Download Group 10 pgs. 907

Shake Things Up to Grow Your Practice
Denise Tumblin, CPA
Wutchiett Tumblin and Associates
Columbus, OH
Making your practice more profitable and positioning it for continued success isn’t about luck. You don’t roll the dice and hope to
meet your medical and financial goals for the year. Being profitable is about playing the right hand at the right moment and making
changes in your practice that maximize your strengths. So use these five critical steps to ensure your practice will be flush with
success.
Step #1: Enhance patient care
Differences in medical philosophies baffle doctors, staff, and clients and can lead to shortcomings in patient care. Say your standard is
to perform annual wellness testing on all your senior patients. But only two of four doctors follow the protocol. This puts half your
patients at a medical disadvantage. Don’t make people guess what you want. Define your standards of care, get them in writing, and
use them as a teaching tool to communicate your expectations to doctors and staff. Your goals are to provide high-quality care,
nurture lasting client relationships, cultivate happy, productive doctors and staff, and enjoy a fun, profitable practice.
Every team member at your practice must be knowledgeable about your standards for the sake of consistency and continuity. It’s
up to you to teach and mentor your team members and communicate your expectations for upholding those standards of care. An
effective training program ensures that new team members start off on the right foot and become successful. Regular internal and
external CE encourages team members to grow and will net your practice major rewards in the future. Improving staff expertise frees
you to focus on other things – like seeing more patients, taking a lunch break or ending the day on time.
Step #2 Create client-centric experiences
Yes, it’s easy to go on autopilot in the exam room – especially when this is the sixth time today you’ve explained the importance of
heartworm and flea prevention or discussed why it’s not a good idea to delay the dental prophylaxis any longer. These days, however,
you simply can’t afford to coast. Every time you’re about to step into the exam room, take a moment to refocus your energy on this
particular client and patient. Look at the chart and note a couple of unique characteristics about this pet and owner. Then mention
them during the visit.
The bottom line is that you want your clients to receive care that’s relevant to them, custom-built for their pet, and different from
what they can get anywhere else. Rather than talking throughout the appointment, try pausing for a few minutes at appropriate
moments so you can listen – truly listen – to what your clients are saying. Make the experience about them. Being strongly present
with each client and each patient creates inspiration in pet owners. Inspiration creates magnetism. And magnetism gets your clients to
“yes”.
Step #3: Improve profitability
Define your goals for spending and revenue growth. Set revenue and expense goals and then share them with the team members
who’ll help you achieve them. And don’t forget to measure and analyze your performance. Create a systematic approach to
reviewing your monthly results, and develop an action plan to respond to problems or opportunities you identify during this review.
Search “budgeting basics worksheet” at www.dvm360.com for a tool to get you started. See figure 1, WellMP® Revenue Chart.
Step #4: Tap into revenue growth
Send consistent messages to clients with concise, clear, and specific recommendations. Clients should hear the same message from
everyone on your team. If your standard is six-month exams for all senior patients, and the doctor and the technician explain that in
the exam room but the receptionist says, “See you next year,” the client will leave confused. Set compliance targets for the services
you perform most often and that are most important to your patients and monitor the results (for a detailed plan on how to do this, see
“Hit Your Goals” - Figure 2). Provide timely reminders about important services. Proactively take the lead with your clients by
offering to schedule the next appointment at the end of the visit instead of waiting for the client to ask about additional care or other
services.
Billing clients for all care provided is an opportunity to improve profit without raising fees. Track how often and by how much
you’re missing charges by completing a Case Review. Pull a random sample of 10 hospitalized cases and 10 outpatient visits for each
doctor. Divide the cases among your healthcare team and ask them to compare the medical record of services provided to the client’s
invoice for services billed. Make a copy of the invoice and write a list at the bottom of the care that was provided for free (either
intentionally or unintentionally) and the amount of the usual fee. (See “Case Review Summary”, Figure 3 to help you tally the
results.) Discuss and identify why the charges were missed. Are the doctors recording charges at the time of treatment – or waiting
until later? Are they waiting until discharge to record charges for hospitalized cases? What discounts are doctors giving? Are your
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team members creating estimates on the fly and underestimating prices? These scenarios lead to missed charges. Once you have an
idea of why charges are slipping through the cracks, develop an action plan to improve how your practice charges for care provided.
Step #5: Protect your pharmacy
They may not know it, but clients receive amazing benefits if they purchase medications like heartworm, flea, and tick products from
you rather than a pet specialty store or Internet pharmacy. Your job is to educate them about these benefits. Emphasize your quality
control for handling and storing drugs. Share information about manufacturer guarantees. Highlight the convenience of purchasing
necessary medications during client visits or ordering from your practice’s on-line home-delivery pharmacy.
Plus – and this is very important – be sure clients know that your products are comparably priced. Many national retailers claim
that they’re less expensive, but often it’s simply not true. Clients, however, don’t realize this unless you point it out
The potential impact on revenue from lost product sales is significant, and many Well-Managed Practices are feeling the pinch.
Thirty-four percent of Benchmarks 2013 participants report that their volume of medication dispensed dropped 5 percent or less in the
last two years, while another 37 percent reported a decline of 6 percent to 10 percent (see Figure 4 for a year-to-year comparison).
In an Elanco-sponsored survey of approximately 1,600 dog owners, four out of five owners purchased flea medication from only
one place, and 36 percent purchased exclusively through their veterinary clinic. Building your own online pharmacy may help
increase those numbers. Plus, the study found that dog owners who purchased their flea and tick medication through their veterinarian
were likely to visit the practice more often in the preceding year than pet owners who purchased from warehouse retailers or online
pharmacies. So encouraging clients to buy from you not only protects revenue from that sale but also bonds pet owners to your
practice and may even help drive up visit rates.
Step #6: Market your practice
For some, the word marketing conjures up thoughts of pushy salespeople touting their product or service as the “best”, whether that
claim is true or not. Some veterinary practices have been reluctant to advertise because of concerns it would seem unprofessional. If
you share similar opinions, it’s time to let go of the negative and embrace the positive side of marketing.
Marketing is really designed to create awareness and educate potential and existing clients about the care their pets need and the
services and products you have available. Marketing drives client visits and revenue growth. Patients are more likely to get the care
they need because of marketing. Your marketing plan will identify the messages you want to promote, the platforms/formats you’ll
use to get your messages out, who’s responsible for each segment of the plan, how much time will be allotted to implement each
segment of the plan, the budget you’ve got to work with, the results you want to accomplish, and a plan for monitoring and tracking
the results.
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Figure 1 – WellMP® revenue chart
The key to successful revenue is to consider every factor that affects your revenue. Shown below are the 12 critical components of
revenue and comparisons from Well-Managed Practices®. Measuring your practice’s results against these benchmarks will help you
identify opportunities for growth.
Revenue
All revenue
Medical revenue
Other revenue
Average doctor transactions (ADT)
Your
WellMP®
Practice
ADT
$173
$____
Exam
$ 50
$____
Other
$ 61
$____
Fees
Services
The overall fee structure and
the service/product mix are
the two main determinants
of a hospital’s ADT.
Accounts Receivable
Your
WellMP®
Practice
1.6%
_____
Awareness
How well known is your
practice in the community?
Your
Practice
$______
$______
$______
WellMP®
$617,100/Doctor
$555,100/Doctor
$ 62,000/Doctor
Transactions
All transactions
Medical transactions
Other transactions
Active Clients
Your
Your
WellMP®
Practice
990/Dr.
______
WellMP®
5,200/Dr.
2,900/Dr.
2,300/Dr.
Visitation
WellMP®
Medical
3.0/yr.
Other
2.2/yr.
New Clients
WellMP®
18/Mth/Dr.
Your
Practice
_____
_____
_____
Practice
_____
_____
Retention
Your
Practice
_____
Visits Scheduled
Your
WellMP®
Practice
70%
_____
WellMP®
4.3 yrs.
Your
Practice
_____
Age of Active Patients
Your
WellMP®
Practice
< 3 yrs.
27%
_____
3-6 yrs.
26%
_____
6-9 yrs.
22%
_____
> 9 yrs.
25%
_____
Figure 2 – Hit your goals
Randomly choose 20 outpatient medical records per doctor. Compare the care provided per the medical record to the ideal care
outlined in your standards. Identify whether:
•
The recommended care met your practice’s standards.
•
The patient received the recommended care.
•
The record noted any recommended care the client declined.
Compile the results and calculate your client compliance rates. If your actual compliance rates are lower than your targets, discuss
the results with your team and develop an action plan to improve your success rate.
Example
A three-doctor practice with 4,500 active patients (60% canine, 40% feline) pulled 60 medical records. Thirty of the record samples
were canine patients and thirty were feline patients. The hospital’s standard of care includes annual fecal exams and annual
heartworm testing for all patients. The staff reviewed the record sample for compliance with fecal and heartworm testing. Their
results follow.
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Active
Target
Tests
Services
Patients
Increase
Needed
Fecal exams: The team reviewed 60 records: 30 of the
4,500
x
20%
=
900
patients had a fecal exam. So the compliance rate was 50
percent.
Canine heartworm testing: The team reviewed 30
2,700
x
15%
=
405
records; 24 patients had a heartworm test. The
compliance rate was 80 percent.
Feline heartworm testing: The group reviewed 30
1,800
x
15%
=
270
records; nine of the patients received a heartworm test.
The compliance rate was 30 percent.
Total potential increase in revenue = $50,400
910
x
Fee
$23
fee
=
Increased
Revenue
$20,700
x
$40
fee
=
$16,200
x
$50
fee
=
$13,500
Figure 3 – Case review summary in a well-managed practice®
Doctor or Practice Name __________________________
Outpatient Case Analysis
1.
2.
3.
4.
5.
6.
7.
Number of cases reviewed
Number of cases with missed charges
Percent of cases with missed charges (line #2 ÷ line #1)
Total dollar value of missed charges
Average dollars missed per case (line #4 ÷ line #2)
Estimated annual number of outpatient cases
Estimated annual missed charges (line #6 x line #3 x line #5)
________
________
________
________
________
________
________
Types of services or products missed
____________________________
____________________________
____________________________
____________________________
____________________________
____________________________
Inpatient Case Analysis
1.
2.
3.
4.
5.
6.
7.
Number of cases reviewed
Number of cases with missed charges
Percent of cases with missed charges (line #2 ÷ line #1) ________
Total dollar value of missed charges
Average dollars missed per case (line #4 ÷ line #2)
________
Estimated annual number of inpatient cases
Estimated annual missed charges (line #6 x line #3 x line #5)
________
________
________
________
________
Types of services or products missed
____________________________
____________________________
____________________________
____________________________
___________________________
___________________________
___________________________
___________________________
A. Total estimated annual missed charges (Outpatient line #7 + Inpatient line #7)
B. Total annual doctor transactions (Outpatient line #6 + Inpatient line #6)
C. Estimated increase in Average Doctor Transaction (line A ÷ line B)
________
________
________
Figure 4 – Slipping product revenue
How much has your volume of medication dispensed declined in the past two years because clients are using internet pharmacies?
No change
Less than or equal to 5%
6% to 10%
11% to 20%
More than 20%
2013
23%
34%
37%
5%
1%
2011
13%
48%
32%
7%
0%
2009
13%
52%
28%
5%
2%
2007
15%
63%
27%
3%
1%
2005
19%
65%
12%
4%
0%
Source: Benchmarks Well-Managed Practice Studies by Wutchiett Tumblin and Associates and Veterinary Economics
911
It’s Time to Get Serious about the Budget
Denise Tumblin, CPA
Wutchiett Tumblin and Associates
Columbus, OH
What would you do with an extra $10,000 to $20,000? How about an extra $50,000? Perhaps you’d invest in that new piece of
equipment you’ve been eyeing. Perhaps you’d invest in raises for deserving staff members. Perhaps you’d set it aside to build a
cushion for a rainy day, or even give yourself an overdue raise. It’s fun to dream about the possibilities of extra cash in your pocket.
Watching what you spend may come naturally in your practice. You work with a practice budget, compare your numbers to the
WellMP benchmarks, and adjust your spending when necessary. If so, kudos to you and your staff! But if you’re not quite where
you’d like to be when it comes to taking charge of your expenses, now’s the time to put your expenses on a diet.
Rather than adopting the “starvation” approach to accumulate the extra cash, start with these Five Easy Slim Downs and these
benchmarks to help you pinpoint where your spending is a little heavy. Then get started with your practice slim down to save that
extra $10,000 to $20,000 towards your dream list.
Pare down your drug inventory
If your shelves are looking a bit bloated, it’s time to eliminate the excess. Veterinarians have many wonderful drugs to choose from to
treat patients. But carrying every wonderful medication that’s available ties up a lot of cash and creates confusion for the staff and for
clients. Doctors – unite! Create a list of the medications that you believe in the most. Conduct a scientific comparison of the
duplicate products you have on your shelf. Consider the pros and cons, safety, and efficacy of each. Make your case scientifically
and medically and come to a consensus among the doctors about what’s your best and second choice. Then eliminate any other
redundant items from your shelves.
•
Tip: Stock $10,000 to $16,000 of drugs and medical supplies per full-time equivalent doctor, or about one month’s
supply. This includes heartworm, flea and tick products and excludes diets.
•
Tip: Spend 8% to 9% of revenue on drugs and medical supplies. Spend 4% to 6% of revenue on heartworm, flea and
tick products.
•
Tip: Move infrequently-used medications to your on-line store.
Evaluate your labor cost
What one or more things could you do differently to increase efficiency and productivity in your hospital? It’s not unusual for
different practices to have the same level of staff support, but significantly different levels of doctor production. I’m currently
working with two practices, each with a 4 to 1 staff-to-doctor ratio; one generates about $440,000 of medical revenue per FTE doctor
and the other generates $670,000 per FTE doctor. What accounts for the $230,000 difference? Explore the following opportunities to
rev up your practice’s productivity.
•
Do more with less. Bump your pay scale to attract more skilled and efficient employees. We’ve all experienced the
employee who seems to get twice as much done in half the time as two other employees combined. You might find that
an employee who merits $18 an hour could easily complete the work of two, less productive $12 an hour employees.
The result: an annual savings of $10,000 to $12,000 depending on the benefit package.
•
Streamline your processes. It’s easy to get into the routine of “that’s the way we’ve always done it.” Take a fresh look
at your protocols – are you doing things the easiest, most efficient way, or could you streamline the process? Are staff
members duplicating efforts? Eliminate the redundancies. Are you taking extra time to track information that no one is
using? Then stop.
o Tip: Hold a contest for your staff. Ask each staff member to submit one or two ideas to improve efficiency
throughout the hospital (reception, exam rooms, treatment, surgery, boarding, etc.). Give awards for the top
four ideas (first, second, and third place, and honorable mention). Be sure your awards are meaningful and
compelling. For example, first prize gets a paid day off; second prize gets a gift certificate for a local spa;
third prize a gift certificate for a favorite local restaurant; and honorable mention gets tickets to the movie of
their choice. Or, you could let the winners choose which award they would like out of your offerings.
•
Get organized. Clutter and untidy work stations add to the chaos of busy days. Spend a day eliminating the mess.
Move frequently used items to more accessible parts of the hospital to eliminate wasted steps. Move rarely used items
to storage. Get rid of items in storage that you haven’t used for a year or more. Adopt the creed: reduce, reuse, recycle.
The hospital will look better, and the doctors and staff will feel better and be more productive!
•
Convert under-utilized space to a medical purpose. Some hospitals have idle or under-used space that’s begging for use
as a medical area. For example, convert a food storage space to another exam room. Convert an under-utilized retail
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space to a patient discharge room. Convert an under-utilized storage space adjacent to treatment to a dental suite or a
procedures room.
o Tip: Hold a contest for your staff to solicit their ideas about under-utilized areas of the hospital that could be
converted to medical use. Give awards for the top ideas (see suggested prizes above).
Bump up your use of technology
Update and/or replace hardware to reduce wasted time waiting for the computer to process or recovering from a crash because the
system can’t handle the hospital’s current needs. Update your software to the latest version. Replace your software if the company
hasn’t provided updates for years or their support is poor. Convert to electronic medical records to eliminate wasted time searching
for lost or misplaced records. Technology saves time and reduces frustration when used well.
•
Tip: Hire a trainer from your practice management software company to spend a day with your staff teaching them
more about your software’s capability. Staff members know the basics. But they may not be aware of all the shortcuts
that help streamline their work, or the options that help enhance client service and patient care. The return you’ll
receive will be much greater than the cost of the training. Example: One veterinary practice estimated that the
knowledge they gained from the training saved three staff members an hour a day, which amounted to an annual labor
savings of about $15,000.
Revisit your administrative costs
It’s easy for fixed overhead spending to creep up without realizing it. Don’t let the word “fixed” change your mind about giving these
expenses another look.
•
Use e-mail for reminders, newsletters, educational materials, and other client correspondence instead of the U.S. postal
service. Postage adds up and clients may actually prefer to receive information via e-mail.
•
Take stock of your office supplies. Organize your inventory in one central location so everyone knows what you have
on hand before requesting and ordering more. Change reorder points to minimize the amount of inventory you have on
the shelf before placing a new order.
•
Evaluate employee health insurance. Talk with your insurance agent about health insurance policies with higher
deductibles and co-pays. Sometimes the premium savings is greater than the difference in the deductible, so you can
offer to pay part or all of the difference in the deductible and still lower the practice’s cost. Ask your agent to research
other policies with lower premiums and similar coverage options. Consider having employees cover part of their health
care.
•
Assess your Workers’ Compensation Insurance rates. Coverage managed by a private insurance company, if an option
in your area, might offer better rates than a fund managed by your state.
•
Conduct an energy audit in your practice. A professional energy audit gives you a clear picture of where your practice
is losing energy and what you can do to save money. Possible resources to conduct the audit include your state or local
government energy or weatherization office or your electric or gas utility company. Per www.energy.gov, you can save
5% to 30% on your energy bill by making the recommended upgrades. Visit www.greenyour.com for an energy audit
checklist.
•
Investigate the possibility of refinancing your debt. If you’ve got any high-rate loans, act now to see what your options
are for getting into a more favorable rate.
Think twice before investing in equipment
Do the math to determine if the equipment purchases you’re planning will pay for themselves in a reasonable timeframe. Investing in
equipment helps you enhance patient care and client service, and grow your practice. But fabulous equipment rarely used, is a poor
investment. Take the time to evaluate how often you’ll use the equipment and the revenue potential before taking the plunge.
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Compare your expenses to these benchmarks
Variable expenses (as a percentage of total revenue)
Drugs and medical supplies (includes radiology, surgery and hospital supplies but
excludes food, shampoos, etc.)
Heartworm, flea, and tick products
Laboratory
Diets (therapeutic and retail)
Over-the-counter retail products (e.g. toys, collars, shampoo)
Credit card fees
Bad debt, collection fees
Cremation, care of remains
Sales and use tax
Medical waste disposal/radiation badget monitoring
Total
Fixed expenses (as a percentage of total revenue)
Advertising and promotion
Bank charges (monthly maintenance fees)
Business consulting services
Business meetings
Charitable contributions
Continuing education, meetings, and travel
Entertainment
Equipment repairs, maintenance, and support contracts
Health insurance
Laundry and uniforms
Legal and accounting fees
Liability insurance
Licenses and permits
Miscellaneous
Office and computer supplies
Payroll service costs, retirement plan administration fees
Postage, freight, and delivery
Printing
Professional dues and subscriptions
Technical (IT) support contracts
Telephone, answering service, internet connection
Workers’ compensation insurance
Total
9.8%
3.9%
4.0%
2.9%
0.4%
1.5%
0.1%
0.5%
0.7%
0.1%
24.0%
0.8%
0.1%
0.3%
0.1%
0.1%
0.4%
0.1%
0.4%
2.0%
0.1%
0.5%
0.2%
0.1%
0.4%
0.7%
0.2%
0.2%
0.2%
0.2%
0.3%
0.5%
0.4%
8.3%
Non-doctor staff compensation (gross W2 wages as a percentage of total revenue)
Wages
Payroll taxes & retirement contributions
Total
21.6%
2.5%
24.1%
Facility expenses (as a percentage of total revenue)
Annual rent or mortgage payments (excluding property taxes, insurance & utilities)
Utilities (gas, water, electric)
Janitorial, housekeeping, and garbage
Facility repairs, maintenance, lawn care, and security monitoring
Property insurance
Real estate taxes
Total
5.4%
0.8%
0.4%
0.6%
0.2%
0.5%
7.9%
Reinvestment
Medical equipment
Computer equipment
Facility improvements
Total
2.0%
1.0%
1.0%
4.0%
914
What Well-Managed Practices Pay:
Are You in the Ballpark?
Denise Tumblin, CPA
Wutchiett Tumblin and Associates
Columbus, OH
Practices must stay on top of current trends in doctor and staff compensation and benefits to remain competitive and attract efficient,
effective and productive employees. Pay scales must also reflect the level of education, experience, skill and personal attributes you
want employees to bring to the table. So, what are the latest trends? Benchmarks 2013 – A Study of Well-Managed Practices® sheds
light on this hot topic.
Employed veterinarians
The majority of practices now pay their doctors some form of incentive-based compensation. About 27% pay purely based on
production. Another 48% pay doctors a guaranteed base plus a percentage of production over a required minimum. The remaining
25% pay their doctors a fixed salary.
Practices who use a blended rate – i.e., one percentage applies to all medical service and product production – typically pay their
doctors between 16% and 21%. Where they fall in the range is dependent upon the practice’s staff-to-doctor ratio. The more staff the
practice provides to assist the doctors, the lower the percentage paid to the doctors. The additional staff members allow the doctors to
produce at a higher level, which increases doctor compensation. The practice also has an added layer of overhead because of the
additional staff members, which the doctors must help support.
Practices who use a split-rate – i.e., one percentage applies to medical service production, and a different percentage applies to
medical product production – typically pay their doctors between 22% and 26% for services, and 4% and 10% for products. The
service/product split – i.e., how much of medical revenue comes from services and how much from product sales - and the staff-todoctor ratio will both impact where you end up in the stated ranges.
To make any percentage-based compensation system work, every team member must understand what is and isn’t credited to the
doctor’s individual production. Doctors receive credit for all medical service revenue provided during an outpatient appointment, inhospital treatment, or dental and surgical procedures. Doctors also receive credit for medications and therapeutic foods dispensed
during an outpatient appointment, during in-hospital treatment, or at the end of a patient’s hospital stay.
Prescription refills and additional food or product purchases that don’t involve a doctor are credited to a hospital provider. The
doctor receives credit for the refill only if it requires his or her time to review the record, assess if the medication or dosage needs to
change, and give direction to the staff member who will fill the prescription. Doctors never receive credit for boarding, grooming, or
retail purchases.
When multiple doctors collaborate to treat a patient, the doctor who provides each point of care receives credit. For example, if
Doctor A examines and admits a patient to the hospital on Day 1, and Doctor B provides or supervises the hospital treatment on Day
2, Doctor A gets credit for everything on Day 1, and Doctor B gets credit for Day 2.
See Figure 1 for the latest on starting salaries for associates based on years of experience. See Figure 2 for other employee
benefits.
Non-doctor staff compensation
Practices spend between 21% and 25% of revenue on staff compensation, payroll taxes, and retirement contributions. This includes
all non-doctor staff positions except groomers – so, hospital administrators, practice managers, receptionists, credentialed technicians,
veterinary assistants and kennel/ward attendants are in this number. Where you fall in this range will depend on the cost of living in
your area, the skill set of your staff, and your staff-to-doctor ratio. See figure 3 for the latest pay ranges by position.
If your staff costs are high, start by evaluating productivity. Often the issue isn’t over-spending, but rather lower-than-expected
productivity. Low productivity has a variety of reasons. Sometimes it’s caused by giving away or significantly discounting care that
the practice provides. Sometimes it’s related to a lower-than-warranted fee structure. Sometimes it’s due to a lack of skills or
inefficient processes. And, sometimes a practice employs people who are a poor fit and who put a damper on the morale of the other
team members. Before you start thinking of ways to cut staff expenses, first determine why your cost is high.
Resources to help evaluate your compensation and benefits
•
Benchmarks 2013 – A Study of Well-Managed Practices®
•
Compensation and Benefits by AAHA Press
•
On-line sources such as www.salary.com or www.payscale.com
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Figure 1 – Starting salaries for employed veterinarians
Years of
75th
Experience
Median
Percentile
0 to 2.9 years
$67,500
$75,000
3.0 to 5.9 years
$76,000
$90,000
6.0 to 10.9 years
$79,500
$100,000
11.0 to 15.9 years
$90,000
$105,000
16.0 to 19.9 years
$87,500
$106,500
20+ years
$94,000
$105,000
Source: Benchmarks 2013 – A Study of Well-Managed Practices® by Wutchiett Tumblin and Associates and Veterinary Economics;
the latest compensation and benefits results from Benchmarks 2015 will be provided during the presentation.
Figure 2 – Benefits in well-managed practices
Percent Who
Provide
Continuing education
96%
Staff single coverage health insurance
87%
Staff family coverage health insurance
23%
Dues & licenses
87%
Retirement plan
85%
Bonus commission
39%
Disability insurance
27%
Child care
2%
Source: Benchmarks 2010 – A Study of Well-Managed Practices® by Wutchiett Tumblin and Associates and Veterinary Economics;
the latest compensation and benefits results from Benchmarks 2015 will be provided during the presentation.
Figure 3 – Pay ranges by position
Low
Low
High
High
Position
Median
75th Percentile
Median
75th Percentile
Hospital Administrator
$22.00
$28.00
$24.25
$30.00
Practice Manager
$21.00
$27.00
$23.30
$28.75
Receptionist
$11.00
$12.00
$15.75
$18.20
Credentialed Technician
$14.00
$16.15
$18.60
$22.00
Veterinary Assistant
$10.65
$12.00
$15.00
$17.00
Ward/Kennel
$8.50
$10.00
$12.00
$13.80
Source: Benchmarks 2013 – A Study of Well-Managed Practices® by Wutchiett Tumblin and Associates and Veterinary Economics;
the latest compensation and benefits results from Benchmarks 2015 will be provided during the presentation.
916
Write an Rx for Your Success (Parts 1 and 2)
Denise Tumblin, CPA
Wutchiett Tumblin and Associates
Columbus, OH
Financial security for your practice and your family takes planning and paying attention. Where do you begin? Take these steps
today to ensure a strong, stable future.
Establish effective documentation systems
Use veterinary and accounting software and a Management Statement™ to manage your patient and financial records. Execute
partnership/shareholder contracts, a buy/sell agreement, lease agreements for equipment and the facility, employment agreements, etc.
Create a foundation for effective practice leadership
Identify the leaders, doctors, and advisors required for practice success. Establish and define responsibility for areas of management
for the owners. Create an internal communication structure. Establish and define the management positions at the staff level. See
Collaborative Teamwork Charts.
Envision the ideal healthcare team
Determine the key positions and the number of support staff needed to meet patient care and client service goals. Define the
parameters for selecting the right people for each position. Establish the pay scale by position and for each level of competency
within each position. Identify the training and education required for continued growth. Define the evaluation and promotion
protocols for your practice.
Determine if the facility configuration and size continues to meet your clients’ and patients’ needs
Do you have a well-designed site and floor plan with ample parking, a sufficient number of exam rooms, and ample treatment and
surgery areas? Does your location continue to be desirable? Is it visible, accessible, and have room to grow? Pay attention to your
physical appearance – the grounds, building, and staff must present a professional, clean, well-maintained image. Stay in tune with
your environment to ensure it’s stress-free, warm and welcoming.
Develop a practice budget
Start with the information you already know – your current year-to-date revenue and expenses. Also consider any additional goals
you want to achieve. Lastly, look at benchmarks set by other practices to get an idea of spending levels (see Benchmarks 2015 A
Study of Well-Managed Practices® at www.wellmp.com/Benchmarks, or Financial Productivity Pulsepoints by AAHA). Keep this
data handy as you plan your revenue and expense changes for the coming year.
•
Revenue. How much will revenue grow next year? Consider planned fee changes, compliance initiatives that will
result in providing more of existing services, and new services you’re adding to the practice such as laser therapy,
ultrasound, behavior consulting, rehabilitative therapy, or acupuncture.
•
Expenses. How will your operating expenses change next year? Have you targeted a reduction in some line items like
inventory costs? Are you planning increases in other items like staff compensation or equipment purchases? Determine
where your spending will remain the same, drop or rise.
Develop a personal budget
Tracking your personal household income and expenses and developing a budget provides an organized, systematic approach to
efficiently measure and analyze your personal financial position. Begin with the information you already know – your current year-todate income and expenses. Then consider any changes or new goals for the coming year.
•
Income - Is your share of income from the practice or any other businesses you own likely to increase or decrease? Is
your spouse/partner expecting any increases or decreases in income? Project how your household income will change
for the coming year.
•
Expenses – How will your required expenditures change in the coming year? Consider loan/lease repayments on credit
cards, autos, your home, or any other debts. Plan for any expected increases in property taxes, insurance, utilities,
medical expenses, and auto expenses. Do you have any home repairs on tap? What about alimony or child support?
Consider any changes to discretionary expenditures like clothing, travel and vacations, entertainment, club dues, gifts
and charitable contributions, etc. And, don’t forget about contributions to savings and retirement accounts or your
children’s educational funds.
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Manage your debt
Maintain a Debt Worksheet that tracks all outstanding loans and leases and includes the original debt amount, payoff date, interest
rate, monthly payment, and current outstanding balance. When you’ve got extra cash, make additional payments on loans with no prepayment penalties to reduce the interest paid over the life of the loan. Apply the extra payments towards the highest interest-rate loans
first.
Have appropriate insurance coverage
Talk with your insurance representative to determine your personal and practice needs, including:
•
Auto: consider bodily injury, property damage liability, personal injury, uninsured or underinsured motorist, and
collision and comprehensive coverage
•
Home property insurance: protection for your dwelling, other structures, and personal property, reimbursed living
expenses, flood, earthquake, water backup, identity theft restoration, and a personal umbrella policy.
•
Practice property insurance: two types of policies - named-perils policy, which only covers losses resulting from
particular events named in the policy, and an all-risk policy (also known as special form coverage) which covers all
events except those specifically named. The type of business and your location and region of the country are all
considered when determining which risks are more likely to affect your business. Property insurance covers loss from
fire, theft or vandalism, provides financial assistance to help cover the cost to rebuild or repair business property so that
operations can continue with as little disruption as possible, and includes compensation to repair damaged business
property or replace what you've lost. Other available coverage includes undamaged stock, data or records, computer
virus, intangible coverage, off-premises property, and terrorism.
•
Employment Practices Liability Insurance: protects against claims filed by disgruntled employees.
•
Health Insurance: provides coverage for medical costs.
•
Liability/Malpractice Insurance: protects professional advice- and service-providing individuals and companies from
bearing the full cost of defending against a negligence claim made by a client, and damages awarded in such a civil
lawsuit.
•
Workers’ compensation: offers payments to employees who are (usually) temporarily, unable to work because of a jobrelated injury; compensates for economic loss (past and future), reimbursement or payment of medical and like
expenses, general damages for pain and suffering, and benefits payable to the dependents of workers killed during
employment.
•
Disability Insurance: designed to replace anywhere from 45-60% of your gross income on a tax-free basis should a
sickness or illness prevent you from earning an income in your occupation.
•
Business overhead expense: reimburses a business for overhead expenses should the owner experience a disability.
Eligible benefits include: rent or mortgage payments, utilities, leasing costs, laundry/maintenance, accounting/billing
and collection service fees, business insurance premiums, employee salaries, employee benefits, property tax, and other
regular monthly expenses.
•
Life Insurance: provides cash to your beneficiary(s) in the event of death. Life insurance proceeds are often used to
fund the purchase/buy-back of a deceased partner’s share of the practice.
Review contracts and agreements regularly
Review Employment Agreements annually, practice Operating Agreements every 3 to 5 years and whenever you’re planning a partial
or full practice sale, and Buy Sell Agreements every 3 to 5 years and whenever you’re planning a partial or full practice sale.
Clean up your financial records
Eliminate the mixing and mingling of personal and practice expenses. Be sure that the practice financial statement reflects only the
operating expenses of the practice. Prepare and review the practice’s financial statements on a monthly basis. Prepare separate, costcenter financials if you’re a mixed animal or multiple-location practice.
Conduct annual strategic planning meetings
Strategic planning is a must for businesses to excel and move forward. To determine where the practice is going, you need to know
exactly where it stands, then determine where you want to go and how to get there.
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Complete a financial security plan
Financial planning entails identifying your desired standard of living/income needs, your existing sources of income and the value of
your investments, and the value of your practice and any other businesses you own. See figures 1 and 2 and see
www.wellmp.com/managementtools/itemS2.
Identify who will buy your practice
Will you sell to an existing partner, a current or future associate, an outside independent practitioner, or a corporate consolidator?
Prepare your buyer
If you’re planning to sell to a current or future associate, develop a plan to mentor him or her about the business of veterinary
medicine, involve the associate in management decision-making, explain the sale process, illustrate affordability and discuss
financing.
You can’t plan for every eventuality, but using last year as your baseline, learning from your mistakes, setting quantitative goals
that can be measured, and creating a plan to ensure you achieve your goals will put you well on your way to accomplishing financial
security.
Figure 1 – Investment sources
Investments
Personal
Liquid
Personal
Practice Related
Illiquid
Retirement
Practice
Real Estate
Real Estate
Figure 2 – Planning for financial security
Expenses
Living Expenses
Tax Liability
Annual Cost of Living
$ 110,000
40,000
$ 150,000
Annual Cost of Living
Return on Investment
$2,500,000
$ 150,000
Target Value
Value without Practice
Shortfall
$2,500,000
1,400,000
$1,100,000
÷ 6%
Income
Personal Investments
Practice Real Estate
Practice
$ 700,000
700,000
?
Future Value of
$1,400,000
Investments without PracticeInvestment Base Required
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Collaborative teamwork organizational charts
920
Find Practice Health- Get LEAN!
Denise Tumblin, CPA
Wutchiett Tumblin and Associates
Columbus, OH
Products made in Japan 50 years ago evoked images of mass-produced, low-quality goods. Today Japanese brand names such as
Toyota, Lexus, and Honda signify quality and durability. How were the Japanese automakers able to improve quality and reduce
cost? Did they just get lucky? No, they got Lean!
While Lean started in manufacturing, Lean processes translate to service industries too. There are tremendous opportunities for the
use of Lean in healthcare. A study of human healthcare facilities concluded that the facilities spent 75% of their time on non-patient
tasks related to communicating, coordinating, and documenting care. In addition, a 2003 report by the New England Journal of
Medicine reported a 45% defect rate in human healthcare. The overall goal of applying Lean strategies in healthcare is to initiate a
process of continuous improvement to improve patient outcomes while lowering costs.
Several human healthcare facilities have used these statistics as a lever for implementing Lean. The results are impressive.
ThedaCare, a Wisconsin-based health system, reduced inpatient total cost of care by 25% while improving patient satisfaction to
nearly 100%. Seattle Children’s new surgery center reduced nonoperative time by 50% versus the main campus surgery center.
Lean defines waste as any activity clients view as not adding value to their experience and not meeting their needs. By focusing on
activities which meet the needs of the client, you will realize benefits such as:
•
Improved patient care
•
Improved client satisfaction
•
Improved staff satisfaction
•
Reduced inventory
•
Improved flow of patient care
•
Reduced expenses
Waste goes beyond expired medications. Lean identifies seven areas of waste.
•
Unnecessary services. Do your appointment scheduling and patient protocols include redundant activities?
•
Mistakes. Does your staff regularly need to redo and correct errors?
•
Delays. Do equipment failures and wait times for obtaining charts, medications, and other information happen
regularly?
•
Unnecessary motion. Could you move equipment or supplies to reduce or eliminate wasted effort to increase
efficiency?
•
Over-processing. Review your protocols and processes on a regular basis to determine if they are still relevant and
provide value.
•
Excess inventory. This goes beyond the products stocked for retail sale and doctor use. For example, too many files
leads to the need for more cabinets and more floor space. Do you have files and equipment you have not used for
months cluttering your work area?
•
Excess transport. Do you juggle patients and clients among rooms?
In addition to the above areas, are you “wasting” the skills of your employees? Do you offer your staff the ability to use their
creativity and knowledge to the fullest? Lean processes offer staff members an opportunity to add to practice profitability by creating
ways to eliminate waste. The traditional top-down management style places stress on the owner to lead initiatives and ensure
implementation. Lean processes empower employees to inspect their own work and redesign their work processes to maximize
efficiency. The result - more time to practice medicine and staff members have newfound enthusiasm for their work.
One of the strengths of Lean is its focus on action. You can get started right away with a small project, see immediate results that
excite you and your staff, and leverage this momentum to take on a larger project. The first step - designate a Change Agent. The
leader of your Lean initiative must have an open mind about change and be able to make things happen. He or she can seize upon a
frustrating experience and turn it into an opportunity to start a Lean project. For example, a staff member may struggle to find needed
medical equipment in a storage area. The Change Agent can use this experience as an opportunity to rearrange the storage area in a
way that makes items easy to find and reduces frustration and wasted time.
The Change Agent begins the Lean project by implementing the 5S System for the targeted area of improvement. While originally
5S was used as a tool for maintaining clean work areas, it has evolved into a systematic method for reducing costs, improving work
flow, and empowering employees to assist in reducing waste. The staff members closest to the service now have the authority and
tools needed to improve work processes or work areas.
Once the first Lean project has been identified, begin by taking photographs or video of the area of focus. Before and after pictures
are a powerful tool for showing staff members the benefits derived from Lean initiatives. Next, utilize the 5S steps.
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1.
Sort
•
Eliminate unneeded items within the target area. Dispose of items that aren’t needed. Fight the urge to hold onto
items because you might need them in the future.
2. Set-In-Order
•
Current State. During this step, document the location of each item and the current work flow. Create a map of
the area to outline it, identify the large items, and map the flow of patients, clients, employees, and paperwork.
Label all significant items, so they are easily identifiable to staff members. This process, called mapping a value
stream, creates a one page picture or flow chart of the current process, and helps identify redundant steps and
unnecessary motion.
•
Future State. With the current state mapped, now create a future state value stream map. How can you eliminate
waste identified in the current state value stream map? What is the ideal flow for completing a task? Brainstorm
with your staff to create an area which has great flow, is well ordered, and reduces unnecessary movement. Items
are now well-labeled and anything can be found within seconds. Everything has a place and there is a place for
everything.
3. Shine
•
Inspect, clean, organize, and de-clutter the area and items within the area. Repair or replace frayed cords, bad
bulbs and batteries, and worn-out parts.
4. Standardize
•
Create standards and visual controls such as signs and checklists to improve efficiency and reduce errors.
Signboards and color code indicators provide important information at a glance.
5. Sustain
•
Teach employees your Lean processes and protocols, so everyone understands the benefits. Continue to evaluate
additional Lean opportunities.
As with any change, you may encounter staff resistance. People may not understand the need for change, may fear it will lead to
more work, or may not understand that they will be playing a key role in determining the changes. Commit to the program, explain
the need for the changes, and address the fears of the resistors. Unfortunately about 10% of the workforce might remain resistant to
the change and leave. But those who embrace Lean will enjoy improved safety, work flow, and reduced costs that lead to increased
customer satisfaction, employee engagement, and practice profitability. Don’t wait to realize the benefits of Lean. Implement Lean in
your practice now!
922
Helping Patients that have Hypertension
Mark Acierno, DVM, DACVIM
Louisiana State University
Baton Rouge, LA
Hypertension may be the most under-diagnosed systemic illness affecting companion animals.
Blood pressure elevations are commonly divided into primary and secondary hypertension. Primary hypertension is the result of an
imbalance in the relationship between cardiac output and systemic vascular resistance. Although more than ninety percent of all
human hypertension cases are primary, the exact cause of this imbalance is not well understood. Secondary hypertension is an increase
in blood pressure that occurs as a consequence of another systemic disease or drug. While relatively uncommon in humans, secondary
hypertension is believed to account for most cases of canine and feline hypertension. This is important since it allows us to focus our
screening efforts on a specific group of patients who are at high risk of hypertension. (Table 1)
Definition
Systemic hypertension is commonly defined as a blood pressure greater than 150/95 mmHg on three separate visits in a patient that
demonstrates no clinical signs directly attributable to the blood pressure elevation or a single reading of greater than 150/95 mmHg in
a symptomatic patient.
Consequences
Patients with mild increases in blood pressure only show signs attributable to the underlying disease process. As the hypertension
worsens, specific organs are damaged:
•
Kidney - Glomerular and tubular damage.
•
Eye - Retinopathy and choroidopathy (retinal edema, tortuous vessels, hemorrhage and retinal detachment).
•
Heart - Cardiac hypertrophy (murmur, arrhythmia, and gallop rhythm).
•
Brain - Hypertensive encephalopathy (ataxia, depression, and seizures).
Measurement
The actual measurement of blood pressure requires the catheterization of a suitable artery and the determination of blood pressure with
an electronic transducer. Although this is the “gold standard,” it is neither convenient nor practical in the clinical setting. Clinically,
we rely on noninvasive indirect estimations of blood pressure using Doppler and oscillometric devices.
Due to its low cost, ease of use, and suitability for use in both cats and dogs, the Doppler flow detector is a commonly used blood
pressure measuring device. Doppler units emit ultrasound waves that travel outward until they strike a surface and then they are
reflected back to the device. If there is movement, such as blood cells traveling through an artery, the frequency of the returned wave
is different than that of the original wave. This change in frequency is amplified by the detector and is heard by the user as a
characteristic “swoosh” sound. The only equipment needed is the Doppler flow detector, a sphygmomanometer and a selection of
different sized cuffs. Although systolic pressure is easily obtained, determining diastolic pressure can be challenging or impossible.
An oscillometric blood pressure device works by inflating a cuff around an extremity until arterial blood flow is stopped and then,
while slowly deflating the cuff, the unit monitors for pulse waves generated by arterial pulsations. Because they are automated and can
determine systolic pressure, diastolic pressure, mean arterial pressure and heart rate, these units are quite popular. Despite their
convenience, oscillometric units can significantly underestimate blood pressure when used on cats and small dogs (<10 kg) and should
not be used on these patients. Recently, a number of oscillometric units that claim to be optimized in cats have been produced;
however, recent studies have produced contradictory information as to whether these units can produce accurate measurements.
Important concepts
Regardless of which blood pressure measuring technology is used, there are four principles that help ensure accurate measurements:
Proper cuff selection, consistency of personnel, acclimation of the patient, and repeatability of results. Perhaps the most important
factor in attaining accurate and repeatable blood pressure measurements is the selection of a correctly sized cuff. Some veterinaryspecific oscillometric units have specially designed cuffs, however for Doppler and most oscillometric units, the width of the cuff
should be 30%-40% of the circumference of the extremity. A cuff that is too wide will overestimate blood pressure while a cuff that is
too small will artificially decrease values. Stress associated with the office visit can cause profound increases in blood pressure; these
effects can be minimized by measuring blood pressure in a quiet area, away from other animals, before other procedures, and only
after patients have acclimated to their surroundings. The owner should always be present, and restraint should be kept to a minimum.
Pressure measurement should be repeated 4-5 times, and the measurements compared. If there is a significant variation (>10%) the
readings should be discarded and the process repeated.
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TreatmentAngiotensin converting enzyme inhibitors (ACEI) are generally considered to be the initial drug of choice in treating
canine hypertension (Table 2). ACEI exert their effect by competitively inhibiting the conversion of angiotensin I to angiotensin II.
Since angiotensin II is a potent vasoconstrictor, systemic vasodilatation occurs when its synthesis is inhibited. Angiotensin II also
stimulates the release of aldosterone, which leads to sodium and water retention and thus, an increased blood volume. Lastly,
angiotensin II directly stimulates the kidney to retain sodium, which results in an increased blood volume. Enalapril is cleared
exclusively by the kidneys while benazepril is cleared by the liver as well. For this reason, benazepril is preferable to enalapril in the
treatment of hypertension in renal failure patients.
Angiotensin converting enzyme inhibitors are less effective in treating hypertension in cats. Therefore, calcium channel blockers
have become the initial drug of choice in controlling feline hypertension. These drugs work by interfering with the influx of calcium
needed for smooth muscle contraction and vascular constriction. Due to its once-a-day dosing, gradual rate of effect and relative low
cost, amlodipine besylate is the most widely used anti-hypertensive medication for cats (Table 2). Studies in humans and dogs suggest
that when calcium channel blockers are used alone for controlling hypertension, they may worsen renal disease despite significantly
lowering blood pressure; therefore, these drugs should not be used as a monotherapy antihypertensive agent in dogs. This effect is
thought to be due to calcium channel blocker’s preferential dilation of the glomerular afferent arteriole paradoxically resulting in
glomerular hypertension. ACEI preferential dilate the efferent arteriole normalizing glomerular pressures and prevent renal damage;
therefore, calcium channel blockers should only be used in conjunction with ACEIs when treating canine hypertension. Calcium
channel blockers do not appear to cause renal damage in hypertensive cats and are considered safe.
Beta-blockers are useful adjunctive therapy in dogs or cats when the initial anti-hypertensive agent has failed to produce the
desired decrease in blood pressure (Table 1). Beta-adrenergic receptors are found in both the heart (B1) and lungs (B2). Blockade of
the B1 receptors will slow the heart and lower blood pressure; blockade of the B2 receptors can cause an undesirable bronchial
constriction. Therefore, selection of a Beta-blocker should be limited to a B1-selective antagonist such as atenolol.
Stimulation of alpha-receptors on blood vessels causes vasoconstriction leading to an increase in system vascular resistance and
elevations in blood pressure. Alpha-blockers selectively antagonize these receptors resulting in vasodilatation. Prazosin, a potent
alpha inhibitor, has successfully been used as an adjunctive treatment for canine hypertension (Table 2). It’s use in cats for this
purpose is not recommended.
Drugs that antagonize aldosterone may protect the heart, brain and kidneys from the harmful effects of hypertension. Although
inhibition of aldosterone causes only a mild decrease in blood pressure, it may protect against hypertension-induced fibrosis of these
target organs. While this information is preliminary, hypertensive patients may benefit from the use of spironolactone as an adjunctive
treatment (Table 2).
Goals
The goal of treating hypertensive patients is to gradually lower systolic pressure to less than 170 mmHg. In the initial stages of
treatment, monitor the patient regularly but avoid large adjustments in medications. Changes in dose and drugs should only be made
every two weeks unless the patient’s condition deteriorates. Once the patient’s systolic pressure has been regulated, it should be
rechecked every three months, and complete blood count and serum chemistry should be checked twice a year.
Table 1. Conditions that are commonly associated with hypertension
•
Hyperadrenocorticism
•
Renal disease
•
Thyroid disease
•
Diabetes mellitus
•
Hepatic disease
•
Drugs: erythropoietin, phenylpropanolamine, others
•
Uncommon conditions: Polycythemia, pheochromocytoma, hyperaldosteronsism (hyperaldosteronism?), chronic anemia
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Table 2 Commonly used antihypertensive medications and their dosages
Drug
Class
Canine Dose
Enalapril (Enacard, Merck)
ACE inhibitor
0.5–1.0 mg/kg q12–24h,
PO
Benazepril (Lotensin, Novartis)
ACE inhibitor
0.25-0.5 mg/kg q12-24h,
PO
Amlodipine (Norvasc, Pfizer)
Ca++ channel
0.05–0.2 mg/kg q24h, PO
blocker
Atenolol (Tenormin, AstraZeneca)
Beta Blocker
0.25–1.0 mg/kg q12–24h,
PO
Metoprolol (Lopressor, Novartis)
Beta Blocker
0.5-1.0 mg/kg q 8-12h, PO
Prazosin (Minipress, Pfizer)
Alpha Blocker
0.5–2.0 mg/dog q12h
Spironolactone (Aldactone, Serle)
Aldosterone
1.0-2.0 mg/kg q 12h, PO
inhibitors
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Feline Dose
0.25-0.5 mg/kg q12–24h, PO
0.25-0.5 mg/kg q12-24h, PO
0.625–1.25 mg/cat q24h, PO
6.25-12.5 mg/cat q12-24h, PO
2.0 – 15.0 mg/cat q8h, PO
Not Recommended
1.0 mg/kg q 12, PO
Dermatology for Technicians
Paul Bloom, DVM, DACVD, DABVP
Allergy, Skin and Ear Clinic for Pets
Livonia, MI
Protocols are useful in helping to diagnose and treated many different disorders. Part of any good protocol should be a minimum data
base (MDB). In addition to signalment, history, etc in veterinary dermatology laboratory testing should be a component of this data
base. Just as you may have a standard set of tests for diarrhea you should have a standard set of tests for dermatology cases. In a
general practice you should be performing these tests MULTIPLE times daily. In addition to these tests other commonly, easily
performed tests are
1. Skin scrapings **
2. Impressions smears **
3. Ear cytologies ** if ear disease is present
4. Bacterial culture
** Component of MDB
Slide examination
When examining a specimen microscopically, once a sample is collected (+/- processed- see cytology) the entire slide should first be
examined under a low (scanning) power (4X objective). Use this scan to evaluate the quality and quantity of the sample collected, to
find larger mites (eg Sarcoptes, Cheyletiella) and to identify areas that should be examined more closely. After evaluating the slide
under 4x power, the slide should be examined using low power (10X objective) for smaller mites (eg Demodex) and then oil
immersion (100X) to identify organisms (eg bacteria, yeast) and cells (eg neutrophils, eosinophils, keratinocytes, neoplastic cells etc).
With experience you will be able to identify cells w/the 40X objective, thereby saving time. You can improve clarity on 40X by
placing immersion oil on the slide and then covering the area w/a cover slip. You then can examine it w/the 40X. When you are
looking for cells or organisms raise the condenser but when examining for ectoparasites, if you drop the condenser you increase the
contrast making it easier to identify the parasite.
Skin scraping
Let’s begin with the MBD- before performing skin scrapings you should ask the following questions
1. What technique do I do (broad superficial or deep scrapings or both)
2. Where do I need to skin scrape?
3. What lesions am I looking for to scrape?
The answers to these questions depend on which parasite you suspect. If you suspect a superficial mite (Sarcoptes, Notoedres,
Demodex gatoi (cats), Demodex cornei (dogs) Cheyletiella) then broad superficial scrapings should be performed. Deep skin
scrapings should be performed when Demodex canis or cati is suspected. (Table 1)
When performing superficial scrapes be sure to:
Scrape from appropriate areas. For Sarcoptes you will be more successful if you scrape pinnal edges, the elbows, ventral chest and
hocks. In addition any papular or erythematous lesion should be scraped.
For any of the superficial mites, broad scraping should be performed. Remember that mites associated w/hypersensitivity (eg
Sarcoptes, Cheyletiellai) may be difficult to find due to their low numbers so be sure to take multiple (10-15) sites. In contrast to
demodex, all scrapes can be placed on 2 or 3 slides because the quantity of mites present is not important, they are either found or not.
When performing a deep skin scrape for demodex (this applies to mostly to dogs) there are a few pitfalls to avoid. By
avoiding these errors the diagnosis and your management of demodex will improve.
These include
•
Failing to squeeze the skin prior to scraping. This helps express the Demodex from the hair follicles
•
Failing to record location of scrapes;
•
Failing to record numbers & stages present;
•
Failing to record whether the mites are alive or dead;
•
Failing to clip hair at skin scrapings sites (if it is a recheck appointment, the hair may be regrowing preventing proper
sample collection);
•
Failure to squeeze the skin prior to scraping to try
•
Failure to recognize that lesions that are granulomatous & fibrotic, especially on the paws may have demodex that are
hard to demonstrate on skin scrapings and a skin biopsy may be necessary to diagnosis;
•
Failure to sedate dogs if the feet are to be scraped
•
Failing to scrape hyperpigmented areas even if they are not alopecic;
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•
•
•
Failing to scrape areas with comedones even if they are not alopecic
Failing to scrape if a dog only has greasy seborrhea (especially along the dorsum). A long body type of demodex mite
has been identified (Demodex injai). This mite lives in the sebaceous glands of the dog's skin, and thus, is commonly
associated with "greasy coats" rather than the moth eaten or pustular appearance that we are used to seeing.
Failing to take broad superficial skin scrapes even if demodex is the only parasite you suspect. There is a short bodied
demodex mite (Demodex cornei), which lives on the surface of the skin layer. Note that there may be a low number of
these mites found because of the superficial location of the mites allowing removal by the animal.
Cytology
Cytologic examination is another very commonly performed procedure in dermatology that should be performed on any dog or cat
presented w/skin or ear disease. Cytology is used to identify the presence (and/or type) of:
•
Bacterial or fungal organisms (Malassezia);
•
Neoplastic cells;
•
Inflammatory cells;
•
Abnormal cells (eg acantholytic keratinocytes associated w/pemphigus foliaceus)
Both the direct smear (scrapings, impression, roll smear or tape) and fine needle aspirates (FNA) are valuable techniques that need
to be mastered.
When the skin is scaly, a superficial skin scraping can be useful. A very small amount of mineral oil is placed on a #15 scalpel
blade to help keep the scale on the blade once it has been collected. The lesion is scraped a few times, and the material collected is
placed on a microscope slide, stained (see below about staining samples), and examined microscopically at 40X and 100X.
Direct smears can be collected by a variety of ways.
Impression (touch) smears are useful when there is an erosion, ulcer, crust, moist or greasy lesion. To perform an impression
smear, a slide is firmly applied to a lesion and, in most cases, is then gently moved back and forth a few times to increase the yield.
Clear acetate tape (“scotch tape”) is also useful for collecting samples. Some people will use slides that are “sticky” on one side.
These slides are reported to increase the yield of sample collected but the author finds that a standard slide works quite well. The slide
is then processed and examined as previously described
If the lesion is fluid filled (eg pustule, papule) but is too small for a fine needle aspirate, “lance” the lesion with a 25 gauge needle
and then do an impression smear.
When sampling crusts, lift the crust and rub both the underside of the crust and the surface of the skin.
Roll smears (swabs) are used when it would be difficult to get a slide into the affected area. This could be the face fold, the
interdigital space on cats and small dogs and the ear canals in all dogs and cats. A cotton tipped applicator is gently rubbed back and
forth across the lesion and then the material from the applicator stick is rolled back and forth on the slide. If the lesion is scaly,
applying a small amount of mineral oil to the swab can help with collection. The sample is rolled onto a microscope slide, stained and
examined as previously described.
A fine needle aspirate is performed when a solid or fluid filled mass or lesion is present. A 22-25 gauge needle attached to a 12 cc
syringe is placed into the lesion and suction is applied by pulling back the plunger of the syringe (½ to ¾ of the way). The syringe
plunger is pulled back and released a few times. Don’t aspirate aggressively enough that you get blood contaminating the sample (you
should not see blood in the hub of the needle). After aspirating one spot, stop aspirating and redirect the needle in the mass w/o
pulling out and repeat the aspiration. This can be repeated 2 or 3 times on each sampling attempt. The needle is disconnected from
the syringe, the syringe is filled w/air and the needle is placed back on the syringe. The material is then ejected from the needle by
compressing the plunger. If the lesion is a fluid filled you only have to pull back far enough to get a sample into the syringe. NoteMeasuring and noting the location of the masses is valuable for monitoring treatment.
Regardless of the collection technique (except when using the tape prep) historically the author would heat fix the sample, using a
cigarette lighter, and then wait a minute or so to allow it to cool. The slide was then stained w/a modified Wright stain (Diff Quik®).
There are 3 jars in the Diff Quik® kit. The first jar is a fixative containing methanol, the second contains buffered xanthene dye,
which stains the cells and organisms red and the third contains a buffered thiazine dye (methylene blue) which stains the cells and
organisms purple. After drying the slide would then be examined.
More recently I have bypassed both the fixative step and the second step (eosin) and directly go to the 3rd step using the methylene
blue only. It doesn’t appear to hinder the identification of organisms or inflammatory cells. If using the tape prep I will put a drop on
stain on the slide and then place the tape, sticky side down, over the stain and examine.
Ear cytologies are performed to identify mites, infectious agents, ectoparasites and inflammatory cells. A cotton tip applicator is
used to collect the samples prior to instituting therapy. Results of the cytology help direct appropriate therapy (presence of infectious
agents would indicate the need for antimicrobial therapy). I will also perform ear cytologies during therapy if either the ear(s) are not
responding to treatment OR if there were mostly rods on the initial cytology even if the ear(s) look normal at recheck.
927
Regardless of how the sample is collected to examine the slide involves the following steps:
1. Raise the condenser and have the light on the highest level
2. Scan the slide slowly at 10 x to identify areas with the most # of cells
3. Use 100X to ID bacteria (cocci/rods), Malassezia, inflammatory cells and neoplastic cells
a. With practice you can use 40X to ID Malassezia and inflammatory cells
4. Look at several representative fields and record your findings
a. For skin cytologies
1. For bacteria look in 10 fields and record a range (eg 0-5, 5-10, 10-20 etc) – be sure to note if they are
cocci or rods and whether they are intracellular or extracellular
2. For Malassezia look in 20-25 fields (unless they are ID sooner). Report them as negative/+0 if NO
Malassezia is found, +1 if 1 or 2 organisms are found (total #) in all the fields examined and there were
never more than 1 in a field, report a +2 if there are more than 1 organism in a field or 1 organism q 3-4
oil fields
b. For ear cytologies
i. There is no universal agreement as to what are normal # of cocci or Malassezia from an ear
cytology
1. Depending on the study, cutoff numbers, per oil immersion field (multiple by 2.5 to get
per HPF), between normal and abnormal ears range from >1 Malassezia to >4 Malassezia
and from >1 cocci to >10 cocci. It is my opinion that the number of organisms needed to
be present to be considered significant is not just a “number”. I don’t perform cytology
on normal ears – I only do them if the ears are inflamed or have exudate. In that case
ANY organism seen will be treated as part of the therapy regardless of the number
present
ii. Inflammatory cells or rod shaped bacteria are never present in a normal ear.
Fine tooth combing
Combing of the hair with a fine tooth comb (“flea comb”) is a method that can be useful in finding fleas and other ectoparasites (ticks,
lice and Cheyletiella). You may also detect miliary lesions on cats that were not appreciated on your physical examination.
Trichogram (“hair plucks”)
Veterinarians are frequently presented w/animals that have hair loss. In establishing the diagnosis of the hair disease, signalment,
history (constitutional signs?) and physical examination (eg pot belly?) are all important components in establishing a diagnosis.
There are times that even w/this information the cause of the alopecia has not been established. A trichogram, which is a microscopic
evaluation of plucked hairs, may be a useful tool to help identify the underlying cause.
To perform a hair pluck
•
Grab the hair that is to be examined w/forceps.
•
Pluck the hairs gently at the base and roll your wrist to gently remove the hair
•
Place the hairs in mineral oil on a slide w/the hairs running in the same direction.
•
Apply a coverslip
•
Examine microscopically
If the alopecia is post traumatic (pruritus) or due to fragile hairs (eg dermatophytosis) the distal end of the hairs will be broken. If
the hair loss is spontaneous (eg endocrinopathy) the tips are tapered.
Hair plucks can also be useful in ruling in (but not ruling out) demodicosis. Other ectoparasites may also be identified such as
Cheyletiella or lice.
Follicular cast can also be identified w/hair plucks. Follicular casts refers to the accumulation of keratin debris that adheres to the
hair shaft as it extends out of the hair follicle. This finding indicates a follicular keratinization disorder which occurs w/vitamin A
responsive dermatosis (Cockers), follicular infections (demodex, dermatophyte, bacterial), sebaceous adenitis, endocrinopathy
(hyperadrenocorticism, hypothyroidism) or primary seborrhea such as ear margin seborrhea.
Bacterial cultures
In the past bacterial cultures were not frequently performed in dogs with skin disease since Staphylococcus intermedius was the most
common bacterial pathogen and had a predictable susceptibility profile. Unfortunately it isn’t that simple any more. Staphylococcus
intermedius , Staphylococcus pseudintermedius, Staphylococcus schleiferi subsp. schleiferi, Staphylococcus schleiferi subsp.
coagalens, and Staphylococcus aureus all w/variable susceptibilities (methicillin resistant, multidrug resistant, combination) are now
928
associated w/pyodermas in dogs. Indications for bacterial culture and susceptibility testing in the dog or cat have therefore been
modified. This would include the presence of:
•
Nodules;
•
Deep draining tracts;
•
A bacterial infection of the skin (confirmed by identifying intracellular bacteria and degenerative neutrophils) that fails
to respond to appropriate antibiotic therapy;
•
A bacterial infection of the skin that is failing to respond to appropriate antibacterial therapy (not recurrent but failure to
respond) especially if there are immunosuppressed individuals in the house hold
•
Suspicion of an uncommon bacterial infection (atypical mycobacteria, nocardia, actinobacillus);
•
Suspicion of an anaerobic infection (gas pocket formation);
A few tips
•
Mini-Tip Culturette (Becton Dickinson Microbiology Systems) - These are culture swabs w/very small tips allowing
insertion into the lesion. Also by limiting the size of the tip, a more precise sample can be collected.
•
Taking samples from 2 or 3 lesions if possible will increase the likelihood of identifying all pathogens
•
Do cytology concurrently
•
When selecting a lesion to culture – from best to worse –
•
pustule >papule>crust>epidermal collarette
•
If you are sampling a crust- lift the crust and swab w/the culturettes the underside of the crust and the surface of the skin
under the crusts
•
For an epidermal collarette lift the edge of the collarette- if you are not able to do this then clip the hair w/scissors to
expose the collarette and take a the culturette swab and gently roll it across the collarette 3 to 4 times.
•
Have the lab do tube dilution (MIC) rather than disc diffusion (Kirby-Bauer)
•
Gentle cleansing with an alcohol swab will help remove surface debris. Once the lesion is dry, a sterile 20 gauge needle
can be used to lance the pustule/papule or used to lift the crust. Don’t use alcohol if the lesion you are culturing is a
collarette.
929
Adrenal Disease in Dogs and Cats
David Bruyette, DVM, DACVIM
VCA West Los Angeles Animal Hospital
Los Angeles, CA
Hyperadrenocorticism in cats
Hyperadrenocorticism develops most commonly in middle-aged to older cats (mean age = 10.4 years; range 6 - 15 years). Of the
reported cases of feline Cushing's syndrome (78%) have been females. This female sex predilection resembles the human syndrome
and contrasts with canine hyperadrenocorticism, where no sex predilection occurs.
The most common historical findings and clinical signs associated with feline hyperadrenocorticism are polyuria, polydipsia, and
polyphagia. These signs likely correspond to the high incidence of concurrent diabetes mellitus (76%) found in cats with
hyperadrenocorticism, and are consistent with the lack of overt signs preceding marked glucose intolerance observed in
experimentally-induced disease. The typical "Cushingoid" pot-bellied appearance with hepatomegaly, weight gain, and generalized
muscle wasting is common in cats as in dogs. Dermatologic abnormalities frequently recognized include an unkempt hair coat with
patchy alopecia, and very thin skin prone to traumatically induced tears and secondary infections.
Hyperglycemia is the most common laboratory abnormality found on serum biochemistries. Cats appear more sensitive to the
diabetogenic effects of glucocorticoid excess than dogs. Cats with concurrent diabetes mellitus often exhibit cortisol-induced insulin
resistance, requiring high daily doses of insulin to control their hyperglycemia and glucosuria. Hypercholesterolemia is also common,
and may relate to insulin resistance and increased lipolysis. Cats lack the steroid-induced isoenzyme of alkaline phosphatase found in
the canine, and the half-life of the enzyme appears to be significantly shorter in the cat. Elevation of serum alkaline phosphatase
(SAP) is present in only approximately one-third of cats compared to nearly 90% of dogs with hyperadrenocorticism. Increases in
SAP and the hepatocellular enzyme ALT appear to correspond with the regulation of the diabetic state, rather than representing direct
indicators of glucocorticoid excess. These enzymes frequently normalize with adequate regulation of diabetes, even without therapy
directed towards the hyperadrenocorticism. Hematologic findings associated with hypercortisolemia (lymphopenia, eosinopenia, and
neutrophilic leukocytosis) occur inconsistently in feline hyperadrenocorticism. Despite clinical polyuria and polydipsia, cats appear to
maintain urine specific gravities of greater than 1.020 more frequently than dogs, and only occasionally exhibit dilute urine and
decreased blood urea nitrogen concentrations commonly seen in dogs with hyperadrenocorticism.
Endocrinologic evaluation of cats suspected of hyperadrenocorticism involves screening tests to confirm the diagnosis, and
differentiating tests to distinguish pituitary-dependent disease (PDH) from adrenal tumors (AT). Adrenocorticotropin (ACTH)
stimulation testing in adrenocortical hyperfunction is not as definitive as for hypoadrenocorticism. Fifteen to 30% of cats with
confirmed hyperadrenocorticism have had normal cortisol response to ACTH administration (false negatives). In addition, stressed
cats and those with non-adrenal illnesses may show an exaggerated response to ACTH in the absence of hyperadrenocorticism (false
positives). A normal urine cortisol-to-creatinine ratio (UCCR) can be used to exclude the diagnosis of hyperadrenocorticism in cats as
described in dogs. The UCCR is attractive due to the ease of sampling compared to other endocrine function tests, but is non-specific
and will be elevated in a variety on non-adrenal illnesses. An exaggerated ACTH stimulation test or an elevated UCCR should be
pursued with suppression testing prior to initiating any therapy.
Normal cats are more variable than dogs with respect to the degree and duration of adrenocortical suppression following
dexamethasone administration. Intravenous doses of dexamethasone that have been evaluated in the cat range from 0.005 to 1.0
milligrams per kilogram. A dosage of 0.01 mg/kg of dexamethasone, commonly used in low-dose dexamethasone suppression testing
in dogs, led to a significant drop in serum cortisol levels in ten normal cats, but 2 of the cats showed a slight escape from suppression
by 8 hours after injection. Intravenous dexamethasone sodium phosphate (DSP), 0.01 and 0.1 mg/kg, produced equivalent reductions
of plasma cortisol levels, but suppression was sustained below baseline longer with the higher dosage. Cats with various non-adrenal
illnesses have also shown inadequate cortisol suppression after a low-dose (0.01 mg/kg) of DSP. The 0.1 mg/kg dosage of
dexamethasone seems to more reliably suppress cortisol levels in normal cats and cats with non-adrenal illnesses. Elevated cortisol
levels eight hours post-dexamethasone injection, using the 0.1 mg/kg dosage, appears to be a sensitive a diagnostic test for feline
hyperadrenocorticism (89%) similar to the low-dose (0.01 mg/kg) screening test in the dog.
The combined dexamethasone suppression/ACTH stimulation test has been used successfully to diagnose hyperadrenocorticism in
the cat. Affected cats display inadequate suppression of cortisol 2-4 hours after an injection of 0.1 mg/kg of dexamethasone, and an
exaggerated response 1-2 hours after ACTH stimulation. The ability of the combined test to discriminate PDH from AT is unclear.
Several cats with confirmed pituitary disease failed to suppress 2-4 hours after dexamethasone. Extending the duration of postdexamethasone monitoring, or using higher doses of DSP may improve the ability of the combined test to distinguish PDH from AT.
Currently, the combined test does not appear to offer more clinical utility than either the ACTH stimulation or dexamethasone
suppression test evaluated separately.
930
An ultra-high dose, 1.0 mg/kg, dexamethasone suppression test has been used to distinguish PDH from AT in the cat. Two cats
with hyperadrenocorticism diagnosed by the combined high dose dexamethasone suppression/ ACTH stimulation test had exaggerated
responses to ACTH with no cortisol suppression 2-4 hours after 0.1 mg/kg DSP. These cats did suppress following the ultra-high dose
of dexamethasone, and were later confirmed to have PDH. Cortisol levels should be monitored at several time points following
dexamethasone administration to determine if any suppression (a 50% or greater reduction in pre-test values) is occurring. Cats with
PDH may show suppression 2, 4, or 6 hours into the test only to escape from the suppressive effects of dexamethasone by 8 hours.
One cat with an adrenal adenoma failed to suppress following dexamethasone doses ranging from 0.1 to 1.0 mg/kg. As is the case in
dogs, suppression following high doses of dexamethasone is diagnostic for PDH, but failure to suppress requires further testing to
distinguish pituitary from adrenal disease.
Determination of plasma ACTH concentrations is an effective way of diagnosing PDH. The normal range of plasma ACTH is
lower in cats than in dogs, and many normal cats may have concentrations of ACTH below the lower limits of the sensitivity of the
assay. Cats with PDH will have normal to elevated ACTH concentrations while cats with adrenocortical adenomas or carcinomas will
have undetectable plasma ACTH levels. Plasma ACTH samples need to be collected and handled carefully. Veterinarians should
consult their diagnostic laboratory for specific instructions prior to performing the test. Incorrect sample handling can falsely lower
measured values. Normal to elevated plasma ACTH levels support a diagnosis of PDH, whereas low concentrations may require
additional diagnostic testing. As in the differentiation of canine hyperadrenocorticism, ACTH levels should only be used to
distinguish PDH from AT after hyperadrenocorticism has been confirmed by other screening diagnostics.
Pituitary-adrenal function tests need to be interpreted in conjunction with historical, clinical, and clinicopathologic findings before
any conclusions can be drawn. No single diagnostic test is infallible. Equivocal results or discordant findings should be reevaluated.
Hyperadrenocorticism is an uncommon disorder in cats. Consequently, false positive test results should be anticipated. Interpretation
of endocrinologic testing should incorporate all available information before any therapeutic intervention is attempted.
Diagnostic imaging can facilitate differentiation of PDH from AT when screening tests and clinical findings suggest
hyperadrenocorticism. Approximately half of canine adrenal tumors are mineralized and can be recognized radiographically. The
frequency of mineralization in feline adrenocortical tumors is unknown, but up to 30% of normal cats may have calcification of their
adrenal glands. Abdominal radiographic findings in cats with hyperadrenocorticism included hepatomegaly (69%) and obesity.
Ultrasonographic evaluation of adrenal size and morphology has been described for dogs and cats. Nonfunctional adrenal tumors can
be incidental findings in humans undergoing abdominal imaging. The incidence of "silent" adrenal masses in the cat is unknown. The
presence of unilateral adrenomegaly or distortion of adrenal architecture in a cat suspected of hyperadrenocorticism is strong evidence
of AT. Abdominal computerized tomography (CT) and magnetic resonance imaging (MRI) offer improved resolution for the
detection of adrenal tumors or hyperplasia. CT and MRI detection of pituitary masses is also now feasible for small animal patients.
Adrenal tumors accounted for 22% of the reported cases of feline hyperadrenocorticism. Half of the adrenocortical tumors were
found histologically to be adenomas and half carcinomas. The treatment of choice for adrenal tumors is surgical adrenalectomy. Two
cats with adrenocortical adenomas responded well to unilateral adrenalectomy, with clinical signs resolving over 4 to 8 weeks. One
cat with an adrenal adenoma removed surgically developed a recurrence of signs 12 months postoperatively. An adenoma of the
contralateral adrenal gland was diagnosed. The cat survived a second adrenalectomy and was disease-free for over two years
following the second procedure. Surgical therapy and long term follow-up for adrenocortical carcinomas in cats has not been
reported.
Treatment options for pituitary dependent hyperadrenocorticism in the cat include both surgical and medical alternatives. Bilateral
adrenalectomy followed by mineralocorticoid and glucocorticoid replacement therapy was performed in 11 cats. Nine cats responded
well to surgery with cessation of polyuria and polydipsia, regrowth of hair coat, and marked improvement (4) or resolution (5) of
diabetes mellitus. One cat developed acute signs of circling, wandering aimlessly, and apparent blindness 2 months post-operatively.
An expanding pituitary tumor was suspected, but no necropsy was performed. Two cats died within one week of surgery from sepsis.
Survival times for 6 cats with adequate follow-up after bilateral adrenalectomy for PDH ranged from 1 to 12+ months (median 5
months). Two cats are still alive, one year post-operatively. These results suggest that surgical complications of bilateral
adrenalectomy may be less frequent in cats than in dogs.
Surgical treatment can also include transsphenoidal hypophysectomy which is performed at WLA for cats with pituitary masses
extending above the sella (macroadenoma). Cats with functional tumors have similar success rates to those reported in dogs with
PDH.
Four drugs (ketoconazole, mitotane, metyrapone and trilostane ) have been investigated for the medical management of
spontaneous feline hyperadrenocorticism. Ketoconazole, an antifungal imidazole derivative, has been shown to inhibit adrenal and
gonadal steroidogenesis in humans and dogs. One month of ketoconazole (15mg/kg orally twice daily) administration in 4 cats did not
significantly reduce baseline plasma cortisol or ACTH responsiveness at doses 3 times greater than those effective in dogs. Two of 4
cats treated with 10 - 20 mg/kg/day of ketoconazole had adequate control of hypercortisolemia. One of the 4 cats developed severe
thrombocytopenia after only one week of therapy and had to discontinue the medication. A cat with adrenocortical adenocarcinoma
931
treated with 30 mg/kg/day for 3½ months showed improved regulation of diabetes and reduction in pu/pd despite no improvement in
hyperresponsiveness to ACTH. The cat ultimately was euthanatized subsequent to a non-healing skin laceration, chronic infections,
and worsening insulin resistance. No evidence of hepatotoxicity or thrombocytopenia was seen at the 30 mg/kg/day dosage of
ketoconazole, but the effectiveness and safety of this therapy remains questionable.
Mitotane, o,p'-DDD, is an adrenal cytotoxic agent and has been used successfully to treat dogs with PDH and AT. Use of mitotane
in cats has been discouraged due to the feline sensitivity to chlorinated hydrocarbons. Three of 4 normal cats treated with o,p'-DDD at
dosages ranging from 25 - 50 mg/kg, divided twice a day, tolerated the drug well, and remained clinically normal throughout
treatment with mitotane. Only 2 of the 4 cats showed a decreased responsiveness to ACTH with mitotane. The cat with the largest
reduction in post-ACTH cortisol levels developed vomiting, diarrhea, and partial anorexia lasting 2 weeks after a 50 mg/kg dosage of
mitotane. Two cats with PDH treated with o,p'-DDD (25 mg/kg/day x 25 days, and 25 - 50 mg/kg/day x 59 days) tolerated the drug
without apparent toxicity, but therapy was ineffective in controlling clinical signs in either cat. A cat with PDH treated with mitotane
(50 mg/kg/day x 1 week, then 50 mg/kg/week) developed signs compatible with iatrogenic hypoadrenocorticism after 40 weeks of
therapy with o,p'-DDD. At that time the cat was anorectic, lethargic, and exhibiting neurologic signs including mydriasis, pacing, and
head pressing. Computerized tomography revealed a large pituitary mass extending above the sella turcica. Mitotane was
discontinued, and the cat was treated with 60Co teletherapy. Subsequent CT examinations revealed shrinkage and then disappearance
of the mass 10 months post-irradiation. The cat was euthanatized for continued diabetes mellitus and post-irradiation cataracts 2 years
after the initial diagnosis of hyperadrenocorticism. We have had 3 other cases where a positive response to mitotane was observed
clinically.
Metyrapone, an inhibitor of the 11-b-hydroxylase enzyme that converts 11-deoxycortisol to cortisol, has been used effectively in
man to reduce the clinical signs of hypercortisolemia. A reciprocal rise in plasma ACTH levels occurs with falling cortisol
concentrations and can eventually override the enzymatic block, allowing a return of clinical signs. In humans, metyrapone is utilized
as an adjunctive therapy with pituitary irradiation or surgery. Dosages ranging from 195 - 250 mg/day have been used in cats with
hyperadrenocorticism without observed toxicity. In a recent report, a diabetic cat with PDH and severe nonhealing skin wounds was
treated with 65 mg of metyrapone orally 3 times a day. After 2 days of therapy the cat developed signs of glucocorticoid deficiency
including depression, tremors, and ataxia. The cat improved rapidly following treatment with injectable steroids, and was discharged
on twice daily metyrapone therapy. Cortisol response to exogenous ACTH was absent when evaluated on day 7. The cat was reexamined 24 days later after a hypoglycemic episode. The cats skin wounds had resolved and hair regrowth was evident. A follow-up
ACTH stimulation test revealed a slightly exaggerated response. The cat underwent successful bilateral adrenalectomy and was
euglycemic, with a normal haircoat, 4 months post-operatively. Two of 3 other cats reported in the literature also showed clinical
improvement with metyrapone therapy, but follow-up periods were short (less than 6 months). Whether longterm therapy with
metyrapone can control hypercortisolemia in cats, or whether rising ACTH levels eventually overwhelm enzymatic blockade has not
been determined. Metyrapone appears to permit rapid correction of hyperadrenocorticism in some cats, and may be useful for presurgical stabilization prior to adrenalectomy.
We have recently evaluated the safety and efficacy of trilostane therapy (Vetoryl, Dechra Pharmaceuticals) in 15 cats with PDH.
Clinical signs (13 of 15 cats) and ACTH stimulation testing results (13 of 15) improved with trilostane therapy. Diabetes mellitus was
reported in 9/15 cases. Insulin requirements decreased by 36% within 2 months in 6/9 diabetic cats. Median survival time was
617 days for all cats (range 80-1,278 days). Complications included weight loss, urinary tract infections, chronic kidney disease,
seizures, and recurrent pancreatitis. Hypocortisolemia was documented in 1 case. Cause of death occurred as a result of non-adrenal or
non-diabetic illnesses (renal failure, seizures [caused by hypoglycemia or unknown]), or lymphoma. Trilostane ameliorates clinical
signs of HAC in cats, is tolerated well in the long term, and can lead to improved regulation of diabetes. It should be considered first
line therapy for cats undergoing medical management of PDH.
Hyperadrenocorticism in dogs
A. Pituitary-dependent hyperadrenocorticism
1. Surgical management
i. Bilateral adrenalectomy
1. Technically difficult
2. Poor surgical/anesthetic risk
3. Permanently hypoadrenal and require lifelong replacement therapy
B. Hypophysectomy
1. See discussion at the end of this section
2. Lifelong therapy with thyroid hormone and prednisone necessary.
3. Medical therapy
932
Trilostane therapy of canine hyperadrenocorticism
The efficacy and safety of trilostane in the treatment of canine PDH were evaluated in a multicentre study at the Royal Veterinary
College in London, the Veterinary Teaching Hospital in Dublin and Small Animal Hospital in Glasgow. Seventy-eight dogs with
confirmed PDH were treated with trilostane for up to 3 years. The starting dose varied from 1.8 to 20 mg/kg (mean = 5.9 mg/kg).
Trilostane appeared to be well tolerated by almost all dogs with only 2 dogs developing signs and biochemical evidence of
hypoadrenocorticism. One of these dogs recovered with appropriate therapy. The other died despite withdrawal of trilostane and
administration of appropriate therapy. A further two dogs died within one week of starting trilostane but in neither case could a direct
link with the trilostane therapy be established. The low prevalence of side effects compared favourably to those reported with
mitotane.
Trilostane was found to be nearly as effective as mitotane in resolving the signs of hyperadrenocorticsm. Polyuria, polydipsia and
polyphagia had dissipated in 40 dogs within 3 weeks after starting trilostane. Within 2 months, a further 20 dogs showed decreases in
their water and food consumption. These improvements were maintained as long as the dogs remained on adequate doses of trilostane.
Skin changes resolved in 24 out of 39 (62%) of dogs that initially presented with dermatological signs. All of these improvements
were maintained as long as the dogs remained on adequate doses of trilostane. Only 8 dogs that were treated with trilostane for more
than 2 months showed poor control of clinical signs. In contrast, mitotane is effective in about 80% of cases of pituitary dependent
hyperadrenocorticism (PDH).
Trilostane caused a significant (p<0.001) reduction in both the mean basal and post-ACTH stimulation cortisol concentrations after
10 days of treatment. The post ACTH cortisol concentration decreased to less than 250 nmol/l (9 µg/dl) in 81% of dogs within one
month and in another 15% at some time whilst on treatment. These improvements were also maintained in the study population for the
duration of the trial.
Thirty-five dogs had at least one dose adjustment over the treatment period. The dose was increased in 23 dogs up to four times the
starting dose. In one dog the dose was increased nine fold over a period of six months. The dose was decreased in nine dogs to as low
as a quarter of the starting dose.
The mean survival of all trilostane treated dogs was 661 days. Direct comparison with mitotane was difficult as 65% of the dogs
were still alive at the time of censor and therefore the mean survival may still increase.By comparison, the mean survival of mitotane
treated dogs has been reported to be 810 to 900 days.
Dosage and administration
The current suggested initial starting dose range for dogs with PDH is 1-2 mg/kg once daily. This needs to be adjusted according to
clinical signs and serum cortisol values (see below). Doses up to 40-50 mg/kg (divided twice daily) have been given with no
unwanted side effects. In some dogs twice daily dosing may be necessary. The drug is given with food.
Transsphenoidal hypophysectomy
A variety of treatments are available for PDH. Medical treatment options include drugs that chemically destroy the adrenals
(lysodren or op-DDD) inhibit enzymes in the adrenal leading to the synthesis of cortisol (ketoconazole, trilostane) or inhibit the
release of ACTH from the pituitary gland (Anipryl or selegiline). While these treatments can improve the clinical signs in 40-80% of
patients they need to be chronically administered, necessitate frequent monitoring and do not cure or address the primary cause of the
disease (the pituitary tumor). In humans, surgery to remove the tumor is the most successful long-term therapy. The most common
approach used is the transsphenoidal method, in which a passage way is made in the sphenoid sinus, an air space behind the back of
the nose, which is just below the pituitary gland. Surgical cure rates for PDH are reported to be in the range of 65-85%, although more
recent long-term follow up data suggest that the recurrence rate is as high as 25 % within 5 years. When no discrete adenoma can be
identified, remission of hypercortisolism is observed in only about 40%. Surgery has also been used to treat PDH in dogs. Several
groups, most notably in the Netherlands have performed these surgeries with success rates paralleling those reported for humans.
However, these surgeries have generally not been performed in the US. Veterinarians at VCAWLAAH, in collaboration with human
neurosurgeons that regularly perform transsphenoidal surgery in humans have developed the methods to perform these surgeries in the
US and are conducting a research study to determine how effectively these surgeries can be performed.
Hypoadrenocorticism
Primary hypoadrenocorticism has been described in cats. Addisonian cats are middle-aged, with a median age of 4 years (mean 5.8
+/- 3.7 years) and range in age from 1.5 to 14 years. No sex or breed predilection is seen. The most common historical problems
include lethargy, anorexia, and weight loss. Unlike dogs with adrenal insufficiency, diarrhea is not noted in Addisonian cats. Forty
percent of cats have histories of episodic vomiting. Similar to hypoadrenocorticism in the canine, cats often have a waxing and
waning clinical course, including temporary "remissions" associated with parenteral fluid and/or corticosteroid administration.
The most common findings on physical examination include depression, weakness, and mild to severe dehydration. Up to 40%
present with in severe shock with weak pulses, slow capillary refill times, and extreme weakness or collapse. The duration of clinical
signs preceding the diagnosis of hypoadrenocorticism ranges from 5 to 100 days, with a median of 14 days.
933
Clinicopathologic findings in cats with primary hypoadrenocorticism parallel the patterns seen in the dog. Serum electrolyte
changes characteristic of mineralocorticoid deficiency are seen in most cats. Serum sodium:potassium ratios are less than 24 (range
17.9-23.7) with hyponatremia, hypochloremia, and hyperkalemia. All cats have had mild to severe azotemia (blood urea nitrogen 3180 mg/dl, normal range 5-30 mg/dl; creatinine 1.6-6.0 mg/dl, normal range 0.5-1.5 mg/dl), and hyperphosphatemia (inorganic
phosphorus 6.1-9.1 mg/dl; normal range 3.0-6.0 mg/dl). Hypercalcemia has been noted in one cat. Despite signs of dehydration and
prerenal azotemia, urine specific gravity was greater than 1.030 in only 40% of cats. The loss of renal medullary solutes, particularly
sodium, is believed to result in impaired renal concentrating ability. Distinguishing hypoadrenocorticism from acute or chronic renal
failure is critical to establishing an appropriate prognosis for clients.
Long-term management of cats with primary hypoadrenocorticism requires lifetime mineralocorticoid and glucocorticoid
supplementation. Oral fludrocortisone acetate (0.1 mg/day) or intramuscular injections of desoxycorticosterone pivalate (DOCP; 10 12.5 mg/month) have been successful in maintaining Addisonian cats. The dose of mineralocorticoid is adjusted as needed based on
follow-up serum electrolyte concentrations monitored every one to two weeks during the initial maintenance period. Normal
electrolyte parameters 2 weeks following DOCP suggests adequate dosing, but does not provide information concerning the duration
of action of each injection. Eighty percent of dogs require DOCP more frequently than every 30 days (5% need to receive DOCP
every 3 weeks), so frequent sampling during the early management period is recommended. Prednisone, 1.25 mg orally once a day, or
intramuscular methylprednisolone acetate, 10 mg once a month, can be used to provide adequate long term glucocorticoid
supplementation. Cats surviving the initial adrenal crisis can be managed successfully for many years. 60% of cats diagnosed with
primary hypoadrenocorticism are alive a median of 2.75 years after diagnosis. With appropriate glucocorticoid and mineralocorticoid
supplementation, cats with adrenocortical insufficiency should have a normal life expectancy.
Primary hyperaldosteronism
Feline primary hyperaldosteronism is diagnosed based on clinical signs, serum biochemistry, plasma aldosterone concentration,
adrenal imaging and histopathology of adrenal tissue. Cats may present with blindness caused by systemic hypertension. Many will
also present with weakness resulting from hypokalaemic polymyopathy. Elevated concentrations of plasma aldosterone and
adrenocortical neoplasia have been documented in all cases. Seven cases had adrenal adenomas (unilateral in five and bilateral in two)
and six had unilateral adrenal carcinomas. Three cases underwent medical treatment only with amlodipine, spironolactone and
potassium gluconate; two cases survived for 304and 984 days until they were euthanized because of chronic renal failure, while the
third case was euthanized at 50 days following failure of the owner tomedicate the cat. Ten cases underwent surgical adrenalectomy
following a successful stabilization period on medical management. Five cases remain alive atthe time of writing with follow-up
periods of between 240 and 1803 days. Three cases were euthanized during or immediately following surgery because ofsurgicalinduced hemorrhage. One cat was euthanized 14 days after surgery because of generalized sepsis, whilst the remaining cat was
euthanized 1045 days after surgery because of anorexia and the development of a cranial abdominal mass. It is recommended that
primary hyperaldosteronism should be considered as a differential diagnosis in middle-aged and older cats with hypokalaemic
polymyopathy and/or systemic hypertension and this disease should no longer be considered a rare condition.
In recent years, there has been renewed interest in primary hyperaldosteronism,particularly because of its possible role in the
progression of kidney disease.While most studies have concerned humans and experimental animal models, a recent paper highlighted
the occurrence of a spontaneous form of (non-tumorous) primary hyperaldosteronism in cats. At presentation, the main physical
features of 11 elderly cats were hypokalemic paroxysmal flaccid paresis and loss of vision due to retinal detachment with
hemorrhages. Primary hyperaldosteronism was diagnosed on the basis of plasma concentrations of aldosterone (PAC) and plasma
rennin activity (PRA), and the calculation of the PAC:PRA ratio. In all animals, PACs were at the upper end or higher than the
reference range. The PRAs were at the lower end of the reference range, and the PAC:PRA ratios exceeded the reference range.
Diagnostic imaging by ultrasonography and computed tomography revealed no or only very minor changes in the adrenals compatible
with nodular hyperplasia. Adrenal gland histopathology revealed extensive micronodular hyperplasia extending from zona
glomerulosa into the zona fasciculata and reticularis. In three cats, plasma urea and creatinine concentrations were normal when
hyperaldosteronism was diagnosed but thereafter increased to above the upper limit of the respective reference range. In the other
eight cats, urea and creatinine concentrations were raised at first examination and gradually further increased. Even in end-stage renal
insufficiency, there was a tendency to hypophosphatemia rather than to hyperphosphatemia. The histopathological changes in the
kidneys mimicked those of humans with hyperaldosteronism: hyaline arteriolar sclerosis, glomerular sclerosis, tubular atrophy and
interstitial fibrosis. The non-tumorous form of primary hyperaldosteronism in cats has many similarities with "idiopathic" primary
hyperaldosteronism in humans. The condition is associated with progressive renal disease, which may in part be due to the often
incompletely suppressed plasma renin activity.
934
References
Mellet, AM, Bruyette D, Stanley S: Trilostane therapy for spontaneous hyperadrenocorticism in cats: 15 cases (2004-2013). J Vet Int Med 27: 1471-77,
2013.
Bisignano J, Bruyette D: Feline Hyperaldosteronism. J Vet Med 19: 76-87, 2012.
Mamelak A, Owen T, Bruyette D: Transsphenoidal surgery for pituitary adenomas using a high definition video telescope in dogs with Cushing’s
disease. Vet Surg Jan 27: 1532-1543, 2014.
935
NeurolocalizationWhy Does this Dog Walk So Funny?
William Bush, VMD, DACVIM
Bush Veterinary Neurology Service
Frederick, MD
When a client presents with a dog or cat the goal of the examination is to determine the location of the disease within the body for the
problem. Once the location is known then limiting the list of possible causes to just a few becomes easy when considering the
location, age, and breed and disease progression. A useful discussion can then occur regarding the diagnostics, treatments and
prognosis for the likely disease (s) that caused the client to present with their pet. In neurology, this is especially important in because
problems are often life-threatening, rapidly progressive and diagnostic testing often involves MRI of the diseased part of the nervous
system. Simply observing a patient’s mentation / behavior, posture (how they support themselves against gravity) and gait (how they
move) will typically allow an observed to determine the location within the nervous system. We will used video case examples to
demonstrate lesions within the forebrain, vestibular system, cerebellum, spinal cord and nerve / muscle.
Forebrain
The forebrain consists of the cerebrum and thalamus and lesions with this area produce seizure and behavior changes like confusion,
irritability (headache?), and inappropriate elimination. The forebrain receives sensory information (visual, tactile) from the opposite
side of the body. A lesion on the left forebrain can result in an inability to recognize or process incoming information from the right
side of the body. This phenomenon is called hemi-inattention or hemi-neglect. Strength, balance and gait are normal because these
attributes are controlled by the brainstem. A patient with a left forebrain lesion might bump into things on the right, turn their head or
circle only to the left and place the limbs on the right side away from midline.
Vestibular system
The vestibular system controls head and body position while we are at rest and moving (accelerating, decelerating). The receptors that
receive information about head position, acceleration and deceleration are called the semi-circular canals and are located in the bones
of the inner ear and the information is processed within the brainstem. Disease of either the nerve or brainstem can generate signs of
vestibular disease which include head tilt, side-stepping (drunk appearance), and spontaneous eye movement (nystagmus). If the
lesion is within the brainstem then dullness, weakness, and other nerve abnormality are often noted.
Cerebellum
The word cerebellum means ‘little brain’ and half the neurons of the brain are located within the cerebellum. The cerebellum is
located just above the brainstem, behind the osseous tentorium within what is called the cranial caudal fossa. The role of the
cerebellum is to smooth out and control movement – the cerebellum does not generate gait or strength. Lesions of the cerebellum
produce a characteristic high- stepping gait and patients can have a movement associated (intention) tremor. Cerebellar lesions do not
produce behavior changes or weakness although patients may hold their pelvic limbs away from midline or wide-based... A head tilt
and spontaneous eye movements can be seen with cerebellum disease but are far more common with disease of the vestibular system.
Spinal cord
The spinal cord delivers signals from the brainstem to the nerve and muscle to generate gait. It also delivers information from
peripheral receptors about limb position to the brain. A severe lesion of the spinal cord will produce paralysis whereas a mild to
moderate lesion will produce weakness from failure of delivery of signals to the nerve and muscle. Poor coordination or
proprioceptive ataxia of the limbs will also be noted from poor delivery of signal about limbs position to the brain. Weakness and
ataxia or a disordered gait are characteristic of spinal cord disease. Spinal cord lesions often cause moderate to severe pain from
compression, stretching, or inflammation of the meninges, nerve root or vertebral column structures. Consequently behavioral changes
associated with pain (abnormal vocalization, slow to sit and rise, unwilling to move) or abnormal posture (arched back) are often
noted. Spinal cord disease is sometimes called upper motor neuron disease. Lesions of the spinal cord cause weakness, ataxia and/or
severe pain.
Nerve / muscle
The nerves start within the spinal cord and carry signals to activate the muscle. An intrinsic, reflexive system of nerves automatically
or reflexively produces muscle tone and support against gravity. Disease of the nerve, muscle or their connection (neuromuscular
junction) produces the same symptoms and is referred to as lower motor neuron disease or neuromuscular disease. Nerve /muscle
disease causes weakness and less commonly paralysis and does not produce incoordination or ataxia. Whereas muscle tone is often
increased with upper motor neuron disease, in lower motor disease there is reduced muscle tone. Patients might stand with their hocks
936
or carpi dropped or too low to the ground. A primary characteristic of this disease is a short-strided or choppy gait where the patient
acts as though they are walking on egg shells. Neuromuscular disease patients are seldom painful. Coughing, gagging, a respiratory
stridor, and a change in the bark might also be noted from weakness of the nerves and muscles going to the back of the throat
(pharyngeal area) and voice box (larynx). Patients may appear dull if they are systemically ill from pneumonia which is commonly
associated with pharyngeal disease.
Table 1. Characteristic behaviors, gaits and postures for neurological lesions
Location
Forebrain
Cerebellum
Vestibular
Spinal Cord
Nerve / Muscle
Behavior
Confused, seizure
Normal
Dull
Painful
Normal
Gait
Not weak, circling
High stepping
Side stepping
Unpredictable
Short strides
Posture
Head turn, limbs
held out
to side
Intention tremor
Head tilt
Normal to unable
to stand
Normal to
unable
to
stand
Note: Behavior or level of awareness can be normal with a lesion in any part of the nervous system
References
De Lahunta AD, Glass E. Small animal spinal cord disease. In: De Lahunta AD, Glass E, eds. Veterinary Neuroanatomy and Clinical Neurology. St.
Louis: Saunders Elsevier, 2009; 243-284.
De Lahunta A. Veterinary Neuroanatomy and Clinical Neurology. 2nd Edit, W.B. Saunders, Philadelphia, 1983
937
Nutrition is a Team Sport:
Technicians Take Charge!
Julie Churchill, DVM, PhD, DACVN
University of Minnesota
St. Paul, MN
Why bother with nutrition?
Integrating preventive healthcare into a practice requires commitment and engagement of the entire veterinary team. This commitment
and participation in developing a strong preventive program will promote success, optimal pet health, the client-pet relationship and a
long term client relationship with the practice. Nutrition is a key component of preventive health care and client interest and belief
that great nutrition positively influences their pet’s health is growing. As a result of recent nutrition assessment guidelines from both
AAHA and WSAVA the initiative to consider nutrition the 5th vital assessment helped promote nutritionals a standard of care. Clients
look to their veterinary team as experts in healthcare as well as nutritional advice. In an AAHA study, 90 % of pet owners want
nutritional recommendations yet 15 % perceive they are given one. The AAHA compliance study revealed 7% of the pets that could
potentially benefit from therapeutic foods were actually employing that therapy. There is tremendous opportunity for veterinary
professionals to take a role otherwise filled with less credentialed.
Why is nutrition a team sport?
There are many benefits to deploying or adopting a team approach to the practice mission and the veterinary technician is poised to
lead the initiative to provide nutritional care for all patients. Group effort increases efficiency by distributing workload and delivering
an integrated cohesive message about the importance of nutrition and the value of preventive care. No one can do it all, and when
roles are delegated everyone contributes to success and individual motivation increases to accomplish results.
There is great variability in the degree with which nutritional care is incorporated in practices. Some are just getting started, while
others may be experiencing some of the predictable pitfalls and challenges. This discussion is intended to be interactive to provide
opportunities, strategies resources and tools to consider for improving patient care and client satisfaction by making nutrition a
foundation. The intent is to use what would work best in your setting.
Elements to develop a practical nutrition program in primary care practice
Team based Care-a role for every member (www.everypeteverytime.com)
You can take a self-assessment to see how your practices doing implementing nutrition in patient care.
•
Define the message
•
Implement 5th Vital Assessment- every pet every time
•
Define practice philosophy and training for the entire staff
•
Tools for the tool kito Develop a written protocol (see example below)
o Client education materials
o BCS charts
o Newsletter, social media
Create the program
1. Develop consensus about nutrition topics and communicate to team members
a. Common client questions
b. Team members questions/concerns
c. Develop written positions
2. Body weight, Body Condition, Muscle Condition/Body Fat Index
a. Choose the scale and score and be consistent
3. Calculate Calories and Food Doses- pet food manufacturers, petobesityprevention.com, usda nutrient database
4. Stock Wellness foods
5. Train team members thoroughly- CE, empower and engage everyone
a. Nutrition training
b. Communication training
c. Academy of Veterinary Nutrition Technician- nutritiontechs.org
6. Encourage use of foods recommended by practice (offer some not sold)
7. Point person to stay up-to-date on recalls pet food safety current events
a. Update practice website, social media, links to avma, FDA
b. Provide list of alternative recommendations
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8. Provide therapeutic diets
Wellness program or package ideas
•
Technician managed
o Puppy/kitten counseling
o Nutrition consultation post every spay/neuter
•
Life stage nutrition
•
Obesity prevention
Nutrition and disease-therapeutic plan
•
Screened and risks identified- veterinary responsibility
•
Chronic disease package- follow-up plan
•
Obesity treatment – include all team members
Nutrition Specialist Referral
•
Multiple Comorbidities
•
Severe obesity, aggressive weight loss plan
References/resources
www.Everypeteverytime.com. Many tools and documents for assessing a veterinary practice and implementing nutritional care.
www.PetNutritionAlliance.org- website with comprehensive nutrition tools for all members of veterinary team, and client education.
Baldwin K, Bartges J, Buffington T, et al. AAHA Nutritional Guidelines for dogs and cats. J Am Anim Hosp Assoc. 2010; 46:285-296.
WSASA, Nutritional assessment guidelines (2011) http://www.wsava.org/PDF/Misc/WSAVA_GlobalNutritionalAssessmentGuidelines_2011.pdf
Nutrition reference manual, Hill’s Pet Nutrition, http://www.everypeteverytime.com/docs/en-us/Pet_Nutrition_Ref_Manual.pdf
Pet Nutrition Alliance. AAHA Tips for Implementing Nutrition as a Vital Assessment in Your Practice (2012)
http://petnutritionalliance.org/PDFS/PNA_TipsGuide_AAHAproof2.pdf
939
Managing Rodenticide Intoxications
Camille DeClementi, VMD, DABT, DABVT
ASPCA Animal Poison Control Center
Urbana, IL
While there are several different products that may be used as rodenticides, including strychnine, zinc phosphide, and aluminum
phosphide, this presentation will focus on the rodenticides that are most often encountered: anticoagulants, bromethalin, and
cholecalciferol. Just as “Kleenex” is commonly used instead of the word tissue, many owners may use the term “D-con” to refer to
any rodenticide regardless of the actual brand name. Therefore it is a good idea to ask the owner to bring in the package to verify
ingredients. Baits may be formulated as pellets, bars, grains, or meals. Unfortunately rodenticides are not color-coded, so the color of
the rodenticide provides no insight into the type of rodenticide.
Anticoagulants
Warfarin and pindone are short-acting anticoagulants and have short half-lives (<24 hours) compared to the long acting products
whose half-lives are up to 6-7 days. Long acting anticoagulants include diphacinone, difethialone, chlorophacinone, brodifacoum, and
bromadiolone. First generation anticoagulants include warfarin, diphacinone, chlorphacinone, pindone and valone. Second
generation anticoagulants may be longer acting and/or more potent than the first generation anticoagulants and are effective against
warfarin-resistant rats. As a general guideline, the minimum toxic dosage of warfarin is >0.5 mg/kg. The minimum toxic dosage of
the other anticoagulants is >0.02 mg/kg.
The anticoagulant rodenticides act by competitive inhibition of the enzyme vitamin K1 epoxide reductase thereby preventing the
regeneration of inactive Vitamin K1 to its active quinone form. Vitamin K1 deficiency results in depletion of the clotting factors II,
VII, IX and X. Because it has the shortest half-life, factor VII it is the first one affected. Depletion of factor VII leads to an elevation
of the prothrombin time (PT). PIVKA, the collective term for the precursors of the vitamin K-dependent clotting factors, also
becomes increased. The PT may be elevated within 36-72 hours, but the animal is usually still clinically normal. Beyond 72 hours, as
other factors become depleted, severe hemorrhage may occur, accompanied by elevations in activated partial thromboplastin time
(APTT) and activated clotting time (ACT). In rare instances (e.g. animals with pre-existing bleeding disorders or hepatic disease, etc.)
depletion of coagulation factors may occur sooner, resulting in clinical evidence of hemorrhage as early as 24-48 hours following
exposure.
In many cases, poisoned animals are not presented to the veterinarian until signs develop. Many patients present with vague
clinical signs of lethargy, weakness and anemia without any overt external hemorrhage although some animals may present with frank
external hemorrhage from surgical or traumatic wounds, the gastrointestinal tract, or other body orifices (e.g. epistaxis, vulvar
bleeding). Hemorrhage into body cavities such as the joints, the peritoneal cavity or the pleural cavity is common. Weakness, pallor,
abdominal distention, lameness, swollen joints, dermal bruising, muscular hematomas, dyspnea, labored breathing, or muffled heart
sounds are also possible. Bleeding into the brain or spinal cord may result in severe CNS disturbances, paresis, paralysis or acute
death. Tracheal constriction due to thymic, peritracheal or laryngeal bleeding may result in severe dyspnea. Clinical pathologic
abnormalities may include anemia, thrombocytopenia, hypoproteinemia and decreases in CO2 and pO2.
Diagnosis is based on history, compatible clinical signs and laboratory confirmation of coagulopathy. Differential diagnoses
should include congenital and acquired coagulopathies, and other causes of anemia (trauma, etc.). Coagulation panels may aid in the
differentiation of anticoagulant rodenticide from other coagulopathies (e.g. disseminated intravascular coagulation, von Willebrand’s
disease, Hemophilia A, etc.). Serum chemistry profiles to detect hepatic or other systemic disease that might affect blood clotting are
usually indicated. Anticoagulant toxicosis may be worsened in cases of significant hepatic disease due to impaired ability to
synthesize coagulation factors and decreased metabolism of ingested rodenticide. Because PT is the first coagulation test to become
abnormal in anticoagulant rodenticide toxicosis, it is the best choice for early detection. Elevations in PIVKA may also be used early
in anticoagulant rodenticide toxicosis, as normal animals should not have PIVKA present in the circulation. Unfortunately, PIVKA
proteins have been shown to be elevated in number of other acquired and congenital coagulopathies
Stabilization of symptomatic animals is a priority. Provide oxygen as needed for dyspnea. Transfusions with whole blood or
plasma may be necessary to replace blood and clotting factors. Oxyglobin may also be used.
Decontamination is only effective early (within the first 12 hours). Do not attempt emesis in a bleeding animal. Monitor
prothrombin time (PT) between 36-72 hours. Any elevation in the PT warrants full treatment with Vitamin K1. No treatment is
indicated if PT remains normal after 72 hours. NOTE: Recent vitamin K1 administration could result in falsely normal PT values
because new clotting factor synthesis only requires 6 - 12 hours. Administer Vitamin K1 as needed, or you may opt to begin it
prophylactically. Vitamin K1 should not be given intravenously and it is possible to have an anaphylactic reaction when it is given
subcutaneously. Oral administration is ideal, because vitamin K1 will be delivered directly to the liver where the clotting factors are
activated through the portal circulation. The dose of Vitamin K1 is 3 - 5 mg/kg/day orally. This dose should be divided BID or TID
940
and should be given with a fatty meal to enhance absorption. The average duration of treatment is 14 days for warfarin, 21 days for
bromodiolone and 30 days for the others.
Also it is advisable to check a PT at 48- 72 hours following the last dose of Vitamin K1. Vitamin K1 should be continued if the PT
is still increased. If possible, avoid the use of other highly protein-bound drugs during the treatment, and instruct the owner to restrict
exercise during this time.
Bromethalin
Bromethalin uncouples oxidative phosphorylation, resulting in depletion of ATP and loss of energy for sodium-potassium transmembrane pumps. Intramyelinic edema ensues, characterized by the presence of fluid-filled vacuoles between myelin sheaths. This
results in decreased nerve impulse conduction. Baits generally contain 0.01% bromethalin and come in 1.5-ounce packs. Although the
literature reports a minimum toxic dose in dogs of 1.67 mg/kg, the ASPCA APCC’s experience indicates that some dogs may show
signs at doses as low as 0.9 m/kg. Because of this discrepancy and because treatment once signs have developed is usually
unsuccessful, we recommend that decontamination be initiated at doses > 0.1 mg/kg. Cats are considered to be three times more
sensitive than dogs, and we recommend decontamination for any cat exposure.
Clinical signs may begin within 24 hours or as long as 2 weeks following ingestion. Earlier onset of signs suggests higher ingested
dosage and poorer prognosis. High doses (>2 mg/kg) result in a convulsant syndrome characterized by acute onset of severe tremors,
hyperexcitability, seizures, rigidity, opisthotonos, decerebrate posturing, hyperthermia and death within 36 hours of ingestion. Lower
doses cause a paralytic syndrome that begins as depression, +/- hyperthermia, progressive paresis originating in the rear and moving
cranially and progressive CNS signs. In sub-lethal exposures, signs may arrest at some level of paresis, and the animal may recover
gradually over weeks to months or may retain permanent motor impairment. Bromethalin causes spongy degeneration in the white
matter of spinal tracts, brainstem, cerebellum, and cerebrum. Electron microscopy demonstrates vacoulation myelin sheaths.
There is no antidote, so aggressive decontamination is critically important. Repeated doses of activated charcoal (every 8 - 12
hours) and cathartic are recommended. Efficacy of activated charcoal in symptomatic animals is poor. Provide supportive care as
needed to manage clinical signs including diazepam or barbiturates for seizures. Agents such as mannitol, furosemide, and
corticosteroids have been recommended to reduce the cerebral edema, but were of little benefit in reducing the severity of signs in
experimental animals. Gingko biloba at 100 mg/kg was shown to reduce the development of cerebral edema and brain lipid
peroxidation in rats following a lethal dose of bromethalin. Efficacy of Gingko in other animals has not been studied. Animals
exposed at lower doses exhibiting paralysis may recover. The prognosis is extremely poor for animals showing severe signs.
Cholecalciferol
Cholecalciferol (Vitamin D3) is metabolized in the liver to calcifediol (25-hydroxycholecalciferol). Calcifediol is then metabolized by
the kidney to calcitriol (1,25 - dihydroxycholecalciferol). Cholecalciferol increases intestinal absorption of calcium, stimulates bone
resorption, and enhances renal tubular reabsorption of calcium. This results in an increase in serum calcium. Prolonged elevation of
serum calcium can lead to acute renal failure, cardiovascular abnormalities, and tissue mineralization. The minimum toxic dose of
cholecalciferol ranges from 0.5 mg/kg to 3.0 mg/kg. The APCC recommends decontamination at 0.1 mg/kg. One ounce of 0.075%
cholecalciferol bait contains 21.28 mg cholecalciferol.
Clinical signs may be delayed in onset and typically occur 18 - 36 hours post ingestion. The most common clincial signs seen with
cholecalciferol toxicosis include vomiting, diarrhea, inappetence, depression, polyuria, polydipsia, bradycardia, and cardiac
arrhythmias. An initial hyperphosphatemia is often seen within the first 12 hours, followed by hypercalcemia within 24 hours.
Hypercalcemic nephropathy develops, resulting in increases in BUN and creatinine. Differential diagnoses for hypercalcemia include
juvenile hypercalcemia, hypercalcemia of malignancy, hypoadrenocorticism, hypoadrenocorticism, primary hyperparathyroidism, and
calcipotriene toxicosis.
Post mortem lesions seen with cholecalciferol toxicoses include diffuse hemorrhages of the gastrointestinal tract and possible
streaking of the renal cortex. Upon cutting, soft tissues of the gastrointestinal tract, heart and kidney lend have a “gritty” feel to the
knife. Mineralization and necrosis of gastrointestinal, cardiac, and renal tissues may be seen histologically. Elevated total kidney
calcium concentrations may be detected toxicologically.
Aggressive decontamination is recommended for recent exposures. Emesis should be induced, followed by multiple doses (3-4
doses q 6-8 hours) of activated charcoal. Obtain a baseline serum calcium and BUN immediately post-exposure. Monitor serum
calcium and BUN every 12-24 hours each day for three days post exposure. If the calcium level remains normal for 96 hrs, no further
treatment is be needed. Treat renal effects with supportive care including fluid diuresis 2x maintenance using 0.9% saline or 0.45%
saline and 2.5% dextrose. Avoid calcium-containing fluids. Normal saline fluids help to decrease tubular reabsorption of calcium.
Pamidronate disodium (Aredia ®) inhibits osteoclastic bone resorption. The dose is 1.3- 2.0 mg/kg as a slow IV infusion over 2 hours.
This dose may need to be repeated in 5-7 days. Expect normalization of serum calcium within 48 hours (often within 12-18 hours).
941
The initial expense of pamidronate may be offset by the fact that the animal may be weaned off of IV therapy and sent home once
calcium levels normalize. The dose listed is for dogs; one case of pamidronate use in a cat at 1.3 mg/kg had a very favorable outcome.
Oral prednisone at 2-3 mg/kg BID can help lower serum calcium by decreasing its gastrointestinal absorption, lowering bone
resorption, and increasing renal excretion. Furosemide at 2.5 to 4.5 mg/kg TID or QID orally, or 5 mg/kg/hr via continuous
intravenous infusion has been shown to decrease serum calcium levels. Salmon calcitonin 4-6 IU/kg q 2-3 hours until calcium levels
stabilize has also been used. Some dogs become refractory and there is a risk of anaphylaxis. Salmon calcitonin and pamidronate
should not be used together, as there is increased risk of soft-tissue mineralization.
Prolonged treatment is often required due to the long half life of Vitamin D3 (> 17 days.) Provide other supportive care as needed
during treatment and monitor serum calcium, phosphorous and renal values. A low calcium diet is indicated and the patient should be
kept out sunlight as much as possible. Antibiotics may be indicated if prolonged prednisone usage is anticipated.
What should I do if I don’t know what this green stuff is?
Endeavor to find the type of bait. Have owner find container. If product was put out by pest control operator, an invoice is required to
be left stating which pesticide(s) was/were used. If the rodenticide is still unknown, and the exposure was recent, induce emesis and
administer activated charcoal. Repeat doses in case rodenticide is bromethalin or cholecalciferol. Follow decontamination with
baseline PT and serum calcium and phosphorus levels. Monitor calcium and phosphorus every 12 hours for 36 hours; if normal, then
can discontinue monitoring for cholecalciferol. Monitor PT at 24 and 72 hours; if normal then no treatment for anticoagulants.
Educate owner to monitor for neurologic signs (paresis, depression) from bromethalin; signs could be delayed several days.
942
Ticks:
What You Don’t Know May Hurt Your Practice
Michael Dryden, DVM, MS, PhD
Kansas State University
Manhattan, KS
While often the same products are used to combat ticks as are used to combat fleas, there are substantial differences between flea and
tick control. One of the major differences is in the number of species that confront a dog. While there is one predominant flea species
that infests dogs in North America, the Cat flea (Ctenocephalides felis), there are at least 10 different tick species that may be
encountered. There can be remarkable regional variability in the number and diversity of tick species that infest dogs.1 While
practitioners in Hawaii may only deal with one tick species infesting dogs (Brown Dog tick, Rhipicephalus sanguineus), practitioners
in New Mexico may encounter three different species, in California six different species and in Nebraska 5 to 6 species.2 This wide
diversity in tick species means that ticks occur at different times of the year, are associated with different reservoir hosts and carry and
transmit different diseases.
Historically the most common tick recovered from dogs and livestock in the Central U.S. hasbeen Dermacentor variabilis, the
American dog tick. However, Amblyomma americanum, the lone star tick has become of increasing importance and over the past few
decades there has been a change in the distribution and abundance of certain tick species in North America.1, 3-6 Two of the best
documented are Amblyomma americanum and Ixodes scapularis.4-6 Since both these ticks are important vectors of human and animal
pathogens these changes in distribution and abundance have had a marked effect upon both human and animal health. Various factors
have contributed to tick population movement including: changes in agricultural practices; reforestation, wildlife conservation,
relocation and restocking; climate fluctuations and decreased environmental pesticide application.
Specific factors that have contributed to the increased range of A. americanum include increased habitat via reforestation and its
wide host range that includes deer, small mammals, birds and man5,6. The White-Tailed Deer is considered a preferred host for A.
americanum, and all life stages will feed successfully upon White-Tailed Deer. Another species that utilizes similar habitats and is an
excellent host for larvae and nymphs is the wild turkey. Areas with high White-Tailed Deer and wild turkey populations can have
remarkably large populations of A. americanum. Similar to A. americanum the distribution of I. scapularis is linked to the distribution
and abundance of the white-tailed deer.4
Ixodes scapularis, the Black-legged Tick, (Deer Tick or Lyme Disease Tick) is an inornate tick without eyes or festoons. Larvae
are small and often difficult to see. They are about 0.5mm long, flat, six-legged, and nearly translucent. Nymphs are approximately
1mm long and darker in color. Unfed males are approximately 2mm long and unfed females about 2.5mm. There are considerable
morphologic differences between male and female Ixodes. Males are dark brown, almost black, with shorter palps than females.
Females have longer mouthparts and appear two-toned. In the non-engorged female the inornate dorsal shield covers the anterior 1/3rd
of the body, leaving the orange-brown posterior portion of the body exposed. Ixodes scapularis is widely distributed in the Eastern
and Central U.S. in at least 35 states.7,8,9 Its distribution is from Florida to Maine, west into far eastern South Dakota, and south
through eastern Kansas into central Texas. Ixodes scapularis is also located in central and eastern Canada.
While white-tailed deer are widely distributed across the central and eastern U.S., the abundance of I. scapularis is not always
directly related to the abundance of the deer populations. Tick populations can vary markedly across a region due to soil type,
moisture and forest cover. In the north central U.S., I. scapularis were more numerous in areas with a deciduous forest canopy, and
where soil textures were classified as sandy or loam-sand.10
Seasonal activity varies by geographic region, but larval activity is generally highest in August and September. Larvae attach to
and feed on a wide variety of small mammals, including mice, chipmunks and shrews. Larvae also feed on birds and lizards. The
white-footed mouse (Peromyscus leucopus) is of particular importance in the tick life cycle and disease transmission, because it serves
as a good host for larval I. scapularis and it is a major reservoir of Borrelia burgdorferi.
Immature ticks typically engorge for 2 to 4 days before dropping off to molt in moist protected areas such as under leaf litter in
forested habitats. Larvae over-winter and then molt to nymphs in the spring. Nymphs will feed for 3 – 4 days on a variety of hosts
including mice, squirrels, chipmunks, raccoons, opossums, skunks, shrews, cats, birds, and humans. Nymphs occur primarily from
May through July in the North. Adults occur most commonly from October through December. Adults that do not find a host will
quest again, typically from March to May. Adults feed for 5 – 7 days, primarily on white-tailed deer, but also on bobcats, cattle,
coyotes, dogs, foxes, horses, humans, opossums, raccoons and other mammals.
Ixodes scapularis is the vector of Borrelia burgdorferi (Lyme Disease) in the central, upper midwest and northeast U.S., it is also
the vector of Anaplasma phagocytophilum (Human Granulocytic Ehrlichiosis), and Babesia microti (Human Babesiosis). Ixodes
scapularis may also cause tick paralysis.
While recent pharmaceutical advances have been made in the control of flea reproduction, such advances in the area of tick control
are lacking. With the exception of the brown dog tick Rhipicephalus sanguineus, our ability to manage tick reproduction is limited, if
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not almost non-existent. As discussed previously in most flea infestations we have the opportunity to control flea reproduction by
either killing fleas before they can reproduce or killing flea eggs. However, it is not just because we have effective residual
insecticides, insect growth regulators or insect development inhibitors that we are successful, it is also due in large part to the fact we
can often target the primary reproductive host, the flea infested dog or cat. And interestingly, failures in flea control often occur when
flea infested feral pets or flea infested urban wildlife invade the owners’ yards.
But when dealing with most 3-host ticks the problem is that the majority of the reproducing ticks are not on the dogs or cats, but on
their native wildlife hosts. Since we are limited in our ability to manage ticks on wildlife, reinfestations are a common occurrence and
protracted use of acaracides is routine in many areas. As mentioned earlier one tick species that is an exception is R. sanguineus.
While this tick is a 3-host tick, practically it can be said to function as a 1-host tick, since all life stages prefer to feed upon dogs.
Therefore, we have the opportunity through rigorous application of acaracides to kill female ticks before they reach repletion.
Since tick control can be extremely difficult and because they are vectors of a variety of bacterial and protozoal diseases,
veterinarians should have an understanding of the ecology of the tick(s) encountered in the area in which they practice. Veterinarians
need to be educated on the various aspects of tick ecology, disease transmission and control methodologies so that they can then
educate their staff and pet owners.
Numerous studies demonstrate the high level of efficacy of the various acaracides but the residual activity is rarely 100% and the
efficacy of products varies between and as well as within species, even in the same laboratory.11-18 Evaluations of acaracides under
natural or field conditions further illustrates that while efficacy is good it is not 100%.
In a field efficacy trial conducted in Kansas U.S.A, an imidacloprid (8.8% w/w)-permethrin (44.0% w/w) formulation was
evaluated on dogs against naturally occurring populations of Amblyomma americanum. When dogs were walked in a naturally tick
infested environment the 48-hour post-exposure efficacy of imidacloprid-permethrin formulation was 93.5%, 98.9%, 94.6%, 94.1%
and 96.6% on days 3, 7, 14, 21 and 28 respectively, post-treatment.15
Variation in product efficacy occurs. In two studies conducted at K-State, different results were found when evaluating the efficacy
of acaricides against Dermacentor variabilis infestations in dogs from two different regions of the USA.11,14 In the first study, the
efficacy of imidacloprid–permethrin and fipronil–(s)-methoprene formulations were evaluated against a D. variabilis isolate from
California. The 48-h post-infestation efficacy on day 30 post-treatment was 92.0% and 83.2%, respectively, for the imidacloprid–
permethrin and fipronil–(s)-methoprene formulations. In the second study, the 48-h post-infestation efficacy on day 30 for the
imidacloprid–permethrin and fipronil–(s)-methoprene formulations against a D. variabilis isolate from Oklahoma was 17.5% and
75.7% respectively. New isoxazoline molecules (afoxolaner and fluralaner) are now offering the first ever oral approach to tick
control. These compounds have demonstrated excellent efficacy against a variety of tick species.16-17
While product efficacy is often excellent in most studies, significant variation in efficacy can occur and 100% control is rarely
achieved. Therefore it can be expected that under natural conditions in areas where dogs are being frequently exposed to ticks pet
owners will see ticks on treated dogs. We might also expect that efficacy in real world situations might be lower due to such factors as
bathing and swimming, differences between dog breeds and haircoat types and frequency and correctness of product application.
Since 100% tick kill is not always achievable, perceived efficacy of acaracides may be directly related to the numbers of ticks to
which dogs are exposed. If a dog is treated with one of these highly efficacious acaracides and encounters just a few ticks it is likely
all those ticks will be killed. However, if tick exposure is considerably larger, we can expect a few ticks to be observed on these dogs
and pet owners may perceive a lack of efficacy. Therefore in areas where tick populations are increasing the perception may be that
the products are not as effective as they once were.
Pet owners often view tick infestations of their pets differently than flea infestations. Whether this is due to concerns about tick
transmitted diseases or simply a phobia, the presence of a couple of ticks on the pet often elicits a more pronounced negative reaction
than the presence of a couple of fleas. A 95% effective flea product may provide great client satisfaction while a similarly effective
tick product may be perceived as a failure. Therefore it is not uncommon that label recommended application of a product does not
appear to control the problem. This may be real or perceived, based upon pet owner expectations of product performance. Given pet
owner concerns, the fact that ticks transmit serious diseases and lack of 100% efficacy; occasionally additional control measures are
needed. If additional control measures are deemed necessary, pet owners need to be educated as to why additional control measures
are necessary and notations made in the pet’s record.
One of the most common practical attempted solutions to this problem in dogs is to increase the frequency of application. Here
increased residual efficacy is the expected outcome, since you are increasing the residual acaracide levels with the shorter application
intervals. EPA registered acaracides should be used according to their product labels. Additionally, with many 3-host ticks,
destruction of tick habitat can reduce exposure pressure. Areas that serve as refuge for ticks and wild mammals such as grass, weeds,
and brush piles, between runs and along buildings, can be eliminated or treated with an approved acaracide.
In some situations, especially in tropical and subtropical regions and in climate controlled kennels brown dog ticks may infest
buildings with ticks crawling up walls, curtains and throughout the home or kennel.19 In these situations acaracides may need to be
sprayed indoors into cracks and crevices, behind and under furniture or cages and along walls and the ceiling. Following application,
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make sure the acaracide is dry before you allow animals or humans back into the premises to minimize toxicity problems. Finally,
restricting pet access from tick-infested environments may be necessary.
It is apparent that the range and local density of certain tick species has increased in many areas. Whatever the factors it must be
recognized that tick infestation pressure may be much higher and associated tick transmitted diseases may be more prevalent in some
locations today than in the past. The increase in tick populations means that pets are encountering ticks more frequently, are exposed
to more ticks per encounter and clients may be seeing more ticks on their pets than in the past. Since tick products do not kill or repel
all ticks instantly, clients may get the false impression that the products are not performing as well as in the past. These situations
necessitate that veterinarians set client expectations, before clients set their own unrealistic expectations of control.
References
Dryden MW, Payne PA. Biology and Control of ticks infesting dogs and cats in North America. Vet Ther 2004; 26:2-16.
Cortinas R, Spomer SM. Occurrence and County-Level Distribution of Ticks (Acari: Ixodoidea) in Nebraska Using Passive Surveillance. J. Med.
Entomol. 51(2): 352-359 (2014)
Cortinas R, Spomer SM. Lone Star Tick (Acari: Ixodidae) Occurrence in Nebraska: Historical and Current Perspectives. J. Med. Entomol. 50(2):
244Ð251 (2013)
Estrada-Pena A. Increasing habitat suitability in the United States for the tick that transmits Lyme disease: A remote sensing approach. Environ Health
Perspectives 2002; 110:635-640.
Childs, J.E.; Paddock, C.D.: The ascendancy of Amblyomma americanum as a vector of pathogens affecting humans in the United States. Ann Review
Entomol 2003;48:307-337.
Paddock CD, Yabsley MJ. Ecological havoc, the rise of white-tailed deer and the emergence of Amblyomma americanum-associated zoonoses in the
United States. Curr Top Microbiol Immunol 2007;315:289-324.
Keirans JE, Hutcheson HJ, Durden LA, Klompen JS. Ixodes (Ixodes) scapularis (Acari:Ixodidae): redescription of all active stages, distribution, hosts,
geographical variation, and medical and veterinary importance. J Med Entomol 1996;33:297-318.
Dennis DT, Nekomoto TS, Victor JC, Paul WS, Piesman J. Reported distribution of Ixodes scapularis and Ixodes pacificus (Acari: Ixodidae) in the
United States. J Med Entomol 1998;35(5):629-38.
Rand PW, Lubelczyk C, Holman MS, Lacombe EH, Smith RP Jr. Abundance of Ixodes scapularis (Acari: Ixodidae) after the complete removal of deer
from an isolated offshore island, endemic for Lyme Disease. J Med Entomol 2004;41(4):779-84.
Guerra M, Walker E, Jones C, Paskewitz S, Cortinas MR, Stancil A, Beck L, Bobo M, Kitron U. Predicting the risk of Lyme disease: habitat suitability
for Ixodes scapularis in the north central United States. Emerg Infect Dis 2002;8(3):289-97.
Dryden MW, Payne PA, Smith V, Hostetler J. Evaluation of an imidacloprid (8.8% w/w)--permethrin (44.0% w/w) topical spot-on and a fipronil (9.8%
w/w)--(S)-methoprene (8.8% w/w) topical spot-on to repel, prevent attachment, and kill adult Rhipicephalus sanguineus and Dermacentor variabilis
ticks on dogs. Vet Ther 2006; 7(3):187-198.
Dryden MW, Payne PA, Smith V, Hostetler J. Evaluation of an imidacloprid (8.8% w/w)--permethrin (44.0% w/w) topical spot-on and a fipronil
(9.8% w/w)--(S)-methoprene (8.8% w/w) topical spot-on to repel, prevent attachment, and kill adult Ixodes scapularis and Amblyomma americanum
ticks on dogs. Vet Ther 2006; 7(3):173-86.
Rugg D, Hair JA. Dose determination of a novel formulation of metaflumizone plus amitraz for control of cat fleas (Ctenocephalides felis felis) and
brown dog ticks (Rhipicephalus sanguineus) on dogs. Vet Parasitol 2007; 150:203-208.
Dryden M, Payne P, McBride A, Mailen S, Smith V, Carithers D. Efficacy of Fipronil (9.8% w/w) + (S)-Methoprene (8.8% w/w) and Imidacloprid
(8.8% w/w) + Permethrin (44% w/w) against Dermacentor variabilis (American Dog Tick) on Dogs. Vet Ther 2008; 9(1):15-25.
Dryden MW, Payne PA, Smith V, Hostetler J. Efficacy of imidacloprid (8.8% w/w) plus permethrin (44% w/w) spot-on topical solution against
Amblyomma americanum infesting dogs using a natural tick exposure model. Vet Ther 2006; 7: 99-106.
Mitchell EB, Dorr P, Everett WR, Chester TS, Larsen D. Efficacy of afoxolaner against Dermacentor variabilis ticks in dogs. Vet Parasitol 2014,
201(3-4):220-222.
Wengenmayer C, Williams H, Zschiesche E, Moritz A, Langenstein J, Roepke R, Heckeroth AR. The speed of kill of fluralaner (Bravecto) against
Ixodes ricinus ticks on dogs. Parasit Vectors. 2014, 18;7(1):525.
Doyle V, Beugnet F, Carithers D. Comparative efficacy of the combination fipronil-(S)-methoprene and the combination permethrin-imidacloprid
against Dermacentor reticulatus, the European dog tick, applied topically to dogs. Vet Ther 2005; 6:303-310.
Dantas-Torres F. The brown dog tick, Rhipicephalus sanguineus (Latreille, 1806) (Acari: Ixodidae): from taxonomy to control. Vet Parasitol 2008;
152(3–4):173–85.
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Video Lessons:
Be an Exam Room Hero
Sheila Grosidier, BS, RVT
Veterinary Management Consultants
Evergreen, CO
Take a moment and ask yourself these questions in regard to your veterinary practice:
•
Are you certain that clients are being offered a consistent standard of care?
•
Do team members have the tools and resources to meet the clients' needs?
•
What future training do you see your team needing to best grow the business?
•
How does your team best learn?
•
What training have you specifically done in the past that has targeted client interaction on an individualized basis?
While there is little argument that costs are rising for training clinic team members, significant debate does exist over what
methods of training will ensure consistency, enable the adoption of new skills, and create an environment that allows team members to
coach themselves to achieve greater performance. When done correctly, recording employee/client interactions on video for one-onone review can be one of the most valuable training tools available to change ineffective behavior into consistently productive client
communication.
This article will cover a number of essential components that should be considered and implement in order to realise the full
potential of video coaching in practice.
Communication
A 2005 survey of the American Management Association identified that more than half of employers use video surveillance as a way
1
2
to decrease theft and violence , while only 16 per cent of those businesses use that information for evaluating employee performance.
While your practice may already be using video technology as a method of monitoring for theft-prevention or safety, video coaching
differs in its ultimate aim, and these differences include how the information will be captured, what will be done with the video and
how it can change your practice.
The success of this process will hinge on clear communication with your team members, assuring them that this will not be a
covert operation but rather an openly acknowledged training tool for reviewing staff and client interactions and subsequent coaching
for future performance. This is not about looking for mistakes; it’s about looking for ways to improve.
Each of us has had those moments when we replay a conversation with a client and wonder, ‘Could I have done something
differently?’ Seeing the entire interaction can provide clear answers – after all, a picture is worth a thousand words. So remember that
the team will need to be reassured that the main goal of filming is for those images to help them choose just the right words in order to
communicate more effectively with clients in the future.
Rules for everyone
Because there may be some initial resistance from the team about being recorded on video, it's important to establish clear, steadfast
rules that will be outlined and followed so as to reassure the team that this is a training tool to be used in a positive manner. Recording
an exam will proceed only after the client has been advised. A consultation could begin, for example, by saying, ‘Ms. Jones, we are
videotaping today for training purposes. Is that okay with you?’ Usually clients are glad to give consent, but if the client does not
approve, then the camera is to be turned off. Signs must be posted to alert clients and remind team members that the practice is using
video cameras, and that it is not a secret activity. While there may be a sense of natural apprehension at the onset of using video, over
time, team members will likely have to be reminded that the video is running—it will become part of the landscape. Establish that the
video will be used as a tool for training only, not as surveillance.
Setting up publicly
Implement a clear policy that outlines how the video will be recorded and evaluated to ensure maximum benefit to the employees as
well as to the practice. To get the most out of the process, this should not be a one-time activity. Plan to evaluate it monthly and set
goals with a timeline for each team member, then evaluate their success. A policy example can be found in Box 2.
1
2
http://veterinaryteam.dvm360.com/firstline/article/articleDetail.jsp?id=622344
http://www.nolo.com/legal-encyclopedia/workplace-cameras-surveillance-employer-rules-35730.html
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One-on-one coaching
Be sure to have your team members assess themselves before their review with their supervisor. It is likely that the team members will
readily pick up on how to improve and know what they need to do before the review. This will help them feel more confident ad
supportive of your coaching over time. Reinforce this action; point out what they are doing on their own to improve and how that not
only directly impacts the well-being of pets, client satisfaction and the health of the practice, but also enhances their skills. This is
where an incentive program can accelerate results.
The rock star reel
Did you just watch Erin give a perfect explanation of why your pet needs to have a senior profile? Did you see how amazing Dr.
Sanchez was in her response to an angry client? Videos are amazing tools for training new staff. Ask your team members if they
would be comfortable sharing their expertise by showing how to perform at that star level in such special videos. Creating a collection
of these interactions is incredibly instructive to new employees.
Positive and productive
Your team members will probably be concerned that this will be a negative experience that consists of looking for what they are doing
wrong. Demonstrate that it’s about building on their current skills and creating positive reinforcement. Start the discussion by asking
them to identify what they did well and what they would do differently. Focus on the interaction, not the person. See Table 1 for
additional recommendations to make coaching a positive experience.
Summary
To change ineffective behavior, the first step is to recognize that it is not working and clearly understand what will work. Video can
dramatically depict how a team member is communicating with clients at that essential point: when they're in your exam room. Don’t
leave it up to chance; leave it up to training.
BOX 1: The benefits of using video for coaching in veterinary practice
•
Team members can specifically review the actual interaction with each client, not simply go on what they remember
about it.
•
Video can be viewed and compared "back-to-back"? to see improvement over time.
•
Team members can review an interaction multiple times focusing on things such as their body language, word choice,
speech volume and cadence and find something different upon each viewing.
•
See a complete visit from the client’s perspective, not just the team member’s part. Set up the camera to show the entire
exam room.
•
Find out what clients do in your exam room when you are not present, then think of what you could do to make this a
productive time for them and you.
BOX 2: Example policies for team video coaching
•
The practice utilizes video as an individual staff coaching tool to evaluate interactions with clients exclusively in the
exam room.
•
Recording will take place in identified exam rooms on specified dates and times. All exam room assistants or
technicians, receptionists, kennel assistants, and veterinarians will be expected to participate, as the entire visit in the
exam room will be recorded. The video camera is to be set up correctly so the entire room will be visible.
•
All staff who greet clients and guide them into the exam room are to state that the visit is being recorded and request the
client's permission (for example, “Mrs. Jones, for training purposes we are recording this on video today—is that
okay?”). If the client declines, the video camera is to be turned off.
•
Team members will have opportunity to review their video and pick which of the clips they would like to review with
their supervisor. Each team member will use an evaluation checklist and submit it to the supervisor prior to the review.
(See checklist examples in figures 1 and 2.)
•
The supervisor will review the clip one-on-one with the team member and complete the checklist for comparison with
the team member’s checklist. An agreed-upon goal will be established for the next videotape session.
•
An incentive will be included, for example, all team members who complete four video reviews in a 12-month period
will receive a $100 bonus and be entered into an annual drawing for a paid day off at a spa.
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Table 1: Positive coaching techniques
POSITIVE COACHING TECHNIQUES 345
DON’T
Use general feedback (“Good job” or “Nice work”)
when reviewing video.
Believe that change isn’t possible.
Make a long list of mistakes.
DO
Be specific: “Your use of the pet’s name was just right in
your introduction.”
Look for changes from one video to the next.
Use a 3-to-1 ratio—identify three positive attributes for
each negative feedback component. This will help keep
you from sounding too negative and provide an overall
tone that reinforces what the team is performing well.
Think you have nothing to learn.
Get feedback from your team members. Ask them about
the process, what is working, what they would change,
and whether they like to mentor a team member in the
future.
Stay specific to the example and not to the individual,
then give a direct way to correct the issue (for example,
“Next time, offer to review the medical care plan with the
client prior to starting the services; this will prevent any
issues with the bill after the services have been
completed”).
Mutually identify with the team member two areas to
focus on in the next video.
Sugarcoat criticism and confuse your team members on
what you want them to do.
Fail to establish goals for the next video session.
Photo—Make the exam room easy to view
3
http://smallbusiness.chron.com/simple-ways-build-trust-employees-11619.html
http://bookboon.com/blog/2013/02/managers-read-these-8-tips-on-giving-the-right-feedback/
5
http://www.inc.com/guides/2010/08/how-to-get-feedback-from-employees.html
4
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Video Lessons:
Technician Tools that Really Work
Sheila Grosidier, BS, RVT
Veterinary Management Consultants
Evergreen, CO
Even pets are going electronic these days with an iPod program that will track medical information such as vaccinations, medications
and upcoming appointments. So, why aren't you taking advantage of one of the strongest assets a veterinary practice can possess?
Clients expect competency. Demonstrating your usage, understanding and ability to embrace technology for the benefit of their pet is
vital. Whether you are concerned about team member productivity, implementing effective marketing programs, or placing your
practice in an advantageous position online, it's time for you to click your way to success. Here are 8 compelling reasons why the
technology superhighway should be your onramp to practice success!
Convert from paper files to electronic files
The costs of staying with paper files
•
How much of your time is wasted in preparing files, filing, retrieving and looking for medical records?
•
What other wonderful things our receptionists could be doing if they did not have to "play" with our files.
•
Do you get a headache from trying to read your own (or someone else's) hand-writing in a record?
•
What the actual cost of your files (paper and space to store the records)?
•
What does it costs to write the same information over and over (time)?
Automation creates a WIN-WIN!
•
Recruiting and keeping quality team members has become one of the most time consuming and frustrating challenges
for practices.
•
There is also frustrating for team members who want to have a balance between challenge and opportunity, and minimal
redundant tasks.
•
You as an owner want to maximize productivity. Your team members want to be engaged in activities that directly help
pets live longer healthier lives.
•
Reduce redundant tasks.
o Take advantage of every opportunity to use team members where that personal interaction with the client and
pet care cannot be realized any other way but with a team member.
o Ask your team members to identify 10-12 tasks that they do during the day that take up the most amount of
time, then consider how you could automate these tasks.
o The savings on time, resources and quality of life are just some of the benefits you will all experience!
Create an online presence
First, look at your website
•
Do you have a web site? If you do have a web site, are you proud of it?
•
In today's era, web sites are no longer an option, but a necessity.
•
What does your web site look like?
o Professional image,
o Pictures of your doctors and bios,
o Virtual tour of your practice.
To be competitive in today's environment, it is imperative for a practice to have a shop site on their web site
•
Select you shop site provider carefully.
•
What products will you offer, and at what prices?
o 3rd party inventory.
Make it convenient for clients
•
After converting to an electronic medical record system, your veterinary software program should allow your clients to
request an appointment via e-mail.
o Available 24-7
o Receptionist can review requests the following day and respond back to the client with a set appointment time.
•
If you choose, clients can also access information about their pet -reminders that are due, medications the pet is on and
even a "family album" of the pet's pictures.
Get some satisfaction
•
Want to know what clients really think? Ask them!
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•
•
Set up a survey online that encourages clients to share their insight about their recent visit to your practice.
Why not send a link via email to all new clients to assure they will be back and tell others about their positive
experience?
•
Post some of those positive comments online and let the word spread…electronically!
The internet world opens a lot of new doors for you and your clients. You can either embrace it or watch as others embrace it. Along
with technology advances come many opportunities to help improve the effectiveness of your practice, its communication with clients
and its marketing of products and services. Your clients are going to the internet for answers as a general rule, be there and be their
answer.
Elements your website needs to attract clients
•
Appointment scheduling,
•
Forms that can be downloaded and completed prior to appointments,
•
Seasonal information for pets,
•
Links to additional info and resources
•
Prescription order portal,
•
Upcoming event information,
•
Option to email clinic with questions or requests,
•
Product information
•
Pet pictures
PERCENTAGE OF INTERNET USERS BY AGE
Next generation client demands = next generation reminders
•
Reminders are the life blood of our practice.
•
Many practices have up to 30% of their clients that have been seen in the past year that do not have future reminders
linked to them in the system.
•
Think of all the patients you see in one day or a week that have eye, ear or skin problems…
o Did we ask them about their vaccination history?
o Do we have a future reminder in the computer for an exam, fecal, heartworm or any vaccination?
•
Contact to Connect
o Most people do not clean out their 'snail mailbox' more often than every couple of days. On the other hand,
most people check their email several times a day.
o Email reminders can reinforce hard copy letter or postcard reminders at a fraction of the cost.

Add a link in your email reminder that directs your clients back to your website.

Clients will see complete, in-depth information about how important your recommendations are to
the health of their pet.

This can be automated!
Ideas for using email to build your practice!
•
Birthday Cards
•
Client Satisfaction Surveys
•
Medication Reminders
•
Upcoming Lab Tests
•
Lab Work Findings
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•
Seasonal Health Alerts
•
New Pet Information
•
Upcoming Education
•
Target Marketing
•
Appointment Follow-Up
List of automated reminders
•
Vaccines
•
Lab Tests
•
Diets
•
Medications
•
Recommended Testing
•
Flea/Heartworm Refills
•
Chronic Medication Refills
•
New Services
•
Tests needed due to change in age or condition
•
Grooming
•
Boarding
Track your success
•
What would you think of a doctor who made a diagnosis without doing a complete physical exam?
•
Lack of client compliance with recommendations is a common topic of discussion among practice owners. How can you
improve this?
•
Many practice owners decide they want to put into place a program and process that will increase client visits, improve
client transaction values and assure client service satisfaction. However, they do not know what their current status is in
these components of the business.
•
Wouldn't it be nice if you could turn on your computer and at a glance see how your practice is doing from a practice
management point of view?
o Veterinary Software
o Graph and communicate with team!
Key indicators to track
•
Per Client Transaction (ACT)
•
Per Doctor Transaction (PCT)
•
Number of New Clients (& where they originate)
•
Number of Dentals/Recommendations
•
Number of Senior Profiles/Recommendations
•
Inventory Costs/Gross Revenue
•
Staffing Costs/Gross Revenue
Are you ready to rev up your practice, electrify your clients electronically and leverage your team by reducing redundancy and
increasing face to face time with clients? The proficiency of your practice will include embracing digital options throughout the
practice. Start with these 8 options and you will see solid and lasting improvements to your practice.
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Video Lessons:
Making the First 90 Days Count- in any Job
Sheila Grosidier, BS, RVT
Veterinary Management Consultants
Evergreen, CO
10 ways to make new associates feel welcome
1. R-e-s-p-e-c-t
It’s not just a word, it’s what you do. Treat them with respect and model the behavior you expect from them with every employee. Part
of respect is praise and feedback; let them know in public when they do well and in private when there’s a concern.
2. Leadership
Associates want to know they are on the right path and there is a plan in the practice for moving forward. They want to belong to
something bigger than themselves and know that someone they can trust is in charge.
3. Empowerment
Allow your Associates to make decisions and to share their ideas with you. While they may not always make the right decisions, they
need to know you will support them when needed. Consider what you learned when you made a mistake and encourage them to make
decisions.
4. Make it fit
Send the new associate out to lunch with different departments in the hospital; one day with the veterinary technicians, one day with
the receptionists and then lunch with the kennel and exam room teams. Have them talk about the successes of the practice and how we
make a difference in the lives of pets every day.
5. Open it up
Have an open house or reception and invite your best clients to meet the new associate. Nothing says welcome like clients who will
tell your new employee how wonderful the practice is from the client’s point of view.
6. Expectations
Ask them what their expectations are in an employer. Let them know clearly how they will be evaluated and the timeline for
performance evaluations.
7. Be proud
Put an ad in the paper welcoming the new associate. Create a flyer that you can give to clients in the practice telling them about the
wonderful addition to the practice. Post their picture and biography in the exam rooms.
8. Mentor
Assign a mentor, someone who can assist them, meet with them regularly and help them to integrate into the practice.
9. Time
Set up regular times to meet and talk about cases, comments, and concerns. Encourage the new associate to ask questions when they
have them, but also make time so you can demonstrate your commitment to them; and remember, you can’t change the tire at 40 mph,
slow down and take the time to talk about it.
10. Make sure there are no misunderstandings
Everything should be put in writing, make sure you have an employment contract, job description and policy manual. Go over these
with your new associate.
11. Walk your talk
Make sure you set the example, not only medically but in your actions. Be to meetings on time, treat other employees with respect, get
to work on time. Remember that any successful business starts from the top.
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Five Everyday Eye Diseases
Amy Hunkeler, DVM, DACVO, MBA
Eye Care for Animals
Overland Park, KS
Veterinary ophthalmologists rely heavily on the skills of a knowledgeable and well-trained veterinary technician or veterinary
assistant. Their role begins with patient care and customer service. It most certainly includes recognizing common ophthalmic
conditions, assisting in diagnostic testing, and explaining the recommended treatment plan or surgery to clients.
In this session we will review 5 commonly encountered ophthalmic conditions and help the attendee become more familiar with
the clinical signs, definitions, differentials, treatments and pitfalls to medical or surgical management.
Entropion
Entropion is an inward rolling of the eyelid(s) and eyelashes such that they rub on corneal and conjunctival tissues causing discomfort
and potentially corneal ulceration. The diagnosis is made during physical examination and is often hard to overlook because the
patient is quite blepahrospastic (painful closure of the eyes, aka squinting) with excess facial wetting. Patients can be affected
unilaterally or bilaterally, inferiorly or superiorly, laterally, medially or centrally. Dogs are more likely than cats to show entropion,
while puppies and juveniles are more commonly diagnosed than senior dogs. It is important to determine if the condition is primary or
secondary to some other condition and then address the root cause. Primary entropion is a surgical disease and correction is
undertaken when the animal is at a mature size. Surgical approach varies by the severity and location of the entropion, but for many
veterinarians a wedge excision or Hotz-Celsus can be effective. Puppies are managed with temporary eyelid everting sutures while
they grow (it may take 2, 3 or 4 procedures to maintain eversion over several months.) It is important to diagnose and treat a patient
with entropion so the cornea can be protected from trauma.
Prolapsed gland of the nictitans
The condition commonly known as “Cherry Eye” describes the pink to red swelling of tissue seen at the medial canthus (middle
corner) of one or both eyes. There are more medically appropriate titles, such as, prolapse of the gland of the nictitating membrane,
but ‘Cherry Eye’ seems to be used by veterinarians, ophthalmologists and owners on a routine basis.
Prolapse of the gland occurs most commonly in young dogs of any breed or gender. The occasional cat will be affected and
typically it will be a Burmese cat. While the cause of a prolapse isn’t fully understood, current science suggests a weakness in the
soft-tissue attachments between the nictitating membrane and peri-orbital tissue. Regardless, a nictitans prolapse is non-painful,
although both color and swelling become more pronounced the longer the conjunctiva and gland are exposed.
It is best veterinary practice to surgically replace the gland into its normal anatomic position. Excision of the gland is considered
by most veterinarians to be a sub-standard practice, bordering on malpractice, based on the glands’ role in producing tears. The
nictitans gland is responsible for up to 40% of aqueous portion of the tear film. Excision of the gland places patients at risk of
developing keratoconjunctivitis sicca (dry eye.) There are at least a dozen surgical approaches employed to successfully correct a
nictitans prolapse; my personal preference is a modified pocket technique.
Keratoconjunctivitis sicca (KCS)
Keratoconjunctivitis sicca is known most commonly as “Dry Eye” and is perhaps being underdiagnosed in your clinic. In severe
cases, diagnosis can be made on the basis of clinical signs, but it is more accurately diagnosed (and diagnosed earlier) when tear
production is measured, via a Schirmer Tear Test (STT), during routine annual examinations. A STT reading of 15mm wetting /60
seconds or less qualifies as a diagnosis of KCS. This condition is identified most commonly in dogs, but cats can also be affected.
Clinical signs include reduced corneal luster, ocular discharge (often thick, grey-green and tacky), conjunctival hyperemia and
blepharospasm. Any age, breed or gender can be affected, but middle-aged and female are slightly over represented and usually there
is bilateral disease.
Treatment of dry eye consists of symptom management employing a combination of medications and supportive care products to
stimulate tear production, reduce inflammation, and remove ocular debris all while protecting the corneal and conjunctival surfaces.
Therapy is always life-long. Failure to treat leads to discomfort, dense corneal scarring and sometimes deep corneal ulcers. We
discuss surgical options with motivated clients. This surgery is called a parotid duct transposition (PDT) and the goal is substituting
saliva for the missing aqueous portion of tears. While not a prefect replacement saliva can be an alternative if / when medication is not
satisfactory.
Corneal ulceration
Corneal ulceration is diagnosed in both dogs and in cats, however they have different etiologies and treatments. Ulcers are extremely
painful due to the density of nerve endings that lay just under the epithelium, so it is important to include pain management in your
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treatment plan. Ulcers can be divided into many categories, but for the sake of simplicity we will discuss just two: Superficial Ulcers
and Deep Ulcers.
Superficial corneal ulcers
Superficial Corneal Ulcers are also known as indolent erosions, boxer ulcers and non-healing ulcers; it is most appropriate to use the
term: Spontaneous Chronic Corneal Epithelial Defect (SCCED.) This is a condition seen in dogs, it is a different condition when
identified in cats and should not be managed in the same manner. SCCED’s are most often diagnosed in middle-aged larger breed
dogs and they present with blepharospasm, epiphora, discharge, conjunctival hyperemia and retention of fluorescein stain only on the
surface of the eye. The hallmark feature is the failure to heal, in spite of appropriate medical management with a topical anti-biotic, an
oral anti-inflammatory, and lubrication, plus an e-collar to prevent rubbing. If the lesion fails to heal in a timely manner (<2 weeks),
then intervention is needed to facilitate healing. Treatment can include debriding the loose epithelium followed by a keratotomy is
performed to disrupt the surface barrier, which is preventing epithelialization. After an appropriately performed procedure and in
conjunction with medication, most corneas will heal in less than a week. Post-procedure therapy should include a topical anti-biotic,
lubricant, anti-inflammatory and pain relief. We always make a point of educating the owner about this condition recurring in a new
location or in the other eye.
Note—Cats are not dogs. Feline superficial ulcers rarely benefit from the same procedure as canine patients (ie debridement +
keratotomy.)
Corneal ulcers (deep)
Deep corneal ulcers are different than superficial ones. They can appear spontaneously and progress rapidly (1-day or less) into the
middle and then deeper aspects of the cornea. The symptoms of a deep ulcer are the same as a superficial ulcer, except more severe.
The tissues appear more inflamed with purulent discharge, corneal edema, a miotic (small) pupil and clouding in the anterior chamber.
The ulcer itself takes on a craterous appearance. Medical management is the first line of defense with a topical antibiotic and other
products to reduce pain and inflammation, such as a topical NSAID, oral NSAID, lubricant, oral antibiotic and an e-collar.
Experience with corneal ulcer management helps fine-tune therapy decisions and the determination if surgical intervention is needed.
In the best cases, medications will work in conjunction with the patient’s immune system and corneal cells to begin repair. In other
cases the damage and tissue loss makes waiting a dangerous proposition for the survivability of the globe. In these cases, surgical
intervention is advised to fill the defect with a permanent graft and proceed with medical therapy. From the ophthalmology
perspective, intervention by a specialist in the early stages of an ulcer can go along way towards returning the globe to good visual
health.
Cataracts
The role of the lens is to focus light on the retina. Any opacity of the lens is labeled as a cataract. Cataracts block light and images on
their way to the retina. Small or mild cataracts block small amounts of light and may not impede vision. However a mature (or large)
cataract blocks all images from reaching the retina, but do not block a patient’s sense of the light. As the lens undergoes a metaplastic
change from clear to opaque, irritating proteins are leaked into the eye causing a form of uveitis called lens-induced-uveitis. While
clinical signs range from subtle to hot and painful, treatment requires anti-inflammatory medications topically and perhaps, orally.
Examination of the eye and the lens by a veterinary ophthalmologist can help determine if surgery should be a consideration for the
patient. We find a moderate percentage of patients referred for cataracts don’t actually have true lens opacity, but rather have an agerelated increased lens density called nuclear sclerosis. Nuclear sclerosis degrades vision and appears ‘grey and hazy’ to the observer,
but typically will not progress to blindness.
The goal of cataract removal is to maintain or restore vision by removing the opaque lens and optimally inserting an artificial lens.
The good news for the client and the patient: removal of the lens has 90-95% success rate and the lens can’t re-grow.
Phacoemulsification is the preferred method of cataract removal and isn’t performed until after a full physical and ophthalmic
examination, pre-operative testing and extensive discussion of the surgery, post-op care, successes and complications.
Conclusion / closing
Ophthalmology in small animal practices can be quite challenging, as the conditions sometimes require quite a bit of time to handle so
the client is satisfied and the patient issues managed. The role of the technician is to assist in the diagnostic process and in client
education. The information in the proceedings and the lecture should enhance the readers knowledge of a 5 important conditions that
may affect one of the animals on your schedule in the coming weeks.
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Maximizing Your Monitoring:
Capnometry
Karl Jandrey, BS, DVM, MAS, DACVECC
University of California
Davis, CA
Capnometry
Capnometry is the measurement of carbon dioxide (CO2) at the airway opening during the ventilatory cycle (thus, the partial pressure
of end tidal carbon dioxide = PetCO2). The capnometer displays the numerical value for PCO2. Capnography is the waveform display
of CO2 as a function of time or volume. A device that measures CO2 and displays a waveform is a capnograph. The waveform
displayed by a capnograph is called a capnogram. Capnometers may use infrared (most common), Raman scattering, mass and
colorimetric spectroscopy for measurement of CO2.
Mainstream or sidestream capnometry describes the location of the measurement chamber or airway sampling site. Mainstream
capnometers place the measurement chamber within the airways. This allows for an almost instantaneous measurement of CO2.
Some drawbacks of mainstream capnometry include: 1) they are easily damaged, 2) their presence increases dead space, 3) they are
difficult to use in spontaneously breathing patients, and 4) water condensation often occurs on the sensor. Sidestream capnometers
sample air aspirated out of the airway through fine bore tubing to a measurement chamber outside the device. An advantage of
sidestream analysis is that the units often measure other gases (i.e. O2, anesthetics). Slight delays in measurement may occur due to
movement of the sample through the tubing. Secretions from the airway may easily obstruct the tubing. Neither is clearly superior,
and the choice between them is most often a personal preference.
Physiologic aspects of the capnogram
A capnogram is shown in Figure 1. In a volume-based capnogram, the x-axis would be labeled as the exhaled tidal volume and the yaxis would be the percent exhaled CO2. Exhalation begins at the point marked A. CO2 starts at zero as gas from anatomic dead space
is exhaled (Phase I- between points A and B). Phase II (sharp rise in the curve between points B and C) indicates the mixing of dead
space and alveolar gas. The capnogram then forms a plateau (Phase III, the alveolar plateau, between points C and D) during most of
the exhalational phase, indicating alveolar emptying. CO2 is measured at the end of exhalation/end of the plateau (point D) and is
called the end-tidal partial pressure of carbon dioxide (PetCO2).
The exhaled capnogram can be used to analyze deadspace; this is called the single-breath test. This test can determine: 1)
anatomic deadspace, 2) alveolar deadspace volume (if you have PaCO2), and 3) the volume of exhaled CO2. The volume-based
capnogram is similar in shape, but the axes are time (x-axis) and PCO2 (y-axis). The angle between Phase II and III is known as the
alpha angle and is usually about 100-110 degrees. As the slope of Phase III increases, the alpha angle also increases. The slope of
Phase III is dependent on the ventilation/perfusion (V/Q) status of the lung. An increase in the alpha angle may indicate an airway
obstruction. The alpha angle may also be affected by the response time of the capnometer, respiratory rate of the patient, or cardiac
output.
Figure 1
The time-based capnogram has both inspiratory and expiratory limbs. Phases IIII are the same as the volume-based capnogram described above. However,
the slope of phase III is typically greater for volume-based capnograms due to
decay in expiratory flow on time-based capnograms. The beta angle is the angle
between phase III and descending limb of time-based curve on the capnogram.
An increase in beta angle indicates rebreathing.
Aberrations in the capnographic waveform may occur. Therefore it is
important to read the PetCO2 and also assess the capnogram. Airflow
obstructions show a lack of an alveolar plateau or an increase in phase III.
Cardiac oscillations can be seen, especially during slow respiratory rates, when
the heart moves against lungs. This is a normal finding. A cleft in Phase III can be seen in patients recovering from neuromuscular
blockade, ventilator dysynchrony, or uneven expiratory flow. Many abnormal waveforms are presented in the lecture presentation that
accompanies these notes along with rule-outs for each.
End-Tidal CO2 (PetCO2) represents alveolar PCO2 that is determined by the rate at which CO2 is added to and cleared from the
alveolus. The rate at which CO2 is produced and added to the alveolus is determined by CO2 production (V) and venous perfusion (Q).
The rate at which CO2 is cleared is determined by alveolar ventilation. Therefore, the alveolar partial pressure of CO2 (PACO2) is a
result of V/Q. With a normal V/Q, PACO2 will approximate PaCO2. With a low V/Q, there is more time to equilibrate PvCO2 and
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PACO2; PACO2 will rise towards PvCO2. With a high V/Q, PACO2 will approach the partial pressure of inspired carbon dioxide
(PICO2, usually 0). PetCO2 is a representation of millions of alveoli; theoretically, it can be as low as 0 and as high as PvCO2.
There are three major causes of a decreased PetCO2: (1) decreased CO2 production and delivery to the lungs, (2) increased
alveolar ventilation, and (3) equipment malfunctions. Decreased CO2 production and delivery to the lungs can be caused by
hypothermia, pulmonary hypoperfusion, cardiac arrest, pulmonary embolism, hemorrhage, and hypotension. Increased alveolar
ventilation defines hyperventilation. Equipment malfunctions may be any of the following: ventilator disconnect, esophageal
intubation, complete airway obstruction, poor sampling, or a leak around the endotracheal tube. Causes of an increase in PetCO2
include: hypoventilation, rebreathing, sepsis, increased metabolism/ malignant hyperthermia, increased skeletal muscle activity, or
hyperthermia.
The arterial to end-tidal CO2 gradient [P(a-et)CO2] is normally less than 5mmHg. This difference between PaCO2 and PetCO2
may increase with deadspace-producing diseases (high V/Q, i.e. due to a lower PetCO2).
Some clinical applications
Non-invasive prediction of PaCO2: The PaCO2 should be predicted only with caution from the PetCO2 due to the fluctuating and
unpredictable nature of the P(a-et)CO2 gradient.
Esophageal intubation: Since carbonated beverages are not likely ingested in veterinary patients, there should be no CO2 in gastric
contents. If CO2 is not present when the proximal end of the feeding tube is connected to the capnometer, intubation of the
gastrointestinal tract must have been successful.
Feeding tube malposition: If CO2 is present, intubation of the airway must have occurred.
Cardiac arrest: The measurement of PetCO2 has been used to monitor pulmonary blood flow in humans and animals during
resuscitation. At the onset of arrest, PetCO2 usually drops off to zero. With the restoration of cardiac output, PetCO2 increases.
Increased dead-space ventilation: Patients with an increase in the slope of the alveolar plateau have been shown to have increased
alveolar dead-space. Pulmonary thromboembolism usually increases the P(a-et)CO2 gradient.
PetCO2 is not PaCO2. It is also not a non-invasive measure of PaCO2. PetCO2 does however differentiate between esophageal and
tracheal intubation.
References/suggested reading
Jubran, A. (1997). Pulse Oximetry. Principles and Practice of Intensive Care Monitoring. M. Tobin, McGraw-Hill Co.: 261-287.
Wright, B. a. H., PW (1996). "Respiratory monitoring during anesthesia: Pulse Oximetry and Capnography." Compendium of Continuing Education
for the Veterinary Practitioner (Comp Cont Ed Vet Pract) 18(10): 10831096.
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CPCR:
Current Guidelines and their Applications
Ari Jutkowitz, VMD, DACVECC
Michigan State University
East Lansing, MI
Cardiopulmonary cerebral resuscitation (CPCR) refers to the re-establishment of circulation and preservation of neurologic function
following an arrest.1 Since its inception in the late 1800’s, CPCR has saved the lives of countless human and veterinary patients.
However, low overall survival rates following CPCR indicate that there is still much room for improvement in these practices. This
session reviews current practices and updates on CPCR in the veterinary patient with an emphasis on evidence-based guidelines
derived from the RECOVER initiative.
Basic life support
Basic life support refers to the process of establishing an airway, initiating positive pressure ventilation, and performing chest
compressions. Because cardiopulmonary arrest (CPA) in veterinary patients is frequently initiated by respiratory arrest, an ABC
approach is generally taken as described below. In recent years, there has been a paradigm shift prioritizing chest compressions above
all other measures (CAB approach).
Circulation
Chest compressions are initiated at a rate of 100-120 per minute, compressing the circumference of the chest by approximately 3050%. The patient should be in lateral recumbency during compressions. In smaller dogs, where the cardiac pump theory is believed to
predominate, hands should be placed over the ventral third of the chest just behind the point of the elbow, corresponding to a position
directly over the heart. In larger dogs, the thoracic pump theory is believed to be most important in generating blood flow, and hands
should therefore be placed over the widest part of the thorax to create a maximal rise in intrathoracic pressure.
Airway
Orotracheal intubation is easily achieved in dogs, as the larynx can be directly visualized by retractig the tongue. The head and neck
should be gently extended and a laryngoscope may be used to improve visualization of the larynx. In cases where hemorrhage, saliva,
or gastric contents interfere with visualization, suction may be helpful. Alternately, the glottis may be palpated with one finger used to
guide tube placement. Once tube placement is verified, the tube should be secured by tying to the nose or around the back of the head.
The cuff should be inflated, and assisted ventilation provided. If chest wall excursion is not seen, lung sounds are absent, or abdominal
distension is noted, tube placement should be reconfirmed by direct visualization and the cuff should be reinflated. Improper tube
placement and tube dislodgement are common causes of CPCR failure.
Breathing
Once an endotracheal tube is in place, breathing is initiated at a rate of 10 breaths per minute with 100% oxygen to a tidal volume of
approximately 10 ml/kg. An ambu bag with attached oxygen line is ideal for this purpose. If only one person is available to perform
CPR, 2 breaths should be given for each 30 chest compressions. If several trained personnel are available, then breaths may be
delivered independent of compressions. Chest wall excursion should be seen with each delivered breath. Airway pressures ideally
should not exceed 20-30 cm H2O. High airway pressures or inadequate chest wall excursion should prompt a search for pleural space
disease, tube malposition, or tube occlusion.
A number of alternative techniques have been investigated that may help to augment blood flow during CPCR. Those that are
directly applicable in veterinary patients include circumferential chest compression and interposed abdominal compressions.
Circumferential chest compression is most commonly performed in cats and small dogs by encircling the chest with both hands to
maximize the rise in intrathoracic pressure during chest compression. In larger animals, interposed abdominal compression may be
implemented by having an additional person perform abdominal compressions during the relaxation phase between chest
compressions. Interposed abdominal compressions increase venous return to the heart, leading to greater stroke volumes and cardiac
output, and have been associated with increased survival to discharge in human patients.
Advanced life support
Advanced life support consists of drug administration, determination of cardiac electrical activity, and application of electrical
defibrillation if indicated. These techniques build upon basic life support to increase the likelihood of successful resuscitation.
Drugs
Establishing vascular access is one of the first priorities during advanced life support. While central lines are preferable for rapid
distribution of drugs, peripheral catheters are acceptable, and drug delivery may be facilitated by following drug administration with a
10-20 ml IV fluid “chaser”. If vascular access is not immediately obtained, surgical cutdown or intraosseous techniques should be
considered. The intratracheal route may also be used initially to deliver drugs. Epinephrine, atropine, vasopressin, lidocaine, and
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naloxone may all be given in this way by administering twice the normal dose of the drug (or using the “high” dose for epinephrine)
and administering several large breaths to disperse the drug.
Drugs administered during CPCR include intravenous fluids, narcotic reversal agents, vasopressors, vagolytics, antiarrhythmics,
and potentially sodium bicarbonate. Shock doses of intravenous fluids should be provided in cases where hypovolemia is believed to
have played a role in the arrest. Moderate fluid rates should be used in euvolemic patients or patients with underlying heart disease, as
rapid administration in these cases may excessively elevate right atrial pressure and consequently decrease myocardial and cerebral
perfusion pressure.
Patients who have received narcotic pain relievers or other sedative/anesthetic drugs prior to arrest should immediately be given
the reversal agent for that drug. Naloxone may be used to reverse most narcotics at a dose that is isovolumetric to the dose of the
original narcotic, or at 0.02-0.04 mg/kg IV if the original dose is unknown. Flumazenil (0.02 mg/kg IV) may be used to reverse
benzodiazepines, and yohimbine (0.1 mg/kg) or atipamazole (0.2 mg/kg or isovolumetric) may be used to reverse xylazine and
medetomidine respectively. Any anesthetic gases, if still in use, should be discontinued and the anesthetic circuit flushed with fresh
oxygen.
Vasopressors are commonly used during CPCR to increase blood pressure and redistribute blood flow to vital organs like the brain
and heart. Epinephrine continues to be the vasopressor of choice during CPCR in veterinary patients, though its use is largely
extrapolated from clinical studies in human patients. Both low dose and high dose epinephrine protocols are described in human
medicine. While high dose epinephrine has been associated with increases in early return of spontaneous circulation, no long-term
benefits have been identified. High dose epinephrine has additionally been associated with increased myocardial oxygen demand and
worse neurologic outcomes.2 For these reasons, it is recommended that low dose epinephrine initially be administered every 3-5
minutes during CPCR, switching to the high dose only if there is a lack of response to the lower doses. Epinephrine dosing may be
rapidly calculated according to the following rule of thumb: 0.1 ml per 20 lb of the 1:1,000 formulation for low dose, or 1 ml per 20 lb
for high dose.
Vasopressin is another potent vasoconstrictor that is increasingly used in resuscitation of human patients. Unlike epinephrine, it
does not increase myocardial workload, and its effect is not blunted by acidosis. Although clinical data in veterinary patients is
currently lacking, animal models and human clinical trials suggest that vasopressin may be as effective as epinephrine.3 Vasopressin
(0.8 units/kg IV) may therefore be considered as an alternative to epinephrine in dogs.4
Atropine is another drug frequently administered during CPCR to reverse parasympathetic contribution to the arrest or to treat
sinus bradycardia. Atropine is administered at a dose of approximately 1 ml per 20 lb (0.04 mg/kg) for asystole or pulseless electrical
activity. When treating sinus bradycardia, only half this dose is needed.
Sodium bicarbonate use in CPCR is controversial, as it has been associated with numerous adverse effects including
hypernatremia, paradoxical CNS acidosis, and decreased resuscitation rates in people. However, its use should still be considered
during long duration (>10 minutes) arrests, as control of acidosis may improve response to catecholamines as well as post-arrest
neurologic outcomes. Bicarbonate is typically given only after 10 minutes of CPCR at a dose of 1 mEq/kg and is repeated every 5
minutes thereafter.
Electrical activity
ECG leads should be attached as soon as feasible to assess electrical activity. Connecting the leads to the skin of the lower forelimbs
and hindlimbs will help to minimize motion artifact associated with resuscitation efforts. Four rhythms are commonly seen during
cardiopulmonary arrest in dogs. Asystole and pulseless electrical activity are the initial arrest rhythms most commonly seen in dogs,
followed by ventricular fibrillation and sinus bradycardia.5,6 Accurate ECG diagnosis is vital to a successful code. The presence of
sinus bradycardia or suspicion of a vagal arrest should prompt administration of atropine. Asystole should be confirmed in more than
one lead, to rule out the possibility of artifact related to poor contact. While some dogs in asystole will convert directly to sinus
rhythm following resuscitation, many develop ventricular fibrillation and require electrical shock for conversion. Once ventricular
fibrillation is identified, electrical defibrillation should immediately be administered, temporarily bypassing all other resuscitation
measures. The greater the time that a dog spends in fibrillation, the lower the likelihood of successful conversion.
Defibrillation
Early application of electrical shock is the only effective method for converting VF to sinus rhythm. VF is a form of disorganized
electrical activity with various portions of the heart muscle firing at different times. Electrical shock essentially "resets" the cardiac
cells so that organized activity can resume. Practically speaking, applied current must pass through at least 30% of cardiac myocytes
to effectively convert VF.
To accomplish defibrillation, the dog is flipped into dorsal recumbency immediately preceding defibrillation and handheld paddles
are placed on either side of the chest directly over the heart. Ample conducting gel should be applied to the paddles to ensure good
contact and prevent dispersion of current. The chest should be compressed between the paddles, minimizing impedance by narrowing
the distance between paddles. If using a monophasic defibrillator, the energy for the first shock should be set at 3-5 J/kg. If
defibrillation is not successful, CPCR is resumed for 60-90 seconds and a subsequent shock should then be given at the same energy
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setting. Electrical shock is discontinued once the rhythm converts from VF. Lower energy biphasic shock waveforms have been
shown to be as effective as higher energy monophasic waveforms and exclusively used at this time in human patients. If using a
biphasic defibrillator, the pediatric settings should be used (2-4 J/kg). 7
For shock-refractory VF, a search should be undertaken to identify problems such as improper paddle position, inadequate contact,
insufficient conduction gel, or the presence of pleural space disease that may increase impedance. Drug-shock techniques may then be
considered, administering epinephrine or amiodarone (5 mg/kg IV) prior to shock to lower defibrillation threshold. Lidocaine was
previously used for this purpose as well, but has been reclassified as a therapy of indeterminate benefit in the most recent ACLS
guidelines.7
Open chest CPCR
There are a number of absolute indications for open chest CPCR. These include cardiac arrest caused by or associated with pleural
space disease (pneumothorax, pleural effusion, diaphragmatic hernia), pericardial effusion, or penetrating injury resulted in cardiac
arrest. However, debate exists in veterinary medicine as to other indications for performing open chest CPCR. Some advocate open
chest CPCR immediately in large breed dogs because of the limited success of restoring adequate circulation with external
compressions while others prefer to perform external CPCR for 5 minutes and then open the chest if there is little or no evidence of
effective circulation. Open chest CPCR has the advantage of allowing the clinician to directly compress the heart and improve stroke
volume. In addition, opening the chest makes assessment of ventricular filling feasible aiding in the decision of volume delivery.
When opening the chest, it is critical to auscult the chest just prior to the incision to rule out ECG dysfunction as the cause of
asystole. The left chest should be crudely clipped of hair at the left 5th-6th intercostals space and a chlorhexidine based antiseptic
solution should be briskly applied. An incision should be made through the skin and subcutaneous tissues from just below the spinal
musculature to the level of the costochondral junction. Between positive pressure breaths, mayo scissors should be used to poke
through the intercostal musculature and the pleura and the chest is opened by sliding the mayo scissors dorsally and ventrally along
the cranial border of the rib (to avoid the neurovascular bundle). The pericardium is opened at the pericardio-diaphragmatic ligament
and the heart is compressed from the apex to the base. In large dogs, the heart can be compressed against the opposite chest wall.
In the event of return of spontaneous circulation, antibiotics should be instituted immediately, the chest should be lavaged with
copious amounts of warm saline, and should be closed using sterile technique over a chest tube.
ICU care
Following a successful code, a search for underlying causes or complications should be performed and any problems corrected. Blood
gases, hematocrit and total solids, blood pressure, and oxygen saturation are carefully monitored and optimized during this time. This
tends to be the most challenging phase of arrest management, as complications and recurrence of CPA are common. Neurologic
recovery is promoted by maintaining arterial blood pressure and oxygen saturation. Because elevation in carbon dioxide levels leads to
cerebral vasodilation and consequently increased intracranial pressure, hypercarbia should be prevented by employing mechanical
ventilation if needed. Once cardiovascularly stable, mannitol (0.25-0.5 g/kg IV over 20 minutes) may also be indicated to treat
cerebral edema and resultant elevations in intracranial pressure. Corticosteroids are associated with potentially deleterious
hyperglycemia in post-arrest patients, and current protocols do not support their use.7
Prognosis
Recurrence of CPA in the post-arrest period is common, occurring in up to 70% of successfully resuscitated dogs. Intensive care and
monitoring during this time is therefore essential. Survival to discharge following cardiopulmonary arrest has been reported in 4-11%
of cases.5,6,8 Transient blindness, seizures, circling, ataxia, and decreased level of consciousness are common for some period of time
following CPA, but the majority of survivors have a good prognosis for functional recovery.6
References
Otto CM. Cardiopulmonary cerebral resuscitation and ACLS guidelines. In Proceedings of the 8th International Veterinary Emergency and Critical
Care Symposium. San Antonio, TX. September 2002. p. 478-481.
Gueugniaud PY, Mols P, Goldstein P. et al. A comparison of repeated high doses and repeated standard doses of epinephrine for cardiac arrest outside
the hospital. N Engl J Med 1998;339:1595-1601.
Wenzel V, Krismer AC, Lindner KH, et al. Comparison of vasopressin and epinephrine for out-of-hospital cardiopulmonary resuscitation. N Engl J
Med 2004;350:105-113.
Schmittinger CA, Astner S, Astner L, et al. Cardiopulmonary resuscitation with vasopressin in a dog. Vet Anaest Analg 2005;32:112-114.
Wingfield WA, Van Pelt DR. Respiratory and cardiopulmonary arrest in dogs and cats:265 cases (1986-1991). J Am Vet Med Assoc 1992;200:19931996
Waldrop JE, Rozanski EA, Swanke ED, et al. Causes of cardiopulmonary arrest, resuscitation management, and functional outcome in dogs and cats
surviving cardiopulmonary arrest. J Vet Emerg Crit Care 2004;14:22-29.
2005 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2005;112(suppl.)
Kass PH, Haskins SC. Survival following cardiopulmonary resuscitation in dogs and cats. J Vet Emerg Crit Care 1992;2:57-65.
959
CRI Use for Anesthesia and Analgesia
Katrina Lafferty, BFA, CVT, VTS (Anesthesia)
University of Wisconsin
Madison, WI
Pain management in veterinary patients has come a long way. There are a myriad of analgesic drugs available and numerous
techniques exist to further provide top-notch analgesia and pain management to animals undergoing even the most painful surgeries.
Constant rate infusions (CRIs) are increasing in their usage, thanks in large part to their wide versatility. There are pharmacologic
agents used as CRIs that can provide analgesia, maintain anesthesia, and provide blood pressure support if needed.
Analgesics
Delivery of analgesic drugs as a CRI is typically far superior to bolus doses for a number of reasons. By administering a constant,
steady infusion of a drug, stable levels of tissue concentration are reached. This prevents the peaks and valleys of comfort versus
discomfort that occurs when bolus doses of analgesics are give as a patient begins to seem painful. When giving bolus doses, drugs
peak, providing analgesia, then fall to below therapeutic levels allowing for breakthrough pain. CRI administration eliminates that rise
and fall. CRIs can be easily adjusted to meet the needs of each individual patient, allowing for lower amounts of the drug to be given.
Less money is spent on the actual drug as well as on supplies (syringes, needles, etc). Lower doses also decrease the incidence and
severity of side effects.
Analgesic choices
Many classes of analgesic drugs can be given as a CRI including opioids, local anesthetics (specifically lidocaine), NMDA receptor
antagonists (ketamine), and alpha-2 agonists (dexmedetomidine). Drug dosages are shown in Table 1.
Opioids work by binding with specific receptors in the central nervous system (CNS) and can, depending on the opioid, provide
relief for mild to severe pain. Morphine, fentanyl, hydromorphone, and butorphanol are commonly used in opioid CRIs. Morphine,
fentanyl, and hydromorphone can be used for moderate to severe pain, while butorphanol is only appropriate for use in mild to
moderately painful cases. CRIs tend to reduce the severity of opioid side effects such as vomiting, dysphoria, and respiratory
depression, but patients should still be monitored closely for any sign of distress.
Lidocaine works by blocking sodium ion channels and causing membrane stabilization. It can reduce the amount of opioid
analgesic and inhalant gases required to maintain anesthesia. Lidocaine is relatively inexpensive and has anti-arrythmic and antiinflammatory properties. It is may be useful in cases where gastrointestinal pain is involved(GDV, laparotomies, etc). Cats have an
increased sensitivity to local anesthetics and it is currently not recommended to use lidocaine infusion on feline cases.
Ketamine works by antagonizing the NMDA receptors which are responsible for central sensitization, hypersensitization, and
“wind-up” pain. Ketamine is not capable of providing adequate analgesia in its own right, however, when administered in combination
with opioid analgesics, it can lower anesthetic requirements of the patient.
Dexmedetomidine has mild analgesic properties, as well as anxiolytic and sedative properties. It works by simulating alpha-2
receptors in the CNS. Dexmedetomidine CRIs are most commonly used in the postoperative phase, for patients that are anxious and/or
vocal despite an appropriate anesthetic regimen.
Anesthetic maintenance
Total intravenous anesthesia (TIVA) with propofol may be indicated for short, painless procedures. It may also been needed in
situations where a patient cannot be intubated (tracheal procedures), where patients need to remain intubated and unconscious for
extended periods (cases requiring long term ventilation assistance), or patients with autosomal disorders where inhalants cannot be
used (malignant hyperthermia). In these cases propofol is administered with a bolus dose of 2-5 mg/kg followed by 0.050.2mg/kg/min. Adequate oxygenation is always a concern, so if possible it is recommended to intubate patients and maintain them on
100% oxygen. Standard anesthetic monitoring is still needed in TIVA patients. It may be harder to control depth when using TIVA, so
good monitoring can act as an early alert system to patients that become too light or too deep, much the same as when anesthetizing a
patient with volatile anesthetics.
Pressor support
Dopamine and dobutamine are the choices most commonly used to provide blood pressure support in hypotensive patients. Both drugs
increase cardiac contractility, and assuming the patient has appropriate vascular volume, these drugs can most boost low blood
pressure. The range for both dobutamine and dopamine is 1-10 mcg/kg/min. There can be a wide variation in patient reactions, so it is
recommended to begin with low end dosing and adjust as needed.
Equipment
One downfall of CRI administration is that it requires specific equipment for the best and safety route of delivery. It is possible to
deliver CRIs using either a fluid pump, syringe pump, or standard drip set. It is ideal to use a syringe pump, which can be programmed
with all the variables involved in administering the infusion, but pumps can range from hundreds to thousands of dollars. If CRIs are
being used on a regular basis, infusion pumps could be worth the investment—less waste, less man-power needed, fewer errors. Fluid
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pumps are a nice piece of equipment to have if you are simply injecting your drugs into a bag; they are programmable and can be set
to deliver specific volumes over time. It is still on the technician to figure out the best concentration of the CRI for the length of time
being it will be delivered. If neither a fluid pump or syringe pump is available, a standard drip set can be used. However, extreme
attention needs to be paid to ensure the patient receives the appropriate fluid rate.
Table. 1: Analgesic CRI drug dosages
Drug
IV Loading Dose
Butorphanol
0.1-0.2mg/kg
CRI Dose
0.1-0.2mg/kg/hr
Notes
Can be expensive
Dexmedetomidine
1-2 mcg/kg
0.5-2 mcg/kg/hr
Fentanyl
2-5 mcg/kg
2-25 mcg/kg/hr
Hydromorphone
0.02-0.05 mg/kg
0.01-0.04 mg/kg/hr
Ketamine
0.5 mg/kg
2-10 mcg/kg/min
Fewer negative side effects
noted
Lower end dose for postoperative management
Lower end of dose for feline
patients
Often used with an opioid
Lidocaine
1-2 mg/kg
25-50 mcg/kg/min
NOT IN CATS
Morphine
0.1-0.3 mg/kg SLOWLY
0.1-0.3 mg/kg/hr
Lower end dose for cats
Morphine-Lidocaine-Ketamine
M: 0.1 mg/kg
L: 0.5 mg/kg
K: 0.25 mg/kg
M: 0.12 mg/kg/hr
L: 1.5 mg/kg/hr
K: 0.12 mg/kg/hr
Can use fentanyl/hydro in
place of morphine
Omit lidocaine for cats
References
Skarda, Roman T. and Tranquilli, William J. 2007. Veterinary Anesthesia and Analgesia, 4th edition. Ames (IA): Blackwell Publishing.
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To Glasgow and Beyond:
Appreciating, Adapting, and Applying Pain Scoring Systems
Katrina Lafferty, BFA, CVT, VTS (Anesthesia)
University of Wisconsin
Madison, WI
The 4th vital sign: pain. There are a myriad of negative consequences associated with inappropriately managed pain: decreased
healing, infection, heightened reactions to pain, changes to the CNS. Utilizing pain scoring systems reduce pain states and improve
patient care.
Poorly managed pain, whether before, during, or after anesthesia, can have a number of harmful consequences. Most publications
on the subject of pain management in both “traditional” canine/feline patients and “non-traditional” exotic patients show appropriate
analgesia and pain management to be essential to wound healing and patient recovery. Improperly managed pain affects the patient
and the owner.
Pain is an individual experience and can be somewhat subjective; many factors can affect how pain is interpreted. In humans and
animals alike pain is tolerated differently. It can be influenced by genetics (think husky dog versus Staffordshire terrier), learned
behaviors, and even culture. In veterinary patients the challenge of adequately recognizing, assessing, and treating pain is further
complicated by the non-verbal nature of the patients. Much of the pain assessment techniques used in animals is modeled after what is
used in human medicine for infants, toddlers, and other non-verbal patients. In the AAHA pain management guide for cats and dogs it
is stated, “It is now well established that animals and humans have similar neural pathways for the development, conduction, and
modulation of pain. According to the principle of analogy, because cats and dogs have neural pathways and neurotransmitters that are
similar, if not identical, to those of humans, it is highly likely that animals experience pain similarly.” Read this to mean if it would
cause discomfort to you, it would cause discomfort to your patient, regardless of species.
To better understand how to manage pain, one should have a fluency in the “language” of pain:
•
Pain: an unpleasant sensory and emotional experience associated with actual or potential tissue damage; the perception
of nociception
•
Nociception: the activity produced in the nervous system by noxious stimuli
•
Analgesia: absence of pain in response to normally painful stimuli
•
Hyperalgesia: an increased response to a normally painful stimulus
•
Allodynia: pain due to a stimulus that does not normally produce pain (i.e. touch)
•
Central Sensitization: “Wind up pain;” changes in the central nervous system that occur as a result of repeated or
chronic painful stimulus
•
Analgesic: an agent or drug that causes or allows for relief from pain; a “pain killer”
The pain pathway in the body can be broken down into four basic groups: transduction, transmission, modulation, and perception.
Analgesics and analgesic techniques work to modify to pain felt and transmitted throughout the circuit. Different analgesic drugs work
on different parts of the pathway.
•
Transduction: change of cellular chemical information into electrical impulses that travel the spinal cord
•
Transmission: travel of the pain impulse; transmitting the signal to the brain
•
Perception: cognizant recognition of painful stimulus
•
Modulation: Brain and spinal cord communicate and work together to change or modify the painful sensation
There are typically describe 6 types of pain:
1. Somatic Pain: at the level of the skin; also involves muscles, tendons, and joints
2. Visceral Pain: Internal organs, soft tissue
3. Acute Pain: Recently occurring, generally less than a few months
4. Chronic Pain: Longer in scope, lasting more than a few months
5. Neuropathic Pain: Atypical pain, ie: phantom limb pain
6. Referred Pain: Pain perceived in a region disparate from the actual painful site
Pain perception can be broken down into 3 sections: Perception (recognition of discomfort), Threshold (point when painful signal
hits the brain), and Tolerance (amount of pain that can be endured). In order to assess pain thoroughly, consider these categories:
Incidence, Level, Location, Length. For each patient, each category can have varying levels of intensity. All veterinary patients will be
non-verbal, so the difficult task is to use behavioral assessments to answer questions of how painful an animal is. There are species
differences in pain behavior, but many pain mannerisms are universal.
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Universal non-verbal pain indicators
•
Abnormal posture
•
Restlessness
•
Splinting
•
Vocalizing
•
Unwillingness to move
•
Trembling/shivering
•
Anorexia
•
Elevated physiologic parameters
•
Aggression (towards self or others)
•
Lack of grooming
•
Self-mutilation
Pain is often characterized and describe as it is relevant to the owner. An adequate and thorough “pain history” can be very useful
when creating an appropriate analgesic plan. The history should include:
•
Previous/ongoing painful states
•
Previous methods of controlling pain
•
Owner’s expectations for pain control
•
How/why the owner feels a patient is painful
The “FLACC” scale is often used in human medicine for non-verbal patients (infants, toddlers, demented patients, critically
ill/unconscious patients) and has applications for veterinary patients. FLACC stands for “Face” (relaxed/grimace/tightened face),
“Legs” (normal posture/kicking/restless), “Activity” (normal/restless/agitated), “Cry” (quiet/whimpering/frequent complaints), and
“Consolability” (content/distractable/unable to comfort). Each area is ranked 0-2, with elevated numbers requiring treatments.
In veterinary medicine, there are 3 primary scales that have been adapted and utilized for pain assessment.
CSU acute pain scales
Colorado State University created pain scales for canine and feline patients, based on behavior and physical reactions to stimuli. It is
an exceptionally easy to use scale, but does not necessarily have clinical validation to support it. It does have forms for both canine
and feline patients.
Glasgow composite measure pain score-short form
This form is based on specific behavioral markers, assigning numeric points to determine level of pain. This scale is used universally,
everywhere from small private practices to veterinary teaching institutes. This scale is designed for canine patients. This scale does
have some clinical research to support it.
UNESP-botucatu multidimensional composite pain scale
This form is the feline companion to the Glasgow Pain Scale. It utilizing 10 categories to assign numbers for painful behaviors.
Using a behavioral checklist is likely the most common way to create a pain assessment chart. Having a chart on hand allows for a
standard, equal, reproducible way to evaluate pain in patients.
Behavior based charts should include categories for:
•
Attitude or Mentation
•
Activity
•
Facial expression
•
Guarding
•
Posture
•
Vocalization
Above all, treat each patient as an individual. If pain is suspected, treat. If an animal responds to analgesic intervention, that too is
considered a point on the pain assessment scale.
References always available upon request.
963
Anesthesia and Analgesia for Avian Patients
Katrina Lafferty, BFA, CVT, VTS (Anesthesia)
University of Wisconsin
Madison, WI
Many technicians (and veterinarians) do not feel comfortable working with avian patients. There is a decided lack of information on
how to appropriately handle, medicate, and anesthetize birds, complicated by the fact that birds are not mammals and have much
different anatomy than cats and dogs. However, the number of bird owners is increasing dramatically and more and more of those
dedicated pet owners are bringing their family members to veterinary clinics expecting the same kind of care cats and dogs normally
receive. Ovariohysterectomies are becoming a common occurrence, as are ceolomic surgeries, fracture repairs, wing amputations, and
mass removals. The purpose of this lecture is to provide basic information on how to competently provide quality anesthesia for birds
in the hopes that technicians will feel more confident about providing a better standard of care for the exotics species that come
through the clinic door.
Anatomy
Avian patients have a number of anatomical differences from their mammal counterparts. The gastrointestinal tract includes an
outcropping of the esophagus known as the crop, 2 chambers in the stomach known as the proventriculus ( a very strong chamber that
secretes acid to break down food) and the ventriculus (aka the gizzard; essentially crushes food), and a common outlet for intestinal,
genital, and urinary tracts called the cloaca.
The respiratory system in birds is very complicated and can be extremely sensitive. Birds have a very long trachea, slower
respiratory rate, and larger tidal volume. They have small, dense lung that cannot handle apnea. They have 9 air sacs that act as a type
of bellows and increase respiratory efficiency. Birds have no diaphragm and their entire body cavity acts as a ventilatory force.
Normal values
•
Temperature: 100-110, Pulse: varies based on species—up to 1000/beats per minute, Respirations: 30-60
•
Packed Cell Volume: 38-50%
•
Total protein: 2.4-5
•
Glucose: 185-455
•
Blood Volume: 55-70 ml/kg
•
Remember, these are all VERY species specific!
Premedication
Drug doses for MOST species of bird
•
Butorphanol: 0.5-2 mg/kg IM/SQ/IV
•
Buprenorphine: 0.01-0.05 mg/kg IM/SQ/IV
•
Hydromorphone/Oxymorphone: 0.05-0.2 mg/kg IM/SQ/IV
•
Midazolam: 0.1-0.5 mg/kg IM/SQ/IV/intranasal
•
Carprofen: 1-2 mg/kg SQ
•
Meloxicam: 0.1-0.2 mg/kg SQ/PO
•
Ketamine: 10-20 mg/kg IM
•
Propofol: 2-5 mg/kg IV* use with caution
As with canine and feline patients, birds should be premedicated with a sedative and analgesic combination before any anesthetic
episode. Premedication helps decrease level of stress in patients, reduces anesthetic requirements, and helps to deal with pain
associated with the procedure. While it is not typically acceptable to mask induce patients, exotic species are the exception. They are
usually not sedate enough from premedication to allow for easy catheter placement. Even if IV induction is an option, many species
are require more time to intubate and an induction with an IV agent, such as propofol, may not allow enough time for intubation
before it reaches a crisis. Birds however, are exceptionally easy to intubate, so intravenous induction is an option.
The primary site for intramuscular injections is the pectoral area. It often the largest muscle mass and is easy to locate by palpating
the keel and angling the needle laterally. The quadriceps muscles can be used, but the potential hepatotoxic effects of the drug must be
considered and weighed.
Subcutaneous injections can be given in the inner thigh or over the keel. The skin in both areas is very thin, which does allow for
easy confirmation of placement. The inner thigh is best for larger volume administration although caution should be used as it is near
an air sac.
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Induction and intubation
Isoflurane and sevoflurane are both acceptable choices of gas inhalant in exotic anesthesia. When performing a mask induction be
extra vigilant in monitoring vital signs. Take care not to over- or under-restrain the patient and use caution not to cause ocular damage
with the induction mask. Birds do not have a diaphragm and cannot respire appropriately if their chest is restricted.
Birds should ALWAYS be intubated. Avian patients frequently become apneic under anesthesia and their physiology does not
tolerate any episodes of respiratory arrest. Birds are also very prone to regurgitation and intubation lessens the likelihood of aspiration.
Tube size for birds usually runs from 2.0mm-5.0mm depending on the size and species of the bird (cockatiels and parakeets can be
intubated using 16 gauge or 18 gauge catheters with the stylet removed). Do not inflate the cuff. Birds have complete tracheal rings
and any pressure from an inflated cuff can cause tissue necrosis. Birds are technically easy to intubate, the tracheal opening is located
just off the base of the tongue and can often be visualized without the aid of a light source.
Venipuncture and intravenous catheter placement
The right jugular veins in birds is usually easily visualized, well tolerated, and excellent for larger volumes. The ulnar/basilic (wing
vein) usually requires anesthesia to attempt. The vessel is very fragile and the technician should expect a hematoma. The vessel runs
directly alongside an artery so take care which vessel is being used. The medial metatarsal vein is an excellent choice in larger birds
and the first choice in waterfowl. The tools necessary for blood collection include a 1cc syringe or small gauge butterfly set, 23g-27g
needles, and small collection tubes. It is important to remember to remove the needle before transferring the sample to the collection
tube as the cells being forced through a small gauge needle can be lysed. Bird blood can clot quickly, so if it will not interfere with the
required tests, it can be advantageous to preheparinize the syringe.
In birds, catheters can be placed in the ulnar vein, medial metatarsal, or jugular vein. The ulnar vein is easy to see, but is located
immediately next to an artery so care should be taken not to catheterize the wrong vessel. The ulnar vein is more challenging to secure
and is not practical for maintence beyond the anesthetic and immediate recovery period. The medial metatarsal vein is an excellent
choice in long –legged birds and can usually be maintained longer term. The jugular vein is an adequate choice for long term catheters
and may be the only choice in very small birds. In birds the right jugular vein is much larger and more prominent.
Equipment needed for intravenous catheters includes 22, 24, or 26 gauge catheters, gentle tape—clear tape or paper tape, and
lightweight access ports.
Monitoring
Similar monitoring techniques are used in canine and feline patients, allowing for a smaller scale. Pulse oximetry can readily be used.
Probes can be placed on the feet, tongue, wings, esophagus, or cloaca.
Doppler flow detector crystals can be placed over the dorsal pedal artery or ulnar artery in birds and in larger patients can be used
in conjunction with a sphygmomanometer to obtain blood pressure readings. The Doppler probe can also be placed in the femoral
area, carotid/thoracic inlet, or on the chest and used for sound and heart rate. Be careful not to restrict respirations if taping the probe
on the chest.
Capnometry can be used on any intubated patient. Dead space adapters exist that can be connected to the endotracheal tube in
place of the regular tube adapter. The size endotracheal tube used is very small and tube obstruction is a concern. A capnograph can be
the first alert to an obstruction or inadvertent extubation. It can confirm proper intubation and can alert the anesthetist to issues with
ventilation or cardiac output.
Non-invasive blood pressure monitoring is an option on some animals—good pediatric monitors usually work well on medium to
large birds. Small blood pressure cuffs can be placed on the wings or legs.
Electrocardiography can be readily monitored. The ECG gives information about rate and rhythm and can be a helpful tool to use
under anesthesia. ECG patches can be placed on both wings and the left leg in birds. It is also possible to use 25 gauge needles pierced
through skin with an alligator clip attached to the needle. If using alligator clips on skin (without an ECG patch) either flatten the teeth
of the clip or use a gauze square to cushion the area and prevent tissue damage.
Temperature monitoring is one of the most vital monitors in birds. Small patients are at a high risk for hypothermia. It is important
to note that for as quickly as small patients can cool down, they can warm up just as fast. Without careful monitoring of temperature,
patients can easily become hyperthermic. Temperature can be monitored using either cloacal or esophageal temperature probes.
Monitoring anesthetic depth in birds has some similarities to monitoring anesthesia in other species. Palpebral reflexes are not
reliable in birds, however, jaw tone, rectal tone, and pedal reflexes are all accurate indicators of anesthetic depth. As with most
species, if an avian patient is too light, heart rate and respiratory rate will increase, if it is too deep, heart rate and respiratory rate will
decrease.
Recovery
Recovery requires almost as much monitoring as during the anesthetic period. Birds can become hypothermic very quickly and
temperature should be monitored closely for several hours postoperatively. It can be difficult to maintain catheters in birds and
965
watchful eye must be kept. Respiratory depression can quickly lead to cardiac arrest—vigilance can catch an issue before it becomes a
critical problem. Always know the reversal drug and dose needed and have an emergency drug dose chart readily available. Birds
should be kept in an area where they can be easily watched but not disturbed. Make sure housing is warm, dark and away from
predators. If necessary make modifications to food and water sources so they can be easily accessed by debilitated or recovering
patients.
References available from the author.
966
Case by Case:
Creating the Right Drug Protocols for Canine and Feline Patients
Katrina Lafferty, BFA, CVT, VTS (Anesthesia)
University of Wisconsin
Madison, WI
Anesthetic patients should be evaluated on a case-by-case basis and an anesthetic protocol created for the individual situation. That
being said, it can be overwhelming and intimidating to pick the right drug combination from the multitude of available options. This
lecture will briefly review available drug choices and considerations for premedication and induction as well as intra- and postprocedural analgesia and sedation. Several case studies (both routine and emergency) will be provided for interactive discussion.
The reasons to premedicate are many. Premedication allows for less stressful and safer restraint and catheter placement (for patient
and technician), it provides for analgesia during a procedure and by and large decreases the amount of drug needed overall. No one
drug possesses every desired quality—good sedation, good analgesia, reversibility, minimal side effects—so it is necessary to choose
a combination of drugs to decrease negative effects and lower the total amount of drug needed. An anesthetic protocol should include
a drug for sedation and one for analgesia. The specific drugs and amounts used will depend on several factors. The anesthetist creating
the plan will have to evaluate the temperament of the patient, the type of procedure being performed, and the co-existing conditions or
contraindications each patient may have.
Sedatives
Generally the available sedatives are benzodiazepines (diazepam, midazolam), phenothiazines (acepromazine), and alpha-2 adrenergic
agonists (dexmedetomidine).
Benzodiazepines offer sedation but no analgesia. The sedative qualities are appropriate for patients with calm (or depressed)
personalities. They have minimal negative effect on cardiovascular or respiratory systems and are the sedative of choice for
compromised patients. Benzodiazepines have many positive qualities; they provide muscle relaxation, have anxiolytic properties, and
are commonly used for seizure patients. Benzodiazepines do not work well alone or on excited patients and may even have an
opposite excitatory effect, counter to the desired sedation. As with all sedatives, it is best to combine this type of drug with an
analgesic opioid for maximum effectiveness. Midazolam is a water soluble benzodiazepine and is safe to administer intravenous (IV),
intramuscular (IM), or subcutaneous (SC). Diazepam is lipid soluble and should only be given IV; when given IM or SC routes,
diazepam injections are painful and absorption is extremely erratic. Flumazenil is the reversal for benzodiazepines.
Phenothiazines provide good sedation (but again, no analgesia) for patients and are often the best option for aggressive,
hyperactive, or extremely anxious animals. Acepromazine is the most commonly available phenothiazine. There are many pros to
phenothiazine sedatives, they are good anti-emetics, a benefit when combining with an emetic like opioids, prevent histamine release,
and have little effect on the respiratory system. There are a number of cons though, including decreasing the seizure threshold,
peripheral vasodilation and resultant hypotension, hypothermia, and inhibition of platelet aggregation. There is evidence that
phenothiazines can cause splenic enlargement. This can cause difficultly for surgeons working in the abdominal cavity.
Unfortunately, phenothiazines are not reversible. Acepromazine can be given IV, IM, or SC.
Alpha-2 adrenergic agonists provide excellent sedation for most patients and provide very minor analgesia (though not enough for
any surgical purpose). Dexmedetomidine is the most commonly used alpha-2. This class of drug can cause respiratory depression, but
it varies greatly from patient to patient. This class of drug can cause dark mucous membrane color that is unrelated to oxygenation of
tissue. It can cause profound bradycardia and vasoconstriction. It is not advisable to treat the bradycardia with anticholinergics as it
increases the workload of the heart. It is best to reverse the drug first, then deal with bradycardia if it continues. This class of drug is
only an appropriate choice for relatively healthy patients and cannot be used on any patient with cardiac compromise. Alpha-2s cause
vomiting in most cats and many dogs, though this is much less when given intravenously. Alpha-2 adrenergic agonists are reversible
with atipamezole. Dexmedetomidine can be given IV, IM, or SC (the dose is dramatically lower when given IV).
Analgesics
Part two of the premedication composition is an appropriate opioid analgesic. There are a plethora of available choices for any given
situation. Opioids fall into three groups: agonist-antagonist, partial agonist, and agonist.
Butorphanol is an agonist-antagonist that provides very minor analgesia and is short acting (30-60 minutes). This drug is best used
for minimally painful procedures such as endoscopy, minor biopsies, imaging, or straight-forward dental cleanings. Buprenorphine is
a partial agonist. It provides mild to moderate analgesia, lasting about 6-8 hours. It works very well in cats, but not well at all in dogs.
Both butorphanol and buprenorphine produce minimal respiratory or cardiovascular depression and usually do not cause vomiting.
They both can be reversed with naloxone, however, they bind very tightly to the receptor and can be difficult to reverse. Both drugs
also occupy the same receptors used by opioid agonists and thus block the effect if another opioid is given before the butorphanol or
buprenorphine have worn off.
967
Opioid agonists such morphine, hydromorphone, oxymorphone, and fentanyl are the best choices for painful or invasive
procedures. With the exception of fentanyl, which only lasts 20-30 minutes, opioid agonists last 3-4 hours. Full mu agonists, when
given IM, will cause vomiting and pytalism. All opioids can be given IV, IM, or SC, however, morphine must be given slowly IV as it
can cause histamine release and should be avoided in patients with known mast cell tumors or history of allergic reactions. Fentanyl
should be given IV as a constant rate infusion (CRI) due to its short duration of action.
Opioid agonists can cause depression of the cardiovascular and respiratory systems leading to hypoventilation and hypotension.
Negative side effects tend to be greater with higher doses. These drugs allow for sedation and excellent analgesia. All can be given
intra-operatively as constant rate infusions. Full reversal (remember, this is reversal of everything, including analgesia) can be
achieved quickly with naloxone. If it is desired to only partial reverse the opioid agonist (if a patient is dysphoric or very slow to
rouse), butorphanol can be used. This allows for a small amount of analgesia to be maintained.
Anticholinergics
To give or not to give? That is the question. There is much debate on whether or not to include anticholinergics (atropine and
glycopyrrolate typically) in a premedication combination. On one side of the argument are those who opt to include anticholinergics
with the thought that it is best to treat opioid-induced bradycardia before it occurs. On the other side of the table are those who believe
you should treat the problem only if it actually does occur. Atropine has a rapid onset, but is short acting, where glycopyrrolate is the
opposite (long onset, long duration). Both drugs can be given IV, IM, or SC.
Induction agents
There are typically three choices for anesthetic inductions: propofol, ketamine/diazepam, and etomidate. Propofol is a sedativehypnotic that is relatively safe for use in most patients. It does cause transient apnea and a dose-dependent cardiovascular depression.
In cats it is known to cause Heinz body formation following repeated administration. Propofol can be used alone, or in combination
with a benzodiazepine such as diazepam or midazolam. Propofol has on onset of about 30-60 seconds and lasts about 10-15 minutes.
Combining propofol with a benzodiazepine allows for a reduction in the amount of propofol needed, thus lessening some of the
negative side effects. It is always a good idea to pre-oxygenate (if possible) when giving propofol as an induction agent.
Ketamine/diazepam is readily available and inexpensive. It is safe for use in most patients. Ketamine can be used as a premedicant,
intra-operative analgesic and an induction agent. Ketamine is a dissociative agent and causes a trance-like state. Patients induced with
ketamine and a benzodiazepine maintain jaw tone and palpebral reflexes. Most patients maintain normal to increased heart rate and
blood pressure due to the increase in cardiac contractility caused by the ketamine. Ketamine/benzodiazepine inductions should be
avoided in patients with hypertrophic cardiomyopathy or pre-existing tachycardia. Ketamine provides excellent somatic analgesia. It
can increase intracranial pressure and should be avoided in neurologic patients. Ketamine can also cause an increase in intraocular
pressure and should be used with caution in ophthalamic cases.
Etomidate is an imidazole derivative that has minimal cardiovascular or respiratory effect. It is expensive and tends to be used for
extremely critical patients. Etomidate can cause suppression of adrenal functioning and should be avoided in patients with adrenal
disease/dysfunction. It can also cause acute hemolysis. Etomidate is given much like propofol—pre-oxygenate, slow, steady
administration—but should NEVER be given without appropriate premedication. It often causes nausea, retching and vomiting at
induction. This side effect can be avoided if the patient is appropriately sedated and if an adequate amount of the drug is used.
Constant rate infusions (CRIs)
CRIs are used regularly as a complimentary analgesic. They help maintain adequate anesthetic depth and allow inhalant levels to be
kept low. Most analgesic agents can be run as a CRI--ketamine, lidocaine, fentanyl, hydromorphine, butorphanol, morphine, and
dexmedetomidine. Many work best when in combinations such as MLK (morphine, lidocaine, ketamine), FLK (fentanyl, lidocaine,
ketamine) or HLK (hydromorphone, lidocaine, ketamine). CRIs are beneficial in that they allow for a steady plane of analgesia
without the side effects usually associated with bolus dosing. Less of the drug is given overall, thus making this approach more cost
effective as well.
One additional drug that should be mentioned as a CRI is propofol. It does not provide any analgesia, but can be used as a form of
total intravenous anesthesia (TIVA). This type of general anesthesia is useful in cases where it is not possible to intubate a patient,
such as tracheal surgeries. It is also relevant for patients with malignant hyperthermia.
General anesthetics
Isoflurane and sevoflurane are the most commonly used gas anesthetics. Some specialty practices may have desflurane available, but
as that is not common, we will not discuss it here. Both iso and sevo provide a state of unconsciousness but absolutely NO analgesia.
It is imperative that an analgesic be used in combination with inhalants. Both gases have dramatic affects on blood pressure and can
cause mild to profound hypotension due to vasodilation. Typically the level of hypotension is dose dependant, but not always.
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The minimum alveolar concentration (MAC) of sevo is 2.4% in dogs and 2.6% in cats; for iso the MAC is 1.3% in dogs and 1.6%
in cats. The MAC of an inhalant is defined as the level of anesthetic gas required to prevent reaction or movement in the face of
painful stimuli in 50% of patients. The higher the number assigned to a MAC value, the less potent the inhalant anesthetic. Thus sevo,
which has a higher MAC is less potent than iso, which is why the level of sevo must be run higher to achieve the same result.
Sedatives and opioid analgesics help lower the MAC requirements, allowing the inhalant to be run at a lower level, thus reducing the
negative effects of the gas.
Post-operative care
The responsibility of affective managing pain does not end once the patient has recovered. Post-operative analgesia should be given
for any painful procedure, with the kind of drug and duration of administration dependant on the type and severity of the procedure or
surgery. All of the drugs listed in the opioid section can be used in the post-operative period—either as single-dose administrations or
CRIs, depending on the situation. Non-steroidal anti-inflammatory agents can and should be used as well, where appropriate.
References
Skarda, Roman T. and Tranquilli, William J. 2007. Veterinary Anesthesia and Analgesia, 4th edition. Ames (IA): Blackwell Publishing.
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Opioids:
So Many Choices, So Little Time
Katrina Lafferty, BFA, CVT, VTS (Anesthesia)
University of Wisconsin
Madison, WI
Opioids: Where do they come from?
•
“Drug of Joy;” one of oldest known drugs in the world
•
Originally from alkaloids found in poppy resin
•
Three types now exist : natural, synthetic, semi-synthetic
Opioids: How do they work?
•
Bind to specific receptors in the central and peripheral nerve system
•
Drugs and receptors act like a lock and key system
•
Not a perfect system though—some opioids “fit” better than others
•
Receptors: Mu, Kappa, Delta, Sigma
Mu
 Located throughout CNS and GI tract
 Responsible for:
 Central interpretation of pain
 PEAR: Physical dependence, Euphoria, Analgesia, Respiratory depression
Kappa
 Mild to moderate analgesia
 Minimal respiratory depression, minimal physical dependence, some dysphoric effects
 SAM: Sedation , Analgesia, Miosis (tiny pupil)
Terminology
 Efficacy: Maximum response achievable from a drug
 Pure agonist: Affinity for binding, efficacy
 Pure antagonist: Affinity for binding, no efficacy, blocks action
 Mixed agonist-antagonist: Agonist at one site, antagonist at another
 Partial agonist: Affinity for binding, low efficacy
Opioid agonists
 Typically exert effect by acting at mu receptors
 Full mu agonists are best analgesics for moderate to severe pain
 Usually produces more analgesic effect with a higher dose
Morphine
 First opioid
 Histamine release, vomiting, full agonist at mu/kapp
 Lasts ~3-4 hours IM/SQ/IV (caution IV); lasts 12-24 hours epidurally (24 hours rare)
 Dosage ranges in dogs: 0.3-2.0mg/kg IM/SQ; 0.1-0.5mg/kg IV; 0.1-0.2mg/kg epidural
 Dosage ranges in cats: 0.05-0.2 mg/kg IM/SQ; 0.1-0.2 mg/kg epidural
Codeine
 Semi-synthetic; Substitution of a methyl group into morphine
 1/10th potency of morphine; lower efficacy than morphine
 Anti-tussive properties
 Do NOT use in cats if combined with acetaminophen
 Duration of ~6 hours; maybe longer if combined with NSAIDs
 Dosage in dogs: 1-2mg/kg PO
 Dosage in cats: 0.1-1.0mg/kg PO
Meperidine
 Synthetic
 1/8th potency of morphine
 Agonist at mu; bind to other receptors?
 Blocks sodium channels/inhibit dorsal horn neurons
 Duration < 1 hr
 Potential problems:
 Broken down into metabolite that can cause seizures in humans
 Has atropine-like effects, caution with existing tachycardia
 Causes histamine release
 Dosage in dogs and cats: 3-5mg/kg IM/SQ
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Hydromorphone
 Synthetic
 8-10x potency of morphine; full agonist at mu
 Hyperthermia in cats?
 Duration of 2-4 hours
 Dosage in dogs: 0.05-0.2mg/kg IM/SQ/IV
 Dosage in cats: 0.05-0.1mg/kg IM/SQ/IV
Oxymorphone
 Synthetic
 Less likely to cause vomiting
 More expensive
 Very similar to hydromorphone ; same dosage as hydromorphone
Fentanyl
 Synthetic
 Full agonist at mu; 80-100x potency of morphine
 Short acting <30 min duration; best given as a CRI
 Opioid induction
 Combined with midazolam or diazepam
 Dosage in dogs: 2-10mcg/kg IV; 2-30mcg/kg/hr CRI; 1-5mcg/kg/hr epidural CRI; 2-5mcg/kg/hr transdermal
 Dosage in cats: 1-5mcg/kg IV; other dosages same as in dogs
Remifentanyl
 Synthetic; structural parallel to fentanyl
 Very short acting--must be on a CRI, like an on/off switch
 Metabolized to inactive metabolites
 Hepatic and renal dysfunction minimally affect drug clearance
 Dosage in dogs: 4-10mcg/kg IV loading dose; 4-60mcg/kg/hr CRI
 Dosage in cats: ???
Methadone
 Synthetic
 Traditionally used in human medicine to treat opioid addictions
 Full agonist at mu
 Affinity for NMDA receptors
 Duration of ~6hrs
 Dosage in dogs and cats: 0.05-0.2mg/kg IV/ IM/SQ
Opioid agonist-antagonists
•
Occupy mu receptor, but do not engage it
•
Analgesic actions at kappa receptors
•
“Ceiling effect”
•
Takes high doses of full mu agonists or antagonists to override
Butorphanol
 Synthetic
 Originally used as an anti-tussive
 Short lived; duration of 1-3 hours;minimal sedation when given alone
 Only good for mild to moderate analgesia
 Dosage in dogs: 0.1-0.4mg/kg IV/SQ/IM
 Dosage in cats: 0.1-0.8mg/kg IV/SQ/IM
Opioid partial agonists
 Binds tightly to mu; slow to leave site
 Does not reach maximum efficacy
 For mild to moderate pain management
Buprenorphine
 Semisynthetic
 Partial agonist at mu
 Delayed onset
 1 hr to peak effect after IM injection;~25 min to peak effect after IV injection
 Duration of 6-12 hours
 Difficult to antagonize
 Better in cats?
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Side effects common to most opioids
 Sedation--Response for most species
 Euphoria
 Mania--Particularly in cats and horses
 Hypothermia—but hyperthermia in cats
 Nausea/vomiting
 Dysphoria
 Respiratory/Cardiovascular depression
 Urinary retention
 Defecation
 Decreased motility/constipation
 Urticaria/itching
 Dependence?/Tolerance?
Cautions
 Respiratory/Cardiac disease
 Hypovolemia
 Hepatic/Renal insufficiency
Opioid antagonists
 High affinity for opioid receptors
 “Bump” opioid agonists from receptors sites
 Rapidly reverse all opioid effects: INCLUDING ANALGESIA!!
 Reserved for emergency situations
Naloxone
 Reverse all opioid effects
 Short lived ~30 -60 min; May need to redose
 May produce excitement or anxiety
 VPC have been noted to occur but are not common
 Dosage in dogs and cats: 2-20 mcg/kg IV
Naltrexone
 Lasts approximately twice as long as naloxone
 Little published information for veterinary use
Signs of an overdose
 Coma
 Depressed respirations: <2-4 breaths a min
 Cyanosis
 Hypotension
 Pinpoint pupils
 Low body temp
 Flaccid muscles
How to treat an overdose
 Establish an airway FIRST!
 Dilute naloxone dose and administer SLOWLY IV
 Closely monitor arousal and respiratory function
 Watch for renarcotization
 EVERTYHING reverse—including ANALGESIA
 What about butorphanol?
References
Grimm, Kurt; Thurmon, John; Tranquilli W.J. (2007). Lumb and Jones Veterinary Anesthesia and Analgesia, 4th edn. Blackwell Publishing Inc, Ames,
Iowa.
Plumb, Donald C. (2011). Plumb’s Veterinary Drug Handbook, 7th edn. Blackwell Publishing Inc, Ames, Iowa.
Thurman, John; Tranquilli, William; Benson, G. (1999). Essentials of Small Animal Anesthesia and Analgesia, 1st, edn. Lippencott, Williams, and
Wilkins, Philadelphia, Pennsylvania.
972
Avian Restraint and Venipuncture
Teresa Lightfoot, DVM, DABVP
BluePearl Veterinary Partners
Tampa, FL
Developing a method or methods for restraining uncooperative birds takes time and experience. The techniques for restraint are best
demonstrated on real patients in a wet lab or at an lunch seminar. Let us know if your hospital is interested in having a stressful,
squawk-filled ‘lunch and learn’ hour and we will schedule it. I’ll bring the Band-Aids..
For this lecture, we will start with how to determine if the stress of restraint is exceeding the bird’s ability to oxygenate. Remember
that birds possess complete cartilaginous tracheal rings (one can not “strangle” a bird). Respiration is accomplished by movement of
the chest and abdomen. Therefore, over-constriction of the body during restraint can cause oxygen deprivation.
The following is a list of parameters to use in determining if the bird is in danger of oxygen deprivation and death while being
restrained.
“Put it down” list – when to stop restraint
•
If panting and open mouth breathing persist..
•
If releasing the head does not cause the bird to attempt to bite..
•
If the bird does not bite at a towel placed in its mouth..
•
If the bird’s grip with both feet is not strong..
•
If the eyes close during the examination..
•
To be safe - “Put It Down!’ and observe!
Venipuncture on psittacine birds is usually performed on the right (the larger) jugular vein. The wing vein (basilic vein, more
commonly referred to as the brachial or ulnar vein) can also be utilized. Venipuncture of the wing vein tends to be uncomfortable,
creates a hematoma, and in birds with calcium deficiency, fractures of the wing may occur. However, many practitioners use this vein
successfully. The metatarsal vein in psittacines is quite short, and difficult to isolate in birds under 300 – 400 grams. Also, although
hematomas are uncommon due to the lack of a metatarsal subcutaneous space, bleeding from the venipuncture site is common and a
pressure wrap will be needed post-venipuncture. Toenail trims should not be used, due to the inaccuracy of samples taken from this
site, discomfort to the bird and danger of septicemia if the toenail cut is high enough to allow free flowing blood.
For birds less than 250 grams, it is usually easiest to restrain them yourself.
Hemorrhage and hematoma formation are possible sequelae following venipuncture. In small birds this can be a major concern,
and is reason not to take the calculated maximum blood volume for diagnostics. Generally, maximum blood volume for withdrawal is
calculated on 1% of the body weight. (i.e. a good sized cockatiel can withstand 1 ml of blood withdrawn. From a 1 kg blue and gold
macaw, 10 ml can be removed).
Blood pressure in birds is higher than in mammals, and elevates more markedly with stress. Many people apply pressure to the
venipuncture site for a full 30-60 seconds after withdrawal of the needle. While this helps impede seepage of blood from the vein, the
restraint needed also causes the blood pressure to stay elevated, increasing the likelihood of continued bleeding. Therefore, some
practitioners, (if no obvious venous laceration has occurred), will elect to replace the bird in its cage immediately after venipuncture is
completed.
Avian emergency and triage - avoiding disaster in the avian patient
Immediate emergency treatment for the moribund bird
•
Slide bird and cage into warm, humidified, oxygenated environment. That’s it.
•
Then go talk to the owner – both to get information that may help direct treatment, to ensure that the owner realizes how
critical their bird is, and to permit the bird to restore oxygenation if possible.
The moribund/minimally responsive bird
If the bird is minimally responsive, palpation of the keel and sterno-pubic area, without moving the bird may be accomplished.
•
Emaciation indicates chronicity
•
Increased sterno-pubic distance (abdominal distention) narrows the differential diagnosis.
•
In the absence of these findings, more acute disease is likely.
After this brief exam, the bird goes back into oxygen.
•
Oxygen should be warm and humidified,
•
Warm, because hypothermia is very common and under diagnosed. The normal body temp of an African Grey, for
instance, is ____???
•
Humidified, since dehydration and hypovolemia are common
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•
Oxygenated because, well, duh…
If the bird is in the exam room
Exam room entrance
•
Enter slowly
•
Sit & allow bird to relax
•
Discuss history with owner
•
Observe bird at rest*
•
Perform cursory PE (Consists of observation of the bird in its cage, noting respiration, mentation, grip, posture) prior to
touching the bird
Discuss differentials, diagnostics and treatment plan with the owner
Seriously ill but currently stable avian patient
•
Fluffed with a weak grip at rest.
•
Temporarily responds to stimulation by smoothing feathers and looking alert.
•
Can’t maintain this posture, returns to being sleepy and fluffed.
•
Hot feet, hot beak often = septicemia
Hospitalization
With sick birds that are still standing, especially those that have had blood loss, don’t forget to provide readily accessible food and
water!!
Remove perches, since sick bird may sit perched without the energy needed to climb down to their food and water.
Offer seed, millet spray, whatever they will eat. Proper diet is important, but diet conversion should be left until the bird has
recovered.
Hemorrhage is theoretically addressed first if acute and copious. However, any bleeding severe enough to warrant intervention
will have caused exsanguination within a few minutes. Birds seldom present at that stage.
Pressure wraps, bandaging, application of styptic, etc., WILL raise the blood pressure, will increase bleeding, and WILL lead to
increased stress and increased oxygen demand. LESS IS OFTEN MORE
Place the bird in a quiet, warm, dark incubator, provide food and water, and leave it alone.
974
ICU Patient Monitoring:
Show Me the Numbers
David Liss, BA, RVT, VTS (ECC, SAIM), CVPM
Platt College
Los Angeles, CA
Most veterinary practice have an anesthetic monitor that provides important digital data about the patient's condition. However, there
are so many beeps, numbers, charts and graphs that it can be difficult to keep everything straight. This lecture will serve to review the
basic physiology of the monitoring device and briefly discuss troubleshooting when problems occur. Monitoring implementations
covered in this talk will be: blood pressure, pulse oximetry, electrocardiography (ECG), end-tidal CO2 monitoring, and temperature.
Blood pressure
Arterial blood pressure is defined in the following equation: ABP = CO x SVR, where CO = Cardiac output and SVR = Systemic
vascular resistance. CO is further differentiated into heart rate (HR) and stroke volume (SV). Stroke volume can, finally, be subdivided into preload, afterload, and contractility. Thus, there are many factors that affect arterial blood pressure. These include: blood
volume/viscosity (preload), arterial tone (vasoconstricton or vasodilation), tachycardia, bradycardia, or decreased cardiac contractility.
Since there are many things that can cause hypo or hypertension, the veterinary technician anesthetist should be diligent in
investigating what the cause of the derangement of blood pressure is. Normal arterial blood pressure is approximately: Systolic: 100150 mmHg, Diastolic 90-95 mmHg, and mean arterial pressure: 80-100 mmHg. Measurement of blood pressure is typically done in
three different ways in veterinary medicine: doppler ultrasound measurement, oscillometric methods, or direct monitoring (using an
arterial catheter and transducer). While direct monitoring is gold standard, most clinics do not have this capability. The Doppler unit
has been shown to be the most accurate in critical patients, but oscillometric methods should suffice for most surgeries. With both of
those methods, cuff placement is very important. The cuff should be the appropriate size, and placed in a variety of spots, but the
measurements should trend logically and not jump around. The systolic value is the pressure in the artery at maximal cardiac
contraction, and the diastolic is the measurement in the artery at maximal cardiac relaxation. A patient with a slightly vasodilated
artery but increased contractility could drive their blood pressure to normal. The mean arterial pressure is important in organ perfusion
as it represents an average pressure across the cardiac cycle. Most organs need a minimum mean pressure to create a physiologic
pressure gradient to deliver blood to the organ or tissue. The most common abnormality experienced in anesthesia is hypotension (due
to inhalants, anesthetic drugs, fluid loss, or potentially blood loss).
Anesthetic monitor indicating arterial hypotension
Pulse oximetry
A pulse oximeter measures the saturation of red blood cells with oxygen and reports this in a percent. It also measures heart rate as it
needs to work over a peripheral artery. This machine is non-invasive, real-time and provides information on oxygenation vs.
ventilation. It works by shining two wavelengths of light (red and infrared) through one side of the emitter, through the tissue bed, and
to the receiver side of the clip. Hemoglobin absorbs both red and infrared light, but it does so differently whether it is oxygenated or
de-oxygenated. The amount of unabsorbed light is also detected by the machine. Pulse oximetry does NOT measure actual oxygen
content of the arterial blood or partial pressure of absorbed oxygen gas. But with the exception of rare conditions, inability to
oxygenate should be reflected on the pulse oximeter. However, these numbers need to be interpreted with caution. As oxygen enters
the lungs, it traverses the capillary-alveolar barrier and diffuses into the blood. It is then absorbed into the hemoglobin molecule. As
inhaled oxygen concentrations increase (to 100% under anesthesia), so should both the pulse oximetry reading and the partial pressure
(dissolved oxygen). If the dissolved oxygen level does not increase or is lower than physiologically acceptable, the same dramatic
change may NOT be represented as a dramatic change on the pulse oximeter. Pulse oximeter readings on room air should be 94% or
greater. Under anesthesia they should be 98% or greater. Changes from 98% to 94% can represent a multiple-fold decrease in plasma
oxygen levels and can represent serious hypoxemia in an anesthetized patient.
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Pulse oximeter reading with waveform
End-tidal carbon dioxide monitoring
As pulse oximetry measures oxygenation in a non-invasive way, ventilation (clearance of CO2) can be measured non-invasively as
well using a capnometer. The capnometer measures the CO2 level in an exhalation at the very end, hopfully mimicking the content of
arterial carbon dioxide. This is done by attaching a T-piece adapter between the endotracheal tube and the anesthetic circuit. The
resulting capnograph represents the exhalation cycle and carbon dioxide levels. Important information can be gathered by interpreting
the capnograph. Hypoventilation is very common under anesthesia for a variety of reasons. Patients can be under the influence of
respiratory depressant agents (inhalant or injectable medications), be on their side, or laying on their backs with their abdominal
viscera encroaching on normal chest wall movement, or potentially be paralyzed for a special procedure. Ventilatory changes do NOT
have the same drawbacks as the pulse oximeter in terms of reporting hypo or hyperventilation. A normal end-tidal CO2 reading should
be a few mmHg less than arterial blood. So typically 30-35 mmHg (arterial of 35-40) is considered normal. And, because the endtidal readings are also in real time, any reading <30 indicates hypocarbia and potentially hyperventilation, and any reading >35
indicates hypercarbia and hypoventilation. Typically hypoxemia, often NOT reflected on the pulse oximeter, can be corrected by
enhancing ventilation under anesthesia (sigh breaths, intermittent positive pressure ventilation, or initiating mechanical ventilation). In
addition, the end-tidal CO2 monitor is very sensitive in detecting cardiac arrest; the capnogram will reveal a 0 mmHg end-tidal
reading as when there is no perfusion there is no gas exchange. This will occur much more quickly than potential ECG or pulse
oximetry readings.
Normal capnograph and end-tidal CO2 reading
ECG
The electocardiograph (or gram) measures the electrical conduction of the heart. Most ECG's used in small animal anesthesia measure
a Lead II reading, which looks at the heart's conduction system from a specific direction. In this lead, the p-wave should always be
positive. The QRS can be variable, but typically the Q-wave is negative, the R wave is positive, and the S-wave is negative. The Twave can be positive, negative, or biphasic. The normal cardiac conduction cycle should begin with the p-wave indicating
depolarization of the sinoatrial (SA) node and atrial depolarization (corresponding to atrial contraction). The depolarization wave
should pass across the atria and travel to the atrioventricular (AV) node where it slows and is directed to the bundle of His. Here the
signal splits into two bundle branches, both innervating a specific ventricle. Blood has been pushed through the right and left atria,
through the tricuspid and mitral valves into the right and left ventricles. As the signal travels down each bundle branch, it continues to
the terminal Purkinje fibers which innervate just about every cardiac cell in the ventricles. This whole cycle corresponds to the QRS
complex on the ECG and comprises ventricular depolarization (corresponding with contraction). Every muscle cell in the body that
receives an electrical (nervous) stimulus, must "reset" before it can contract again, and so a repolarization wave then crosses over the
ventricles (the T-wave) before the next p-wave occurs. Arrhythmias are abnormal rate, rhythm, or cardiac conduction that can be
detected by the ECG. Typical examples include: rate (tachycardia, bradycardia), rhythm (premature, paroxysmal, etc), or cardiac
conduction (atrial, ventricular, junctional arrhythmias). Common anesthetic arrhythmias include: sinus tachycardia (from sympathetic
stimulation, pain, hypovolemia, light anesthetic depth), ventricular premature contractions (from pain, shock, hypoxia, etc), and some
AV-blocks indicating slowed conduction through the AV node (typically from anesthetic drugs).
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Temperature
Although temperature seems like temperature is simplistic to measure and monitor, not all monitors continuously measure
temperature and it is an important anesthetic parameter. Monitors that utilize an esophageal ECG often have a temperature function,
but a continuous rectal temperature, or intermittent monitoring (with a digital thermometer) should be done routinely with the patient
under anesthesia. Hypothermia is a common occurrence under anesthesia, and derangements in temperature can affect the cardiac
cycle, blood pressure, and even coagulation.
References available upon request.
977
All About Kidney Disease:
ARF, CRF, and Beyond
David Liss, BA, RVT, VTS (ECC, SAIM), CVPM
Platt College
Los Angeles, CA
Renal disease is a commonly encountered presentation to the veterinary hospital. Both cats and dogs alike can become afflicted with
the various classes of this group such as: acute or chronic, tubular, interstitial, or glomerular. Kidney insufficiency and kidney failure
are also two different things. This lecture will serve to clarify and explain kidney anatomy, physiology, pathophysiology, and
treatment tenets of kidney disease.
Anatomy and physiology
The kidney is a small bean shaped organ that lives in the retroperitoneal space located in the latter two thirds of the abdomen. Felines
and canines each have two kidneys. The canine and feline kidneys are typically easily palpable and the right kidney lies more cranial
than the left. The gross anatomy of the kidney includes the capsule, cortex, medulla, and renal pelvis. The capsule is a tough, fibrous,
sheath that encloses the kidney and keeps it relatively free from movement. The cortex is the outer layer of tissue, the medulla is the
inner part. The renal pelvis is a large collecting area for urine which empties into the ureters. The caudal abdominal aorta branches
into the renal arteries which each go to one kidney. The caudal vena cava branches off as well, forming the renal vein. The individual
cellular unit of the kidney is the nephron. Below is the structure of a nephron:
Figure 1: Nephron
Blood flows to the nephron from the afferent arteriole.
Within the glomerulus, high pressures force water and
small electrolytes out into Bowman’s capsule. Larger
molecules such as proteins are kept within the
vasculature. Blood then travels away from the
Glomerulus via the efferent arteriole. The “ultrafiltrate”
crosses the proximal tubule, where around 70% of Na,
Cl, K, and HCO3 are reabsorbed. Most of the urea is
also excreted here. This makes it easier for water to
move into or out of the loop of Henle. This concentrated
pre-urine product then crosses the loop of Henle, where water is reabsorbed or excreted as needed depending on hydration. Lastly, the
“almost” urine product finds the distal tubule, where some sodium is reabsorbed and potassium excreted, based on the action of
Aldosterone. It then congregates in the collecting ducts and passes into the renal pelvis, and into the ureters.
Renal blood flow is very important. The kidney only has one artery and one vein, so blood supply to each and every nephron relies
on the patency, and continuity of flow. Should cardiac output drop suddenly for any reason, the kidney’s perfusion could be highly
compromised. This is why monitoring blood pressure under anesthesia is very important! The kidneys are able to independently
manage their own blood pressure (autoregulate) at a range of blood pressures. There are various numbers, but 60-160 mmHg is a good
range. This means that below 60mmHg (mean pressure) the kidneys cannot perfuse themselves adequately. Above 160mmHg as well
can cause renal damage.
Types of renal disease
There are two major categories of renal failure, acute and chronic. Renal insufficiency represents >70% loss of nephrons, required for
azotemia to develop, but does not necessarily manifest as a clinical syndrome. Renal failure means a syndrome of either acute or
chronic nature, causing uremia, acid/base disturbances, and abnormal fluid balance. Acute renal failure is a sudden decline in GFR
(glomerular filtration rate) which is potentially reversible. Chronic renal failure is slower process of destruction of healthy renal
tissure. CRF is not reversible. Acute on chronic renal failure represents a sudden decline in GFR associated with pre-existing renal
disease.
Whether the renal disease is acute or chronic it can be associated with renal parenchyma (tissue), or interstitium, the tubules, the
glomerulus, or more than one section of the nephron. Some examples of each disease process are listed below.
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Table 1. Various forms of renal disease
Various forms of renal disease
Disease
Part of the nephron
Acute or chronic
Glomerulonephritis
Glomerulus
Can be acute, usually chronic
Acute tubular necrosis
Tubules
Acute
Intersitial nephritis
Interstitium
Chronic
Amyloidosis
Glomerulus
Chronic
Toxicity: Ethylene Glycol
Tubules
Acute
Toxicity: Lillies/Grapes/Raisins
Interstitium
Acute
Pyelonephritis
Interstitium +/- tubules
Acute
Aminoglycoside toxicity
Tubules
Acute
Effort is often made to clarify the type of renal failure as actually diagnosing a disease can be challenging. For example, if a patient
has azotemia that is renal in origin, they will have intrinsic renal failure as opposed to a renal failure caused by a vascular or extrarenal event.
Presentation
Animals with renal failure are often pretty sick. They may present with a history of anorexia, weight loss, vomiting, or diarrhea. They
may have had a known toxin ingestion, or may have been potentially exposed to toxins in the home. They may also be
polyuric/polydipsic. Initial interventions include a full history and physical exam.
Diagnostics
A full set of laboratory tests should be run including: Chemistry, CBC, PCV/TS, venous blood gas, and a urinalysis.
Chemistry results may reveal azotemia (hallmark of decreased GFR). Azotemia is characterized by an increase in nitrogenous
waste products, namely BUN and Creatinine. Azotemia can be pre-renal, renal, or post-renal. A urine specific gravity will help
differentiate between the two. The chart below helps break down the difference in azotemia.
Table 2. Classification of azotemia
Types of Azotemia
Type of azotemia
USG results
Pre-renal
Concentrated <1.030
Renal
Isosthenuric 1.007-1.012
Post-renal
Varies: usually concentrated
Patient condition
Patient is dehydrated or hypovolemic. This results in a
decline in GFR as the body preserves fluids for vascular
volume.
If patient is dehydrated/hypovolemic: The kidneys are not
doing their job and concentrating urine. The urine is the same
USG as plasma, meaning it is being excreted without any
water retention.
Hard to simply diagnose post-renal azotemia from USG but
if any evidence of osbtruction present this would result in a
post-renal azotemia.
Other lab work abnormalities may reveal:
Hyperphosphatemia, Hyperkalemia (inappropriate retention)- acute, Hypokalemia- chronic, Anemia (lack of erythropoeitin
production)- non-regenerative, Glucosuria, proteinuria if glomerular damage, Casts on sediment analysis- if tubular function damaged,
Metabolic acidosis from uremic acids
Additional workup options include:
Ultrasound with fine needle aspirate and cytology, Leptospirosis titers (acute), Ethylene Glycol tests (acute), Tick borne disease
titers (acute and/or chronic). All patients should also have baseline blood pressures as many of these patients are hypertensive
Treatment- acute
Treatment of the ARF patient is very labor intensive. These patients need fluids and volume so a peripheral IV catheter should be
placed. Any intravascular volume deficits should be addressed immediately via fluid blouses. After volume replacement hydration,
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maintenance and urine production should be of concern. A central line may be an option as well for CVP monitoring. They should
have regular blood pressures, weights, and a urinary catheter placed to monitor output. An increase in weight after hydration, elevated
blood pressures, CVP’s, or decreased urine output should alert you to potential volume overload. Urine output should be 1-2ml/kg/hr
on maintenance fluids. Ins should equal outs. If the patient is polyuric, fluids should be increased to meet demand. If anuric, fluids
slowed to prevent iatrogenic fluid overload. They should potentially have broad spectrum antibiotics started in the face of a potential
infectious process. If Lepto is suspected, care should be taken to vigilantly avoid urine. Life-threatening electrolyte disturbances
(hyperkalemia and hypocalcemia) should be addressed with insulin/glucose, and/or parenteral calcium. If the patient is hypokalemic,
postassium should be added to their fluids. Do not exceed 0.5meq/kg/hr. Early nutrition is also important in the renal failure patient.
Acid-base abnormalities (typically metabolic acidosis) will often resolve or improve with fluid therapy. Sodium bicarbonate therapy is
only reserved for life threatening academia. These patients should receive stress ulcer prophylaxis, including an H2 blocker and/or a
proton pump inhibitor (omeprazole or Pantoprazole). Because emesis can be caused by uremia, a centrally acting anti-emetic may be
necessary. Metoclopramide, Maropitant, or Ondansetron/Dolasetron are efficient in managing emesis in these patients.
Hyperphosphatemia can be nauseating so phosphorus binders (Aluminum hydroxide) should be given if the patient can tolerate enteral
medication. If the patient is anemic, and blood transfusion may be necessary, however, the acute renal failure patient is usually not
anemic. Renal function should be assessed with fluid therapy, if the patient decompensates into oliguria or anuria, dialysis should be
considered. These patients should be monitored for fluid overload as well. This can manifest as chemosis, peripheral edema,
tachypnea, hypoxemia, and/or pulmonary edema. Constant auscultation of lung fields may help catch development of wet lungs.
Treatment-chronic
Patients hospitalized for chronic renal failure should receive all of the monitoring an acute renal failure patient does. However, they
may also be anemic. Some patients compensate well for anemia, but some may require a transfusion. The decision to transfuse is not
always easy and should be based not solely on the PCV values. These patients may also have GI blood loss as uremia affects platelet
function and predisposes to gastric ulceration. Chronic renal failure patients are typically hypokalemic and should receive potassium
supplementation. The philosophy of treatment with chronic cases is to treat the acute crisis and then focus on long term management.
Nutritional support may be necessary in the form of an E-tube, PEG tube or other longer term feeding device. Low protein and
phosphorus diets truly slow progression of the disease and enhance survival. Hypertension should be managed typically with calcium
channel blockers, and proteinuria managed with ACE inhibitors.
Table 3. Renal pharmacology
Drug
Famotidine
Drug Class
H2 blocker
Frequency
SID
Route
IV, SQ
Indications
Uremia, gastritis
Pantoprazole
Proton pump inhibitor
SID
IV
Uremic gastritis
Aluminum
Hydroxide
Furosemide
Phosphorus binder
SID
PO
Hyperphosphatemia
Diuretic
As needed
IV
Anuria/Fluid overload
Mannitol
Metoclopramide
Diuretic
Anti-emetic
Once
CRI
IV slow
IV
Anuria/Fluid overload
Vomiting
Sucralfate
Gastric coating agent
QID
PO
Gastric ulceration
Amlodopine
Anti-hypertensive
SID-BID
PO
Hypertension
Omeprazole
Proton pump inhibitor
SID
PO
Uremic gastritis
Benazapril
ACE Inhibitor
SID-BID
PO
Proteinuria
Prognosis
For chronic renal failure, prognosis depends on the severity of the disease. With mild-moderate disease (Creatinine <3-5 mg/dL)
survival is 1-3 years. Proteinuria and hypertension are negative survival indicators. With ARF, mortality is 60%. 2/3 of the patients
that survive ARF have some degree of chronic renal failure.
Summary
Kidney disease is complex. This arises from the complex nature of the urogenital anatomy of the kidney, and the variability with
presentations. With a greater understanding of kidney disease, veterinary technicians are more prepared to institute intricate and top
notch nursing care to these often quite critical patients.
References available upon request
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Pain Management in the ER:
The Fifth Vital Sign
David Liss, BA, RVT, VTS (ECC, SAIM), CVPM
Platt College
Los Angeles, CA
The recognition and treatment of pain is an incredibly important part of the hospitalized veterinary patient's regimen. Patients that do
not have their pain addressed might suffer longer hospitalization times or face increases in morbidity and mortality from pain. Pain is
known to elicit a sympathetic response worsening or inciting shock states which promote decreased wound healing and decreased
organ perfusion. The veterinary technician is invaluable in assessing and reporting findings to the veterinarian. The veterinary
technician, in conjunction with the veterinarian, can discuss and implement a multi-modal approach to managing pain in critically ill
patients.
Pain physiology and pathophysiology
Pain is typically thought of as an adaptive response to prevent injury. If you stick your arm over a fire, it hurts so you can pull away
and minimize tissue damage. However, severe injury, or failure to treat pain can cause detrimental physiologic effects, beyond the
positive effects of self-preservation. In the periphery, specialized nerves, called nociceptors, exist and transmit pain signals to the
spinal cord and to the brain. The free nerve endings, which terminate in soft tissue, have various receptors that can be activated in
response to thermal, chemical, or mechanical noxious stimuli. For example, an acid burn will stimulate different fibers than a
laceration. The first step in the pain process is transduction, where nerve endings convert stimuli into electrical signals. The two main
nerve fibers (each with separate ability to transmit various stimuli) are the A-delta and C fibers. The A-delta fibers tend to fire faster,
sending quicker signals to the spinal cord. The C-fibers tend to have a slower ability to reach their threshold. Thus, pain that is felt
immediately upon exposure to noxious stimuli (crushing, pinching, tearing) is transmitted through A-delta fibers. Pain that is felt with
a bit of a pause, cold temperature, etc is transmitted across C-fibers. Another important point is that there are various A-delta and C
nerve fibers contain endings that typically do not transmit pain signals (initially) but can be "woken up" and recruited in severe
circumstances. The next step in the pain process is transmission; after the nociceptors have converted the stimulus to energy it is sent
to the spinal cord for initial processing. The signal travels through the nerve fibers to the dorsal part of the spinal cord. As discussed
earlier, C-fibers are 10x slower than A-delta fibers in their transmitting speed. After pain signals reach the spinal cord, modulation
occurs. Here, the spinal cord either dampens or increases the pain signal according to various neurotransmitters or chemicals that are
activated/deactivated in the spinal cord. The majority of pain signals that make it to the spinal cord and are sent on are mediated by
glutamate, a neurotransmitter. Glutamate acts on the AMPA, KAI, and neurokinin (NK) receptors and stimulates a response by
sending the signal up the spinal cord to the brain. The NMDA receptor (upon which ketamine exerts it's effects) is responsible for
amplifying pain signals, whether they are incredibly strong or not. The NDMA receptor is thought to be important in
prolonged/amplified pain states. A neurotransmitter called Substance P activates the NMDA receptor. Finally, GABA receptors, when
activated, tend to inhibit signals from crossing into the spinal cord to be processed. There are other important neurotransmitters
involved in modulation of signals in the dorsal horn of the spinal cord. These include: serotonin, norepinephrine, and opioid receptors.
Serotonin, norepinephrine and opioid receptors, when activated, inhibit excitation of neurons, thus agonists of these drugs have
analgesic properties. The last, and final, step of the pain pathway is perception. Perception occurs in multiple parts of the brain and is
then perceived as an unpleasant sensation associated with real or perceived tissue damage. Pain can be categorized in various different
ways: disease or anatomy related (pancreatic, etc), location (superficial, visceral, deep), duration (acute, chronic) or intensity (mild,
moderate, or severe). These often require some objective input) from the patient, so categorizing these in veterinary patients can be
challenging.
A few other important concepts in pain management in the acute patient include: Allodynia, sensititzation, windup, and referred
pain. Allodynia refers to an exaggerated reaction to a stimulus that is normally not painful. This can occur due to an exaggerated pain
response where the pain threshold of nociceptors is lowered. Sensitization and windup are the result of peripheral and central
physiochemical changes that occur during tissue damage and the inflammatory response. Peripherally, inflammatory mediators and
cells can reduce the threshold of normally high-threshold nociceptors, and awaken "sleeping" nociceptors causing an exaggerated pain
response. Central sensitization (windup) occurs as another mechanism for an exaggerated pain response, and because this occurs in the
spinal cord, can result in severe pain that lasts much longer than the initial tissue insult. Repeated signaling to the spinal cord activates
excitatory neurotransmitters which activate various receptors (NMDA, notably) and secure open-channels for pain stimuli to pass
through. It appears that central sensitization can be responsible for allodynia. Referred pain is pain in a body part that is not affected
by tissue damage. This might occur in a limb that was not amputated (phantom limb pain), or pain in limbs where the source of the
pain is in the abdomen, for example.
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Pain pharmacology
Drugs used in the treatment of pain are best described by their effects on the pain pathway. Major classes of drugs used for pain in the
acute setting include: opioids, NSAIDS, alpha-agonists, NMDA-antagonists, and local anesthetics.
Opioid medications act peripherally (transduction) and centrally (modulation) on opioid receptors. There appear to be three subtypes of receptors: mu, kappa, and delta. There are various types of opioid drugs including agonists, antagonists, and partial
agonists/agonist-antagonist drugs. The below table summarizes these drugs.
Drug
Primary
receptor
Secondary receptor
Level of
pain
appropriate
for
ModerateSevere
ModerateSevere
ModerateSevere
ModerateSevere
Morphine
Mu
NA
Hydromorphone
Mu
NA
Oxymorphone
Mu
NA
Fentanyl
Mu
NA
Buprenorphine
NA
Mildmoderate
Methadone
Mu
(partial
agonist)
Mu
NMDA antagonist
Butorphanol
Kappa
Mu
Moderatesevere
MildModerate
Tramadol
Mu
agonist
Serotonin/Norepinephrine
reuptake inhibitor
Mildmoderate
Naloxone
Duration of
action
Species
Routes to be
administered
Up to 4 hours
Cat, Dog
Up to 4 hours
Cat, Dog
IV, IM, SQ-IV Can
cause histamine release
IV, IM, SQ
Up to 4 hours
Cat, Dog
SQ, IM, IV
Single
injection up to
30 minutes
Up to 6 hours
Cat, Dog
IV- CRI
Cat, Dog
SQ, IM, IV
2-6 hours
Cat, Dog
SQ, IM, IV
1-6 hours
(Dogs
typically 1
hour or less)
Twice-four
times daily
dosing
NA
Cat, Dog
SQ, IM, IV
Cat, Dog
PO
Mu
Reversal
Cat, Dog
IV
antagonist
agent
The second class of important analgesic drugs are the non-steroidal anti-inflammatory drugs (NSAIDS). These drugs have a potent
ability to slow/stop inflammatory processes which are responsible for pain signaling. Although tissue damage may exist, of the
inflammatory cascade can be prevented, pain signals will not be transduced. NSAIDS work on transduction of pain, working locally to
prevent cytokine release, cell recruitment, and other inflammatory signs. They do have some significant side-effects and their use in
critical patients are limited. Examples include: carprofen, meloxicam, aspirin, etodolac, piroxicam, deracoxib, fibrocoxib, tepoxalin,
and ketoprofen.
Next, alpha-agonists, such as dexmedetomidine, can act in the spinal cord to prevent modulation of pain signals through agonizing
norepinephrine at the alpha-receptors in the dorsal horn. Alpha-agonists tend to have severe cardiopulomonary effects, even at low
doses, and so their use in critical patients is also limited. However, they remain an important part of the pain arsenal in dealing with
anesthetic delirium, or as a continuous rate infusion for sedation with desired analgesic effects.
Local anesthetics are the next major class of analgesic drug to discuss. These drugs, ending in -caine, are Na-channel blockers.
Influx of Na+ ions into the neuron is responsible for the creation of an action potential in the nerve. The action potential propagates
and the signal travels along the neuron to the spinal cord. Blocking Na+ influx would stop the action potential and prevent
transmission of the painful stimulus. Examples include: lidocaine, bupivicaine, proparacaine, and tetracaine. A summary of these
drugs is found below.
Drug
Duration of action
Routes administered
Notes
Lidocaine
60-120 minutes
Local, SQ/Intradermal, IV
Can provide effective
adjunctive analgesia as a CRI
Reduce dosages in cats****
Bupivicaine
180-480 minutes
Intrathecal, Intrapleural, NOT Only to be used
IV
Proparacaine
Variable
Topically (ocular)
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Finally, the adjunct drug that might be used in analgesia in the critically ill is ketamine. Ketamine functions as an NMDAantagonist, preventing or stopping exaggerated pain signals from passing through these channels to the brain (windup). Ketamine does
not have analgesic properties on it's own. Rather, it seems to potentiate the effects of other drugs (opioids notably) by blocking
NMDA-receptors and lowering the needs for the other analgesic drug (opioid) by itself.
Assessment of pain
Assessing pain in small animals in the ICU can be somewhat difficult. There has been alot of research into physiologic and behavioral
responses to pain. This research has allowed the veterinary professional to better assess and categorize pain states in animal patients.
While it might seem somewhat intuitive that a patient who was hit by a car and growls is painful, the veterinary community didn't
always see things that way. The best recommendation is to implement a comprehensive pain scale in the hospital and use that when
assessing pain in your patients. A commonly used chart is the Colorado State University pain scales found here:
•
Canine: ivapm.evetsites.net/refid.20468/refDownload.pml
•
Feline: ivapm.evetsites.net/refid.20467/refDownload.pml
Behaviors associated with pain can be found in the following charts
Canine pain behaviors
Anxiety
Decreased desire for interaction
Reluctance to move
Whimpering/Howling/Growling
Aggression
Anorexia
Submissiveness
Guarding
Self-mutiliation
Feline pain behaviors
Hiding
Reluctance to move
Lack of grooming/unkempt coat
Hissing/spitting
Attempting to escape
Crouching
Decreased desire for interaction
Excessive licking/grooming
Tail flicking
Vitals alone (blood pressure, heart rate) have been found to be poor predictors of pain. Many animals with normal vital signs are in
pain. Approaches to a patient for a pain assessment might include:
•
Observation of the animal in the cage
•
Observing the patient interacting with another staff member
•
Taking vital signs: HR, RR, Temp, Mentation, BP
•
Attempting to elicit a painful response: palpating incision or limb/organ affected
•
Observing quality of life: eating/drinking, coat, ambulation
Once the assessment is complete, the decision is made to institute analgesic therapy or modify current therapy, if it is inadequate.
Treatment of pain
Treating a patient with acute pain involves a multi-modal approach. The first step is to assess the pain and make judgments as to the
level of pain, location, and analgesic therapy that is appropriate. This involves thinking of where the pain occurs, what stimuli is
causing it, and if there is a windup component.
Options for treating pain in the ICU include: injections of analgesic medications, continuous rate infusions of analgesic
medications, use of local anesthetic blocks near site of pain, epidural injection and catheter placement, transdermal patches,
continuous infusion of analgesics into pain site ("soaker catheters), and non-allopathic interventions such as acupuncture and/or
physical therapy.
An example of a multi-modal approach to analgesia in a thoracotomy patient:
•
Pre-medication:
o Hydromorphone (pure u opioid) + Midazolam
•
Induction:
•
Fentanyl (pure u opioid) + Lidocaine (Na-channel blocker) + Ketamine (NMDA antagonist) + Midazolam
o Intra-operatively:
o Fentanyl + Lidocaine + Ketamine CRI
o Intercostal block (local anesthesia)
•
Post-operatively:
o Bupivicaine infusion into thoracostomy tube
o FLK CRI
o +/- NSAID
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Garbage Gut:
Acute Pancreatitis
David Liss, BA, RVT, VTS (ECC, SAIM), CVPM
Platt College
Los Angeles, CA
Pancreatitis is a commonly seen disease presenting to the emergency room. Technicians often can get a hint from the history, (“Oh he
got into the trash last night”), and are ready to implement orders and treat these patients. But what about some of the nuances like:
nutrition, pathophysiology, and even critical care if these patients go south? This lecture will present a holistic view of acute
pancreatitis, focused on the dog, but some information about feline pancreatitis will be presented as well.
Pathophysiology
The pancreas is a glandular organ in the cranial abdomen. It is attached to the wall of the duodenum and it lies between the duodenum
and the stomach on the right side of the body. It has two lobes; the right and left. The right lobe extends down the duodenum and the
left lobe angles medially, underneath the body of the stomach.
The major function of the exocrine pancreas (endocrine pancreas secretes insulin) is to store and then release inactive enzymes for
digestion of nutrients. The acinar cells produce these and store them in granules. Dogs have two pancreatic ducts, the pancreatic and
accessory pancreatic ducts which attach to the duodenum, where the enzymes are released. Cats only have one duct. The majority of
the pancreatic cells are consumed in this function.
Pancreatic enzymes digest tissue, and thus are relatively toxic to the body if activated. The pancreas creates and stores the
enzymes in an inactive form, called zymogens. The zymogens are sequestered into granules, so they will not come into contact with
other pancreatic tissue and cells. Once the inactive zymogens are secreted into the duodenum they are activated by enzymes in the
small intestine. Trypsinogen is a major pancreatic enzyme, and is converted into its active form, trypsin. In a cascade-like effect,
trypsin activates other pancreatic enzymes.
The pancreas also has inhibitor enzymes, preventing the body from being over-run by these irritating chemicals. Trypsin inhibitor
is produced and stored in the pancreas and inhibits trypsin activity. In addition to local pancreatic anti-enzyme chemicals, are the
circulating anti-proteases; the primary one is α-macroglobulin among others. However, there is only a certain amount of these antienzyme inhibitors and once they are consumed, pancreatic enzymes are free to wreak havoc with bodily tissue.
Acute pancreatitis is seen relatively frequently in the veterinary hospital. It results from an inappropriate activation of the typically
inactive zymogens, inside the pancreas, causing autodigestion of the pancreas. Pancreatic inflammation, cellular edema, and necrosis
typically occur. Once the pancreatic cells rupture, they leak active pancreatic enzymes in the peritoneum and systemic circulation.
This causes widespread systemic inflammation causing a SIRS syndrome. In rare cases, these pancreatic enzymes and systemic
inflammation can cause coagulation cascade activation, and thus DIC, and multiple organ dysfunction and death.
Pancreatitis can take the form of severe or non-severe acute pancreatitis. Chronic pancreatitis also exists, but a different approach
to treatment is often taken. Severe acute pancreatitis is elicited when systemic signs of pancreatitis occur with multiple organ
involvement or dysfunction. Pancreatic necrosis, abscesses, or pseudocysts are typically found in these patients.
History/physical examination
Due to the variability of the disease, some patients remain in a subclinical phase, or have mild GI signs. Anecdotally, miniature
schnauzers are more prone to the disease; however, this has yet to be proven. In addition, gluttony, and the consumption of a fatty
meal, or “garbage gut” is also thought of in conjunction with pancreatitis.
Owners will often report GI signs such as anorexia, and vomiting. Diarrhea may occur. Patients are often lethargic. The signs may
mimic an upper GI obstruction, so it is important to carefully evaluate the patient and perform timely diagnostic tests.
Patients will often present with dehydration, fever, icterus (if biliary tree is involved), and abdominal pain. Pancreatitis is reported
to be a painful human disease, and generally regarded as a painful animal disease as well. These patients may show signs of shock,
such as tachycardia, tachypnea, weak pulses, hypotension, mental dullness.
Diagnostic testing
Radiography and ultrasonography
Abdominal radiography is recommended in patients suspected of having acute pancreatitis. It is difficult to diagnose pancreatitis via
radiography but it is still a useful modality to help rule out upper GI obstruction. Radiographic findings may include: loss of detail in
cranial abdomen, displacement of stomach to the left, displacement of duodenum to the right or ventrally. However, only 24% of
patients in a large study on fatal pancreatitis had radiographic changes. Ultrasonography is a relatively useful test in diagnosing acute
pancreatitis. However, it certainly relies on the skill of the ultrasonographer. Ultrasonographic findings include an enlarged pancreas,
hypoechoic pancreatic center, hyperechoic area surrounding the pancreas (peripancreatic fat necrosis), and effusion surrounding the
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pancreas. Ultrasonography is more sensitive (less false negatives) than radiography. In human medicine CT is considered gold
standard for evaluation of the pancreas. By contrast, in few limited veterinary studies, CT did not hold up to ultrasonography or
serologic testing.
Laboratory analysis
All patients presenting to the emergency room will benefit from a minimum database (PCV, TS, Blood Glucose, BUN, Electrolytes,
Venous blood gas), and a complete blood count and biochemical profile.
Common findings include: inflammatory leukogram (neutrophilia with left shift and toxic changes), anemia and thrombocytopenia
(if patient is in DIC), elevated PCV from dehydration, hemoconcentration, elevated amylase and lipase levels, azotemia,
hyperglycemia, hypoglycemia, hypercholesterolemia, elevated liver enzymes and hyperbilirubinemia, and hypocalcemia.
Important testing notes
Elevated amylase and lipase are not highly correlated as diagnostic of pancreatitis. Firstly, the tests run on typical in-house
biochemical analyzers are not pancreas specific. Amylase and lipase are found in the oral cavity, GI tract, pancreas, and liver. And
decreased glomerular filtration can greatly affect amylase/lipase levels. The reported sensitivities (amount of accuracy compared to
false positives) is 50-70%. Meaning 30-50% of increased amylase/lipase enzymes were not associated with actual diagnosis of
pancreatitis. Also, normal amylase/lipase levels do not rule out pancreatitis either. As the pancreas is quite near the bile duct,
inflammation and swelling can cause an extrahepatic bile duct obstruction. Thus liver enzymes and makers of biliary tree disease, such
as total bilirubin levels, may be eleavated. Hyperglycemia is a common finding and is either a marker of stress or development of
diabetes mellitus. 30% of dogs presenting for pancreatitis were found to be hyperglycemic, and 63% of those were found to be
diabetic. Hypocalcemia can result from calcium salt formation in the pancreas, related to pancreatic inflammation. In cats, this finding
carries a poor prognosis. The prognostic value of this in dogs is unknown.
Pancreatic markers/inflammatory markers
C-reactive protein is used in humans to determine severity of pancreatitis. It is an acute-phase protein, (one that is induced in
inflammatory states) and may have a prognostic value in dogs. Elevated levels were found in dogs with pancreatic abscess compared
to those with just pancreatic inflammation. Elevated C-reactive protein levels were found in dogs with acute pancreatitis vs. normal
dogs, making it a marker of pancreatitis. However, although it is sensitive, it is not entirely specific to pancreatitis as elevated levels
are found in patients with generalized systemic inflammation. The trypsin-like immunoreactivity (TLI) and pancreatic lipase
immuoreactivity (PLI) tests are both pancreas-specific tests and are used in the diagnosis of pancreatitis. While the TLI test is useful in
diagnosing exocrine pancreatic insufficiency, its sensitivity and specificity with pancreatic inflammation and dysfunction are low.
Therefore, the PLI is the preferred test. It reports pancreas-specific lipase, which is chemically unique from other lipases, and is
unaffected by renal failure. The fPLI test will run feline specific pancreatic liplase, and the cPLI test will run canine specific lipase.
The spec-CPL test (same as cPLI) can be run through commercial laboratories, and a snap test was introduced into the market a few
years ago. It is still recommended to follow up a positive snap test with a spec-CPL measurement. The spec-CPL has greater accuracy
for canines, than the fPLI test does for felines. Typically values in the dog >400ug/dL are considered diagnostic with a sensitivity of
93%.
Treatment
Fluid therapy
Patients with pancreatitis are typically dehydrated, and potentially hypovolemic. If there are any perfusion deficits present, boluses of
balanced crystalloid solutions should be used to replace intravascular volume. Once perfusion is restored, rehydration and treatment of
ongoing losses can occur. Typically a crystalloid solution that is isotonic and contains some trace electrolytes is used. Potassium
supplementation may be used to treat losses.
Anti-emetics
Patients that are vomiting are typically treated with anti-emetics to prevent further vomiting and fluid loss. Maropitant (Cerenia®) a
NK1 receptor antagonist, can be a very useful anti-nausea and anti-emetic drug. It is labeled for SQ use and can sting when injected.
Metoclopramide (Reglan®) is a pro-kinetic and anti-emetic drug. It increases lower esophageal sphincter tone, stimulates peristalsis
and acts peripherally and centrally to prevent vomiting. The 5-HT3 serotinin receptor antagonists Ondansetron (Zofran®) and
Dolasetron (Anzemet®) can be used to treat vomiting as well. Anti-acid drugs, such as H2 receptor antagonists Famotidine (Pepcid®)
and Ranitidine (Zantac®) are effective in lower gastric pH to prevent ulcer formation. The proton-pump inhibitor class of antacid
medications are superior to the H2 blocker drugs and include Pantoprazole (Protonix®) and Omeprazole (Prilosec®).
Pain management
Analgesia is an important part of treating the pancreatitis patient. Pain assessment and scoring should be used to assess the severity of
pain. The first important step is observing the patient. Are they hunched? Do they have a praying stance? Are they crouched at the
back of the cage? Are they growling or snarling? Are they attention seeking? These may be signs of pain in addition to physiologic
parameters (hyperthermia, hypertension, tachycardia, tachypnea). Pure mu opioids are best at achieving analgesia in these patients.
Morphine, Hydromorphone, Oxymorphone or Fentanyl are highly effective. Buprenorphine can be used, but it is a milder analgesic,
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lasts a long time, and is harder to reverse. I have often found that pure mu opioids need to be given above a Buprenorphine dose for
“breakthrough” pain. Fentanyl CRI’s are nice in the ICU because they can be titrated to effect. In addition, Lidocaine and Ketamine
adjunctive analgesia can be added for additional pain control.
Nutrition
This can be very important in pancreatitis. Historically, patients were not fed at all during the course of pancreatitis. Feeding during
vomiting is thought to be controversial, and the addition of food to the stomach induces the pancreas to work, and secrete digestive
enzymes. So post-pyloric feeding is often indicated. This is accomplished with a jejunostomy tube. Nasojejunostomy tubes are
described but rare. Typically a J-tube is fed through a Gastrostomy tube and used that way. However, these require anesthesia for
surgical or percutaneous (endoscopic) placement. Diets fed through a J-tube need to be easily digestible and several elemental diets
exist (Clinicare®, Vivonex®, Enteral Care®). These diets are not truly balanced in nutrients and not for the long term. Cats also
require different combinations of fat, protein, and carbs so Feline Clinicare® may be the better option for them. In cats, pre-pyloric
feeding is often well tolerated, (nasogastric, nasoesophageal, or esophagostomy tubes). In my experience, nasogastric tubes in dogs are
typically well tolerated. It is advised to use the enteral route whenever possible. If the patient will not tolerate enteral feedings, the
parenteral route may be used. Indications for parenteral nutrition include: intractable vomiting, large volume raging diarrhea, or
complications with tube placement. Patients with pancreatitis are typically in a catabolic state and thus partial parenteral nutrition is
probably not enough. Total parenteral nutrition, or TPN, is often required. This is an expensive and technically demanding nutritional
intervention, requiring 24 hour care and central line placement. There are many complications with TPN but it can be a rewarding
treatment if successful.
Rare complications
If pancreatitis is severe, complications such as DIC and multi-organ failure can result. Careful screening for these problems can help
catch them before they have progressed. DIC is a difficult syndrome to treat and is characterized by early hypercoagulability and
subsequent hypocoagulability. Fresh frozen plasma and anticoagulants are typically employed in the treatment of DIC. FFP use prior
to DIC is not indicated in the literature. Multi-organ failure can include liver failure, renal failure, pulmonary dysfunction (acute
respiratory distress syndrome) or GI dysfunction. Gut necrosis can lead to bacterial translocation and sepsis, despite most
uncomplicated pancreatitis being considered a non-infectious disease. Careful nursing monitoring of the hematologic, renal, and GI
systems can help prevent these problems from occurring.
Conclusion
Pancreatitis has a favorable outcome if treated early and aggressively. There is no definitive treatment, and most treatments are
symptomatic. Early aggressive nutrition can help provide a positive outcome. Careful monitoring of vital signs and organ systems can
catch problems early and help guide therapy.
References available upon request.
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Emergencies of Summer
David Liss, BA, RVT, VTS (ECC, SAIM), CVPM
Platt College
Los Angeles, CA
Summer is approaching! What better way to prepare for summer than to review three different emergencies that are commonly seen in
a veterinary practice during the summer months. These emergencies might be location-specific but certainly the treatment principles
apply to a wide variety of cases and are applicable to any veterinary hospital. The three emergencies presented during this session
include: heatstroke, rattlesnake envenomation, xylitol toxicity
Heatstroke
Heatstroke is defined as a core body temperature greater than 104 F (40C) which results in organ dysfunction. Heatstroke is severe
hyperthermia induced, typically, by high environmental temperatures and an inability of the patient to effectively dissipate heat. It is
most often reported during summer months and body temperatures are often reported greater than 108 F (42C).
As body temperature increases, compensatory mechanisms kick in to assist in releasing heat. Panting occurs to lose heat from the
respiratory tract and peripheral vasodilation occurs to assist in heat loss. Eventually these measures are over-run and systemic
vasodilation commences, along with dehydration as water is lost from evaporation. As the heat continues, direct thermal injury occurs
to cells and if left untreated organ dysfunction will lead to organ failure.
Patients presenting with heatstroke may have a history of exercise or it might be a hot day. These patients often present
hyperthermic, but hypothermia (in this case body temperature less than 100F or 37.8 C) might be a sign of late heatstroke. These
patients might be panting, dyspneic, hyperemic, tachypneic, tachycardic, obtunded or seizuring. They may also have petechiae or
ecchymoses on their skin.
Due to the excessive vasodilation, blood pooling occurs and cardiac output is reduced. Blood pressure is often low and massive
amounts of fluids are required to restore effective circulating volume. Initial treatment includes a rapid assessment of the patient’s
ABC’s, and then subsequent cooling measures. A large-bore IV catheter should be placed and room-temperature fluids administered
via bolus. Room temperature water can be poured over the patients skin and a fan used for cooling. Ice baths are not recommended. In
extreme cases pleural, abdominal, or rectal/colonic lavage can be used to lower core body temperature. However, these are most often
not needed.
Cooling measures, tap water baths, IV fluid infusion, fans, ice packs, should be used until rectal temperature approaches 103.5-104
F *39.7-40 C). At this point body temperature typically drops rapidly and patients can become hypothermic. Hypothermia is also
damaging to the body’s physiology and thus, should be avoided. The patients vital signs: heart rate, pulse quality, mentation,
MM/CRT, lung sounds, blood pressure, urine output and lactate (if available) should be monitored on a regular basis to anticipate and
deal with changes. Critical patients are often dynamic requiring treatment of sequelae that occur after they are admitted to the hospital.
Heatstroke can result in a multitude of complications, most of which manifest in organ failure: The CNS system, renal system,
cardiac system, hepatic system, respiratory system, gastrointestinal system and coagulation system are all at risk. The following table
summarizes these detrimental developments:
Organ dysfunction
Clinical signs
CNS
Obtundation, Seizures, Anisocoria, Head pressing
GI tract
Hematochezia, Melena, Vomiting, Diarrhea
Renal
Anuria, Oliguria, Hematuria, Uremia
Hepatic
Liver function failure- Hypoglycemia, Hypoalbuminemia,
CNS signs
Cardiac
Hypotension, arrhythmias
Respiratory
Pulmonary edema, dyspnea, hypoxemia, tachypnea
Coagulation system
Platelet dysfunction, clotting factor dysfunction, mucosal
bleeding, bleeding at catheter sites, bleeding into joints, thorax,
abdomen, hypercoagulability (Thromboembolism)
Treatment of these various disorders requires intensive care and monitoring. The veterinary assistant and technician is extremely
valuable in alerting the veterinarian to various problems that might develop.
Development of these organ failure signs constitutes a negative prognosis. Heatstroke is a very serious condition with a high
mortality rate. However, with diligent monitoring and intensive care these patients can recover! Client education is key to preventing
this disease. Animal should not be worked hard on hot days. They should NEVER be left in the car on a warm or hot day. And
brachycephalic patients should be walked and exercised carefully as their body condition limits their ability to dissipate heat.
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Rattlesnake envenomation
The first concept to cover in discussing snake envenomations is identifying the snake and analyzing its venomous effects. Pit vipers,
such as the water moccasin, rattlesnake, and copperheads, are common in the U.S. and apparently the Eastern Provinces of Canada.
The rattlesnake is most commonly responsible for envenomations and the diamondback and Mojave rattlesnakes are most common of
this species. Toxins are either neurotoxic (more rare) or proteolytic (tissue digesting).
Venom is surprisingly 90% water and 10% enzymes and proteins. Although it is only 10% enzymes and proteins there are many
different kinds that have a variety of functions. The proteolytic venoms immobilize prey and digest tissue. Locally they cause wound
necrosis and extensive tissue damage and pain. As the venom is injected intravascularly it can incite the coagulation system and cause
cardiotoxic effects. Neurologic venom causes widespread muscular paralysis and weakness. Patients may seizure, have muscle
twitching, or go into respiratory failure from muscle paralysis.
Patients presenting with snake envenomation typically cry out in pain and come running to their owners. Often two small puncture
marks are present on the affected area. Rarely sudden death may occur. Bites are common to the face and lips and forelimbs. Severe
inflammation at the bite causes local tissue necrosis, severe effusion and swelling. Swelling around the face or neck may be lifethreatening.
A blood smear might assist with diagnosis in snake envenomations. Echinocytosis, a clinicopathologic finding of erythrocytes
characterized by several blunt projections extending from the cell surface, is indicative of envenomation. Theories postulate that the
venom induces some enzymatic changes in the red blood cell producing a chemical that causes the echniocytosis. An old
restrospective study found this to be present in 89% of dogs and not present in “dry bites.”
Initial treatment is similar to any patient in a shock state: IV fluids, analgesic medication, and initial bloodwork. After initial
diagnostics are run and a tentative diagnosis of rattlesnake envenomation is made the only definitive treatement is antivenin.
Antivenin will be summarized below. There are three major types of antivenom’s: polyvalent, “Cro-Fab” and Antivypmin types.
Antivenin type
Species covered
Chemical structure
Polyvalent
Crotalidae
Complete IgG and Albumin from
immunized horses
Typically administer 1-2 vials
Only effective against North American
snakes
Cro-Fab
Cleaved Fab1 molecules from the IgG
molecule. Less antigenic
5.2 times the efficacy
Antivypmin
Fab2 fragment
Cleared faster than Fab1
Administering antivenom should be done in controlled situations and with constant monitoring. The bottle should be reconstituted
with the diluent inside the bottle. Never shake the bottle, as with insulin, the proteins are really fragile. The powder is quite dry and it
takes some time to reconstitute. It may take up to 10-15 minutes to fully reconstitute. After it is reconstituted the bottle should be
further reconstituted in an amount of 0.9% Normal Saline, typically 100-250mL of fluid. Infuse that slowly over 1-2 hours. Monitor
the patient for any signs of a reaction: tachycardia, tachypnea, swelling of the face or limbs, vomiting, or collapse. If these signs occur
STOP the transfusion. DO not flush the catheter initially. Potentially administering a steroid or antihistamine (like diphenhydramine)
may help alleviate clinical signs.
Other treatments for snake envenomations include: analgesic medication, IV fluids, potentially antibiotics and wound care will be
required as well. Due to the extent of the seriousness of envenomations it is not uncommon for patients to be hospitalized for several
days. Complications of envenomation can include development of wound infections, DIC, and hypoalbuminemia/third spacing of
fluid. Sometimes these complications develop a day or two after hospital admission, so the veterinary staff must be ready to monitor
for these.
Xylitol intoxication
Xylitol is a sugar alcohol found in “sugar-free” gums. It causes a massive release of insulin, thereby causing widespread and
uncontrollable hypoglycemia. It also may cause liver failure up to 72 hours after initial exposure.
Sugar-free products are more common than ever and chewing gum is a prime example of a product marketed to have no caloric
intake and no sugar. However, the replacement of glucose with xylitol has had drastic effects on animals who get into these sweet
chewy substances. Xylitol is not toxic to humans but causes massive insulin release in the dog. Severe hypoglycemia results and can
cause seizures, obtundation and coma. Hypokalemia may also be observed as insulin mobilizes potassium to move intracellularly. In
addition, xylitol can cause massive hepatic necrosis resulting in liver failure. This occurs after the initial hypoglycemia episode and up
to 72 hours after exposure. The toxic dose seems to be as little as 1-2 pieces of gum for a small dog (10 kg).
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Initial treatment involves decontamination with an emetic such as apomorphine. After administration of apomorphine symptomatic
treatment should ensue. Activated charcoal is not needed because it does not effectively bind the xylitol molecule. Hypoglycemia
should be treated with boluses of 50% Dextrose and an infusion if necessary. Because of the severe nature of the hypoglycemia, high
doses of dextrose are often needed. An infusion >5% should be administered via a central vein due to the hyperosmolar nature of the
sugar infusion. Intravenous fluids should be administered with the sugar infusion and blood glucose levels monitored on a regular
basis. Cerebral edema may occur secondary to decreased cerebral metabolism and should be treated if encountered. If live enzymes
elevate and liver function is affected liver protective medications like SAM-e and silymarin may need to be administered. Nutrition is
very important in regulating blood glucose levels and should be administered if possible. Xylitol intoxication is very serious and even
if the patient survives the hypoglycemic episode may suffer from liver failure days later.
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The Technician’s Role in the Dentistry Service
Annie Mills, LVT, VTS (Dentistry)
Florida Veterinary Dentistry and Oral Surgery
Punta Gorda, FL
The technician is an integral part of the dental service team which will be outlined in this discussion, including the oral exam, admit
and discharge of patient, and the intraoperative role. I would encourage you to continue to seek continuing education in the field of
dentistry to increase your marketability and subsequently your job security.
A paradigm shift is occurring in veterinary dentistry with many practices increasing the quality of their dental service. As little as
5 years ago, the majority of dental practices did not have dental xray. Now those hospital that don’t are in the minority. Veterinary
dental lectures and wetlabs have a much larger presence at national conferences than they did years ago. That being said, this will not
be a how-to on extraction for the technician. Our role encompasses much more and oral surgery should be left to the veterinarian,
although it is allowed for credentialed technicians to perform extractions in some states. Many of the statutes are somewhat
contradictory, allowing technicians to perform extractions but not surgery. AAHA and the dental college recognize extractions as
being oral surgery. This is an extremely controversial topic, and though a debate on technician vs. DVM would be exciting, this
discussion will cover the role within the scope of AAHA and the dental college standards.
The oral exam is the first step to recognizing pathology and staging the oral cavity. This can be performed by the veterinarian.
However, a well trained technician can also perform the oral exam and free up the veterinarian to perform tasks which only he can do.
The technician can then continue with educating the client in professional dental services as well as home care.
The technician can also alleviate the pet owner’s fear of anesthesia as well as set expectations as to what will occur during the
dental procedure.
Admitting the patient and giving an estimate of charges falls under the technician realm. Very rarely, if ever, should the
veterinarian discuss finances with the owner. The most successful practices let the veterinarian remain as the medical authority and
leave the finances to office staff or the technician. Home care is also discussed at this point to determine the owner’s willingness to
provide regular home care. This will help when making extraction decisions during the procedure, primarily where periodontal
patients are concerned.
Technicians wear many hats and radiology technician is absolutely required for the dental service. The dental assessment and
subsequent diagnosis is so crucial in order to provide the correct treatment for the dental patient. Many practices have dental xray but
do not use it on a regular basis. Client compliance and time management tend to be the 2 main reasons for not taking full mouth
dental xrays. Increased compliance can be accomplished by educating the client properly. Using the “prophy and assessment”
approach as opposed to “just a cleaning” is very effective in gaining the client’s willingness to allow for dental xray. Time
management can be an issue when full mouth radiographs take the technician 45 minutes or more per patient. If 3 or more procedures
are scheduled, a significant amount of time is added on to an already full dental surgery day. Continuing education and practice can
greatly reduce the amount of time it takes to get diagnostic films on a patient. A reasonable goal to achieve would be 15 minutes on
an average to large dog and under 5 minutes for a small dog or cat. The importance of dental xray is beyond the scope of this lecture,
however, if extractions are being performed in a general practice, radiographs should be a requirement to perform extraction
procedures efficiently and correctly.
Common extraction scenarios for the general practice include fractured teeth, tooth resorption, and advanced periodontal cases.
When fractured teeth are noted, it is best to recommend all options to client including referral, root canal and crown. Tooth resorption
and periodontal cases can be of varying stages which can dictate different treatment options.
Once a diagnosis is made based on the assessment (radiographs and probing), a treatment plan is created and an estimate for
additional procedures is made based on the treatment plan. While the veterinarian is discussing the treatment plan, the technician can
be setting up instrumentation, as well as, placing the regional blocks as needed. Again, additional continuing education is
recommended with regards to regional blocks, but are an effective component of the pain management protocol for those patients
requiring extractions. By blocking the painful stimulus at the site of trauma prevents the impulse from reaching the cerebral cortex.
This allows the patient to be kept at a much lighter plane of anesthesia and significantly reducing the risk to the patient. It also will
prevent central sensitization or “wind up” postoperatively.
Instrumentation for the procedure itself can be made available and organized to help expedite the extraction process. Knowing the
step by step procedure of a surgical extraction is helpful in anticipating the veterinarian’s needs.
The technician can play an important role during the discharge of the patient. This can be an excellent opportunity to impress the
client by explaining and showing the dental radiographs. The laptop computer can be brought in the room to discuss with the owner.
In addition, a print out of the radiographs can be sent with owner. This is a great marketing tool that shows value as well as helps the
client to understand the diagnosis and treatment. Home care protocols should be reiterated as well, especially with the periodontal
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cases. The importance of plaque prevention should be stressed to prevent further tooth loss. Follow up visits for continued oral care
is also discussed at this time.
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The Dental Chart:
The Oral Roadmap
Annie Mills, LVT, VTS (Dentistry)
Florida Veterinary Dentistry and Oral Surgery
Punta Gorda, FL
Periodontal disease is progressive-the dental chart tracks how a patient is progressing (or not) from cleaning to cleaning. The dental
chart is a permanent record of a patient’s dental care and should include: exam of the oral cavity, tooth by tooth exam, pathology
found in the oral cavity, radiographic finding, treatment performed, and home care instructions.
The dental chart is the “blueprint” for treatment of the patient and should be a complete record to refer to from one procedure to
the next. It should be organized and comprehensive in a simple, easy to read format. Abbreviations should be used to minimize
writing and save time. A complete list of approved abbreviations are available from the American Veterinary Dental College and can
be found on the website at www.avdc.org.
The complete dental examination starts with the physical exam with the patient before sedation. Any changes in facial structures,
ie. swollen face, muzzle, eyes, etc. should be noted. The occlusion should also be evaluated during as well. It is extremely difficult to
properly assess a malocclusion in an anesthetized patient due to the endotracheal tube preventing the mouth from being closed
completely. A complete pain evaluation should also be performed at this time if possible. If the patient will allow, the pain evaluation
is performed by palpating the muzzle, opening and closing the mouth, and digital pressure on any abnormal areas on the gingiva.
A Class 1 Malocclusion is indicated when 1 or more teeth are malpositioned. It is common in brachycephalic patients to have
rotated maxillary premolars. This would be an example of a Class 1 malocclusion. Another common example of a Class 1
malocclusion would a “lance tooth” canine that is often seen in Shetland Sheepdogs. The canine tooth points toward the nose instead
of its normal position. The AVDC abbreviation is noted by the following: Mal/1/MV.
The next group of classifications pertain to the relationship between the maxilla and mandible. There are several dental issues that
can occur when these structures are not aligned or one is shorter than the other. In many cases, these conditions are considered
congenital. In some cases, early intervention is recommended and can possibly avoid later dental problems. Interceptive orthodontics
is a term used to describe certain treatment plans to correct some orthodontic issues. The mandible and maxilla normally grow
independently of each other during a puppy’s development. There is a condition known as dental interlock. This occurs when the
mandibular teeth lock with the maxillary teeth and prevent the jaw from growing any further. By extracting the involved teeth, this
interlock can be eliminated, allowing the jaw to grow at its normal rate and eventually produce a normal occlusion. However, in more
severe cases, the occlusion can’t be corrected, and intervention is required to prevent trauma.
A Class 2 Malocclusion is characterized by the mandible being shorter than the maxilla. The degree of malocclusion can be mild to
severe. In more severe cases, the mandibular incisors will make contact with the soft palate and cause trauma. This is when surgical
intervention is necessary. Treatment options may include odontoplasty and bonding of the mandibular incisors to eliminate trauma if
they are just touching the palate. Extractions are required when the incisors are contacting enough to actually puncture the palate.
The abbreviation is noted as Mal/2.
A Class 3 Malocclusion occurs when the maxilla is shorter than the mandible. Typically, the maxillary incisors will cause trauma
to the floor of the mouth. Treatment options include odontoplasty or extractions. The abbreviation is noted as Mal/3.
A Crossbite can be classified as rostral or caudal and affects either the incisor alignment or the molar alignment.
The charting process itself should be done the same way each time for consistency. This will prevent areas being missed. The
quadrants should be done in the same order. The triadan numbering system is used to speed up the process as opposed to using the
anatomical notations. The triadan numbering system can be mastered easily if used consistently. Each quadrant is assigned a “100”
number, and each tooth then is assigned a single number. The numbers get larger as the teeth move away from the midline.
The right maxilla are the “100’s”. Starting at the right central incisors, they are numbered as 101, 102, 103. The right maxillary
canine is 104, the right maxillary 1st premolar is 105 and so on. Moving in a clockwise direction, the left maxilla is noted as “200’s”,
left mandible is noted as “300’s”, and the right mandible as the “400’s”. Charting can be done using a two or four handed technique.
A four handed technique is preferred as it reduces the time to chart the oral cavity. This technique is achieved by having one person
assessing the oral cavity and a second person making the notations on the chart as the pathology is found and communicated.
Directional terms are used to indicate specific areas of the oral cavity or of individual teeth. Mesial and distal are used when
noting individual teeth. Areas that are toward the midline are noted as mesial. Away from the midline is distal. In the maxila there are
2 terms used to indicate direction. Buccal refers to areas toward the cheek, and palatal is toward the palate. In the mandible, lingual is
used to indicate any area toward the tongue and labial is toward the lips. Rostral (toward the nose) and caudal (toward the back) are
used for indicating direction within the oral cavity itself.
Stage versus index when used in the charting process. Stage is the assessment of the extent of pathological lesions in the course of
the disease that is likely to progress. For example, the term “stage” is used when noting periodontal disease. Index is a quantitative
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expression of predefined diagnostic criteria whereby the presence or severity of pathological conditions are recorded by assessing a
numerical value. This term is used when denoting the amount of plaque or gingivitis.
Specific instrumentation and equipment is necessary to perform a comprehensive oral assessment. A periodontal probe/explorer is
used to measure periodontal pocket depths, or to detect any enamel defects present. Normal sulcal depth on a canine patient is 1.03.0mm and 0.5-1.0mm on a feline patient. The proper lighting and magnification is absolutely required when working in the oral
cavity. Oral radiology is also a required component in order to properly assess pathology above the gumline. Changes in bone
structure as well as other pathologies can only be found if radiographed.
A comprehensive dental chart is also used and should allow enough space to place diagnostic and treatment abbreviations on
individual teeth, as well as, a space for radiographic findings, follow up care, etc.
Common pathologies
Periodontal changes should be noted including attachment loss, bone loss, furcation exposure, and mobility. Attachment loss is
measured from the cementoenamel junction to the apex. Furcation exposure is staged using a periodontal probe. Mobility is
measured in millimeters based on the movement of the tooth.
Tooth fractures have several classifications. An uncomplicated crown fracture (UCF)is indicated by a crown fracture that does not
involve the pulp chamber. A complicated crown fracture (CCF) is noted when the pulp chamber is open. Other classifications of
tooth fracture include uncomplicated crown-root fracture (UCRF), complicated crown-root fracture (CCRF), and root fracture (RF)
Tooth resorption also has several classifications and abbreviations ranging from mild enamel loss (TR1), to complete crown loss
(TR5).
Other common pathologies found in the oral cavity include gingival hyperplasia (H), tooth abrasion or wear patterns (AB), oral
nasal fistual (ONF), stomatitis (ST), oral masses (OM). Cavities (CA) in dogs aren’t commonly seen, but should always be noted on
the dental chart.
Radiographic findings are noted on the dental chart. Horizontal bone loss or vertical bone loss is recorded where applicable, as
well as apical lucencies. Other anomalies that can be found include root fractures, impacted teeth (T/I), and abnormally formed teeth.
Common treatment modalities are also noted using the AVDC abbreviations. Open root planing (RPO) and closed root planing
(RPC) are techniques used to treat early to advance stages of periodontal disease in order to reduce pocket depths to prevent tooth loss.
Simple (x) and surgical (xss) extractions are also noted.
A complete dental chart is essential in making a complete record to diagnose, treat, and monitor the patient’s oral conditions.
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What Lies Beneath:
Dental Radiography
Annie Mills, LVT, VTS (Dentistry)
Florida Veterinary Dentistry and Oral Surgery
Punta Gorda, FL
Changes in the dentistry service
Dentistry within the general practice has always been regarded as a “simple teeth cleaning”. The patient is anesthetized and the crowns
are cleaned with an ultrasonic scaler and the patient is recovered. This approach for many years was the acceptable standard of care
within the dental service. However, we have learned over the last several years that there is so much more that we could be doing for
our patients. The approach has been changing across the country from a “teeth cleaning” to a prophy and assessment, with the
emphasis being on the assessment portion. If we assess properly, we can then diagnose and treat accordingly to provide a higher
standard of care for the dental patient.
Imagine a patient with clinical signs including polyuria, polydipsia, weight loss, vomiting. The top “rule outs” for this patient
would include diabetes or renal disease. In order to make a definitive diagnosis, the best next step would be to perform a full blood
panel. Now imagine that there were no blood machines available to run the bloodwork. This makes treating this patient effectively
extremely difficult. Blood machines are standard equipment in most practices. Dental radiology needs to be regarded just as
important to the dental service.
Importance of dental xrays
Dental radiology is the single most important diagnostic tool in the dentistry service. Statistically, 70% of cats and 80% of dogs have
some degree of Periodontal disease. If periodontal disease is caught early, it can be treated and prevent tooth loss. Most clients would
agree that prevention of tooth loss is important to them and their pets, as well as, keeping their pets pain free and comfortable. The
standard of care in most practices that have dental radiographs is to take radiographs on an “as needed” basis. For instance, if there is
any redness, swelling, oozing or other noticeable lesions seen on an oral exam, then a radiograph is warranted. However, a study at
UC Davis showed that 28% of dental lesions in dogs and 42% in cats are missed on oral exam. The AVDC recommended standard of
care is full mouth radiographs on every patient to detect pathology.
Equipment
Digital software, sensor and laptop are standard equipment for making dental radiographs easy to implement into the practice. Film
and developing fluids are considered outdated and cumbersome, as well as, time consuming. Digital equipment speeds up the process
considerably, making it more efficient and cost effective for the practice. A Dental xray generator is also needed. Any generator can
be used with any software and sensor.
The two systems that are most popular are the direct and indirect. A sensor that plugs directly into the computer via USB is a
direct system. It produces an image within seconds. Phosphur plates that are fed into a digitizer to produce a digital image is an
indirect system.
Radiographic techniques
There are 2 techniques that are used primarily to image the entire oral cavity. The parallel technique is the simpler of the techniques
to master, however, this technique can only be used in the caudal mandible. The sensor is placed parallel to the teeth being imaged
and the tube head is placed perpendicular to the sensor.
The bisecting angle technique is more of a challenge to the user. The tube head is placed perpendicular to the angle that bisects the
angle that is created by the long axis of the tooth and the sensor. This definition lends itself to a large amount of confusion. It can be
difficult to determine the angles and bisecting angles and therefore, difficult in placing the tube head correctly to obtain a diagnostic
image. A more simplified version is illustrated when the tube head is thought of as the “sun”, the sensor is the ground or horizon, the
tooth is the object, and the shadow that is cast by the “sun” is the xray image. If an object is out in the sun at high noon, the shadow is
very short. Conversely, if the object is out at 6 pm, the sun is low in the sky and shadow that is cast is elongated. The ideal angle to
place the tube head or “sun” is somewhere between noon (90 degrees off the horizon) and 6 pm (30 degrees off the horizon). A
resource for correct positioning is the Radiographic positioning guide by Brett Beckman DVM, FAVD, DAVDC, DAAPM.
Patient positioning is important, as well, to eliminate as many angles as possible to simplify the process even further. When
imaging the maxilla, the patient is placed in sternal recumbency with a rolled towel placed under the chin to position the maxilla as
parallel to the horizon as possible. To image the mandible, the patient is placed in dorsal recumbency with a rolled towel under the
neck to extend the mandible parallel to the horizon.
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Troubleshooting
A significant component to taking dental radiographs is troubleshooting. When an image is taken but is not diagnostic, the key is to
know what adjustment to make in order to take a diagnostic film in the very next shot. Effective troubleshooting can decrease the
frustration of taking dental radiographs, as well as, decrease the amount of time to complete a full mouth series.
There are typically 2 errors that are made. The first error produces an image that is distorted. The image is either elongated or
foreshortened. When this type of error occurs, the tube head will need to be adjusted to eliminate the adjustment. If an image is
elongated or “stretched out”, the angle of the tube head should be increased by at least 5 or 10 degrees. For example, if the image was
taken at 50 degrees, increase the tube head angle to 60 degrees. If an image is foreshortened or “stubby”, decrease the angle of the
tube head. The second error produces an image that is not distorted, but is “cut off” or missing from the image. The adjustment to
correct this error involves repositioning the sensor in relation to the tooth or teeth being imaged. The best example of this occurs
usually when imaging the apex of the canine. The canine tooth in an average or large size dog is longer than a typical Number 2
sensor. In most cases, the sensor needs to be moved caudally in order to have enough sensor in place to “catch the shadow” of the
apex.
Evaluation of radiographs
When evaluating radiographs, it’s important to be able to recognize normal anatomy versus pathology. The structures that are
evaluated include the tooth itself, the periodontal ligament space, the pulp chamber, the apices of the tooth, and the bone around the
tooth. Subtle to significant changes in these structures indicate varying degrees of pathology.
Common pathology
The most common pathology found on dental radiographs include periodontal lesions, endodontic lesions, tooth resporption,
neoplasia, impacted and non-vital teeth. Specific changes in bone, periodontal structures and apices can indicate different pathology.
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Periodontal Disease and Therapies
Annie Mills, LVT, VTS (Dentistry)
Florida Veterinary Dentistry and Oral Surgery
Punta Gorda, FL
Understanding periodontal disease
•
Defined as an inflammation and infection of the tissues surrounding the tooth, collectively called the periodontium._
•
Systemic affects from bacteria present can compromise liver, kidneys and heart.
•
Returning the mouth to a healthier state with a thorough cleaning and periodontal therapy affects the overall health of
the patient.
Etiological timeline
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A glycoprotein component of saliva (acquired pellicle) attaches to the tooth surface.
•
The pellicle takes only 20 minutes to form and helps bacteria attach to the tooth surface.
•
About 6-8 hours after pellicle formation, bacteria start to colonize the tooth surface-this is what we know as plaque.
•
The bacteria that have colonized the surface die. The bacteria that are attached to the tooth absorb calcium from saliva
and become calcified-what we know as tartar or calculus._
More fun facts
•
The bacteria present in the normal oral flora consist primarily of gram-positive aerobic bacteria.
•
As periodontal disease progresses, gram-negative bacteria begin to colonize the tooth surface. Specifically, blackpigmented anaerobic bacteria (BPAB).
•
The bacteria are arranged in what is called the biofilm-it is the disruption of this biofilm, more than anything else that is
important in the control of periodontal disease._
•
Patient Response
•
As the bacteria infiltrate and colonize the pocket between the free gingiva and tooth, known as the sulcus, the patient
attempts to fight the infection.
•
White blood cells are sent in to attack the bacteria.
•
The bacteria often contain endotoxins and enzymes that are toxic to gingival tissues, specifically collagenase, an enzyme
which breaks down tissue.
•
Gingivitis, loss of tissue (gum recession), furcation exposure, bone loss, and eventually tooth loss can occur without
treatment.
Staging periodontal disease
•
The worst tooth is used to establish the stage of periodontal disease.
•
Periodontal staging is based on factors such as plaque, calculus, inflammation and topography. Can be done in the
awake patient if cooperative
•
The anesthetized patient should have each tooth evaluated and charted for effective treatment.
•
Healthy Gingiva (Stage 0) has a knifelike margin, smooth topography (the surface features of the gingiva as if flows
from tooth to tooth), and normal sulcus depth 2-3 mm in dogs, 0.5-1 mm in cats.
•
Early Gingivitis (Stage 1) is limited to gingival tissue and appears reddened, with a mild amount of plaque.
•
This is the only stage that is reversible.
•
Early Periodontitis (Stage 3) There is a moderate loss of attachment and moderate pocket formation.
•
There is also some degree of furcation exposure (the space between tooth roots where the roots join the crown). There is
also a fair amount of gingival bleeding when probed.
•
Established Periodontitis (Stage 4) A significant amount of bone loss and attachment structures is noted with severe
pocket depths. Significant gum recession and tooth mobility are also present. These patients usually have a strong
odor, and pus may be present in the oral cavity
Management of PD begins with prevention
•
Client education regarding local and systemic effects can help with client compliance.
•
Home care for every patient-give owners options to help with client compliance. Home care options can include
dentifrices, CET chews, dental diets, plaque prevention gel, etc.
•
The goal of periodontal therapy is to keep the teeth as clean as possible, thereby reducing the number of pathogenic
bacteria that destroy periodontal tissues._
•
The four main objectives of periodontal therapy include removing the biofilm (plaque, tartar), minimizing attachment
loss, minimizing pocket depth, and maintaining a minimum of attached gingiva.
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Advanced periodontal therapies
The following can and should be performed in general practice to treat most periodontal disease.These therapies can be performed by
a technician with the correct training. Charging appropriately for treatment of periodontal disease can significantly increase revenue
in the practice.
Ultrasonic Periodontal Debridement removes calculus and debris subgingivally. It also disrupts the cell wall of bacteria thereby
destroying it. This procedure is performed with a specific ultrasonic periodontal tip which can be used safely subgingivally.
Subgingival Curettage is the debridement of the periodontal pocket to encourage healing and reattachment of gingiva to reduce
pocket depth._ This technique is performed with a curette.
Closed root planing is the debridement of the root, to remove a layer of cementum, soft and hard substrate, and diseased sulcal
lining. The purpose of root planing is to remove irregularities and a thin layer of superficial cementum-loaded with bacterial toxinsthat will inhibit healing if left in place._ The instrument used is also a curette with the Modified Pen Grasp technique.
Perioceutic placement-doxirobe gel
Placement of doxycycline gel is used in periodontal pockets of 4 mm or greater. This acts as a barrier to prevent epithelial tissues from
reinhabiting the pocket and allowing the periodontal tissues to grow. It also provides antibacterial properties, immunoregulatory
properties to dampen the inflammatory response, and anti-collagenase properties which counteract the tissue destruction process.
More advanced periodontal therapies
The following therapies can be performed in general practice. They are considered oral surgery and should be performed by a
veterinarian with advanced training. Always recommend referral to a dental specialist if treatment needed is beyond your capabilities.
Gingival Flaps with open root planing are performed on periodontal pockets 6mm or greater. By creating a gingival flap, it allows for
better visualization into the deeper pockets for more effective removal of tartar, bacteria laden cementum and debris. A 12% EDTA
solution is then placed to dissolve debris and open the dentinal tubules. A bone graft material is then placed to promote bone growth
around the affected tooth.
Raising the bar
Periodontal therapy techniques improve the dental care of your patients. These therapies allow the practitioner to treat and save teeth
as opposed to premature extraction. These techniques are important to master not only for the improved health of the patient, but also
to increase revenue for the practice.
References
1
S.E. Holmstrom Veterinary Dentistry for the Technician & Office Staff (Saunders 2000) pg. 149_2 S.E. Holmstrom Veterinary Dentistry for the
Technician & Office Staff (Saunders 2000) pg. 149_3 S.E. Holmstrom Veterinary Dentistry for the Technician & Office Staff (Saunders 2000) pg.
150_4 H. Lopbrise, R. Wiggs Common Dental Procedures (AAHA Press 2000) pg. 47_5 S.E. Holmstrom, P. Frost, E. Eisner Veterinary Dental
Techniques (Saunders 2004) pg. 240_6 S.E. Holmstrom, P. Frost, E. Eisner Veterinary Dental Techniques (Saunders 2004) pg. 237_
997
Regional Nerve Blocks
Annie Mills, LVT, VTS (Dentistry)
Florida Veterinary Dentistry and Oral Surgery
Punta Gorda, FL
Regional nerve blocks as part of a total multi modal approach to pain management for the dental patient. Regional blocks interrupt
impulse transmission along the pain pathway to inhibit the pain response. Placing a regional nerve block can benefit the patient, not
only perioperatively, but postoperatively as well. One of the greatest benefits of the regional block is that the anesthetist is able to
maintain the patient at a much lighter plane of anesthesia, thereby, significantly reducing the risk of anesthesia. This is extremely
important as anesthesia is frightening to the pet owner and can be a major contributing factor in non-compliance with regards to the
pet’s professional dental care. Regional blocks also allow for a much smoother recovery. The animal recovers without the initial pain
response that can occur in other surgical procedures. For instance, a dog recovering from a spay procedure will have some pain on
recovery once the inhalant is cleared and the cerebral cortex recognizes the pain impulse. When a regional block is placed, the pain
impulse never reaches the cerebral cortex, so even when the animal is fully awake, there is no recognition of pain.
The drugs of choice
Lidocaine 2% and bupivicaine 0.5% are used in combination in a 1:4 ratio.
Bupivicaine can be used alone as well. Lidocaine was added to increase the time of onset of the agent as it was thought that
bupivicaine could take up to 15 minutes before taking effect. However, it is now thought that the time of onset is closer to 3-5
minutes of that agent. The duration of bupivicaine is approximately 6-8 hours post administration.
An opioid can be added for prolonged or extremely painful procedures. Human studies have shown that adding an opioid to the
mix can extend the efficacy of the block up to 24 hours in duration.
The maximum dose for each agent used is 1 mg/kg.
The amount used depends on the size of the patient and the number of sites to be blocked with the maximum amount of sites being
4 to block all 4 quadrants of the mouth._
Recommended volume for each site is based on the size of the patient.
•
Small up to 12 lbs. 0.1-0.3 ml
•
Medium 12-50 lbs. 0.3-0.6 ml
•
Large 50-80 lbs. 0.8-1.2 ml
•
Patients over 80 lbs. 1.4-1.6 ml_
Materials needed
•
A 1, 3 or 6 cc syringe with a 22ga x 1 in needle for patients over 30 lbs.
•
A 1 cc syringe with a 25 or 27 ga x 5/8” needle for patients under 30 lbs.
The technique
The needle is inserted at the appropriate site. The syringe is aspirated to check for “flash” to avoid injecting into a vessel. If flash is
present, then the needle is reinserted and aspiration is repeated. If no flash is present, the drug is injected slowly. Digital pressure is
applied for 30-60 seconds after injection to “hold” the agent in place in order to bathe the nerve and achieve a more effective block.
In the maxilla
Caudal Maxillary block-infiltrates the infraorbital nerve at the caudal portion of the canal and provides local anesthesia of the entire
ipsilateral side. The foramen is located dorsal to the last molar. The landmark of insertion is located behind the last maxillary molar
into the soft tissue. The needle is inserted perpendicular to the maxilla just caudal to the last molar and is advanced no more than
halfway. The provides analgesia for the entire ipsilateral side including tooth, bone and soft tissue. It also anesthetizes the
pterygopalantine nerve which innervates the palate.
Infraorbital block-infiltrates the infraorbital nerve at the rostral portion of the canal and provides local anesthesia from the 1st
premolar to the rostral portion of the maxilla in the mesocephalic patient. This technique provides local anesthesia to the entire
ipsilateral side in the cat and brachycephalic patient. The infraorbital canal in these patients is only a few millimeters in length,
making this technique the one of choice in these patients. The maxillary technique previously discussed is not necessary to use in the
cat and brachycephalic patient. In the mesocephalic patient the foramen lies dorsal to the mesial root of the 3rd maxillary premolar.
The lip is retracted dorsally and the foramen is palpated. In the cat, the foramen is much more dorsal to the 1st premolar and is much
larger relative to the skull. The syringe is positioned parallel to the maxilla and the needle is inserted through the mucosa in a rostral
to caudal direction into the foramen.
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In the mandible
Inferior Alveolar Block-infiltrates the inferior alveolar nerve within the mandibular canal on the lingual aspect of the mandible,
provides local anesthesia of the entire ipsilateral side. The foramen lies on the lingual side of the mandible above the mandibular
notch. It can also be located by drawing a line from the lateral canthus of the eye to the ventral edge of the mandible or by palpating
the mandibular notch by running a finger along the ventral portion of the mandible until the notch is reached. The needle is inserted
through the skin at the mandibular notch perpendicular and lingual to the mandible. The needle should be inserted about halfway to
the hub.
Middle Mental Block-infiltrates the inferior alveolar nerve in the mandibular through the middle mental foramen and provides
local anesthesia from the 3rd premolar to the rostral portion of the mandible. The foramen lies on the lateral aspect of the mandible at
the apex of the canine and ventral to the mesial root of the 3rd premolar. The landmark for this foramen is the mandibular frenulum.
The syringe is positioned parallel to the mandible and the needle is inserted through the mucosa at the base of the frenulum in a rostral
to caudal direction._ The needle should fit “snugly” into the foramen as opposed to loosely if inserted into soft tissue only.
By adding this protocol to the pain management treatment plan, it allows for a smoother recovery for the patient. More
importantly, it provides intraoperative pain control and prevents the nociceptive process. The anesthetist can then keep the patient at a
much “lighter” plane of anesthesia. Cardiac output, blood pressure and temperature are stabilized at a lower concentration of inhalant
which provides a much safer anesthetic event for the patient.
References
1
Beckman, B.W. “Regional Nerve Blocks Key to Delivering Quality Dental Care” September 2007, 1-3_2 Beckman, B.W. “Regional Nerve Blocks
Key to Delivering Quality Dental Care” September 2007, 1-3_3 Beckman B.W. “Regional Nerve Blocks Key to Delivering Quality Dental Care”
September 2007, 1-3_
999
Home Care Strategies
Annie Mills, LVT, VTS (Dentistry)
Florida Veterinary Dentistry and Oral Surgery
Punta Gorda, FL
Periodontal disease is the most prevalent disease among humans as well as our 4 legged patients.
In order to manage this disease, home care must be a large part of the total treatment plan for those patients with early to advanced
periodontal disease.
Plaque can form in as little as 8 hours after a professional cleaning. By educating our owners on the process and consequences, we
can achieve much higher compliance.
The process starts with saliva or the acquired pellicle, also known as the smear layer. This forms a matrix where plaque begins to
organize and eventually mineralizes and becomes calculus or tartar. As this occurs, inflammation begins in response to the bacteria
which accumulates along the gingival margin. Pocketing, tissue loss and eventual tooth loss then follows. During this entire process,
the patient suffers in silence in most cases. Owners may not notice subtle changes in appetite, activity, etc. Many times, the behavior
changes are attributed to “old age” changes. Most owners act when the disease has progressed far enough that the patient is showing
clinical signs including halitosis, loss of appetite, severe lethargy, oral pain (ie pawing at the mouth, chewing on one side, dropping
food), bleeding, and noticeable loose teeth or even lost teeth. As veterinary professionals, we need to be proactive and institute a
dental care strategy that prevents or at the very least, manages periodontal disease.
A healthy mouth through professional dental cleaning, assessment and treatment improves the quality of life for the patient
significantly but needs to be maintained between professional care with aggressive home care protocols. Client education prior to and
following a dental procedure is paramount to gaining compliance on effective home care.
A thorough client discussion needs to occur to create a protocol that the patient will tolerate and that the owner is able to perform
easily and consistently. Ideally, 2 or more modalities of home care will achieve the best results. The ultimate goal of home care is to
prevent plaque and, subsequently, inflammation of the gingival tissue.
There are 3 primary modalities of home care and they include mechanical, chemical, and barrier/sealants. Mechanical includes the
physical brushing or scraping of plaque from the tooth and includes all veterinary dentifrices. Human toothpaste contains fluoride and
can be toxic if swallowed on a regular basis. Brushing, in order to be effective, needs to be done at least 3 times weekly. Daily is best
but unfortunately the client does not do that often and compliance is extremely low. The patient’s temperament is a factor as well. If
the patient is not cooperative, this method would not be the best choice as a home care strategy.
Hill’s diet t/d is formulated in such a way that it does not crumble like most kibble. It is extremely fibrous and the tooth sinks into
it as the patient chews causing it to scrape the tooth and removing plaque. This is a palatable diet and can be fed as a sole diet or given
as a treat after eating. This is more effective and tends to get better client compliance, however, this method only affects the carnassial
teeth. Another consideration is the patient’s restrictions. If there are any food allergies, this would not be a viable choice. Dental
chews and rawhides also act as a “brush” to remove plaque. Greenies and CET chews are included in this group. We can use the
patient’s chewing activity to work to our advantage in preventing plaque at home. Chemical home care include those products that are
impregnated with chlorhexidine, zinc, or hexametaphosphate. Chlorhexidine when in contact with the tooth surface for an extended
period of several minutes can inhibit the accumulation of plaque. This can be offered as a chew or water additive. Healthy mouth is
also a water additive which prevents plaque. It is an all natural product which uses plant extracts and has been shown clinically to
reduce plaque. Hexametaphosphate prevents the plaque from mineralizing and becoming calculus. All of the Eukanuba diets are
coated with hexametaphosphate. Barrier sealants include products like Oravet. This has a vaseline type consistency and is applied in
hospital to start and then is used at home by the owner on a once a week basis. This can be of significant benefit to those periodontal
patients that will have to forego certain types of home care if extractions and other procedures were performed. The in hospital
application can last up to a month and will continue to prevent plaque while the oral cavity heals. Again, client compliance is not as
high with this product. Once a week can be forgotton and then may turn into once a month and drop off entirely. An adjunct product
that has recently been introduced is 1-TDC which is an emulsified fatty acid. It binds with inflammatory cells and removes them from
the body. This adds an extra “punch” against the periodontal process by reduces inflammation. In resisitant periodontal cases we
have used Doxycycline as part of a comprehensive home care protocol at a subtherapeutic dose, not for the antibiotic properties, but
for the anticollagenase properties inherent to this medication. Because it is prescribed at such a low dose, it can be used long term
without the risk of creating resistant strains of bacteria which is always a factor when using antibiotics in these patients. Pulse therapy
antibiotics is now considered to be contraindicated due to this risk.
Home care is an important component to the overall treatment and management of the periodontal patient. It’s important to create
a partnership with the owner in the dental care of the patient. If the owner is not willing or is unable to provide appropriate aggressive
home care, then the treatment of the patient may need to compensate for this. For instance, if there are any teeth that may be saved by
performing periodontal therapy including root planing, bone graft, etc., the owner must be made aware that in order for the treatment
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to be successful, home care has to be performed consistently. Home care discussions should take place before a dental procedure, as
well as, during the discharge of the dental patient. Keeping the owner involved is the best way to manage the disease and improve the
quality of life for their pet.
1001
Making the Move from Technician to Lead Technician
Heather Prendergast, RVT, CVPM
Synergie, LLC
Las Cruces, NM
Many veterinary technicians are elevated into a leadership position based on the exceptional skills they possess on a daily basis.
However, fellow team members also wanted that position, and now resist the new role their counterpart is trying to fill. Attendees will
learn how to develop RESPECT from fellow team members and overcome the resistance that can be felt for years if not dealt with.
A common scenario that occurs in practices throughout the United States is the advancement of a long time team member into a
leadership role. Of course this seems absolutely logical; internal team members are familiar with the practice’s policies and
procedures. This person may have some of the skills needed to excel in this leadership position. However, the one skill most lack is
the ability to overcome the resistance of fellow team members who also wanted to be elevated into a leadership position. Let us look at
a few details to help the suffering leader to overcome obstacles and build respect from the team.
First and foremost, those being elevated, as well as those who were not, must realize that a leader is no one without their team, and
a team needs a leader to help provide the vision to achieve goals. No leader is hero without the team; and no team achieves goals
without leadership. With that being said, every organization must have a mission, vision and values statement which helps provide
guidance to the entire team. If every team member is living and breathing the mission and vision, then the road to a positive
environment built with respect for one another is being paved. If a practice does not have a Mission, Vision or Values statement
established – no fear! The new leader is here to save the day!
Create a mission, vision and values statement
A mission, the vision and the values (MVVs) of a hospital are core competencies that must be integrated in every practice. MVVs set
the structure, creating a positive culture, and goals that help define team member expectations. Without these, team members have no
direction; they simply show up to work and complete the tasks assigned to them. Owners make it day to day, with no clear light at the
end of the tunnel, and managers struggle to implement successful goals and policies to increase value in the hospital. The mission and
vision should be evaluated every couple of years, ensuring that they are still in alignment with the beliefs of the owner.
Utilize the team to help establish the MVVs. Of course, the owners opinion is critical in the development of these, but so is the
teams. If team members do not feel apart of this, they will not buy into it, they will resist it, and will in fact, will rebel against it. Seek
team members opinions and implement it, then they will hold themselves accountable.
Leadership
Leadership, not just management, is vital to the success and growth of a practice. Leadership is influence. Leaders motivate team
members into action, and inspire them to be the best that they can be. They guide through effective communication, and create an
environment that facilitates teamwork.
Leadership is about character, behavior and actions (actions speak louder than words!). Every leader must look in the mirror; are
the characteristics and behaviors that one is striving for (within the team) exhibited day in and day out (by oneself)? Through these
characteristics, leaders compel individuals to pursue the mission, value and goals of the leader.
Exceptional leaders create environments where team members are empowered to communicate openly, voice their concerns, and
make changes where necessary to produce an improved service. Inhibiting this environment can be detrimental.
Veterinary practice is a team business. A team is a simple concept: a group of individuals with different skills and attributes, which
contribute the positive culture of the hospital. Effective leaders build teams that allow the business to succeed at all levels, including
providing excellent patient and client care and maintaining a friendly and cohesive work environment, all while being able to create
and maintain a profit for the practice. Leaders invite creative thinking from team members, and integrate this creative thinking into
daily conversations. Creative thinking facilitates productive, problem solving team members that are not afraid to move outside the
box.
Delegation/empowerment
Team members who are elevated into positions of leadership soon realize there are many responsibilities that come with the
promotion. Too often, these newly emerging leaders feel it is their responsibility to get all tasks done themselves, and if they delegate,
it will how signs of weakness or the inability to handle the job. The fact is: leadership is more than a one-person job; it is a team job.
Therefore, effective leadership includes delegations and empowering team members to aid in the completion of tasks. Mangers can
oversee tasks, and provide assistance to those in which the tasks have been delegated. When we choose not to delegate, tasks get
completed late and often lack in completeness. This breeds disrespect from fellow team members, and stirs the pot for gossip. Develop
respect by delegating and empowering the team, and make them feel proud (and accountable) for their contributions.
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Training and continuing education
Every team member needs training in the veterinary practice. This starts the first day of employment and continues through the last
day (which can be 5 years, 10 years, even 15 when we have a well managed team). Phase training must be implement to ensure
potholes are not created in the road we are paving. Ask team members to help create this phase training program (cover all position
AND lengths of employment) and gain respect by asking them to help implement it. They can train and be accountable for their new
team member. In addition, they will understand the need for continuing education, even in seasoned team members.
Leveraging
Who does what in the hospital? All team members drive passive income (DVMs drive active income), so be sure each team member is
completing the tasks that they have the capabilities to do. Does a team member seem disengaged? Ask why and what responsibilities
they could take on that would ignite the passion again. Leveraging team members drives income, client retention, and team member
respect.
Recognition
Team members receive energy through recognition. Team members should be recognized for a job well done as soon as it is
warranted. Many team members only hear of mistakes they have made and the necessary corrections and never hear about the
excellent quality of work they produce. Positive situations need to be recognized and brought to the attention of all team members so
they can all benefit.
Don't give up with the first failure. Developing respect comes with overcoming adversity and having resilience. Being an
outstanding leader comes with time, patience, and many mistakes. A respected leader accepts criticism well and builds character and
moral values based off the criticism. In addition, the leader takes the fall for the team when applicable and gives all recognition to the
team for successes.
1003
Technician Accountabilities the Enhance Productivity
Heather Prendergast, RVT, CVPM
Synergie, LLC
Las Cruces, NM
Veterinary team members can drive approximately 50% of the practice revenues, yet often don’t realize how much they actually
contribute, or can contribute. The team drives client compliance, client retention and referrals. Attendees will be exposed to 6 tools
and scenarios that help drive practice productivity, which can be taken back into the practice and used immediately.
When practice income is analyzed, it can be broken down into two segments; active and passive income production. Veterinarians
that diagnose, prescribe and perform surgery produce active income. Passive income is produced by the remainder of the team
(receptionists, kennel assistants, veterinary assistants, veterinary technicians) through appointment booking, client education,
treatments of hospitalized patients, generating radiographs and performing dental prophylaxis procedures, just to name a few. A wellmanaged practice with a strong performing team can produce 50% of the income; however, veterinary technicians must excel at
communication, client education, and have leadership abilities (leading clients) in order to drive this income.
Communication
Communication is essential to the success of the veterinary hospital. Team members must be able to communicate clearly with each
other, as well as educate clients with clear and concise information. Team members must communicate clearly regarding treatment
plans, ensuring that patient care is a priority. These treatment plans must then be communicated clearly to clients, making sure they
understand the importance of the recommended care. Excellent communication will increase team member satisfaction, client
compliance and client retention.
A message is composed of three parts: verbal, paraverbal and nonverbal. The verbal component of the message includes the words
that are chosen to relay the message, and is responsible for 7% of the message. The enunciation of words and the tone of voice used to
relay the message is the paraverbal component and contributes to 38% of the message. The remaining 55% of the message is the
nonverbal component, and refers to the body language displayed while talking to another person or persons. Most people think that the
words chosen to relay a message play the largest component of a message, when in fact, the body language portrayed dominates. If a
listener is confused about the message being sent, they will respond more so to the body language being demonstrated than the words
being spoken (actions speak louder than words!).
Client education
Client education is obviously a piece of communication, as education will not occur without communication. However, the way we
educate clients can make or break a relationship that drives production.
There are several learning styles that have been identified, three of which apply to the veterinary setting: visual, verbal and tactile.
Visual learning involves the use of pictures, images and spatial learning. Verbal utilizes words, both in speech and writing. Tactile
uses hands and a sense of touch.
Since we cannot identify which client learns by which style, it is important to incorporate a small amount of each into our
educational plan. Consider the items available to you in the practice to educate clients: manufacture brochures, client education
handouts, models and videos. We must always send home information with the client; therefore, we must verbally review written
materials. Most of the written materials will have pictures or images included, so we have covered the verbal aspect and a bit of the
visual. Now include the use of models (many models are available for free from manufactures, or they can be purchased in the exhibit
hall). Let the clients feel and touch as you verbally explain the service or procedure. Third, show a short video (watch it with the
client, don't walk out of the room). As a final touch, email the video to the client (you may also ask if they would like the client
handout emailed to them; if it is on their smartphone, they can review it anytime!).
Clients must hear a message three times to absorb the information; these methods address the different learning styles and repeat
the message(s) subtly. Clients must understand a procedure and the value of it, or they will decline the service. In fact, 8 out 10 clients
will decline a service not due to money, but because they are confused or do not understand the need.
Positive culture
Positive cultures generate a harmonious environment; team members enjoy working with one another, respect flows through the team,
and clients build strong and loyal relationships. When a negative culture exists, clients “feel” it. It is cold when they enter the practice,
team members snap at each other, and the employee turnover rate is exceptionally high. Due to these 3 simple factors, client trust and
bonding rates drop and compliance falls, both having a direct relation to driving referrals and increasing the number of active clients.
Team members must stop gossip, facilitate teamwork and respect all team members to help drive a positive culture.
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Leveraging staff
The veterinarian’s job description is rather simple: diagnose, prescribe and perform surgery. Therefore, when veterinarians are
trimming nails, expressing anal glands, filling medications and taking radiographs, the income production will likely drop. In addition,
when team members are unable to perform the functions they have been trained to do, team member satisfaction decreases and the
turnover rate increases.
Team members must perform duties that their position specifies. If team members are lacking in the skills needed to complete
tasks, continuing education should be sought, whether online or at an event. Often, team members must step up and show their
enthusiasm to learn and complete these tasks.
Continuing education
Veterinary technicians never quit learning. There are always new drugs, equipment, or emerging diseases. In addition to these hard
skill enhancers, team members should also learn soft skills that enhance their personal and professional lives. Soft skills include (but
are not limited to) communication, customer service, and leadership. Continuing education ignites passion and decreases the risk of
burnout.
LEADership
Every team member is a leader. They may not be a practice or office manager, but they do lead client’s everyday. In addition, the
actions that each leader emits can persuade a client to accept recommendations being made, or can make them reject any
recommendation being made. Actions speak louder than words, and those with confident, respected actions will drive income through
the roof.
1005
Becoming the Indispensable Team Member
Heather Prendergast, RVT, CVPM
Synergie, LLC
Las Cruces, NM
We can all be replaced…. or can we? If you left the practice, would you be rehired (in an instant)? Yes, technically, we can be
replaced, however, creating shoes that are hard to fill is always a desirable trait. What do you bring to the exam room table, or perhaps
the better question is, what are you not bringing to the table? Attendees will learn how they can become the superstar of the hospital,
and inspire others to do the same.
Mission, vision and values of the practice
Identify the mission, vision and values of the practice. Live and breathe these statements day in and day out, with every client, every
time. If your practice does not have a mission, step up and ask leadership if you can lead the development of one. A mission defines
why you come to work everyday. It provides guidance and structure for the practice. What is the vision of the practice? Where will the
practice be, and what does the owner want in 2 years, 5 years, and 10 years? If you do not know what the vision is, how can you help
obtain these goals? Determine what the vision is, and contribute to achieving those goals everyday. What are the core values of the
hospital? Compassion, empathy, accountability, or respect? Team members must exhibit these values 100% of the time, to both clients
and team members.
Client service orientation
Every team member must be customer service oriented. This is a service-oriented industry, and therefore, every client must be
satisfied with your performance every time. Do clients know your name? Do they ask for you when they call or come into the
practice? Do you provide such stellar service that they compliment you to others? These are great questions you can ask yourself,
before asking for a raise. Team members that positively influence clients through education drive client compliance through the roof.
Start with wearing a name tag or have your name inscribed on your scrubs. Second, look professional! Never wear stained and
wrinkled scrubs. How is a client ever to take you serious, when you look “frumpy”? Next, evaluate your communication platform.
Communication
Communication is they key to success, and must occur with both team members and clients. Evaluate the words you use on a daily
basis. Are they professional, and do they communicate respect? Is your enunciation of words clear or do you include slang in your
vocabulary? Does your tone of voice convey respect or does it degrade the listener? Before answering these questions, it is strongly
encouraged to record your conversations over a period of days and evaluate them. Knowing you are recording your conversations is
going to subconsciously change the communication pattern (until it is forgotten about); once forgotten, then you can truly evaluate
yourself.
Pay attention to key phrases you may be saying, but completely unaware of. Consider these three words: “I don't know”. Now
consider the negative effect that these 3 simple words can have on a person asking a question. Most commonly, the tone of voice used
when uttering these words is negative. It may add to the message that you are lazy and unwilling to find an answer; perhaps you are
too busy, or you simply don't care. Regardless, the end result is the same; a negative message has just been conveyed. Rather than
stating, “I don’t know”, reply with, “that is a great question, let me find an answer for you!” The tone of voice changes, resulting in a
positive message to the person asking the question. This applies to both team members and clients.
Evaluate yourself for the nonverbal language that is exhibited. Nonverbal communication dominates the message being sent,
accounting for 55% of the message, while words contribute 7%, and enunciation and tone of voice contribute 38%. Do you stand tall,
walk with a peppy step and portray a positive self-image? Facial expressions subconsciously communicate our true internal feelings.
Are your facial expressions communicating a positive or negative message? If your practice has security cameras, ask management to
view those recordings and evaluate yourself for positive and negative nonverbal cues you may be exhibiting.
Respect for one another
Every client and team member deserves respect. Each person has different strengths and weaknesses; you may be great with treating
patients while another team member is incredible when it comes to client entertainment. There is no need to publicly ridicule a person
for a weakness that they posses, however this is often the case in the practice setting. On the flip side of the coin, rarely do team
members compliment fellow team members on strengths they exhibit. Be the first in your hospital to compliment others for their
strengths, while evaluating your own. What weaknesses can you improve, in order to gain the respect of others?
Respect for one another develops a positive team culture and an incredible team dynamic. Teams that work well together have
higher client satisfaction, client retention and client compliance, in addition to increased team moral. Ask yourself if you are breaking
down this phenomenal dynamic, or contributing positively, day in and day out.
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Respect for one another is not sharing gossip; it is being the person to stop the gossip from flowing through the hospital. Do not
talk about other team members unless it is a positive statement; likewise, never talk about clients to other clients. Gossip results in a
toxic workplace, and a toxic employee.
Learning motivation
How motivated are you to learn new concepts and apply them to the practice? Take a good look in the mirror before answering this
question. We may say we are the motivated learner, but the answer most often heard when trying to implement new concepts in the
practice is “we have done it this way for years, why do we have to change?” Now ask, do you eagerly accept change and apply
yourself, or does your ‘nonverbal communication’ suggest otherwise?
Now consider personal education. What steps are you taking to improve your value to the practice? Do you take courses online or
at a local community college? Have you considered taking your career to the next step (approved veterinary assistant, a credentialed
veterinary technician, a veterinary technician specialist or a CVPM)? It is not necessarily the practices role to push you to improve
yourself. Take the first step and become a life long learner, and enhance your value.
Influential personality
Being an influence on others can have two outcomes: positive or negative. In the veterinary practice, we influence both team members
and clients, and if either is negative, it affects the other. If we have a negative effect on team members, clients “see and hear” it. If we
have a negative effect on clients, team members “see and hear” it. A positive influential personality is exhibited by a person that is
professional, speaks with a positive tone of voice, carries themselves with pride and is willing to take a few extra minutes to educate
(both clients and team members). Being a positive influence on others is contagious and leads to a positive team culture.
Work ethic
If management were to rate you on work ethic, would it be strong, mediocre, or poor? Work ethic, as defined by Wikipedia is a value
based on hard work and diligence. It is also a belief in the moral benefit of work and its ability to enhance character. A strong work
ethic includes being reliable, having initiative and pursing new skills. Breaking this down further, being reliable includes
accountability. Are you on time or early for your shift or required meeting, every time? Are you accountable for your actions, or do
you consistently blame others (actions do speak louder than words)? Having a mediocre work ethic is unacceptable, it must be strong,
and include motivation, passion, and ambition.
Resilience
Resilience is the process of adapting well in the face of adversity, trauma, tragedy, threats or significant sources of stress - such as
family and relationship problems, serious health problems or workplace and financial stressors. It means "bouncing back" from
difficult experiences. It is behaviors, thoughts and actions that can be learned and developed by any team member. Consider how you
respond to adversity in the work place, including constructive coaching, difficult clients and the loss of patients. Does your ‘nonverbal
communication’ indicate you are angry, in a bad mood or offended? A resilient team member takes the adversity, builds a positive
response and implements change to compliment the situation at hand. This resilience builds confidence in character, enhances
communication and problem solving skills. Every person experiences adversity in life; it is your choice how you chose to deal with the
event.
Empowerment
Do you possess the soft skills described above, and allow leadership to delegate tasks to you? More often than not, leadership does not
delegate as they should due to the lack of soft skill qualities in team members. Increase your value to the practice by accepting skills
that can be delegated. Before asking for these tasks, analyze yourself for accountability: can you accept tasks and complete them with
100% by the due date? Resilience: can you accept constructive criticism to improve the task, realign yourself and bring back a new
and improved task? Work place ethic: do you give 100% all the time (or do you just “look” busy?) Influence: can you positively affect
fellow team members with your newly delegated task, or will you negatively affect others with an “I am better than the” attitude?
Learning: are you willing to learn in order to enhance the effectiveness of the task, or will you just complete the task? How can this
task help achieve the vision of the practice? All soft skills tie into successful delegation, which results in an empowered employee.
Listening skills
How well we listen often dictates the outcome of the message being given. In today’s society, we often finish sentences for others,
anticipate what the next question is going to be, or have preconceived ideas of what the result of the conversation should be. The result
is misunderstood messages, assumptions and sometimes, an intense conflict. Good listeners give their full attention to the person that
is speaking (either clients or fellow team members). Eye contact is made, and preconceived thoughts and opinions are placed aside. It
is important to listen to not only the words that are being said, but the nonverbal component as well. Identify if the speaker is closed
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off or upset (closed, folded arms – protecting the core cavity), happy and engaged (facial expressions), stressed or annoyed (facial
expressions and hand gestures). Enhanced listening skills build professionalism, integrity and value.
Organization
Not all team members have a ‘desk space’ to keep organized, and that is often how others judge the organizational skills of a team
member. However, a desk space is not the only thing that can be organized. Consider organized thoughts. Team members that have an
organized thought pattern have an increased ability to conceptualize, problem solve and make a sound judgment. They also have an
increased ability to positively persuade others and complete tasks, whether delegated or not. Organization is a soft skill that can be
built, enhanced and managed on a daily basis.
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Cytology of Fluid Aspirates
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Cytology is the examination and interpretation of smears made from tissues and fluids. The purpose of the cytology evaluation is
differentiation of inflammation from neoplasia. In general, samples that are inflammatory are characterized by a predominance of
neutrophils, macrophages (tissue monocytes), and/or eosinophils. Cytology samples can be collected without specialized equipment
and are usually prepared with several different techniques.
Sample collection
Centesis refers to removal of fluid from a body cavity, such as the thorax, abdomen, joints, urinary bladder. When collecting fluid
from the chest or abdomen, syringes of 12 cc and up may be needed, depending on the amount of fluid to be removed. Washes are
procedures in which sterile physiological saline is introduced into a space, following which the fluid is aspirated back out of the body
and examined. The aspirate may contain cells or other elements that help in diagnosis. Types of washes commonly done are prostatic,
tracheal, and nasal. The tracheal wash can be done either under anesthesia, introducing the saline through a catheter put down the
lumen of the endotracheal tube, or by introducing a catheter through the skin of the neck at the cricothyroid ligament while the animal
is conscious.
Cytologic evaluation of samples obtained from the trachea, bronchi, or bronchioles may assist with diagnosis of pulmonary disease
in animals. Tracheal washes may be performed by passage of a catheter through an endotracheal tube in an anesthetized animal
(orotracheal approach), via the nasal passages (nasotracheal approach), or through the skin and trachea (percutaneous approach) in a
conscious, sedated animal. The transtracheal route minimizes pharyngeal contamination of the specimen, but it is an invasive
procedure and requires aseptic technique. The percutaneous method requires the use of an 18 – 20 gauge through-the-needle (jugular)
catheter. The laryngeal area is clipped of hair and aseptically prepared. A small amount (usually 0.5 – 1.0ml) of 2% lidocaine is
injected into the cricothyroid membrane and surrounding skin. The needle is inserted into the trachea through the cricothyroid
membrane. Sterile physiologic saline solution is infused through the catheter at a rate of 0.5 to 1.0 ml/kg of body weight. When the
animal coughs, the syringe plunger is retracted several times and the fluid collected placed into a plain sterile tube. Samples should be
processed immediately.
The orotracheal technique may be preferred in very small or fractious animals. The patient must be lightly anesthetized and an
appropriate size endotracheal tube placed. A urinary or jugular catheter is then placed through the endotracheal tube and saline is
infused as described for the percutaneous method. Depending on the level of anesthesia, the animal will often not cough so the saline
should be withdrawn within a few seconds and evaluated. Bronchoalveolar lavage (BAL) is an orotracheal technique used to collect
samples specifically from the lower respiratory tract. Bronchoscopy is the preferred method for performing a BAL but specialized
equipment (e.g. bronchoscope) is required.
With either method, only a small amount of the saline infused will be harvested with the initial collection. Subsequent coughing of
the animal may also contain cells of interest so all fluid released during coughing subsequent to the initial collection should also be
collected once the animal has been returned to its cage. This fluid should be placed in a sterile tube with a notation containing the site
of collection. Such fluids are often contaminated but can sometimes be used for evaluation when the initial collection yields
insufficient information.
Cytologic evaluation of samples obtained from the nasal cavity may be useful in investigation of diseases affecting the upper
airway. Fluid (normal saline) may be infused into the nasal cavity via the nose, using a syringe and tubing, and then aspirated. This
procedure is referred to as a nasal flush. Such specimens are processed as for a tracheal wash. Various abnormalities may be
demonstrated with this procedure, such as inflammation secondary to sepsis, fungi and yeasts, and neoplasia. These should not be
confused with glove powder, which may be present in some specimens.
Concentration techniques
Samples with little mucus (generally corresponding to small numbers of cells) should be centrifuged at low speed, and smears
prepared from the sediment. Samples containing much mucus (and usually numerous cells) may not need to be centrifugeconcentrated before a smear is made.
When a cytologic smear is to be made of fluid with a cell count below 500/ml, concentration of cells is mandatory. Such
concentration may be helpful even at higher cell counts. For most sample types, the fluid is centrifuged 5 minutes at 165 to 360 G with
a centrifuge with a radial arm length of 14.6 cm (the arm length of most urine centrifuges) at 1000 to 1500 rpm. After centrifugation,
the supernatant is separated from the sediment and analyzed for total protein concentration. The sediment is resuspended in a few
drops of supernatant by gently thumping the side of the tube. A drop of the resuspended sediment is placed on a slide, and a smear is
made by the blood smear or compression preparation technique. When possible, several smears should be made by each technique.
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Addition of plasma may help cells adhere to the microscope slide. After air drying, the slide may be stained with a Romanowsky
stain.
Preparation of smears
The most common method for preparing cytology samples for microscopic evaluation is the compression smear. This technique
compresses the sample between two clean glass slides that are held at right angles to each other. These slides are then pulled apart in a
smooth action. A modification of the compression smear procedure involves rotating the slides rather than pulling them at right
angles.
Starfish smears and line smears are usually prepared when the compression smear is found to be unsuitable to evaluation. The line
smear is particularly useful for samples with very low cellularity. Fluid samples may also be prepared using a wedge film technique.
Staining techniques for cytology samples are similar to that used for blood films. However, the samples normally need increased
fixative time and slightly increased staining times as compared to procedures for staining of blood films. Romanowsky stains are the
most commonly used type in the veterinary practice.
Terminology
Consistent terminology must be used when describing cell types. Specific details on the morphology of each cell type will also assist
the clinician in making the diagnosis. Neutrophils and macrophages should be evaluated for presence of vacuoles or phagocytized
material. Neoplastic cells should be evaluated for malignant changes, such as mitotic figures and basophilic cytoplasm.
Fluid samples should also be evaluated for cellularity. The total nucleated cell count (TNCC) and total protein values for the
sample will allow it to be classified as transudate or exudate. In general, transudate samples are clear or colorless, with TNCC less
than 500/microliter and total protein less than 3.0 g/dl. Exudates are characterized by increased cellularity and total protein greater
than 3.0 g/dl. This higher cell count and protein value is usually indicative of inflammation. Transudates are more commonly found
in ascites and are usually clear and amber or pink in appearance. Fluid aspirates are also described according to the character of the
sample. Terminology such as hemorrhagic and chylous are commonly used to describe samples containing blood and lymph fluid,
respectively.
Inflammation
Inflammation is a normal physiologic response to tissue damage or invasion by microorganisms. This damage releases substances that
have a chemotactic effect on certain white blood cells. These chemotactic factors, therefore, are involved in attracting white blood
cells to the site of inflammation. The first white blood cells to arrive are the neutrophils. Neutrophils phagocytize dead tissue and
microorganisms. The process of phagocytosis creates pH changes both within the neutrophils and in the site. As the pH changes,
neutrophils become unable to phagocytize any further and the cells quickly die. At this point, macrophages move in to the site and
pick up the phagocytic activity. Cytology samples from inflammatory sites are therefore characterized by the presence of white blood
cells, particularly neutrophils and/or macrophages. Occasionally, eosinophils or lymphocytes may also be present. In fluid samples,
total nucleated cell counts of greater than 5000/ul is a common finding with inflammation. The fluid is often turbid and may be white
or pale yellow. Total protein is often greater than 3 gm/dl.
Inflammation can be categorized as suppurative (purulent), granulomatous, pyogranulomatous, or eosinophilic based on the
relative numbers of the various cell types present. Suppurative (purulent) inflammation is characterized by the presence of large
numbers of neutrophils, usually greater than 85% of the total nucleated cell count. When significant numbers of macrophages are
present (greater than 15%) , the sample is classified as granulomatous or pyogranulomatous Fungal and parasitic infections often
manifest with this presentation. The presence of greater then 10% of eosinophils along with increased neutrophils indicates an
eosinophilic inflammation. This is usually found with parasitic infection but may also be present in some neoplastic disorders.
Inflammatory samples must also be evaluated for evidence of degeneration and presence of microorganisms. Nuclear changes that
may be found in inflammatory cells (i.e. neutrophils) are nuclear karyolysis (swollen pale nucleus) or karyorrhexis (nuclear
fragmentation). Cells should also be evaluated for the presence of bacteria. Inflammatory cells that contain phagocytized
microorganisms are referred to as septic. Additional phagocytized material may include erythrocytes or parasites.
Cytology of neoplasia
Neoplastic specimens normally contain rather homogeneous populations of a single cell type. Although mixed cells populations are
sometimes seen, these usually involve a neoplastic area with a concurrent inflammation. Neoplasia is indicated when the cells present
are of the same tissue origin. Once identified as neoplastic, the technician should identify the tissue origin and evaluate the cells for
presence of malignant characteristics.
Neoplasia must first be differentiated as either benign or malignant. Benign neoplasia is represented by hyperplasia with no
criteria of malignancy present in the nucleus of the cells. The cells are of the same type and are relatively uniform in appearance.
Cells that display at least three abnormal nuclear configurations are identified as malignant. Nuclear criteria of malignancy can include
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anisokaryosis, high or variable N:C ratio, increased mitotic, coarse chromatin pattern, nuclear molding , multinucleation and nucleoli
that vary in size, shape and number.
In general, if three or more nuclear criteria of malignancy are present, the specimen is identified as malignant. Exceptions to this
general rule would be indicated if inflammation is also present or only a few cells display malignant characteristics. Specimens that
have been classified as malignant should be further evaluated to determine the cell type involved. The basic tumor categories seen in
mammals include epithelial cell tumors, mesenchymal cell tumors, and discrete round cell tumors.
Summary
With careful attention to appropriate collection, preparation, and staining technique, a high quality cytology sample can be obtained.
Such samples yield valuable results for the clinician and often preclude the need for more invasive procedures to determine diagnosis
and prognosis for a patient.
References available from the author.
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Current Research in Hemostasis and
Implications for Diagnostic Testing
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Hemostasis involves a number of complex pathways, platelets and coagulation factors. Any alteration in these parameters can result
in a bleeding disorder. Primary hemostasis, can be initiated when a blood vessel is ruptured or torn. The exposed blood vessel
endothelium is a charged surface and platelets are attracted to this surface. As platelets congregate at the site, they undergo
morphologic and physiologic changes. These changes cause the platelets to adhere to each other as well as the blood vessel. This also
causes platelets to release the initiating factor for the chemical phase of hemostasis. Secondary hemostasis (the coagulation cascade)
involves a number of coagulation factors. Many of the components of the secondary systems also serve to recruit and activate
additional platelets. The end result of the coagulation cascade is the formation of a mesh of fibrin strands that forms the clot. The final
phase, tertiary hemostasis, involves degradation of the fibrin clot.
Recent research has focused on characterization of a cell based hemostasis model. These cell based models demonstrate that
hemostasis is initiated by interactions of negatively charged phospholipid surfaces of cells and platelets or microparticles.
Microparticles are membrane-bound cytoplasmic fragments released from platelets, leukocytes, and endothelial cells. They serve to
increase the surface area on which the coagulation complexes in the secondary phase of hemostasis can form.
Tissue factor released from damaged tissues initiates the coagulation reactions. Factors I-XI amplify the cascade. Coagulation
pathways do not operate as independent and redundant pathways. Platelets are essential for secondary hemostasis. The thrombin
generated by the coagulation cascade recruits and activates platelets and inhibits fibrinolysis. When platelets are activated,
phosphatidylserine (PS; formerly referred to as platelet factor 3) is exposed on the outer surface of the membrane. Platelets also
release small vesicles from their surface during activation. These microparticles are enriched in PS. PS acts as a binding site for the
complex of FVIIIa, FIXa, and FX. and the complex of FVa, FXa, and FII. The FVa,/FXa/FII complexes activate prothrombin (FVII),
Coagulation factors are assembled into a complex on the surface of platelet and microvesicles, where they can amplify the coagulation
cascade and generate large amounts of thrombin, which converts fibrinogen to fibrin.
In the presence of plasmin and tissue plasminogen activator (tPA), fibrin can be broken down into soluble fibrin degradations
products (FDP’s). Insoluble FDP’s as well as d-dimers are formed from the breakdown of insoluble fibrin and result in the dissolution
of the clot.
Coagulation testing
Coagulation tests are designed to evaluate specific portions of the hemostatic mechanisms. Some tests measure just the mechanical
phase of hemostasis. Others can measure specific parts of the chemical phase. All patients should be evaluated for coagulation
defects prior to undergoing surgery. Most coagulation tests can be completed with minimal time and equipment and are relatively
inexpensive.
Platelet counting methods
Laboratory evaluation of the thrombocytopenic patient must begin by ruling out sample collection and processing errors. Platelets
adhere to charged surfaces such as uncoated glass and this will manifest as a decrease in platelet count. Platelets that are activated
during the sample collection and processing procedures will also falsely decrease the platelet count. Common causes of platelet
activation during sample collection include prolonged venous stasis and patient excitement. EDTA can trigger platelet activation so
samples should be evaluated as soon as possible after collection. Use of automated analyzers for a cell count can also mask
abnormalities in both numbers and function of platelets. Lysing reagents used in cell counting do not affect platelet aggregates. The
presence of aggregated platelets often results in falsely decreased platelet numbers and falsely increased red or white blood cell
counts. Macrothrombocytes in the blood sample can also lead to erroneous results when using automated blood cell counters. A
scanning peripheral blood film should be performed to provide an overall indication of platelet size. Some automated analyzers can
then be adjusted to count the larger platelets. Since thrombocytopenia can occur in a wide variety of conditions, samples for bacterial
culture and immunologic testing may be needed.
A platelet estimate is performed by counting number of platelets seen on differential blood film as averaged over ten oil immersion
fields. The presence of an average of 7 to 21 platelets is reported as ‘adequate’. Using this average and multiplying by 20,000
provides an estimate the total platelet count. Another indirect measure of platelet numbers is performed by counting the number of
platelets seen per 100 white blood cells on the differential blood film. This number is then used to calculate the platelet estimate using
the equation below.
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Platelets counts can also be performed with manual methods and with some automated analyzers. If a coagulation disorder is
suspected, a manual platelet count should be performed. Always use a freshly collected blood sample to perform manual platelet
counts. Although many automated analyzers provide a platelet count, these are often inaccurate due to platelet clumping and
platelet/RBC overlap. Morphologic changes in platelets include aggregation and giant platelets. These abnormalities will not be
evident with automated analyzers and must therefore be detected using the differential blood film. Platelets counts can be performed
using a hemocytometer but require manual dilution of EDTA-anticoagulated whole blood in Ammonium Oxalate.
Platelet histograms
Many automated analyzer provide a platelet histogram as part of the CBC results. If a platelet histogram is available, this will aid in
the overall evaluation of platelet sufficiency. The platelet histogram can identify the presence of macrothrombocytes, aggregated
platelets, and alterations in platelet indices.
Platelet indices
Automated analyzers usually provide additional platelet parameters, referred to as platelet indices. These include mean platelet volume
(MPV), platelet distribution width (PDW), and Plateletcrit (PCT). Other platelet indices may also be provided depending on the
instrument manufacturer. Different analyzer manufacturers vary in the methods used to obtain these results. Clinical usefulness of
platelet indices is under investigation. Research is focusing on utilization of platelet indices in differential diagnosis and as prognostic
indicators. Current research indicates that the highest values for the various platelet indices may be most likely in patients with
immune-mediated thrombocytopenia.
Mean platelet volume (MPV)
Even in healthy dogs and cats, individual platelets can vary markedly in size. Increased MPV might be expected in situations where
increased loss, destruction, or consumption of platelets is accompanied by megakaryocytic hyperplasia. Accelerated thrombopoiesis
tends to result in the release of larger platelets. A. high MPV in dogs indicates adequate bone marrow response; however a normal or
low MPV in thrombocytopenic dogs does not predict an inadequate bone marrow response. Healthy cats generally have variably sized
platelets and some may be quite large. Some breeds of dogs, e.g. Cavalier King Charles Spaniels, have larger platelets than other
breeds. These may be missed with some automated counters because the platelets fall outside the size threshold the instrument uses for
counting platelets.
Platelet distribution width (PDW)
This measurement is also referred to as platelet size deviation width, platelet component distribution width (PCDW) and platelet dry
mass distribution width (PMDW). Increases in PDW are associated with bone marrow hyperplasia.
Plateletcrit (PCT)
This measurement is a calculated ratio of the platelet volume to the whole blood volume. Its usefulness in diagnosis and prognosis of
hemostatic disorders is not well characterized.
Clot retraction test
This procedure provided a crude evaluation of platelet number and function and intrinsic and extrinsic pathways. Blood is drawn into
plain sterile tube and incubated at 37 degrees. The tube is examined at 60 minutes and re-examine periodically over a 24-hour period.
A clot should be evident in 60 minutes, retracted in about 4 hours, and markedly compact at 24 hours.
Activated clotting time
This test can evaluate every clinically significant clotting factor except Factor VII. The test requires a pre-incubated tube that contains
a diatomaceous earth material. Venipuncture is performed and 2 ml of blood is collected directly into the tube. A timer is started as
soon as the blood enters the tube. The tube is mixed once by gentle inversion and placed in 37-degree incubator or water bath. The
tube is observed at 60 seconds and then at 5-second intervals for presence of a clot.
Buccal mucosa bleeding time
This is a primary assay for the detection of abnormalities in platelet function. The test requires a Simplate® I or II spring-loaded
lancet, blotting paper or #1 Whatman filter paper, stopwatch, and tourniquet. The patient should be anesthetized and placed in lateral
recumbency. A strip of gauze is used to tie the upper lip back in order to expose the mucosal surface. A 1 mm deep incision is made
using the Simplate® device. Standard blotting paper or #1 Whatman filter paper is used to blot the incision site. This is done by lightly
touching the paper to the drop of blood and allowing the blood to be absorbed. Blotting is repeated every five seconds until bleeding
has stopped. It is important that the incision not be disturbed in any way until bleeding has stopped. A prolonged bleeding time occurs
with most platelet dysfunction syndromes. It will also be prolonged in thrombocytopenia so a platelet count must also be performed.
Activated partial thromboplastin time and partial thromboplastin time
These tests are usually performed with automated coagulation analyzers. The tests evaluate the intrinsic pathway. Some methods
require multiple reagents.
PIVKA
The acronym PIVKA refers to “Proteins induced (invoked) by Vitamin K absence.” Vitamin K is required to activate coagulation
factors II, VII, IX & X. When vit.K is deficient, precursor proteins of factors II, VII, IX & X (known as PIVKA) build up & can be
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detected by the PIVKA, or Thrombotest. The test can differentiate rodenticide toxicity from primary hemophilia when ACT is
prolonged. It is a more sensitive test than PT when there is depletion of these factors.
D-dimer and FDP’s
Both of these tests are used to evaluate tertiary hemostasis. D-dimers and fibrin degradation products (or fibrin split products) are
formed as a clot is degraded. These tests are therefore useful in identifying the presence of DIC and will also provide diagnostic
information in cases of liver failure, trauma, and hemangiosarcoma. A canine in-house tests is available for d-Dimer analysis.
Bone marrow biopsy
A bone marrow biopsy can be used to determine whether thrombocytopenia is accompanied by a concurrent pancytopenia. Mature
megakaryocytes are large cells containing 32 to 64 fused nuclei. Shedding of platelets by the bone marrow megakaryocyte is
stimulated by thrombopoietin. Thrombopoietin is produced by the liver. Megakaryocytes are not evenly distributed in a bone marrow
aspirate. They are often seen in clusters, particularly at the edges of the slide. Megakaryocytes may number as much as 8-10 per lowpower field, although 2-3 per low power field is more common. Dysmegakaryopoiesis (Dysthrombopoiesis) is characterized by the
presence of megakaryocytes with separate nuclear lobes or dwarf megakaryocytes.
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Leptospirosis
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Etiology
Leptospirosis is a zoonotic bacterial disease found throughout the world. It is caused by a gram-negative, motile spirochete of the
genus Leptospira. (Figure 1) More than 250 pathogenic serovars of Leptospira species have been identified. The primary serovars that
were historically implicated in clinical disease were Leptospira interrogans servoars icterohemorrhagiae and canicola. The
widespread use of vaccines effective against those serovars resulted in a dramatic decrease in infections. However, recent studies
suggest that the current increases in infections are caused by serovars autumnalis, pomona and Leptospira kirschneri serovar
grippotyphosa. Vaccines that include serovars icterohaemorrhagiae, canicola, grippotyphosa, and pomona are available and appear to
provide protection from infection for at least a year. The vaccine is considered a non-core canine vaccine and is generally
administered to those dogs at greatest risk of exposure to the spirochete. Frequent vaccination may be needed for high-risk dogs such
as working dogs and those living in environments with high presence of wild mammal reservoirs. Cats may also become infected but
usually do not develop clinical disease and may serve as a reservoir for the organism.
Figure 1.
This scanning electron micrograph (SEM) depicts a number of Leptospira sp.
bacteria atop a 0.1. µm polycarbonate filter. (Photo courtesy Centers for Disease
Control. Janice Haney Carr)
Distribution
Specific serovars are often found in specific geographic areas. These include the
following:
Region
New Jersey
Massachusetts
Michigan
New York
Illinois
California
Ontario, Canada
Serovar(s)____________________________
L. pomona, L. grippotyphosa, and L. autumnalis
L. pomona and L. grippotyphosa
L. pomona, L. grippotyphosa, L. autumnalis
L. pomona and L. grippotyphosa
L. grippotyphosa
L. pomona and L. bratislava
L. autumnalis ,L. bratislava, L. grippotyphosa, L. pomona
Risk of exposure
Leptospirosis is most prevalent in warmer climates with relatively high average rainfall. The highest canine infections in the United
States are found in the southeastern states, the Pacific Northwest , Hawaii, the upper Midwest, northern California, the coastal midAtlantic region, and parts of Texas and Colorado. Periods of high rainfall precede outbreaks of the disease in dogs. Peak incidence
usually occurs in late fall.
Clinical disease is most likely in dogs that are exposed to or drink from lakes and streams containing high levels of spirochetes.
While dogs living in rural areas are generally at greater risk of exposure, dogs in suburban areas may also be exposed when they come
into contact with wild animal reservoirs.
More than 150 species of wild and domestic mammals can be infected with the organism, including:
•
Cattle
•
Pigs
•
Horses
•
Dogs
•
Rats
•
Raccoons
•
Skunks
Pathogenesis
The spirochete can penetrate intact mucous membranes and initial infection involves rapid replication of the organism. Once the
spirochetes enter the body, they travel to the vasculature and replicate. They then spread to other tissues, including the kidneys, liver,
spleen, eyes, and genital tract. Clinical signs begin to develop in seven to ten days. Different serovars also release different toxins and
1015
this may account for variability in severity of infection. Damage to vascular endothelium, vasculitis, hepatitis, and nephritis are
common findings. Fatality rates are reportedly as high as 20%. Polyuria and polydipsia can develop in dogs with leptospirosis as a
result of a decreased glomerular filtration rate that impairs the renal concentrating ability. Other manifestations of infection can
include uveitis, conjunctivitis, tachypnea, and dyspnea.
Assuming the patient mounts an adequate immune response, the spirochetes are generally cleared from most tissues within a few
weeks. Organisms tend to persist in the kidneys and can be shed in the urine for many months. Pathologic changes to the kidneys and
other organs and tissues often persist even after successful treatment.
Clinical signs
The organism colonizes the kidney tubules and is shed in the urine. Transmission is by direct contact with urine containing the
spirochetes or contact with urine-contaminated soil, water, food, bedding, or other fomites. The incubation period can be as short as
one week but infected animals may also be asymptomatic carriers. Disease can also develop months or years later. When symptoms
are present in infected dogs, they can include
•
Fever
•
Jaundice
•
Renal failure
•
Lethargy
•
Anorexia
•
Vomiting
•
Dehydration
•
Oliguria
•
Diarrhea
•
Hematemesis
•
Petechiae
Clinical signs in cats are rare but can include renal failure, ascites, and hepatomegaly.
Diagnosis
Leptospirosis is a historically under-diagnosed disease. The most commonly used diagnostic test is the microscopic agglutination test
(MAT), which identifies the presence of serum antibodies to the spirochetes. This test is often interpreted in conjunction with the
results of antibody titer testing. Antibody tests may not yield a positive response for the first ten days of illness. Multiple serum
samples may be required, especially in the early stages of the disease. The MAT test usually uses from five to eight different serovars
and the laboratory may only be testing for certain serovars. The veterinarian may also base a diagnosis on clinical signs and response
to treatment. A polymerase chain reaction (PCR) test is also available that may be able to provide earlier diagnosis than the MAT.
Culture of the spirochetes is difficult and may require three to six months of incubation.
Increased BUN and serum creatinine concentrations, thrombocytopenia, and leukocytosis with a left shift are present. Urine
becomes progressively more dilute as the disease progresses. Disseminated intravascular coagulation (DIC) may occur. Alterations in
electrolyte concentrations may also occur. Radiographs may demonstrate enlarged kidneys. Glucosuria, hematuria, and pyuria are
often present and urine sediment examination may demonstrate epithelial cell casts or granular casts.
Treatment
Treatment involves antibiotic therapy (ampicillin, amoxicillin, doxycycline) as well as aggressive supportive care to support renal
perfusion. Severely infected patients may require dialysis. Patients generally respond to treatment in ten to fourteen days. Some
patients will have residual permanent kidney damage.
Renal function should be monitored at least once every 24 hours during treatment. Fluid therapy and continuous monitoring of
urine output via closed collection bags is vital. Closed collection systems minimize staff exposure to infection. Serial evaluations of
body weight, respiratory rate, lung sounds, blood pressure, and central venous pressure are important assessments to track the course
of disease. Repeat antibody titers can also be used to evaluate response to treatment.
Control
Infected dogs shed spirochetes in their urine and will likely continue to shed viable organisms for several days after the initiation of
appropriate antibiotic therapy. Shedding will be prolonged if antimicrobials therapy is not initiated. Early suspicion with restriction of
the infected patient’s movement around the clinic should minimal. Housing in an isolation ward is not generally required as the
organisms are not readily transmitted between dogs. Veterinary team members should wear appropriate PPE (i.e. gloves, protective
eyewear, facemask, and a disposable gown) when working with infected patients. Routine disinfection is sufficient to decontaminate
1016
runs, cages, bedding, etc. Pressure washing should not be used as it may result in aerosolization of the urine and subsequent dispersal
of the organisms. Clients should be advised to take precautions to reduce exposure of their pet to wild animals and standing water.
Summary
Leptospirosis is an emerging disease in the United States Since and was reinstated as a reportable human disease in 2013. The true
incidence of infection is not known. The disease may be fatal if left untreated. Efforts must be made to reduce exposure and increase
vaccination of dogs at high risk of exposure. The zoonotic potential is also of great concern and clients must be properly counseled to
avoid human infection.
References
Leptospira species infection in cats: ABCD guidelines on prevention and management. Hartmann K, Egberink H, Pennisi MG, et al. J Feline Med
Surg 15:576-581, 2013.
Purdue University-Banfield National Companion Animal Surveillance Program for emerging and zoonotic diseases. Vector-Borne Zoonot 6:14-23,
2006.
Leptospirosis. Greene CE, Sykes JE, et al. In Greene CE (ed): Infectious Diseases of the Dog and Cat, 4th ed—St. Louis: Saunders Elsevier, 2012, pp
431-447.
Emerging Diseases - Leptospirosis - Epidemiology & Diagnostics. Glickman, L. Clinicians Brief. February 2005 Supplement, pg 2
2010 ACVIM Small Animal Consensus Statement on Leptospirosis:
Diagnosis, Epidemiology, Treatment, and Prevention. J.E. Sykes, K. Hartmann, K.F. Lunn, G.E. Moore, R.A. Stoddard, and R.E. Goldstein. J Vet
Intern Med 2011;25:1–13
Canine Leptospirosis.Harkin, K. Clinicians Brief. June 2005: 15-19
1017
Introduction to Urinalysis
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Formation of urine
When blood enters the renal corpuscles, a portion of the plasma, along with its wastes, is filtered through the glomerulus into the next
portion of the tubule, the proximal convoluted tubule. Large proteins and cells do not enter the tubule unless there is damage to the
glomerulus. The filtered fluid passes slowly through the rest of the nephron and is modified as it moves along. Substances, such as
water and glucose, are resorbed back into the blood of the capillary network. The nephron has a specific limit for resorption of specific
substances, known as the renal threshold. Should the filtrate contain extremely high concentrations of any of those substances, the
excess is not resorbed and is excreted in the urine. By the time the fluid in the nephron reaches the collecting tubules, it has become
urine. Collecting tubules of all nephrons drain urine into the renal pelvis to the opening of the ureter. Urine is transported to the
urinary bladder by the ureters, muscular tubes that conduct the urine by smooth muscle contractions. The ureters enter the bladder at
oblique angles, forming valvelike openings that prevent backflow of urine into the ureters as the bladder fills. The urethra is the tube
that carries urine from the urinary bladder to the outside of the body. In females, it is relatively short, straight, and wide, and has a
strictly urinary function. In males, it is relatively long, curved, and narrow, and serves both urinary and reproductive functions
Sample collection
The first step in performing a urinalysis is proper collection of a urine sample, which must be carefully obtained to ensure accurate
results. Analysis of urine samples should be performed only on samples taken before administration of therapeutic agents. Urine
specimens may be obtained by natural voiding of urine, bladder expression, catheterization, or cystocentesis. The two preferred
methods are cystocentesis and catheterization; these methods provide optimal samples for all aspects of urinalysis by avoiding
contamination from the distal genital tract and external areas. Collecting samples by voiding or expression of the bladder may be
easier, but urine collected in these ways may be of limited diagnostic value
Specimen storage and handling
Ideally, samples should be analyzed within 30 minutes to 1 hour of collection to avoid postcollection artifacts and degenerative
changes. If immediate analysis is not possible, refrigeration preserves most urine constituents for an additional 6 to 12 hours.
Refrigeration may have an impact on urine specific gravity, so this test should be done before refrigeration. If a urine sample is going
to be refrigerated, it should have a tight-fitting lid to prevent evaporation and contamination. Crystals may form when the urine cools.
Decreased glucose and bilirubin concentrations, increased pH resulting from bacterial breakdown of urea to ammonia, crystal
formation with increased sample turbidity, breakdown of casts and RBCs (especially in dilute or alkaline urine), and bacterial
proliferation may occur in samples allowed to stand for long periods at room temperature. Many crystals may form in refrigerated
samples. Refrigerated urine should be warmed to room temperature before evaluation, and crystals that formed during cooling may not
dissolve when the sample is brought to room temperature. The urine sample should be mixed by gentle inversion before evaluation so
that formed elements are evenly distributed. Cells tend to break down rapidly in urine, so if cytologic evaluation is to be performed,
the urine should be centrifuged soon after collection and 1 to 2 drops of the patient’s serum or bovine albumin added to the sediment
to preserve cell morphologic characteristics.
Physical evaluation
Physical properties of urine include all the observations that may be made without the aid of a microscope or chemical reagents.
Volume, color, odor, transparency, and specific gravity of urine are evaluated.
Color
Evaluate the color and clarity of urine by placing it is a clear container and holding it against a white background. Normal urine color
is light yellow to amber as a result of the presence of pigments called urochromes. The magnitude of yellow color in urine varies with
the degree of urine concentration or dilution. Colorless urine usually has a low speci fic gravity and is often associated with polyuria.
Dark yellow to yellow-brown urine generally has a high specific gravity and may be associated with oliguria. Yellow-brown or green
urine that produces a greenish-yellow foam when shaken is likely to contain bile pigments. Red or red-brown urine indicates the
presence of RBCs (referred to as hematuria) or hemoglobin (referred to as hemoglobinuria). Urine that is brown when voided may
contain myoglobin (referred to as myoglobinuria) excreted during conditions that cause muscle cell lysis. Some drugs may alter the
color of urine; red, green, or blue urine may be observed.
Clarity
In most species freshly voided urine is transparent or clear. Normal equine urine is cloudy because of a high concentration of calcium
carbonate crystals and mucus secreted by glands in the renal pelvis. Normal rabbit urine also has high concentrations of calcium
carbonate crystals and appears milky. When observing urine for the degree of transparency, it should be placed against a letter-print
1018
background. Transparency is noted as clear, slightly cloudy, cloudy, or turbid (flocculent) depending on how well the letters can be
read through the sample. Clear samples usually do not have much sediment on centrifugation. Cloudy samples usually contain large
particles and often yield a significant amount of sediment on centrifugation. Urine may become cloudy while standing because of
bacterial multiplication or crystal formation. Substances that cause urine to be cloudy include RBCs, WBCs, epithelial cells, casts,
crystals, mucus, fat, and bacteria. Other causes of turbidity can include contaminants from the collection container or surface and
contamination with feces. Flocculent samples contain suspended particles that are sometimes large enough to be seen with the naked
eye.
Odor
The odor of urine is not highly diagnostic but sometimes may be helpful. Normal urine has a distinctive odor that varies among
species. The urine of male cats, goats, and pigs has a strong odor. An ammonia odor may occur with cystitis caused by bacteria that
produce urease (Proteus spp. or Staphylococcus spp.) that has metabolized urea to ammonia. Samples left standing at room
temperature may occasionally develop an ammonia odor as a result of bacterial growth. A characteristic sweet or fruity odor to urine
indicates ketones and is most commonly found with diabetes mellitus, ketosis in cows, and pregnancy disease in ewes.
Specific gravity
Specific gravity is defined as the weight (density) of a quantity of liquid compared with that of an equal amount of distilled water. The
number and molecular weight of dissolved solutes determine the specific gravity of urine. Specific gravity may be determined before
or after centrifugation because the particles that settle during centrifugation have little or no effect on speci fic gravity. Whichever
method is used to perform the specific gravity in a specific clinic, whether before or after centrifugation, the same method must be
consistently performed by all clinic personnel. If the urine is turbid, the sample should be centrifuged and the supernatant used to
determine the specific gravity. The specific gravity of urine from polyuric patients tends to be low, and urine from oliguric patients
tends to be high. The specific gravity of normal urine depends on eating and drinking habits, environmental temperature, and when the
sample was collected. Specific gravity of normal animals is extremely variable and fluctuates throughout the day. In normal dogs
the urine specific gravity may range from 1.001 to 1.060 and in normal cats from 1.001 to 1.080.
To determine specific gravity of urine, the refractometer, urinometer, or reagent strips can be used. Reagent strip specific gravity is
the least reliable method for determining urine specific gravity in animals. Urine specific gravity is less frequently determined by use
of a urinometer. This instrument requires a large amount of urine (approximately 10 ml) and generally provides less-reproducible
results than a refractometer.
Chemical evaluation
Testing for various chemical constituents of urine is usually performed with reagent strips that are impregnated with appropriate
chemicals or with reagent tablets. There are some automated analyzers used for serum chemistry that can also be used for urine
testing. Modifications of the procedures may be required. The container of reagent strips must be stored at room temperature with the
lid tightly closed. The expiration date should also be noted. Some reagent strips simultaneously test for numerous constituents, and
other strips exist for individual tests. The reagent strip should be dipped into the sample so that it is fully immersed, then removed and
the long edge tilted on a paper towel to allow excess urine to be wicked away. Color changes on each reagent pad are noted at speci fic
time intervals. The concentration of various constituents is determined by comparing the colors on the strip with the color chart on the
label of the strip container. The manufacturer’s directions must be carefully followed. It is important to note that a large number of
conditions, such as medications, dietary factors, and environmental factors, can affect urinalysis test results.
pH
The pH expresses the hydrogen ion (H+) concentration. Essentially, pH is a measure of the degree of acidity or alkalinity of urine. A
pH above 7.0 is alkaline, whereas a pH below 7.0 is acidic. Proper technique must be used to obtain accurate results. The urine sample
must be fresh to obtain accurate results. The pH of samples left standing open at room temperature tends to increase resulting from a
loss of carbon dioxide, whereas delays in reading the reaction may lead to color changes and false readings. If samples containing
urease-producing bacteria (Proteus spp. or Staphylococcus spp.) are left standing, the pH is usually increased.
The kidneys play a role in acid-base regulation of the body. Kidneys must vary the pH of urine to compensate for diet and products
of metabolism. The pH of a healthy animal’s urine depends largely on its diet. Alkaline urine usually is found in animals on plant
diets, whereas high-protein cereal diets or diets of animal origin cause acidic urine. Therefore herbivores normally have alkaline urine,
carnivores have acidic urine, and omnivores have either acidic or alkaline urine depending on what was ingested. Many dog foods
contain substantial amounts of plant material that may cause the urine to be slightly alkaline. Other factors such as stress and
excitement, especially in cats, increase the urine pH and may create a transient glucosuria.
Urine pH is usually measured with reagent strips or a pH meter. Factors that may decrease the pH (acidity) include fever,
starvation, high-protein diet, acidosis, excessive muscular activity, or administration of certain drugs. Increased pH (alkalinity) may be
caused by alkalosis, high-fiber diets (plants), infection of the urinary tract with urease bacteria, use of certain drugs, or urine retention
such as occurs with urethral obstruction or bladder paralysis. If the pH of the urine is too acidic or too alkaline speci fic crystals or
uroliths can form. The pH can be manipulated with diet to help dissolve the solids or prevent them from forming.
1019
Protein
Protein is usually absent or present in only trace amounts in normal urine obtained by catheterization or cystocentesis. In healthy
animals, plasma proteins that pass into the glomerular filtrate are resorbed in the renal tubules before the filtrate reaches the renal
pelvis. However, voided samples or those obtained by expressing the bladder may contain a small amount of protein from secretions
that may contaminate urine during its passage along the urinary tract. Trauma to the urinary tract that results from cystocentesis,
catheterization, or bladder expression may occasionally cause suf ficient bleeding that results in a trace of protein in the urine. Urine
protein measurements are interpreted in light of the collection method, urine speci fic gravity, rate of urine formation, and contributions
from any hemorrhage or inflammation noted by sample analysis. Protein levels in the urine may be measured by several methods,
including reagent test strips, sulfosalicylic acid turbidity test, and urine protein/creatinine ratio.
Glucose
The presence of glucose in urine is known as glucosuria or glycosuria. Glucose is filtered through the glomerulus and resorbed by the
kidney tubules. The amount of glucose in the urine depends on blood glucose levels and the rates of glomerular filtration and tubular
resorption. Glucosuria usually does not occur in normal animals unless the blood glucose level exceeds the renal threshold
(approximately 170 to 180 mg/dl for dogs). At this concentration tubular resorption cannot keep up with the glomerular filtration of
glucose, and glucose passes into the urine.
Glucosuria occurs in diabetes mellitus as a result of a deficiency of insulin or an inability of insulin to function. Insulin is necessary
to transport glucose into body cells, and a deficiency causes hyperglycemia and spilling of glucose into the urine. A high-carbohydrate
meal may lead to blood glucose levels exceeding the renal threshold and thus glucosuria. Because of this, a period of fasting is
recommended before urine glucose concentration is determined. Fear, excitement, or restraint, especially in cats, often causes
hyperglycemia and glucosuria as a result of epinephrine release. Glucosuria often occurs after intravenous administration of fluids
containing glucose and occasionally after general anesthesia. Rarely glucosuria is found in hyperthyroidism, Cushing’s disease, and
chronic liver disease. Glucosuria may occur in some cats with chronic disease, possibly as a result of altered proximal renal tubular
function.
Ketones
Ketones include acetone, acetoacetic acid, and b-hydroxybutyric acid. Ketone bodies are formed during incomplete catabolism of fatty
acids. Normal animals may have small amounts of ketones in the blood. Conditions characterized by altered carbohydrate metabolism
may result in excessive amounts of fat catabolism to provide energy. When fatty acid metabolism is not accompanied by sufficient
carbohydrate metabolism, excess ketones are present in the urine, a condition called ketonuria.
Ketonuria frequently occurs in animals with diabetes mellitus. Because the animal lacks the insulin necessary for carbohydrate
metabolism, fat is broken down to meet the animal’s energy needs and excess ketones are excreted in the urine. Ketones are important
sources of energy and are normally produced during fat metabolism. Problems develop, however, when excessive ketones are
produced. Ketones are toxic, causing central nervous system depression and acidosis. Acidosis resulting from ketonemia is termed
ketoacidosis.
Ketonemia with ketonuria also occurs with high-fat diets, starvation, fasting, long-term anorexia, and impaired liver function. With
a high-fat diet, carbohydrates meet a relatively low percentage of energy needs, so a great amount of fat is used to meet energy needs.
In the fasting, starved, or anorexic animal, body fat is used to meet energy needs, producing a greater than normal amount of ketones.
With liver damage, impaired carbohydrate metabolism leads to fat serving as the main energy source, especially when the damaged
liver cannot store adequate amounts of glycogen.
Urinary ketones are detected by using urinary reagent strips with a ketone reagent pad. The color intensity is roughly proportional
to the concentration of urine ketones. These methods are most sensitive to acetoacetic acid, less sensitive to acetone and do not detect
b-hydroxybutyric acid. b-Hydroxybutyric acid is the first ketone produced by the body in any condition that causes ketosis. Urine
reagent test strips may not adequately identify these patients until the ketosis has been present for some time.
Bile pigments
Bile pigments commonly detected in urine are bilirubin and urobilinogen. Only conjugated bilirubin (water soluble) is found in urine
because unconjugated bilirubin does not pass through the glomerulus into the renal filtrate; it is bound to albumin and is not water
soluble. Normal dogs, especially males, occasionally have bilirubin in their urine because of a low renal threshold for conjugated
bilirubin and the ability of their kidneys to conjugate bilirubin. Many normal cattle also have small amounts of bilirubin in their urine.
Bilirubin is usually not found in the urine of cats, pigs, sheep, or horses. In cats the renal threshold is many times that of dogs, and any
amount of bilirubin in the urine is considered abnormal and suggests disease.
Bilirubinuria is seen in a number of diseases, including obstruction of bile flow from the liver to the small intestine and in liver
disease. Bilirubinuria results from accumulation in hepatic cells of conjugated bilirubin that is released into the blood and excreted in
the urine. Conditions causing biliary obstruction include calculi in the bile duct, tumors in the area of the bile duct, acute enteritis,
pancreatitis, and obstruction of the upper intestinal tract. Hemolytic anemia may also cause bilirubinuria, especially in dogs. In
hemolytic anemia, the liver’s ability to metabolize the excess bilirubin may be exceeded, resulting in release of conjugated bilirubin
1020
into the blood and ultimately bilirubinuria. In dogs, unconjugated bilirubin from hemoglobin catabolism in the mononuclear
phagocytic system can be conjugated in the kidney and passed in the urine.
Bilirubinuria is detected with the Ictotest (Bayer Corporation). A diazo compound in reagent the tablet reacts with bilirubin to
produce a blue or purple color. The speed with which the color change occurs and the degree of color change indicates the amount of
bilirubin present. Reagent strips are less sensitive than Ictotest tablets. Icotest tablet tests should be performed to confirm bilirubinuria
as detected by the dipstick test. Urine to be tested for bilirubin must not be exposed to light because bilirubin is broken down by shortwave light. False-negative results for bilirubin occur in urine that is exposed to sunlight or arti ficial light.
Blood (hemoprotein)
Tests for blood in urine detect hematuria, the presence of intact RBCs in urine; hemoglobinuria, the presence of free hemoglobin in
urine; and myoglobinuria, the presence of myoglobin in the urine. Hematuria, hemoglobinuria, and myoglobinuria may occur
simultaneously. The presence of one does not rule out the others. The urine sediment should also be examined for intact RBCs.
Hematuria usually is a sign of disease causing bleeding somewhere in the urogenital tract, whereas hemoglobinuria usually
indicates intravascular hemolysis. Some systemic conditions may also cause hematuria. In very dilute or highly alkaline urine, RBCs
often lyse to yield hemoglobin. Therefore in dilute or highly alkaline urine, hemoglobinuria may not be the result of hemoglobin
entering the urine through the glomerulus. Ghost cells (the shells of lysed RBCs) may be seen on microscopic examination of
sediment if the source of hemoglobin is lysis of RBCs within the excretory pathway or in vitro.
Moderate to large amounts of blood impart a cloudy red, brown, or wine color to urine. Similar colors, but with a transparent
appearance that remains after centrifugation, indicate hemoglobinuria. With minute amounts of blood in the urine, a visible color
change usually is not evident. Occult, or hidden, blood occurs when the urine is not obviously discolored by blood but blood is
detected by chemical analysis.
Leukocytes
Presumptive evidence of leukocytes (WBCs) in urine may be obtained with the leukocyte reaction of certain reagent strips. However,
many false-negative reactions occur with animal species, and microscopic evaluation is necessary to con firm a positive result. The
leukocyte reagent strip test is not valid for cats because of false-positive results.
Urinalysis analyzers
Analyzers used for in-house evaluation of urine samples are generally the semi-automated types that are used only for reading and
recording of test results. These analyzers use a standard urinalysis reagent dipstick to which the sample is applied by the technician.
The dipstick is then loaded into the analyzer and results read and recorded at the appropriate time. Larger reference laboratories
generally have fully automated analyzers capable of performing a greater number of evaluations than the semi-automated analyzers.
Many of these also evaluate the gross characteristics of the sample (i.e. turbidity)
Microscopic evaluation
The primary purpose of microscopic examination of urine is to determine the presence of abnormal formed elements (i.e. cells, casts,
crystals) in the sample. Urine sediment may contain a variety of cells, casts, crystals, and miscellaneous components such as parasites.
The presence of specific formed elements usually provides detailed diagnostic information to the clinician
Ideally, urine sediment examination should utilize 5 to 10 mls of fresh urine. The sample should be centrifuged at low speed for
about 5 minutes and then the supernatant poured off, leaving about 1ml of supernatant with the sediment. The remaining sediment is
re-suspended in the supernatant and mixed gently. A drop of this suspension is then placed on a microscope slide, a cover slip is
added and the specimen is examined microscopically. Although stain may be added to the sample, this often creates artifacts and can
add bacteria to the sample.
The specimen should first be scanned with the low power lens. Large formed elements (i.e. casts) are evident at the lower
magnifications. A minimum of 10 microscopic fields with the high power lens should be observed. The results of the microscopic
examination are reported as the number of elements seen per low-power field (LPF) or high-power field (HPF). Report cells and
bacteria in numbers/HPF and casts in numbers/LPF
Elements in urinary sediment
Urine sediment may contain a variety of cells, casts, crystals, and miscellaneous components such as parasites. The presence of
specific formed elements usually provides detailed diagnostic information to the clinician.
Cells
Erythrocytes (RBCs)
The presence of intact RBC’s (hematuria) in urine may indicate bleeding within the urogenital tract. Up to five RBCs per high-power
field is considered normal. RBCs are smaller than WBC’s or epithelial cells, so they are round and slightly refractile and lack internal
structure. In concentrated urine, the RBCs crenate (shrivel); in dilute urine they swell and lyse, and appear as colorless rings (ghost
cells) that vary in size and shape.
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Leukocytes (WBC’s)
Up to five WBC’s per high-power field can be found in the urine sediment of normal animals. Greater than 5 WBC/HPF can indicate
inflammation. These cells are round and granular, larger than RBCs, and smaller than epithelial cells. They degenerate in old urine and
may lyse in hypotonic or alkaline urine.
Epithelial cells
Squamous epithelial cells are common in urine samples and are the largest of the three types found. The cells are thin and flat with
angular borders and large nuclei. The cells originate in the distal urethra, vagina, vulva, or prepuce. Transitional epithelial cells
originate in the bladder, ureters, renal pelvis, and proximal urethra. They are usually round, but can be oval or caudate. The nucleus is
dense and round. Transitional epithelial cells may occur in clumps, especially if the urine was collected by catheterization. An increase
in the number of transitional cells suggests inflammation. Renal epithelial cells are the smallest epithelial cells seen in urine. They
originate in the renal tubules, and their presence may represent tubular degeneration. They are small, round, and slightly larger than
WBC’s.
Bacteria
Bacteria may be present as the result of infection or contamination. Normal urine is free of bacteria but may be contaminated by
bacteria from the distal urethra and genital tract. Urine obtained by cystocentesis is the preferred sample for evaluation of bacteria
because contamination is avoided. Bacteria numbers are reported as few, moderate, or many. Because bacteria often proliferate in
urine that has been left standing for some time, it is important to examine a fresh sample.
Casts
Urinary casts are cylindrical structures formed from a matrix of protein secreted by the renal tubules. The cast takes on the shape of
the tubule. Cast types include cellular casts, hyaline casts, granular casts, and waxy casts, depending on the material trapped in the
protein matrix at the time of formation and the age of the casts. Therefore, The presence of a specific type may aid in identification of
the location of damage within the nephron. Casts dissolve in alkaline urine, so identification and quantification is best done with
fresh urine samples. Although a few casts may be seen in normal urine, the presence of casts in urine samples usually indicates
tubular damage. The formation of casts requires slow moving filtrate. Casts are fragile structures that are easily destroyed with
improper preparation of sample.
Hyaline casts are colorless and translucent. Cellular casts contain specific recognizable cells (i.e. WBC, RBC, epithelial cells).
Granular casts are formed when cellular casts degenerate or when material from degenerated tubular cells becomes imbedded in the
hyaline cast. Granular casts may be described as either coarse or fine. The presence of granular casts usually indicates severe kidney
damage. Waxy casts are wide and smooth, with sharp margins and blunt ends. Fatty casts contain high amounts of lipid material
incorporated into the protein matrix of the cast.
Crystals
The presence of crystals in the urine is called crystalluria. Crystals are common in urine sediment, but only a few types are significant.
Formation of crystals is dependent on the amount of the substance in the urine, the solubility of the particular crystal type, and is
affected by the pH and specific gravity of the urine. Crystals found in acidic urine include: (1) Calcium Oxalate, (2) Amorphous
Urates, (3) Sodium Urates, (4) Uric Acid, (5) Calcium Sulfates, (6) Cystine. Alkaline urine may contain amorphous phosphates or
struvite crystals.
Struvite crystals have a characteristic “coffin lid” appearance. This type of crystal, sometimes referred to as triple phosphate, is a
common finding in urolithiasis in dogs and cats but may also be seen in urine samples from normal patients. Calcium oxalate crystals
and stones are also found in normal urine and are common in urine from older dogs and cats. They are seen in acidic, neutral, or
alkaline urine, and appear as small squares containing an X. These crystals can be associated with oxalate ingestion in large animals,
ethylene glycol (antifreeze) poisoning in small animals, and calcium oxalate urolithiasis. Uric acid crystals can be seen in alkaline
urine and are associated with a metabolic defect (most common in Dalmatians) and formation of uroliths. Calcium carbonate crystals
are commonly found in the urine of normal horses and cattle. These crystals resemble colorless “dumbbells” and can be seen in neutral
or alkaline urine. Amorphous urate crystals, seen in acidic urine, appear as granular precipitate.
Ammonium biurate(also known as ammonium urate) crystals are found commonly in Dalmatians and with presence of certain liver
diseases. These crystals are round and brownish, with long spicules (thorn apple–shaped) and are not present in the urine of normal
animals; they are seen in the urine of animals with liver disease or porto-systemic shunts. Cystine crystals appear as flat, hexagonal
(six-sided) plates and are associated with congenital defects in cystine metabolism and are common in certain canine breeds (i.e.
Newfoundland).
Miscellaneous
Parasites and/or their ova may be seen in urine sediment. Capillaria plica, Dichtopyma renale, and some liver flukes may be present.
Additional organisms such as mites are seen as contaminants when samples are collected improperly. Fungal organisms, sperm, etc
may also be seen.
1022
Examination of Urine Sediment
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Microscopic evaluation
The primary purpose of microscopic examination of urine is to determine the presence of abnormal formed elements (i.e. cells, casts,
crystals) in the sample. Urine sediment may contain a variety of cells, casts, crystals, and miscellaneous components such as parasites.
The presence of specific formed elements usually provides detailed diagnostic information to the clinician
Ideally, urine sediment examination should utilize 5 to 10 mls of fresh urine. The sample should be centrifuged at low speed for
about 5 minutes and then the supernatant poured off, leaving about 1ml of supernatant with the sediment. The remaining sediment is
re-suspended in the supernatant and mixed gently. A drop of this suspension is then placed on a microscope slide, a cover slip is
added and the specimen is examined microscopically. Although stain may be added to the sample, this often creates artifacts and can
add bacteria to the sample.
The specimen should first be scanned with the low power lens. Large formed elements (i.e. casts) are evident at the lower
magnifications. A minimum of 10 microscopic fields with the high power lens should be observed. The results of the microscopic
examination are reported as the number of elements seen per low-power field (LPF) or high-power field (HPF). Report cells and
bacteria in numbers/HPF and casts in numbers/LPF
Elements in urinary sediment
Urine sediment may contain a variety of cells, casts, crystals, and miscellaneous components such as parasites. The presence of
specific formed elements usually provides detailed diagnostic information to the clinician.
Cells
Erythrocytes (RBCs)
The presence of intact RBC’s (hematuria) in urine may indicate bleeding within the urogenital tract. Up to five RBCs per high-power
field is considered normal. RBCs are smaller than WBC’s or epithelial cells, so they are round and slightly refractile and lack internal
structure. In concentrated urine, the RBCs crenate (shrivel); in dilute urine they swell and lyse, and appear as colorless rings (ghost
cells) that vary in size and shape.
Leukocytes (WBC’s)
Up to five WBC’s per high-power field can be found in the urine sediment of normal animals. Greater than 5 WBC/HPF can indicate
inflammation. These cells are round and granular, larger than RBCs, and smaller than epithelial cells. They degenerate in old urine and
may lyse in hypotonic or alkaline urine.
Epithelial cells
Squamous epithelial cells are common in urine samples and are the largest of the three types found. The cells are thin and flat with
angular borders and large nuclei. The cells originate in the distal urethra, vagina, vulva, or prepuce. Transitional epithelial cells
originate in the bladder, ureters, renal pelvis, and proximal urethra. They are usually round, but can be oval or caudate. The nucleus is
dense and round. Transitional epithelial cells may occur in clumps, especially if the urine was collected by catheterization. An increase
in the number of transitional cells suggests inflammation. Renal epithelial cells are the smallest epithelial cells seen in urine. They
originate in the renal tubules, and their presence may represent tubular degeneration. They are small, round, and slightly larger than
WBC’s.
Bacteria
Bacteria may be present as the result of infection or contamination. Normal urine is free of bacteria but may be contaminated by
bacteria from the distal urethra and genital tract. Urine obtained by cystocentesis is the preferred sample for evaluation of bacteria
because contamination is avoided. Bacteria numbers are reported as few, moderate, or many. Because bacteria often proliferate in
urine that has been left standing for some time, it is important to examine a fresh sample.
Casts
Urinary casts are cylindrical structures formed from a matrix of protein secreted by the renal tubules. The cast takes on the shape of
the tubule. Cast types include cellular casts, hyaline casts, granular casts, and waxy casts, depending on the material trapped in the
protein matrix at the time of formation and the age of the casts. Therefore, The presence of a specific type may aid in identification of
the location of damage within the nephron. Casts dissolve in alkaline urine, so identification and quantification is best done with
fresh urine samples. Although a few casts may be seen in normal urine, the presence of casts in urine samples usually indicates
tubular damage. The formation of casts requires slow moving filtrate. Casts are fragile structures that are easily destroyed with
improper preparation of sample.
Hyaline casts are colorless and translucent. Cellular casts contain specific recognizable cells (i.e. WBC, RBC, epithelial cells).
Granular casts are formed when cellular casts degenerate or when material from degenerated tubular cells becomes imbedded in the
hyaline cast. Granular casts may be described as either coarse or fine. The presence of granular casts usually indicates severe kidney
1023
damage. Waxy casts are wide and smooth, with sharp margins and blunt ends. Fatty casts contain high amounts of lipid material
incorporated into the protein matrix of the cast.
Crystals
The presence of crystals in the urine is called crystalluria. Crystals are common in urine sediment, but only a few types are significant.
Formation of crystals is dependent on the amount of the substance in the urine, the solubility of the particular crystal type, and is
affected by the pH and specific gravity of the urine. Crystals found in acidic urine include: (1) Calcium Oxalate, (2) Amorphous
Urates, (3) Sodium Urates, (4) Uric Acid, (5) Calcium Sulfates, (6) Cystine. Alkaline urine may contain amorphous phosphates or
struvite crystals.
Struvite crystals have a characteristic “coffin lid” appearance. This type of crystal, sometimes referred to as triple phosphate, is a
common finding in urolithiasis in dogs and cats but may also be seen in urine samples from normal patients. Calcium oxalate crystals
and stones are also found in normal urine and are common in urine from older dogs and cats. They are seen in acidic, neutral, or
alkaline urine, and appear as small squares containing an X. These crystals can be associated with oxalate ingestion in large animals,
ethylene glycol (antifreeze) poisoning in small animals, and calcium oxalate urolithiasis. Uric acid crystals can be seen in alkaline
urine and are associated with a metabolic defect (most common in Dalmatians) and formation of uroliths. Calcium carbonate crystals
are commonly found in the urine of normal horses and cattle. These crystals resemble colorless “dumbbells” and can be seen in neutral
or alkaline urine. Amorphous urate crystals, seen in acidic urine, appear as granular precipitate.
Ammonium biurate(also known as ammonium urate) crystals are found commonly in Dalmatians and with presence of certain liver
diseases. These crystals are round and brownish, with long spicules (thorn apple–shaped) and are not present in the urine of normal
animals; they are seen in the urine of animals with liver disease or porto-systemic shunts. Cystine crystals appear as flat, hexagonal
(six-sided) plates and are associated with congenital defects in cystine metabolism and are common in certain canine breeds (i.e.
Newfoundland).
Miscellaneous
Parasites and/or their ova may be seen in urine sediment. Capillaria plica, Dichtopyma renale, and some liver flukes may be present.
Additional organisms such as mites are seen as contaminants when samples are collected improperly. Fungal organisms, sperm, etc
may also be seen.
1024
Ethylene Glycol Toxicosis
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Ethylene glycol is a sweet, odorless, water-soluble chemical with many common household uses. It may be found in automotive antifreeze, de-icing agents and windshield washer fluids, home solar units, portable chemical toilets, and some household heating
components. Ethylene glycol toxicosis most commonly affects dogs, but cats and other animals may also be exposed. While the
compound itself is not toxic, it is metabolized into many other components (i.e. glycolic acid, oxalate, and aldehyde) that are
extremely toxic and potentially fatal. Animals are attracted to the sweet odor and taste of the chemical and will readily consume it.
Several U.S. states have laws that require the addition of bittering agents to some forms of commercially available products containing
ethylene glycol in an effort to discourage ingestion Clinical signs may develop within 30 minutes or may be delayed for several days,
depending on the total amount consumed. While specific toxic doses have not been established, the lethal dose is relatively small (4.4
to 6.6 ml/kg in dogs; 1.4 ml/kg in cats).
Metabolism
Ethylene glycol is rapidly absorbed in the gastrointestinal tract and distributed throughout the body. It is primarily metabolized in the
liver. The kidneys excrete unaltered ethylene glycol.
Ethylene glycol is initially oxidized to glycoaldehyde by the enzyme alcohol dehydrogenase. Glycoaldehyde is oxidized to glycolic
acid by mitochondrial aldehyde oxidase and subsequently metabolized to gyloxide. The glyoxide is then further metabolized to form
oxalic acid, glycine, formic acid, hippurate, and several other compounds. Oxalic acid binds to serum calcium and forms calcium
oxalate crystals.
Clinical signs
Symptoms generally progress through three stages, although some patients may skip a stage and the stages may overlap. Death may
occur at any stage. The timing for each stage varies with different species. Initial clinical signs include vomiting, diarrhea, and ataxia.
This stage usually begins within 30 minutes of ingestion and lasts approximately 12 hours. Owners of dogs allowed to roam may be
unaware of these initial signs. After 12 hours, symptoms progress to cardiovascular and pulmonary abnormalities due to the acidosis
and electrolyte abnormalities that result from metabolism of the chemical. Tachypnea and tachycardia are the most common clinical
signs during this stage, which generally lasts until 24 hours after ingestion. The third stage is characterized by oliguric renal failure
and usually occurs within 24 to 72 hours after ingestion, although it may be much earlier in cats. Signs typical of renal failure, such as
oliguria progressing to anuria, vomiting, and anorexia, are common
Diagnosis and treatment
Early diagnosis is essential for effective treatment. Initial diagnosis is generally based on history and physical examination. Some
forms of the chemical may fluoresce and remnants of the chemical may be evidenced by fluorescence of the paws, muzzle, urine, and
vomitus using a Wood’s lamp. Blood levels of ethylene glycol generally peak about 4 hours after ingestion and diagnostic tests for
blood ethylene glycol may be useful up to 12 hours after ingestion. Blood chemistry testing usually indicates azotemia,
hyperphosphatemia, hyperkalemia, hypocalcemia, metabolic acidosis, increased anion gap, isosthenuria, and aciduria
Metabolic acidosis results from the accumulation of glycolic acid and other toxic metabolites and can occur within three hours of
ingestion. Calcium oxalate crystalluria can occur as soon as three hours after ingestion. The monohydrate form is most common. The
crystals can precipitate in the renal tubules and cause mechanical damage and obstruction
Treatment
It is important to obtain and diagnostic samples needed prior to the initiation of treatment. Patients presented for treatment within 8
hours of ingestion of ethylene glycol have the greatest chance of survival. The veterinarian will usually induce vomiting if ingestion
has been known to occur less than an hour prior to presentation. Activated charcoal may be useful if given within three hours of
ingestion. Administration of compounds that interfere with or delay formation of the metabolic by-products are also useful. Examples
include ethanol and fomepizole. Ethanol is a competitive inhibitor that prevents the conversion of ethylene glycol into glycoaldehyde
and other toxic metabolites Fomepizole may be less effective in dogs than cats.
Supportive care aimed is at preventing further kidney damage and maintaining acid-base balance. Fluid therapy is essential to
correct electrolyte imbalances and promote diuresis.
1025
Summary
Clinical signs vary depending on the amount of ethylene glycol ingested and the time since ingestion. Without early diagnosis and
initiation of treatment, prognosis is poor. Patients that survive may have ongoing renal impairment. Prevention of exposure requires
aggressive client education. Replacement of ethylene glycol based products with those containing the less toxic compound, propylene
glycol, will also help reduce accidental exposures.
References available from the author.
1026
Tick-Borne Diseases
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Tick-borne diseases are a significant concern in companion animal practices. The geographic range in which disease-carrying ticks
were historically found has been expanding. While not diseases that can be transmitted between pets and people, most of these ticks
are capable of infecting humans and a variety of other species. The tick transmits the disease-causing organisms when it bites dogs,
humans, or other suitable hosts. Francisella, Hepatozoon, and a number of viruses can also be transmitted by tick vectors.
The most commonly encountered tick-borne diseases are:
•
Anaplasmosis
•
Babesiosis
•
Ehrlichiosis
•
Borreliosis
•
Rocky Mountain Spotted Fever
Risk factors include frequent exposure to tick habitat, such as seen with hunting dogs. Cats are rarely infected due to the fastidious
grooming habits of most cats. Most incidence of disease occurs during spring through fall seasons when the ticks are most active.
Clinical signs of infection can be variable and non-specific and other organisms may also be transmitted that will influence clinical
signs. A history of tick attachment along with fever and lethargy may prompt investigation into tick-borne illness. It is helpful to have
the client bring or describe the tick as well as provide information regarding the length of time the tick was attached to the pet.
Anaplasmosis
The causative agents of canine anaplasmosis are Anaplasma platys (formerly referred to as Ehrlichia platys) and Anaplasma
phagocytophilum (formerly referred to as Ehrlichia equi, Ehrlichia phagocytophila and the human granulocytic ehrlichiosis (HGE)
agent). The organisms are gram-negative, non-motile, obligate intracellular rickettsiae that primarily infect granulocytes, particularly
neutrophils. The organisms replicate inside the blood cell, forming the morula. Clinical signs include fever, anorexia, splenomegaly,
hepatomegaly, and CNS signs. Thrombocytopenia is common.
Primary vectors are ticks of the genus Ixodes A. marginale, which causes hemolytic anemia in cattle, is primarily transmitted by
ticks of the genus Dermacentor and Rhipicephalus (Boophilus). Rhipicephalus sanguineus has also been implicated in transmission of
canine anaplasmosis. Reservoir hosts include mice, chipmunks, squirrels, deer and coyotes. Minimum feeding time for transmission
of the organisms is 24 hours and the incubation period is one to two weeks.
Ehrlichiosis
The primary causative agent of canine ehrlichiosis is Ehrlichia canis. The gram-negative obligate
intracellular rickettsial organism primarily infects monocytes, but may also be seen in granulocytes.
Infections have rarely been seen in cats. The primary vectors are Rhipicephalus sanguineus ticks.
Reservoir hosts include the coyote, fox, and domestic dogs. Granulocytes of dogs can also be infected
with E ewingii, which are transmitted by the lone star tick, Amblyomma americanum.(Figure 1)
White-tailed deer and dogs are reservoir hosts. Infections with E. canis are characterized by high
fever, anorexia, lymphadenopathy, CNS signs. Thrombocytopenia, leukopenia, anemia, and
proteinuria also occur.
Figure 1.
Dorsal view of a female "lone star tick", Amblyomma americanum CDC/ Dr. Amanda Loftis, Dr.
William Nicholson, Dr. Will Reeves, Dr. Chris Paddock
Babesiosis
Canine babesiosis is caused by the protozoal organisms Babesia canis and Babesia gibsoni. The pear-shaped trophozoites of B. canis
can be seen in canine red blood cells and are typically in pairs. Three sub-species of B. canis have been identified: B. canis canis,
transmitted by Dermacentor reticulatus; B. canis vogeli, transmitted by R. sanguineus; and B. canis rossi, transmitted by
Haemaphysalis leachi. The sub-species seen in North America are B. canis canis and B. canis vogeli. An attachment time of at least
24 hours is needed for transmission of the organisms to the host. Direct transmission via dog bites is also believed to occur. The
incubation period is approximately 1 to 3 weeks.
Mild fever, thrombocytopenia, and petechiae usually occur. Clinical signs can also include depression, anemia, anorexia, lethargy,
and splenomegaly. Diagnosis is generally dependent on identifying the organism within the red blood cells. IFA and PCR testing is
1027
also available to confirm a diagnosis. Infection is characterized by depression, anemia, anorexia, lethargy, and splenomegaly.
Treatment with imidocarb dipropionate or azithromycin is usually successful at clearing the parasite.
Babesia gibsoni is a smaller organism that generally occurs singly within the red blood cells. It can be transmitted by R.
sanguineus, Haemaphysalis bispinosa, and Haemaphysalis longicornis ticks but bite wound infection is thought to be the most
common mode of transmission. Clinical signs include fever, hemolytic regenerative anemia, thrombocytopenia, splenomegaly,
lymphadenomegaly, anorexia, lethargy, and vomiting. Babesia conradae is another small form of Babesia is found in dogs and
occurs in southern California.
Lyme borreliosis
The causative agents of Lyme Borreliosis are a group of related spirochetes. Borrelia burgdorferi sensu stricto is the primary one
found in the United States. Vectors are the hard-shelled ticks, Ixodes scapularis (Figure 2) and Ixodes pacificus. Attachment time of
at least 24 hours is thought to be needed for the organism to be transmitted. The disease may be asymptomatic or may manifest as
acute arthritis with lameness. Fever, anorexia,lymphadenopathy,
and depression may occur. If untreated, the disease may progress to
fatal renal failure. Patients respond well (within 3-4 days) to
antimicrobial therapy. Lyme borreliosis is the most commonly
diagnosed vector-borne disease in people. Diagnosis is often based
on history, clinical signs, and response to antibiotic therapy.
Figure 2.
These "black-legged ticks", Ixodes scapularis, are found on a wide
range of hosts. CDC/ Michael L. Levin, Ph. D.
Rocky mountain spotted fever
The causative agent of Rocky Mountain Spotted Fever is the rickettsial agent, Rickettsia rickettsia. Vectors include Dermacentor
variabilis, Dermacentor andersoni (Figure 3), Rhipicephalus sanguineus,(Figure 4) and Amblyomma cajennense. Reservoir hosts
include wild rodents and canines. Infection with R. rickettsia causes a severe and sometimes fatal illness. The organisms can be
transmitted in after as little as 5 hours of tick attachment and the incubation period varies from a few days to two weeks. The
organisms infect the epithelial cells of small blood vessels. The
subsequent blood vessel damage leads to petechial and ecchymotic
hemorrhage of the skin and other organs. Thrombocytopenia is
common. Other clinical signs include anorexia, lymphadenopathy,
polyarthritis, coughing or dyspnea, abdominal pain, vomiting and
diarrhea. Diagnosis requires IFA testing. Fatality rates can be as high
as 10% in dogs. Human infections exhibit fatality rates as high as
20%.
Figure 3
Dorsal view of male and female Dermacentor andersoni. CDC/ Dr.
Christopher Paddock
Figure 4
Festoons along the posterior abdominal margin of this North American hard
tick of the genus Rhipicephalus. CDC
Diagnosis
Diagnosis of tick-borne diseases generally involves visualization of the
organisms on a peripheral blood smear in combination with laboratory
testing and clinical signs. An ELISA test is commercially available that will
demonstrate presence of antibodies to a number of organisms that cause
tick-borne diseases. Indirect fluorescent antibody (IFA) assays and polymerase chain reaction (PCR) tests are also available to referral
laboratories to confirm a diagnosis.
Tick identification
Ticks are usually identified by the shape and length of the capitulum (mouthparts), the shape and color of the body, and the shape and
markings on the scutum. Male and unengorged female ticks are easier to identify than engorged female ticks. Identifying the species
1028
of larval or nymphal ticks is extremely difficult. The common species can be identified by their size, shape, color, body markings,
host, and location on the host.
Treatment
A variety of antimicrobials are used for treatment of infections with tick-borne diseases, including Doxycycline, Imidocarb,
Clindamycin, and Enrofloxacin. Response to therapy varies depending on the presence of concurrent related infections and overall
patient physical status. Many dogs will show improvement within 48 hours of the start of antimicrobial therapy. Therapy may not
completely eliminate the organisms and infected animals may develop recurrence of clinical signs.
Control of infection requires focus on avoiding exposure to the tick vectors. Attached ticks should be promptly removed and saved
for later identification or photographed. Tick collars and topical tick control medications are recommended for those dogs at highest
risk of exposure to ticks (i.e. hunting dogs and other outdoor dogs in tick-infested areas).
Summary
A large number of viral, bacterial, and protozoal agents can be transmitted to both pets and people. Many of these can cause severe
disease. Diagnosis is complicated by the fact that the tick vectors can transmit more than one type of infectious organisms
simultaneously. This may account for the wide variation in severity of disease.
References available from the author.
1029
Diagnostic Testing for Human Drugs of Abuse
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
Dogs and cats may be exposed to a variety of illegal and prescription medications in the household. Many times, patients are not
presented for treatment until after the onset of clinical signs. Information may also not be forthcoming from the owner due to fear of
legal entanglements. In most localities, veterinarians are not required to report exposure of pets to illicit drugs. Making this point
known to clients may help increase client comfort in providing accurate and detailed information.
Few studies exist on mechanisms of action of many of these medications in animals. In addition, the mode of exposure often
differs from that seen with humans. Drugs that would normally be inhaled or injected by a human user usually result in exposure by
ingestion in a pet animal. An additional complication of exposure relates to the potential presence of other substances mixed with the
drugs that may not be identifiable or readily apparent. Studies have demonstrated that as much as 50% of illicit drugs may contain
none of the drug they are supposed to be or contained other drugs and stimulants
Cannabis (cannabis sativa)
Marijuana can contain up to 60 different cannibinoids. The primary psychoactive compound of marijuana and its derivatives is delta 9tetrahydrocannabinol, more commonly called “THC.” Three primary forms exist and the amount of THC present varies in each form.
The dried herb contains from 1-8% THC. The resin of the flowering tops is used to create hashish, which contains from 3-6% THC
and the concentration in hash oil is 20-50%. Medical uses of marijuana include use in glaucoma patients to decrease intraocular
pressure in glaucoma, use in patients undergoing chemotherapy to alleviate nausea. It is also used as an appetite stimulant in anorexic
AIDS and cancer patients. A synthetic form (nabilone) is available by prescription and is a Schedule I controlled substance
Pets are usually exposed by ingestion and clinical signs can appear within 30 minutes, depending on the form of the drug and total
amount consumed. The drug is absorbed into multiple organs and the highest concentrations are localized in fatty tissue. Metabolism
occurs in the liver and metabolites are excreted in both bile and urine. Enterohepatic circulation results in very slow elimination of
metabolites. Complete elimination of the drug and its metabolites can take several days.
Clinical signs of marijuana toxicosis include ataxia, disorientation, and bradycardia. Other signs that may also be present include
depression, agitation, vocalization, vomiting, diarrhea, hypersalivation, tachycardia, hypothermia, mydriasis, urinary incontinence,
seizures, and coma. Fatal exposures are not common. Definitive diagnosis can be aided with the use of urinary TCH tests. The tests
can also be performed on other sample types, such as stomach contents. Accuracy of test results depends on the total amount
consumed, elapsed time since consumption, and total fluid intake after exposure. No specific serum chemistry abnormalities are
usually evident.
Cocaine (benzoyl-methylecgonine)
Cocaine is an alkaloid compound available either as a pure alkaloid or as cocaine hydrochloride. Either form may be laced with a
variety of other substances, including sugars, caffeine, and talc. Other drugs such as heroin and lidocaine may also be present. The
medical grade of the compound is a Schedule III controlled substance and is available as a topical anesthetic in either a 1-4%
ophthalmic solution or 10-20% solution used in the nasapharynx.
Cocaine is a potent CNS stimulant, local anesthetic and appetite suppressant that acts to inhibit the re-uptake of serotonin as well
as norepinephrine and dopamine. Initial clinical signs include hyperactivity, bradycardia and erratic behavior. Hyperthermia,
hypersalivation, and vomiting may also occur. Seizures are possible depending on the dose consumed. Later clinical signs can include
hypoglycemia, hypoxia, tremors, tachycardia, and hypotension. The intravenous LD100 of cocaine hydrochloride in experimentally
exposed dogs and cats has been reported as 12 to 20 mg/kg. Oral exposures are most common and the oral LD50 for dogs is
approximately 13 mg/kg).
Detection of cocaine in the plasma, stomach contents, or urine can usually be performed as soon as 30 minutes after administration
and detectable levels are often present for as much as a week.
Opioids
Alkaloid drugs derived partially or wholly from the poppy plant are classified as opioids. These include morphine, codeine, heroin,
fentanyl, Percocet, and oxycontin. The prescribed medications are a Schedule II, III or IV controlled substances. These drugs are
rapidly absorbed and exhibit CNS effects that include analgesia and sedation. Clinical signs may include vomiting, hypersalivation,
lethargy, ataxia which may be followed by respiratory depression, seizures, and coma. Opioids tend to affect cats differently, with cats
more likely to exhibit CNS stimulatory effects. Specific urine and hair sample tests are available for a variety of opioids. Because the
compounds are similar, some tests are capable of detecting more than one type of opioid.
1030
Amphetamines
A variety of prescription and illicit drugs are categorized as amphetamines. These include medications prescribed as appetite
suppressants, mood enhancers, and for treatment of attention deficit disorder. The prescribed medications are a Schedule II controlled
substances. Illicit drugs in this category are commonly referred to as ‘speed’, or ‘meth’. Pet exposures usually occur by ingestion of
medications prescribed to the pet owner. Clinical signs are dose dependent and similar to that seen with cocaine toxicosis, such as
restlessness, panting, tachycardia, tachypnea, and hyperthermia. Illicit drug preparations may be laced with other substances such as
caffeine, pseudoephedrine, and lidocaine. In addition, some illegal preparations may contain toxic levels of lead. Urine tests are
available that either to evaluate exposure to specific amphetamines or provide quick screen results for the presence of metabolites of
drugs in this class
Barbiturates
The barbiturates are a group of Schedule II, III or V controlled substances prescribed as sedatives and anticonvulsants. Clinical signs
of exposure include depression, ataxia, hypothermia. Bradycarida or tachycardia may be present. Barbiturates exposure can be
confirmed with tests of urine, stomach contents, serum, or fecal contents.
Other agents
Phenyclcidine (PCP) and ketamine are dissociative anesthetics that are common recreational drugs. Pet exposures may result in
hyperactivity, tremors, nystagmus, and seizures. Lysergic acid diethylamide (LSD) is a hallucinogenic agent. The specific mechanisms
of metabolism and resulting clinical signs in are not well documented for animals. Many other agents, particularly prescribed
medications such as muscle relaxants and antidepressants, can result in toxicities in pet animals. Pet animals may also be exposed to
potentially toxic doses of anabolic steroids, nicotine (patches, gum, cigarettes, etc.) and alcohol.
Diagnostic concerns
Diagnosis of toxic exposures to human drugs of abuse may be complicated by the lack of specific information regarding the potential
of exposure. Clients may be unaware that an exposure has occurred or may fear prosecution by admitting to possessing drugs of abuse
without a legal prescription. Clinical signs can vary considerably depending on the drug and the total amount ingested.
Routine biochemical analysis of blood and urine rarely demonstrates any abnormality in otherwise healthy patients following an
acute exposure. A variety of rapid screening tests are available that can aid diagnosis. The vast majority of these tests utilize a
competitive binding immunoassay technique contained within a lateral flow assay. The tests are highly accurate with strict adherence
to sample collection, processing and test performance requirements. The test are similar to the type first marketing for use as home
pregnancy tests and correlation data indicates a high degree of agreement between laboratory and field test results. The most common
types of tests are urine dipstick assays. They are available in numerous configurations that test for a single analyte or for multiple
analytes. A few of these tests can be utilized on other body fluids as well. Some manufacturers allow for purchase of very small
quantities of tests
The accuracy of the tests depends somewhat on the dose consumed and the time elapsed since exposure. The tests utilize
standardized minimum concentration levels established by international regulatory authorities, specifically the National Institute on
Drug Abuse, World Health Organization (WHO) and Substance Abuse and Mental Health Services Administration (SAMHSA) of the
US Dept of Health and Human Services. Detailed published studies on the validity of these tests for use in veterinary species are not
available.
Summary
While few detailed studies are available on the incidence of exposure to human drugs of abuse, exposures do occur. Exposures may
involve illicit drugs or prescribed medications to which the pet has access. Owners may be unwilling to share information on potential
exposures. Early intervention minimizes the effects of many toxic exposures to human drugs of abuse. Diagnostic testing used in
screening the human populations for drug abuse can be a useful adjunct in diagnosing drugs of abuse toxicities in pets. Such tests are
highly accurate with strict adherences to proper sample collect and handling and test procedures.
References
Brown, Andrew J., Mandell, Deborah C., Illicit Drugs in Silverstein, Deborah. Small Animal Critical Care Medicine. W.B. Saunders Company, 2009.
p. 342-345).
Donaldson, Caroline W., DVM Marijuana exposure in animals Veterinary Medicine June 2002 437
Kisseberth, W.C.; Trammel, H.L.: Toxicology of selected pesticides,drugs, and chemicals. Illicit and abused drugs. Vet. Clin.North Am. (Small Anim.
Pract.) 20 (2):405-418; 1990. 
Novotny, Thomas E Tobacco and cigarette butt consumption in humansand animals. Tobacco Control 2011;20(Suppl 1):i17ei20.
doi:10.1136/tc.2011.043489 i19
Roder, Joseph D., Pharmaceuticals in Plumlee, Konnie. Clinical Veterinary Toxicology. Mosby, 2004. p.. 282-336).
1031
Blood Typing and Cross Matching
Margi Sirois, EdD, MS, RVT, LAT
Port Richey, FL
The increased availability of blood components such as packed red blood cells (pRBCs) and platelet-rich plasma has improved
treatment for some patients in emergency and critical care settings. Veterinary blood banks provide blood components, and most also
perform blood typing and crossmatching. These procedures can also be performed in the in-house veterinary practice laboratories.
Veterinary technicians must understand the concepts of blood component transfusion and the procedures to help ensure that
transfusion therapy is safe.
Blood groups and immunity
Red blood cell (RBC) antigens are structures on RBC surfaces in an animal that may react with antibodies in the plasma of another
animal. The specific surface markers in an individual animal are genetically determined and are referred to as blood group antigens.
The number of blood groups varies among species. Antigen-antibody reactions can occur with blood transfusions due to variation in
blood group antigens between the recipient and the donor.
Erythrocytes (RBCs) of some domestic animals have naturally occurring antibodies (alloantibodies). Once a transfusion has been
given to an animal, antibodies against the RBC antigen (immune antibodies) form. Breeding females should always be given properly
matched blood to avoid sensitization that results in destruction of the neonate’s RBCs
Blood types
Dogs
More than a dozen different canine blood groups have been described. Nomenclature for the blood group systems is designated with
the letters DEA (for Dog Erythrocyte Antigen) followed by a number. For DEA systems, the erythrocytes are designated as positive
or negative for that specific antigen. The DEA 1 group was once considered to have three subgroups but recent research has
documented that these reflected varying degrees of expression of the same gene
DEA-3, DEA-4, DEA-5, and DEA-7 also designate major blood groups. The blood groups considered to be clinically significant
are DEA-1 and DEA-7. The DEA1 sub-group elicits the greatest antigen response and causes the most serious transfusion reactions.
Approximately 50% of all dogs are positive for the DEA 1 antigen. Transfusion reactions to the other blood groups are less likely to
cause clinical signs. An additional canine antigen, designated Dal, has also been described. Because naturally occurring anti-DEA1
antibodies are not known to exist, the first transfusion of DEA1-positive blood into an DEA1-negative recipient may not result in an
immediate reaction. However, antibodies can develop and result in a delayed transfusion reaction in as little as a week following the
original mismatched transfusion. If a previously immunized DEA1-negative dog receives DEA1-positive blood, severe reactions occur
in less than 1 hour.
Cats
One blood group system has been identified in the cat, designated the AB system. Blood groups of cats include A, B, and AB. Few
cats have group AB. The vast majority of cats have group A, which probably accounts for the low incidence of transfusion reactions in
cats. Type B occurs in certain purebred breeds and certain geographic areas. Unlike dogs, cats do possess naturally occurring
antibodies to the erythrocyte antigen they are lacking. Type B cats have strong anti-A antibodies while Type A cats have weak anti-B
antibodies. Transfusing type B cats with type A blood may result in serious transfusion reactions and death. Thus blood for
transfusion of purebred cats should be selected by typing or crossmatching. An additional blood cell antigen, the Mik antigen, has also
been described in cats. Neonatal isoerythrolysis has been documented in Type A or Type AB kittens born of Type B queens with
naturally occurring anti-A antibodies.
Blood typing
Methods of identifying some canine and feline blood groups are available for use in veterinary practice. These methods include an
immunochromatography assay and a card/slide agglutination assay. The tube method is the gold standard for blood typing but is
primarily used in reference laboratories.
The tube method
The tube method for determining blood type requires the use of antisera, which consist of antibodies specific for each possible blood
type of a given species. Commercial antisera for canine and feline group testing are available for canine and feline blood group. The
tube method requires collection of a whole blood sample using EDTA, heparin, or acid-citrate-dextrose anticoagulant. The blood is
centrifuged at 1000g for 10 minutes. After removal of the plasma and buffy coat, the erythrocytes are washed three times in a saline
solution, centrifuged, and resuspended. The RBC suspension is distributed among as many tubes as required for the number of blood
type antisera being tested. A small amount (usually 0.1 mL) of the antisera is added to the appropriately labeled tube. The tubes are
incubated for 15 minutes at room temperature and then recentrifuged for 15 seconds at 1000g. Each tube is examined macroscopically
and microscopically for evidence of hemolysis or agglutination. Weak positive results may require additional testing.
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The card agglutination test
Blood samples used to perform the card-based assay must not already show evidence of autoagglutination, usually visible as clumps in
the blood sample. Washing the RBCs with phosphate-buffered saline may help salvage a sample that is showing evidence of
agglutination. The RapidVet®-H (DEA 1; DMS Laboratories) is a blood-typing test card used to classify dogs as positive or negative
for DEA 1. The typing card contains a monoclonal antibody specific to DEA 1. Each card has three visually defined wells labeled
“DEA 1–positive control,” “Auto-agglutination Saline Screen” and “patient test.” One drop of EDTA-anticoagulated whole blood and
1 drop of phosphate-buffered saline are mixed onto the lyophilized reagents within each well. In the patient test well, the monoclonal
antibody forms an antiserum and is then mixed with whole blood from the patient. DEA 1 positive erythrocytes react with the
antiserum, causing agglutination. The antiserum in the patient test well does not react with DEA–1 negative erythrocytes.
RapidVet®-H (Feline) is a similar blood typing test card is available to classify cats as type A, B, or AB. The assay uses test wells
that contain lyophilized reagent representing an antibody to the A-antigen and an anti-B antigen component consisting of a lectin.
Erythrocytes from type A cats will agglutinate with anti-A monoclonal antibodies (the well labeled A on card) and erythrocytes from
type B cats will agglutinate with anti-B solution (the well labeled B on card). Erythrocytes from type AB cats will agglutinate with
both anti-A and anti-B reagents. The third well on the card serves as an auto-agglutination saline screen and must be negative for
results to be valid. Samples are first screened for auto-agglutination. Should auto-agglutination be present, the red blood cells may be
washed with phosphate buffered saline and the auto-agglutination screen repeated. If a negative auto-agglutination result is obtained,
the typing test may be performed.
Immunochromatographic assay
Two commercial test kits use the immunochromatographic test principle rather than agglutination The control band detects a separate
antigen on the red blood cells. The canine test uses a monoclonal anti–DEA 1 antibody strip impregnated onto a paper strip and a
second antibody to a universal RBC antigen as a control. An RBC solution diffuses up the strip, and if the cells express DEA 1, they
concentrate in the area of antibody impregnation. The cells also concentrate in the area of the control antigen, demonstrating that cells
have successfully diffused up the length of the strip. The feline test works the same way; however, it has an area containing an anti-A
monoclonal antibody, an area containing an anti-B monoclonal antibody, and a control antibody for a common feline RBC antigen,
allowing identification of blood type A, B, or AB.
Crossmatching
In the absence of commercial antisera, crossmatching a blood donor and a recipient reduces the possibility of a transfusion reaction.
The two-part procedure (major and minor crossmatches) requires a serum sample and a whole blood sample. RBC suspensions,
collected as for blood typing, are prepared. In the manual major crossmatch, a few drops of serum from the recipient are added to a
few drops of washed packed RBCs from the donor. The mixture is incubated and then centrifuged. Macroscopic or microscopic
presence of hemolysis or agglutination indicates a blood-type mismatch. The minor crossmatch is similar except that donor serum and
recipient RBCs are used. Both procedures should be performed on all animals that require transfusion but whose blood types are
unknown. Two controls are used for the test, which consists of using donor cells with donor serum as well as recipient cells with
recipient serum. A commercial test kit for crossmatching is also available.
Agglutination reactions are sometimes graded. Several classification schemes are used for this purpose. The clinician determines
whether evidence of agglutination constitutes an unsuitable transfusion.
Summary
Proper blood typing and crossmatching can provide valuable information to clinicians and help minimize problems in critically ill
patients. Ideally, all critically ill patients should undergo blood typing and crossmatching before a transfusion.
References available from the author.
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How Anthropomorphism, Communication, and Learning Theory
Change Patient Perceptions of Common Procedures (Parts 1 and 2)
Melissa Spooner, LVT, VTS (Behavior), BS, KPA-CTP
Leader Dogs for the Blind
Bloomfield Hills, MI
Anthropomorphism
Anthropomorphism occurs when humanlike characteristics are given to real or imagined nonhuman things. Some of the characteristics
may include physical appearance where animals or objects are believed to look humanlike, emotional states where animals or objects
are perceived to be uniquely human or have human like motivations. Anthropomorphism does not include behavioral descriptions of
observable actions, therefore it is important describe objective actions that occur in a given situation rather than assuming what the
motivation may be. Anthropomorphism is also not limited to non-human animals; it can be casts onto an object or a particular
situation, for example: “my car loves to go fast, she’s got a real attitude” or “my computer hates cooperating with me.” At times,
these assumptions may not always be inaccurate; however more information regarding a particular situation should be gathered in
order to be certain.
So why do we anthropomorphize? Because it allows us to better understand, sympathize, control, predict or act on a situation that
we can relate to. It may also occur when we are lacking social connection with other humans so we may compensate by creating
humans out of non-human things. It is a way of coping with momentary or chronic loneliness. That being said all anthropomorphism
isn’t bad. Often it enhances the human-animal bond and strengthens the connection between people and their pets. It can create friends
and family during times of depression and may offer a since of security when it is needed most.
Anthropomorphism has both positive and negative qualities when it pertains to better understanding animal behavior because it
may have an impact on how we react to a given situation. It could also lead to a behavioral miss-diagnosis and thus inappropriate
treatment may be issued. This can be problematic when pet owners inadvertently and/or unknowingly apply inappropriate actions
and/or labels to companion pets. While there is no doubt that pet dogs and cats are intelligent we may overestimate that animal’s
mental complexity and true motivation for behavior. Therefore anthropomorphism should be avoided when pet owners, trainers,
veterinarians and other animal professionals are attempting to better understand why a particular behavior is occurring. For example:
many common canine behaviors such as aggression, mounting and pulling on a leash are described as the dogs attempt to become
alpha however this assumption could be detrimental when it comes to treating the problem. Instead we as veterinary and animal
professionals should rely on scientific facts to make decisions or a formal veterinary diagnosis before proceeding. It is important to
assess the environment and context in which the problem behavior occurs in, minimize assumptions of the pet’s emotional state and
most importantly watch closely for signs of canine communication.
Communication
Canine communication eliminates “guessing” and anthropomorphism of assumed emotional states. For many of us it’s easy to detect
when a dog is happy and relaxed but what do fearful dogs look like? A relaxed, happy dog will have a soft appearance to their body,
similar to puppies. They are more apt to bounce, bow, wiggle and jump. They should be social and highly willing to interact. The
tail should be found in a relaxed neutral position or typical position for their breed and possibly wagging. Tail wagging in some cases
can be difficult to interpret because it will not always indicate that the dog is happy, as we will discuss later. Other things to note will
be the position of the ears, mouth and eyes. All should appear soft, the eyes should be bright not squinting or furrowed eye brows and
the pupils should remain small. Happy dogs are generally easy to identify; however the signs that are somewhere between happy and
relax to phobic with the possibility of aggression can be a little more difficult to sort. The signs of stress and anxiety that are found in
the middle may be referred to as preliminary anxiety signs. There are several excellent articles and pictorials that have been designed
to improve ability to read canine body language in a simplified manner (see the Ladder of Aggression by: Kendal Shepherd or Body
Language of Fear and Aggression by: Sophia Yin). When assessing body language you will want to continue to watch the eyes, ears,
body posture and tail for information. Although some changes can be subtle more often than not, they exist and most animals do their
best to display them. The changes in body language may also be referred to as distance increasing signals. That is the animal’s way
of saying “no thank you,” “I’ve had enough,” or “I don’t want to be in this situation.” It is our job to read those signals and honor
them. Some signs of stress and anxiety may include an overall tensing of the body, and a crouched or ducking position. Remember
that dogs are highly dependent on body language to communicate, signs such as turning their head away, turning their body away,
backing up and trembling can be displayed by the dog in an anxiety causing situation. Another sign to watch for is the wet dog shake
also referred to as the full body shake. This is an anxiety sign that is thought to be offered as the dogs stress level is decreasing. Keep
a close watch on the ears and eyes for information too. One clear anxiety sign that we get from the eye is something that is referred to
as “whale eye.” Whale eye is where the sclera or white part of the eye becomes more prominent. It is demonstrated by a moon
shaped appearance in the lateral or medial aspect of the sclera. Whale eye is most typically observed as the dog turns his head away.
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In certain breeds this sign may be difficult to appreciate do to variations in confirmation or the amount of facial hair that covers the
eyes. The ears can also offer a lot of information depending on their position. Ears that are low or flattened indicate signs of stress
and concern. Again, depending on the confirmation, ear position may vary, so while ears do give us a lot of information they should
not be assessed alone. The mouth also says a lot about how a dog is feeling. Yawning, lip licking, whether it s a quick tongue flick or
a full mouth swipe, and tightly held lips are good measures of anxiety. Some of these behaviors occur very quickly and can be
difficult to catch in action so it is important to watch the dog closely for noticeable changes in behavior. Lastly, take a look at the tail
for additional information. As mentioned previously, tail wagging isn’t always happy, in fact this could be one of the most
misunderstood body language signs; that’s why it is so important to assess the whole body not just one section. Typically a fast wag,
similar to a windmill or a propeller that involves the entire body is indicative of a happy relaxed dog. Wagging that is slow and
cautious with the tail held low is a little more concerning and may mean that the dog is unsure about the present situation. Rolling
over exposing the belly is often misinterpreted as well. While some dogs do enjoy a good belly rub, for others this is truly a distance
increasing signal. If the limbs including the tails are tightly close to the body this may not be the best time to rub the dog’s belly. A
spread eagle dog with loosely relaxed limbs is more likely to enjoy the belly rubbing interaction. The events leading up to the dog
rolling over can also lend some information as to how the dog is feeling and whether this is a solicitation for a belly rub or way of
saying “stay back.” Again, remember to assess the whole dog, not just one aspect. If possible spend 5-10 seconds before approaching
the dog to note subtle signs of communication. In some settings it will not be practical for medical staff to avoid interactions with
fearful dogs, but learning their signs of stress will give you a different perspective for their present state of mind and allow you to
consider a different approach. What can you do to decrease the signs of stress and anxiety? Increase distance between the dog and
anxiety causing stimuli, use motivators to create a positive association, prevent, prevent, prevent and follow guidelines of scientific
based learning theory.
Learning theory
Training is the process of modifying the behavior of an animal, either for it to assist in specific activities, undertake in particular tasks,
or for it to participate effectively in contemporary domestic life. The basic paradigm of reinforcement and punishment is a breakdown
of all training techniques; it gives a scientific explanation of how particular techniques are applied. When discussing learning theory
‘positive’ and negative are used as mathematic terms that imply an addition or a subtraction of a consequence. The terms
‘reinforcement” and ‘punishment’ are often paired with the terms positive and negative to fully define the behavior technique.
Reinforcement is used as a consequence to increase behavior; whereas a punishment is used as a consequence decrease a behavior.
Positive Reinforcement (+PR) is likely one of the most popular terms; however its definition may not be fully understood. Simply,
positive reinforcement can be explained as when a behavior offered results in receiving a desirable reward or added consequence.
What is used for reinforcement? Adding something the animal finds motivating to strengthen or increase the frequency of a behavior.
Giving the dog a treat for sitting in order to increase the probability that the dog will sit again is a good example of how positive
reinforcement works.
Positive reinforcement can be further broken down into two separate techniques; classical conditioning and operant conditioning.
Classical conditioning can be used to alter an animal’s emotional response to a stimulus (ex: a response that is independent of
voluntary control). Classical conditioning may also be known as Pavlovian conditioning; with this technique we are then able to take
something that has no meaning to the animal, pair it with a reward, and teach the animal to have a conditioned emotional response, or
a pleasant association with the stimulus. Common examples of classical conditioning are a dog’s response when they see the leash;
they assume it means a walk. Another example is a can opener. By itself the can opener has no meaning, however because it
routinely opens cans of food, which then results in the animal being fed, thus the can opener becomes the conditioned stimulus. The
application of this technique can then be used in behavior modification for everyday pets. A possible application would be to
introduce a new puppy to a cage for the first time. If every time the puppy makes contact with the cage on his own, he is then
rewarded, he will quickly make the association that the crate is indicative of a positive reward. Counter-conditioning takes classical
conditioning to the next level. It is the process whereby an animal is trained to perform a behavior or response that is incompatible
with the response that is to be eliminated when presented with the problem-evoking stimulus. In other words when a stimulus is
present that the animal already has a negative association with it is then presented with something that is more appealing and desirable
then the behavior that is normally offered. For this to be accomplished it will be important to first determine motivators for the
animals and rank them from low to high levels. Depending on how negative the association is with the stimulus, the level of the
motivator should be increased. Response substitution is considered a branch of counter conditioning; it uses a conditioned response
such as a previously taught behavior to control the undesired behavior. The new behavior should be incompatible with the undesirable
behavior, easy and enjoyable for the pet to offer. Dogs who are fearful of men are good subjects for the counter conditioning
technique. In this application whenever the dog see’s a man who would normally trigger the dog to have a negative response, they are
presented with a highly desirable reward (from the trainer or owner and not the man), they may then be asked to complete an easy and
well known behavior on cue such as sit. This sequence should continue while the man is present and discontinue when he is gone.
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Thus, the presence of the man then becomes the predictor of a reward and a positive association is formed. Desensitization is often
used in conjunction with counter conditioning; it is where an animal is gradually exposed to situations or stimuli that would previously
bring on an undesirable behavior, but at a level so low that there is no negative response. It can be used to improve emotional
perception towards any sound, item or situation. It is a slow process that yields long term positive results; however at intense levels
accidental sensitization may occur.
Operant conditioning is the primary method by which training of dogs is achieved. It is dependent on a voluntary behavior being
offered, and then it is followed by a reward. There are three primary methods that are used with operant conditioning which include
shaping, capturing and luring. Shaping is defined as a force free method of training. It focuses on successive approximation, by
deciding what your ideal final behavior should look like then slowly rewarding behaviors along the way until the end result is
achieved. A conditioned reinforcer such as clicker can be helpful for shaping behaviors but it not necessary. If a conditioned
reinforcer is not used then rewards are given alone to mark the desired behavior. It is Important to increase criteria as the desired
behavior is achieved or decrease the criteria to help the learner if they are struggling. Shaping is a great training method to teach
increasingly complex tasks however it can at times be a slow process. Capturing is another force free method of training. The focus
in this training method is put on behaviors that occur naturally such as sit, down, lying on a side or cocking a head. Rewards can be
given alone to mark the desired behavior or a conditioned reinforcer such as clicker can be used to accelerate the training process.
Luring is likely the most popular method of positive reinforcement/ operant conditioning; it is the process that most trainers and pet
owners gravitate to. Luring uses coaxing, prompting or guiding to achieve the behavior while still being a force free method of
training. One downfall of luring is that the learner may catch on quickly but then may become dependent on the lure in this case it is
best if the prompts or lure is faded out quickly. Like shaping and capturing a conditioned reinforcer can be used to mark the desired
behavior.
Negative Reinforcement (-NR) is the process of removing something unpleasant to increase the frequency of the desired behavior
or removing something the animal will work to avoid to strengthen or increase the frequency of a behavior. Heeling is traditionally
taught using this method; corrections are given when the dog is in any other place but heel, removal of the unpleasant strengthens the
desired behavior. Negative Punishment (-NP) is the process of taking away something the animal will work for to suppress (lessen the
frequency of) a behavior. For example if dog jumps on you to get attention, by turning your back or leaving the room, you apply
negative punishment by removing the attention they want.
Positive Punishment (+PP) is the process where the behavior that is offered results in receiving an undesirable consequence.
Adding something the animal will work to avoid suppressing or lessening the frequency of a behavior is the basis for positive
punishment. Common examples of positive punishment include yelling, spanking, shock collar (any kind), and assorted “booby
traps.” It can be any action taken to interrupt or discontinue a behavior; it can be verbal, physical or any action that the learner
perceives is unpleasant. Positive punishment is the most common type of training used, although it can be difficult for clients and
animal professionals to be good at punishment. Punishment must be strong enough to be effective, for some animals this may be hard
to achieve. Unintentionally; positive punishment could cause intense fear which may generalize and could lead to aggression. In
order to be effective the punishment also must occur while the animal is performing an undesirable behavior and the immediate
rewards may outweigh the future possibility of punishment. It can accidentally strengthen the undesired behavior or suppress other
behaviors, thus leaving the underlying emotional state of the animal untreated. Punishment may lead to poor association and poor
bond with the family or handlers. It teaches an animal what you don’t want it to do but fails to teach it what you expect of it.
Is some punishment ok? Yes, however the timing must be precise, the punishment must be consistent while not being too aversive.
Some automatic punishment tools such as a Scat Mat can be used to extinguish an undesirable behavior but this method should only
be implemented for non-fear based behaviors. Automatic punishment tools are also known as remote punishment devises or
environmental punishment. Most importantly this process does not directly involve human interaction; instead the environment is
rigged so that an unpleasant consequence occurs when the undesired behavior occurs.
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10 Things Technicians Can do to Improve Animal Behavior
Melissa Spooner, LVT, VTS (Behavior), BS, KPA-CTP
Leader Dogs for the Blind
Bloomfield Hills, MI
As veterinary professionals it is our duty to prevent or treat illness. In fact many of us chose this profession to better the lives of the
animals that we are surrounded by. As the field of veterinary medicine continues to grow we continue develop new diagnostic
techniques and treatment methods. With these developments it is only natural that our knowledge for our patient’s mental health and
well being expands too. Naturally we see patients that require our attention and we jump into action, whether they are in need of a
preventative vaccine or to be prepped for a more in depth procedure. However, no matter how urgent the medical concern is, it is also
important to remember the emotional needs of the patient as well. Learning to assess the emotional status of the patient will then
allow you to prevent or treat stress as it occurs in a veterinary setting.
1. Know the statistics
Behavior problems continue to be the leading cause of relinquishment and euthanasia of pets in the United States; which research
shows leads to approximately 224,000 pets being euthanized each year. For this reason it becomes integral for veterinary technicians
to have a solid understanding of animal behavior. Bad behavior costs the veterinary hospital time and money due to the amount of
staff that needs to care for a single patient and the risk for potential injury for employees. Another study reports that dogs and cats that
were fearful, hyperactive, noisy, soiled or damaged the house, or escaped frequently were much more likely to be turned in to shelters.
A separate study revealed that most dogs will leave their original home by their second birthday whether these dogs are re-homed or
euthanized these occurrence will result in lost revenue for the hospital. A study by AAHA revealed that as many as 90% of dog
owners noted one or more behavior problems that they would like to improve. This research suggests that we as veterinary
professionals are not doing our part to help decrease these statistics. While so much focus is being put into the potential revenue lost, it
may be more important to us these statistics to potentially make behavior profitable by adding services to the hospital that teach clients
and their pets to prevent or improve problematic behavior.
2. Be an advocate for low stress handling
Veterinary visits are rarely enjoyable, and though there is often a treat made available upon checking check out at the end of the visit,
it is typically not enough to make of the other unpleasant events worth being there. As a veterinary professional it is imperative to be
constantly mindful of how stressful veterinary appointments and hospitalization can be. Therefore one of the most important low
stress handling tools is having compassion and patience for the fearful patient. It is easy to become frustrated with patients that are
difficult to handle and require more time. They may be reacting out of fear of previous negative experiences, or they may feel painful,
defensive and vulnerable. It is our job as veterinary professionals to protect them, calm them and ultimately ease their pain. While
working with any patient, staff should try using minimal restraint, minimal force while adding motivational elements to achieve the
desired task. Becoming rough or aggressive with patients will likely not teach them to behave better, especially if the unwanted
behavior you are seeing is manifested by fear. Try to stay calm, offer a soothing touch to patients that are frightened, treat all patients
as you personally would wanted to be treated as a patient or how you would want another veterinary professional to handle your pet.
Remember that actions such as growling and snapping are information and you should use that information to re-asses your approach
and make that patient feel more comfortable. Avoid the “I can’t let him get away with that” mentality, pursuing this thought process
will likely make the patient more aroused and leave you feeling stressed or frustrated. Be proactive rather than reactive, these types of
approach will likely yield better results. If you only implement low stress handling techniques on the worse patients, or wait until they
are explosive and impossible to control, your rate of success will be poor. Remind yourself to start when the patient’s anxiety level is
minimal, this approach will give you a much higher success rate.
3. Label records and take notes
Now that all of the appropriate tools have been gathered to calm the apprehensive patient it is now time prepare the staff and the exam
rooms. Start by determining the best way to label patient charts, in a manner that is easy to locate. It should describe in detail what
concerns the patient may have in a professional and respectful manor. For example, avoid charting that this patient “hates men”
instead it would be more appropriate to log “fearful of men” or “works best with women.” By changing your wording, you can also
change the emotional response you or other staff members will have with this patient. Remembering that it is important to have
compassion for the fearful patient it will be your job to make the patient’s trip to the veterinary hospital as pleasant as possible and
ultimately successful. It will also be imperative to log what techniques or procedures have worked in the past and the ones that have
not worked as well. Note, if this dog has someone in particular it works best with or does best in a particular area in the hospital.
Demonstrating that your behavior logging system is easily implemented can impress clients and can teach them about having
enjoyable experiences at your hospital, which will make them more likely to return. Notes about the animal’s behavior should also be
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made in the appointment book when the client is scheduled to come in. It would be a good idea to be prepared for that patient before
they enter the building. If the patient is known to be reactive in the lobby, whether it is to other dogs or people you should recommend
to the client that the dog wait in their car until their name is called, the patient should be brought in through a back a side door and
escorted directly to their exam room. If the client were available to, it would also be ideal if this patient were scheduled at a time of
the day when there is less traffic in the hospital.
4. Teach life skills to puppy owners
Socialization is a term that often gets over used yet underutilized. It may be term that is mentioned a lot but not completely
understood however it plays an integral role in the prevention of behavior problems. Proper socialization could be considered a
vaccination for behavioral problems later in pet’s life, just as important as anti-viral vaccinations. One common thought is that
puppies should not begin the socialization process (going classes, interacting with adult dogs, being introduced to new environments,
etc.) before begin completely vaccinated. Traditionally, puppies complete their initial vaccination series around 16 weeks of age,
incidentally, dogs are best able to form new relationships with those of their own species and other species and adapt to stimuli in their
environment (habituation) during their socialization period, commonly considered to be between 4-14 weeks of age. So, if puppies are
kept isolated during this period they may have a more difficult time being comfortable in new environments and around multiple
species in the future. If they have not been properly socialized with people and other pets by the end of this period, they are likely to
be fearful, defensive and potentially aggressive when exposed to them at a later age. How to appropriately introduce puppies to new
people, places and things is the key to quality socialization. Socialization is more than just introductions, it’s an art and a science.
Although exposure is important, having a positive and pleasant experience makes the socialization enjoyable to the puppy. If the
puppies are introduced to novel people places and things, and their experience is negative, then there is the possibility that the will
learn to develop a negative association. Early and adequate socialization and programs of positive training can go a long way in preventing
behavior problems and improving bonding between humans and dogs. While the first three months is the most important socialization period
in a puppy’s life, owners of puppies that have passed this milestone are strongly encouraged to continue to socialize their puppies to as many
people, pets, and locations as is practical. However, owners of puppies displaying fear should seek veterinary guidance. The fact is more pets
are likely to die because of behavior problems than of infectious disease such as parvovirus or distemper: so teaching your clients the
importance of proper socialization is critical. Before the socialization process begins, the veterinary team set new families up for success by
assisting them when they are selecting a new pet.
5. Teach life skills to kitten owners
Preventative behavioral care for puppies is far easier to remember to address than it often is for kittens; however addressing the
behavioral needs for kittens is just as important. Teaching clients techniques to make husbandry such as nail trimming, grooming,
medication administration, confinement and traveling will last cats a lifetime. These skills can be taught to kittens in a fun low stress
manner that is enjoyable for the cat and its family. Administering medication to an adult cat can be a stressful event for both the cat
and its owners. There are however several methods that can decrease the stress to make the medication giving process a pleasant
experience. The duration that a cat may require medication can vary from just a few doses to life long. Long term medication
administration can be especially stressful because of the frequent unpleasant interactions. Physical restraint and manual manipulation
may not be unpleasant for all cats; but for many cats this interaction with its owner on a daily basis may deteriorate their bond,
causing the cat to want to interact with its owner less or cause stress to manifest into other undesirable behaviors. There are easy
solutions to make giving medication a hands-free process or if needed, the physical manipulation low stress. Being proactive and
teaching kittens to take medication prior to needing it can set them up for a lifetime of success. Start by offering the kitten a variety of
foods that include both hard and soft textures so that if medication needs to be hidden in food later on the cat is already keen to eat a
variety of textures. Just as it was important to introduce kittens to novel foods early on in life it is just an important to expose them to
physical handling, restraint and manipulation. When any of these techniques are practiced they should be done out of context prior to
the cat actually needing to be medicated. Start by gathering a variety of dry cat food kibbles, crunchy and soft cat treats and pieces of
real tuna or chicken. Use one hand to cup the kittens head and upper jaw. The index finger on the second hand will be used the open
the cats mouth by placing the finger by the opening of the mouth, just under the cats nose but just above the lower incisors. The index
finger will be used to open the cat’s mouth while the other hand is holding the cats head in place. Now, drop a piece of the higher
value food into that cat’s mouth and release his restraint. The cat may seem unsure after this first interaction but with several more
repetitions the kitten will quickly form a positive association with this process. It is recommended that each time the kitten is
restrained and falsely medicated a variety of the pre-selected treats are being given. Teaching a new kitten to be comfortably confined
while traveling is another skill that can be appreciated more as the cat ages. Cats that are fractious and too frightened to go into a cat
carrier may result in missing out on veterinary care because of the owners desire to avoid this stressful interaction. This is not only the
case for routine care, but treatment for early onset or less serious illness may be delayed in order to avoid having to place the cat in a
carrier. Making the cat carrier a more permanent fixture in the home and a interactive part of the kittens environment will eliminate
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the initial alarm and fear when the cat typically is presented and approached with a carrier, simply because the carrier will already be
familiar to them. The door of the carrier should remain open so that the kitten has access to the inside. Toys, treats and soft bedding
should be placed inside of the carrier so that the kitten is encouraged to seek this location out. Pet safe heated beds can also be placed
inside of the carrier to introduce another valuable element. As it becomes more obvious that the kitten has deemed the carrier their
sanctuary then it would be appropriate for the owner to begin closing and latching the door, then eventually picking it up and moving
short distances. Lastly short travels in the car can be implemented but owners should remain mindful of the kittens comfort level
while doing so. It the kitten shows signs of stress then earlier stages of the training process should be revisited before proceeding.
6. When to refer and who to refer to
Recommendations for behavior problems are readily available because animal behavior affects every animal owner. Behavior can be
a conversation starter, it can be the one thing you have in common with an unfamiliar person, and it can be what builds the bond or
breaks down the bond between a pet and their family. For that reason, when families begin to experience behavior problems with their
pets it is very important to assist them in finding the appropriate help to remedy the problem. Sending a dog with behavior problems
to the wrong person can be as dangerous as not recommending any treatment. Not all trainers and behaviorist are the same.
Veterinarians are often the first professionals who are asked for help in improving a undesirable behavior. The veterinary technician
can then help advise the owner which professional would be most appropriate to assist the family. Behavior professionals can include
trainers, veterinarians, veterinary technicians, and veterinary technicians specialized in behavior, Board Certified Veterinary
Behaviorist or a Certified Applied Animal Behaviorist. Clients may need additional help differentiating between each of these
professionals, and selecting the right individual for the job. Dog trainers can be a good resource to help owners with their dogs.
However, there are no licensing or experience requirements to be a trainer, meaning that there is no oversight of trainers or assurances
that a trainer is using appropriate methods with each individual animal. In addition, there is no experience or licensing requirement for
someone to call themselves pet behavior counselor or dog behaviorist. Therefore, owners must be careful when choosing trainers for
their pets. Trainers can be very helpful in the role of preventing behavior problems. Hosting classes such as puppy socialization,
puppy kindergarten and variety of levels of obedience and specialty training classes can assist clients with teaching manners and
avoiding nuisance behaviors like jumping, pulling on a leash and basic commands. If the problem is well-defined and does not pose a
safety concern, the veterinarian may refer the client to a trainer. If the problem is complicated, they may feel the pet needs a higher
level of expertise such as a Board Certified Veterinary behaviorist or a Certified Applied Animal Behaviorist. Often the term
“behaviorist” gets used very casually and it may be difficult to discern what the credentials of a behaviorist are. A Board Certified
Veterinary Behaviorist is one that has a degree in veterinary medicine; they also have completed a behavior residency under a mentor,
and passed board certification. Because they have extensive experience in animal behavior they are able to diagnosis and prescribe
treatment for problems including, separation anxiety, aggression, inappropriate elimination, generalized anxieties, stereotypic
disorders, cognitive dysfunction and several other problems in a variety of species. The veterinary behaviorist can fully evaluate the
pet, both medically and behaviorally, and is trained to recognize where an underlying medical condition may either cause or contribute
to a behavior problem. A certified Applied Animal Behaviorist (CAAB) is another professional that can assist pet owners with many
of the same behavioral problems. CAAB's have two to five years of formal postgraduate academic education in the field of applied
animal behavior resulting in the attainment of master’s degree (MS/MA) or a doctoral degree (PhD). It is important to remember that
CAAB’s may not necessarily be veterinarians, so they are unable to prescribe medications for behavioral treatments. Than can
however, be very helpful working closely with a veterinarian to obtain solutions to many behavior problems. The veterinary
technician can be valued addition to a general practitioner or a Board Certified Veterinary Behaviorist. Technicians can assist the
doctors by taking a detailed history and after a diagnosis and treatment plan is made, they can help the family implement and follow
through with the techniques.
7. Build a behavior tool box
Being prepared for a reactive or aggressive patient will partially influence whether or not your experience and interaction were
successful. Building a behavior tool box is like building a crash cart to assist in low stress handling. If there is a patient scheduled
with a known history of aggression at the veterinary hospital, or it is determined that the patient you are working with is fractious and
has the potential to have a negative experience, stop and prepare tools before continuing with the procedure. The tools used in each
situation will vary from patient to patient. Ideally you should have a designated area in the hospital for your “behavior toolbox” this
will save time and eliminate staff searching for necessary items when needed. Towels and blankets are one of the easiest tools to use
when implementing low stress handling. They can be used to swaddle a patient, cover their head to decrease visual arousal or warmed
to add comforting support. Muzzles are the most basic safety tools that should be added to the behavior toolbox. While the standard
blue or black nylon veterinary or grooming muzzle can be helpful, it’s not the only muzzle you should reach for. A cage muzzle, also
known as a basket muzzle, and an Air Muzzle should be added to your supply. Each of these muzzles are designed to prevent bites
but should be implemented at different times and for each unique situation. The nylon muzzle is designed to fit snuggly around the
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snout, and extend to or past the tip of the nose. They should be used only for limited portions of time, no more than 5 minutes. Due to
the fit of the muzzle, it may restrict airflow and prevent proper ventilation by panting. If your patient is requiring to be muzzled for a
longer period of time, then a cage muzzle or Air Muzzle will be a better option. A nylon muzzle should never be left on a patient
while unattended or be used to prevent barking. The basket type muzzle can be implemented during procedures that will likely take
longer than 15 minutes. This form of muzzle may be ideal for a non-aggressive patient that is being hospitalized and has attempted to
chew his bedding, IV line and/ or bandage material. Cage muzzles come in various is sizes. A Calming Cap, by Thundershirt® is a
hidden gem and a “must have” in a veterinary hospital. The Calming Cap is made from a sheer nylon material and is designed to
cover the eyes of a fearful or fractious dog. The Calming Cap has elastic trim around the mouth opening that can conform to a variety
of dogs and can easily be used in conjunction with a standard veterinary muzzle or basket muzzle. The goal of this product is to
decrease visual stimuli by essentially filtering the dog’s vision through the sheer fabric panel. The applications for this product are
seemingly limitless. They can be used during any standard veterinary procedure such as a physical exam or nail trim. Calming Caps
make excellent tools for patients that are being induced for an sedation or anesthetic procedure. Having the cap in place as they are
falling asleep encourages their ability to relax; the same applies as they are waking up from anesthesia. The cap will decrease light and
stimuli in the surrounding area allowing them to recover calmly and smoothly. The Calming Cap is also a great tool for hospitalized
patients that are stressed by their stay, or aroused by other pets passing their kennel. For best results the Calming caps should be
implemented proactively. A head halter is a tool that can be used to improve many unwanted canine behaviors. In general a head
halter’s abilities extend beyond controlling unwanted pulling or settling of an unruly dog. An experienced staff member can
implement it in the veterinary hospital. This tool has been designed to assist in restraining an aroused patient by controlling its head
(similar to the rationale of a horse’s head halter). A head halter will not only assist with restraint but it can also calm the patient just by
wearing it. If the restrainer has better control, the dog is kept calm, and there is less confrontation. The patient will ultimately have a
better experience at the veterinary hospital. The head halter can also provide an opportunity to reinforce desirable behaviors by
releasing tension on the mouth and by offering favored food treats if the dog is sufficiently motivated. Peanut butter, squeeze cheese
and other soft, highly desirable, easy to administer foods are also “must haves” in the veterinary hospital. Although many of the
patients seen in the veterinary practice may be too anxious to eat, they may be more motivated to do so if the food is somewhat rare,
novel and highly desirable. Combining the peanut butter with a long handled wooden spoon makes the perfect set of behavior
modification tools. The long handle allows the food to be offered to a fearful dog at a safe distance and the spoons can easily be
sanitized after each use. By using food during the veterinary exam, dogs can be lured or shape-trained into performing more desirable
behaviors. They can be quietly taught to sit, lie down, settle or even offer a paw to perform a procedure, all the while enjoying a
favored food, being rewarded for good behavior and steadily decreasing their anxiety. Using food rewards each time a patient is
brought to the hospital will teach them to have a positive association with all that is involved. If you find that patients are too anxious
to take food during a procedure that’s ok; instead try the sandwich technique. The sandwich technique is where positive pleasant
things such as food and toys are offered prior to and directly after a procedure. So while the procedure itself was not enjoyable
everything before and after was pleasurable and more likely to stand out in the patients mind. Lastly, canine and feline pheromone
products can also be very helpful tools in low stress patient care. CEVA Sante Animale produces Adaptil and Feliway for cats. Any
of the products can be used to comfort canine or feline patients in situations that may cause them to be apprehensive or fearful. The
spray can be used for situations that include: traveling by car, trips to the veterinary hospital or any other new or potentially
challenging situation. It can be applied directly to bedding, inside cages, indoor kennels or in the car. Veterinary staff can spray their
clothing to calm the patients they restrain. Wait approximately 15 minutes for the product to become active after spraying 8-10
pumps. It will stay concentrated in the environment for 1-2 hours, although each animal may respond differently. Reapply as needed.
The diffuser’s make a great addition to hospital exam rooms or in the hospital kennel area. It can then be diffused at a constant level
to comfort patients that are spending long periods of time in your practice. The items kept in the behavior toolbox should be regularly
inventoried, checked for damaged and restocked or replaced as needed.
8. Continuing education
Much like other areas of veterinary medicine, behavior is ever changing. Behaviorists continue to research new theories, strategies,
medications and techniques to improve animal behavior and to prevent behavioral problems from occurring. Continuing education for
behavior is becoming more and more available. The American Veterinary Medical Association, the National Association for
Veterinary Technicians in America and the Society of Veterinary Behavior Technicians are excellent resources for staying current
with behavior topics. Food and drug companies are also good resources; they often make continuing education meetings and
programs available either at national conferences or through online resources. Websites such as clickertraining.com offer a wealth of
information; however researching behavior on the internet may provide inaccurate information. Caution should be used when
reviewing any website to ensure the authors have desirable credentials.
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9. Watch your language
The words that we choose to express how we feel about a particular patient or in a given situation may have an impact on our
behavior. This becomes especially problematic when veterinary professionals inadvertently and/or unknowingly apply inappropriate
actions and/or labels to companion pets; these are considered some of the negative results of anthropomorphism. For example; if a
canine patient is vocalizing in a kennel and biting at the bars of the cage while he is being hospitalized it is easy to label this dog
“annoying” or “a jerk” however if we look at the situation closer and analyze the dogs behavior from a medical stand point we may
have a better understanding for the motivation of his behavior. Likely if he is hospitalized he is ill in some way; he may be painful or
uncomfortable in some way. The dog may not have a history of being kenneled previously therefore is concerned about the
confinement. The patient may have previous hospitalization experiences that were unpleasant or he may be frightened simply because
he is surrounded by unfamiliar people. No matter what the reason is it is likely that the dog is not motivated to “annoy” the staff or to
make the veterinary staff have a bad day. If you feel like your patient is attempting to annoy you, you may be motivated to react in a
different way, such as yelling at the patient or scolding them for their behavior. If you feel that the patient is fearful or painful you are
more likely to take appropriate steps to make them more comfortable. If you find yourself feeling frustrated because of a patient’s
behavior; remember to assess the environment and context in which behavior is occurring in. You should watch closely for signs of
canine communication and most importantly minimize quick assumptions of the pet’s emotional state.
10. Don’t be afraid to talk about behavior
It should be our goal as veterinary professionals that we improve the behavioral health and well being of our patients so that the rate of
relinquishment and euthanasia due to behavior problems can be decreased. By opening up the lines of communication it will set
clients up for success and ultimately allow them to have a better relationship with their pet. Many common behavioral problems can
be prevented, avoided or caught and treated at an early stage with proper client education. Although it may not always feel
comfortable to make behavioral recommendations to a co-worker or a pet owner the long term benefits will outweigh the short term
uncomfortable conversation. Find opportunities to begin sharing your education with individuals that may not have the same set of
experiences or education that you have. When a client calls and enquires about a good breeder or postings for available puppies, take
the time to discuss pre-selection counseling with them; encourage them to set the up an appointment for this service. If a you see a coworker struggling with a fractious patient offer to help and demonstrate an alternative technique to better manage their behavior.
While seeing a patient for a routine nail trim discuss options with the client on what exercises they can do at home to decrease stress
for future nail trims. With each experience the conversations should become easier; clients and coworkers will likely feel more
comfortable approaching you with future questions and concerns.
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Behavior Therapies:
From Natural Supplements to Pharmaceuticals
Melissa Spooner, LVT, VTS (Behavior), BS, KPA-CTP
Leader Dogs for the Blind
Bloomfield Hills, MI
An anxiolytic is defined as any drug or supplement used to treat chronic or acute anxiety. Medications or natural supplements used as
anxiolytics can be helpful adjuncts for behavior modification if the animal’s fearful or anxious behavior is so intense that it interferes
with learning or other normal activities. Though both nutraceuticals and pharmaceuticals play important roles in animal behavior, it is
important to understand the different options and how they can most effectively be implemented into a behavior modification plan.
The information offered in this presentation should act as a guide, outline or overview of possible applications in a clinical setting.
Over the last five years there has been an increased desire to treat medical issues using natural remedies and alternative medicine.
This desire has slowly moved from the human to veterinary world. It is the goal for many pet owners to improve their pet’s medical
or behavioral status without altering their pet’s personality negatively. It is also hoped that natural supplements are a healthier choice
and will cause less harm to the body. Nutraceutical Medicine is defined as the use of micronutrients, macronutrients, and other
nutritional supplements as therapeutic agents. Communication on the potential risks and benefits from the use of these compounds
within the context of a valid veterinarian/client/patient relationship is important. Continued research and education on the use of
nutraceuticals in veterinary medicine is advised.
Adaptil® by Ceva formerly known as DAP is a synthetic version of a pheromone that is excreted from bitches that are nursing
their offspring. Adaptil assists new born puppies to search for, orient and bond to their mother. The pheromone elicits a soothing and
calming response to the puppies, however it is thought that the pheromone in the synthetic form can be beneficial for dogs at any age.
Adaptil is available as a veterinary Over the Counter (OTC) product. As of today, Adaptil can be found in three different forms; a
spray, plug in diffuser and disposable collar. Each works slightly differently. The rate of onset and the longevity varies with each
product. Because the rate of onset is generally fairly short (15-30 minutes) depending on the product it can be classified as a
situational anxiolytic that can be used on an as needed basis. While the Adaptil collar and diffuser last for four consecutive weeks, the
spray can be used as needed in a specific location and should last for several hours before needing to be re-applied.
Rescue Remedy is another natural supplement that has both oral and topical applications. It is often selected as a first form of
treatment by many pet owners because of it availability and longevity. The ingredients of Rescue Remedy include Impatiens, Star of
Bethlehem, Cherry Plum, Rock Rose and Clematis. This is an alcohol based product and the company suggests that some pets
may be sensitive to alcohol, in which case, Rescue Remedy should be diluted before it is administered, or the alcohol-free Rescue
Remedy should be selected as an alternative. Similar to many of the other behavior targeted nutritional supplements, Rescue Remedy
can be used for pets that experience anxiety during visits to the vet, separation anxiety, noise phobias such as thunderstorms and
fireworks, excessive barking, hissing or being kenneled. Shock, trauma, obsessive cleanliness, mistreatment, constant licking, and
self-mutilations are listed as aliments that can be treated by Rescue Remedy. The solution can be given to pets orally, in their food or
water bowl. Rescue Remedy can also be rubbed directly on an animal’s nose, ear or paw. It can be used for an immediate calming
effect in any stressful situation.
Harmonease contains natural extracts of Magnolia officinalis and Phellodendron amurense combined in a chewable tablet.
Harmonease helps dogs to overcome stressors such as noises and fear causing situations. The intent of Harmonease is to decrease
anxiety without causing lethargy, which is a desirable state for maximum learning. Harmonease has been evaluated in kenneled dogs
and shown to stop stereotypical behaviors, such as lick granulomas, spinning and cowering within five days of administration. Dosing
directions are recommended once daily as follows; for dogs up to 50 lbs, give ½ tablet and for dogs over 50 lbs give 1 tablet. For noise
phobia, administration is recommended 7 days before the anticipated event and throughout the necessary period of time. As with any
anxiolytic, Harmonease should be used under the guidance of a veterinarian and in conjunction with a behavior modification plan.
Anxitane is a product from Virbac which sole ingredient is Suntheanine brand L-Theanine in a neurologically active chewable
form. Anxitane promotes relaxation in pets exhibiting nervousness, anxiety or response to environmentally induced stress. This
nutraceutical targets undesirable behaviors such as fear on walks, people and other animals. It also improves anxiety or stress
associated with change in family situation or environment, episodic fear such as; noise phobias grooming, car travel and veterinary
visits. The goal of this supplement is to significantly reduce stress related reactions; however Virbac recommends that this product
should not be used for patients with severe phobias, separation anxiety or aggression. One reason that this product may be selected
over some of the other options is due to its highly palatable form, a poultry flavored tablet, which makes administration to both dogs
and cats very easy. There are also no known interactions with other therapeutics. It is recommended that Anxitane is used for no less
than 60 days to fully assess the effectiveness and so that maximum results can be observed. Anxitane is available in two different
sizes; small (50mg) for dogs and cats under 22lbs which is administered ½ tablet every 12 hours, and medium/large (100mg) for dogs
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22.1-55lbs, the dose is ½ every 12 hours and dogs that exceed 55.1 lbs should be given 1 full tablet every 12 hours. The tablets are
scored and can be easily divided to achieve the desired dose.
Composure is a nutritional supplement by Vetri-Science, which combines three natural ingredients. Similar to Anxitane,
Composure contains Suntheanine brand L-Theanine, which is a naturally occurring amino acid found in green tea and it has been
researched extensively for its ability to reduce stress, anxiety and unwanted behavior. It helps the body to produce other calming
amino acids such as Dopamine, GABA and Tryptophan and helps bring certain neurotransmitters into better balance. Studies done on
L-Theanine showed that dogs reduced anxiety-related behavior without adverse effects or drowsiness; dogs were alert, playful and
calmer than expected given their situations, which are the desirable effects when utilizing an anxiolytic. L-Theanine also promotes
calming and relaxation and reduces irritability and low mood states. The second ingredient is Colostrum Calming Complex, which is
an isolated form of colostrum proteins, which have a calming effect on animals. These bioactive proteins have been found to support
cognitive function and support stress reduction. The Colostrum Calming Complex works synergistically with the L-Theanine in this
formula to promote relaxation and cognition in dogs. Lastly, Thiamine helps manage stress and reduces irritability. Thiamine (Vitamin
B1) has been shown to affect the central nervous system to help calm and soothe anxious animals. A lack of Thiamine can cause
mental confusion, muscular weakness, muscle spasms, nervousness, and weight and appetite loss during periods of stress. The
Composure formula is available in two forms; a suspension and palatable bite sized chews. Recommended directions for the
suspension in cats is ¼ teaspoon twice daily. Dogs under 25 lbs ¼ teaspoon twice daily, 26 - 49 lbs ½ teaspoon twice daily, 50 - 75 lbs
¾ teaspoon twice daily and 76 lbs and over 1 teaspoon twice daily. Recommended directions for the chews are for pets up to 25 lbs 1
chew daily, 26-50 lbs 1 chew daily, 51-100 lbs 2 chews daily, over 100 lbs 3 chews daily. Both forms of Composure can be used
either as needed for immediate support or on a daily basis for on-going support. During times of increased stress it is safe to double or
triple the directed amount.
Novifit also by Virbac, is targeted towards a slightly different area of behavior. Its active ingredients are S-Adenosyl-LMethionine-Tosylate Disulfate also known as SAMe. Novifit is designed to support cognitive function of aging dogs and cats. These
tablets help to control behavioral disorders related to brain aging such as disorientation, changes in social interactions with people and
other pets, changes in sleep-wake cycles and loss of housetraining skills. They are a highly pure and stable form of SAMe
(NoviSAMe) presented in an enteric-coated tablet. As a nutraceutical, it is a first line treatment of behavioral problems associated with
cognitive decline for both dogs and cats. Novifit is available in three different sizes; small (100mg) for dogs and cats under 22lbs,
medium (200mg) for dogs 22.1-44lbs, and large (400mg) for dogs 44.1-88lbs. The tablets can be given once a day in food, but should
not be crushed or divided up into smaller pieces.
Not all behavior problems will demonstrate the desired level of improvement by using a natural supplement as therapy. Instead
they may require a prescribed short term or long-term pharmaceutical anxiolytic. Some problems such mild noise phobias
(thunderstorm & fireworks), activity or location specific (veterinary hospitals or grooming visits) anxieties may need only to be
treated on an as needed basis. Using a short-term medication may efficiently treat this diagnosis. Under the supervised care of a
veterinarian, a patient’s anxiety status can be thoroughly assessed and the appropriate method of treatment can be determined.
Alprazolam and Diazepam are in the same drug category called Benzodiazepines. Benzodiazepines are anxiolytic medications
with rapid onset of action that last for a few to several hours depending on the specific drug and the species. They are frequently used
as augmenting agents for SSRIs or SNRIs in the treatment of anxiety disorders but also can be prescribed as a standalone drug.
Benzodiazepines are metabolized by the liver and excreted into the urine. They should be used for situational anxiety because of the
short duration of onset. Although Alprazolam and Diazepam are in the same family, there are significant differences between the
drugs so they may be selected for different reasons. Alprazolam, which is the generic for Xanax is available in both tablet and
suspension form. It is often prescribed to improve symptoms related to noise phobia, separation anxiety or generalized anxiety.
Alprazolam is most likely to be effective when given 30-60 minutes before the occurrence of the earliest stimuli that elicits a fear
response, and may remain in the system for 2-4 hours. Dosing recommendations are 0.02-0.1mg/kg every 6-8 hours for dogs and 0.020.05mg/kg for cats as needed for anxiety. If a patient has been receiving Alprazolam daily for several weeks, discontinuation should
be gradual, and conducted over a period of at least one month. Diazepam (Valium) has been used in many areas of veterinary
medicine. Diazepam has a CNS depressant effect that results in calming, sedative, skeletal muscle relaxation and anticonvulsant
effects. Although Diazepam is available in multiple forms, oral administration is the preferred route for improvement of behavior
problems. The drug reaches full levels at 30-120 minutes after administration and may last 2-3 hours. Dosing recommendations are
0.5-2mg/ kg every 6 hours for dogs and 0.2-0.5mg/kg every 8-12 hours for cats as needed for anxiety. Previously Diazepam was the
drug of choice used to treat cats for spraying, anxiety motivated inappropriate elimination, general anxieties and fear related
aggression, however after it was determined that it was more likely to cause hepatopathy, it’s use was decreased. Similar to
Alprazolam, patients receiving long-term daily treatment with Diazepam should be gradually weaned before completely discontinued.
All of the drugs in the benzodiazepine category are controlled substances with the potential for human abuse. When drugs in this
category are prescribed they should be monitored closely. If medications in this class are going to be prescribed over a long period of
time only a limited amount of medication should be dispensed as needed, and when additional refills are requested, the previous
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amount dispensed, previous date issued and the doctor’s directions should be compared closely. Benziodiazepines are generally safe
drugs to use with minimal side effects. The side effects reported most often are lethargy, hyperactivity and ataxia. Benzodiazepines
have the possibility to cause disinhibition, or fearful animals could become more aggressive. For this reason it is important to monitor
the patient closely while this medication is in use, and appropriate behavior modification should be implemented along with any
behavior medication. Fulminant hepatic failure associated with oral administration of Diazepam was reported in some feline patients
so blood work should be done on cats to check liver values. Hyperphagia may also be reported in both dogs and cats but in some
cases that is a side effect that may be considered desirable at times.
Acepromazine falls under the antipsychotic drug category. It is a tranquilizer that causes decreased motor function and reduced
awareness of external stimuli. Patients that are prescribed Acepromazine will appear sedated and possibly lethargic, which can be
beneficial in some areas of behavior treatment. Classical antipsychotics can calm anxious patients and may be considered for pets that
are destructive to themselves or their surroundings. Acepromazine also has an antiemetic effect so it may be recommended for dogs
that experience car ride anxiety characterized by nausea or vomiting. However, there is some concern whether or not Acepromazine
makes an appropriate behavior modification drug. Since it causes sedation, it may limit the animal’s ability to learn and repeat desired
behaviors in difficult situations. Ataxia, hypotension, decreased seizure threshold, and bradycardia are all possible side effects that
may occur after administration of this drug. Any patient that is prescribed Acepromazine should be monitored closely. Recommended
doses for Acepromazine is 0.5-2mg/kg orally every 8 hours or as needed for dogs and 1-2mg/kg orally as need in cats.
Situational anti-anxiety supplements or medications may not always be suitable in every case. Patients that experience ongoing
anxiety, extreme phobias or when quality of life is severely impacted by their behavior may require long term drug therapy. There are
several drug classes to choose from when selecting the appropriate drug for the patient.
SSRIs selectively block the reuptake of serotonin back into the presynaptic neuron. Consequently they increase the levels of
serotonin in the synapse. Fluoxetine has been used most commonly in the treatment of behavior problems in companion animals,
particularly those with anxiety disorders, such as separation anxiety and aggression, however it may be utilized to decrease reactivity,
vigilance and compulsive disorders. Fluoxetine is a Selective Serotonin Reuptake Inhibitor (SSRI) generic for Prozac or Reconcile, a
veterinary brand name. Drugs such as Fluoxetine found in the SSRI category are intended as long term anxiolytics, because they may
be used over several months, years or lifelong. When Fluoxetine is prescribed it should be explained as a commitment to the client.
Improvement from this medication may take 4-6 weeks from the start date to asses, and it is important for clients to have appropriate
expectations of the drug. Using a veterinary brand name drug such as Reconcile can have several advantages over choosing the
generic version. One important advantage is the palatability of the tablet, which is made from beef flavoring and can ease
administration to an already anxious animal. The second advantage is the extensive research that has been completed to fully
understand the effects, expectations and benefits of the medication. The company also offers veterinary education and support to
prescribers. Despite the many positive aspects of using Fluoxetine it does have several side effects that both prescribers and
veterinary staff should be aware of. Lethargy and decreased appetite are most often observed though they are generally transient and
reported during the first 1-4 weeks of treatment. Vomiting, diarrhea, changes in urinary frequency, insomnia and sedation are also
possible side effects. Dosing the medication every other day for the first 7-10 days can lessen side effects. Food may delay its
absorption by 1-2 hours, so it may be most effective if given on an empty stomach. The combination of Fluoxetine and MAOIs can
result in serious and sometimes fatal drug interactions. These two medications should never be given together. However, combing an
SSRI with a benzodiazepine may enhance the drugs to achieve a better effect. Recommended dosing of Flouxetine is 0.5-2mg/kg
once daily. Paroxetine is another SSRI used to treat anxieties involving social interactions; it is very similar to Fluoxetine. Dosing
recommendations are 0.5-1mg/kg orally 1-2 times daily. Side effects include sedation, increased anxiety, animals seeming withdrawn,
loss of appetite and the possible lowering of seizure threshold. Urine retention and constipation are also possible side effects. It may
have the advantage of being more calming and therefore more preferable for some anxiety disorders. It is less likely to lead to
agitation and insomnia compared to Fluoxetine. Paroxetine has a much shorter half-life than Fluoxetine. After the desired level of
behavioral improvement is achieved the patient should slowly be weaned off of the SSRI, over a 4-6 week period. If medical side
effects are observed that suggest interference from the medication, it can be safely stopped abruptly.
Another major class of drugs used for long-term behavior therapy is Tricyclide Anti Depressants, which block the reuptake of
norepinephrine, dopamine, and serotonin into the presynaptic terminal. They effectively increase the level of neurotransmitter in the
synapse. They are commonly used in dogs to manage behavior problems ranging from aggression to urine marking, repetitive
behaviors, and separation anxiety. In cats, TCA’s can be used to treat certain forms of aggression, urine spraying, excessive
vocalization and grooming. Clomipramine and Amitriptyline are well known drugs in this category. Clomipramine, also known as
Clomicalm, is one of two drugs licensed in the United States used to improve separation anxiety, (the other is Reconcile).
Clomipramine is unique from other TCA’s because it is the most selective inhibitor of serotonin reuptake. There is wide dose range
offered for Clomipramine. Recommended doses for cats is 0.125-1mg/kg and dogs 0.5-2mg/kg divided every 12 hours depending on
the diagnosis. Amitriptyline, (Elavil), may be used for diagnosed separation anxiety and generalized anxiety in both dogs and cats.
Because of its sedative, ant-anxiety, anti-histaminic effects as well as its potential improvement for chronic pain it may be useful in
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some self-traumatic disorders such as early stages of ALD-type lesions in dogs. Typical dosing for Amitriptyline is 50-150mg per day
which is likely divided into 12 hour doses. For both Clomipramine and Amitriptyline, behavioral improvement will take 2-4 weeks to
assess and if the desired improvements are not observed by 6-8 weeks, the dose may need to be increased. Potential side effects
include cardiac arrthymias and seizures. Urinary retention and dry mouth may also occur during therapy. Amitriptyline is also
notoriously known for being very bitter tasting, it can be difficult to mask in food and both dogs and cats may become disagreeable to
taking it. Both Clomipramine and Amitriptyline should be slowly weaned before they are discontinued so that the undesired behavior
problems do not reoccur.
Most psychoactive medications are used off-label for animals. Only a few medications, such as Fluoxetine (Reconcile, Lilly) and
Clomimpramine (Clomicalm, Novartis Animal Health), are indicated for specific use in dogs.
Another class of drugs that is important to be aware of is Azapirones. Azapirones are described as anxioselective instead of
anxiolytics because they do not cause sedation, which may occur during treatment with other classes. Similar to some of the TCAs
and SSRIs, Buspirone can be used to treat generalized anxiety, inappropriate elimination, (specifically feline urine spraying),
separation anxiety and some forms of aggression. A veterinarian may choose to treat with Buspirone when the patient’s anxiety is
decreased as it can often make them friendlier and more likely to seek attention. The prescriber should be aware that inhibition could
lead to aggression. However, the desired effects may not be achieved by using Buspirone alone. Often Buspirone may be combined
with SSRIs or TCAs in order to have an optimal effect. Azapiriones should not be combined with Monoamine Oxidase Inhibitors,
(MAOI’s), because of the potential for toxicity. Dosing for Buspirone for dogs is 0.5-2mg/kg every 8-24 hours. The feline dose
varies slightly. It can be prescribed as 2.5-7.5mg/ cat every 12 hours or 0.5-1mg/kg every 12 hours. The rate of onset is shorter than
other long-term behavior therapy drugs and behavioral improvement can typically be observed in 1-4 weeks.
Prior to starting any new behavior medications it is always recommended that baseline blood work be performed. It is important to
understand how the drug that is being prescribed is metabolized and excreted and select appropriate blood work accordingly. An
extensive chemistry panel and complete blood count are usually recommended. Depending on the prescribing physician, signalment
and history of the patient, additional blood work may be indicated. Age, history and current health status of the patient may also
determine how often blood work is repeated. Schedule guidelines for blood work can be as follows: 1-3 years old, once yearly, 4-9
years old, every 6 months, and 10 years and above every 3 months. The prescribing physician should ideally perform a physical exam
at regular scheduled intervals. Depending on the reason for the patient being on behavior medications, an observational physical exam
may be the only reasonable option. An observational physical exam will allow the physician to assess the patient from a comfortable
distance. Gate, body condition score, skin, coat and neurologic status can all be assessed in this manner, however it should be the long
term goal of the veterinary staff and client that patient be desensitized for physical exam at future medical visits. Grouping multiple
medical procedures together for patients that are fractious during veterinary visits, such as blood draws, vaccinations, nail trims and
physical exams, may prove to be easier for the patient to cope with. This will assist in decreasing the amount of “negative” veterinary
interactions, although some patients may do better if the procedures are scheduled on separate visits.
Veterinary technicians can play a very important role assuring that multiple medications or other treatments are not prescribed
where contraindicated. Patients that are being treated by various doctors run the risk of two or more medications being recommended
simultaneously when they should not be paired together. It will be the job of the veterinary technician to work closely with clients on
obtaining a complete behavior and medical history and reporting your findings to the veterinarian. The owner should be encouraged
to list all medications that the patient may be taking. This list should include the medication strength, frequency, when it was started,
last dose given or any medications that have been discontinued recently. Any nutraceutical or over the counter medications that are
being administered should be included in this list. This drug list should be updated anytime medications are added or altered and
anytime the patient is seen at the hospital. If possible, an alert should be made in the patient’s chart in both digital and hard copies.
Fluorescent stickers are an inexpensive yet effective method of alerting all veterinary staff that the patient is taking a medication that
may be contraindicated with other medications. As with children, all medications should be stored in tamper proof containers that are
out of reach. Due to several behavior medications now being made highly palatable for the patient, they should be kept were family
pets do not have access to them.
Concerns arise when SSRIs, MAOs or TCAs are combined with other medications or supplements that may cause excess
serotonergic activity at the central nervous system (CNS) and peripheral serotonin receptors. This is a potentially life-threatening
adverse drug reaction that known as Serotonin Syndrome, may occur following therapeutic drug use, inadvertent interactions between
drugs, or overdose of particular drugs. The most serious cases result when an SSRI are combined with an MAO inhibitor, which
decreases serotonin metabolism, and a serotonin receptor agonist, such as Buspirone, a TCA which is a non-selective serotonin
reuptake inhibitor, or Meperidine, Tryptophan or Dextromethorphan. There is still much to be learned about how Serotonin
Syndrome effects animals, we do know that it has the potential to be fatal and precautions should be taken to avoid this possibility.
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Parvovirus:
Nursing Considerations
David Twedt, DVM, DACVIM
Colorado State University
Fort Collins, CO
Canine parvovirus (CPV) is a family of viruses that attacks rapidly dividing cells including the lymphoid tissue, bone marrow and GI
tract causing vomiting, hemorrhagic diarrhea, and leukopenia. CPV infection is acquired by the fecal-oral route. The virus generally
infects dogs less than 1 year of age. The diagnosis is made based on clinical signs, signalment of the patient and poor vaccination
history. There are currently 2 active variants of the virus CPV-2b and CPV-2c - of which 2c is the most recent recognized and thought
by some to be the most virulent. Confirmation of canine parvovirus infection is achieved using in-hospital ELISA SNAP test and
detects CPV-2b and CPV-2c variants of the virus. The test requires a small sample of stool from the patient. There is some debate if
these tests show false positive results due to recent vaccine but a recent study found that these tests did not produce positive results
following a modified live parvo vaccine, suggesting when positive they have parvovirus. False negatives can occur possibly
secondary to antigen dilution from diarrhea.
Clinical findings
Patients suspected of being infected with parvovirus are commonly between 6 weeks to 3 months of any breed that are undervaccinated. The Doberman and Rotweiller appear to be more seriously affected with the disease. Clinical signs include vomiting,
hyperthermia or hypothermia, tachycardia, altered pulse quality, tachypnea, evidence of dehydration and or abdominal discomfort.
Early in the disease vomiting may be the only clinical sign but is shortly followed by hemorrhagic diarrhea.
Typical laboratory abnormalities include leukopenia and neutropenia, hypoalbuminemia (from GI losses), hemoconcentration early
and anemia later, hypokalemia, and hypoglycemia. Due to decreased perfusion from dehydration, metabolic acidosis and increased
serum lactate concentrations are evident on a blood gas analysis.
With aggressive therapy a majority of patients survive the disease however some do die likely secondary to septicemia,
hypovolemia and or coagulopathy. It is therefore important to provide aggressive therapy in these patients to improve their outcome.
Therapy
The typical therapy for the CPV patient will include intravenous fluids, electrolyte and glucose replacement, antibiotics, antiemetics,
and analgesics. Other therapies may include antacid or GI protectant therapy. Anti-diarrheals are generally not given.
Intravenous fluid therapy of crystalloid fluids is the primary therapy. Fluids such as Plasma-Lyte™, Normosol-R, or Ringer’s
solution are commonly administered. Fluids should replace dehydration, provide maintenance requirements and to replace ongoing
loses from vomiting and or diarrhea. With replacement crystalloid fluids, only 20–25% of the infused volume of fluid remains within
the intravascular space 1 hour after infusion. Therefore, large volumes of replacement crystalloids need to be administered initially to
replace intravascular volume and are continued to replace the ongoing losses from the vomitus and diarrhea.
Colloids are high molecular weight compounds that do not readily leave the intravascular space and exert their effect of expanding
intravascular volume by holding and potentially drawing water into the vasculature. Common colloidal solutions used in parvovirus
patients include plasma and synthetic compounds such as hydroxyethylstarch (Hetastarch™). There is recent blackbox warnings of
Hetastarch causing renal damage in humans and is now being avoided by many veterinarians. The veterinary VetStarch™, is a
tetrastarch and may not cause renal damage but this is unknown at this time. Fresh frozen plasma transfusion is occasionally
administered to CPV infected patients and has colloidal effects, provides albumin, immunoglobulins, and coagulation factors.
Intravenous fluids are frequently supplemented with dextrose and/or electrolytes based on individual cases. Hypoglycemia is
common in young puppies. Concentrations of 2.5–5.0% are common. Hypokalemia is the most common electrolyte abnormality and
daily monitoring of the patient's serum potassium is required. Potassium can be added to the crystalloid fluid but potassium should not
exceed a rate of 0.5 mEq/kg/hr. We routinely administer 20 mEq KCl/liter of fluids as a starting point.
Because of the immune-compromised nature of these patients and the damage to their GI tract septicemia and bacteremia is
common. Consequently antibiotics are routinely prescribed to prevent and help combat infection. In mildly affected patients, singleagent antibiotics are often prescribed. We usually give ampicillin + sulbactam. Enrofloxacin in combination with ampicillin is also
used in severe cases but has been shown that enrofloxacin has the potential to damage developing cartilage in growing puppies.
Second or third-generation cephalosporins can also be used in some cases.
Antiemetics are indicated to stop vomiting and prevent nausea. Antiemetics will lower the risk of aspiration pneumonia in these
debilitated patients and may improve a more rapid return to nutrition. Metoclopramide, dolasetron, ondansetron, and maropitant have
all been used to control vomiting in CPV infected patients. Each of these antiemetics has a different mechanism of action and
combinations of these medications can be used. Our antiemetic of choice is maropitant (Cerenia). We have shown it is well tolerated,
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parvovirus cases had less nausea and had greater nutrition intake during therapy. We have also shown maropitant has effects on
blocking visceral pain as well. Additional pain management may include buprenorphine, morphine, hydromorphone, as examples.
Reflux esophagitis is a common finding in patients that have protracted vomiting. The use of gastric cytoprotective medications
such as famotidine or pantoprazole are often used.
Parvovirus-infected patients often are not able to tolerate enteral nutrition due to the vomiting, abdominal discomfort, and
gastrointestinal pathology. However with aggressive therapy and antiemetics one can begin early nutrition. It has been shown that
early nutrition will decrease hospitalization time and improve recovery. Nasoesophageal tube placement and Clinicare™
administration to provide 25% of caloric needs is used. Alternatively we will sometimes just syringe feed a recovery diet such as Hills
a/d. Lack of nutrients in the GI tract causes villous atrophy and increased mucosal permeability with bacterial translocation.
Other therapies
Some veterinarians recommend oseltamivir (Tamaflu) is a neuraminidase inhibitor originally developed for treatment of human
influenza virus or the administration of hyperimmune serum. There is yet evidence of the benefit and further investigation regarding
the efficacy of these therapies is needed before they may be recommended.
Nursing care
Appropriate nursing care and monitoring of these patients is essential as they can rapidly decompensate in a matter of a few hours.
We monitor twice daily body weight and pain scores in each patient. PCV, TS, K and WBC are our usual monitoring methods. We
monitor body temperature and pain scores qid. Keeping the patients clean, hydrated and comfortable will improve outcome.
Can parvovirus be treated as an outpatient?
Often because of economical reasons it is not possible to treat parvovirus cases in the hospital. In a research study we performed to
determine if we could be successful in managing cases on a semi-outpatient basis and found it to be successful in many. In a
ramdomized clinical study parvo dogs were treated in the hospital or in a outpatient type situation. These outpatient dogs however
were treated in a hospital environment so we could critically evaluate the animal. In general our outpatient protocol involved 2 hours
of rapid IV fluid replacement followed by daily SQ fluid administration, daily maropitant, once only Convenia™ injection and force
feeding of Hills a/d. In this study the survival rate was similar. Go to the website for more information http://csucvmbs.colostate.edu/documents/parvo-outpatient-protocol-faq-companion-animal-studies.pdf. Although many dogs were
successfully managed we would recommend hospitalization and monitoring in the moderate to severe cases.
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Postoperative Orthopedic Patient Care
Jennifer Wardlaw, DVM, MS, DACVS
Gateway Veterinary Surgery
St. Louis, MO
The most common orthopedic conditions scene in a small animal private practice are cruciate tears, fractures, luxations, hip dysplasia,
arthritis, amputation, tendon repair and bone biopsies. While each of these conditions/procedures have their own variations on what
the patient needs, in general terms they are all very similar, especially in the early postoperative period, while in hospital.
Due to the condition of the animal, many are unable to walk before and sometimes after surgery, witout assistance. Also some
animals may want to walk, or even run, but are not allowed due to instability or potential harm to themselves. For this reason slings,
gurneys and stretchers may be used to transport our patients. Care givers should be mindful of fear as well as pain, which often may
indicate the use of a muzzle, especially in trauma cases in the preoperative period.
After surgery, most orthopedic patients will have radiographs taken immediately following surgery as well as during recheck
examinations. For postoperative films it is imperative to know this ahead of time so a second machine may be tested and in place to
avoid excess time under anesthesia. Preordering films on the digital server, telling other staff prior to moving the anesthetized patient
and having a clear order on the views to be taken will limit wasted body temperature, blood pressure and time under anesthesia.
Postoperative radiographs are typically taken when implants are put into the patient, when implants are removed and to document the
fixation method. Certain cruciate surgeries need specific views taken for postoperative measurements to assess the success of surgery.
You should wear lead gowns, gloves, thyroid protectors as well as a radiation badge every time you take a radiograph.
After the patient is awake they may also need help ambulating with a sling for balance, to prevent slippage or to protect the
surgical repair. Slings for the patient may be placed to control movement, produce a non-weightbearing gait, or cushion the surgical
repair. Depending on the indication, the sling may be in place for weeks to months. When slings are sent home on a patient, proper
owner education is vital to successful care. The owners should assess the sling three times daily for slippage, making sure it is clean,
dry and not too tight.
Slings are often used for the owner as well. Slings can be purchased to help them carry their pet, assist in walking or make it easier
to traverse stairs. Some slings and harnesses are make to remain on the dog all day, others are to be used just when walking the
patient. It is important the owners understand the difference and know where to watch for rub sores and irritation. It is a good rule to
use a supportive slings on orthopedic patients on all slick floors, including when they return for recheck examinations. These slings
are used to prevent them from falling and injuring themselves while they are healing.
In some instances, special braces and prosthetics can be used to replace bulky bandages for more chronic orthopedic patients.
Commercial braces should be gradually introduced to assure they use the brace and do not develop pressure sores or chew on it.
Custom braces and orthotics are easily made with a cast mold for a perfect fit, but can be quite costly for the temporary orthopedic
condition.
Incisional care is vital to preventing an infection. If an infection reaches the depth of an orthopedic implant, those implants will
have to be removed with another surgery once the bones have healed. Bacteria form a glycocalyx over the implants that prevents
antibiotics from completely clearing the infection. However, if the surgery is stable and has a good blood supply with a properly
confined patient, the bone can heal in the face of infection. But the infected implants will have to be removed, cultured and antibiotics
continued based on that culture.
Incisions should be kept clean, dry and intact. A healthy incision will have minimal bruising and minimal discharge. A
serosanguinous or resolving sangunous discharge can be seen for 1-3 days, especially after an arthroscopic procedure. Swelling
should resolve and move ventral/distal with gravity. Clod packs are used for the first 2-3 days after surgery to help minimize swelling
and bruising. They should be placed in a thin paper towel and placed on the incision and around the leg for at least 15 minutes. Cold
packs can penetrate 3cm. They can be made using commercially available products, a bag of frozen vegetables, or a Ziploc back with
1:3 alcohol:water to create a pliable and moldable pack. Cold packs should not be started until the patients core body temperature has
recovered after anesthesia. After 3 days, warm packs should replace the cold packs. Warm packs help with pain relief and healing.
Ideally these would be performed 3-5 times a day for 15 minutes. If the patient develops a seroma during the recovery period, strict
cage rest and frequent warm packs will resolve it in a few days. Do not aspirate seromas to avoid making them into potential
abscesses. Warm packs can be commercial packs, microwaved tube socks filled with lentils or a microwaved wet towel placed in a
Ziploc. Again the warm pack should be wrapped in a thing paper towel before applying it to the incision and wrapping it around the
leg. You do not want to place a wet thermal pack on a fresh incision to avoid potential nosocomial infections.
External fixators require bandages for the postoperative period to help with swelling. Several days after surgery the bandages are
usually changed to a smaller less cumbersome bandage. These bandages are to prevent selftrauma to the patients other legs or
household furniture with the fixator pins and clamps. Exfix pins should be checked 2-3 times a day assessing for drainage, swelling,
and trauma. Some clinicians like to clean the pin tracts several times a day while others leave them to form a scab or seal over the pin.
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Any bandage needs to be protected from the environment when the animal uses the restroom. An IV bag, or commercial product is
useful to prevent a bandage becoming prematurely soiled. However, many owners are tempted to leave on the bag and must be
instructed to remove it to avoid excessive humidity soaking the bandage from the patient’s own foot.
Since orthopedic patients have so many more things going on while in hospital. Communication and documentation are vital.
Every day’s SOAP should comment on the incision, bandage and leg usage. A sudden change in leg usage is cause for concern and
should be addressed immediately.
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