, like handling feces). A glove puncture in surgery could potentially lead to contamination of sterile tissues, resulting in a surgical site infection. A glove puncture (or contamination of the hands when removing gloves) when handling high-risk material like feces can lead to transmission of fecal pathogens to anyone or anything that person may touch afterward (including themselves). In a sense, hand hygiene is actually even
more important in situations when gloves are typically worn! Although proper glove use and hand hygiene applies primarily to veterinary and healthcare workers, there are times when glove use is also recommended at home (e.g. caring for pets with certain kinds of infections, higherrisk individuals performing certain tasks like cleaning up pet messes). Remember that gloves are not a substitute for hand hygiene always wash your hands or use hand rub after taking gloves off. It is also important not to touch anything with your gloved hands that will later be touched by someone without gloves, and be sure to put used disposable gloves directly in the garbage.
To Watch WORM AND GERMS TALKS TAPEWORM
University of Guelph’s Worms and Germs Blog has created an Infosheet all about different groups and species of tapeworms which can infect pets, people, and other domestic animals. Help educate your clients about Echinococcus multilocularis and other nasty tapeworms. Go to www.wormsandgermsblog.com/uploads/file/M2%20 Tapeworms%20General.pdf NEW CODE OF PRACTICE FOR THE CARE AND HANDLING OF BEEF CATTLE RELEASED
September 6, 2013
The Canadian Cattlemen’s Association (CCA) and the National Farm Animal Care Council (NFACC) are pleased to announce the release of the new Code of Practice for the Care and Handling of Beef Cattle. The Code is available electronically at www.nfacc.ca/codes-of-practice/beefcattle.
The American Veterinary Medical Association (AVMA) has developed a new online game. “AVMA Animal Hospital” is available for free through Apple’s AppStore, Google Play, and AVMA’s website. The game takes place at a virtual veterinary clinic, where clients bring their pets in for treatment. Players must race the clock as they learn about each animal’s condition, diagnose its ailments, and provide treatment.
VetGirl is a new ‘techy’ way for veterinarians, veterinary students, and veterinary technicians to obtain high-quality continuing education (CE). Specifically, VetGirl is a subscription-based service offering RACE-approved CE via a unique and convenient format: podcasts. The goal of VetGirl is to provide clinically relevant vignettes within a 3-5 minute podcast. With over 50 podcasts offered a year, you’re able to stay up to date on the most current veterinary literature and get “take home” points of what you really need to know. That way, you can learn while you’re commuting to work, pounding it out on the treadmill, or taking a walk with your dog. VetGirl’s CE learning experience is really for anyone who has a smartphone, computer, or tablet… any device where you can learn on the go.
IDEXX VETCONNECT® PLUS AVAILABLE FOR CANADIAN VETERINARY PRACTICES
IDEXX Laboratories announced that IDEXX VetConnect® PLUS diagnostic results reporting is now available in Canada. VetConnect PLUS lets veterinarians view, on one screen, a patient’s entire blood work history generated by IDEXX point-of-care equipment and IDEXX Reference Laboratories. Results are presented in an easy-to-read interactive format that can be viewed anytime on a desktop, laptop, tablet or smartphone. VetConnect PLUS eliminates the need to look in multiple places to gather a patient’s test results, because all patient data is automatically integrated for easy comparison and trend spotting. Veterinarians can compare and crossreference current results with up to 10 years of historical results on a single screen. Interactive graphs let clinicians trend one or multiple parameters as well as click on any data point to see its source, run date and test value. Users can also request additional reference laboratory tests and email results to clients or specialists from the same screen.
VET TECH CONNECTIONS ON FACEBOOK: YOU’RE AMONG FRIENDS
Vet Tech Connections is a lively and very active community of Veterinary Technicians, Practice Managers, Vet Tech Students, and other staff members. ‘Like’ them soon and join the discussion.
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Controlling canine urinary incontinence just got simpler.
With new PROIN™ Chewable Tablets, you have an easier way to help control female canine urinary incontinence due to urethral sphincter mechanism incompetence (USMI)—also known as urethral sphincter hypotonus. Here’s why. • Chewable tablets for easy administration • Twice-a-day dosage for enhanced client adherence to your directions • Scored tablets in three strengths to provide accurate dosing • Highly palatable1 – liver-flavour that patients love • Proven efficacy of phenylpropanolamine hydrochloride in controlling USMI1,2 • 98.1% of clients surveyed during a clinical trial of PROIN Chewable Tablets were satisfied with the results2 Thanks to PROIN Chewable Tablets, controlling urinary incontinence is easy for your clients. Visit www.virbac.ca to learn more.
© 2013 Virbac Canada, Inc. All Rights Reserved. PROIN is a trademark of Pegasus Laboratories, Inc. and is used under license. 1. Multi-Centre, 28-day, Placebo-controlled, Clinical Field Study (PLI-CL001) Clinical evaluation of PROIN Chewable Tablets for the control of urinary incontinence in dogs due to sphincter hypotonus. 2. Multi-Centre, Open Label, Clinical Field Study (PLI-CL002) Clinical evaluation of the long-term effectiveness and safety of PROIN Chewable Tablets for the control of urinary incontinence in dogs.
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CE Article #2 Nursing Care for the Septic Patient Amy Breton, CVT, VTS (ECC) History Sepsis is the systemic inflammatory response to infection. There are a myriad of diseases or injuries that can cause a patient to become septic. In 1991, the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) Consensus Conference Committee met and established standards that defined sepsis in human medicine.1 Up until that time the use of words such as infection, bacteremia, septic shock and sepsis were being used interchangeably. While there are no official set of standards used to diagnose sepsis in veterinary medicine, there have been numerous studies in recent years working on creating such standards. In 1991, the ACCP/SCCM Consensus Conference Committee identified common abnormalities in septic human patients with regards to temperature, heart rate, respiratory parameters, and the leukogram.1 In 2001, these criteria were expanded to include parameters for systemic inflammatory response syndrome (SIRS).2 During the ACCP/SCCM Conference several definitions were defined (Box 1.1). While these terms have not been officially defined in veterinary medicine, for the purposes of this paper the ACCP/SCCM terminology will apply. In 1997, veterinarians J Hauptman, N Olivier and R Walshaw looked at temperature, heart rate, respiratory rate, white blood cell count, percent of immature neutrophils, platelet count, and serum glucose concentration as markers of clinical canine sepsis, in an effort to establish veterinary parameters. Based on the
1997 Hauptman recommendations, veterinary medicine currently has a set of parameters that defines SIRS. SIRS can be diagnosed in a dog or cat when two or more of the parameters are met (Box 1.2). Sepsis, defined by human medicine, is the presence of an infection combined with SIRS. BOX 1.1 Infection: A pathologic process caused by the invasion of normally sterile tissue or fluid by pathogenic or potentially pathogenic microorganisms. Sepsis: The presence of infection, documented or strongly suspected, with a systemic inflammatory response, as indicated by the presence of some of the features in Box 1.2. Severe Sepsis: Sepsis complicated by organ dysfunction. Septic Shock: Severe sepsis complicated by acute circulatory failure characterized by persistent arterial hypotension, despite adequate volume resuscitation, and unexplained by other causes.
BOX 1.2 Heart rate: >160 bpm in the dog and >250 bpm or < 140 bpm in the cat Respiratory rate: >20 bpm in the dog and >40 bpm in the cat Body temperature: <37.8°C or >39.7°C White blood cell count: >12,000 or <4,000 or > 10% bands
Pathophysiology In order for sepsis to occur there first must be a source of infection. The first step in the initiation of the inflammatory response is for the body to recognize there is an infection. The body will attempt to contain and destroy the pathogen through controlled inflammation.3 The inflammatory response results in the ac-
tivation of endothelial cells, neutrophils and monocytes. In response, the inflammatory cascade becomes activated. The inflammatory cascade is mediated by cytokines, which are macrophage-derived.4 There are several types of cytokines with the most important being tumour necrosis factor (TNF) and interleukin-1 (IL-1).5 Both of these will have direct and indirect effects on all organ systems.5 When TNF and IL-1 are released the body will see a change in temperature (hyper- or hypothermia), depressed cardiac output and increased vascular permeability. 5 During sepsis, the body will elicit an inappropriate inflammatory response resulting in hypercytokemia.6 Hypercytokemia is a potentially fatal reaction which occurs between cytokines and immune cells. This results in too many cytokines being released resulting in too many immune cells damaging the body. It is the hypercytokemia that will cause the SIRS.5 Ultimately the inflammatory mediators can overwhelm the organs leading to multiple organ dysfunction. It is important to note that the coagulation system and inflammatory cascade work together.4 Thrombin, a key player in the coagulation cascade, also has important inflammatory and cellular proliferative properties.4 Cytokines themselves also help to activate the coagulation cascade.4 It is for this reason that septic patients are at risk of clotting disorders such as disseminated intravascular coagulation (DIC). Another common problem in septic patients is hypoglycemia. Hypoglycemia likely occurs due to the increase in glucose consumption which is triggered by the inflammatory mediators.7 Other causes of hypoglycemia during sepsis may be secondary to decreased food intake, decreased liver function, hypotension or hypoxic-induced anaerobic glycolysis.7
Signs/Symptoms Certain diseases may cause a pet to be predisposed to developing sepsis. These generally include diseases that have caused a weakened immune system or are infection-based.3 Pets receiving chemotherapy or those that have immune dysfunction are at a greater risk.3 Pets diagnosed with peritonitis, pneumonia or those with traumatic infected wounds are
Amy is currently employed at the Veterinary Emergency and Specialty Center of New England in Waltham, Massachusetts as the Head Emergency Technician. In 2003 she became boarded as a Veterinary Technician Specialist in Emergency and Critical Care. Amy is well published in over nine subjects, is an international speaker, has received numerous awards and is highly involved in her community. Amy lives in Massachusetts with her husband and wonderful furry kids.
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Acronyms SIRS - Systemic Inflammatory Response Syndrome: A body-wide severe inflammatory response to a disease process or injury. DIC - Disseminated Intravascular Coagulation: When the body inappropriately uses up all the clotting factors leaving the body at risk for excessive bleeding and the inability to clot. MAP - Mean Arterial Pressure: A measurement between systolic and diastolic. This must be kept above 60mmHg in order to perfuse the kidneys. CVP - Central Venous Pressure: A measurement of the pressure of blood coming from the right atrium.
predisposed to developing sepsis.3 During the early stages of sepsis the body will experience high cardiac output, low systemic vascular resistance, hypoglycemia, metabolic acidosis and normal to increased systemic blood pressure.5 Appropriate inflammatory signs such as localized pain, fever, redness, swelling and brick red/muddy mucous membranes will also occur. 3 Ultimately if the infection cannot be controlled the patient may experience decreasing cardiac function, capillary leaking, organ dysfunction, organ failure and death.3 As the sepsis worsens patients will develop tachypnea, tachycardia or bradycardia, severe hypotension, marked mental depression, gastrointestinal issues (hematachezia/vomiting), multiple organ dysfunction and DIC.5
Treatment The veterinary septic patient can prove to be one of the toughest nursing challenges in veterinary medicine. A veterinary technician typically spends more time with the patient than the veterinarian, which allows for technicians to notice subtle changes in the patient. Ultimately the treatment of sepsis depends on the inciting cause. Treatment may be relatively simple with just intravenous antibiotics and fluid therapy, such as in the case of a bacterial infection. In more complex infections, such as septic peritonitis, surgery may be required to remove the infected source. Due to the numerous complications arising from sepsis, patients may experience everything from respiratory
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complications requiring ventilatory support to DIC which requires plasma transfusions. 3 One of the key factors in treating sepsis is ensuring that the patient is on an appropriate antibiotic that will target the specific infection. In order to ensure that an appropriate antibiotic is chosen, an infected sample must be submitted to a laboratory where it will be cultured. It is important to ensure that an infected sample is collected before any antibiotics are started.3 This will yield the best results from the laboratory. Studies in humans have shown that administering antibiotics within six hours of being admitted into the hospital improves the patientâ€™s survival.8 So, while obtaining a sample is important, antibiotic therapy should not be delayed due to sample collection.
Treatment in all septic patients should be aggressive. The goal is to rid the body of the infection and to support and treat multiple organ failures resulting from the sepsis.9 Early goaldirected therapy is imperative when treating septic patients.9 In human medicine, it is recommended that every septic patient have serum lactates measured, blood cultures obtained prior to antibiotic administration, and broad spectrum antibiotics used until culture results are known and early goal-directed therapies have been initiated.9 These early goal-directed therapies include fluid therapy and blood pressure maintenance.
Specific Nursing Care Depending upon how critical is the patient, nursing care may be directed towards fluid therapy only or may include more involved care like ventilatory assistance. Septic patients should be immediately admitted into an intensive care unit if one is available. 9
Basic Monitoring Septic patients should minimally have a full physical exam performed every 4-6 hours. This should include a heart rate, respiratory rate and effort, mucous membrane color, capillary refill time, rectal temperature and neurological status. If there is any change from normal parameters, the veterinarian should be notified. Because patients are at risk for DIC it is important to look for early signs, which includes excessive bleeding after venipuncture sticks and/or petechiae on the gums, pinna or abdomen of the pet. Monitoring the septic patientâ€™s fluid therapy is important. Patients should be weighed at the beginning of treatment and then at least two times a day to determine fluid losses and gains. Rapid changes in body weight are usually a result of fluid gains or losses. Septic patients can often experience large fluctuations in weight due to fluid shifting, retention or loss of fluids through vomiting and/or diarrhea. A 0.5 kg weight gain is equivalent to a 0.5 liter fluid gain.10 Since septic patients may experience multiple organ dysfunctions (MODs), kidney failure may occur in these patients. In both dogs and
“Urine output should be monitored and recorded. Quantifying urine output is key in monitoring fluid therapy as well as in patients with renal disease.” cats, one to two ml/kg/hr of urine should be produced if the patient is not on fluids.11 If the patient is on fluids then the total volume you are giving into the patient should ideally be urinated out.11 Place non-absorbent litter in cages with cats and catch the urinations of canine patients in a bowl for quantification.
Advanced Monitoring Since septic patients often require frequent blood draws a central line should be placed. This will allow for faster and pain-free blood collection from the patient. Without a central line oftentimes veins become overused and obtaining blood can be a real, if not impossible, challenge. An arterial line should be considered in patients experiencing respiratory problems. This will allow for measurement of PaO2 (partial pressure of oxygen in arterial blood), which is the gold standard when measuring overall oxygenation ability.12 Besides a stethoscope and thermometer to monitor vitals there are generally a couple other tools necessary for appropriately monitoring the septic patient: blood pressure, blood glucose, lactate and central venous pressure (CVP). It is important that septic patients have their blood pressure monitored minimally every 6-8 hours. Septic patients are at risk of developing hypotension. If the mean arterial pressure (MAP) falls below 60 mmHg, the kidneys and other organs are not appropriately perfused putting them at risk for organ failure. Arterial hypotension is defined by a MAP (diastolic + 1/3 (systolic-diastolic)) less than 60 mmHg or by a doppler ultrasonic blood pressure with a systolic reading less than 80 mmHg.13 Normalization of blood pressure, defined by a MAP of 80-120 mmHg or systolic between 110-160 mmHg, is the goal in any septic patient.13 Septic patients are at risk for developing hypoglycemia.3 Blood glucose should be monitored at least once a day or when hypoglycemia is suspected. When hypoglycemia is present intra-
venous dextrose should be added to the intravenous fluids to help ensure the patient doesn’t seizure from a low blood sugar. Blood pressure can be monitored either directly or indirectly. Direct arterial pressure monitoring is the gold standard.14 It requires the placement of an arterial catheter, which can also be used to obtain arterial blood gas samples to monitor PaO2. An electronic transducer is then placed at the end of the arterial catheter and measured continuously. If an electronic transducer is not available then the blood pressure can be measured using a central venous pressure manometer.14 Indirect methods include oscillometric devices or doppler ultrasound flow detectors. Indirect readings are less accurate, but require less skill and are noninvasive.14 Central venous pressure (CVP) is generally used when a patient is prone to changes in blood pressure or when aggressive fluid therapy is being utilized, which is the case with septic patients. CVP is considered a measurement of cardiac pumping ability, circulating blood flow, vascular tone and intrathoracic pressures.14 A central line is placed into the jugular vein and is fed down until it rests on the right atrium. The pressure in the right atrium indicates how the heart handles the volume of fluid presented to it. The measurement helps to determine how much fluid can be administered to a patient without causing fluid overload or dehydration. Depending on the literature, normal CVP measurements vary, but most will agree it is somewhere between 1-10 cm H2O.14 Lactate accumulates in the tissues and blood as a result of inadequate oxygen availability which is generally caused by tissue hypoperfusion. In some cases, increases in lactate may be the only indication that hypoperfusion still exists. Increases in lactate are commonly seen in septic patients. A value of under 2 mmol/l is normal. In human medicine monitoring lactate trends are common. Studies in human medicine have shown that lactate values that remained above 4 mmol/l are a predictor of poor outcome with mortalities of greater than 40%.9 Lactate can
be measured using a simple hand-held device similar to a blood glucose machine. It is important to normalize lactate concentrations through fluid therapy and blood pressure normalization.
Nutritional Support Nutritional support must be considered in septic patients that are hospitalized more than 48 hours. Sepsis causes an increase in resting energy expenditure and an increased protein consumption.15 Providing nutritional support to these patients early is essential in order to minimize weight loss and to provide adequate energy for metabolic support.15 In both human and veterinary patients a better outcome is seen in those that receive nutritional support earlier. Enteral feeding is the best. Many times these patients will not eat on their own, so placement of a feeding tube should be considered.15 Certainly if the patient continues to vomit or enteral feeding is not appropriate, parenteral feedings should occur.
Pain Management Most septic patients are in some level of pain. This is particularly true for post-operative septic peritonitis patients. As the patient’s technician, it is imperative that you watch for signs of pain. In dogs this may include vocalizing, shaking, aggression and panting.16 In cats, more commonly, they will become aggressive or hide.16 If a pet is painful it should receive pain medication. Opioids are the choice of drugs for septic patients.16 They offer excellent analgesia with limited effects on the hemodynamic system. Multimodal and continuous rate infusion analgesia should be considered in these patients.16
The Post-Operative Surgical Patient There are many reasons a septic patient may require surgery. It could be from a necrotic tumour, perforated intestine from a foreign body or other similar causes. Perforating trau-
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ma (such as a stick or bullet) into the abdomen may also introduce bacteria causing peritonitis. The infection in the abdomen may lead to septic peritonitis. Septic peritonitis is the inflammation of the peritoneum (the membrane which lines the abdominal cavity) due to the introduction of bacteria into the abdominal cavity from a perforation or rupture of a hollow viscous. Depending on the cause, many patients may have limited symptoms such as anorexia or restlessness. As the disease progresses vomiting, diarrhea, abdominal pain and/or abdominal distention may be noted.3 Generally, in advanced stages of peritonitis the abdomen becomes very painful. These patients often require surgery to remove the source of infection. Post-operatively the abdomen may be left open or closed, depending on the degree of infection and the cause of the peritonitis. Open abdominal drainage allows for septic material to passively drain out of the abdomen. It also allows for easy evaluations of the area and decreases the survival of anaerobic bacteria.17 The incision is covered with highly absorbent sterile towels or pads and is held in place by an abdominal bandage or umbilical tape that has been woven through stay-sutures in the abdomen.17 Because the incision is open, a urinary catheter must be placed to ensure the patient does not soil the bandages. The dressing should be evaluated every 6-8 hours for discharge and changed aseptically at least three times a day or whenever the bandage is soiled.17 The amount of fluid lost can be estimated by weighing the bandages after they are changed with the dry bandages. Fluid should be examined microscopically to look for any cellular changes (such as reduction of bacteria). Open abdomens are associated with a high number of complications including hypoproteinemia, hypothermia, ascending infection and evisceration.17 Closed abdomens create fewer intensive care challenges for technicians. Closed suctions drains are placed in the abdomen and the incision is closed around the drain. This technique does not allow for complete drainage of the abdomen, but the fluid that is removed is confined to the drain itself. The drain must be kept in place until the fluid amounts are within physiologic limits and the fluid cytology shows no evidence of infection.17 Studies have shown survival between closed and open abdomens to be similar.3 It is interesting to note that despite advances in medicine, the survival rate for dogs that un-
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dergo surgery for septic peritonitis has not improved in ten years. A study performed at the University of Pennsylvania concluded that there was no significant difference in survival among dogs treated surgically for septic peritonitis between 1988 and 1993 (64%) and 1999–2003 (57%)2,18. It is important for owners to understand the level of critical nursing care their pet will need post-operatively and the high mortality rate associated with septic peritonitis.
Ventilation Patient In some cases, septic patients may be put on a ventilator if they are experiencing severe respiratory distress due to poor overall oxygenation ability. As a veterinary technician you will be responsible for the maintenance of the ventilator machine. Besides the machine, the patient itself will require a lot of nursing care. Ventilation patients often require a round-the-clock technician assigned to only them. It is important that the air entering the patient is humidified. Oral mucous membranes and eyes should be moistened and lubricated to avoid drying out. The oral cavity itself should be cleaned and rinsed every four hours.19 The endotracheal or tracheotomy tube should be suctioned sterilely every four hours and the endotracheal tubes should be replaced every 24 hours.19 In addition, the cuff on the tubes should be deflated, repositioned and reinflated every four to six hours.19 Since the patients are recumbent, passive range of motion must be performed every four to six hours and patients should be repositioned at that time as well.19 Since patients are not moving, it is best to place a urinary catheter to keep them as clean and dry as possible. Adequate soft bedding should be used and bedding replaced once a day.
Conclusion Most registered veterinary technicians will encounter a septic patient at some point in their career. It is important to understand not only how sepsis affects the body, but also the unique nursing care your patient will require. Providing excellent nursing care will mean the difference between life and death to the septic patient.
REFERENCES 1. Balk R, Bone R, Cerra F, Dellinger R, Fein A, Knaus W, Schein R, Sibbald W, “Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis”, The ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest 101;1644-1655, DOI 10.1378/chest.101.6.1644 2007 2. Otto C., “Sepsis: A Basic & Clinical Update”, ACVIM Conference Proceedings 2002 3. Raffe M, Wingfield W, eds (2002) The Veterinary ICU Book. Sepsis. Jackson, Wyoming: Teton NewMedia: 695-709 4. Maki D, Tambyah P (2001) Engineering Out the Risk of Infection With Urinary Catheters Inflammatory Cascade. Pharmacotherapy 21(11): 1389-1402 5. Murtaugh R, ed (2002) Quick Look Series: Critical Care. Pathophysiology of Sepsis. Jackson, Wyoming: Teton NewMedia: 64-65 6. Campbell V (2005) SIRS, Sepsis, MODS Demystified, International Veterinary Emergency and Critical Care Symposium Proceedings 7. Koenig A (2010) Hypoglycemia: Causes, Essential Diagnostics, and Treatment International Veterinary Emergency and Critical Care Symposium Proceedings 8. Dellinger R, Levy M, Cartlet J, Bion J, Parker M, Jaeschke R, Reinhart K, Angus D, Brun-Buisson C, Beale R, Thierry C, Dhainaut J, Gerlach H, Harvey M, Marini J, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson T, Townsend S, Vender J, Zimmerman J, Vincent J (2008) Surviving Sepsis Campaign: International Guidelines for Management of Severe Sepsis and Septic Shock: Crit Care Med 2008; 36(1): 296-327 9. Daniels R, Nutbeam T, eds (2010) ABC of Sepsis. The Role of Critical Care. West Sussex, UK: Wiley-Blackwell: 68-72 10. Davis H (2008) Fluid Therapy for Veterinary Technicians, Atlantic Coast Veterinary Conference Proceedings 11. Raffe M, Wingfield W, eds (2002) The Veterinary ICU Book. Fluid and Electrolyte Therapy. Jackson, Wyoming: Teton NewMedia: 166-188 12. Crowe D (2008) Oxygen Therapy, Atlantic Coast Veterinary Conference Proceedings 13. Bryant S (2009) Blood Pressure: Physiology and Troubleshooting Hypotension Under Anesthesia International Veterinary Emergency and Critical Care Symposium Proceedings 14. Battaglia A, ed (2007) Small Animal Emergency and Critical Care, 2nd Ed. Basic Monitoring of the Emergency and Critical Care Patient. St. Louis, Missouri: Elsevier: 9-32 15. Battaglia A, ed (2007) Small Animal Emergency and Critical Care, 2nd Ed. Nutritional Support of the Critically Ill Patient. St. Louis, Missouri: Elsevier: 85-108 16. Battaglia A, ed (2007) Small Animal Emergency and Critical Care, 2nd Ed. Pain Assessment and Treatment. St. Louis, Missouri: Elsevier: 124-138 17. Battaglia A, ed (2007) Small Animal Emergency and Critical Care, 2nd Ed. Gastrointestinal Emergencies. St. Louis, Missouri: Elsevier: 270284 18. Bentley A, Otto C, Shofer F, Otto C (2007) Comparison of dogs with septic peritonitis: 1988–1993 versus 1999–20. Journal of Veterinary Emergency and Critical Care 17 (4): 391–398 19. Hopper K (2009) Management & Weaning of Ventilated Patients, ACVIM Conference Proceedings 2009 20. Ettinger S, Feldman E, eds (2010) Textbook of Veterinary Internal Medicine. Sepsis and the systemic inflammatory response to infection. 7th Edition, St. Louis, Mo: Elsevier Saunders: 523high-protein, high-fiber diet designed for weight loss improves satiety in dogs. J Vet Intern Med 2007; 21(6): 1203-1208. 11. Wei A, Fascetti AJ, Villaverde C, Wong RK, Ramsey JJ. Effect of water content in a canned food on voluntary food intake and body weight in cats. Am J Vet Res 2011; 72: 918-923. 12. Roudebush P, Schoenherr WD, Delany SJ. An evidence –based review of the use of therapeutic foods, owner education, exercise, and drugs of the management of obese and overweight pets. J Am Vet Med Assoc 2008; 233: 717-725. 13. Chauvet A, Laclair J, Elliot DA, German AJ. Incorporation of exercise, using an underwater treadmill, and active client education into a weight management program for obese dogs. Can Vet J 2011; 52: 491-496. 14. Trippany JR, Funk J, Buffington CAT. Effects of environmental enrichments on weight loss in cats (abstr). J Vet Intern Med 2003; 17: 430. 15. Michel, K. Nutritional Management of Body Weight. In: Fascetti A and Delaney SJ (eds). Applied Veterinary Clinical Nutrition. 1st Edition. Chichester, UK: Wiley-Blackwell 2012. pp. 109-124. 16. German AJ, Holden SL, Mason SL, Bryner C, Bouldoires C, Morris PJ, Deboise M, Biourge V. Imprecision when using measuring cups to weigh out extruded dry kibble food. J Anim Physiol Anim Nutr (Berl) 2011; 95: 368-373. 17. Battaglia A, ed (2007) Small Animal Emergency and Critical Care, 2nd Ed. Gastrointestinal Emergencies. St. Louis, Missouri: Elsevier: 270284 18. Bentley A, Otto C, Shofer F, Otto C (2007) Comparison of dogs with septic peritonitis: 1988–1993 versus 1999–20. Journal of Veterinary Emergency and Critical Care 17 (4): 391–398 9. Hopper K (2009) Management & Weaning of Ventilated Patients, ACVIM Conference Proceedings 2009 20. Ettinger S, Feldman E, eds (2010) Textbook of Veterinary Internal Medicine. Sepsis and the systemic inflammatory response to infection. 7th Edition, St. Louis, Mo: Elsevier Saunders: 523
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Submitting Articles to TECHNEWS We welcome your participation in the quarterly magazine, TECHNEWS, distributed nationally. In Ontario, articles submitted receive 2 C.E. credits and articles chosen for printing receive an additional 2 C.E. credits. Please contact your Provincial Association Registrar to determine your provincial C.E. values. Do not forget to include your return address information. Manuscripts should be submitted electronically either via email (address:email@example.com), CD/DVD-R or USB stick in a format compatible with Microsoft Word 97 or better.
nursing skills, neonatal care, research, exotics, large animal medicine, emergency procedures or anything else you feel is important to the continuing education of technicians.
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Nutraceuticals & Veterinary Care – Show me the evidence Gary Landsberg BSc, DVM, DACVB, DECAWBM, Colleen Wilson DVM, Sagi Denenberg DVM, DACVB The word nutraceutical, as defined by Webster’s dictionary, originates from the words “nutrition” and “pharmaceutical”; it is a food or food product that reportedly provides health and medical benefits, including the prevention and treatment of disease. Health Canada defines the term as, “A product isolated or purified from foods that is generally sold in medicinal forms not usually associated with food.” Nutraceuticals are becoming increasingly popular as many clients are attracted to the appeal of natural products. Yet, just because a product is natural does not mean that it is safe or free from side effects and contraindications. It is also essential that veterinarians evaluate the evidence of efficacy before recommending or dispensing any natural therapeutic, since the placebo effect can reach 50% or greater in behavioural studies. In addition, for those products where efficacy can be demonstrated, standardization and quality can only be insured if the branded and tested version of the product is used.
A common factor underlying most behaviour problems is anxiety. Recurrent or chronic anxiety and stress can also affect physical health including gastrointestinal, dermatologic and urinary tract disorders, as well as immunosuppression and a shortened life span. Thus, anxiety affects the health, behaviour and welfare of the pet and can contribute to a weakened pet-owner bond. When this bond is broken, the client’s commitment to health care is affected, and euthanasia is not uncommon.
Treatment of anxiety should begin with identifying and avoiding stimuli and situations that incite anxiety, along with behaviour modification and medication to reduce anxiety. In Canada, of the hundreds of natural products marketed to treat anxiety, very few have been evaluated in controlled studies. Presently there are evidence based studies for l-theanine (Anxitane®), alpha-casozepine (Zylkene®), pheromones (Adaptil® and Feliway®), melatonin, aromatherapy (e.g. lavender), SinSusto, and a diet containing trytophan and alpha-casozepine (Royal Canin Feline and Canine Calm®). Alpha casozepine (Zylkene®, Vetoquinol) is derived from casein, the protein in milk. It may potentiate the effects of gaba amino butyric acid (GABA), an inhibitory neurotransmitter. In two separate studies by Beata the authors concluded that alpha-casozepine was as equally effective as selegiline (used and marketed in Europe to treat anxiety) for the treatment of anxiety disorders in dogs and was significantly more effective than placebo in reducing anxiety disorders in cats. L-theanine (Anxitane®, Virbac Animal Health) is made of 99.9 per cent pure L-theanine. It may also increase GABA as well as block glutamate (an excitatory neurotransmitter). In a controlled laboratory study, l-theanine was significantly more effective than the placebo in reducing fear of unknown humans. Pheromones (Adaptil and Feliway, Ceva Animal Heath) have many potential applications for reducing anxiety; they have demonstrated efficacy in reducing urine marking in cats, reducing stress in hospitalized pets,
improving socialization and reducing anxiety when dogs are first adopted into the home and in reducing separation anxiety. Aromatherapy (lavender) was demonstrated to reduce travel anxiety and smaller studies or case reviews have reported a reduction in anxiety with melatonin. A diet supplemented with alpha-casozepine, l-tyrptophan and B6 (Calm Royal Canin) has also been demonstrated to reduce the cortisol response in dogs subjected to the anxiety of nail trimming. Most recently SinSusto (Bioniche Life Sciences), a blend of botanicals containing Souroubea plantanus species which is also purported to act on the GABA-A receptor, has been shown to reduce anxiety in a model of fearful behaviour during thunder. In short, very few of the natural products marketed for the treatment of fear and anxiety have any evidence of efficacy. Although some of the studies are preliminary or small, to date only those products mentioned above have demonstrated that they might be useful either alone or in combination with other behavioural medications in the prevention or reduction of anxiety, stress and the health and behaviour problems with which they are associated. Veterinary practices should strive to recommend only those products that have a plausible and scientifically sound mechanism of action and evidence of efficacy that exceeds the placebo effect. References available on request
Dr Gary Landsberg and Dr. Sagi Denenberg operate a behaviour referral practice, North Toronto Veterinary Behaviour Specialty Clinic in Thornhill, ON (northtorontovets.com). Both Dr. Landsberg and Dr. Denenberg are board certified diplomates of the American College of Veterinary Behaviourists. Dr. Landsberg is also board certified by the European College of Animal Welfare and Behavioural Medicine. Dr. Landsberg is also the mentor for the behaviour residency program of Dr. Colleen Wilson at the Osgoode Animal Clinic (osgoodevet.com).
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CE Article #3 The “How To” on End Tidal CO2 by Lisa Randon, RVT, VTS (Anesthesia)
Capnometry is based on a discovery by chemist Joseph Black, who in 1875 noted the properties of a gas released during exhalation, that he called “fixed air.” That “fixed air” or gas is called carbon dioxide (CO2), produced as a consequence of cellular metabolism. It is a waste product of the metabolism of oxygen and glucose that combine to produce energy. The amount of CO2 in an exhaled breath reflects cardiac output. It also reflects pulmonary blood flow as the gas is transported by the venous system to the right side of the heart and then pumped into the lungs by the right ventricle. Capnography measures the expired arterial carbon dioxide, also known as end tidal carbon dioxide (EtCO2). EtCO2 is an estimation of arterial carbon dioxide, which provides information about the adequacy of ventilation. It also provides important information about metabolism and circulation and depth of anesthesia. Capnography’s main development has been its use as a monitoring tool during anesthesia, intensive care and cardiac resuscitation.1 This is brief guide to help describe what capnometry is, and how you as an anesthetist, may interpret some of the more common waveforms encountered in veterinary medicine. There are a variety of capnometry instruments available on the market today. When looking for a tool to measure CO2, one must be careful, as there are monitors
available that are qualitative carbon dioxide monitors as opposed to quantitative devices. Qualitative monitors are designed to distinguish between esophageal or endotracheal intubation only and are therefore not intended to quantitate EtCO2. Although quantitative instruments are very advantageous, they do have a few disadvantages. The equipment increases dead space, may increase potential leaks within the breathing system, and may cause contamination between patients with re-usable connectors, if not properly disinfected. This article discusses qualitative monitors only.
The connector between the endotracheal tube and Y-piece (side stream).
Capnograph analyzers are found in two designs: main stream and side stream. Main stream analyzers are attached to the patient and placed directly near the CO2 expired by the patient. The analyzer is connected to the monitor by long electrical wires and can be a bit bulky to use. The side stream analyzer is set away from the expired CO2. The gases
have to travel further in the sampling tube (located between the endotracheal tube and the anesthesia circuit before reaching the sensor. The instrument measures the CO2 passing this monitor on both inspiration and expiration. This manner of measuring CO2 leads to a comparative delay in sensing changes, resulting in a slower response time than main stream analyzers. Side stream analyzers use a thin tube, connected at the patient end and easily attached to a face mask/or endotracheal tube. A negative aspect of the side stream analyzer is that the tubing can easily become blocked or kinked. With either type of monitoring, water can interfere with CO2 analysis and lead to errors. Therefore it is important to prevent moisture from the patient’s expired breath condensing onto the analyzer.
Condensation occurs when warm expired water vapour (at body temperature) cools down to room temperature. In main stream analyzers, condensation is minimized by electrically heating the analyzer. In side stream analyzers, water vapour from the patient’s expired breath can more easily condense in the sampling tube. If this condensed water enters the sensor, there will be errors in CO2 measurement. To minimize this situation, there is a water trap before the tube enters the sensor, able to collect any condensation. Patients that may benefit the most from capnography are those with pre-existing respiratory disease, ie. patients with diaphragmatic hernias, pneumothorax,
In 1994 Lisa Randon graduated honours from St. Clair College in Windsor, Ontario. Lisa is proud to work at Allandale Veterinary Hospital (Veterinary Economics 2013 Hospital of the Year) since graduation. In 2009, Lisa became a member of the Academy Veterinary Technician Anesthetists, earning her Veterinary Technician Specialty in small animal anesthesia. Lisa has travelled to Jamaica twice volunteering at the “Animal House Jamaica” anesthetizing strays for a spaying and neutering program. She intends to travel to Guatemala in 2014 with the “Vets without Borders” program. She has authored various articles for TECHNEWS, and started a consulting career last year. From time to time Lisa runs local seminars for technicians on small animal anesthesia topics. Spare time is sparse but she always manages to fit in travelling, downhill skiing, and cycling with her family and lounging with her fur children Mr. Meowzers and Phoenix.
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pneumonia, asthma, surgical thoracotomies, as well as patients with sepsis, shock, trauma and the critically ill patient. By understanding the mechanics of capnography, and how this type of instrumentation works we can now put our knowledge to use by analyzing the waveforms and numbers that are produced by our anesthetized patient. The following graphs illustrate normal and abnormal waveforms (or lack thereof ):
Trace 1: Normal waveform
Time A-B is Phase I - the “Respiratory Baseline”- the expiration of gas from anatomical dead space. B-C is Phase II - the “Expiratory Up stroke”- alveolar gas is mixing with dead space gas. C-D is Phase III - the “Expiratory Plateau” - expired gas consists almost entirely of alveolar gas. There may be a slight incline slope at D. This is the most important phase, as it shows how the lungs are emptying. D is the EtCO2 Peak. D-E is Phase IV - the “Inspiratory Down stroke” – inspiration phase The angle between Phase II and Phase III is an indicator of the ventilation/perfusion ratio of the lungs.3
Normal exhaled CO2 levels are between 35-45 mmHg. Hypercapnia (higher than normal CO2) is present if the EtCO2 is greater than 45 mmHg. Hypocapnia (lower than normal CO2) is present if the EtCO2 is less than 35 mm Hg.2 Low values for EtCO2 may occur with rapid respiratory rates. Examples of this include: panting on a light plane of anesthesia, apnea, improper endotracheal tube placement, bronchial intubation, excessive dead space diluting the exhaled gas or if the monitor has been disconnected or occluded. Conversely, hypercapnia may be seen if the patient is breathing in CO2 due to causes such as expired soda lime or a faulty flutter valve. Sloping expiratory trace without alveolar plateaux
Relaxant or Surgeon’s Notches
The wearing off of muscle relaxants can cause relaxant notches. These types of drugs let the diaphragm contract and disturb the CO2 waveform. A similar effect can be seen when the surgeon or any other source (e.g. equipment) presses on the chest wall. Sudden decrease in ETCO2 to a low non-zero value
Sloping expiratory trace without alveolar plateaux
Tracings like this can result from hyperventilation. The ventilation is higher than necessary to rid the carbon dioxide produced by the body. Hypothermia can also be a factor, as is dead space and sedation.
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Potential cause could include the endotracheal tube placement in the esophagus; there will be little or no CO2 registered. You may either see a flat trace or a rapidly descending series of curves. Complete ventilator malfunction can also be blamed. Check to ensure that there is no leak in the system, no kinking or airway disconnection, or if a facemask is being used, that it is secure.
Elevated EtCO2 with good alveolar plateaux
Inadequate minute ventilation, hypoventilation, respiratory depressant drugs, or hyperthermia and pain and shivering can all result in an elevated EtCO2 with good alveolar plateaux. Gradual decrease in EtCO2
This is an important tracing of which you want to be aware, as it will let you know of a serious emergency. Sudden hypotension, massive blood loss, pulmonary embolism and cardiac arrest could be a result. You may also see the opposite, i.e. a gradual increase in the waves, where possible causes may be hypoventilation, malignant hyperthermia, partial airway obstruction, an increase in metabolism, or absorption of carbon. Rise in Baseline and EtCO2
When you see this tracing, examine for a defective exhalation valve or exhausted soda lime (which would cause rebreathing previouslyexhaled carbon dioxide). A capnogram that forms only a straight line – i.e. no wave is present
circulation. Those listed above are just a few of the common waveforms you may encounter. When interpreting waveforms, ask yourself: a) Is there CO2 present? b) Look at the respiratory baseline. Is there rebreathing? c) Expiratory upstroke: steep, sloping or prolonged? d) Expiratory plateaux: flat, prolonged, notched or sloping? e) Inspiratory down stroke: steep, sloping or prolonged? f ) Read the numerical EtCO2 value. As in cardiopulmonary resuscitation, we also have ABC’s in capnography. “A” is for Airway. Look for signs of an obstructed airway (steep, upsloping expiratory plateaux). “B” is for Breathing where we examine EtCO2, looking at the waveforms. “C” is for Circulation looking for trends. Are the waveforms long, or short? Are there increases or decreases in EtCO2 values?5 The American Heart Association recommends using capnography to ensure endotracheal tube placement and judge the effectiveness of chest compression during cardiopulmonary resuscitation.4 By using capnography, the anesthetist can provide a lot of information about our patients in newer and faster ways than other instrumentation used in veterinary medicine. Capnography, used properly with a good understanding of how to read the monitor, will certainly enhance the care of our anesthetized patients.
REFERENCES Diagrams provided by Vince Gervais – Smiths Medical Canada 2012
Before you panic, rule out a capnograph that is not connected! An unconnected capnograph will read room air, which has nearly zero CO2. Other possibilities include a complete obstruction of the lungs, due to a very severe bronchospasm or a complete obstruction of the airway due to a large mucous plug, a dislodged tube, a kinked endotracheal tube or complete obstruction of the capnograph sampling tube. This type of tracing can also result from a respiratory arrest, perhaps due to an opioid overdose or ventilator malfunction. Lastly, it could indicate cardiac arrest, where there is simply no 30
1. Cone DC, Cahill JC, Wayne MA. Cardiopulmonary resuscitation.Gravenstein JS, ed. Capnography: Clinical Aspects 2004. Cambridge University Pres 2. Let’s Talk About Capnography- Smiths MedicalKeith Simpson, MRCVS August 2003 3. Capnography in Veterinary Medicine Dr. Deb Wilson DVM Dip ACVA Michigan State, Dec 2002 4. IVECCS Symposium Proceedings 2013 End Tidal CO2 During CPR-Why Bother 5. IVECCS Symposium Proceedings 2013 Hemodynamic Waveforms-What are They and Why do we Care? 6. www.howequipmentworks.com
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Technews Winter 2014 CE Quizzes CE Article #1: What the Heck is a COHAT? 1. COHAT stands for: (a) casual owner health and attitude tally (b) comprehensive oral health assessment and treatment (c) common old habits and traditions (d) convenient organizational home animal treatment 2.
What is wrong with the term “a dental”? (a) “dental” is an adjective not a noun (b) it is far too vague (c) it suggests all dental procedures are alike (d) all of the above
3. The Dental Care Guidelines for dogs and cats was put out by: (a) AAHA (b) AVMA (c) CVMA (d) AVDC 4. At what point can a detailed treatment plan/estimate be developed? (a) After a conscious examination (b) After an in-depth interview with the owners at admission (c) After a detailed examination under general anaesthesia including whole- mouth intra-oral dental radiographs (d) At discharge
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5. Intra-oral dental radiographs, while useful, are too expensive to justify their routine use. (a) true (b) false 6. While many portions of a COHAT can be the responsibility of the support staff, there are several portions that require direct, hands-on involvement of the attending veterinarian. (a) true (b) false 7. Client communication can be greatly enhanced by using: (a) digital photographs of their pet’s mouth (b) the intra-oral dental radiographs (c) dental models (d) all of the above 8. Who is the most important member of the dental care team? (a) RVT (b) DVM (c) Owner (d) all are essential and must work together
9. The purpose of the pre-admission interview is: (a) to explain the identified pathology and its significance (b) to outline the tentative treatment plan and estimate of cost (c) to get a sense from the owner regarding their level of commitment and their expectations (d) all of the above 10. Which of the following statements is true? (a) If a COHAT is done properly, there should be no need for further dental care (home or professional). (b) Following a proper COHAT, maintenance of optimum oral health relies on daily home plaque control and regular professional care (i.e. further COHATs). (c) If owners promise to brush their pet’s teeth daily and use other plaque-control measures, no further professional care will be needed (d) If the owners promise to return for annual COHATs, there is no need for them to provide daily home plaque control.
CE Article #2: Nursing Care for the Septic Patient 1.
The inflammatory process is mediated by: (a) Neutrophils (b) Macrophages (c) Cytokines (d) Lymphocytes
Septic patients are at risk for developing: (a) DIC (b) Hypoglycemia (c) Organ failure (d) All of the above
3. Which of the following pets is considered to be more at risk for developing sepsis? (a) Dog receiving chemotherapy (b) Cat with a broken leg (c) Dog with anal sac infection (d) Cat that is pregnant 4. Administering _____ within 6 hours of arrival to the veterinary clinic will improve the pet’s chance of survival from sepsis. (a) Oxygen (b) Antibiotics (c) Nutritional support (d) Surgery
5. It is imperative that the mean arterial pressure in a patient remains above: (a) 150 mmHg (b) 120 mmHg (c) 60 mmHg (d) 40 mmHg
8. ________ are the ideal choice of pain medication for septic patients (a) NSAIDS (b) Opiods (c) Benzodiazepines (d) Alpha-2 Agonists
6. Central venous pressure measures the (a) Pressure in the left atrium and how the heart handles the volume of fluid presented to it (b) Pressure in the centre of the heart and how the heart handles the volume of fluid presented to it (c) Pressure in the jugular and how it handles the volume of fluid presented to it (d) Pressure in the right atrium and how the heart handles the volume of fluid presented to it
9. Surgery to remove the septic source may be indicated in which case: (a) Pneumonia that developed into sepsis (b) FIP that caused sepsis (c) Chemotherapy patient with sepsis (d) Perforated foreign body that caused sepsis
7. Lactate is a measurement of (a) Hypoperfusion (b) Hypertension (c) Hypoglycemia (d) Hyperperfusion
10. If a patient is on a ventilator, the endotracheal tube should be replaced in a sterile manner every (a) 4-6 hours (b) 12 hours (c) 36-48 hours (d) 24 hours
CE Article #3: The “How To” on End Tidal CO2 1. This can cause interference with Capnography analyzers (a) electrons (b) water (c) static electricity (d) none of the above 2. Hypercapnia is best described as an EtCO2 reading above 45 mmHg. (a) true (b) false 3. Low values of EtCO2 (less than 30 mmHg) can be caused by: (a) bronchial intubation, a blockage within system, excessive dead space (b) improper endotracheal tube placement, apnea (c) normal respiratory rate, no dead space (d) a and b 4. A rise in the baseline portion could indicate: (a) patient is on a light plane of anesthesia (b) patient is on a too deep plane of anesthesia (c) rebreathing of CO2 from exhausted soda lime (d) the surgeon is physically pressing the diaphragm
5. The most important phase of the capnogram is: (a) Phase IV (b) Phase I (c) Phase III (d) Phase II 6.
“Fixed air” is also known as (a) carbon monoxide (b) carbon dioxide (c) carbon trioxide (d) the carbon molecule itself
7. “Relaxant notches”: (a) may occur when the surgeon places pressure on the chest wall (b) occur because the patient is too relaxed (c) mean nothing as they are just a “blip” on the screen (d) may occur if too much muscle relaxants are given
8. What would the tracing look like in the case of an emergency situation such as a massive blood loss, hypotension, pulmonary embolism, or cardiac arrest? (a) a sustained low tracing with good alveolar plateaux (b) a tracing with a gradual decrease of EtCO2 (c) a sloping expiratory trace without alveolar plateaux (d) a tracing with Surgeon’s notches 9. The American Heart Association recommends using capnography to ensure endotracheal tube placement and judge the effectiveness of chest compression during cardiopulmonary resuscitation. (a) true (b) false 10. To minimize analyzer error, this device is placed within the unit to collect condensed vapour. (a) a water plug (b) a water line (c) a humidifier (d) a water trap
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Help your patients get back to a normal life. the ONLY nutrition clinically tested to dissolve struvite stones in as little as 7 days1 2 and reduce the recurrence of FiC signs by 89%.
Change their FOOD. CHange tHeir WOrLD. Lulich JP, Kruger JM, MacLeay JM, et al. Efficacy of two commercially available, low-magnesium, urine-acidifying dry foods for the dissolution of struvite uroliths in cats. J Am Vet Med Assoc. 2013;243:1147-1153. Average 28 days in vivo study in urolith forming cats. TECHNEWS VOLUME ISSUE 2 of Veterinary Internal Medicine Forum 2013. Kruger JM, Lulich JP, Merrils| J, et al. Proceedings37 . American College ®2013 Hill’s Pet Nutrition Canada, Inc. ®/™ Trademarks owned by Hill’s Pet Nutrition, Inc.
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12419 (Nov 15, 2013): RVT Barrie Animal Hospital requires a full time Registered Veterinary Technician. We are a full service 2 doctor, 3 technician small animal practice located in Barrie Ontario. Please send a cover letter and resume to Dr. Stephen Choles at email@example.com. 12392 (Nov 6, 2013): RVT/AHT Full/Part time Algonquin East Animal Clinic is full service veterinary clinic located in Barry’s Bay, Ontario, right in the heart of the scenic Madawaska Valley. We are looking for a friendly, personable, self-motivated technician to work in a busy, rural practice. Good patient care and customer service are required. Our clinic is open Monday to Thursday 8-4. We offer hourly wages and generous benefits. New graduates welcome. Email: firstname.lastname@example.org; Fax: 613-756-4038. 12390 (Nov 6, 2013): Experienced, Energetic RVT We are looking for a highly experienced RVT who thrives on a heavy surgery load, high volume of appointments and in patient procedures but will not sacrifice quality medicine and client services! If you are enthusiastic, highly skilled and passionate about vet medicine you may be right for our team. Competitive wages, OAVT licence and dues paid annually, OAVT conference, medical/dental benefits, +++ Please e-mail email@example.com.
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12360 (Oct 24, 2013): Veterinary Technician We are looking for a bilingual veterinary technician to join our team, part-time or full-time in a well-established small animal clinic in a modern new facility in downtown Hull, located five minutes from Ottawa. All types of surgeries performed in-house from orthopedics to general surgeries. This practice has old world values in a modern facility with the latest computer software(Cornerstone to the fullest capacity) and equipment, from in-house labs, digital radiology and digital dental radiology. Contact: Jenn Maxsom, Clinique Veterinaire de Hull Inc, 546 St-Joseph Boulevard, Gatineau, Quebec J8Y 4A4; phone: (819) 777-1333, ext. 225; e-mail: firstname.lastname@example.org 12357 (Oct 24, 2013): Registered Veterinary Technician We are looking for a Registered Veterinary Technician to start immediately for a busy clinic in Scarborough. Good salary and full benefits. Call 416266-9380 or e-mail email@example.com
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Volunteer Abroad with
Animal Experience International Heather Reid DVM We were worried we wouldn’t spot her – the giant Leatherback Turtle emerging from the dark surf to lay her eggs on the Costa Rican beach. After hours spent on a moonless night patrolling our assigned stretch of Caribbean coast, we were beginning to wonder. Then our leader stopped and silently pointed to the sand ahead. We had found her. And she was magnificent, her carapace measuring well over a metre in length. Now, thanks to the dedication of the organization, and the hard work of the volunteers, her eggs would be safe from poachers. Moved carefully to a nursery until they hatched – baby turtles would be returned to the ocean to continue the cycle of life. The organization responsible for the efforts mentioned above is one of countless groups working tirelessly to help animals around the world. Groups that depend on volunteers to run their programs, educate the public, and tackle the problems affecting animals in their native countries heads-on. Animal Experience International (AEI) is proud to support these organizations and help people like you take part in quality international volunteer experiences. Through AEI’s placement programs, veterinary technicians and other animal lovers are able to fulfill their dream to volunteer abroad, while making a huge difference in the lives of animals. Work with Flying Foxes in Australia, Giraffes in Kenya, or Elephants in Sri Lanka Traveling can be a life-changing experience, but choosing where to go and how to get there can be stressful. We want to encourage as many people as possible to volunteer their time and skills by letting us handle the details for you. From airport pick-up to accommodation and training, AEI ensures that your experience is safe and successful. By working with our partners we are able to keep the volunteer fees as low as possible. And we have personally visited all of our partners to experience what our volunteers will be doing during their stay. This means we have seen firsthand the excellent work these groups are accomplishing and therefore we can answer any questions you may have. AEI works with groups in more than ten countries around the world. The large range of comprehensive and flexible programs ensures that you will find your perfect experience, whether it is at a sanctuary, TECHNEWS | VOLUME 37 ISSUE 2
hospital, rescue centre or in the field. Our partner in Thailand offers placements at a sanctuary for elephants rescued from the streets of Bangkok, and relies on volunteers for their care. Our partner in Guatemala saves wildlife that has been confiscated from the illegal pet trade, animals such as spider monkeys, parrots, coatimundis and even jaguars. And our partner in Australia cares for injured and orphaned wildlife in their rehabilitation centre, while running a captive breeding program to help the threatened Bilby population. AEI also supports the important work of organizations that help manage feral dog populations. Throughout the world these groups deal with problems that occur when dogs are forced to live and survive on the street. These animals suffer from terrible diseases and injuries, and can pose serious health threats to people. Our partners run effective spay-neuter-vaccination clinics, treat sick and injured dogs, and educate the public about these issues. You can lend your skills and help our partners in Mexico, Sierra Leone, India, Madagascar and Nepal. At AEI, we learn more every day about the plight of animals around the world. Reality for many of these creatures is quite bleak, and the problems and pressures they experience are almost always human-related. But the work of our partner organizations brings us hope. And the Animal Experience International volunteers are an inspiring group of dedicated people. We know how satisfying international volunteer work can be and the rewards that come from giving your time and energy to provide the assistance these animal groups desperately need. As a volunteer you gain so much in return – new medical skills, friendships, professional connections, personal growth and the satisfaction of having done something incredibly important for animals. Animal Experience International can help you find the experience that is perfect for you. For full details about AEI’s programs, please visit our website at www.animalexperienceinternational.com. We look forward to working with you and helping you live your dreams, travel the world, and volunteer with animals!
Canine Toxins Lurking in the Equine Tack Trunk Hovda TK, Hovda LR, Pet Poison Helpline, Bloomington, MN
About Pet Poison Helpline Pet Poison Helpline, an animal poison control center based out of Minneapolis, is a cost-effective animal poison control centre in North America, charging $39 (USD) per call. This price includes unlimited follow-up consultations. Pet Poison Helpline is available 24 hours, seven days a week for pet owners and veterinary professionals that require assistance treating a potentially poisoned pet. The staff provides treatment advice for poisoning cases of all species, including dogs, cats, birds, small mammals, large animals and exotic species. Pet Poison Helpline is available in North America by calling 800-2136680. Pet Poison Helpline also has an iPhone application with an extensive database of over 200 poisons dangerous to cats and dogs. The app, “Pet Poison Help,” is available on iTunes for $1.99. For more information, please visit www.petpoisonhelpline.com. Equine tack trunks are typically stuffed full of horse paraphernalia, but buried in among the leg wraps, bell boots, brushes, and braiding utensils lurk some products that are poisonous to dogs. Access to them is easy for dogs – trunk lids are left open, grooming kits taken out and placed on the ground, or medications are removed for administration and forgotten next to the horse’s stall. Sometimes dogs are just curious and sometimes they are lured to the tack trunk by smells of horse treats or people food. Whatever the case, when dogs find and eat these toxins, the results can be deadly.
Nonsteroidal Antiinflammatory Drugs At least one nonsteroidal anti-inflammatory drug (NSAID), such as phenylbutazone oral paste, tablet, or powder; flunixin oral paste; or diclofenac topical cream is usually found in most tack trunks. Phenylbutazone is by far the most common, primarily because of availability and low cost. It is not unusual to find a bottle containing anywhere from 50 to 100 one-gram tablets or a two-pound container containing 1 gram of phenylbutazone/2 teaspoonsful of powder. Phenylbutazone paste, however, is the most popular, generally containing 6 or 12 grams of phenylbutazone/tube; a few generic products now contain 20 or 30 grams 36
of phenylbutazone/tube. The large amount of phenylbutazone in these products is of concern should a dog, especially one of the smaller breeds, find them and ingest the contents. Clinical signs associated with overdoses in dogs are related to the gastrointestinal, renal, hepatic, and circulatory system. The most common signs are anorexia, abdominal pain, vomiting, diarrhea, and edema followed by weakness, tremors, ataxia, jaundice, renal insufficiency, and blood dyscrasias. Most dogs will start to show signs after eating only a small amount of phenylbutazone and 3 grams can be a deadly amount for a 10 kg dog. Any dog ingesting equine phenylbutazone (or any other NSAID) should be seen by their veterinarian for an evaluation. In addition to inducing vomiting and providing activated charcoal, supportive care such as agents to prevent or treat gastroduodenal ulcers (i.e. omeprazole, ranitidine, sucralfate, etc.), intravenous fluids, and intravenous diazepam or phenobarbital to control seizures may be needed. Special attention should be paid to the amount and rate of fluid therapy administered so that edema, a potential side effect in overdoses, does not occur.
Concentrated Pyrethroid Products Many pyrethroid-based fly repellants are used on horses, but the most dangerous to dogs are the concentrated spot-on products containing 45% to 60% permethrins (e.g. Equi-Spot®). Not only are these products highly concentrated, but the volume in each tube is often 10 mLs or higher. It is the combination of the high concentration and large volume that make them so toxic to dogs. The clinical signs and treatment vary depending on the route of exposure and weight of the dog, with the smaller weight dogs generally having the most serious problems. Common clinical signs include hypersalivation, vomiting, diarrhea, dyspnea, seizures, and death. Dogs that open the tube and roll in the product may not show signs for 12-24 hours. Those that chew the tube and swallow the contents have a more rapid onset of signs. In these dogs, drooling and frothing at the mouth begin almost immediately, followed a short time later by abdominal pain, vomiting, and diarrhea. Sometimes dogs rub the product into their eyes with resulting redness, pain, and photophobia. Treatment depends on the route of exposure and weight of the dog. Large dogs with a small skin exposure should be bathed several times in a good degreasing shampoo and seen by their veterinarian if any signs develop. Smaller dogs with a similar skin exposure should be bathed several times and evaluated by their veterinarian. Vomiting should not be induced in dogs with oral exposures due to the risk of aspiration into the lungs. Treatment for symptomatic topical exposures and ingestions may include an antiemetic (e.g. diphenhydramine, maropitant, metoclopramide), stomach protectants (e.g. omeprazole, ranitidine) intravenous fluids, methocarbamol to control tremors, and intravenous phenobarbital to control seizures. If an ophthalmic exposure occurred, one or both eyes should be irrigated with room temperature (not hot) water for 15 minutes and evaluated by a veterinarian.
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Equine Paste Wormers Many riders store spare tubes of an equine paste wormer in their tack trunk. Several different formulations are commercially available and most are harmful when the tube is chewed and the contents eaten by a dog. Ivermectin and moxidectin (e.g. Eqvalan®; Quest®) are newer products with excellent activity against equine gastrointestinal parasites. They are often combined with praziquantel (e.g. Eqvalan® Duo; Equimax®, Quest® Plus®), a drug with known activity against tapeworms. Common signs associated with excessive ingestion of many paste wormers include anorexia, hypersalivation, diarrhea, vomiting, lethargy, and weakness. Depending on the product and amount eaten, clinical signs related to the cardiac, nervous, and respiratory system or even death may occur. The large amount of ivermectin found in equine paste wormers makes it especially harmful to dogs. A 10 kg dog would begin to show signs after swallowing about 1/5 the contents of a tube and have severe signs if an entire tube were chewed and the contents swallowed. Several breeds of dogs, in particular Australian shepherds (normal and minis), Border collies, Collies, Long-haired whippets, McNabs, Shetland sheepdogs, Silken wind hounds, and other herding breeds (“white footed”), have an ABCB1 genetic mutation that makes them susceptible to central nervous system (CNS) poisoning at very low doses. In these breeds, lethargy, weakness, ataxia, hypersalivation, mydriasis, blindness, and seizures can appear in as little as 4 hours after an overdose. A veterinarian or animal poison control centre should be consulted anytime a dog eats an equine paste wormer. The specific product as well as the weight and breed of dog are important pieces of information to obtain. In some instances, emesis followed by activated charcoal once vomiting has stopped, is the only therapy needed. Intravenous fluids and more advanced supportive care including hospitalization with nutritional and ventilatory support may be warranted in larger ingestions or smaller weight dogs. Often these dogs require nursing care with attention to decubital ulcer formation for many days due to prolonged recumbency and/ or coma. In several cases of dogs with larger overdoses of ivermectin and moxidectin, an intravenous lipid emulsion (ILE) has been used successfully as a potential antidote. Dogs with
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the ABCB1 genetic mutation require early and aggressive decontamination and similar but more extensive supportive care for survival and even then, many do not live. Intravenous lipid emulsions have been used as a potential antidote in these dogs but sadly do not seem to be as effective.
Methocarbamol has been used therapeutically in dogs for many years, but the main issues here are the size of the dog versus the size of the equine product and the amount ingested. Clinical signs of poisoning in dogs are rapid in onset, usually occurring within 1-2 hours, and include hypersalivation, vomiting, weakness, lethargy, ataxia, sedation, loss of consciousness, and death.
Hydrocarbons or “petroleum distillates” are substances that contain hydrogen and carbon as their main ingredients. There are thousands of hydrocarbon products on the market, ranging from gasoline to mineral oil and others. Tack trunks are strongholds of these products, frequently containing baby oil, clipper lubricating oil, various hoof treatments, coat enhancers, sweat solutions, liniments, and other hydrocarbon-containing products.
The rapid onset of signs mandates that dogs must be seen immediately by a veterinarian for evaluation and treatment. If the dog is conscious, the veterinarian may induce vomiting and administer activated charcoal once vomiting is completed. If the dog is unconscious, vomiting should not be induced. Further care is supportive but generally includes intravenous fluids and good nursing care.
Toxicity in dogs depends on the specific agent, amount ingested, and route and duration of exposure. Dogs with a skin exposure may develop irritation or burns, while those drinking or licking the product may have gastrointestinal problems such as vomiting or diarrhea; nervous systems signs including lethargy or depression; or more rarely cardiac arrhythmias. Dogs that vomit run the risk of aspiration pneumonia requiring hospitalization with extensive antibiotic and bronchodilator therapy. Treatment varies according to the route of exposure and specific product. Dogs spilling a container and rolling in the contents should be bathed with a good degreasing shampoo. Dogs licking or drinking a hydrocarbon-based product should not have emesis induced and a veterinarian or animal poison centre should be consulted prior to therapy. Specific care depends on the product involved but intravenous fluids, stomach protectants (e.g. omeprazole, ranitidine) and thoracic X-rays may be needed.
Methocarbamol Methocarbamol is a widely used skeletal muscle relaxant in horses, especially in the hunter and jumper arena. Many different forms powder, paste, or tablet – are available for use in horses and can be found in tack trunks. Dogs with access to open trunks may chew up the containers and eat the contents, sometimes as many as several hundred pills or a pound or two of powdered methocarbamol.
Human Medications It is not unusual for people to store human medications in their tack trunks. Aspirin, acetaminophen and other human pain relievers such as the NSAIDs naproxen and ibuprofen are present in some form in just about every tack trunk. Other medications such as multiple vitamins containing iron, calcium and vitamin D supplements, acne medications, topical ointments and creams, and prescription drugs find a home there as well. The use of childresistant containers is of no help as dogs quickly chew up the container and gain access to the medications. Dogs ingesting almost any human medication are likely to develop some sort of clinical signs associated with poisoning. The onset and duration of signs depends on the specific substance as well as the weight of the dog. Accurate identification of the product as well as consultation with an animal poison control centre and veterinarian is necessary for a good outcome. The assumption by many owners that one or two pills or a lick or two of a topical product will do no harm may prove deadly. When human medications are involved it is always best to consult with a veterinarian or animal poison control centre.
Flying with Pets UK - It’s possible to fly pets to a number of locations around the globe, but it comes at a steep cost. A recent trip with a chocolate Labrador flown from London to Sydney, Australia cost more than £4,000, which is about $6,430 U.S. Apparently enough people are willing to pay high fees to make sure their pets are where they need to be. According to the U.K’s Animal Health and Veterinary Laboratories Agency, 139,000 dogs were brought into the UK last year compared with 85,000 in 2011. Imports of cats jumped 74% to more than 14,000. Even ferrets, rose from 68 in 2011 to 93 in 2012.
IDEXX Laboratories announces a new test to help manage diabetic patients Feline Parasites
PEDv US - Researchers have discovered evidence that Porcine Epidemic Diarrhea virus, or PEDv, can be carried through the air on dried fecal matter. Previously, scientists had found the swine virus was transmitted only by physical contact, or carried in on dirty boots or contaminated equipment. (Vet Advantage - Reuters) 38
US - Researchers at the University of Florida have identified a new species of Tritrichomonas parasite in domestic cats. The new species, Tritrichomonas blagburni, causes an intestinal disease which results in chronic diarrhea, flatulence and fecal incontinence. (Veterinary Practice News Heska Corporation announced the launch of the Element POC.
US - IDEXX Laboratories announced the addition of fructosamine testing to its test menu for the Catalyst Dx Chemistry Analyzer. With a single fructosamine slide, veterinarians can get an average of blood glucose levels for the previous 2-3 weeks using just one blood sample with results available during the client visit. When run in support of glucose curves, fructosamine testing with the Catalyst Dx analyzer provides a more complete view of patient health, facilitating diabetes management for patients, clients and staff. (veterinary advantage weekly news).
US - This latest generation, handheld, wireless rapid blood analyzer delivers rapid blood gas, electrolyte, metabolite, and basic blood chemistry testing. (Brakke)
1. Estrumate 2. Proin 3. Denagard 4. Zuprevo 5. Ventipulmin 6. Excenel 7. Sedivet 8. Onsior 9. Fortekor 10. Zactran
a) b) c) d) e) f) g) h) i) j)
ceftiofur sodium romifidine HCl benazepril HCl phenylpropanolamine HCl robenacoxib gamithromycin clenbuterol HCl cloprostenol tiamulin tildpirosin
Source: Compendium of Veterinary Products -25th Anniversary edition Answers: 1 h), 2 d), 3 i), 4 j), 5 g), 6 a), 7 b), 8 e), 9 c), 10 f)
BANFIELD - Banfield Pet Hospital® announced a partnership to create affordable programs for becoming a Credentialed Veterinary Technician (CVT). Through this partnership, any Banfield associate can enroll in Penn Foster’s veterinary technician degree program at a discounted rate to help reach their career goal of becoming a CVT. Banfield is committed to increasing the number of CVTs throughout the profession and is working to support demand for this growing career in a variety of ways. The practice is also piloting a CVT Development Program to pay a percentage of Penn Foster’s tuition for a number of veterinary assistants currently working in its hospitals. Banfield intends to expand this program and open it to more associates in 2014, as part of its ongoing commitment to increase the number of veterinary technicians working in the profession. (veterinary advantage weekly news).
US - There’s something new on the menu in Montana and it comes fresh from the local Interstate. Eating roadkill is now legal in the U.S. state, under a new law that took effect September 30, 2013. Some residents there said the potentially good meal should not go to waste, even if the animal came to what some would consider an unseemly end. (cbc.ca)
Global news Banfield, Penn Foster partner to offer affordable programs for certification
Eating roadkill legalized in Montana
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Did You Know? 9 leading causes of bird deaths in Canada. Cats are the No. 1 culprit, followed by collisions with tall structures 1. Domestic and feral cats: 200 million 2. Power lines, collisions and electrocutions: 25 million 3. Collision with houses or buildings: 25 million 4. Vehicle collisions: 14 million 5. Game bird hunting: 5 million 6. Agricultural pesticides 2.7 million 7. Agricultural mowing: 2.2 million young birds, equivalent to one million adult birds 8. Commercial forestry: 1.4 million nests, equivalent to 900,000 adult birds 9. Communications towers: 220,000 (excerpted from cbc.ca) The oldest evidence of dogs in North America comes from the northernmost outposts, where Inuit sled dogs can be traced back to animals who lived there more than 10,000 years ago. Discovery News reports that the genetics of the animals suggests that they originated in Asia, and are thought to have followed people across the landmass that once covered the Bering Strait. These dogs show no European heritage in their genetic makeup, making them rare among American dogs, most of whom can be genetically linked to animals brought over with European settlers of the New World. Cats have 32 muscles that give them the ability to control the direction of their ears, including rotating them in opposite directions. veterinarypartner.com When it comes to stretching before any activity, no personal trainer or coach will ever be as committed to the idea as the average cat. When a cat wakes up, she carefully stretches every muscle to make sure her strong, supple body is ready for action. Typically, the stretching routine starts with a good arching of the back and a very, very big yawn. Next is a full-body stretch, right down to the tip of the tail. veterinarypartner.com US - In three decades, the number of white-tailed deer has gone from 300,000 to more than 30 million, and with them, the numbers of ticks have likewise exploded. Deer are hosts for ticks, taking the heinous hitchhikers everywhere they go. As the animals take over suburbs and are now pretty common in cities as well, tick-borne diseases are of even greater concern to veterinarians and physicians alike. Wacky pet names from the VPI 2013 database CAT
Sir Knuckles da Dragon
Hot Rod Whoofington
Rum Tum Tugger Too
Bunny Money Dogg
TECHNEWS | VOLUME 37 ISSUE 2
Pet music truly does have calming charms. A Juilliard-trained pianist and an expert in the therapeutic value of sound have been steadily producing music aimed at calming pets and people alike. The “Through a Dog’s Ear” and “Through a Cat’s Ear” collections have been clinically shown to help pets relax. The company recently released a collection of CDs for noise-phobic pets in conjunction with dog-trainer Victoria Stillwell, as well as a small, self-contained player called iCalmDog that loops the selections for constant play while the pet is alone. The iCalmDog is $79 from ThroughADogsEar.com or other retailers. 11 Business Scams That Can Destroy Your Practice. You may have heard stories about practices falling for a business scam and losing data, money or even their business. Perhaps you’ve fallen for a scam yourself. Don’t feel bad. Today’s scam artists are getting more and more sophisticated when it comes to sending offers and warnings that look very real, from legitimate companies you’d normally trust. They simply emulate the marketing style of companies, using the same look, feel and logos so it’s easy to be fooled. Here is an outline of 11 scams to watch out for: • “Your Password Has Expired” email • Directory advertising • “The customer overpaid” • Domain renewal notification • Donation request for a worthy cause
• “Online orders” or “invoices” • “Government Information Needed” • “Your company is a winner” • Email address blackmail • Hotel request for information
• Free WiFi offer
With the right information, you can outsmart the scammers and protect your practice. For more information, go to American Express’s Open Forum blog: (https://www.openforum.com/articles/11-scams-that-can-destroy-your-business/?extlink=of-syndication-sb-p)
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TECHNEWS | VOLUME 37 ISSUE 2
TechNews winter 2013