EN Vet Trainee Manual by ACTAsia

CONTENTS Page no.

1 Introduction

2 Overview of the China companion animal welfare programme

3 The Essentials of ABC surgery

4 Reproductive anatomy female (dog â&#x20AC;&#x201C; lateral view)

5 Reproductive anatomy female (dog)

6 Eartipping feral cat identification protocol

7 Juvenile desexing protocol

8 Neonatal care - kittens and puppies

9 Veterinary nursing (Aseptic protocols and patient monitoring)

10 Veterinary nursing handout

11 Nursing Manual

12 Maintaining asepsis

126

13 Care of the theatre

127

14 Cat handling

148

15 Cat mood score and body language

150

16 Anaesthetics

152

17 Statements on need for suitable anaesthesia

158

18 Monitoring anaesthetics

163

19 Basic monitoring

164

20 Anaesthetic emergencies

177

21 Cats are NOT little dogs

178

22 Pain

182

23 The new philosophy of pain management

186

24 Pain management guidelines for dogs and cats

191

25 Isolation rooms

205

26 Surgical scrub preps

206

27 Premed dosages

208

28 Feline xylazine, ketamine, diazepam anaesthetic regime

209

29 Drug doses for kittens less than 4 months

210

30 Drug doses for adult cats

211

31 Canine xylazine premed im and sc

212

32 Canine xylazine, ketamine, diazepam anaesthetic regime

213

33 Canine ketamine/diazepam IV induction

214

34 Drug doses for puppies less than 4 months

216

35 Drug doses for adult dogs

217

36 Other treatments

218

37 Zoletil 50

219

38 Feline anaesthesia

220

39 Canine anaesthesia

221

40 IV fluid calculations

222

41 Intravenous fluids chart

225

42 Emergency drug doses

226

43 Anaesthetic record

227

44 Surgery consent form

228

45 Convalescent care

230

46 Progress reporting forms: a. Assessment of trainee husbandry - clinic, pre-op, post-op

231

b Assessment of trainee husbandry - prep, handling, monitoring

232

47 Euthanasia Algorithm for Companion Animals

233

48 Internet use for veterinarians - Useful links

244

1. Introduction The Vets Beyond Borders-ACTAsia for Animals (VBB-ACTAsia) Trainee Reference Manual is a compilation of veterinary reference materials, charts and procedures related to the skills and welfare standards required to conduct successful sp ay/neuter operations in a clinical setting. The manual also p rovides other useful resources that are related to general practice. This manual is provided to all trainees of the VBB-ACTAsia veterinary training workshops to use as reference materials during the workshop s and afterwards in their own p ractices. These workshops have been conducted annually in China for the last three years, and the resources in this manual have been compiled from the materials used at these workshops by the Vets Beyond Borders team. All the materials have been written or provided by the VBB team. This manual has been edited and translated into Chinese by ACTAsia and its team of volunteers. Please contact ACTAsia if there are any errors in the translation so that they can be corrected. We would like to thank all the organisations and individuals who have given us permission to use their materials. If there is any material in this manual where copyright has not been acknowledged, we apologise for the oversight, and we will rectify it immediately.

2. Overview of China companion animal welfare programme

Vets Beyond Borders

Dr Elaine Ong • BVSc Melbourne 1987 • Principal and owner Box Hill Veterinary Hospital, Australia

• ASAVA accredited Hospital of Excellence • Australia Veterinary Association Emergency Task Force

• Academic Associate University of Melbourne • Principal Trainer Vets Beyond Borders/ACT Asia CHINA Train the Trainers program

Dr. Elaine Ong

• ABC AR training the trainers program • Mentor and trainer Bali Animal Welfare Association • Board Member Tsunami Animal People Trust Sri Lanka

10.2011

Vets Beyond Borders

1.P .Problems roblems faced by China faced by China and and its companion its companion animals

2,Mission of animal control 2, Mission of animal control

Development of animal management does not match the growth of animal population

   

 The overgrowth of the stray animal population has reduced the pleasure companion animals give to people of China

government vets animal organization i l i i public

    

 Stray animal population in bad condition and are suffering 

 Constant cruelty to animals is intolerable to most Chinese and can social conflicts

Animal birth control (ABC) Animal Rabies control (AR) Animal disease prevention Responsible pet ownership Animal shelters and Rehoming

management system:public control and regulations on animals

 Threat of rabies outbreaks ACTAsia For Animals

Vets Beyond Borders

3,Success of ABC 

 

4,Pet sterilization is like vaccination

30 years ago: started in Britain and South Africa, followed by USA and others All developed countries promote neutering of pets g Agreement among animal protection and international public health experts that neutering is: 



the most humane method of reducing numbers of feral cats and street dogs the most effective way to control disease vectors

Pet sterilization is in fact vaccinating against overpopulation  70% of the susceptible population must be sterile in order to reduce the growth rate population to approximately zero  The births only occur at a rate great enough to replace normal attrition 

Vets Beyond Borders

5,ABC AR and Community benefits

Vets Beyond Borders

Benefits to Government 



Elimination and prevention of rabies,Less stray animals, no rabies outbreaks, Reduced cost ( much cheaper to vaccinate dogs than to vaccinate people, much cheaper to have ABC-AR program than to treat humans that have been bitten by rabid dogs, Community health ( less strays , better sanitation, less rodents)

Vets Beyond Borders

Benefits to Community

Vets Beyond Borders

Benefits to Vets Community service= High profile= respect , recognition and increased business, Continuing education and professional development= better service and results, Caring professional services= increased business

   

Community health, better living environment, Animal welfare, welfare Owned and un-owned animals in much better condition



Vets Beyond Borders

Benefit to Animals –Improved animal welfare in China

Vets VetsBeyond BeyondBorders Borders

6,Key points for ABC‐AR • • 

Consultation , cooperation and support with/from Government Local community  

people who object to the animals people who feed the animals



Animal protection /welfare organizations Veterinarians undertaking the project Local public health officials

・

Cooperation with all or at least tolerance

 

Vets Beyond Borders

Vets VetsBeyond BeyondBorders Borders

7,Role of vets in ABC‐AR

8,Role of government • Access to variety of cost efficient drugs , including

Vets are the leaders

•

Important role in rabies prevention and elimination for your community and country Crucial Community services C i l C i i Consulting with and advising local Government and animal welfare organizations Lift standing of Vets In China Lift animal welfare standards

ii. iii.

iv. v.

Action·Compassion·Together

• • • • •

good anaesthetics, pain relief drugs and long acting antibiotics g p y Free rabies vaccinations for dogs especially Provide training facilities ( North South East West) for training the trainer program Responsible pet ownership campaign Education program at schools Support the Veterinary surgeons ‐Desexing vouchers for the public

Vets Beyond Borders

Flank Spey

9,ABC Program Must be

•

Advantages 

 economical to Vet ; 80 RMB per cat ,100 RMB



for big dog ( including antibiotics , pain relief p ) and parasite treatment)  sustainable  high standards of anaesthesia , pain relief and surgery and asepsis

High standard technique

awareness of animal welfare

   

Small incision Less risk of dehiscence‐ no pressure on wound Healing is quicker Use less expensive sutures Easy to observe wound Intradermal sutures‐ no need to remove

High quality drugs ACTAsia For Animals

Vets Beyond Borders

Key Points for ABC surgery   

 

  

Flank Spey technique for earlier release No bandaging required Pain relief crucial ( 1 single injection of meloxicam, carprofen or tolfedine) Give single dose long acting penicillin High quality but economical IV or IM anaesthetic eg ketamine/diazepam/xylazine or xylazine /zoletil Aseptic technique crucial Practise high standard surgical technique

Action·Compassion·Together

Vets Beyond Borders

Key points to successful surgery           

Gentle handling of animals Gentle clipping‐ avoid clipper rash Correct concentration of skin disinfectant solutions Gentle blunt dissection Location of uterus‐ see diagram 3 clamp technique using 2 clamps Knot tying technique Inspect knot before release Gentle suturing of muscle – Not too tight Wash off most of disinfectant on skin Quiet recovery area

ACTAsia For Animals

Action·Compassion·Together

Vets Beyond Borders

10,VBB/ACTAsia programme

Nice recovery

• To provide vets and their assistants with a better understanding of welfare issues in their work

• To enable vets and their assistants to improve their technical skills with respect to spay/neuter surgery, handling and pre/post operative treatment of cats

• To train local vets to become trainers and expand this programme • To increase collaboration between vets , government and animal protection groups

• To increase understanding within animal groups of the issues around sterilisation and how to promote it

• To promote humane rabies control

ACTAsia For Animals

Action·Compassion·Together

Vets Beyond Borders

11, Who we focus on

12, 12, ABC‐ ABC‐AR program in China Companion Animal Welfare Veterinary Programme

• We focus on Veterinarians who are working or will • •

work with animal welfare organizations Who are willing to upskill Who are willing to become potential trainers Wh illi t b t ti l t i

    

1)Animal Birth Control(ABC) techniques 2008 Research 2）Principles of asepsis, 2009 1st surgery, anaesthetic, animal 2010 2nd handling and patient care 2011 3rd 3）Recognise the importance of …… vets in rabies prevention based on WHO guidelines

Vets Beyond Borders

• Shenzhen 2009 – 51 Vets and technicians from 15 clinics participated in

ABC ABC‐‐AR program in China AR program in China 2009 2009

lectures and demonstration – 40 Vets and technicians received hands on surgical ,

anaesthetics and patient care training

Shenzhen April 27 Shenzhen April 27th ‐ May 1 May 1st Beijing May 2nd ‐ 7th

Vets Beyond Borders

• Beijing 2009

Progress 2009

– 32 Vets and technicians from 14 clinics

• 9 selected surgical trainers • Shenzen 60% % increase in cat sterilization after the program • Vet clinics offering subsidized neutering increased by 40% .

participated in lectures – 16 Vets and technicians received hands on surgical, anaesthetic and patient care training

• • • •

g Business increased for vets working with animal welfare organization due to referrals Cats neutered were released 48 hours later Recovery was faster due to gentler techniques and provision of pain relief Anaesthetics were used instead of just sedatives eg Zoletil and xylazine instead of xylazine alone

Vets Beyond Borders

Train the Trainers 2010 ABC ABC‐‐AR program in China AR program in China 2010 2010 Shenzhen July Shenzhen July Beijing Aug

• • • • • • • •

3 VBB surgeons 1 VBB feline medical specialist 4 VBB anaesthesist nurses 4 Chinese trained surgeons as trainers 60 Chinese surgical and anaesthetic trainees In Shenzen,> 110 Chinese vets participated in lectures ‐ from Shenzen Zhu Hai and Guangzhou 36 Vets received hands on surgical , anaesthetic training and patient care • In Beijng, >60 Vets in Lectures and demonstrations ; • 36 Vets received hands on surgical, anaesthetic training and patient care

Action·Compassion·Together

Vets Beyond Borders

China 20102010- Shenzhen & Beijing

Vets Beyond Borders

Dr Liang training surgeons under Dr Barton’ Barton’s supervision

Surgical training and anaesthetic monitoring

Dr Chris Barton demonstrating using model of uterus 猫科专猫科专家 Dr Richard Gowan 高文医高文医师师正在说明猫的牙科学

Vets Beyond Borders

2010 Progress

• Beijing municipality gives 1000 free desexing vouchers for

• Beijing government collaboration • The BGSAHVS from the Beijing Agricultural Bureau.

cats

• Over 100 vet clinics in • Beijing participating in programme. Act Asia working with • • •

provided the venue in Beijing, all drugs and medical supplies used for the Beijing programme .The Director of BGSAHVS, Wei Hai Tao, said: BGSAHVS W i H i T id “The Beijing government is Th B iji t i already distributing 1,000 free neutering vouchers every month. This programme by ACTAsia is a very worthwhile contribution to our efforts to reduce the stray animal problem in our area.” In addition, the government’s participation also encourages Beijing vets to be more open to new surgical techniques and animal welfare knowledge

j g p y y Beijing Municipality on stray animal control 6 selected Trainees from Beijing to become new trainers Improvement of animal recovery Reinforcement of pain relief treatment , reinforcement of gentle handling of animals, peri ‐operative intravenous fluids, introduction of long acting penicillin, correct techniques for preparation of kits and correct sterilization of surgical instruments .

Action·Compassion·Together

Vets Beyond Borders

ABC ABC‐‐AR program in China AR program in China 2011 2011

Vets Beyond Borders

Shenzhen 2011 Chinese trainer discussing the experiences and challenges in the last year.

Shenzhen Oct.17‐ Shenzhen Oct.17 Sh h O t 17‐18 Beijing Oct.19 Beijing Oct.19‐‐21 Dalian Oct.24 Dalian Oct.24‐‐27

Vets Beyond Borders

2011.10.18 Visiting Shenzhen animal husbandry and veterinarian station, animal epidemic prevention department Discussing animal management policy and p pp practical application

Vets Beyond Borders

2011.10.19 Beijing Small Animal Veterinary Association & Beijing Station of Animal Husbandry and Veterinary Discussing animal management policy and practical application

Vets Beyond Borders

2011.10.25

Dalian- Pilot programme

2011.10.20-21 Beijing potential trainers in training

Vets participating in flank-spey technique to further promote and improve ABC-AR development in Dalian.

Vets Beyond Borders

2011.10.26-27

Dalian

4 vets and 4 nurses from 4 animal hospitals received hands on training

3. The Essentials of ABC Surgery Dr. Ian H. Douglas BVM&S, MRCVS, MACVSc(Surg) Vets Beyond Borders

Contents Pg 2: Pg 3: Pg 4: Pg 5: Pg 8: Pg 9: Pg 10: Pg 12: Pg 17: Pg 18: Pg 20:

Components of surgical facility Pre-surgical management Anaesthetic protocols Surgeon: preparation for surgery Preparation of surgical kits and drapes Intravenous fluids & Antibiotics Surgical sterilisation of street-dogs Ovario-hysterectomy Castration Record-keeping & Post-surgical release Common syndromes of surgical significance

SURGICAL FACILITY â&#x20AC;˘

Components: Patient preparation area Operating theatre Surgical supply Surgical store Kennels / Recovery area

â&#x20AC;˘

Policies: Thorough pre-operative assessment Safe anaesthesia protocols Sound surgical technique Consistent post-operative care Detailed and accurate record-keeping

Patient Preparation Area: To minimise contamination with hair and excreta, anaesthetic induction, shaving and prepping should be performed in a separate room or at least on a separate surface from the surgery table.

Operating Theatre / Surgical Area: This area should be reserved for theatre staff and anaesthetised surgical patients only and should contain: ! ! ! ! ! !

Surgical scrub sink and tap Surgical tables Sterile surgical kits Drugs and/or equipment for anaesthetic maintenance Supply of surgical materials (suture, needles etc) Surgical waste bins

Surgical Supply: This area is dedicated to the cleaning and sterilising of surgical instruments and drapes, and should include: ! Sinks or bowls for cleaning of used instruments and drapes ! Table with clean/dry surface for preparing new kits and storing sterile kits ! Autoclave

Surgical Store: ! ! ! ! !

Secure storage of surgical instrumentation, materials and drugs Appropriate storage conditions: e.g. refrigeration; cupboard for light-sensitive drugs Lockable dangerous drug cupboard and register Maintenance of accurate inventory Pre-emptive ordering: must ensure adequate stock to allow clinical work to be performed

Kennels: To enable adequate post-operative care, it is essential that the kennels offers:

! ! ! ! ! ! !

Supervision by trained personnel Secure, sheltered accommodation Regular removal of stools and daily washing of floors with disinfectant (bleach) Adequate lighting and heating Water supply Provision of appropriate, clean and dry bedding Isolation pens: for patients with suspect contagious disease, most notably Rabies and also for patients receiving Chemotherapy (esp. Vincristine: TVT)

PRESURGICAL MANAGEMENT • • •

•

Routine pre-surgical examination Confirm diagnosis pre-op if possible Assessment of fitness for anaesthesia and surgery Detailed plan: pre-operative anaesthesia intra-operative postoperative: in-patient or outpatient

Routine pre-operative examination: General physical assessment with specific regard to the possible coexistence of problems such as: • • • • • • •

Body condition: e.g. cachexia Dehydration Toxaemia Azotaemia Shock Hypothermia Premature ventricular contractions: following trauma

_____________________________________________________________________________

ANAESTHETIC PROTOCOLS • Premedication 1) Sedation/Tranquillisation/Analgesia: given to: • Reduce dose requirements of anaesthetic agents as a result of analgesic action • Facilitate handling of patient for induction 2) Atropine: given to:

•

Lessen side-effects of premedicants and anaesthetic agents e.g. cardio-depressant effects of xylazine and11 barbiturates

•

Inhibit production of mucus in respiratory tree

Commonly-used combinations: - Xylazine + atropine: Xylazine (20mg/ml): 1ml/10kg (recommended max. dose approx. 2ml) + Atropine (0.6mg.ml): 0.2ml/10kg : NB: young pups (6-12 weeks): approx 0.2-0.3 ml/10kg Xylazine (20mg/ml). - Phenothiazine tranquilliser (e.g. trifloupromazine, acetylpromazine) +/- butorphanol (opiate analgesic) + atropine; NB phenothiazines have NO analgesic properties

• Induction Should be performed on preparation table An ideal agent used should be:

• • • • •

Safe Able to be given intravenously Rapid in action Non-irritant perivascularly Enable smooth induction and recovery

Commonly-used agents: –

Ketamine (50mg/ml) and Diazepam (5mg/ml): non irritant perivascularly: given as 50/50 mixture: 1ml/10kg in premedicated patient

–

Thiopentone 2.5 % : lessens risk of severe reaction to perivascular administration associated with administration of 5% solution. Administer 2.5% solution @ 4ml/10kg to premedicated patient; avoid administration to cachexic or very lean patients (barbiturates are metabolized by adipose tissue). Must still inject isotonic saline locally if administered perivascularly (twice the estimated volume of perivascular Thiopentone); less analgesic effect than Ketamine (therefore premedication should include Xylazine or Opiates)

NB: Immediately following induction, a suitably-sized endotracheal tube should be placed and the cuff inflated to the minimum pressure required to prevent inhalation of gastric contents should vomiting occur; the patient should be placed on and partially-covered with an insulating pad/towel/bubble-wrap etc to minimise heat loss

• Maintenance – –

–

Ideally should involve use of inhalation anaesthetic agents such as isofluorane or halothane in combination with medical oxygen In the absence of inhalation agents, anaesthesia may be maintained using incremental administration of induction agents. Note: avoid giving multiple low-dose increments as this will result in a significant increase in the total dose of agent, and prolonged recovery time (esp. barbiturates). Ensure very careful placement of i/v needle/catheter and tape to limb securely If prolonged anaesthesia is likely, intravenous fluids (preferably warmed) should be administered

• Recovery – –

Following completion of surgery, patient should be kept warm and closely observed in a quiet area. A rolled-up towel should be placed under the shoulder region to elevate the thorax and minimise the risk of aspiration following removal of the endotracheal tube. Analgesia: Meloxicam: 0.2mg/kg should be administered 12

– – – –

Endotracheal tube should not be removed until patient has a strong gag reflex – remember to deflate cuff before removal. Examine tube for evidence of blood, vomit etc, and manage if necessary. In the event of excitation/distress on recovery: administer tranquilliser (eg diazepam) or additional analgesia (eg opiate) as required. Only return patient to kennels when able to sit up unassisted.

SURGEON Preparation for Surgery • • • •

Clothing: the surgeon should wear clean and fluff-free, loose-fitting clothing; the top must be short-sleeved to enable appropriate scrubbing as far proximally as the elbow. Ideally a surgical hat and mask should be worn; at the very least, long hair must be tied-up and facial hair closely-trimmed. Finger nails must be cut short. Should the surgeon have an infected wound or sore on the hands or forearms, it is preferable that surgery be postponed until such time as this has healed.

Surgical Scrub: An acceptable germicidal preparation, e.g. Chlorhexidine or Betadine, must be used.

• Scrubbing: o

The hands and arms are washed first with the scrub mixture to remove any gross contamination.

The nails are cleaned next, before the scrubbing procedure begins.

A sterile brush is used to scrub: 1. the fingers 2. the hands 3. finally, the arms

- in that order, scrubbing over a period of no less than 3 minutes. Once the brush has been used on the arms, it should not return to the fingers. Each finger should receive ten strokes on each surface, making a total of forty strokes per finger. The fingernails and both surfaces of the hands should receive twenty strokes. The number of scrubbing strokes is far more important than the time spent scrubbing.

• Rinsing When scrubbing is completed, the hands, arms and the brush should be rinsed in water, allowing the water to drip from the elbows to prevent contamination of the hands with drips from upper arms. •

Drying of hands Two sterile hand towels are provided. The first towel is unfolded and used to dry thoroughly the fingers, hand and forearm (in that order) of one arm, taking care that the 13

fingers of the hand holding the towel do not contact the skin of the other arm. The second towel is used to dry the other hand and forearm in identical fashion.

• Alcohol Spray

With the hands held above the level of the elbows, surgical spirit should then be sprayed on the hands and then the forearms, and allowed to dry.

Surgical Gloving: •

Once the arms and hands are dry, sterile surgical gloves are donned in the appropriate manner, ensuring that the fingers do not contact the outside of the gloves. If this occurs, both gloves should be discarded and a new pair applied.

•

ONCE GLOVED, THE SURGEON’S HANDS MUST NOT BE HELD BELOW THE LEVEL OF THE OPERATING TABLE UNTIL THE END OF THE PROCEDURE (THE AREA BELOW THE TABLE TOP CANNOT BE CONSIDERED STERILE)

Opening of instrument pack: A non-scrubbed assistant will then present the kit to the surgeon in one of two ways, depending on whether the kit was double- (preferable) or single-wrapped: •

Double-wrapped: the outer wrap will be held and opened by the assistant; the surgeon will then remove the pack, handling only the inner wrap, place it on the plastic sheeting covering the table and patient and then unwrap the kit. Care must be taken, at all times, not to touch the plastic, the table or the patient as these are not sterile areas.

•

Single-wrapped: the assistant will place the kit on the plastic covering the table and will unwrap the first fold only. The surgeon may then completely unfold the wrap, taking care to handle only the sterile aspect of the wrap.

Sterile Draping: •

To isolate the surgical site in a sterile field, one of two draping options may be considered: o o

•

Single fenestrated drape: frequently used in routine procedures such as desexing Quadrant draping: using four non-fenestrated drapes: for procedures requiring longer incisions.

In both techniques, the drapes are stabilised to the patient using at least four sterile towelclips. The clips should not be applied in such a way as they grasp the entire thickness of the dermis, as this will lead to painful puncture-wounds which may cause the patient to lick the area and traumatise the surgical site. It is best to ensure that, when unfolded, the field drape overlaps the kit drape: this will reduce the risk of a breakdown in sterile technique.

Lay-out of instruments: •

The surgical instruments should then be arranged in a logical and consistent fashion as befits the procedure. 14

On completion of surgery: • •

Following removal of the patient, the surgery table should be thoroughly cleaned with an appropriate disinfectant solution, such as Lysol. Do not forget to clean the sides of the table. Plastic sheeting should be washed in disinfectant and hung to dry. Once dry, it should be sprayed with surgical spirit.

_____________________________________________________________________________

KITS AND DRAPES Cleaning of used kits and drapes: •

• • •

As soon as possible after the completion of a procedure, both the surgical instruments and drapes should be thoroughly washed and rinsed, ensuring removal of all blood and discharges. A toothbrush is useful to clean instruments thoroughly, with particular attention to the jaws, box joints and ratchets. Drapes should then be hung to dry; once dry, they should be brushed to remove all hair. Cleaned instruments should be placed on a towel to dry; instruments with ratchets should be left open. Periodically, instruments should be left to soak overnight in protective instrument milk.

Preparation of surgical packs: • • • • • • •

Dry instruments should be laid on a dry wrap. A useful technique is to feed one of the handles of all instruments with finger-loops, other than the towel-clips, through the shaft of the longest instrument (frequently the needle-driver). An appropriate number of swabs should be included in the kit. The swabs should be folded over the ends of the instruments to avoid puncture of the wrap. The wrap is the folded once, longitudinally. A hand towel is then laid. The final folding is performed and the wrap secured with a small piece of autoclave tape. Ideally this inner-wrap is then covered with a second wrap, and autoclave tape applied as before. The pack is identified and dated (by writing on the tape) and placed in autoclave (best) or pressure cooker

Autoclave: • • • • • •

Carefully follow instructions for operation and care of the autoclave. Unit must be regularly checked for faults/safety. Use indicators in packs to check adequacy of sterilisation. Packs should be double-wrapped if at all possible. All packs for sterilisation must be dated and re-sterilised after 4-6 weeks if unused. Items should be laid on their side in the chamber of the autoclave and must not be tightly packed, as this will reduce efficiency of sterilisation; steam must be able to circulate.

•

If packs are moist when removed from the autoclave, recalibration of the drying-cycle of the unit may be required. 15 Until the recalibration has been carried out by a trained technician, moist packs should 94

•

only be placed to dry on clean, dry, plastic sheeting which has previously been sprayed with surgical spirit; otherwise contamination of packs will occur. Time/temperature relationships for steam under pressure: The following are times at which materials being sterilised must be at the target temperature. They do not take into account time for penetration by steam or ‘heat-up lag’. ! !

3 minutes at 134°C (273.2 deg F) 29.4 psi 15 minutes at 121°C (249.8 deg F) 15 psi

_____________________________________________________________________________

INTRAVENOUS FLUIDS Intra-operative intravenous fluid administration: Indications: • • • • •

Debilitated patient Very young patient: poor homeostatic response Prolonged procedure Procedures associated with high risk of intra-operative complication Procedures likely to require intra-operative administration of intravenous medications

NB: Ideally fluids should be administered at body temperature Choice of fluid: • • •

Healthy patient: preferably Lactated Ringers Solution Paediatric patients: 5% Dextrose Solution (prone to hypoglycaemia) Sick patient, choice of fluids is dependent on symptoms/diagnosis/biochemistry results (see previously)

Rate of administration: • •

Routine procedure: during surgery: 20-40ml/kg/hour 10-20 ml/kg/hour in paediatric procedures

_____________________________________________________________

SURGICAL USE OF ANTIBIOTICS • Peri-operative antibiotics: Classification of surgical procedure: • • • •

Sterile: eg routine ovario-hysterectomy Clean: eg fracture with implants Clean/contaminated: eg cystotomy / gastrotomy / pyometra Contaminated: eg compound fracture 16 95

•

Dirty: eg debridement and suturing of grossly contaminated wound / resection of perforated bowel

Prophylactic administration of antibiotics : may be used in sterile, clean and clean/contaminated procedures: • • •

If prophylactic antibiotics are to be given, they must be administered intravenously, no less than 15 minutes before the initial skin incision is made. Adequate antibiotic concentration in tissues at the surgical site cannot be obtained if the drug is administered following incision, as the local blood supply is then impaired. Local irrigation of the site with antibiotic solutions is of no benefit and may cause tissue irritation.

Commonly-used antibiotics: cephalexin, amoxycillin, cloxacillin, gentamycin. Repeat doses should be given as necessary during surgery (eg cephalexin: given hourly at 25mg/kg). If there is no obvious failure of sterile technique in a sterile, clean or clean/contaminated procedure, there is no merit in continuation of antibiotics after completion of surgery. Therapeutic administration of antibiotics: used in contaminated and dirty procedures: to treat existing or inevitable infection • • •

Selection of antibiotic depends on likely pathogen (eg aerobe/anaerobe, G+ve/G-ve). These should be administered at recommended dose prior to, during and for several days after surgery: Initially parenterally and then orally for several days, as dictated by clinical response. Antibiotic(s) may be changed if no response or if culture/sensitivity performed on samples obtained during procedure indicates alternate antibiotic(s) would be preferable.

SURGICAL STERILISATION OF STREET-DOGS Appropriate anaesthetic protocols and surgical asepsis are the keys to success: ANAESTHESIA: see previous notes Option 1:

•

Premedication: Xylazine/Atropine; Induction: Diazepam/Ketamine This is the protocol most often used by SARAH surgeons

Option 2:

•

Premedication: Xylazine/Atropine; Induction: Thiopentone

•

Premedication: Chlorpromazine/Atropine; Induction: Thiopentone

Option3:

Followed by either: 1) Intravenous Maintenance: Usually incremental administration of Diazepam/Ketamine or Thiopentone NOTE: Administration of repeated doses of Thiopentone leads to very prolonged recovery time, especially in the thin patient or 2) Gaseous maintenance: Delivery of Isofluorane in oxygen via anaesthesia unit is much superior to maintenance by repeated intravenous administration of an induction agent. The Fresh Gas Flow is like the flow of a river. The CO2 produced by the patient is similar to the dumping of waste (pollution, septic) down stream. If the river water is to enter the drinking system, there are 2 ways to make this safe: •

The flow of the river must be much greater than the waste entering. The flow washes the waste away (high Fresh Gas Flow of a non-rebreathing system) The long, narrow river and the intermittent dumping makes this washing action effective. (A lake, rather than a river, and constant dumping would make it almost impossible to wash it away.)

We may not get sick unless exposed to a certain level of the waste in our drinking water. Thus a lower flow than will completely wash all waste away can be acceptable (partial rebreathing flow / system). •

The water must go through a process to remove the waste. Flow is not critical (high or low flow is OK). It filters the waste out, before we drink it. (CO2 absorber of a circle system)

Also recognize that the flow required will vary depending on the amount of waste entering the system. Larger factories, farms upstream will require the flow to be higher or the filter larger than if a small factory or farm was polluting the system (flows relate to the weight of the animal expressed as ml/kg/min). •

•

Non-rebreathing o

All the exhaled gases are exhausted (washed out by the fresh gas flow or directed out a valve).

Fresh gas flow is between 200-300 mL/kg/min based on pattern and depth of ventilation. With a valve included in the circuit, flows at 100 mL/kg/min can be nonrebreathing.

Total rebreathing o

All the exhaled gases are recirculated and rebreathed with only the addition of fresh gas flow equivalent to metabolic oxygen consumption (MOC). Valves are needed to ensure exhaled gas goes through the CO2 absorber to remove the CO2. Fresh gas flow is approximately 3-10 mL/kg/min (inversely proportional to animal size). 18

•

Partial rebreathing (somewhere between the above conditions) o o

Quite acceptable if a CO2 absorber present. The amount of acceptable partial rebreathing is limited if a CO2 absorber is not available (>100 ml/kg/min dependent on the circuit, patient breathing pattern and tidal volume).

http://www.ovc.uoguelph.ca/personal/ddyson/online/HOMEPAGE/home.html http://instruction.cvhs.okstate.edu/vmed5412/pdf/07AnesthesiaMachine.pdf Usual settings for anaesthesia maintenance: •

Circle system: 1-5-2% Isofluorane with Oxygen flow rate of 1-1.5 litres per minute; pop-off valve set to allow voiding of excess gases during expiration

•

T-piece: 1-1.5% Isofluorane with Oxygen flow rate of 0.7-1 litre per minute

•

Scavenger in place if available or voided gases ducted to outside of building

SURGICAL ASEPSIS: • • • • •

Appropriate sterilisation of instruments and drapes Careful clipping/shaving, cleaning and disinfection of surgical field Diligent scrubbing of hands and forearms with approved antiseptic (Chlorhexidine or Povidone Iodine) prior to surgery Wearing of sterile surgical gloves Aseptic and atraumatic surgical technique

Patient Preparation: • • • • •

• • •

Anaesthetic induction, shaving and prepping must be performed on a separate table to the surgery table, to minimise contamination. If intravenous fluids are to be administered, the catheter site should be shaved and prepped as described for the surgical site below. The catheter is then inserted and the primed intravenous line connected. The bladder should be palpated and expressed if necessary and genitalia examined for presence of Transmissible Venereal Tumour (TVT). The surgical site should be widely and carefully shaved, avoiding trauma to the area: even small cuts can lead to wound infection. The site should be thoroughly cleaned with Chlorhexidine solution. Multiple pieces of cotton-wool should be used in turn, commencing at the centre of the area and moving towards the periphery of the shaved area, and NEVER back into the centre, otherwise the wound will be re-contaminated. Avoid wetting non-shaved areas of the patient. Once the shaved area appears free of gross dirt and hair, and the pieces of cotton wool used come off the skin with no staining, then the site can be considered clean, but NOT disinfected at this point. Disinfection of the site is achieved using three spray-applications of surgical spirit – one minute between applications. A final spray of Iodine solution may also be applied, but ONLY once the spirit has evaporated and the skin is dry. Do not touch the skin during this 19

• •

process, otherwise adequate disinfection will not be achieved. Once again, avoid wetting the non-clipped area as this may lead to “run-off” and contamination of the site. The patient is then transferred to the surgery table; in so-doing, take care not to contaminate the prepped area with your hands or non-disinfected parts of the patient. The prep table should then be carefully cleaned with an appropriate disinfectant, such as Lysol solution.

Operating table: • • •

A clean insulating blanket (e.g. “Mirotec”) should be placed underneath the patient to minimise the risk of iatrogenic hypothermia. Bubble-wrap or aluminium cooking foil may also be used, both underneath and on top of patient, but avoiding the prepped area. A clean fenestrated plastic sheet (previously sprayed on both sides with surgical spirit, and allowed to dry) is then placed on top of the patient; be careful that the plastic does not contact the prepped area. If the surface of the table is exposed where the surgical kit is to be placed, a second sheet of plastic should be laid, overlapping with the first. This is to stop “strike-through” contamination of the surgical instruments (especially with urine or faeces).

OVARIOHYSTERECTOMY - Surgical removal of both ovaries and uterus -

Flank Approach versus Midline Approach In pet dogs, the choice of approach is influenced greatly by the experience of the surgeon, and the condition and reproductive status of the patient. However, in street-dog projects, the flank approach is recommended. FLANK SPAY- ADVANTAGES: !

Reduced healing time due to increased vascularity of sutured tissue (muscle) and absence of wound tension from weight of abdominal contents

Little likelihood of catastrophic wound breakdown

·In lactating bitches, less likelihood of trauma to wound by suckling activity of pups

·Easy to check the wounds of fractious animals post-operatively

·Animals can usually be released earlier than following midline approach

FLANK SPAY - DISADVANTAGES !

More traumatic approach in pregnancy or obese patient, as a larger incision is required.

It may be difficult to expose the opposite ovary and uterine bifurcation, especially if the incision is poorly located. 20

If myotomy approach (undesirable) is performed, rather than muscle separation (preferable), there is an increased likelihood of post-operative pain and infection.

Recovery of a dropped or bleeding ovarian pedicle is difficult: if this occurs, the skin wound should be quickly closed and the dog repositioned in dorsal recumbency. Following skin preparation, a midline laparotomy should be performed to enable location and ligation of the bleeding pedicle. Following completion of the midline surgery, all layers of the flank wound should be sutured as normal.

MIDLINE APPROACH - ADVANTAGES !

White Line incision – possibly less post-operative pain than flank approach

In the event of haemorrhage or dropped pedicles, the incision can easily be extended to locate, clamp and ligate bleeding vessels

In operations requiring a longer incision, such as advanced pregnancy or pyometra, a midline approach may be less traumatic than via flank

MIDLINE APPROACH - DISADVANTAGES !

Surgical wound is harder to check post-operatively in fractious animals

Risk of catastrophic wound breakdown and herniation following release patient

Dogs must be kept hospitalised for longer periods, as the healing rate of the White Line is slower than muscle

THE PROCEDURE Important considerations: • • • • • •

Palpation of abdomen to assess bladder and status of uterus (pregnancy/pyometra): express bladder if necessary Examine vulva and vagina for evidence of Transmissible Venereal Tumour Careful preparation of skin Appropriate site of incision Appropriate size of incision; should be as small as possible (reduced healing time) Haemostasis

Flank Approach ! !

Tie upper hind-limb back Location of incision: dependent on age and reproductive status: more cranial in mature or pregnant bitch; more caudal in immature bitch

100

! ! ! ! ! ! ! ! !

Oblique skin incision (approx 3cm long in routine spay) Blunt separation of subcutaneous fat: avoiding large local blood vessels Identification of external abdominal oblique muscle (EAO) Small stab incision in EAO Blunt separation of muscle fibres parallel to the direction in which they run Identification and separation of Internal Abdominal Oblique (IAO) and then Transverse Abdominal (TA) muscles as with EAO Tag TA with Allis forceps at ventral margin of wound Insert spay hook into peritoneal cavity at an angle of around 20-30 degrees from horizontal with hook pointing up; raise hook end towards abdominal wall, retract and identify uterine horn or broad ligament fat Perform ovario-hysterectomy

Midline Approach ! ! ! !

Skin incision from umbilicus caudally: length of incision: between 3 and 6 cm; longer in obesity, pregnancy or pyometra Careful sharp dissection with scalpel to define White Line Tent White Line and make small incision into peritoneal cavity May then inset blunt-tipped instrument (eg haemostat) along the inside of the abdominal wall and cut down through the Linea Alba onto this instrument.

OVARIO-HYSTERECTOMY TECHNIQUE • • • • • • • • • • •

Elevate right ovary from abdomen Gently stretch or “pop” ovarian ligament Double-clamp vascular pedicle Ligate vessels Double-ligate ovarian pedicle before incising Check pedicle for haemostasis and return to abdomen Tear, crush or ligate broad ligament: Clamp uterine body near cervix Double-ligate uterine body before incising Check pedicle for haemostasis and return to abdomen Elevate left ovary and proceed as per right side 22

101

FLANK CLOSURE: • • • • • •

Insert 1 or 2 horizontal mattress sutures or 2 to 4 simple-interrupted sutures of synthetic material to close TA wound Remove Allis forceps from TA and apply to IAO: suture as with TA Remove Allis forceps from IAO and apply to EAO: suture as before Suture s/c fat with continuous pattern Skin closure with subcuticular pattern (simple-interrupted sutures or continuous with buried knots : simple-interrupted associated with less risk of wound separation following automutilation) +/- superglue In lean patients, may combine s/c and subcuticular closure as one layer, using simple-interrupted pattern, ensuring knots are buried.

MIDLINE CLOSURE: • • •

Suture Linea Alba with simple-Interrupted sutures: ideally ensuring that both the internal and external rectus sheaths are included, but not the rectus muscle itself. Suture subcutaneous tissues using continuous pattern Appose skin edges with subcuticular sutures +/- superglue

Choice of Suture Material • • •

Catgut is appropriate for ligation of ovarian and uterine pedicles Choose appropriate strength for size of dog (5-10kg: 2/0 or 1/0; 1025kg: 1/0 or 1) Synthetic absorbable (eg PGA, PDS) is preferable for muscle, s/c and subcuticular sutures, as catgut induces a marked inflammatory response and may predispose to establishment of local infection (5kg: 3/0 PGA; up to 25kg: 2/0 PGA)

Perioperative Medications • • • •

Antibiotics: preferably i/v at induction (at least 10 mins before start of surgery) +/- long acting i/m dose Meloxicam (NSAID) - analgesia (NB renal function) Ivermectin - to treat intestinal parasitism and Scabies Rabies vaccination

Methods of Identification: • • •

Ear notching: ‘V’ shaped excision in leading edge of right pinna Application of coloured collar Tattooing sites: medial aspect of pinna or medial thigh

102

CASTRATION In general, there are two techniques described for removal of the testes; both involve a prescrotal skin incision. A testis is then manipulated into the incision site and the incision extended down through overlying fat and fascia until the outer (parietal) tunic of the testis is visualized. Thereafter, the two techniques differ: Open technique: incision extended through the parietal tunic. This procedure is associated with an increased incidence of post-operative scrotal haematoma, and is not recommended in an intensive ABC setting. Closed technique: recommended:

•

The parietal tunic enclosing the testis is NOT incised but is fully exposed by gentle sharp dissection with a scalpel blade, in a cranio-caudal direction, whilst exerting upward pressure on the testis with the fingers of the other hand.

•

The testis is then prolapsed into the incision and carefully exteriorized.

•

The vascular, spermatic cord and cremaster muscle components are visualized within the tunic.

•

The fat and fascial tissues adherent to the caudal aspect of the parietal tunic are manually torn from off the tunic – this may require significant effort, but should be performed with care – rubbing with a dry swab is of great assistance in disrupting this tissue and in achieving full exposure of the cord.

•

The entire cord is clamped with a haemostat and a second clamp applied approximately 1 inch distal to the first.

•

A circumferential ligature is tied into the crush created by the first clamp (1/0 or 1 Catgut or PGA)

•

½ inch distal to the ligature, a transfixing ligature is placed, carefully avoiding puncture of the spermatic vessels

•

A third clamp is placed immediately distal to the second, and the testis is resected by incising between these two clamps.

•

The proximal stump is assessed for security of the ligatures and is gently returned into the depths of the prescrotal incision

•

The remaining testis is resected in similar fashion

•

The deep fascia is sutured using continuous 3/0 or 2/0 PGA, incorporating the tissue on both sides and medially. 24 103

•

The skin is closed with PGA using a subcuticular, simple-interrupted pattern, taking care to ensure that the knots are buried.

POTENTIAL COMPLICATIONS: The risk of haemorrhage from spermatic vessels is much less likely if this double ligation technique is employed. However, if noted, an attempt should be made to locate the ends of the cord on the side from which the haemorrhage is occurring, by grasping the deep tissue with haemostats and applying gentle traction. Should this prove unsuccessful, the skin incision should be extended into the scrotal sac as this will improve access to the inguinal canal, enabling location of the bleeding stump and application of two secure ligatures. If the skin incision is extended in this manner, scrotal ablation is necessary to excise the sac and associated dead space, which would otherwise predispose to scrotal haematoma.

RECORD KEEPING Accurate records are absolutely essential to ensure appropriate care of patients and guarantee that dogs are returned to the location in which they were caught. Minimum required documentation: • • • •

Admission Chart: completed by Vet-Aides during catching and admission and upon release Surgery Chart: completed by duty Veterinarians Discharge Chart: to ensure patients are returned to exact catch location In-patient Chart: used for any patients with complications or non-ABC surgeries

Required details include: • • • •

Exact capture Location Estimated age Gender Weight

• • •

Category of patient: stray or community dog Clinical records: including presence of TVT etc Release information

104

POST-SURGICAL CARE AND RELEASE •

All dogs are assessed by duty Veterinarians at end of working day and at least twice daily thereafter until release

•

If follow-up treatment is necessary, an In-patent Chart is completed and full details of clinical findings and treatment are entered

•

Routine procedures: released after 24 hours, if: -

Flank spay or closed castration was performed Intra-dermal skin sutures used High energy meal eaten before release No signs of complication

•

If aseptic surgical technique not maintained: patient is kept under observation for 72 hours, and additional antibiotics administered (this should be a rare occurrence if adequate clinical standards are maintained)

•

Ventral midline incisions: patients not to be released for at least four days

EXPECTED CASE-LOAD •

In a well-organised hospital setting, an experienced team of two surgeons should perform at least 20 desexing surgeries per day (male and females)

•

Requires sufficient, trained and experienced support staff (vet-aides and kennel hands)

•

Aim to have second surgeon making skin incision when first surgeon in half-way through procedure, to ensure most efficient use of staff

•

In camp setting: fewer surgeries possible in a day

COMMON SYNDROMES OF SURGICAL SIGNIFICANCE a) Cachexia (emaciated condition): •

Postpone surgery if possible, and feed high protein, high energy meals and multivitamin supplementation, treat parasitic disease

•

If not possible: –

Intravenous dextrose saline

105

– – –

Avoid iatrogenic hypothermia Shave and skin prep b4 anaesthetic induction Avoid use of barbiturates

b) Dehydration: – •

Assess percentage dehydration:

4% Dehydrated: • • • • •

•

8 % Dehydrated: • • • • •

•

Skin pliable Skin twist disappears immediately Skin tent persists for no more than 2 seconds Eyes: bright but slightly sunken Oral mucosa: moist and warm

Skin leathery Skin twist disappears immediately Skin tent persists for 3 seconds or more Eyes: duller and obviously sunken Oral mucosa: sticky but warm

12% Dehydrated: • • • • •

Skin: no pliability Skin twist persists indefinitely Skin tent persists indefinitely Eyes: cornea dry; eyes deeply sunken (2-4mm between eye-ball and bony orbit) Oral mucosa: dry, cyanotic, warm to cold

Correct Dehydration: •

Calculate volume required: Multiply the estimated percentage dehydration by the patient’s bodyweight in kg E.g.: 20kg dog estimated to be 7% dehydrated would require: 20 x 0.07 = 1.4 litres i/v fluid to correct deficit

However: •

Must then supply maintenance requirements: Approximately 40-60mls/kg/day

•

May have to also provide for abnormal fluid losses (e.g. vomiting, diarrhoea, effusions)

Rate of i/v fluid administration: •

If no cardiovascular disease, deficit can be replaced as follows: 27

106

–

¼ to ½ of the deficit can be administered over 2 to 3 hours

–

Remainder of deficit + volume to allow for abnormal losses and maintenance requirements are given over next 24 hours

NB: If heart disease present: rate must be slowed

•

In addition to fluid volume lost, one must also consider losses of: • • • • • • •

Electrolytes/Acid-Base Balance Glucose Blood cells Clotting factors Proteins And also renal perfusion and function Vomiting (gastric): Metabolic alkalosis due to loss of H and Cl: administer Isotonic Saline

•

Diarrhoea (small intestinal): Metabolic acidosis due to loss of HCo3: administer Lactated Ringers Solution NOTE: During treatment, Renal Function must be closely monitored

c) Shock: Definition: function

state of very low tissue perfusion, leading to deranged cellular

Forms: Hypovolaemic, Septic, Vasculogenic, Cardiogenic In a surgical setting, shock most commonly hypovolaemia secondary to: – – –

Haemorrhage (external or internal) Plasma loss (transudation, exudation, burns) Water and electrolyte loss: especially vomiting and diarrhoea

Clinical signs of hypovolaemic shock: – – – – – – – – –

Depression Tachycardia with reduced volume of heart sounds Rapid, weak pulse Pale, dry mucous membranes (due to peripheral vasoconstriction) Prolonged capillary refill time (> 2 seconds) Collapsed peripheral veins Hyperventilation and tachypnoea: especially when very rapid bleeding is occurring Oliguria (urine output < 2ml/kg/hr) / Anuria: as a result of reduced GFR which occurs when mean arterial pressure is < 60mm Hg Coldness of extremities and footpads 28

107

Treatment of Hypovolaemic Shock: – – o

Should be rapid, aggressive and comprehensive Response should be closely monitored

Volume Replacement: !

If PCV > 20: LRS rapidly i/v (within 15 to 30 mins if possible: i.e.: in the absence of cardiac arrhythmia / murmurs. • Dogs: 90ml/kg • Cats: 50ml/kg

If PCV < 20: administer whole blood

Drug therapy: Corticosteroids in high doses; administered slowly i/v (over 15 mins) as early as possible. ! !

Methylprednisolone sodium succinate (50g/kg): but very expensive Dexamethasone: 5mg/kg ideally in water-soluble phosphate ester

Intravenous antibiotics: in severe cases: • Sodium penicillin @ 20,000iu/kg to counter risk of anaerobic bacterial overgrowth in the biliary tree • Gentamycin @ 3mg/kg

Hypothermia must be prevented, but the patient must not be excessively warmed as this leads to vasodilatation and hypotension

NOTE: During treatment, Renal Function must be closely monitored

d) Renal Failure: •

Assess urine output: volume (closed collection system using indwelling catheter) and parameters: Dipstix Test, Specific Gravity Haematology / Biochemistry

•

In the absence of anuria: encourage output via administration of LRS (Retention of H in renal failure leads to metabolic acidosis). Must also observe for signs of hyperkalaemia (increased serum Potassium) in the oliguric patient (signs include weakness/coma/death)

•

If severe oliguria or anuria: administer diuretic (i/v fluids must be administered very slowly until urine output increases): • •

•

Mannitol (osmotic diuretic): 0.5g/kg repeated at 15 min intervals for three doses if required. Furosemide: 5-20mg/kg (following rehydration)

Avoid use of NSAIDS if hepato-renal function may be impaired (pre-existing disease / prolonged surgery time / failure to administer intra-operative fluids.

108

4. Reproductive anatomy female (dog â&#x20AC;&#x201C; lateral view)

5. Reproductive anatomy female (dog)

EARTIPPING: FERAL CAT IDENTIFICATION PROTOCOL

“EARTIPPING IS THE ONLY RELIABLE CHOICE FOR IDENTIFYING FERAL CATS.”

■

Julie Levy, DVM, Ph.D., DACVIM College of Veterinary Medicine University of Florida

artipping is the only effective method that currently exists to identify a sterilized feral cat in a managed colony. Immediate visual identification is necessary in order to:

■

Show that the cat has been sterilized and vaccinated, and is part of a managed colony. Without an eartip, animal control could mistake the cat for one that is not being cared for and euthanize her immediately. Assist the caretakers in managing the colony. Because they are family members, cats in a colony often look very much alike—several black cats, black and white cats, brown tabbies, etc. An eartip indicates that a particular cat has already been trapped and vetted, preventing the trauma of a second trapping and unnecessary surgery. Alternatively, a cat with no eartip signals to caretakers that this cat has not yet been sterilized and vaccinated.

Because it is difficult to get close to feral cats, the sterilization ID must be obvious from a certain distance. Tattooing is not effective. Eartags can become infected, drop off, or tear the cat's ear. Collars are not safe or practical for feral cats, because as a cat grows and gains weight, the collar will tighten and could strangle him. Microchipping is only useful if the cat is trapped and taken to a shelter that scans for microchips. Eartipping is performed under sterile conditions and does not significantly alter the appearance or beauty of the cat. Rather, it does much toward keeping her safe and healthy. No other method of visual identification has proven to be as safe or effective. See the other side for clear instructions how to perform an eartipping procedure. Veterinarians around the world endorse eartipping. See Dr. Julie Levy's comments, at right. Dr. Levy is a veterinarian, professor, and founder of Operation Catnip, one of the busiest feral cat spay/neuter clinics in the world. ■

I have been working with feral cats for many years now, in California, North Carolina, and Florida. Our efforts have sterilized and eartipped more than 15,000 feral cats. One thing that is very important is that all groups working with feral cats agree on a universal method of identifying sterilized animals. Feral cats may interact with a variety of caretakers, vets, and animal control people during their lives. If every group has a different method of identifying the animals, there is no way to interpret what the marks mean. It is very traumatic for a feral cat to be retrapped and transported because of unclear markings. Tattoos are frequently unreadable in feral cats unless they are anesthetized. Eartipping cannot be considered inhumane. It is performed under anesthesia at the same time as a major surgery and is certainly less traumatic than a spay or neuter. The worst possible thing is to perform unnecessary surgery on a cat that is already spayed because it was not marked with a universally recognized symbol, and this I have done. I have experimented with tattooing (great for identifying individuals), but this must be done in addition to eartipping. However, many people forget that tattoo equipment should be autoclaved between each cat to prevent the spread of FeLV, FIV, and viruses we don't know about yet. Cold sterilization will not work when there is blood, tattoo ink, and hard to clean crevices on equipment. I have also used various eartags and buttons designed for mice and rabbits, but these became infected or fell out too often. Rest assured that eartipping is considered essential by experienced feral cat advocates and is endorsed by all the major humane groups. This is NOT equivalent to ear cropping for cosmetic fashion in dogs. ■

Alley Cat Allies • 1801 BELMONT ROAD, NW, SUITE 201 • WASHINGTON, DC 20009-5147 ALLEYC AT @ ALLEYC AT. ORG

• WWW. ALLEYC AT. ORG or WWW. PETS 911. COM

EARTIPPING INSTRUCTIONS

artipping is the removal of the distal one-quarter of the ear, which is approximately 3/8 inch or 1cm in an adult and proportionally smaller in a kitten. *

Eartipping is performed while the cat is already anesthetized for spay/neuter surgery. There is little or no bleeding.

WHILE THE CAT IS STILL UNDER ANESTHESIA 1. Place a straight hemostat across the left eartip exposing no more than 3/8 inch for an adult cat and proportionally less for a kitten.*

2. Use straight blade to cut the tip off leaving the hemostat on the ear. 3. Apply a small amount of Kwik-Stop Stypic Powder to the cut edge. 4. Remove hemostat. 5. Transport cat to grooming.

Alley Cat Allies • 1801 BELMONT ROAD, NW, SUITE 201 • WASHINGTON, DC 20009-5147 ALLEYC AT @ ALLEYC AT. ORG

• WWW. ALLEYC AT. ORG or WWW. PETS 911. COM

7. JUVENILE DESEXING PROTOCOL 1. Puppies and kittens have to b e examined b y veterinarian and should be in good condition (healthy). 2. Puppies and kittens should b e over 800 grams in weight 3. Puppies and kittens should b e older than 6 weeks old 4. Give water and food at least 2 hours before surgery. Do not fast more than 2 hours. Take food away 1 hour b efore. 5. Puppies have more peritoneal fluid. It is normal to see serous fluid in the ab domen. 6. Place all patients on I.V. Fluids at a surgical rate of 10mls/kg/hour. If it is not possible to place an IV Catheter, Give SC infusion, dose 10 mls per kg. SC fluid no more than 10 mls in one site (max 10 mls one site at a tim e). Fluid must b e warm (Place near heating pad)

Beware Of Pulmonary Edema Do not run fluid in too fast or administer more than surgical dose rate. 7. Place endotracheal tube under anesthetic and remove endotracheal tube only when puppies trying to cough and swallow (Do not leave puppy alone with ET tub e in, they must be watched). 8. Heating pads during and after surgery -

Be careful, do not b urn the patient

Place all hot water b ottles and pads under very thick layer (towel or blanket)

After surgery, check temperature, if it is under 38 degrees Celsius, place heating pads/bottles under towel/blanket.

9. Provide food and water as soon as possible, if patient does not want to eat or drink , they should b e given water and food with syringe (slowly) 4

10. Post operative check. (temperature, respiratory rate, heart rate, and eating and drinking frequency). Continue checks for at least four days. 11. Puppies / kittens can be adopted after 4 days. Puppies and kittens do not need to stay in hospital if they have owners to care for them.

Anaesthetic & Surgical Consideration Potential for hypoglycemia: Do not withhold food for more than 2 hours prior to surgery. Feed as soon as possible after anaesthetic recovery.

Potential for hypothermia: Use warm blankets during and after surgery. Warm i.v. fluids. Short anaesthesia times (Short surgeries). Minim al wetting of patient when preparing for surgery. Use warm scrub solution. Small blood volume:

Meticulous hemostasis very im portant. I.V. drip is important at surgical rate.

Delicate nature of tissue: Very friable in young animals â&#x20AC;&#x201C; HANDLE CAREFULLY Use less traction than with an adult animal. When castrating young kittens, care should be taken to prevent tearing of the spermatic cord due to its small size.

Serous Fluid in abdomen: This is normal. Young animals have substantial serous fluid. If abdomen is difficult to vis ualize, use sterile swabs to soak up some of the fluid.

8. NEONATAL CARE – KITTENS AND PUPPIES **Must be respon sibility of 1 person** 1. Hygiene  Wash hands before handling kittens and puppies  M ake milk fresh and keep in fridge for 24 hours, then discard unused portion  Wash all sy ringes and bottles in hot water after use and store in clean sp ot for next feed (fridge is good to prevent bacterial growth) 2. Feeding care **Only use one type of milk formula – what you start with is what you finish with** A. For 1-3 week old (eyes still closed)  Keep warm: Place blanket/towel over kittens/puppies. If nights are cold use a hot water bottle underneath towels  Feed at a rate of 20% of body weight in milk per day divided equally over many feeds – 6 feeds (every 4 hours). Example: 1 week kitten = 100 gram, therefore 20% of 100 = 20, so feed 2.5 ml every 2-3 hours as a base. More will be fed each day as kittens/puppies are growing  Neonates will be happy and will sleep when they have been fed enough milk  Restless neonates are cold and/or hungry  Stimulate neonates to urinate/defecate before or after feeding using tissue/toilet paper  Warm milk to body temperature B. For 4-6 week old (eyes open)  Feed at a rate of 25% of body weight per day over 5-6 feeds per day  To do this increase amount of milk offered and also introduce semisolid food (ie warmed soft food)  At 5 weeks start decreasing the amount of milk offered and increase the amount of semisolid food  Hand feed until neonates are 6 weeks old  Neonates can urinate/defecate by themselves now, but it is important that carers observe that all kittens and puppies are self toileting

9. Veterinary nursing (Aseptic protocols and patient monitoring)

A veterinary nurse’s role in the clinic

Carolyn Maguire BSc Surgical Veterinary Nurse 

Veterinary Nursing A veterinary nurse’s role in the clinic

To help the veterinarian, to make observations and report them to the veterinarian to ensure veterinarian, that whilst the patient is staying in the clinic all its needs are taken care of including comfort , pain control, toileting and mobility

Hospital Stay

A veterinary nurse’s role in the clinic Temperature/Pulse/Respiration (TPR) observations are completed and reported back to the veterinarian  Medicating under the instructions of the veterinarian  Safety in the work place  Animal handling  Environmental hazards  Chemicals 



In our clinic we have found that separating cats from dogs is extremely important in reducing stress therefore you have a calmer patient to deal with.

Removing a cat from a cage or pen

Carrying cats 



  

In difficult patients great care should be taken with cats as they can bite and scratch with all four limbs. In some cases it may be necessary to cover the patient with a blanket to assist with safe handling. In other cases it may be wise to use chemical restraint (tranquillizers, sedatives) to assist with safe handling. 5

Once removed from their enclosure many patients will need to be carried. When carrying the patient it should be done in a way that they feel secure and that they cannot injure you by biting or scratching. 6

Holding a cat for general examination

Restraining a patient for intravenous injection 



Once on the table the patient may require restraint for examination. The patient is often restrained in a sitting or standing position.



The patient may be in a standing or sitting position. The head will need to be restrained by cupping the chin in one hand (or by scruffing if the cat does not respond to gentle restraint), and the front limb extended by placing a hand behind the patient’s elbow. The thumb is placed over the anterior (front) aspect of the extended limb which causes the vein to fill with blood. This is called ‘holding up the vein’.

Handling Aggressive Cats 

   



Caring for I/V lines

Using welding gloves to cover most of forearms Crush cages Perspex shields W Wrapping i cat in i a towel or blanket Distracting them with elastic bands or face tapping can help. Sometimes using minimal scruffing until necessary

  

I/V catheters must not be in the same vein for more than 3 days I/V site must be prepared correctly before inserting catheter Checking viability must be performed 2 2--3 times daily, to check no leaking, i/v line patent and also there is no swelling of the limb below or above site of catheter

Pre and post operative analgesia 



 

Providing effective analgesia reduces the time taken for post-operative recovery, as well as being important for patient welfare. When post post-operative operative pain is anticipated, an analgesic may be given as a premedication or during surgery. This helps to avoid a painful recovery If clinical signs become apparent, the veterinarian should be informed so that analgesics can be administered

Asepsis and methods of sterilisation 



Aseptic technique is an important role of the surgical nurse. By definition aseptic technique is the performance of tasks that render the surgical field free from pathogenic microorganisms.

Pre--operative animal Pre preparation 



Clipping the patient 

The aim of this preparation remains the same, that is to minimise postoperative infections infections. Preparation of the anaesthetised patient prior to surgery varies considerably from practice to practice.



The area is usually clipped using electric clippers with a size 40 clipper blade. As a general rule the clipped area should be 4.5 cm2 larger than the required surgical site. The area should be vacuumed to reduce contamination of animal and environment.

Monitoring of patient under anaesthesia

Swabbing the patient  



There are many scrub methods used in practice – no particular method is the correct method but you should always work from the incision site outwards. An example of a simple yet effective scrub method is as follows: • scrub site with the first scrub then rinse and repeat • swab with second scrub working outward from the incision site. • spray on final scrub solution and allow to dry before surgery begins (again working outward from the incision 15 site)

Disinfectants and antiseptics

Post operative monitoring 



  

Keep veterinarian updated on any variations of vital signs During anaesthesia check heart rate, respiratory rate, temperature, SPO2, eye reflex and position, capillary refill time, reflex actions

Advise veterinarian of any vomiting, bleeding, pale mucous membranes, decrease or increase of heart rate or signs of pain Keep patient warm and comfortable byy p placing g on or wrapping in blanket Recovery area to be kept quiet as possible Keep patient’s bedding free from urine or faeces 5 minute observations until sternal recumbency then 1010-15 mins observations till discharge



Hygiene is a set of principles that are followed to minimise the risk of infectious disease Disinfectants and antiseptics are used to minimise the spread of disease by reducing the numbers of disease causing organisms such as bacteria, viruses, fungi and spores.

Cleaning instruments and materials

Packing of instruments and materials



Instruments should be carefully cleaned prior to sterilisation.



Although methods of cleaning vary there are some general rules which should be followed followed. You should: • soak instruments immediately after use • clean them of all biological debris with plenty of running water • handle instruments carefully • be careful not to damage sharp edges • take care to clean locks and ratchets well. 19

Regardless of the packing technique which is used, they should be packed so that: • proper sterilisation is promoted • equipment and materials are not damaged • packs can be stored (if necessary) so that they maintain sterility for a reasonable period of time. • sterilisation indicators show whether sterilisation has been effective • packs are dated and named for proper identification • ratchet instruments should not be closed any further than the first click and it is preferable that they are left open 20

Thank You 

10. Veterinary nursing handout 1 2 3

8 2

Veterinary Nursing A veterinary nurse’s role in the clinic Carolyn Maguire BSc Surgical Veterinary Nurse A veterinary nurse’s role in the clinic  First and foremost is to assist the veterinarian  To make observations and report them to the veterinarian, to ensure that whilst the patient is staying in the clinic its needs are taken care of.  As veterinary nurses we need to ensure the patient’s comfort , pain control, toileting and mobility A veterinary nurse’s role in the clinic  Clinical observations to be completed and reported back to the veterinarian are  Temperature/Pulse/Respiration (TPR)  Medicating under the instructions of the veterinarian  Safety in the work place  Animal handling eg muzzles, gloves  Sharps  Environmental hazards  Chemicals Hospital Stay  For the time patients are staying in our clinic we have to be mindful of the amount of stress they endure. Not just for the wellbeing of the animal but also the more stressed an animal is the harder it is to handle therefore putting the staff at greater risk of injury. Hospital Stay (2)  In our clinic we have found that separating cats from dogs is extremely important in reducing stress therefore you have a calmer patient to deal with.  We are fortunate enough to have a separate cat and dog waiting area. So whilst waiting to be seen by the vet they don’t have to be in direct contact with each other. Cat Ward  In our cat ward the cats are in stainless steel cages which are a metre off the floor as cats feel vulnerable if caged near the floor  Their cages have a front door but all walls are solid so as not to be looking at other cats, and to prevent spread of diseases  The examination table is in the cat ward to reduce the stress from transporting the cat from room to room  Sometimes if we have a very nervous cat we cover the door of the cage with a towel to reduce stress and anxiety Handling and restraint of cats  You should approach the patient with confidence, whilst talking in a reassuring tone.  If possible, you should avoid cornering the patient, as their fear will be greater if they cannot see a way to escape.  Of course this is difficult when patients are in cages or pens.  At all times you should assume that the patient is at least capable of inflicting injury and you should never trust any patient completely.  Removing a cat from a cage or pen  Once inside a cage or pen even frightened patients may feel that they are in a secure area.  For this reason removing patients from their enclosure is often the most dangerous aspect of handling. The patient has no means of escape and may feel trapped.  Their response may either be to cringe at the back of the enclosure or rush at the opening. Removing a cat from a cage or pen (2)  Behaviour may change suddenly as the patient may be unsure of how to behave.

14 15

 When opening the cage or pen door you should make sure that the patient cannot slip past you and escape.  At the same time you should coax them to the front of the enclosure rather than placing your hand inside.  Once at the entrance the patient can be lifted and restrained. Removing a cat from a cage or pen (3)  In difficult patients great care should be taken with cats as they can bite and scratch with all four limbs.  In some cases it may be necessary to cover the patient with a blanket to assist with safe handling.  In other cases it may be wise to use chemical restraint (tranquillizers, sedatives) to assist with safe handling. Carrying cats  Once removed from their enclosure many patients will need to be carried.  When carrying the patient it should be done in a way that they feel secure and that they cannot injure you by biting or scratching.  Other ideas for a well run cat ward  Quiet environment  Soft music  Comfort for cat –placing fluffies in cage  Groom cats to encourage eating  Change litter immediately when soiled  Warm/cool climate ideally 15-21c  Using heat pads but ensuring cat can move away if it gets too hot  Feline pheromones Pheromones Lifting an injured patient  Lifting patients which are injured adds to the problem. We do not want to aggravate the patient’s condition because pain may cause the patient to bite.  In many cases the patient can be lifted using modifications of the techniques already described.  In other cases it may be wise to use a stretcher.  These are commercially available but a blanket or board will often do the job. Holding a cat for general examination   Once on the table the patient may require restraint for examination.  The patient is often restrained in a sitting or standing position. Restraining a patient for intravenous injection  A commonly performed technique in clinical practice is the administration of medication by intravenous injection into the cephalic vein that is located in the front leg.  The patient may be in a standing or sitting position. Restraining a patient for intravenous injection (2)  The head will need to be restrained by cupping the chin in one hand (or by scruffing if the cat does not respond to gentle restraint), and the front limb extended by placing a hand behind the patient’s elbow.  The thumb is placed over the anterior (front) aspect of the extended limb which causes the vein to fill with blood. This is called ‘raising the vein’. Placing a patient into a cage or pen  Once the patient has been treated it may be necessary to place it into a cage or pen.  In many cases the patient will be reluctant to enter the enclosure.  In these cases it may be necessary to place the patient in backwards so that it cannot see the back of the enclosure.

21 22 23

25 26

 In the case of patients liable to bite or scratch a warning sign should be placed onto the front of the enclosure. Handling Aggressive Cats  Using welding gloves to cover most of forearms  Crush cages  Perspex shields  Wrapping cat in a towel or blanket  Sometimes placing an elastic band around ears gives them something else to think about whilst giving an i/v injection  Sometimes using minimal scruffing until necessary Protective Gloves Crush Cage Caring for I/V lines  I/V catheters must not be in the same vein for more than 3 days  I/V site must be prepped correctly before inserting catheter  Checking viability must be performed 2-3 times daily, to check no leaking, i/v line patent and also there is no swelling of the limb below or above site of catheter Caring for I/V lines (2)  When bandaging leg after inserting i/v catheter the limb must be bandaged down to the toes to reduce chance of swelling  When disconnecting/reconnecting line ensure this is done in an aseptic manner  Check volume overnight, check drug labelling of additives  Keep i/v lines low in cage Limb bandaged down to toe Signs of pain  Some signs that may indicate the animal is in pain include looking repeatedly at an area on the body, biting at the painful area, alterations in breathing pattern, vocalisation, attempts to protect (eg bite) or move away when it is touched, limping, crying, guarding and licking an area.  Restlessness, pacing, trying to get comfortable, reluctance to move and lying in one place for prolonged periods, are other symptoms that may be present. Pain and pain control Drugs used to control pain  Pain may be relieved, at least in part, by environmental or behavioural (eg petting, stroking) manipulations, as well as by drugs.  In the case of environmental control, emphasis is placed on the well being of the animal.  In dogs, socialisation with humans appears to be an important stress relieving factor.  Petting, stroking, verbal encouragement and eliciting a purr from a cat will help alleviate pain and stress.  In the case of drugs, analgesics, sedatives and tranquillisers may all be used.  The appropriate drugs and dosage will tend to be different for each case depending on the species, age and the severity of pain present. Pain and pain control (2)  Pain in animals is often difficult to assess as they possess an inborn behavioural tendency to mask pain.  Evolution has enhanced this inborn behavioural tendency because animals showing weakness, pain or distress become targets for predators.  Therefore, careful observation of the animal is required to identify sometimes subtle behavioural changes that indicate that the animal is in pain. Pre and post operative analgesia  Providing effective analgesia reduces the time taken for post-operative recovery, as well as being important for patient welfare.  When post-operative pain is anticipated, an analgesic may be given as a premedication or during surgery.

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 This helps to avoid a painful recovery  The animal should be monitored for signs of pain during the recovery period.  If clinical signs become apparent, the veterinarian should be informed so that analgesics can be administered Dogs - Hospital Stay  In our clinic 2 doors separate dogs from cats and the outside environment  Dogs are housed in stainless steel cages again with one door and 4 solid walls  Small dogs are housed in upper cages unless aggressive  The dog ward is also climate controlled  Is kept quiet, with quiet music playing  All dogs are given the opportunity to toilet often; especially when on I/V fluids Asepsis and methods of sterilisation  Aseptic technique is an important role of the surgical nurse.  By definition aseptic technique is the performance of tasks that render the surgical field free from pathogenic micro-organisms.  The success of any surgical procedure depends on healing. If infection is present healing will not occur or will be delayed.  Minimising the risk of infection is a fundamental principle of surgical technique. Sources of post operative infection  Sources of post operative infection are surgical staff, the patient, surgical materials, equipment and the environment.  The aim of asepsis is to minimise the number of pathogens thereby minimising the risk of post operative infection. Pre-operative animal preparation  Preparation of the anaesthetised patient prior to surgery varies considerably from practice to practice.  The aim of this preparation remains the same, that is to minimise post-operative infections.  Described below is one standard procedure. It is divided into clipping and swabbing. Clipping the patient  The area is usually clipped using electric clippers with a size 40 clipper blade.  The area should be large enough so that hairs don’t contaminate the surgical site during surgery.  As a general rule the clipped area should be 4.5 cm2 larger than the required surgical site.  The area should be vacuumed to reduce contamination of animal and environment. Swabbing the patient  There are many scrub methods used in practice – no particular method is the correct method but you should always work from the incision site outwards. An example of a simple yet effective scrub method is as follows: • scrub site with the first scrub then rinse and repeat • swab with second scrub working outward from the incision site. • spray on final scrub solution immediately before surgery begins (again working outward from the incision site) Swabbing the patient (2) Irrespective of the chemicals used, the principles remain the same.  Initially swabbing the incision line then working outwards always applies.  Never return to a swabbed area with a contaminated swab.  Do not damage the area by scrubbing too vigorously Cetridine, alcohol & Chlorhexidine spray bottles Monitoring of patient under anaesthesia  Keep veterinarian updated on any variations of vital signs  During anaesthesia check heart rate, respiratory rate, temperature, SPO2, eye reflex and position, capillary refill time, reflex actions

39 40

Nurse monitoring dog Post operative monitoring  Advise veterinarian of any vomiting, bleeding, pale mucous membranes, decrease or increase of heart rate or signs of pain  Keep patient warm and comfortable by placing on or wrapping in blanket  Recovery area to be kept quiet as possible  Keep patient’s bedding free from urine or faeces  5 minute observations until sternal recumbency then 10-15 mins observations till discharge Maintain Hygiene in an Animal Housing Facility  Hygiene is a set of principles that are followed to minimise the risk of infectious disease.  Disease (which is defined as an abnormality of structure or function) can be caused by many different factors and is generally categorised into infectious and non-infectious causes.  In many instances there is interplay between infectious and non-infectious causes. Disinfectants and antiseptics  Disinfectants and antiseptics are chemical agents used for the destruction of microorganisms such as bacteria, viruses, fungi and spores.  The aims of using these products are to minimise the spread of disease by reducing the numbers of disease causing organisms. Maintain Hygiene in an Animal Housing Facility (2)  Non-infectious causes of disease include: • Nutritional • Physical (Trauma) • Degenerative or Aging • Metabolic • Genetic  Infectious disease is disease caused by living organisms including • Bacteria • Viruses • Fungi • Yeasts • Protozoa • Parasites (worms and insects)  Most of these causes are not visible to the naked eye, which makes control of infectious diseases very difficult. • Why is hygiene important?  Regular and thorough cleaning will prevent the build up of potentially infectious organisms in the environment.  Sick, very young and older animals are more vulnerable to infection as their immune system may be compromised.  Personal hygiene is important to prevent transmission of infectious agents from something you contact.  This can be from one part of your body to another part, or another body (animal or human) or bodily secretions. What is involved with hygiene?  Hygiene involves constant, effective and thorough cleaning and washing – there is no easy way out of elbow grease!  Infectious agents lurk on dust and secretions and any surface or object with which an animal has contact.  Disinfection involves the use of chemicals to assist in the destruction of microorganisms.  Sterilisation includes the use of heat to kill microorganisms. What is involved with hygiene? (2)  Waste disposal practices minimise levels of contamination in the clinic.

49 50

 Protocols to handle suspected infectious animals, including isolation.  Wearing appropriate protective clothing when working in particular areas.  All sharps (needles, scalpels and glass) should be disposed of using approved sharps containers. Handling and Restraint of Dogs   A major role of veterinary nurses in practice is to handle and restrain patients.  The aim of handling and restraint is to allow procedures to be carried out on patients in a manner that is safe to the operators and the patient with a minimum of stress to both parties.  When placed in a clinical situation patients are stressed. Their response to this stress varies.  On approaching the patient the handler should be able to assess the patient’s response to this stress and decide on the best way to approach without causing a confrontation which may cause injury to either the patient or the handler. Handling and Restraint of Dogs (2)  In general you should approach the patient with confidence while talking in a reassuring tone.  If possible you should avoid cornering the patient as their fear will be greater if they cannot see a way to escape.  Of course this is difficult when patients are in cages or pens.  At all times you should assume that the patient is at least capable of inflicting injury and you should never trust any patient completely. Handling and Restraint of Dogs Difficult dogs  In difficult patients it may be advisable to leave a lead on the patient whilst they are in the cage  Although the lead may be destroyed by chewing it allows the patient to be more easily removed from the enclosure.  In some cases it may be necessary to apply a muzzle to guard against being bitten.  Muzzles may be made of material such as gauze or they may be constructed of leather.  Welding gloves can be used when pilling small dogs Lifting Dogs  Once removed from their enclosure many patients will need to be lifted onto a table.  When lifting the patient it should be done in a way that they feel secure and that they cannot injure you by biting or scratching.  It should also be done in a way which protects your back from occupational injury.  Larger patients should be lifted by two people.  In addition you should follow the rules of bending at the knees and keeping a straight back to minimise the risk of injuring yourself. Lifting smaller patients Method 1  Simply place one arm over the rump and the other under the patient’s chest and lift them whilst restraining the head  Method 2  Place one arm around the front of the chest and the other around the rump.  Although this lift gives the patient a feeling of security it should be noted that the head is not restrained and that the lifter’s face is close to the patient’s face.  In cases where you are unsure of the patient’s reaction you should either apply a muzzle or ask for an assistant to restrain the patient’s head. Lifting larger dogs  Where possible larger patients may be treated on the floor.  If however they must be lifted it should be done by two people.  In general one person lifts the front of the patient by holding them around the head and

chest whilst the second person lifts the rear of the patient by holding around the rump.  Care should be taken not to lift patients around the abdomen as this may be painful and/or aggravate the patients condition Lifting the injured patient  Lifting patients which are injured adds the problem that we do not want to aggravate the patient’s condition and that pain may cause the patient to bite.  In most cases it is wise to apply a muzzle.  The patient should be examined to determine the sites of major injury and then the patient may be lifted.  In many cases the patient can be lifted using modifications of the techniques already described.  In other cases it may be wise to use a stretcher.  These are commercially available but a blanket or board will often do the job. Holding a dog for general examination  Holding a dog for general examination  Once on the table the patient may require restraint for examination. The patient may be  restrained in a standing, sitting or lying position Restraining a patient for intravenous injection  A commonly performed procedure in clinical practice is the administration of medication by intravenous injection into the cephalic vein which is located in the front leg.  The patient may be in a standing or sitting position.  The head will need to be restrained and the front limb extended by placing a hand behind the patient’s elbow.  The thumb is placed over the anterior (front) aspect of the extended limb which causes the vein to fill with blood.  This is called ‘Holding up the vein’. Cleaning instruments and materials  Instruments should be carefully cleaned prior to sterilisation.  Although methods of cleaning vary there are some general rules which should be followed. You should: • soak instruments immediately after use • clean them of biological debris with plenty of running water • handle instruments carefully • only use instruments for their intended purpose • be careful not to damage sharp edges • take care to clean locks and ratchets well.

 Three methods are commonly used to clean instruments - fresh running water, ultrasonic cleaners and chemical agents Packing of instruments and materials  Many different techniques are used for packing instruments and materials depending on personal preference.  Regardless of the technique it is important to ensure that the instruments or materials are thoroughly cleaned to ensure that sterilisation is enhanced. Packing of instruments and materials (2) Irrespective of the packing technique which is used the following principles should be adhered to. They should be packed so that: • proper sterilisation is promoted • equipment and materials are not damaged • contents can be unpacked in an aseptic manner • packs can be stored (if necessary) so that they maintain sterility for a reasonable period of time. • sterilisation indicators such as steamclox indicate whether sterilisation has been effective • packs are dated and named for proper identification • ratchet instruments should not be closed any further than the first click and it is

62 63

preferable that they are left open Two methods of packing instruments and materials for autoclaving When performing this task particular notice should be taken of the following points:  All folds should be crisp and neat  The finished bundle should be firm but not excessively tight  It is preferable to double wrap packs as this extends their storage life.  Packs should be secure with autoclave tape  Pack should be dated and named Autoclaving Thank You 

11. Nursing manual

Veterinary Nursing Training Manual For use by Vets beyond Borders This training manual was developed by Box Hill Institute in Melbourne, Australia free of charge to support the work of Vets beyond Borders. Box Hill Institute is a vocational education and training (VET) provider with a strong track record in the development of skills to meet the workforce needs of students and enterprises in the global arena. The Centre for Biotechnology and Animal Sciences at Box Hill Institute provides specific training at VET and higher education levels for the biotechnology, animal sciences and veterinary nursing industries. Training is accessible by flexible, classroom, online and/or correspondence methods and students from around the world are welcome to discuss their training needs with us. Tel: 1300 269 445 Email: courses@bhtafe.edu.au

ÂŠ Box Hill Institute 49

Centre for Biotechnology and Animal Sciences Learner Resource: Certificate IV in Veterinary Nursing RUV4601A: Unit 5 â&#x20AC;&#x201C; Animal Housing

Animal Housing Introduction When discussing animal housing facilities a number of important issues need to be considered. These are general design, materials used, provision of temperature control, ventilation, lighting and drainage, and maintenance routines.

General design of housing facilities When designing an animal housing facility it is necessary to consider: the purpose for housing the animals, (boarding, research, holding animals for sale or accommodating sick animal) species and the number of animals to be housed, the available space, the area required for housing, and the area required for movement of staff in cleaning and maintenance, the location of the facility and the money available. In general enclosures may be divided into two (2) types. These are the walk in type or run and the cage/locker type. They may be indoors, outdoors or a combination of both. The walk in enclosure is a larger area where the animal has the opportunity to move around. Walk in enclosures are more common in an outside setting but may have an indoor sleeping area and an outdoor run or be entirely inside. They have the disadvantage that where restricted room is available they limit the number of animals, which may be accommodated. Outdoor runs/pens have disadvantages such as little or no climate control, difficulties in servicing during bad weather and problems with controlling vermin and disease carrying insect vectors. The locker or cage type is more commonly found in veterinary clinics/pet shops and boarding facilities where the animals are only being accommodated for a short amount of time.. They have the advantage that they confine the animal and that they may be stacked one on top of the other so that more animals can be accommodated in a small space. Open mesh cages in close proximity however provide an environment where disease spread can be hard to control The locker type has the disadvantage that it is more difficult to provide adequate drainage than in the case of the walk in type. Some pet shops have walk in Aviary type caging for housing birds.

ÂŠ Box Hill Institute 50

Centre for Biotechnology and Animal Sciences Learner Resource: Certificate IV in Veterinary Nursing RUV4601A: Unit 5 â&#x20AC;&#x201C; Animal Housing

Materials used in housing facilities Apart from the consideration of expense, the materials for use in housing facilities should require a minimum of maintenance, be smooth, strong and corrosion resistant. They should also be easily disinfected and non-toxic. Materials that may be used include stainless steel, galvanised metal, fibreglass and sealed timber, brick or concrete.

Stainless steel With the exception of cost, stainless steel is the most desirable material for use in animal housing areas, as it is strong, easily cleaned and disinfected, resists staining and corrosion. In addition it is reflective and gives the kennelling area a brighter appearance.

Galvanised metal Galvanised metal is often used as a cheap alternative to stainless steel. Despite its strength galvanised steel is less desirable than stainless steel as the zinc which coats the metal may wear off. The exposed metal stains easily and rusts.

Fibreglass Fibreglass is a smooth material that resists staining and provides good insulation. Fibreglass however is not as strong as stainless steel and wears quickly.

Sealed timber, brick and concrete Timber, brick and concrete are relatively inexpensive materials that may be used in animal housing areas. Although they are commonly used for floors and walls they may also be used to form kennels. In any case the timber, brick or concrete should be sealed with a lead free paint so that they are non-pervious to water. These materials are less desirable than stainless steel for animal housing as they are generally more difficult to maintain.

ÂŠ Box Hill Institute 51

Centre for Biotechnology and Animal Sciences Learner Resource: Certificate IV in Veterinary Nursing RUV4601A: Unit 5 – Animal Housing

Environmental control in housing areas Control of temperature, ventilation, lighting and drainage are important factors in the design and maintenance of animal housing areas. Failure to ensure that these factors are well maintained may contribute to skin, respiratory and gastrointestinal disease. In addition inadequate control of these factors makes the animal housing area difficult and undesirable to work in.

Temperature Although the heating/cooling system may vary, the ambient temperature in animal housing areas should be between 15°C and 21°C and fluctuations should be kept to a minimum. Reptiles, for instance, require their environment to be at a certain temperature to ensure that they can digest their food.

Ventilation Efficient ventilation of animal housing areas may be achieved with the use of extractor fans or air conditioning units. In general it is desirable to keep doors and windows closed to minimise the risk of escapes and to prevent environmental variation that will occur with changes in the weather. It is important to make sure birds are not housed in draughty areas

Lighting Lighting should be provided at a comfortable level so that animals can easily be observed and maintenance routines can be carried out. Special UV lighting is required for reptile cages.

Drainage Ideally drainage should be provided so that urine and faeces are removed from the cage immediately and so that refuse does not pass from one cage to another. Both drainage and cleaning are made easier if corners are rounded and so that floors slope towards a drainage point.

Centre for Biotechnology and Animal Sciences Learner Resource: Certificate IV in Veterinary Nursing RUV4601A: Unit 5 – Animal Housing

General housing Trays and grids The use of trays and grids, especially in small cages, can reduce the amount of urine and faecal soiling on animals.

Bedding In cages, newspapers, towels or blankets may be used for added warmth and comfort. These should be of a material that is machine washable. Hay, straw, sawdust and fibrecycle are commonly used in rodent and rabbit cages/boxes. The latter two are absorbent and reduce urine dampness in cages

Feed and water bowls Water should be provided on a permanent basis in non-spill, fully washable bowls made of stainless steel or plastic. Animals may occasionally chew plastic bowls. Automatic water supply may also be used although regular checks to ensure proper operation is essential. Hoppers of food are also utilised for rabbits, rodents and ferrets to enable them to ‘graze’ at will.

Locks and catches Locks and catches must be well designed, as some animals will work out how to lift a simple latch or slide a bolt.

Cleaning All sections of cages in use should be cleaned and disinfected daily. Animal housing area floors should be swept and mopped, litter trays emptied, washed and refilled and water bowls likewise. Food bowls should be cleaned between each feed. Avoid the use of ammonia cleaners as the smell may deter some species from feeding.

Maintenance of housing facilities If there are any problems encountered with the animal housing facility such as broken catches, flickering light bulbs, water nozzles not working etc they should be repaired under instruction as soon as possible or if not possible to repair it yourself it should be reported.

Maintain Hygiene in an Animal Housing Facility What is hygiene? Hygiene is a set of principles that are followed to minimise the risk of infectious disease. Disease (which is defined as an abnormality of structure or function) can be caused by many different factors and is generally categorised into infectious and non infectious causes. In many instances there is interplay between infectious and non infectious causes. Non-infectious causes of disease include: •

nutritional

•

physical (trauma)

•

degenerative or aging

•

metabolic

•

genetic.

Infectious disease is disease caused by living organisms including •

bacteria

•

virus

•

fungi and yeasts

•

protozoa

•

parasites (worms and insects)

•

Most of these causes are not visible to the naked eye, which makes control of infectious diseases very difficult.

Why hygiene is important? •

Regular and thorough cleaning will prevent the build up of potentially infectious organisms in the environment

•

Sick, very young and older animals are more vulnerable to infection as their immune system may be compromised.

•

Personal hygiene is important to prevent transmission of infectious agents from something you contact. This can be from one part of your body to another part, or another body (animal or human) or bodily secretions.

Centre for Biotechnology and Animal Sciences Learner Resource: Certificate IV in Veterinary Nursing RUV4601A: Unit 9 – Nutrients

What is involved with hygiene? •

Hygiene involves constant, effective and thorough cleaning and washing – there is no easy way out of elbow grease! Infectious agents lurk on dust and secretions and any surface or object with which an animal has contact.

•

Disinfection involves the use of chemicals to assist in the destruction of microorganisms.

•

Sterilisation includes the use of heat to kill microorganisms.

•

Waste disposal practises minimise levels of contamination in the clinic.

•

Protocols to handle suspected infectious animals, including isolation.

•

Wearing appropriate protective clothing when working in particular areas.

Disposal of biological wastes Biological wastes are a potential occupational risk as: •

sharp materials such as scalpels, glass and needles may cut or injure

•

tissue, excreta and other biological wastes have the potential to carry zoonotic diseases

•

tissue, excreta and other biological wastes have the potential to contaminate the environment.

Therefore all biological wastes should be disposed of in an acceptable manner. Some local authorities have specific rules in regard to wastes and these should be followed. However, there are some general rules that are applicable. •

All sharps (needles, scalpels and glass) should be disposed of using approved sharps containers.

•

All animal tissue should be disposed of in a manner that conforms to local regulations and the regulations of appropriate health authorities.

Disinfectants and antiseptics Disinfectants and antiseptics are chemical agents used for the destruction of microorganisms such as bacteria, viruses, fungi and spores. The aims of using these products are to minimise the spread of disease by reducing the numbers of disease causing organisms. Although there are some inherent differences in the process of disinfection and antisepsis many chemicals may be used for both purposes. Sterilisation is a third technique that is used to destroy microorganisms.

Centre for Biotechnology and Animal Sciences Learner Resource: Certificate IV in Veterinary Nursing RUV4601A: Unit 9 â&#x20AC;&#x201C; Nutrients

Rules for effective use of chemicals For chemicals to be effective in the destruction of microorganisms several rules should be followed: (a)

The surface being treated should be as clean as possible. Many chemical products are inactivated by the presence of foreign materials such as blood, pus or oil.

(b)

The chemical must contact every surface of the article. For example scissors that are being soaked must be left open to ensure that the chemical comes in contact with all surfaces.

The solution must be used at the correct concentration. Many chemical products lose their effectiveness if the concentration of the solution is either too high or too low. It is therefore important to firstly, make up the solution to the manufacturerâ&#x20AC;&#x2122;s specifications, and secondly, maintain the concentration of the solution as the active ingredient is either leached out or inactivated during use.

Chemical groups commonly used for disinfection and antisepsis Chemical agents for antisepsis and disinfection are broadly allocated into groups depending on their characteristics and uses. These are alcohols, aldehydes, chlorhexidines, chlorines, iodines, quaternary ammonium products (QUATS), phenols and combination products. Important features of chemicals used for disinfection and antisepsis Features, which are of importance in relation to chemicals used in the destruction of microorganisms are: (a)

Tissue toxicity This, refers to the degree of damage which the chemical causes to healthy tissue at its correct concentration for use.

(b)

In the case of antiseptics it is important that tissue toxicity is negligible whereas in the case of disinfectants this feature is less important.

(c)

Effectiveness in the presence of foreign material This, refers to how well the activity of the chemical is maintained in the presence of dirt, blood, pus, etc.

(d)

(e)

This feature is important in both antiseptics and disinfectants. However, it is most important that disinfectants which are to be used on surfaces such as concrete should be highly effective in the presence of foreign materials. Spectrum of activity This, refers to the range of microorganisms which the chemical is effective in destroying. Microorganisms with which we are mostly concerned are bacteria, viruses and fungi. In addition, some chemicals are active against spores. Residual effect This, refers to a lasting or ongoing effect after application. This feature is particularly useful in that it ensures continued activity against microorganisms.

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Handling and Restraint of Dogs and Cats Introduction A major role of veterinary nurses in practice is to handle and restrain patients. The aim of handling and restraint is to allow procedures to be carried out on patients in a manner that is safe to the operators and the patient with a minimum of stress to both parties. When placed in a clinical situation patients are stressed. Their response to this stress varies. On approaching the patient the handler should be able to assess the patient’s response to this stress and decide on the best way to approach without causing a confrontation which may cause injury to either the patient or the handler. In general you should approach the patient with confidence while talking in a reassuring tone. If possible you should avoid cornering the patient as their fear will be greater if they cannot see a way to escape. Of course this is difficult when patients are in cages or pens. At all times you should assume that the patient is at least capable of inflicting injury and you should never trust any patient completely.

Removing a dog from a cage or pen Once inside a cage or pen even frightened patients may feel that they are in a secure area. For this reason removing patients from their enclosure is often the most dangerous aspect of handling. The patient has no means of escape and may feel trapped. Their response may either be to cringe at the back of the enclosure or rush at the opening. In either case the initial behaviour may change suddenly as the patient may be unsure of how to behave. When opening the cage or pen door you should make sure that the patient cannot slip past you and escape and at the same time you should coax them to the front of the enclosure rather than placing your hand inside. Once at the entrance a lead and/or correction collar can be applied. A diagram of the correct use of a correction collar is depicted in figure 5.1.

Figure 5.1 – Correct application of a correction collar

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In difficult patients it may be advisable to leave a lead on the patient whilst they are in the enclosure. Although the lead may be destroyed by chewing it allows the patient to be more easily removed from the enclosure. In some cases it may be necessary to apply a muzzle to guard against being bitten. Muzzles may be made of material such as gauze or they may be constructed of leather. These are depicted in figures 5.2 and 5.3.

Figure 5.2 – Application of a gauze muzzle

Figure 5.3 – Application of a leather muzzle

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Lifting dogs Once removed from their enclosure many patients will need to be lifted onto a table. When lifting the patient it should be done in a way that they feel secure and that they cannot injure you by biting or scratching. It should also be done in a way which protects your back from occupational injury. Larger patients should be lifted by two (2) people. In addition you should follow the rules of bending at the knees and keeping a straight back to minimise the risk of injuring yourself. Lifting smaller patients Smaller patients may simply be lifted by a number of methods. Method 1 Simply place one arm over the rump and the other under the patient’s chest and lift them whist restraining the head. This is depicted in figure 5.4.

Figure 5.4 – A method of lifting a smaller patient

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Method Place one arm around the front of the chest and the other around the rump.

Although this lift gives the patient a feeling of security it should be noted that the head is not restrained and that the lifters face is close to the patient’s face. This is depicted in figure 5.5. In cases where you are unsure of the patient’s reaction you should either apply a muzzle or ask for an assistant to restrain the patients head.

Figure 5.5 – Another method of lifting a smaller patient

Lifting larger patients Where possible larger patients may be treated on the floor. If however they must be lifted it should be done by two (2) people. In general one (1) person lifts the front of the patient by holding them around the head and chest whilst the second person lifts the rear of the patient by holding around the rump. Care should be taken not to lift patient’s around the abdomen as this may be painful and/or aggravate the patients condition.

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Lifting an injured patient Lifting patients which, are injured adds the problem that we do not want to aggravate the patients condition and that pain may cause the patient to bite. In most cases it is wise to apply a muzzle. The patient should be examined to determine the sites of major injury and then the patient may be lifted. In many cases the patient can be lifted using modifications of the techniques already described. In other cases it may be wise to use a stretcher. These are commercially available but a blanket or board will often do the job.

Figure 5.6 – A method of restraining an injured dog in a standing position

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Holding a dog for general examination Once on the table the patient may require restraint for examination. The patient may be restrained in a standing, sitting or lying position as depicted in figures 5.6, 5.7 and 5.8.

Figure 5.7 – Restraining a patient in a sitting position

Figure 5.8 – Restraining a patient in a lying position

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Restraining a patient for intravenous injection A commonly performed procedure in clinical practice is the administration of medication by intravenous injection into the cephalic vein which is located in the front leg. The patient may be in a standing or sitting position. The head will need to be restrained and the front limb extended by placing a hand behind the patient’s elbow. The thumb is placed over the anterior (front) aspect of the extended limb which causes the vein to fill with blood. This is called ‘raising the vein’. An example of this type of restraint is depicted in figure 5.9.

Figure 5.9 – Restraining a patient for intravenous injection

Placing a patient into a cage or pen Once the patient has been treated it may be necessary to place them into a cage or pen. In many cases the patient will be reluctant to enter the enclosure. In these cases it may be necessary to place the patient in backwards so that they cannot see the back of the enclosure. In difficult cases it may be wise to leave a lead attached so that removal is easier. In the case of patients liable to bite a warning sign should be placed onto the front of the enclosure.

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Handling and restraint of cats in veterinary practice Introduction A similar approach should be taken for the handling and restraint of cats as applies to dogs and other pets in the workplace. You should approach the patient with confidence, whilst talking in a reassuring tone. If possible, you should avoid cornering the patient, as their fear will be greater if they cannot see a way to escape. Of course this is difficult when patients are in cages or pens. At all times you should assume that the patient is at least capable of inflicting injury and you should never trust any patient completely.

Removing a cat from a cage or pen Once inside a cage or pen even frightened patients may feel that they are in a secure area. For this reason removing patients from their enclosure is often the most dangerous aspect of handling. The patient has no means of escape and may feel trapped. Their response may either be to cringe at the back of the enclosure or rush at the opening. In either case the initial behaviour may change suddenly as the patient may be unsure of how to behave. When opening the cage or pen door you should make sure that the patient cannot slip past you and escape. At the same time you should coax them to the front of the enclosure rather than placing your hand inside. Once at the entrance the patient can be lifted and restrained. In difficult patients great care should be taken with cats as they can bite and scratch with all four limbs. In some cases it may be necessary to cover the patient with a blanket to assist with safe handling. In other cases it may be wise to use chemical restraint (tranquillizers, sedatives) to assist with safe handling.

Carrying cats Once removed from their enclosure many patients will need to be carried. When carrying the patient it should be done in a way that they feel secure and that they cannot injure you by biting or scratching. An example of a technique is depicted in figure 5.10.

Figure 5.10 – Carrying a cat

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Lifting an injured patient Lifting patients which are injured adds to the problem. We do not want to aggravate the patient’s condition because pain may cause the patient to bite. In many cases the patient can be lifted using modifications of the techniques already described. In other cases it may be wise to use a stretcher. These are commercially available but a blanket or board will often do the job. An example is depicted in figure 5.11.

Figure 5.11 – A method of lifting an injured cat

Holding a cat for general examination Once on the table the patient may require restraint for examination. The patient is often restrained in a sitting or standing position as depicted in figure 5.12.

Figure 5.12 – Restraining a patient in a sitting position

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Restraining a patient for intravenous injection A commonly performed technique in clinical practice is the administration of medication by intravenous injection into the cephalic vein that is located in the front leg. The patient may be in a standing or sitting position. The head will need to be restrained by cupping the chin in one hand (or by scruffing if the cat does not respond to gentle restraint), and the front limb extended by placing a hand behind the patient’s elbow. The thumb is placed over the anterior (front) aspect of the extended limb which causes the vein to fill with blood. This is called ‘raising the vein’. An example of this type of restraint is depicted in figure 5.13.

Figure 5.13 – One method of restraining a patient for intravenous injection

Placing a patient into a cage or pen Once the patient has been treated it may be necessary to place it into a cage or pen. In many cases the patient will be reluctant to enter the enclosure. In these cases it may be necessary to place the patient in backwards so that it cannot see the back of the enclosure. In the case of patients liable to bite or scratch a warning sign should be placed onto the front of the enclosure.

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Basic Nutrition Introduction Nutrition is derived from food that is ingested by an individual. Diets should supply all the essential nutrients required by an animal for growth, repair, energy and reproduction. Nutrients can be divided into six categories: 1.

proteins

fats (lipids)

carbohydrates

vitamins

minerals

Water Water is an essential nutrient, which must be consumed regularly to maintain health. Lack of water intake rapidly leads to dehydration and death. Water requirements will vary depending on the ambient temperature and humidity, whether or not the animal is pregnant or lactating, the composition of the diet (eg. moisture and the mineral content), the animal’s stage of growth and the animal’s state of health (eg. animals with diarrhoea and kidney disease have higher requirements). As a general guide, dogs and cats, which are not losing excessive amounts of water (eg through lactation or diarrhoea), require between 40–60 mls of water/kg/day. Requirements for cats and dogs are greatest at approximately 60mls/kg/day; large dog breeds require about 40 mls/kg/day.

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Protein Proteins are found in every cell of the body. They are present in large amounts in tissues, such as muscles, tendons and connective tissue. The basic unit of proteins is the amino acid. Twenty (20) amino acids have been identified, eleven (11) of which are identified as essential in the cat. This means that they must be provided in the diet if the individual is to remain healthy. Requirements for essential amino acids vary between species and physiological status, but the commonly accepted list of essential amino acids, include: arginine, histidine, isoleucine, lysine, methionine, phenylalanine, threonine, tryptophan and valine. The other amino acids are not essential because the body can manufacture them. Proteins in the body serve four (4) functions. They are used as a source of energy, to build and repair tissue, regulate body processes, as is the case with enzymes and hormones and protect the body from infection, as is the case with antibodies. Proteins in the diet are available from meats, eggs, dairy products and plant proteins.

Fats Fats are found in every cell of the body, especially in the cellular membranes. Fats are also important in the transport of fat soluble vitamins. In addition, fat is accumulated as a stored form of energy in the adipose tissue. The basic unit of fats is the fatty acid. As is the case with amino acids, some are considered essential fatty acids, which must be supplied in the diet whilst others can be manufactured by the body. Fats in the body are an important energy source. Fats in the diet are available from both animal and plant sources.

Carbohydrates Carbohydrates are probably not an essential nutrient for dogs or cats but are a useful and economic energy source. Carbohydrates are commonly found in commercial dog foods. Carbohydrates in the diet are available from sugars or starches and are commonly provided in the form of cereals, potato or rice.

Vitamins Vitamins are chemicals, which are required by the body in small quantities to assist with the regulation of body processes. Vitamins, A, D, E and K are fat-soluble and can be stored in the body if ingested in quantities greater than required. All other vitamins are water-soluble. These water-soluble vitamins cannot be stored by the body and are excreted in the urine if ingested in excessive quantities. Vitamins are available in the diet through ingestion of various foods. Deficiency or excess of vitamins may result in disease. Sources and functions of vitamins are summarised in table 8.1.

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Minerals Minerals are inorganic chemicals that serve a number of structural, metabolic and osmotic functions within the body, particularly during growth and reproduction. A summary of mineral sources and functions is summarised in table 8.2

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Table 8.1: Sources and functions of vitamins

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Table 8.2: Sources and functions of minerals

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Feeding Cats and Dogs Introduction Good nutrition is essential in maintaining the health and well being of an animal. It is important that diets are complete and balanced, ie the diet contains all the essential nutrients for a particular animal in the correct proportions. This means that when formulating a diet several factors must be considered: (a) (b) (c) (d) (e) (f)

Species and breed (cats and dogs have different requirements; in some cases breeds may also have specific requirements) Individual variation (metabolic rate will vary between individuals) Life stage (growing animals have higher requirements than geriatric animals; pregnant and lactating animals also have increased requirements) Climatic conditions (in hot environments, nutrient requirements are reduced in comparison to cold environments) Level of activity (active animals will have higher nutrient requirements) Other stresses (stress will increase nutrient requirements).

As a general rule of thumb the amount of calories to feed is that amount which will maintain the animal’s optimum weight. When at optimum weight, the animal’s ribs and spine can be palpated but are not visible.

Cats versus Dogs Cats and dogs have different nutritional requirements. Unlike dogs, cats are strict carnivores whereas dogs prefer an omnivorous diet. Hence dog foods are generally quite inadequate in meeting the nutritional requirements of cats. Some dietary differences between cats and dogs include: • cats have higher protein requirements • arachidonic acid is an essential fatty acid in the cat but not in the dog • taurine and arginine are essential amino acids in the cat, but non essential in the dog • cats have greater requirements for some vitamins, eg Vitamin A and niacin (one of the B complex group). • cats should be fed ad lib or at least twice a day Because of the essential requirements for amino acids and fatty acids, diets for cats must be based on an animal source, ie cats cannot be fed a vegetarian diet.

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Requirement for adults Maintenance requirements refer to the dietary requirements of a healthy adult animal, which is moderately active but not in work, not pregnant or lactating, and not unduly stressed (eg exposed to extremes of heat or cold, or recovering from illness or surgery). There are many types of complete and balanced maintenance diets available that meet the requirements of adults in a maintenance state.

Growth requirements Growing animals have greater energy and nutrient requirements than adult animals as dietary requirements must maintain bodyweight as well as supplying nutrients for growth. In cats and dogs, growth occurs most rapidly in the first six months of life. Cats usually attain their adult body size at 6–12 months of age. Small breeds of dogs reach their adult body size at 6–12 months of age, large breeds reach their adult size at 10–16 months of age whereas giant breeds reach their adult size at 18–24 months of age. Growing animals have higher dietary requirements for energy, protein (for tissue growth and repair), calcium and phosphorus (for bone growth) than adult animals. When compared to an adult animal of similar weight, a growing animal should be fed 2 adult maintenance from the time of weaning until it has reached 1/2 its adult weight; 1.5 maintenance is required until the animal is 4/5 of its adult size, and in the latter stages of growth the requirement is 1.2 maintenance.

Figure 10.1 – Growth graph

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Table 10.1: Age at which adult size is attained Species

Age when adult size is attained

Cat

6–12 months

Small breeds of dogs

6–12 months

Large breeds of dogs

10–16 months

Giant breeds of dogs

18–24 months

Complete and balanced commercial growth diets are readily available for cats and dogs. They are usually more convenient and reliable than preparing a diet from scratch and should be fed at least until the animal has reached 75% of its adult body weight. Commercial growth diets supply all the essential nutrients for growth in correct ratios and therefore should not be supplemented. Supplementation can be detrimental to the health of the growing animal, for example supplementation with calcium can result in skeletal development problems. Commercial growth diets are usually nutrient dense This allows growing animals with comparatively smaller gastrointestinal capacity, compared to adults, to ingest sufficient nutrients in relatively small volumes of food. . Growing animals must also be fed on a more regular basis than adults. At weaning, food must be offered at least three to four times daily. The number of feeds should be slowly reduced as the animal grows. As adults, dogs only need to be fed once daily ; cats should be fed twice daily as a minimum. Overfeeding a growing animal should be avoided, as it is detrimental to the animal’s health, especially in the case of dogs. Overfeeding accelerates the growth of the animal and results in the development of an increased number of fat cells, predisposing the animal to obesity. Rapid growth can also lead to defects in skeletal development particularly in large and giant breeds. To prevent overfeeding, food intake should be monitored. Ad lib feeding should only be introduced, if at all, once the dog has reached 80% of its adult size. In most dog breeds this occurs at around nine months of age; in giant breeds this occurs much later at around 18 months of age. Mild to moderate underfeeding of a growing animal is not detrimental. Animals that are underfed somewhat will develop normally and reach normal body size. Cats are less likely to overfeed and therefore growing cats can often be fed ad lib without risking overfeeding especially if the cat exercises regularly. Many owners are tempted to offer cow’s milk to their growing pet, especially kittens. Cow’s milk is best avoided as it contains more lactose than carnivorous milk and may lead to diarrhoea as many puppies and kittens lose the ability to digest lactose. If pups and kittens are orphaned they should be fed a commercial milk replacer designed for puppies and kittens eg.Divetelact .

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Requirements for geriatric animals As animals age their energy requirements decrease. Geriatric animals usually lead a sedentary lifestyle, ie physical activity is greatly decreased, and their metabolic rate slows. Hence energy requirements may decrease by as much as 30–40% of maintenance. Body constitution also changes with age. Muscle mass decreases and body fat percentage increases. These changes become more marked as the animal becomes more sedentary. A controlled exercise program, where appropriate, will help to slow these changes. Geriatric animals should be fed less calories than a normal adult and protein intake should be adequate and of good quality. Changes in metabolism and digestion associated with aging may also increase requirements for Vitamins A, B and E. Choice of diet in the geriatric should take into consideration concurrent disease. Where dietary management is appropriate prescription diets may be recommended eg. renal diet, heart diet liver diet, weight management diets etc. As routine is often important to a geriatric animal, any diet changes should be made slowly and in some cases, especially in cats, a more palatable diet may need to be fed. It is often beneficial to feed geriatric animals 2-3 times daily to minimise hunger between feeds and to ensure better use of nutrients.

Requirements for pregnant animals The bitch and queen vary in their feeding requirements during pregnancy although at the end of gestation the requirements for both will be about 25%–50% more than normal maintenance requirements. Total weight gain at the end of gestation should be about 15–25%. In the bitch, food intake needs to be increased at around weeks five to six of gestation. Rapid weight gain occurs in the last trimester and hence food intake will increase accordingly and by the end of gestation the bitch will consume about 25–50% more than maintenance requirements. In the queen, weight gain occurs from week two of gestation and is associated with foetal growth as well as an increase in body fat, which is lost during lactation. Food requirements therefore increase from week two and weight gain occurs in a linear fashion throughout pregnancy. By the end of gestation, food requirements will be 25–50% more than maintenance requirements. A good quality highly digestible food should be fed during gestation. In the case of the bitch a growth diet can be fed in the last trimester although growth diets for large breed dogs should be avoided. If home prepared food is fed during pregnancy, it is essential that it be complete and balanced.

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Supplementation is unnecessary if a complete and balanced diet is fed. Calcium supplementation during pregnancy should be avoided as excessive amounts of calcium can lead to eclampsia or hypocalcaemia once the bitch is lactating and the offspring may be born with soft tissue calcification. During the last trimester the feeding routine may need to be changed. The uterus is enlarging rapidly during this period and taking up more space in the abdomen. The stomach therefore, has a smaller capacity within which it can expand, so smaller meals should be offered more frequently. Alternatively the animal can be fed ad lib or fed a food that is more nutrient dense. (ie. the volume of food needing to be ingested to meet requirements is reduce ) Prior to breeding, the bitch and queen should be at an optimum weight. If underweight prior to breeding, the animal may not be able to meet demands of pregnancy and foetal death may occur; if overweight the foetuses may be too large and dystocia may occur.

Requirements for lactating animals During lactation energy requirements increase, peaking at the time of peak lactation (three to four weeks after parturition). Requirements will then begin to taper off. Table 10.2: Feeding Requirements during lactation Week of lactation

Food requirement

Week 1

1 maintenance

Week 2

2 maintenance

Weeks 3-4

2- 3 maintenance

Week 5 onwards

Requirements decline

It is important that adequate energy is provided to meet the demands of milk production so that weight loss during lactation is not excessive. A highly digestible, nutrient dense food should be fed and is best offered ad lib. When the offspring begin to eat solids, the bitch and queen are best fed away from their offspring so that the offspring cannot eat their food. Water needs to be freely available to meet the increased needs of milk production.

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Requirements for working dogs Dietary requirements are greater than maintenance when an animal is in work and vary depending on the type of work performed. Commercial working dog diets are available, however if the demands of work are moderate, increased amounts of a maintenance diet can be fed to meet the animal’s requirements. In the case of sprinting animals, where work involves small bursts of activity, additional energy should be supplied in the form of carbohydrates. This will help to maintain the body glycogen stores. Endurance animals, such as cattle and sheep dogs, work for long periods of time. Depending on the level of work, working dogs may require two to three times their maintenance energy requirements. This is best addressed by increasing the amount of energy in the food in the form of fat. A nutrient dense, high fat, highly digestible food such as a commercial working dog diet should be offered several times a day.

Maintaining equipment and hygiene standards It is important that high standards of hygiene are maintained when food is being prepared. Such hygiene standards relate to: •

The general food storage and preparation area

•

Equipment used to store, prepare and present food

•

Personal hygiene

General food storage and preparation areas and equipment Food storage and preparation areas should be cleaned of spills, liquid or otherwise immediately; to ensure safety of workers (avoid slips and falls), prevent cross-contamination of foodstuffs and/or to avoid leaving potential food sources for vermin. The food preparation area should be one that can be kept free of pests. It should be fully enclosed and where required have screens on doors and windows. It should be constructed of materials that are non-porous, free of cracks and/or crevices and can be easily cleaned. The same applies for surfaces upon which animal diets are prepared – non-porous, free of cracks and be easily cleaned. Discrete food preparation areas (i.e. chopping boards and tables) should be cleaned after use and the entire food preparation area should be completely cleaned daily, using appropriate cleaning products. All equipment used should be well maintained, cleaned after each use and appropriately stored when not in use.

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Personal hygiene A common and easily avoided source of contamination to animal feed is by humans. Poor personal hygiene can lead, in particular, to an increased risk of biological contamination of food. Practicable measures should be taken to maintain personal hygiene and includes: •

Wearing clean clothes (avoid cross-contamination as a result of animal faeces picked up on clothes)

•

Washing hands –

after blowing nose or coughing into hand

–

after using the toilet

–

after handling raw food

–

after emptying rubbish containers

–

after cleaning animal enclosures

–

before handling food

NOTE: Hands should be washed with appropriate cleaning agent and hands then dried with a single use towel (ie paper towel) •

report illnesses to workplace supervisor

•

make sure cuts and sores are covered

•

don’t cough, sneeze, smoke, drink or eat near food

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Personal Protective Equipment (PPE) The importance of PPE should not be underestimated as it protects the worker from hazards associated with preparing feed for animals and cleaning associated with feeding. The following is a list of PPE, which maybe required when preparing and feeding animals. •

Boots – good sturdy boots with added toe protection (steel caps) or even gumboots maybe required for foot protection and worn as protection against chemical agents.

•

Overalls – maybe required to prevent cross contamination from outside/inside the workplace (eg from cleaning animal waste) and worn as protection against chemical agents.

•

Gloves – maybe required to prevent cross contamination from outside/inside the workplace (eg from cleaning animal waste) and prevent exposure by direct contact to the worker. Gloves are also worn as protection against chemical agents. Mesh gloves are also recommended when cutting up food to prevent injury to hands.

•

Protective eyewear – worn to protect the eye from chemical splashes and feedstuffs

•

Hearing protection – maybe required to protect the ears from noise such as machinery or animal noises (eg piggery or boarding kennels)

•

Respirator or facemask – maybe required to protect against chemical inhalation or dust inhalation from some feeds

•

Sun protection – such as sunscreen, hats or long sleeved shirts and long trousers are required when feeding animals outdoors

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Injection Techniques Intravenous injection Introduction Administration of medication by intravenous injection is a technique that is commonly performed in veterinary practice. It is a technique that requires skill on both the part of the operator and the handler who is restraining the animal.

Equipment required for intravenous injection Equipment, which is required for intravenous injection, includes clippers, swabs, syringes, needles and the agent for injection. These are depicted in figure 2.1. Syringes and needles are available in various sizes. Syringes are selected according to the volume of fluid to be injected and needles according to the size of the patient; examples are depicted in figures 2.2. The size of the ‘bore’ is referred to as the ‘gauge’, 18 gauge has a large bore, and 25 gauge has a small bore. The length of the needle commonly varies from to 1 inch (1 to 2.5 cm). These are depicted in figure 2.3. Selection of the needle size for injection is determined by the size of the vein and the operator preference. For example, a 21 gauge, 1 inch (2 cm) needle is often used for intravenous injection in the dog whereas a 23 or 25 gauge needle is commonly used in cats.

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Common sites for intravenous injection There are three sites that are commonly used for intravenous injection. They are the: 6.

cephalic vein

jugular vein

recurrent tarsal or saphenous vein

These are depicted in figures 2.4, 2.5 and 2.6.

Figure 2.1 – Equipment required for intravenous injection

Figure 2.2 – Syringes used for intravenous injection

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Figure 2.3 – Needle sizes commonly used for intravenous injection

Figure 2.4 – Cephalic vein

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Figure 2.5 – Saphenous vein

Preparing sites for intravenous injection Prior to injection, the site must be prepared. In most cases the site is clipped and swabbed with an antiseptic. See Figure 2.6.

Performing intravenous injection Having correctly prepared the injection site it is now possible to inject an agent directly into the vascular system.

Connecting the needle and syringe After selection of an appropriately sized syringe and needle, these are connected. The hub of the needle is firmly placed onto the nozzle of the syringe so that the bevel of the needle is upwards, as depicted in figure 2.7.

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Filling the syringe When the needle and syringe are correctly fitted, it is possible to fill the syringe from a container. When filling the syringe it is important to ensure that the following guidelines are considered: •

the top of the drug bottle should be swabbed

•

the prescribed agent should be selected

•

the syringe should be filled accurately to the desired level

•

the syringe should be free from air bubbles.

See Figure 2.8.

Inserting the needle into the vein When inserting the needle into the vein the following steps should be followed. Points to take specific note of are: •

identify the location of the vein

•

stabilise the vein with the free thumb

•

insert the needle through the skin in a swift manner without jabbing

•

slowly position the needle so that 75% of the needle is in the vein.

See Figure 2.9.

Checking for blood on drawback If the needle is correctly positioned, applying gentle drawback pressure on the syringe plunger will allow blood to enter the syringe. However, in very small or shocked patients (if blood pressure is poor) blood may not enter the syringe on drawback. See Figure 2.11.

Injecting the agent Having determined that the needle is correctly placed in the vein, the agent may be injected. Applying gentle pressure to the syringe plunger will cause the agent to be administered. See Figure 2.12.

Removing the needle and applying pressure to the vein Having administered the agent into the vein, the needle should be removed. This is achieved by applying gentle but firm traction on the needle and syringe. Pressure should then be applied to the vein to minimise unwanted bleeding. See Figure 2.13.

Disposing of the syringe and needle Used syringes and needles should be disposed of in an appropriate manner. Syringes may be placed in a rubbish bin, or cleaned and recycled. Needles should be placed into a properly designed Sharps container. See Figure 2.14. © Box Hill Institute 84

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Figure 2.6 – Preparing an injection site

Figure 2.7 – Positioning the bevel for intravenous injection

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Figure 2.8 – Filling the syringe

Figure 2.9 – Inserting the needle into the vein

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Figure 2.10 – Drawing blood back into the syringe

Figure 2.12 – Approved sharps disposal containers

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Intravenous catheters Intravenous catheters may be inserted in cases where a constant infusion, repeated injections or injection of irritant materials is required. They are inserted into the vein and a plastic cannula is left in place. The parts of an intravenous catheter are depicted in figure 2.13.

Figure 2.13 – Parts of an intravenous catheter

Intravenous catheters are available in a number of styles, gauges and lengths. They should be selected according to the size of the patient. For example, an 18 gauge catheter may be used in a dog and a 22 gauge in a cat. In addition to the intravenous catheter you will require clippers, swab, 2 cm adhesive tape, and a catheter plug.

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Placing an intravenous catheter The patient should be restrained in a similar manner as for intravenous injection, the site should be clipped and swabbed. The instructions below are for right-handed operation. Vein should be occluded before commencing this procedure. Step 1 Place your left hand under the animal’s carpus and grip the leg firmly, with your thumb and fingers on the top of the carpus. See Figure 2.14. Step 2 Hold the catheter in the right hand. Note that the catheter is held parallel to the surface of the skin and the operator’s fingers are not curled underneath the catheter. See Figure 2.15. Step 3 Insert the catheter through the skin. See Figure 2.16. Step 4 When the catheter enters the vein, blood will appear in hub of the catheter. See Figure 2.17. Step 5 Extend the fingers and thumb of your left hand to stabilise the catheter whilst removing the stylet with your right hand whilst advancing the cannula into the vein. See Figure 2.18. Step 6 Place a plug into the end of the catheter and tape the catheter to the patient’s leg. See Figure 2.19.

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Removal of an intravenous catheter The procedure for removal of an intravenous catheter is similar to that of an intravenous needle. After removal, pressure should be applied to the site to avoid unwanted bleeding and if necessary a light dressing should be applied.

Figure 2.14 – Restraining a patient for intravenous catheterisation

Figure 2.15 – Clipping the cephalic vein for intravenous catheterisation

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Figure 2.16 – Preparing the injection site

Figure 2.17 – Holding the catheter for insertion

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Figure 2.18 – Inserting the catheter

Figure 2.19 – Stabilising the catheter

Figure 2.20 – Injection into vein via catheter © Box Hill Institute 92

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Subcutaneous injection The loose skin from the back of the neck to the rump is the most common site for the administration of this injection Only non irritant drugs should be administered by this route as there may be irritation or necrosis 1. Draw up the require volume of drug using a sterile needle and syringe 2. Restrain the patient 3. Raise a fold of skin (e.g. the scruff) 4. Clean the skin with an alcohol swab (Spirit should not be used when injecting a vaccines, as it may inactivate the drug.) 5. Insert the needle under the skin and drawback gently on the plunger. If blood appears, a blood vessel has been punctured, and a new site must be selected. If no blood appears then the drug may be injected into the patient. 6. Massage the injection site gently to disperse the medication 7. Record details of the medication given and the route of administration 8. Dispose of the needle and syringe safely

Intramuscular injection The quadriceps muscle group in front of the femur is the most common site for intramuscular injections. Other sites include the lumbodorsal and triceps muscles. The gluteal and hamstring muscles should be avoided, as there is a danger of bone and sciatic nerve damage. The technique is similar to that for the subcutaneous injections except that the needle should be inserted at right angles to the muscle mass. Intramuscular injections can be painful and volumes injected should not exceed 2ml in cats and 5 ml in dogs.

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Pain and Pain Control Drugs used to control pain Pain may be relieved, at least in part, by environmental or behavioural (eg petting, stroking) manipulations, as well as by drugs. In the case of environmental control, emphasis is placed on the well being of the animal. In dogs, socialisation with humans appears to be an important stress relieving factor. Petting, stroking, verbal encouragement and eliciting a purr from a cat will help alleviate pain and stress. In the case of drugs, analgesics, sedatives and tranquillisers may all be used. The appropriate drugs and dosage will tend to be different for each case depending on the species, age and the severity of pain present. Pain in animals is often difficult to assess as they possess an inborn behavioural tendency to mask pain. Evolution has enhanced this inborn behavioural tendency because animals showing weakness, pain or distress become targets for predators. Therefore, careful observation of the animal is required to identify sometimes subtle behavioural changes that indicate that the animal is in pain.

Signs of pain Some signs that may indicate the animal is in pain include, looking repeatedly at an area on the body, biting at the painful area, alterations in breathing pattern, vocalisation, attempts to protect (eg bite) or move away when it is touched, limping, crying, guarding and licking an area. Restlessness, pacing, trying to get comfortable, reluctance to move and lying in one place for prolonged periods, are other symptoms that may be present.

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Narcotics or Opiates These drugs act to elevate the pain threshold and alter the bodyâ&#x20AC;&#x2122;s response to pain. Examples include codeine, morphine, oxymorphine, pethidine, methadone (Methone), butorphanol (Dolorex) and buprenorphine. Side effects include respiratory depression, cardiac depression and vomiting. The severity of the side effects depends on the drug used, the species of the animal and the dose rate. An advantage with the use of these S8 drugs is that these potentially hazardous side effects can be reversed with the use of a narcotic antagonist such as Naloxone (Narcan) or Nalorphine.

Non-narcotic Analgesics This is a large group of diverse drugs that includes aspirin, indomethacin (Cu-Algesic), flunixin (Finadyne), phenylbutazone (Myoton), ketoprofen (Ketofen), carprophen (Zenecarp) and meloxicam (Metacam). One of the problems with prolonged use of these drugs especially if given orally and in combination with coricosteroids, is the potential to cause gastrointestinal trace ulceration and bleeding. The newer drugs such as carprophen and meloxicam are less likely to cause this problem. Oral medications should be given with food to reduce the potential for gastric irritation. Tranquillisers such as acepromazine (Promex) and diazapam (Valium) do not have good analgesic properties when used alone. If given in combination with an opiod however, they improve the analgesic effect of the opiod. In contrast xylazine (Rompun) is a potent analgesic at doses that does not cause sedation. If higher doses are required sedating effects can be reversed with the use of yohimbine (Reversine).

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Pre and post operative analgesia Providing effective analgesia reduces the time taken for post-operative recovery, as well as being important for patient welfare. When post-operative pain is anticipated, an analgesic may be given as a premedication or during surgery. This helps to avoid a painful recovery The animal should be monitored for signs of pain during the recovery period. If clinical signs become apparent, the veterinarian should be informed so that analgesics can be administered. The following Opioids and NSAIDs are commonly used in veterinary practice for pain control. Opioids Opioids are classified as Controlled Drugs, previously known as S8 or Drugs of Addiction. They have stringent storage and recording requirements and must be stored in a locked cupboard with detailed records kept of their use. They should only be handled by the veterinarian. Morphine Morphine is an opioid which gives excellent analgesia and some sedation. It is presented as a clear liquid which is generally given as an intramuscular injection, but may also be given via slow intravenous drip (morphine infusion), or as an epidural injection administered while the patient is anaesthetised. An intramuscular injection of morphine provides analgesia for 2–4 hours, epidural morphine provides analgesia for up to 12 hours, and a morphine infusion provides continuous analgesia. Atropine is often used with morphine to counteract the side effects of bradycardia and salivation. •

•

Beneficial effects of morphine include: –

excellent analgesia

–

sedation

–

reduced dose of anaesthetic required

The side effects of morphine include: –

excitement or mania in cats and horses, especially if given large doses

–

vomiting

–

bradycardia or slow heart rate

–

defecation

–

salivation

–

slight respiratory depression

–

colic in horses

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Contraindications Morphine is not generally used in cats or horses due to the risk of excitement. Buprenorphine Buprenorphine is one of the longest acting opioid and is marketed as 'Temgesic'. It is presented in 1 ml glass ampoules. It is a strong analgesic used for short term relief of moderate to severe pain. Its duration of activity is variable but will generally last between 3-8 hours. It can be given s/c, i/m or slow i/v. It has an onset of activity of 15-30 minutes and hence, is often given as a premedicant. It works better if given before pain is established. •

The beneficial effects of buprenorphine include: – –

•

good analgesia some sedation

Side effects of buprenorphine include: – – – –

only slight decreases in heart rate only a slight decrease in blood pressure minimal respiratory depression occasional vomiting

Contraindictions Buprenorphine relies on the liver for metabolism and excretion, and should therefore not be used in-patients with liver disease. Butorphanol Butorphanol is marketed as 'Torbugesic' or 'Dolorex', and is usually given by subcutaneous or intramuscular injection. and is a good analgesic as well as a mild sedative. Butorphanol is generally injected subcutaneously or intramuscularly, and provides 3–4 hours of analgesia. It also has an antitussive (anti-coughing) effect, which can be useful in keeping brachycephalic patients intubated for as long as possible in recovery. •

Beneficial effects of butorphanol include: – – – – –

•

good analgesia some sedation heavy sedation if combined with another sedative such as acepromazine very little cardiovascular or respiratory depression antitussive (ie anti-coughing) which allows the endotracheal tube to be removed later into recovery

There are no major side effects of butorphanol.

Contraindications Butorphanol is metabolised by the liver, so is often avoided in-patients with liver disease. © Box Hill Institute 97

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Pethidine Pethidine is a clear liquid, usually given by subcutaneous or intramuscular injection. The effects of pethidine, as with other opioids, can be reversed by administering naloxone. •

Beneficial effects of pethidine include: – – – –

•

analgesia for one to two hours after administration onset of analgesia is 10-15 minutes light sedation can be used in cats

The side effects of pethidine are: – –

excitement or mania in cats and horses, if given large doses sudden drop in blood pressure if given intravenously

Contraindications Pethidine is considered a safe drug and can generally be given even to old or sick patients. Non Steroidal Anti Inflamatory Drugs (NSAIDs) Non-steroidal anti-inflammatory drugs (NSAIDs) are a class of analgesics which includes such drugs as aspirin, carprofen, ketoprofen and meloxicam. They are not opioids but usually scheduled as prescription drugs. They act to control pain and inflammation, and may be used to control either chronic pain (such as with degenerative joint disease) or post-operative pain. Use of NSAIDs can lead to gastrointestinal ulceration, especially long term use, as well as kidney problems, especially if used in patients who are dehydrated or who have renal disease patient). Antibiotics should be used with NSAIDs if an infection is present, as NSAIDs will interfere with some inflammatory processes necessary for fighting infection. Carprofen Carprofen ('Rimadyl') is an NSAID which may be used to relieve post-operative pain. 'Rimadyl' should be refrigerated, and any unused drug discarded 4 weeks after opening. It may be injected subcutaneously or intravenously, and provides analgesia without sedation. The NSAID side-effects such as gastric ulceration, kidney problems, and platelet disturbances are rarely a problem with short term (up to 3 days) use of carprofen. However carprofen should be avoided in patients already having gastric or renal problems, or dehydration. It is also contraindicated in animals which are pregnant, hypotensive, or have heart disease.

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Clean Theatre Equipment Introduction Preparing instruments and materials for sterilisation begins with cleaning following by packing. Although there are many methods of preparing packs the principles, which should be followed, remain the same and these will be discussed. In addition we shall discuss one (1) suitable method of preparation. Preparation of packs is a single link in a chain of events that lead to the production of sterile equipment and materials, which are suitable for use in the surgery. If any element in this chain of events should not be effectively completed the pack may not be completely sterile and could result in post operative infection.

Cleaning instruments and materials Instruments Instruments should be carefully cleaned prior to sterilisation. Although methods of cleaning vary there are some general rules which should be followed. You should: •

soak instruments immediately after use

•

clean them with plenty of running water

•

handle instruments carefully

•

only use instruments for their intended purpose

•

be careful not to damage sharp edges

•

take care to clean locks and ratchets well.

Three methods are commonly used to clean instruments. They are the use of fresh running water, ultrasonic cleaners and chemical agents.

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Fresh running water Washing instruments with large volumes of clean running water is an effective, if time consuming, procedure if carried out properly. When using this method it is important to use plenty of water and to ensure that difficult to clean areas such as locks and ratchets are effectively cleaned. In addition it is important to ensure that sharp instruments are not damaged by rough handling or the use of abrasives such as ‘steel wool’.

Ultrasonic cleaners Ultrasonic cleaners are machines, which use high frequency sound waves moving through water to which has been added a low sudsing detergent. They produce their effect by vibrating foreign material away from surgical instruments. An example is depicted in figure 3.1.

Figure 3.1 – An ultrasonic cleaner

This method has the advantages that they are quick and easy, producing clean instruments thoroughly without damaging them.

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Chemical Cleaners (‘Rapidex’, ‘Pyroneg’ and ‘Endozyme’) Chemical agents such as ‘Rapidex’, ‘Pyroneg’ (depicted in figure 3.2) and ‘Endozyme’ are agents that effectively clean instruments by soaking. This is an effective method of cleaning instruments and avoids the need for special equipment.

Figure3.2 – Chemical agents used for cleaning and lubricating instruments

Instrument milk Instrument milk (depicted in figure 3.2) is a commercially available agent that is used to lubricate and polish instruments after cleaning. It is recommended that instrument milk should be used regularly. Lubricants that are used to ensure that instruments open and close easily are removed by constant cleaning and sterilising. Materials Materials such as drapes and gowns should be carefully cleaned prior to packing for sterilisation. In most cases materials are laundered and the following rules should be followed. You should: •

soak materials prior to washing to remove blood and other foreign materials

•

rinse all materials well after washing to ensure that any traces of detergent are removed

•

remove any lint

•

remove any x-ray badges prior to soaking or washing.

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Packing of instruments and materials Many different techniques are used for packing instruments and materials depending on personal preference. Irrespective of the technique it is important to ensure that the instruments or materials are thoroughly cleaned to ensure that sterilisation is enhanced. Irrespective of the packing technique which is used the following principles should be adhered to. They should be packed so that: •

proper sterilisation is promoted

•

equipment and materials are not damaged

•

contents can be unpacked in an aseptic manner

•

packs can be stored (if necessary) so that they maintain sterility for a reasonable period of time.

•

sterilisation indicators such as steamclox indicates whether sterilisation has been effective

•

packs are dated and named for proper identification

•

ratchet instruments should not be closed any further than the first click and it is preferable that they are left open

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Two methods of packing instruments and materials Depicted in figure 3.3 are two (2) methods that may be used to pack instruments or materials. When performing this task particular notice should be taken of the following points. (g)

all folds should be crisp and neat

(h)

the finished bundle should be firm but not excessively tight

(i)

it is preferable to double wrap packs as this extends their storage life.

(j)

packs should be secure with auoclave tape

(k)

pack should be dated and named.

Figure 3.3 – Two (2) methods of packing instruments and materials

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One (1) method of folding surgical drapes and towels Depicted in figure 3.4 is one method of folding surgical drapes and towels. You will notice that all folds are made in an ‘accordion style’. This technique is used as it ensures that steam penetrates materials easily and that they are most readily autoclaved. When performing this task particular notice should be taken of the following points: (l)

all folds should be crisp, neat and ‘accordion style’

(m) the finished bundle should be firm but not too tight.

Figure 3.4 – One method of folding surgical drapes and towels

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A method of folding a gown Depicted in figure 3.5 is suitable method of folding a gown that is to be sterilised for use within the operating theatre. When performing this task particular notice should be taken of the following points: (n)

the gown is folded inside out so that only the inside surfaces are touched by operating theatre staff

(o)

all folds should be crisp, neat and ‘accordion style’

(p)

the finished bundle should be firm but not excessively tight.

Figure 3.5 – One method of folding a gown

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Cleaning the operating room environment Between surgical cases the operating table, instrument trolley’s etc should be wiped down with a suitable disinfectant and body tissues disposed of according to legislative requirements. At the completion of the surgical session the entire operating room should be cleaned thoroughly. Floors should be vacuumed, and mopped with an appropriate disinfectant. All horizontal and vertical surfaces should also be cleaned. Particular attention should be made to the moving of the operating table (where possible) and clean underneath.

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Asepsis and Methods of Sterilisation Introduction Aseptic technique is an important role of the surgical nurse. By definition aseptic technique is the performance of tasks that render the surgical field free from pathogenic micro-organisms. The success of any surgical procedure depends on healing. If infection is present healing will not occur or will be delayed. Minimising the risk of infection is a fundamental principle of surgical technique.

Sources of post operative infection Sources of post operative infection are surgical staff, the patient, surgical materials, equipment and the environment. The aim of asepsis is to minimise the number of pathogens thereby minimising the risk of post operative infection. In practice it is not possible to carry out ‘sterile surgery’ (which implies that the surgical field is free from all micro-organisms). Even if all possible care is taken in the preparation of materials, equipment and the patient it is not possible to sterilise the patient’s skin. When the surgeon makes the first incision, bacteria deep in the skin of the patient enter the wound. This is therefore, not a sterile environment, rather it is an aseptic environment.

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Sterilisation Sterilisation is an integral part of aseptic technique associated with surgery conducted in veterinary practice. Sterilisation techniques that may be seen in practice include boiling (moist heat), autoclaving (steam under pressure) and cold sterilisation (disinfection). Sterilisation using radiation is a common feature of articles purchased already sterilised. There are a number of factors that should be considered when choosing a suitable method of sterilisation. These factors include the type of material to be sterilised and whether the materials are to be stored prior to use.

Rules which should be followed to perform effective sterilisation Irrespective of the sterilisation technique which is chosen there are a number of rules which should be followed to minimise the risk of failure. These rules include: (q)

The materials and equipment to be sterilised must be compatible with the technique.

(r)

Materials should be thoroughly clean and free from oil, grease and proteins such as blood, pus etc

(s)

All materials should have adequate exposure to sterilising agent at the correct concentration or amount for an adequate time.

(t)

The sterilising equipment should be in good working order.

(u)

All equipment and packs must be properly prepared and loaded into the sterilising environment.

Assessing the effectiveness of sterilisation The effectiveness of sterilisation may be assessed physically, chemically or biologically. Physical assessment The use of gauges to indicate time, temperature, pressure or other parameters is referred to as physical assessment. These techniques are unreliable because they are open to human error and the gauges may be faulty. They should only be used as an indicator that the sterilising process is occurring.

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Chemical assessment Chemical assessment involves the use of indicators that undergo a colour change when certain parameters are reached. Examples of chemical indicators are autoclave tape and steamclox. •

Autoclave tape Autoclave tape is used to indicate that the temperature of steam has reached an adequate level. It does not indicate the period of time at which that temperature was maintained and therefore does not imply that correct sterilisation procedure has occurred. An example of autoclave tape is depicted in figure 2.1.

Figure

2.1

–

Examples

chemical

indicated

autoclave

tape,

steamclox,

sterilope and OK indicators

•

Other indicators Other chemical indicators for assessing the effectiveness of steam sterilisation include ‘sterilope autoclave bags’ and ‘propper OK strips’. These are depicted in figure 1. In addition chemical indicators are found on the items which have been gamma sterilised. The indicator undergoes a chemical change in response to irradiation.

Biological indicators Biological indicators imply the use of living matter to indicate the effectiveness of sterilisation. As it is biological matter that we are trying to destroy, this is the most effective form of monitoring. Biological indicators are usually found in the form of spores as in ‘Sporestrips’. These strips are impregnated with non pathogenic bacterial spores which if placed on an agar plate will activate and grow into a colony. These strips are placed in the steriliser. Upon completion of a sterilising cycle, the strip is ‘plated out’. If the sterilising has been complete no growth will occur.

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Boiling Boiling is a technique which does not destroy all bacterial spores. Some of the bacteria responsible for post operative infection are spore forming eg bacteria which cause gas gangrene and tetanus. The advantage of boiling is that the equipment requirement is cheap and reliable. It is a rapid method of destroying most organisms (with the exception of spores) rapidly. The major disadvantages are that boiling does not destroy spores, instruments and materials are wet and hot when ready for use and cannot be stored. Some equipment, such as drills, cannot be boiled as they contain oil or grease. Some materials will not withstand immersion in water (eg most types of suture material).

Cold sterilisation (disinfection) Cold sterilisation requires the use of chemicals to disinfect materials and equipment. Like boiling, cold sterilisation should be considered unreliable as not all spores are destroyed by this process. However if these chemicals are used correctly it is a useful technique where other methods are unavailable. Cold sterilisation is commonly used for instruments required for minor procedures where contamination has already occurred eg minor stitch-ups, abscesses. Chemical groups that may be used for cold sterilisation include alcohol, iodines, chlorhexidine and chlorines. Care should be taken to ensure that the chemical will not damage the instruments or materials and that any residues on the equipment will not irritate the tissues of the patient. The effectiveness of the disinfection is influenced by the: •

nature of the micro-organisms (especially the presence of bacterial spores)

•

number of micro-organisms

•

the concentration of the disinfectant

•

the length of exposure to the disinfectant

•

the amount of organic matter present

•

temperature

•

type and conditions of materials to be disinfected.

An anti-rust additive must be added to the disinfectant solution to prevent instruments rusting.

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Radiation sterilisation Radiation sterilisation is not to be performed in the clinic. Gamma sterilisation is commercially performed to sterilise items such as scalpel blades, surgical suture materials, rubber gloves, syringes, dressings and catheters. Radiation sterilisation is reliable and does not damage delicate materials. This process requires extremely expensive specialist equipment.

Dry heat Dry heat involves the use of an oven to sterilise equipment. This technique is commonly used in laboratories to sterilise glassware. This technique has the advantages that the equipment required for dry heat sterilisation is cheap, that it does not damage sharp instruments and that it is relatively quick (sixty minutes at 160Â°C). The disadvantages of this technique are that many materials such as plastics, rubber and cloth are damaged by dry heat. In addition the equipment sterilised by this method cannot be readily stored.

Steam sterilisation (autoclaving) Autoclaving requires the use of special equipment which produces steam in a confined space. When placed under pressure the temperature of the steam rises and becomes a reliable method of sterilisation. The simplest form of autoclave is a pressure cooker. Most commonly in veterinary practice displacement autoclaves are used. Displacement autoclaves work on the principle that air in the sterilising chamber is removed by pressure as the steam is produced. In large hospitals vacuum autoclaves are used. In this case all air is removed from the sterilising chamber by a vacuum pump thus speeding the sterilisation process. The advantage of steam under pressure is that it is a reliable method of sterilisation, it penetrates many materials, is relatively quick and equipment may be stored prior to use.

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For example, a pack which requires exposure to steam under pressure at: Temperature

Sterilising Time

110°C

Requires

18 minutes

121°C

Requires

12 minutes

125°C

Requires

8 minutes

132°C

Requires

2 minutes

The disadvantage of autoclaving is materials such as rubber and some plastics are damaged by the intense heat. Equipment containing oil or grease is damaged and super sharp instruments are blunted by the steam.

Figure 2.2 –An example of an autoclave

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Procedure for operation of the autoclave Although autoclaves vary, the basic operating procedure is similar. Some autoclaves are more automatic and therefore avoid the need to carry out some steps manually. Described is a standard procedure for a non-automatic unit: 9.

Plug in the autoclave and turn it ‘ON’.

10.

Check the water level in the water reservoir. Fill if necessary.

11.

Fill the autoclave chamber to the correct level.

12.

Load the autoclave.

13.

Close the chamber.

14.

Set the autoclave to the correct autoclaving time.

15.

Switch the autoclave on to sterilise.

16.

When the autoclaving time has finished turn the sterilising switch to ‘OFF’.

17.

Release the pressure from the autoclaving chamber.

18.

Wait until the pressure gauge reads ‘ZERO’ pressure.

19.

Open the chamber. Carefully unwind the door. Watch out for hot steam, remove stopper and open the door about 10 cm.

20.

Set the autoclave to ‘DRY’.

21.

Collect the sterile packs when cool and dry.

Prepare Theatre or Surgical Operating Area for Use Preparation of surgical team Preparing the surgical team for surgery is yet another link in a chain of events that are designed to minimise post operative infections. In this case the overall aim is to produce and maintain a sterile field. This sterile field is considered to be the area of the front of the body above the waist. Described in this unit is a technique that might be used to maintain the highest standards of asepsis possible. We do however recognise that in many clinics ‘short cuts’ are taken where only a selection of these techniques are performed to produce what is considered to be an acceptable level of asepsis for the particular practice. Aspects of preparation that are considered here are applying mask and cap, the surgical scrub and gowning.

Applying surgical masks and caps Although surgical masks and caps are not worn in many veterinary clinics others insist on their application prior to entering the surgical area. The aim of the surgical mask is to prevent contamination of the patient by any microorganisms from the operator’s airways or oral cavity. The aim of wearing a surgical cap is to prevent hair or scurf contaminating the patient and therefore predisposing to post surgical infection. An example of how to wear a surgical mask and a surgical cap is depicted in figure 3.3.

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Figure 3.3 â&#x20AC;&#x201C; The surgical mask and cap

Scrubbing and drying Scrubbing and drying of hands prior to surgery is common to all veterinary practices. Although the technique may vary the aim remains the same. The surgical team is attempting to remove pathogenic micro-organisms that are on the hands without damaging the skin itself. Micro-organisms found on the skin are divided into three (3) types: 1. contaminant or transient 2. resident 3. deep or hidden. Contaminant or transient flora These are acquired casually by contact, e.g. working in the garden, changing dressings. These bacteria may be pathogenic or harmless. These micro-organisms are easily removed by washing with soap and running water for one minute. Resident flora These are the stable, persistent residents of the skin. These are harder to remove or kill than the transients. Fortunately only about 5% of the resident flora is pathogenic but this proportion may be increased by constant contact with infected material. The bacteria population of the hands may increase rapidly under gloves. A surgeon or assistant who wears gloves continuously for a few hours may end up with a bacterial population greater than before the pre-surgical scrub. Fortunately mechanical cleansing (washing) and use of anti-septic solutions can significantly reduce the bacterial count.

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Deep or hidden bacteria These bacteria live deep in the hair follicles and sebaceous glands. Most of these are nonpathogenic and cannot be removed without sterilising the skin. Effective scrubbing technique will remove transient and some resident bacterial. A suggested method of scrubbing is described below and shown in figure 3.4. The three (3) minute scrub 22.

Turn on the water and adjust it for temperature and pressure

23.

Apply antiseptic to the hands and wash up to within 4 cm of the elbows producing a good lather

24.

Clean the nails with a nail file or nail pick

25.

Rinse beginning at the hands and moving towards the elbows keeping the hands elevated to prevent water flowing back from elbows to hands

26.

Obtain a sterile brush, wet it and apply antiseptic

27.

Scrub from hands to within 4cm of the elbows completing one arm at a time: •

Finger nails – 10 strokes each

•

Each finger surface and interdigital space – 5 strokes each

•

Palms – 5 strokes each

•

Backs of hands – 5 strokes each

•

Each arm surface – 5 strokes each covering 4-5cm at a time

28.

Rinse from hands to elbows keeping the hands elevated

29.

Turn water off with elbows

30.

Dry the hands

Figure 3.4 – The principles of scrub technique © Box Hill Institute 116

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Drying technique One technique of drying hands is described below. Let towel open, use one end and thoroughly dry fingers then start up the arm using a slow circular motion – never return to an area you have already dried. Take the opposite end of the towel and dry the other hand and arm, again starting with the fingers and moving up the arm. This is depicted in figure 3.5.

Figure 3.5 – Drying technique

•

Discard the towel.

You are now ready to put on the sterile gown.

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Gowning The principle aim of putting on a sterile gown is to ensure that the front surface of the gown remains sterile. This means that you are permitted only to touch the inside surface of the gown. One way this can be achieved is by following the steps below. 31.

Pick up the sterile gown by the neck and allow it to unfold. Do not allow it to fall on the floor or touch any other item.

32.

Identify the arm holes

33.

With the right or left hand holding the collar, place the other hand into the arm hole.

34.

Hold both arms upwards and extended to support the gown and wait for an assistant to adjust and tie the gown.

35.

The assistant may adjust the gown by using the inside surface of the gown and must not touch the outside of the gown

This is depicted in figure 3.6.

Figure 3.6 – Putting on a sterile gown

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Gloving The principle of putting on gloves is that the outside surface of the glove must not be touched by the hand. There are two (2) methods of achieving this. One is open gloving and the other by closed gloving technique. The open gloving technique is described here. 36.

The glove pack will be opened by an assistant.

37.

The right or left glove is picked up by the turned cuff and the right or left hand is placed into the glove

38.

The other glove is picked up by the turned cuff, with the gloved hand, and the other hand is placed into the glove.

39.

The cuff of both gloves are then pull up.

40.

The gloves are adjusted

This is depicted in figure 3.7.

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Pre-operative animal preparation Preparation of the anaesthetised patient prior to surgery varies considerably from practice to practice. The aim of this preparation remains the same, that is to minimise post operative infections. Described below is one standard procedure. It is divided into clipping and swabbing. Clipping the patient The area is usually clipped using electric clippers with a size 40 clipper blade. The area should be large enough so that hairs don’t contaminate the surgical site during surgery. As a general rule the clipped area should be 4.5 cm2 larger than the required surgical site. The area should be vacuumed to reduce contamination of animal and environment. Swabbing the patient There are many scrub methods used in practice – no particular method is the correct method but you should always work from the incision site outwards. An example of a simple yet effective scrub method is as follows: •

scrub site with Betadine scrub then rinse and repeat

•

swab with 70-80% alcohol working outward from the incision site.

•

paint or spray with Betadine solution immediately before surgery begins (again working outward from the incision site).

Figure 4.2 – Swabbing the patient

Irrespective of the chemicals used, the principles remain the same. •

Initially swabbing the incision line then working outwards always applies. Never return to a swabbed area with a contaminated swab.

•

Do not damage the area by scrubbing too vigorously

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Unpacking surgical equipment In principle this should be done in such a way that equipment maintains sterility and can be handled safely by the surgeon or surgical assistant. The unpacking of ‘peel packs’ and ‘double wrapped surgical packs’ is described. Opening ‘Peel Packs’ Scalpel blades, surgical gloves and some suture materials are presented in ‘peel packs’ Peeling back the outer package as depicted in figure 3.1 opens these.

Figure 3.1 – Opening ‘peel packs’

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Opening ‘Double Wrapped’ surgical packs Double wrapped surgical packs must be opened for use by the surgeon or surgical assistant. When opening these packs it is essential not to touch the inner wrap. This is depicted in Figure 3.2.

Figure 3.2 – Opening a ‘double wrapped’ surgical pack

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Control of Reproduction Introduction Management, surgical or chemical methods, can achieve reproductive control. Control may be necessary for several reasons, for example so that breeding can be delayed until the female is of mature size, or to give the female adequate time between litters, or to allow breeding when the appropriate male is available, or if the animal is not required for breeding purposes.

Management practices Management practices to control reproduction involve separating the female from the male so that mating cannot occur. The female must be confined so that males cannot gain access to the female and so that the female cannot escape. In queens, where ovulation is induced by cervical stimulation and the oestrus cycle continues until the queen is mated, ovulation can be induced artificially. A glass rod can be used to stimulate the cervix and induce ovulation. The ovulated eggs will not be fertilised and the queen will go into anoestrus. This technique is used when the queen is not required for breeding in a particular season.

Surgical procedures reproduction

for

controlling

There are a variety of surgical procedures that are used to control reproduction. They involve either the removal of the ova or sperm producing organs or surgery to prevent the release of ova or sperm. Ovariohysterectomy and castration are the most commonly performed procedures and are desirable because they also remove the source of oestrogen and progesterone production in the female and the source of testosterone production in the male. As well as affecting sexual behaviour, an absence of sex hormones will also contribute to a reduction in certain diseases such as prostatic disease and perianal adenomas in male dogs and mammary tumour in the bitch, if ovariohysterectomy is performed before the bitchâ&#x20AC;&#x2122;s first oestrus cycle. Both procedures are irreversible.

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Ovariohysterectomy Ovariohysterectomy or speying is a procedure that involves the removal of both the ovaries, which produce ova as well as the hormones oestrogen and progesterone, and uterus. This means that the female will not experience oestrus and cannot become pregnant.

Tying tubes This procedure involves tying the fallopian tubes so that ova are unable to pass from the ovary to the uterus. Although this procedure is effective in preventing breeding, it is not commonly performed in companion animals. Fertilisation of the ova and pregnancy cannot occur, however the female will still experience oestrus and will mate because the ovaries are still functional. Uterine infections, such as pyometra, can also still occur because these infections are dependent on female hormones.

Castration Castration involves the removal of both testes and hence the removal of the spermatogenic cells and the interstitial cells, which produce testosterone. This means that the castrated male cannot breed and secondary sex characteristics such as muscle development and accessory sex gland development are reduced. Castration may also influence behavioural characteristics associated with the hormone testosterone such as roaming, aggression and urine spraying, especially when performed prior to the animal reaching sexual maturity.

Vasectomy Vasectomy is a procedure, which involves tying off and removing part of both of the vas deferens, preventing the passage of sperm therefore rendering the male infertile. As the testes are still able to produce testosterone, the male will still exhibit secondary sex characteristics and mating behaviour, however the ejaculated seminal fluid will not contain any sperm. This procedure is not commonly performed in veterinary practice as it has no affect on the secondary sex characteristics and does not prevent testosterone dependant diseases.

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Chemical control of reproduction Hormones can be used in the control of reproduction to: •

postpone the onset of oestrus

•

suppress the signs of oestrus

•

terminating pregnancy

•

suppress sexual activity in the male

•

treat prostatic disease.

Suppression of sexual activity in the male Progesterone’s have an anti-androgenic effect, ie they oppose the effects of male hormones by suppressing the release of testosterone. As a result they may be used to suppress sexual activity as well as behaviours such as roaming, aggression and urine spraying. The fertility of the male remains unaffected.

Prostatic disease The progesterone-like chemical Deladumone acetate is often used in the treatment of diseases of the prostate gland in the dog. In entire male dogs, the function and size of the prostate gland is dependent on the hormone testosterone, and as they age the prostate gland often enlarges. This enlargement may interfere with the passage of faeces through the gastrointestinal tract by pressing on the colon and rectum, resulting in constipation, or it may interfere with urination by constricting the urethra. Castration is indicated in these dogs to remove the source of testosterone and thus reduce the size of the prostate gland. If castration cannot be performed, Deladumone acetate injections can be administered at regular intervals to suppress the release of testosterone. .

12. Maintaining asepsis

Need to maintain high standards as we are already working under co mpromised conditions: 1. Put face mask on and sterile go wn. 2. Scrub hands 5 â&#x20AC;&#x201C; 10 minutes with chlorhexidine scrub. No rings, watch or bracelets to be worn. 3. Dry hands with autoclave hand towel (correct procedure). 4. Put on gloves (correct procedure). 5. Maintain hands above table height at a ll times. 6. Ensure that hands and instru ments do not touch the non-sterile areas. 7. Apart from Vet and anaesthetist/assistant no one should be in the operating theatre unless necessary. 8. Minimum movements in the o perating roo m. 9. Use autoclave tape when steriliz ing instru ments to indicate co mp lete sterilization. 10. Use lint roller to re move fur from drapes. 11. If instruments fall off drape â&#x20AC;&#x201C; assistant to p ick up; if possible do not re-use. If you have to re-use, wash with running tap water, soak in alcoho l at least 5-10 minutes.

12. If break sterilit y ie hands/instruments touch non sterile objects- must re-glove and re-drape

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13. Care of the Theatre Theatre design has come a long way since ‘table top’ surgery in a back room of the veterinary practice. The modern ‘high tech’ theatres in veterinary hospitals of today are of a standard equal to many human theatres. Before planning the layout of the theatre, it is necessary to understand the reasons behind the design. The most important being – asepsis (absence of pathogenic micro-organisms). Wound infections can be a major problem if an aseptic technique is not adopted. The aim of the theatre is to have an area as free from microbial contamination as possible, so that surgery can take place with a significantly reduced risk of infection to the patient. As well as the environment and the equipment being free from contamination, it is essential that the theatre personnel also follow strict aseptic protocols during surgery and within the theatre suite. Surgery may be classified as:

Dirty Contaminated Clean contaminated Clean

It is important, therefore, to construct a daily operating list so that clean operations, such as orthopaedic work, take place before dirty or contaminated operations such as anal or aural surgery. In larger establishments a separate theatre may be used for each category: orthopaedics, soft-tissue and contaminated/dirty operations. There may also be specialist theatre such as ophthalmology or neurology, which are used specifically for that particular service as they contain specialist equipment.

Theatre Design There will always be the ideal type of theatre suite with many rooms for all the different requirements. As long as basic principles are followed, many smaller surgeries may be adapted quite adequately. The theatre should always be a separate area that is used for nothing else but surgery. It should be conveniently close to the kennels, treatment and radiography areas, but well away from hospital traffic. There should be clearly defined lines dividing the sterile area and the dirty, contaminated area. Adjacent to the theatre should be the preparation room. Usually animals are brought into this room, anaesthetised, clipped and prepared for surgery. They can then be taken straight through to theatre where the final preparation takes place. The preparation room may also serve as he treatment room or for contaminated, unsterile procedures such as dentals. Also adjacent to the theatre should be the scrub room. This may also be combined with the preparation room. It is essentially the area for the preparation of the surgeon(s), containing scrub sinks and sterile gowns and gloves. Scrub sinks should not be located in the theatre as the wet conditions encourage the growth of bacteria. There should also be an area or room where the animals may recover quietly and where they can be closely monitored closely until they are ready to return to the ward or kennels. A sterile store is always more convenient when there are a number of theatres in use. The sterile kits and additional instruments are kept either on shelves or in glass fronted cabinets. The shelves should be labelled so that it is easy to locate the instruments quickly. If there is only one theatre then the instruments should be stored in ‘floor to ceiling’ glass fronted cabinets where they are more accessible. Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 1 127

Theatre Practice Adjacent to the sterile store may be an instrument preparation and sterilisation room. The instruments are brought here after the operation and then cleaned and sterilised. In addition, drapes and gowns may be washed, dried and re-sterilised. There should also be a separate changing room where outdoor clothes are changed for clean scrub suits, hats and shoes.

Necessary Equipment The theatre should contain only a bare minimum of equipment and furniture. A â&#x20AC;&#x2DC;clutteredâ&#x20AC;&#x2122; room is not easily cleaned and collects dust. It can also obstruct movement around the theatre and may lead to contamination of the surgical field. Basic equipment: Operating table It should be adjustable so that it can be moved up and down It may be fixed to the floor or mobile but with locking wheels. Some tables may tilt longitudinally or have sectioned parts that can be adjusted independently. It should be easy to clean or be dismantled easily in order to clean it thoroughly. Instrument trolley Comes in different sizes and have glass or metal tops They may be single or two tiered. Two tiered tables are used when a lot of additional equipment is required, as in many orthopaedic operations. They should have rubber anti-static wheels that are identified by their yellow colour. Mayo trolleys (single tiered trolleys with removable trays) may be positioned over the end of the table. Larger single tiered trolleys may straddle the end of the table and be included in the draping. Kickabout Bowl A removable stainless steel bowl held in a frame with anti-static castors. All waste from the operation is put in the bowl and disposed of at the end of the operation. Larger versions contain two bowls at waist height. This is useful as one bowl may be kept specifically for swabs. This helps when carrying out a swab count at the end of an operation. Anaesthetic machine Also with anti-static wheels May be connected to piped anaesthetic gases and an active scavenging system. Clock Fitted flush to the wall or control panel. Useful for timing procedures, especially vascular work. X-Ray Viewer Fitted flush into the wall. Necessary for orthopaedic work.

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Theatre Practice Clinic Construction The walls, floors and ceilings should be made from impervious hardwearing materials with sealed seams. Paintwork should be washable. The floors should be easily cleaned and disinfected and should be non-slip. Ideally the floor should curve up at the wall slightly to ease cleaning. Lighting Fluorescent lighting provides adequate background lighting. Natural light can also be used but the glare of bright summer sunlight may cause problems. Focussed lights should be available which are wall or ceiling mounted. Sterile light handles may be used if the surgeons prefer to position the light themselves. Portable lights may be used but are more cumbersome and less convenient. The focussed or spotlights should contain heat absorbing filters to reduce the risk of exposed tissues drying out. Wall mounted examination lights are useful in the preparation room to aid certain procedures such as the placement of intravenous catheters. Heating Room temperature within the theatres should be kept at approximately 21ยบC (70ยบF). The temperature should be warm enough to maintain the animals body temperature during surgery but not too uncomfortable for the surgeons and other theatre personnel. Heating may be provided by the ventilation system or from panel heaters within the wall. A slightly less expensive system would be to have slim line, non-ribbed, wall mounted panel heaters. Radiators are dust traps and fan heaters disturb the air too much. Ventilation The theatres should have slight positive pressure ventilation so that when the door is opened the air flows out, rather than in. Therefore the air moves from the least contamination to the greatest potential of contamination. The air exchange system should be 25 times per hour for re-circulated air, and 15 times per hour for air exhausted to the outside. Adequate scavenging is necessary to comply with occupational health and safety regulations. Electrical Supply Normal wall mounted sockets are adequate although they should ideally be ceiling mounted to avoid too many trailing flexes on the floor.

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Theatre Practice

Cleaning and Maintenance Cleaning Equipment Wet Vacuums

Preferable to mopping Can be used with disinfectant

Mops

Can be a source of infection Must be washed and dried daily Rinse thoroughly after use and soak in disinfectant, then rinse and dry. Use a double bucket method (cleaning solution/water)

Gloves

For protection against the disinfectants Preferably disposable to prevent contamination

Cloths and Sponges

Preferably disposable to minimise contamination Otherwise launder and dry daily

Each area of the hospital should have itâ&#x20AC;&#x2122;s own cleaning equipment to minimise the spread of infection. At the start of each day Damp dust all surfaces and equipment, including the lights. This should be done using a cloth moistened with the correct strength disinfectant solution. Between cases Remove and clean any instruments and drapes Remove all waste materials (tissue, swabs and empty sterilising packets). Clean and disinfect the table and trolleys. Clean gross dirt (blood etc.) from the floor After each consulting/operating session (Daily) After removing the instruments and equipment, clean and disinfect all the surfaces and remaining equipment. Disinfect an area of the floor so that the equipment may be wheeled onto this area whilst the rest of the floor is being cleaned and disinfected. The whole clinic, including walls and doors should be cleaned and disinfected weekly. Routine sampling for bacterial culture should be performed regularly.

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Theatre Practice Care of the Instruments Modern surgical instruments are made of stainless steel, an alloy of iron, chromium and carbon. The inclusion of chromium increases the resistance to corrosion. With proper care and attention, our surgical instruments will last for years. In most veterinary hospitals it is necessary to have a number of general surgical packs with additional specialised instruments packed separately. Surgical Instrument marking systems

Autoclavable colour tape is often used for identification of instruments from within the same set to allow for easy repackaging. However, this must be used with caution as it may harbour microorganisms, the fibres may detach and it needs regular replacing. Engraving also harbours microorganisms and may compromise instrument strength. Ring handle colour coding claims to be long lasting, autoclavable and unlikely to harbour bacteria. However they may be uncomfortable for the surgeon during lengthy surgical procedures. Etching coats part of the instrument with a block of colour or code for identification however it may not be cost effective unless treating a large number of instruments. A card index system, outlining the equipment needed for each procedure facilitates efficient preparation prior to surgery. This may include a list of instruments or a clear photograph of the surgical pack. It is therefore essential that veterinary nurses have a good knowledge of surgical instruments to allow proper processing of surgical packs.

Handling of Instruments Instruments should only be used for the purpose for which they were designed. Allis tissue forceps should not be used as bone holders and Metzenbaum scissors should not be used for cutting sutures! Instruments should always be placed on surfaces, not dropped or thrown! Heavy items should not be placed on top of or adjacent to delicate equipment. Instruments with cutting blades should be protected to avoid dulling of the edges. Protective sheaths should be left in place until the instrument is ready for use. During surgery, the swab nurse should ensure that the instruments are kept free of blood and debris by wiping with a moistened swab after each use. Instruments should be checked after each procedure (that is if they havenâ&#x20AC;&#x2122;t already been thrown across the room in frustration). Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 5 131

Theatre Practice Ratchets should close easily and hold firmly. Box locks that are too loose will cause misalignment and will not hold tissue securely. When not in use, the box locks should be left secured on the first ratchet. The shaft of instruments should be straight to ensure correct alignment. Needle holders become damaged when too large a needle has been used for the given size and type of needle holders. An approximately sized needle will be gripped firmly with the jaws locked on the second ratchet. Some needle holders have tungsten carbide inserts which increase strength and reduce wear on the gripping surface. These instruments are usually more expensive but they will last longer as the inserts can be replaced therefore prolonging the life of the whole instrument. Instruments with tungsten carbide inserts are identified by their gold coloured handles. Cutting instruments (scissors, osteotomes, chisels, peri-osteal elevators and Rongeurs) should be checked for sharpness and chips in the metal. Protective sheaths should be applied for storage. Soaking stainless steel should be avoided as this may lead to staining and corrosion. Titanium alloy is used for microsurgical and ophthalmological instruments. This alloy has a bluish colour which reduces glare under the operating lights. Such instruments are lighter and stronger than surgical steel instruments. Because of the design and physical properties of the instruments, the surgeon is able to control their movements much more easily. Extra care should be taken when handling these instruments because they are not only delicate but also expensive to replace. They can be placed in special trays for cleaning and storage. Before cleaning the surgical pack the priority is the safe removal and disposal of all sharps!

Manual cleaning When processing surgical instruments correct occupational health and safety procedures should be adhered to. An apron, gloves and mask should be worn and in addition, a disposable cap should be worn to prevent hair form becoming a contaminant. Always clean instruments straight after use. If thorough cleaning is not possible then at least rinse the instruments in cold water to remove gross dirt and blood. Instruments should not be soaked for prolonged periods as this is detrimental to the chromium oxide layer on the instrument surface. When cleaning the instruments try to hold them below the surface of the water to avoid self contamination with potentially harmful water droplets. The instruments can be cleaned in a mild, liquid detergent solution since our aim is to remove dirt and grease. Enzymatic cleaners are available which break down the dirt and grease and lift it away from the instrument surface. It is worth remembering that 99.9% of microbial contamination can be removed by thorough cleansing alone. Instruments that have movable parts should be disassembled prior to cleaning (e.g. depth gauges and drill guides etc.) All box locks and ratchets should be opened to ensure thorough cleaning. Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 6 132

Theatre Practice Serrations and box locks should be cleaned with a soft bristle brush. Abrasive materials should never be used as they scratch the surface of the instrument, which may organic debris in later use, and cause corrosion. A final water rinse will remove any traces of detergent prior to autoclaving. Ultrasonic Cleaning Ultrasonic cleaners are effective at removing debris from inaccessible areas such as box locks, serrations and deep grooves. These cleaners act by a process of cavitation. Ultrasonic energy produces high frequency sound waves that generate tiny bubbles in the solution in the cleaner. The bubbles expand until they become unstable and collapse. This collapse generates minute vacuum areas that dislodge and dissolve debris. The bath is filled to a level one inch above the tray. Only instrument cleaner recommended by the manufacturer should be used. The instruments are place into a wire mesh tray (heavier, bulkier instruments at the bottom) and lowered into the bath. The tray should only be half full to avoid overloading and damage to the instruments. Instruments are thoroughly rinsed after ultrasonic cleaning to remove any surface debris and detergent residue.

Instrument lubrication Following cleaning and rinsing instruments with moving parts may be lubricated in a watermiscible lubricant The routine, long term use of instrument â&#x20AC;&#x2DC;milkâ&#x20AC;&#x2122;is not recommended so it is advisable to check with the instrument manufacturer or supplier. Machine or mineral oils are not suitable as lubricants as they leave sheen on the instrument surface and will inhibit steam penetration during the sterilisation process. Some instruments, such as orthopaedic drills, have their own silicone gel. This should always be used in accordance with manufacturer instructions. Always follow manufacturer instructions. Once the instruments have been cleaned they should be checked for correct alignment, sharpness and potential faults. Any problems should be dealt with promptly. Sterilising Disinfection

is the process of destroying or inhibiting the growth of microorganisms on an inanimate surface.

Sterilisation

refers to the destruction of all living microbes, including viruses and spores.

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Theatre Practice Methods of Sterilisation Cold Ethylene Oxide Individually packed items are placed in a polythene liner bag which is then placed in a fume cupboard. An ampoule of liquid is activated, the ventilator is then turned on and the items are left to sterilise. The unit operates at room temperature for 12 hours. At the end of the sterilising period a pump is turned on to aerate the container. After two hours the unit can be opened and the items are removed and placed in a well-ventilated room for a further 24 hours to allow the ethylene oxide to dissipate. The use of ethylene oxide is restricted to items which are damaged by heat such as: Fibreoptic equipment Plastic containers and trays Anaesthetic tubing Optical instruments High speed drills/burrs Gluteraldehyde Gluteraldehyde is supplied as an acid solution which is activated by the addition of a powder. The user must wear gloves, aprons and masks and as it is extremely irritating to tissue, sterilised items must be rinsed in sterile water prior to use. It is primarily used (under strict regulations) to sterilise fibre optic equipment in hospitals although it’s use in veterinary hospitals is precluded by its carcinogenic nature! Chlorhexadine Based Solutions Although many veterinary hospitals have a ‘wet kit’ or otoscope heads soaking in a chlorhexadine solution, it has poor activity against spores fungi and viruses and therefore not really suitable for sterilising surgical instruments. Irradiation A form of gamma radiation used in industry. Many pre-packed items are sterilised in this way. Heat Hot Air Ovens These are heated by electric elements to between 150 - 180ºC, as microorganisms are much more resistant to dry heat than when heated in the presence of moisture. Items sterilised in this way include: Cutting instruments Ophthalmic instruments Drill bits Powders and oils Glassware The oven must not be overloaded and items should be placed so that air can flow freely around them. For this reason packaging materials are not used to wrap the items.

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Theatre Practice Steam under pressure – Autoclave Water is boiled under pressure and the steam is enclosed within a chamber. Individually packed items are placed in the chamber and the steam circulates around. Temperatures of 121 - 134ºC are generally used to sterilise items. Individual manufacturer’s handbooks should be consulted to calculate the cycle time. Some autoclaves incorporate a vacuum cycle which allows steam to build up more rapidly. A second vacuum cycle will dry the load. Maintenance requirements include wiping out the chamber to prevent build up of mineral deposits, cleaning the water chamber and following proper monitoring procedures. Regular servicing is also advised. Packaging Surgical instruments are generally packaged, autoclaved and stored ready for the next use. In some cases a surgeon may request a particular item be ‘flash sterilised’ for imminent use. In this case the individual item is placed unwrapped directly onto a metal tray and processed with a rapid steam sterilisation cycle. Boiling is not sufficient as many harmful micro-organisms can survive this temperature. Items may be packaged in many different ways: Metal instrument boxes have ventilation holes to allow steam penetration when autoclaved. These holes must be closed for storage. These may be lined to prevent instrument damage. Linen drapes are most commonly used but have a limited number of reuses. The weave should be dense enough to prevent contamination during storage but loose enough to allow steam penetration during autoclaving. Instrument trolleys should be dry to prevent ‘strike through’. This is the wicking of moisture from underneath up to the surface, potentially bringing with it harmful microorganisms. They also commonly harbour contaminants such as lint or hair. Careful processing of linen drapes can be time consuming; however the ability to reuse can make them cost effective. Paper wraps need to be of a certain thickness and weight to repel water, allow steam penetration during autoclaving and should not leach toxic substances. Potential problems include a break of seal and moisture contamination. Paper bags, window packs and pouches are generally designed as single use. The size and weight of the item should be appropriate for the size of bag. Packaging sheets provide an excellent barrier to microorganisms and are suitable for autoclave sterilisation. However, they are designed for single use only as re-use may cause a breakdown in sterility due to loss of barrier properties. Sealing Items should be labelled with: Contents of the pack Full date on which the pack was sterilised Name of the person who prepared the pack for sterilisation Packing the autoclave It is important not too crowd packages in the autoclave as this may result in breakdown of the sterilisation process. Ideally items of a similar size should be stacked side by side without touching the sides of the autoclave drum.

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Theatre Practice Monitoring Chemical indicator strips may be placed on the inside of the pack before sterilisation. These will change colour when exposed to the correct temperature, pressure and time. ‘Brownes’ tubes work in a similar way. These are glass bottles filled with a brown liquid which changes to orange when exposed to the correct environment. Indicator tape is often used to secure packs and is differentiated by the pale strips crossing the tape. These strips will darken when exposed to steam. However, they do not indicate the correct pressure or time so should be not used as the sole method for monitoring. Spore strips are paper strips that contain a controlled-count spore population. After exposure to the autoclave they can be cultured for 72 hours to see if all the spores have been destroyed. This delay in obtaining results is a major disadvantage of this system; however it may be used periodically as a useful adjunct to the routine monitoring procedures. Storage of Sterilised Equipment The length of time that sterile instrument packs can be stored is ‘event’ related and not time related. Ideally the sterile instrument store should be a separate, well-ventilated, dust free room. Closed cabinets are preferred to open shelves. Sterilised packs in the instrument store should be handled as little as possible. This is facilitated by coded storage, adequate labelling and easy accessibility. All items should be labelled with the sterilisation date and initialled. Equipment should be resterilised after expiry of the 3-month shelf life. Instruments should be resterilised if the packaging is damaged, if the seal is broken or if the pack has become wet.

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Theatre Practice

Care of the Surgeon (And theatre personnel) A good surgical team is always prepared!

Preparation The nurseâ&#x20AC;&#x2122;s role in theatre is varied and in larger veterinary hospitals it can be divided into categories. The roving nurse Responsible for: Preparing the surgical facility & equipment Performing the pre-operative preparation of the patient Assisting with scrubbing, gowning and gloving Opening the outer layer of sterile packs Assisting with cleaning of the facility Cleaning and resterilising equipment and materials The surgical assistant Responsible for: Scrubbing, gowning and gloving Unpack and layout surgical equipment Application of the drape(s) Assisting with surgery May be responsible for suturing the skin A good surgical assistant should have an understanding of the aseptic technique and be able to anticipate the surgeons needs. The anaesthetic assistant Responsible for: Assisting with anaesthetic induction Maintaining fluid therapy protocol for patients Monitoring the patient during anaesthesia In reality we are responsible for all three. Before surgery can be started it is a good idea to take care of all bodily functions. This may seem like obvious advice but is frequently not adhered to. If surgery is likely to be prolonged then make sure you have something to eat and drink if lunchtime is a long way away. Snacking on biscuits or drinking coffee in theatre should not be done under any circumstances. If you are feeling unwell then try to swap with another nurse as leaving the patient unattended may be life threatening. Always consult the surgeon prior to surgery to check what equipment will be necessary. Have the patient notes, including any lab results, on hand and place any radiographs on the viewer in theatre. Inform other members of staff, if necessary, that surgery is about to commence and you should not be disturbed. Establish a protocol for theatre conduct and ensure that all members of staff are familiar with this and adhere to it.

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Theatre Practice The following protocol has been taken from a theatre at a veterinary referral hospital. The basic rules are the same and can be adopted for any theatre.

Remove all jewellery before entering theatre Remove nail polish Never enter a sterile area without changing into a theatre suit, anti-static boots or clogs, theatre hat and mask If scrub assistant, nails must be short and clean Theatre suit must be tucked in at the waist and into boots Theatre suits must be changed if they become damp or soiled If all doors to theatre are closed do not enter unless absolutely necessary Non-sterile persons must not touch or lean over anything sterile The sterile assistant must always face the sterile field The sterile assistant should always have hands above waist level and clasped when not being used All sterile persons must be aware of what is not sterile and all non-sterile persons must be aware of what is sterile! Non-sterile persons should not place themselves between the surgeon and the surgical field Always change back into normal clothes when leaving the sterile area

Applying surgical masks and hats Surgical hats are usually disposable although linen caps are available. Several styles are available and range from the ‘mop style’ caps to full-face covers, which accommodate beards. Masks are also available in several styles and may just cover the lower part of the face or include a plastic shield to cover the eyes. Whatever style you choose, basic principles apply. All hair must be within the theatre hats The surgical mask should cover the mouth and be ‘pinched’ at the nose During surgery, unnecessary talking should be avoided unless it is relevant to the case. Talking increases bacterial contamination due to saturation of the surgical mask

Scrubbing The aim of the surgical scrub is to clean the hands and arms to within a few centimetres of the elbows. Micro-organisms found on the skin are divided into three types: Transient flora

These micro-organisms are easily removed by washing with soap and running water. They are acquired by casual contact eg. changing dressings

Resident flora

These are persistent residents of the skin. Mechanical cleaning and use of antiseptic solutions can significantly reduce the numbers of bacteria present. However, the bacterial population on the skin can increase significantly when wearing gloves for a few hours.

Deep bacteria

these bacteria live in the hair follicles and sebaceous glands. These cannot be removed without sterilising the skin. Unfortunately, this is impossible!

When performing a presurgical scrub you should always begin by adjusting the water temperature and pressure. The hands are initially cleaned with water and a little antiseptic solution, and the nails are cleaned with a file or pick. Keeping the arms raised: Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 12 138

Theatre Practice The hands and arms are the cleaned with the antiseptic solution. The hands then arms are then scrubbed with a sterile brush and antiseptic solution. It is important to do this in a methodical fashion to ensure that each surface of the skin is cleaned. The water can then be turned off using the elbow or foot controls. The hands, then the arms are dried using a sterile towel. Remember to keep the hands raised at all times to prevent water running down from the elbows to the hands.

Gowning The front surface of the gown should remain sterile so gowns are usually packed so that the inside is out. The gown should also be folded in such a way to ensure minimal handling and movement when putting it on. For this reason gowns are either rolled or packed in a concertina fashion. The armholes are located and the surgeon/surgical assistant carefully ‘plunges’ into the gown ensuring that the hands are not exteriorised. Depending on the type of gown used, the roving nurse then secures the gown with ties. Types of gown Disposable paper gowns These are resistant to wetting so they are less permeable to bacteria. They are useful for procedures which may require frequent irrigation of the surgical site. Donning a new gown for each surgical procedure and disposing of it at the end ensures sterility. Linen (cloth) gowns Linen gowns are both comfortable and reusable. It is however, time consuming to launder the gowns and resterilise them. As linen is a woven material when it becomes wet, bacteria permeate through causing a breakdown in sterility. Plastic gowns Plastic is superior in its resistance to wetting and bacterial penetration. Plastic can be used to reinforce paper or linen gowns during wet surgery eg. plastic sleeves for equine abdominal surgery.

Gloving Know your glove size! Gloves should fit comfortably without cutting of circulation or leaving ‘flappy bits’ at the ends of the fingers. If the gloves are the wrong size it may impede the sensation in your fingertips therefore compromising the surgical technique. All too often glove size is incorrect to accommodate ease of application. When applying the surgical gloves the outside surface of the gloves should not be touched.

Two methods are commonly used in veterinary hospitals. The closed gloving technique requires a bit of practice. Basically the hands remain covered by the surgical gown and the gloves are wrapped around the fist. When the cuff is securely in place the fingers are extended to fit neatly into the gloves. This is all done in one swift movement! The opening gloving technique is much easier but still requires practice. The fingers are partially exteriorised and slipped into the inside of the glove. The glove is then pulled onto the hand about halfway to Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 13 139

Theatre Practice the level of the gown, by grasping the upturned cuff. The fingers of the glove are then inserted into the cuff of the opposite glove and pulled onto the other hand. When this is complete both cuffs can be secured. The principal is not to touch the outside surface of the gloves with exposed hands. In larger hospitals the surgical assistant may be expected to apply their gloves using one of the methods described above and then hold the surgeons gloves open to allow them to â&#x20AC;&#x2DC;plungeâ&#x20AC;&#x2122; into them. Unpacking surgical equipment When unpacking sterile equipment it is important that sterility is maintained and the packs can be handled safely by the surgeon. The roving nurse should not shake instruments out of bags onto the instrument trolley. Bags should be peeled back to cover unsterile hands and held for the surgeon to remove the instrument(s). When opening double wrapped packs it is important not to touch the inner wrapper.

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Theatre Practice

Care of the Patient Initial considerations Surgical cases will be one of the following:A) elective or non-urgent eg. desexing B) Necessary or urgent eg. fracture repair C) Emergency surgery eg. traumatic chest injury

The time between admission and surgery will depend on various factors. In the simplest elective procedures the patient is admitted on the morning of surgery and returns home later that day. Pre-operative preparations in these cases are minimal. In others, there may be a delay before surgery is performed. Reasons for this include: I.

Investigative procedures â&#x20AC;&#x201C; blood samples, diagnostic tests, radiographic studies

II.

Fluid therapy/transfusion â&#x20AC;&#x201C; to improve the patients physiological status before surgery.

III.

To allow reduction of swelling / debridement of wounds

IV.

Presence of other injuries / shock which require treatment before surgery is undertaken eg. Presence of thoracic trauma associated with a limb fracture.

Stabilisation of a patient with a metabolic disturbance eg. diabetes mellitus, renal disease.

Admission of the Patient 1. Record all relevant details on the case notes. Check the reason for admission and identify the proposed surgical site (draw a diagram if necessary). 2. Ensure that the owner understands what is to be done and how the patient will look when it is discharged eg. Elizabethan collar, clipped area or wearing a bandage. 3. Ensure that in the ownerâ&#x20AC;&#x2122;s opinion the patient is in good health and that symptoms have not changed since last seen by a veterinary surgeon. 4. Ensure that you have a contact number in case of emergency. 5. If the surgery is to be performed the same day, ensure that the animal has been starved as instructed. 6. Give owners instructions regarding inquiries and estimated collection time. Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 15 141

Theatre Practice 7. On admission the patient should be weighed, and identification collar fitted which contains patient details and clinic details.

Preparation of the patient Starving Food is usually withheld prior to surgery. This is primarily done to prevent regurgitation of food under general anaesthesia and during recovery and to prevent impedance of respiration due to a full stomach. An empty gut is desirable prior to surgery of the gastro-intestinal tract depending on individual patient needs. Clipping •

Under general anaesthesia

Advantages Takes less time Fewer people required to restrain the animal Desirable with fractious animals or painful/inaccessible sites Disadvantages Decreases asepsis – small loose hairs very difficult to remove even with the vacuum cleaner Increases anaesthetic time

•

Pre-anaesthesia

Advantages Shorter anaesthetic time Improves asepsis – loose hairs generally shed before surgery Allows cleaning of the surgical site beforehand Improves theatre efficiency Disadvantages Patient may be unco-operative Generally requires two or more people Clipping more than twelve hours before surgery increases skin bacteria.

Considerations for clipping Ensure clipping is neat Clip an area at least 5cm greater than the proposed surgical site Ensure clipper blades are in good order. Clean blades between cases When clipping around a wound, K-Y jelly useful to prevent hairs entering the wound. Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 16 142

Theatre Practice For clipping around the eye smaller, finer clippers may be used. Hair is then removed from the site using zinc-oxide tape instead of a vacuum. Bathing In an ideal world all the patients would be bathed prior to surgery and wouldn’t go swimming in the local river. In real life the best we can hope for is that the patient is free from gross dirt and long-haired animals are free from mats. It is unwise to bath an animal directly before surgery unless there are adequate drying facilities available. A damp or wet patient will lose body heat rapidly under anaesthesia. Administration of an enema It may be desirable to give an enema to evacuate the bowel prior to surgery eg. rectal, colonic or major orthopaedic surgery.

Immediately before surgery Anaesthetic premedication Usually given ½ to 1 hour prior to surgery. Administration of other drugs Antibiotics – to ensure effective blood levels at the time of surgery Eye drops eg. Atropine to dilate the pupil for ophthalmic surgery Catheterisation of the bladder To minimise the risk of soiling during surgery To monitor urine output To prevent risk of bladder perforation or rupture To facilitate access to organs of the urinary tract during surgery Note that urinary catheterisation may cause trauma which can lead to a urinary tract infection Purse string suture around anus For surgery to the peri-anal area Do not forget to remove it at the end of surgery Application of a tourniquet A tourniquet may be applied to allow bloodless surgery of the distal limb (a technique commonly used in large animal surgery) Introduction of a throat pack To prevent aspiration of blood etc. during oro-nasal surgery Cover any wounds not associated with surgery Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 17 143

Theatre Practice Cover foot with bandage during surgery on limbs to minimise contamination by hairs

Preparation of the Skin Aims: to destroy as many skin micro-organisms as possible without damaging the skin itself. Skin preparations only kill surface bacteria. 20% of bacteria are inaccessible to disinfectants. The ideal skin disinfectant is a broad-spectrum bactericidal agent that rapidly kills accessible organisms. Commonly used agents include: Alcohol Acts rapidly – 90% kill rate 2 minutes after application Tissue necrosis follows application to open wounds Some residual action Prolonged contact causes skin irritation Combination with chlorhexadine or povidine/iodophor solution increases efficacy

Povidine/iodophor Slow continuous release of active ingredient – iodine Effective against most fungi, viruses and protozoa Sporocidal Rapid destruction of 99% of accessible bacteria after 30 seconds contact time Effect reduced by blood, fat and necrotic debris

Chlorhexadine Broad spectrum bactericidal agent Bacterial kill rates of 99%, 30 seconds after application Excellent residual activity Effective when exposed to organic matter May cause skin irritations if the solution is too strong

Quatery Ammonium Compounds Slow to act Inactivated by soap or organic materials Undiluted – may cause ulceration of the skin and mucous membranes Not effective against pseudomonas spp. Hexachlorophene Not effective against gram –ve bacterial spores Activity is decreased by organic material Repeated applications are necessary to form bacteriostatic film Must be used alone as bacteriostatic film is removed by soap and alcohols Residual action is less than Chlorhexadine

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Theatre Practice

Technique Using lint free swabs, the site should be scrubbed using one of the surgical scrub solutions and a little warm water, beginning and the proposed surgical site and working outwards. Once the edges of the clipped area are reached, the swabs should be discarded. Scrubbing should be continued until the area is clean eg. There is no dirt discolouration on the white swab The longer the scrubbing continues, the greater the number of bacteria will be destroyed. The area can then be sprayed with a compatible antiseptic solution or alcohol based solution to remove any remaining detergent. Once the patient is positioned in theatre the site should be cleaned once more, as it is likely to have been contaminated to some extent when moving and positioning the patient. The final preparation of the patient should be carried out using sterile swabs moistened with an antiseptic solution such as Povidone.

Preparation of the eye and mucous membranes As the eye and mucous membranes are sensitive to many of the agents normally used in pre-operative preparation great care must be taken when preparing them for surgery. Many people use a sterile saline solution to flush the eye but this has not been shown to significantly reduce the number of bacteria present. It is therefore advisable to use an anti-bacterial agent. A 1:50 (0.2%) solution of Povidone/iodine and saline has been recommended for chemical preparation of the eye. It has been shown to effectively reduce the number of bacteria without causing irritation to the cornea. A 0.05% chlorhexadine solution has also been shown to be effective. However, if the solution is more concentrated or contains alcohol then it has been shown to be irritating to the cornea. Suggested Protocols • Intraocular preparation Irrigate the conjunctival sac and cornea with sterile saline followed by a 0.2% povidine/iodine and saline solution. • Around the Eye A dilution of 1:10 (1% solution) of povidone/iodine and saline on soft, sterile swabs or ‘spears’. • Mucous membranes A 1% solution of povidone/iodine and saline solution is used to thoroughly irrigate the area. Positioning The animal is positioned according to the surgeon’s instructions and only after the anaesthetic has been stabilised. There should be no constrictions around the throat and chest of the patient. The head and neck should be supported. Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 19 145

Theatre Practice Sandbags, ties, vacuum bags and cradles can all be used to position the animal. It may be necessary to pad certain areas of the animal to avoid pressure points. Patients having orthopaedic surgery may have the affected limb tied to a drip stand to facilitate scrubbing and draping. Draping the patient The aim is to prevent contamination of the surgical site and surgeon. Various materials can be used as surgical drapes. Re-useable: linen Advantages Cheaper (Usually) more conforming

Disadvantages Porous (allow strike through) Time consuming (to wash, dry, fold and resterilise) Quality becomes poor after repeated use Threads may detach and contaminate the wound

Disposable: Paper, plastic and paper based Advantages Labour saving

Disadvantages Expensive

Pre-sterilised

Cheaper brands are less conforming

Usually water resistant

A large stock of various sizes is needed

Always in perfect condition

Draping Systems Four drape method The first drape is placed between the surgeon and the nearest side of the table, then on the opposite side of the table, then over both ends. They are then secured in place with towel clips which are â&#x20AC;&#x2DC;hiddenâ&#x20AC;&#x2122; under the folds of the drape. The drapes can then be carefully moved if the incision site needs to be extended during surgery. Fenestrated drapes This is a single drape with a window. As the size of the hole is predetermined it is difficult to extend the incision if necessary during surgery. Sub-draping The patient is draped using the four-drape method. The initial skin incision is made and plain disposable drapes are attached to the skin using a continuous suture pattern.

Keeping the patient warm The ambient room temperature should be adequate to maintain the normal body temperature in an uncompromised patient. However the patients temperature may drop for a number of reasons during surgery. Anaesthetic drugs lower the blood pressure Intellectual property of Wendy Smith VN DipAVN (Surgical) Written 01/2000 Amended 09/2008 20 146

Theatre Practice Clipping the hair reduces the patient’s ‘natural insulation’ The use of cold surgical scrub solutions The use of alcohol during the skin preparation Opening a body cavity causes evaporation of fluid and heat from the tissues Laying on a stainless steel table Allowing drapes to become wet Irrigation of the surgical site using cold flushing solutions The administration of cold intravenous fluids There are various methods that can be used to provide additional heating for the patient. However, care should be taken when choosing the appropriate heating device Hot water bottles and heated fluid bags may burn if in direct contact with the skin They are warm when first applied but may be cold by the end of a long surgery Some heated pads will only work when direct pressure is applied and will not work for small patients Ideally a heated waterbed would be used but these are expensive to purchase and may be damaged by claws! When using any of these methods the warming device should be covered with a suitable ‘fluff free’ towel or thick drape. In addition, the patient can be wrapped in bubble wrap or silver foil. These materials can also be used to make socks to put on the paws, tail and ear tips of very small, thin patients. The patient should be monitored throughout surgery to ensure optimum temperature is maintained

References: Slatter, D. H. (ed.) (1993) Textbook of Small Animal Surgery, 2nd edn. W.B. Saunders, Philadelphia Lane, D. R. & Cooper, B. (ed.) (1994) Veterinary Nursing 1st edn. Pergamon Press, England British Small Animal Veterinary Association, Continuing Education Course, Theatre Practice, March 1994 Handouts to accompany Diploma in Advanced Veterinary Nursing (Surgical), August 1995

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14. CAT HANDLING Do's

Don'ts

Be gentle

Be rough

Slow movements

Rush

Always keep hands on cat, it lets them feel safe

Leave alone on table

Wipe table with “Urine Off” or odour remover

Place on dirty surface

Wash hands between handling animal

Risk injury to yourself or cat

Keep cat in small enclosed room

Take into bigger room

Keep owner present

Handle alone

Position cat on towel (there if required)

Take cat out of cage with clinic doors open, or room noisy

Rest cat between clipping, prep and taking blood Be on same level

Put cat in cage on floor

Speak quietly

Speak loudly

Remain relaxed and calm

Lose your temper – cats get worse

Try gentle approach first

Smack

Look at positioning from cat’s perspective

Use spotlight on cat

Wait until primary handler says they're ready

Ignore directions from primary handler

Stop when primary handler says stop

Scruff, unless lose control and cat nasty

Use smallest gauge needle possible ******************************* If a cat is well behaved gentle handling will keep it that way. A firm hand on top of neck keeps firm control.

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If a cat is borderline then wrap it in a towel. If cat is nasty, use sedation or crush cage. ******************************* REMEMBER: YOU CANNOT DISCIPLINE A CAT SO THERE IS NO POINT GROWLING , GETTING UPTIGHT, OR SMACKING........KEEP CALM, QUIET AND IN CONTROL Be gentle, use slow movements, keep your hands on the cat, it lets them feel safe. If a cat is scared or stressed, they may become aggressive and therefore become dangerous as a defence mechanism. They do not mean to hurt us, they are just reverting to a protective behaviour. This is especially true if they are in pain or have experienced stress in a veterinary clinic or in human company.

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15. Cat mood scoring Cats use different body postures to communicate their emotions. Below are some typical postures you may observe in your cat. When observing your cat, try to get an idea of its usual attitude when alone and in contact with other animals, including people. As cats become more anxious about their surroundings, they will try to avoid contact with threats. The highest scores usually are seen only when escape is not possible.

Score

Relaxed

Alert

Tense

Anxious

Fearful

Terrified

Body Postures

Activity – sleeping or resting, alert or active, may be playing Body – lying on side, on belly or sitting; if standing or moving, back horizontal Breathing – slow to normal Legs – bent, hind legs may be laid out; when standing extended Tail – extended or loosely wrapped; up or loosely down when standing Activity - resting, awake or actively exploring Body – lying on belly or sitting; if standing or moving the back is horizontal Breathing – normal Legs – bent; when standing extended Tail – on body or curved back; up or tense downwards when standing; may be twitching Activity – resting or alert, may be actively exploring, trying to escape Body – lying on belly or sitting; if standing or moving the back of the body is lower than the front (“slinking”) Breathing – normal Legs – bent, hind legs bent and front legs extended when standing Tail – close to body; tense downwards or curled forward, may be twitching when standing. Activity – alert, may be actively trying to escape Body – lying on belly or sitting; if standing or moving the back of the body is lower than the front Breathing – normal or fast Legs – under body, bent when standing Tail – close to the body; may be curled forward close to body when standing. The tip may move up and down or side to side. Activity – motionless, alert or crawling Body – lying on belly or crouched directly on top of all paws, may be shaking; if standing the whole body is near to the ground, may be shaking Breathing – fast Legs – bent; when standing bent near to surface Tail – close to the body; curled forward close to the body when standing. Activity – motionless alert Body –crouched directly on top of all paws, shaking. Hair on back and tail bushy. Breathing – fast Legs – stiff or bent to increase apparent size Tail – close to body

Head Postures

Head – laid on surface or over body, some movement Eyes – closed to open, pupils slit to normal size Ears –normal to forward Whiskers – normal to forward Sounds –none, purr Head – over the body, some movement Eyes – open normally, pupils normal Ears – normal or erected to front or back Whiskers – normal to forward Sounds –none or meow

Head – over the body or pressed to body, little or no movement Eyes – wide open or pressed together, pupils normal to partially dilated Ears – erected to front or back Whiskers – normal to forward Sounds – none, meow, or plaintive meow Head – on the plane of the body, little or no movement Eyes – wide open, pupils dilated Ears – partially flattened Whiskers – normal to forward or back Sounds – none, plaintive meow, growling, yowling Head – near to surface motionless Eyes – fully open, pupils fully dilated Ears – fully flattened Whiskers – back Sounds – none, plaintive meow, growling, yowling Head – lower than the body Eyes – fully opened, pupils fully dilated Ears – fully flattened, back on head Whiskers – back Sounds – none, plaintive meow, growling, yowling, hissing

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Catâ&#x20AC;&#x2122;s postures also try to communicate their emotions about other animals to them. These postures often are either friendly or conflict-related, depending on the situation at the time you observe them. Conflict related behaviors are often more subtle than those shown here, and only noticed when one learns what to look for. For example, you also might observe one cat appearing tense or anxious when another (more dominant) cat blocks access to food, litter boxes, or other resources in the home. Cat behavior can be quite complex; entire books on the subject are available. These descriptions of the basic postures are only provided as an introduction to your catâ&#x20AC;&#x2122;s emotions.

Friendly postures

When cats approach in a friendly way they often hold their tail straight up and rub their chins or heads against other cats or people. Cats do this when greeting or when confidently investigating something new.

When cats want to play they may roll over and expose their bellies. This behavior is also seen in females during mating. Unlike dogs, cats rarely expose their bellies to show submission, doing it only to try to stop an attack when no escape is possible. In this case, the ears and whiskers are back and flat against the head when approached by the aggressive threat. Cats also may arch their tails over the back or may move it fast when they are happy and want to play. Their pupils may be dilated (large) and ears forward. Cats with rapidly moving tails can be quite aroused, however, and it may not be a good idea to play with them as they may become aggressive and bite or scratch.

Conflict-related postures When a cat (left cat) is about to attack, the body is held in a straight-forward position, pupils are narrow, the tail may be moving rapidly from side to side, ears are back, and whiskers are forward.

When a cat is defending itself from another cat (right cat) it will lean backwards with an arched back. It may move the tail very fast, arch it over the back, or put it between the back legs. The ears are flat, pupils dilated (large), and the hairs may be erect. Cats do this to appear as large and threatening as possible.

When the threat is near, the belly and legs of the defensive cat (right cat) may touch the floor. The ears lie flat and the teeth may be exposed.

Adapted from Kessler MR, Turner DC. Stress and adaptation of cats (felis silvestris catus) housed singly, in pairs and in groups in boarding catteries. Animal Welfare 1997;6:243-254, Beaver BV. 151Feline Behavior: A guide for veterinarians. St. Louis: Elsevier Science, 2003:349, and UFAW Animal Welfare Research Report No. 8; An ethogram for behavioural studies of domestic cats, 1995.

16. Anaesthetics

Anaesthetics Dr Christopher Barton BVSc ( Hons) BSc Dip Ag Sci Principal and owner Diamond Valley Veterinary Hospitals, Australia ASAVA Accredited Hospital of Excellence Academic associate University of Melbourne Trainer for Tsunami Animal People Alliance Sri Lanka AVA Emergency Task Force Member American Hospitals Association Merit award- for Best Hospital design 1998

ADVANTAGES of using a GOOD ANAESTHETIC

ADVANTAGES of using a GOOD ANAESTHETIC 



Uncons cious at level to allow easy s urgery Humane (premat ure babies f eel pain & alt ers survival – refer to USA stu dy) Analgesia. Prevent s windup of pain- magnified aft er surgery . No pain= bett er healing and recov ery

• Client sat isfac tion (see pain f ree smooth recov ery and no behav ioral changes due to severe traum a) and t herefore increased busines s • Stat us with peers • National pride in being progres sive and humane

Musc le relaxat ion makes life eas ier f or surgeon thus increased throughput and profit Decreas ed com plications = humane, bett er result s, happier clients thus increased profit s

PROPERTIES OF A GOOD ANAESTHETIC 

Renders patient s in unc onsc ious and unaware of surroundings and st imuli



Musc le relaxat ion



Safet y



Analgesia



Cost eff ect ive

MINIMUM STANDARDS FOR ANAESTHESIA 

Animal mus t be in surgic al anaest hesia (complet ely uncons cious and unaware)



Must have analgesia during and af ter surgery



Provide adequate musc le relaxat ion



Preferably a prem edicat ion s hould be used to reduce anxiet y and quant ity of anaest hetic used

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MINIMUM STANDARDS FOR ANAESTHESIA • We must be progress ive. The west did not use pain relief and s ome anaest hetic t echniques were inadequat e 30 years ago. • The us e of inadequate anaest hesia is very cru el. How would you feel if you were operated on without adequate anaest hesia?

Specialist Anaesthesists Testimonials As Veterinary Anaesthetists we can achieve this by ensuring anaesthetic protocols provide Three t hings: 1/ Unc onsc iousnes s 2/ Antinoc iception (or reflex suppress ion) 3/ Mus cle relaxat ion

Specialist Anaesthesists Testimonials

Specialist Anaesthesists Testimonials 10th July 2010 As Veterinarians with specialist qualifications in Veterinary Anaesthesia we w rite to you to express our opinion on the importance of a balanced anaesthetic technique for animals. As Veterinarians w e have an obligation to ensure that our patients are free from pain and suffering.

Specialist Anaesthesists Testimonials • There is no s ingle drug that creates a balanced anaest hetic so drugs are always c ombined to ensure the 3 object ives are ac hieved. • There are misconcept ions about cert ain drugs and it is important to underst and the clas s of drug to which a cert ain drug belongs. This way an appropriate decis ion can be made. • Opioids, like butophanol for exam ple, are not capable of producing uncons ciousnes s, they are theref ore not appropriate for use on t heir own.

Specialist Anaesthesists Testimonials

• Tranquilizers like ac ety lpromazine and

haloperidol are usef ul f or sedating patient s when us ed in com bination with ot her drugs , but do not provide analgesia, and will not render a patient uncons cious • Alpha 2 adrenorec eptor agonist s suc h as xy lazine are us eful sedativ e drugs, but they will never render a patient unc onsc ious on t heir own. They provide some analgesia and good musc le relaxat ion. • In order t o choos e a com bination of drugs for anaest hetis ing patient s the 3 f act ors listed above mus t be c onsidered. I f a drug com bination will not achiev e all 3 of thes e fac tors then the protoc ol has failed.

Dr GC Mus k BSc BVMS Cert VA Dipl ECVAA

Dr AL Raisis BVSc MACVSc DVA PhD

Dr MM Mc Ewen

Dr S Zaki

BVSc DACVA MACVSc

BVSc MACVSc GradCertEdS tud

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

Mild Sedatives

Butorphanol

Acepromazine

Cheap and s afe ( av ailable in China) Good narcot ic analges ic but only last s 2-3 hours Good premed for sic k/ old or v ery young patient s

•

Cheap

•

Good prem ed

•

No pain relief

•

Contraindic ated with Z oletil

Mild Sedatives

Heavy Sedatives

Valium

Xylaz in e and Domitor 

Alpha 2 adrenergic agonist Sedativ e 1-2 hrs



Mild sedat ion

●

Antix iolyt ic and antic onvuls ant

●

Musc le relaxant



Can last up t o 4 hours

●

Short analgesia- last 15-30 mins



Usef ul for reducing dose of general anaest hetic

●

Xylazine cheap D omitor expens ive



NOT AN ANAESTHETIC (opiod eff ect )

Heavy Sedatives

Di hydroetorphine

Xylazine   



Cheap – costs $120 rmb per bottle Reduces doses of general anaesthetic Not for patients with cardiac disease,respiratory depression, hypotension, shock failure, kidney or liver disease, last trimester of pregnancy Vomitting after administration( good for strays that have eaten before surgery) NOT an ANAESTHETIC - refer manufacture statement

• Cheap • Mu recept or agonist opiat e lik e morphine • In cat s can get opposit e ef fec t- ie m usc le spasm • Pain control very short • Can be good premed before an anaes thet ic exc ept cat s but saf ety margin small • NOT an ANAESTH ETI C

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

Antipsychotic/Sedative

Haloperidol

Haloperidol and Dihydroetorphine (846)

For humans to calm down schizophrenic patient s



Hypert onia



Stif fening of mus cles



Opposit e eff ect to what you want in an anaest hetic

• Both Sedativ es do not cause profound cortic al depress ion (uncons ciousnes s). • The anim als will be f ully consc ious of the experienc e of fear and pain while unable to esc ape it. • This must be c onsidered a s ignific ant iss ue with regards to animal welfare

NOT an ANAESTH ETI C

Antipsychotic/Sedative Te stimonial from Specialist Anaethetist • The c ombinat ion of Dietorphine and H aloperidol (846) does not render t he anim al unc onsc ious and does not provide enough m usc le relaxat ion. • The anim als will still be c onsc ious and f eel pain • Zoletil in c ombinat ion with 846 does not provide enough m usc le relaxat ion in cats

Antipsychotic/Sedative • Apart from the humane reasons ,s urgery would be much easier and with less complic ations if a general anaes thet ic is used Dr Ted W hitt em Profes sor of Veterinary C linical Sc iences Aass ociat e Dean for Clinical Programs Univers ity of Melbourne

ANAESTHETICS Ketamine 

Related to tilet amine in Zolet il - less side eff ect s



Dissoc iativ e anaest hetic

ANAESTHETICS Advant ages 



Cannot reach Stage 3 Anaes thet ic with Ketam ine alone. Has to be prot entiat ed with gas anaest hetic or Heavy Sedativ e/M usc le relaxant eg Xylazine

Cheap- 100 rm b f or 20 m ls- 20 c ats Cardiac st imulation(of fs ets depress ants like xylazine).I ncreas es Cardiac Output and mean aortic press ure

Disadvant age 

Salivat ion

Last s 30 minutes



Preserv es laryngeal and phary ngeal reflex es

Cheap



Musc ular act ivity so cannot use alone

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ANAESTHETICS 



ANAESTHETICS Zoletil

Note IM inject ions painful Not to use in s eizuring patient s, cerebral t rauma renal insuf fic iency and hy povolaem ia



Tiletamine/Z olezepam



Related to ket amine/v alium



Highly eff ect ive GA



Musc le relaxant , Analgesia, prof ound uncons ciousnes s

ANAESTHETICS 

ANAESTHETICS

Safe. No hepatic or renal tox icity and high therapeut ic index

Thiopentone 2.5 %



Disadvant ages

Cheap ( 6 rmb per cat)



Expens ive- 175 R MB for Zoletil 100



great for IV induct ion and put on gas

Disadvant ages 

Only last 10 m ins



Poor analgesic



If drug gets outs ide v ein- causes cert ain sloughing of tiss ue aft er a f ew weeks ; mus t flush with saline outs ide v ein im mediately

ANAESTHETICS

Gas

Alfaxan

Halothane and I sof lurane Best com bination is a good induct ive drug eg thiopent one or Z oletil IV and t hen m aintain on gas

Great anaest hetic for cats ( use alone or m aintain with gas  Last s 30-40 minutes IV  Expens ive

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COMBINATIONS FOR ABC WORK

1/ Xylazine /Ket amine/Valium 2/ ACP/ Thiopentone IV only with t op ups* 3/ ACP/ Thiopentone/ Gas 4/ Zolet il/Xylazine * caution sloughing of t issue if injected outside vein, best not to t ake too long for surgery

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17. Statements on need for suitable anaesthesia

158

159

Hi Elaine

After researching the drug combination on the weekend, my primary concern remains: 1. Haloperidol's action persists long after the profound analgesia provided by the hydroetorphine. Haloperidol: 10-12h Dihydroetorphine: 2h (max) 2. the action of Haloperidol is to block dopamine receptors and increasing turnover of dopamine in the limbic system of the brain, producing a state of "ataraxia" or behavioural quieting that is characterized by decreased emotional reactivity and aggression, and apparent indifference to stressful situations. Tranquilizers do not cause profound cortical depression (unconsciousness), but will suppress spontaneous movements while sparing spinal reflexes and unconditioned pain reflexes. Given the above.. animals may be fully conscious of the experience of pain while unable to escape it.

To me this must be considered a significant issue with regards to animal welfare...

Dr Katrina Gregory BVSc. MACVSc. ( animal behaviour; anaesth. & critical care)

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The combination of dietorphine and haloperidol does not render the animal unconscious and does not provide enough muscle relaxation. The animals will still be conscious and feel the pain. Zoletil in combination with 846 does not provide enough muscle relaxation in cats. Apart from the humane reasons,surgery would be much easier and with less complications if a general anaesthetic is used.

Dr Ted Whittem Professor of Veterinary Clinical Sciences Aassociate Dean for Clinical Programs University of Melbourne

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18. Monitoring Anaesthetics These minimum standards should be unifor m irresp ective of duration, location or mode of anaesthesia.

1. The anaesthetist must be present and care for the patient throughout the conduct of an anaesthetic. 2. M onitoring must be continued until the p atient has recovered from the effects of anaesthesia.

TPR’s are made up of: 1. 2. 3.

Heart rate, Respiratory rate, Temperature,

Take each TPR sign to a count over 15 seconds and multiply by 4 to ascertain the rate for one minute. TPR’s should be taken and recorded every five minutes, and mor e frequently if the patient is clinically unstable. An overview of TPR p rogress is essential for a safe anaesthetic. Monitoring will not p revent all adverse incidents or accidents in the perioperative period. But it will give you early warning signs and enou gh time to perhap s prevent a death. Whilst monitoring the patients’ TPR’s, other clinical observations will allow you t o gauge the depth of the anaesthesia and well being of the p atient. Appro priate clinical observations may include: 1. 2. 3. 4. 5. 6. 7. 8. 9.

M ucosal color. Capillary refill time, Jaw tone, paw retraction from stimuli. Eye and/or ear reflex. Pupil size. Response to surgical stimuli. M ovements of the chest wall and/or the reservoir bag/or moisture movement in ET tube. The anaesthetist should undertake p alpation of the pulse, Auscultation of breath sounds.

A stethoscope must always be available

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19.

BASIC MONITORING “If you monitor without the intent or ability to intervene, you simply become the scribe whose job it is to record the time of death” MONITORING = OBSERVING +/- MEASURING +/- RECORDING SOME BASIC THOUGHTS ON MONITORING When people think of monitoring, they usually think of blood pressure, pulse oximetry, ECG etc. However, there are myriad observations that must be made during anaesthesia. Ironically, the most catastrophic occurrences during anaesthesia are NOT due to ECG disturbances, decreases in SPO2 or drops in blood pressure. They are usually caused by human error- the pop-off valve was left closed, the endotracheal tube kinked, the isoflurane or the oxygen ran out. EMERGENCIES RARELY OCCUR WITHOUT SOME WARNING So it is essential to be well grounded in basic monitoring (that means NO TOYS) before we leap into the world of gadgets. Simple observations provide a huge amount of information, even if we own no toys at all. Most ‘toys’ simply permit earlier detection and more objective assessment of what we can already surmise through more or less subjective observations. Anaesthetic monitoring is performed to recognise any harmful trends in any body system – but particularly the cardiovascular, CNS and respiratory systems, and to allow timely and appropriate action to be taken. Cardiovascular and respiratory depression occurs at therapeutic doses of anaesthetic agents The level of sophistication of monitoring technology available in general practice has increased hugely.

But it is important to remember that expensive and complex

equipment is no substitute for good observation and sound clinical judgement. Monitoring should be continual, although data are usually recorded on a chart every 5 minutes- this serves as a pictorial record of the anaesthetic and allows early appreciation of developing trends. A written record is also a medico-legal document. •

The degree and complexity of the monitoring performed will depend on the /American society of anaesthetists (ASA) Risk category of the animal and the

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complexity of the procedure •

Increasing levels of risk require increasing intensity and complexity of monitoring

MORTALITY RATES 1 in 679 healthy dogs and cats 1 in 100 horses 1 in 31 ASA 3 dogs and cats 1 in 73 rabbits 1 in ~100 000 humans: qualified anaesthetists, minimum standards of monitoring In human anaesthesia: “…continuous monitoring of ventilation and circulation is essential.

This may be performed by use of human senses augmented, where

appropriate, by the use of monitoring equipment…” MINIMUM STANDARDS: AMERICAN SOCIETY OF ANAESTHETISTS Qualified personnel must be present at all times. There must be continual monitoring of: CNS –depth of anaesthesia Oxygenation •

Inspired oxygen concentration

•

SpO2

Ventilation •

Observation

•

End-tidal CO2

Circulation •

HR, pulse quality, auscultation

•

ECG

•

Blood pressure

Temperature

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WHAT TO MONITOR – remember that monitoring covers the entire anaesthetic period, from before induction to recovery PRE-INDUCTION: Resolve all problems identified during pre-anaesthetic evaluation before induction DURING INDUCTION •

respiration (rate, depth, pattern)

•

heart rate

•

mucous membrane colour (pale, pink, injected, cyanotic)

•

palpebral reflexes

•

muscle activity

•

swallowing and coughing

•

eye position

WHILE ANIMAL IS UNCONSCIOUS •

Cardiovascular system (HR, pulse rate, rhythm, BP, mucous membrane colour, CRT

•

Respiratory system (RR, tidal volume, mucous membrane colour, oxygenation, [CO2]

•

Eye signs (position, movement, pupil size, palpebral reflex)

•

Muscle activity (movement, shivering, genera tone)

•

Body temperature

•

Swallowing

•

Anaesthetic equipment: Gas flows, vaporiser settings, circuit integrity, anaesthetic concentrations in the circuit, rebreathing bag distension, scavenge connection)

DURING RECOVERY

166

•

swallowing

•

cardiovascular system

•

respiratory system

•

temperature

•

adequacy of pain control

REFLEXES The ‘signs’ of general anaesthesia are based on cranial nerve reflexes, other reflexes which may be used to assess the degree of neuraxial depression, and CVS, respiratory and musculoskeletal responses to surgery. Palpebral reflex The palpebral reflex (blink reflex) can be tested by lightly tapping the medial or lateral canthus of the eye and observing if the animal blinks in response. Alternatively the upper eyelid hairs can be stroked to initiate a blink reflex. Loss of the palpebral reflex indicates an increase in anaesthetic depth, whereas return of the reflex usually indicates lightness of the anaesthetic plane. Repeated testing reduces the presence of the reflex. NB: Ketamine anaesthesia is associated with a brisk palpebral reflex and a central eye position Corneal reflex •

Rarely used since it is easy to damage the cornea

•

poor indicator of depth of anaesthesia – it can remain present after cardiac arrest.

•

usually tested with a damp cotton bud wiped over the cornea; the patient blinks and withdraws and the eye retracts into the orbit.

Eye position and pupillary reflexes •

As a rule, rotation occurs during light and medium anaesthesia. The extent and direction of rotation varies with the species and the anaesthetic agent.

•

In dogs and cats at a ‘surgical’ plane of anaesthesia, eye position becomes

167

ventromedial, a return to a central eye position occurring with deep anaesthesia or when awake •

The palpebral fissure widens during very light or very deep anaesthesia

•

pupillary light reflex is active but obtunded during anaesthesia

•

Mydriasis or miosis may be present, depending on the anaesthetic technique used. For example, buprenorphine causes mydriasis in cats, ketamine causes mydriasis in many species

Lacrimation Lacrimation may be occur during light anaesthesia, as can nystagmus (particularly in horses). Lacrimation slows dramatically in deeply anaesthetised animals and a sterile ophthalmic ointment should be instilled into the conjunctival sac following induction of general anaesthesia to minimise corneal desiccation, particularly when ketamine is used for anaesthesia. Swallowing reflex •

This reflex is usually stimulated by the presence of saliva or food in the oesophagus in the conscious animal.

•

Pharyngeal and laryngeal tone diminishes with increasing anaesthetic depth

•

The patients’ ventral neck region can be observed for the swallowing reflex. This reflex is lost at a medium depth of anaesthesia and is usually regained just before the patient recovers consciousness.

•

In ruminants, swallowing or regurgitation commonly indicate lightening of the anaesthetic plane

•

The swallowing reflex must be present before the endotracheal tube is removed on recovery, this is so that, it the animal vomits - they will usually swallow rather than aspirate the vomited material.

Pedal withdrawal reflex • •

The reflex between the digits or of the digital pads. Present only at the light stages of anaesthesia – useful when gauging when

168

intubation should be attempted. Ear flick reflex Not a particularly reliable reflex, but useful particularly in cats, tested by gently touching the hairs on the inner surface of the pinna and observing the resultant twitch of the ear. This reflex is not particularly reliable. Muscle tone •

With increasing anaesthetic depth, skeletal muscles become more relaxed and offer little resistance to movement.

•

Among the muscles that can be readily assessed are the muscles of mastication, the tone of the jaw (ease of opening mouth) and flexing and extending of the elbow and carpus, neck muscles (horses, swans, small ruminants)

•

Shivering may occur in light anaesthesia and in animals recovering from anaesthesia

•

Muscle rigidity (hypertonus) may be seen in animals anaesthetised with ketamine mixtures

CARDIOVASCULAR MONITORING 1. Capillary refill time and mucous membrane colour 2. Palpation of a peripheral pulse 3. Oesophageal stethoscope 4. Electrocardiography 5. Arterial blood pressure measurement 6. Central venous pressure 1. Mucous membrane colour and capillary refill time Note that there is no correlation between mucous membrane colour and ABP. Assuming normal Haemoglobin levels, gives some idea of peripheral perfusion •

pale….vasoconstriction

•

pink….normal

•

congested….vasodilation

•

ashen grey – circulatory failure

169

•

cyanotic : < 5 g oxygenated Hb per 100 ml blood

•

Normal CRT < 2 seconds

•

Gives some indication of tissue perfusion

•

Can be misleading - Capillaries can refill from distended veins as well as arteries; can obtain a CRT in a freshly dead animal

2. PALPATION OF PERIPHERAL PULSES •

Dog – cranial tibial, ulnar, lingual veins, femoral, pedal

•

Cat – femoral, predal

•

Horse – facial, transverse facial, median, lateral metatarsal

•

Cow – auricular, facial, median

•

Pig, sheep, goat – auricular, median, cranial

Remember to palpate superficial arteries – such as the lingual, palatine, palmar metacarpal, auricular. In very small furry animals it may be well nigh impossible to palpate the peripheral pulse, in which case palpation of the apex beat will indicate mechanical activity of the heart (but not its adequacy of output). Interpretation •

reflects stroke volume, not blood pressure

•

difference between systolic and diastolic pressure

•

hypovolaemia results in a weak pulse but BP may be normal

•

femoral pulse just palpable at systolic 80 mm Hg

3. HEART RATE: OESOPHAGEAL STETHOSCOPE •

Blind ended plastic tube with distal holes covered in thin plastic sleeve

•

Inserted down oesophagus until level with the heart, attached to stethoscope from which the bell has been removed

•

Can identify and measure respiratory rate and heart rate

•

Especially useful when palpation of a peripheral pulse is difficult, e.g. cats, rabbits

•

Simple and cheap

4. ECG

170

•

Electrical activity of the heart – without normal electrical activity there cannot be coordinated myocardial contraction

•

Provides information on cardiac arrhythmias and the myocardial environment

•

Non-invasive and low morbidity

•

Gives no information on mechanical function of the heart (i.e. stroke volume)

•

Gives no indication of cardiac output

•

Should not be relied upon as the sole monitor for cardiovascular function

It is important to monitor the ECG since without normal electrical activity there cannot be co-ordinated myocardial contraction.

However, the ECG can be

misleading: •

Will be normal with hypovolaemia

•

May be normal during cardiopulmonary arrest (electromechanical dissociation)

•

Correct interpretation of the significance of abnormalities requires experience!

5. ARTERIAL BLOOD PRESSURE MEASUREMENT BP = Cardiac output X total peripheral resistance To maximise the information we obtain from blood pressure measurement, it must be evaluated in combination with mucous membrane colour and capillary refill time. May be used as an indicator of cardiac output and often used to infer adequacy of tissue perfusion Aim to maintain MAP > 60 mm Hg, SAP > 80 mm Hg Low blood pressure in an animal with pale mucous membranes and a poor CRT is of more concern than low blood pressure in an animal with bright pink membranes and a brisk CRT Measurement of blood pressure is important because: •

hypotension may lead to reduced perfusion of vital organs e.g. kidney, brain, liver

•

hypertension may lead to damage to certain organs e.g. brain, heart, kidney, eye

•

helps to assess anaesthetic depth and evaluate course of therapy

•

urine output also gives an indirect indicator of cardiac output and blood pressure;

171

kidneys must be perfused to produce urine, Normal urine output of 1-2 mlkg-1min —1

requires MAP of > 60 mm Hg.

6. CENTRAL VENOUS PRESSURE •

Used to assess right-sided heart function and the adequacy of circulating blood volume

•

Normal CVP is 2-5 cm H2O and indicates adequate circulating blood volume and adequate right-sided cardiac function

•

Elevated CVP (> 15 cm H2O) indicates that the right ventricle is unable to deal with the volume of blood returning to it. Likely causes may be decreased cardiac function or fluid overload.

•

Low CVP ( < 1 cm H2O) indicates low circulating blood volume

INTERPRETING CHANGES IN CARDIVASCULAR VARIABLES HEART RATE Remember the importance of trends and initial pre-anaesthetic rates when deciding what is bradycardia or tachycardia in an anaesthetised animal. Bradycardia: Large dogs < 60, small dogs < 80, cats < 90 •

Hypothermia

•

Anaesthesia too deep

•

Drugs – opioids, α2 agonists

•

Increased vagal tone – manipulation of the vagus, endotracheal intubation, pulling on viscera, bladder distension

•

Oculocardiac reflex – traction on the eye can induce bradycardia, particularly in young dogs

•

Electrolytes imbalances – especially hyperkalaemia in urethral obstruction

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Tachycardia: large dogs > 160, small dogs > 200, cats > 240 •

light anaesthesia

•

pain

•

sympathetic stimulation

•

hypovolaemia

•

hypotension

•

hypoxaemia

•

hyperthermia

•

hypercapnia

•

drugs – e.g. atropine, ketamine

Abnormal rhythm: while major irregularities can be detected by listening or by palpation, an ECG is needed to accurately identify the arrhythmia Common causes of arrhythmias during anaesthesia •

myocardial disease

•

light anaesthesia causing pain and sympathetic stimulation

•

excessively deep anaesthesia

•

hypoxaemia

•

respiratory acidosis (hypercapnia)

•

metabolic acidosis

•

electrolyte abnormalities (especially potassium)

•

hypothermia

RESPIRATORY MONITORING 1. Rate (observation, Apalert) 2. Depth/ tidal volume (observation of chest excursions, measurement with respirometer) 3. Pattern 4. Oxyhaemoglobin saturation 5.

End-tidal CO2 measurement (capnograph)

6. Blood gas analysis

173

RESPIRATORY RATE •

Count chest or reservoir bag excursions

•

Listen using oesophageal stethoscope

•

Apalert – small, cheap electronic monitor that connects to the end of the ET tube, containing a thermistor, which detects warm exhaled air. Has audible BEEP and adjustable sensitivity

Interpreting changes in Respiratory rate slow respiratory rate or apnoea intubation – can cause breath holding excessive anaesthetic depth respiratory depressant drugs (opioids, barbiturates, isoflurane) hypocapnia (usually

rapid respiration light anaesthesia drug related – opioids can cause panting hypercarbia

following hyperthermia

hyperventilation) muscle relaxants increased intracranial pressure

2. DEPTH OF RESPIRATION •

Shallow respirations are likely to result in a reduced tidal volume (increase risk of rebreathing CO2 and reduced efficacy of anaesthetic uptake)

•

Tidal volume can be measured using a respirometer (e.g. Wrights respirometer) attached to the end of the ET tube

3. RESPIRATORY PATTERN •

normal is chest wall out on inspiration and abdominal wall quietly in on expiration, with a smooth transition between the two

•

Chest wall in on inspiration with any pronounced abdominal component is abnormal

•

ANY definite inspiratory or expiratory abdominal wall movement is abnormal

•

Certain breathing patterns are associated with CNS damage – e.g. apneustic breathing, Cheyne Stokes breathing

•

Ketamine can induce slightly apneustic breathing patterns

174

•

Horses can have an apneustic breathing pattern under normal conditions, under ketamine or inhalational anaesthesia

4. HAEMOGLOBIN SATURATION – see notes on supplementary monitoring, pulse-oximetry 5. END-TIDAL CO2 CONCENTRATION– see notes on additional monitoring equipment, capnography CHANGES ASSOCIATED WITH LIGHT AND DEEP ANAESTHESIA VARIABLE Heart rate Blood pressure Mucous membrane

LIGHT ANAESTHESIA usually increases usually elevated usually pink

DEEP ANAESTHESIA Usually decreases low usually pale

colour CRT < 2s may be prolonged Respiratory rate may be rapid usually slow Tidal volume normal shallow Eyeball position rotated (ventromedially) central Palpebral reflex brisk sluggish or absent Jaw tone strong relaxed Responsiveness to stimuli may move no movement ESSENTIAL MONITORING: ROUTINE ANAESTHESIA versus HIGH RISK PATIENTS SYSTEM/PARAMETER

CVS

MINIMUM

Additional monitoring

MONITORING

for the HIGH RISK

•

heart rate

•

PATIENT ECG

•

rhythm

•

blood pressure

•

pulse characteristics

•

+/- CVP

•

mucous membrane

•

inspired and end-tidal

colour Respiratory

• •

CRT rate

•

depth

•

oxygenation

CO2 •

tidal volume

•

arterial blood gases

175

Eye

Muscle activity

Body temperature Anaesthetic machine

•

palpebral reflex

•

eyeball position

• •

pupil size degree of relaxation

•

movement in response

to surgery rectal • oxygen flow

oesophageal - core anaesthetic vapour

•

vaporiser setting

concentrations

•

anaesthetic circuit

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20. Anaesthetic Emergencies To be used as a guide only RESPIRATORY ARREST +/- CARDIAC ARREST 1/

If no visible respiratory movements, check pulse or auscultate heart

A If strong pulse / heart beat detected: *Intubate (but all patients should be routinely intubated) * Commence artificial respiration: app. 1 breath every 2 minutes * Attempt to stimulate spontaneous respiration: A needle (25 gauge) inserted into the midline of the nasal philtrum may do so * If patient was premedicated with Xylazine and shows no response to artificial respiration in one minute, administer Reversine: 1ml per 10kg iv. But, as this may cause the animal to arouse dramatically, be prepared to administer more Diazepam/Ketamine * Commence i/v fluids if no response within one minute * Check for spontaneous respiration every minute * Monitor heart rate/pulse continuously * Keep patient warm (hot light, hot-water bottles, towels) * Give Dopram - If young cat/dog give 1 drop on tongue or 0.06 to 0.5ml/kg i.v can stimulate respiration 2/

If pulse/heart-beat parameters are poor (<40 bpm), deteriorating or not detectable:

* Reverse with Reversine if Xylazine used as premed * Intubate animal * Administer Adrenaline (1:1000) - I/V or intra-cardiac administration at 0.5-1ml/10kg OR

- Via ET tube (using urinary dog catheter or precut length of administration set tubing) to the level of the carina at approximately 2 mls per 10kg then flush with 2 â&#x20AC;&#x201C; 10mls sterile water to flush (no more then 1ml/per kg total) follow with 2 strong ventilations - Repeat every 1 to 2 minutes - Place animal in right lateral recumbency

* Commence cardiac massage: - Animals less than 10kg: 2 compressions per second, - Larger animals 3 compressions per 2 seconds * Ventilate every 20th compression * If no response to Adrenaline, administer Atropine (0.5mg/ml) @ 2mls per 10kg i/v, via e/t tube or intra-cardiac 3rd assistant - Place i.v. fluids at shock rate 70mls/kg/hr Note: Dopram = Doxapram Hydochloride 20mg/ml

177

21. Cats are NOT little dogs

Cats are NOT little dogs !

≠

Liver Enzymes • ALP half life much shorter in • • • •

cats contrast to dogs Dogs - 2 times elevation significant Cats – any elevation significant Dogs – AP can be steroid induced steroid isoenzyme Cats and humans humans--No steroid isoenzyme

Blood and urine -

Liver disease Dogs Hepatocellular disease Majority are acute and chronic hepatitis ( see cirrhosis,parenchymal disease) ( infection,, drug g induced ,herbal , medicines,, breed related eg g Copper pp toxicity) Cats Biliary tract disease ( cholangitis) Infection always significant Part of TriadTriad- pancreatitis/ Inflammatory bowel disease If ALT high but AP normal – think hepatocellular disease due to underlying disease eg Inflammatory bowel disease ,GIT disease , tumour hyperthyroid

Heart Disease • Dogs

Cats *Should not see bilirubin in urine as renal threshold 9 times that of dog High g bilirubin in urine means kidneyy disease as well High amylase in blood means kidney disease or GI • Anorexic and sick cats cats-- see bilirubin in urine due to disease - decreased excretion • StressStress- see lymphocytosis in cats; lymphopenia in dogs

– Heart murmur

• Usually cardiac disease

– Pulmonary oedema – Show early signs of CHF as coughing, exercise intolerance.

• Cats

– Heart murmurs

• Innocent or cardiac disease • Pleural effusion is main sign

– FATE (cool hind limbs, paralysis, paresis, no pulse) – DON’T tend to cough like dogs – Often don’t show any signs ( good at resting) then suddenly develop severe dyspnoea

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Chronic diarrhoea

Pancreatitis

Cats Young cats< 1 year=Tritrichomonas common Multicat house= Giardia common parasites Older cats Other metabolic diseasedisease- Triad of liver pancreas Inflammatory bowel syndrome (IBD)( vomiting common), tumour

• Dogs

Dogs Breed , infection Parasites IBD ,Addisons, hypothyroid ,Exocrine pancreatitic insufficiency, liver disease

Pancreatitis in cats and dogs Amylase and lipase not specific for pancreas Amylase levels usually high in renal disease Amylase and lipase high in intestinal disease Test with Canine CPL test and Feline FPL tests( Idexx snap test) In both cats and dogs amylase and lipase may be normal with pancreatitis

•

– Clinical signs ; vomiting, diarrhoea, abdominal pain – May see elevations in amylase and lipase – Fasting ( maximum 2 days)till vomiting ceases the start carbohydrates and then moderate levels fat and protein Cats – Clinical signs – 100% Lethargy – 90% dehydrated – Vomiting only 35% – Will never see elevation of lipase and amylase Always associated with Inflammatory bowel disease and liver disease ( Triad) – Do NOT withhold food and do not restrict fat ( normal food )

Arthritis • Dogs • Silent disease disease-- stiff when getting up or sitting down • Lameness, not walking as far • Cats • Limits exercise, more resting • Not jumping, climbing with front legs • Both cats and dogs do not cry but they are in pain

Dental disease Dogs- gingivitis and periodontal disease DogsCats-- gingivitis, periodontal disease plus Cats stomatitis and resorptive lesions

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Laryngeal reflex

Asthma

Unique in cats Causes laryngospasm when stimulated Larynx must be sprayed with a local anaesthetic prior to entubation

Common in cats but not in dogs

Paracetamol (Brand name; Panadol®, Tylenol®)

• Paracetamol is highly

Diazepam Liver failure in cats Oral form if used for long term

TOXIC to Cats • Liver failure and red cell damage • DO NOT give! • Glucuronyl transferase deficient

– Cats are relatively deficient contrast to dogs/humans Also causes liver damage in dogs at high doses

Dermatology

Otitis

• Dogs • Sometimes can tell cause

• Dogs with recurring bacterial or

malassezia otitis -70 70--80% food allergy

by distribution

• Cats with otitis otitis-- usually primary • Only 18% food allergy

• Cats • Miliary dermatitis is not a diagnosis

• A response to allergies ( food , atopy ,bacterial folliculitis and fungal disease

Miliary dermatitis in a cat

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Diabetes • Cats – Type II diabetes (insulin resistance) – Humans - tend to occur in older people. – Excess weight higher risk for insulin resistance – High protein diet – Glargine is best insulin to use – Some cats go into remission

• Dogs – – – –

Type I diabetes (insufficient insulin) Humans - juvenile onset diabetes Higher Carbohydrate diet Caninsulin

Antiemetics • Dogs • Metoclopramide Metoclopramide-- commonly used as antiemetic and prokinetic • Cats • Metoclopramide not goodgood- no dopamine Receptor – only act as prokinetic Use proclorperazine, ondansetron, Cerenia

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22. Pain

Pain

The Greatness of a nation and its moral progress can be and its moral progress can be judged by the way its animals are treated

Can babies feel pain?

Dr Christopher Barton BVSc ( Hons) BSC. Dip. Sc Ag ‐ Private practitioner Equine , mixed and Small animal practice ( 1979 2010) 1979 ‐2010) ‐ 1979‐ 1987 – no pain relief used ‐ 1987 to 2010‐ used Pain relief

Do animals feel pain?

• Not recognised until about 30 years ago

3 biggest myths of pain • Animals don’t feel pain • Animals feel pain differently from humans

Myth #1 – Animals don’t feel pain Myth #2 – Animals feel pain differently from humans

• Animals EXPRESS pain differently from humans – Behaviour: people, dogs, cats – Evolutionary instinct to hide pain Evolutionary instinct to hide pain

• Pain is beneficial for the animal

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Myth #1 – Animals don’t feel pain Myth #2 – Animals feel pain differently from humans

• FACT – Animals do feel pain. Pain pathways are essentially the same. • FACT – Animals cannot tell us how much pain they are in We have to assume anything they are in. We have to assume anything painful to a human, would be painful to an animal. • FACT – By the time the animal is showing overt signs of pain, they are in excruciating pain.

Pain pathways • Evolutionary development of pain perception – – – – –

Many neurotransmitters C fibres A fibres Spinal cord dorsal horn Spinal cord dorsal horn Cerebral Cortex

• Essentially the same in both people & animals

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Pain management Guidelines American Animal Hospitals Association AAHA • AAHA Pain management Task Force • American Association of Feline Practitioners Journal AAHA 2007 • Refer to Journal article

AAHA Pain Manamement Guidelines • Well established that Animals and humans have similar pathways for development, conduction and modulation of pain • Pain is absolutely detrimental to healing • Vets have the responsibility to recognize, assess ,prevent and treat pain • Pain is the 4th Vital sign ,after Temp ,Pulse, Respiration • Must integrate pain prevention/treatment in all patients pre, during and post surgery , and in all patient evaluation

Myth #3 – Pain is beneficial • Physiological effects of pain • Controlled versus uncontrolled pain P i Pain

Myth #3 – Pain is beneficial • FACT: Pain is actually detrimental to healing • Confinement, owner education very important

Cortisol release (stress hormones) Stress Delayed Wound Healing

Myth #3 – Pain is beneficial • FACT: Uncontrolled pain can increase risk of complications, wound breakdowns, decrease recovery rates.

Animals in Pain • Animals do feel pain • Animals feel pain just like people do • Pain delays healing

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Animals in Pain

Benefits of pain relief

• Unlike people, animals cannot rationalise pain – Their behaviour and response are based on evolutionary instinct The Patient

• Pain is suffering Pain is suffering – As veterinarians and animal carers, our role is to relieve unnecessary suffering

• Adequate pain relief is the first step to improving the welfare of our patients The Pet Owner

You, the Veterinarian

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23. The New Philosophy of Pain M anagement Nancy Shaffran, RVT, VTS (ECC) Erwinna, PA, USA 18282542

Before analgesia can be successfully administered on a case by case basis, pain management must become the standard of care for the practice as a whole. Once the practice adopts a standard, that is decides that elimination of pain is the ideal, all personnel can work together to achieve it. It is not possible to have a successful practice with varying views among staff members about the legitimacy of treating pain. When the practice adopts pain management as a standard of care it reaps all of the rewards. In the patients they see improved respiratory function, sleep, increased tissue healing and faster recovery times. Additionally they create the ability to monitor true physiological changes, provide excellent client service and improve staff morale. The past 10 years have brought remarkable changes in the practice of human and veterinary pain management. In1995 The American Pain Society challenged U S health care sy stems to adopt pain as the Fifth Vital Sign; ranking it with the same importance as temperature, pulse, respiration and blood pressure. In 2001 the Joint Commission for Accreditation of Healthcare Or ganizations (JCAHO) issued a mandate requiring ALL medical facilities to show that they meet pain standards or their funding will be revoked. M any leading pain sp ecialist have already adopted pain as the Fourth Vital Sign in veterinary patients. Last year the American Animal Hospital Association (AAHA) instituted rigorous pain management standards as a requirement for certification. This is a monumental move for all veterinary practices whether or not they seek certification because it has set forth in writing the standard of care for all veterinary patients. The AAHA standards can be found on their website: http://www.aahanet.org/. In brief the standards call for: Pain assessment for every patient regardless of presenting complaint Assessment recorded in the medical record Utilization of pre-emptive pain management App ropriate pain management for anticipated level and duration Pain management with all surgical procedures Reassessment for pain throughout procedures M edical and chronic pain is also treated Written protocols Teaching clients to recognize pain in their pets Challenging the Myths The major barrier to good pain management is the mythology that has persisted around this topic. Technicians must work constantly to dispel the myths for themselves. It is also essential to develop educated coherent arguments to help dispel the myths for veterinarians, other staff and even pet owners who may still believe them. Myth #1. Animals do not feel pain as people do 186

From a physiologic standpoint, mammals and humans process pain in the same way; by nociception and cognition. Nociception, derived from the Latin word nocere (to injure), uses sp ecific pathways--transduction, transmission, and modulation for its physiologic processes. The pain pathway begins at the point of tissue trauma, such as a site of inflammation, injury, or surgical incision, where nociceptors (pain receptors) are stimulated. These specialized nerve endings convert mechanical, chemical, and/or thermal energy into electrical impulses (transduction). If the noxious stimulus is large enough to exceed the nociceptor's threshold, a nerve impulse is generated and transmitted along peripheral nerves to the spinal cord (transmission). Once at the sp inal cord, a nerve impulse is either projected upward to the thalamus and then to other parts of the brain, including the cerebral cortex, or it may be transmitted to a nerve cell located entirely within the central nervous system that modifies nerve signals and links sensory and motor neurons that in turn activates sympathetic reflexes damping the pain sensation (modulation).

Although the terms pain and nociception are often used interchangeably, they are not synonymous. What differentiates nociception from pain is consciousness: Pain perception typically requires conscious perception. In contrast, nociception occurs even when an animal is in a state of unconsciousness, such as that produced by general anesthesia. Without the benefits of preemptive analgesia, the nervous sy stem is still activated by noxious stimuli to process pain signals, triggering deleterious physiologic effects even though no pain-related behaviors are seen. As the effects of anesthesia subside, postoperative pain perception occurs. M ost often, this postoperative pain is greater than if preemptive analgesia had been provided; therefore, the patient requires more analgesia "catch up." Consequently, pain management should be initiated if pain is anticipated. An important characteristic of nociceptors that distinguishes them from other sensory receptors is a lack of fatigue with continued stimulation. Although continuous stimulation of a touch receptor results in receptor fatigue and eventual numbness, a nociceptor that is repeatedly activated transmits a nerve impulse every time and develops increased sensitivity by lowering the pain-detection threshold. The result is heightened pain sensation, a condition known as peripheral sensitization or hyperalgesia. This physiology gives rise to the concept of multimodal analgesia. That is, attacking pain from many angles is more effective than from only one. Since the pain pathway has distinct phases, pain can be interrupted at various points. For example, we may want to do a local block (transduction or transmission) in addition to preemptive NSAIDS (transduction and modulation) as well as postoperative opioid administration (modulation and perception). Using drugs from three different classes provides better pain control and has the added benefit of allowing us to use lower doses of individual agents thereby reducing side effects. Effective analgesia can also reduce the amount of gaseous anesthesia required for a procedure. Myth #2. Animals tolerate pain better than people do In many cases animals do "appear" to tolerate pain better than humans. There may be several explanations for this. In contrast to pain-detection threshold, pain tolerance--the greatest intensity of pain that is voluntarily tolerated--varies widely between sp ecies and individuals within a sp ecies. Like humans, animals likely tolerate pain to a particular level before showing changes in behavior. Knowing that patients may exhibit a wide range of pain tolerances as well as a broad sp ectrum of behaviors can improve pain recognition and treatment. In the past much attention has been given to recognizing the signs of pain in animal patients. This approach focuses on the individual and requires the patient "prove" he/she is in pain in order to receive treatment. By consensus we have concluded what we believe may be clinical signs of pain in our patients. Increased HR, increased RR, restlessness, increased temp, increased BP, abnormal posturing, inappetence, aggression, frequent movement, facial expression, trembling, depression and insomnia have all been listed among the top signs of pain by veterinary professionals. Anxiety, nausea, pupillary enlargement, licking/chewing/staring at site, poor MM color, salivation, decreased CO2 and head pressing are also sited by some observers. We see that many behaviors and clinical signs may be evidence of pain. Ultimately, we must conclude that any abnormal sign(s), in a veterinary patient, which cannot be attributed to another cause are suspect of indicating pain. In actual practice, the clinical manifestations may be quite different between sp ecies and even among different members of the same sp ecies. 187

When evaluating animal pain we must always bear in mind that, much to their detriment (in a setting without predators) animals, in fact, attempt to hide pain from us. Science has shown us dogs observed by closed circuit camera post spay surgery. These dogs displayed many pain behaviors that abruptly abated when a human researcher entered the room. This type of research has led us to become less reliant on pain signs. Recently, the focus of much research in pain management has shifted toward identifying and even predicting known painful events. For example: Severe pain is expected with cervical disc herniation, extensive inflammation, medical or surgical, fracture repair, limb amputation, declaw, TECA, etc. M oderate to mild pain is expected with cruciate repair, laparotomy, mass removal, castration, dental procedures, etc. This approach encourages us to treat patients who undergo painful procedures or diseases processes without requiring proof. It does not however, consider the vast variation in pain tolerance in the individual. It seems reasonable to incorporate both concepts to develop a truly effective analgesic plan. That is, to have direction given by what are known to be painful events and be prepared to provide adequate analgesia for the expected level of pain but also to look a the individual and tailor analgesic protocols accordingly. The Best Way To Treat Pain Is To Prevent It! This is the concept of pre-emptive analgesia. All research in human and veterinary medicine shows that preventing pain is unquestionably the best approach to treatment. Imagine that tomorrow at 5 PM you were going to have an excruciating headache, guaranteed. What would you do at 4:30? Probably you thought, "I would take something", like Ibuprofen or another NSAID. You would make that choice because the looming headache is an example of a planned painful event. Knowing the pain is coming allows you the opportunity to stop that pain before it starts. Elective surgery is also a planned painful event. It makes sense to pre-empt the pain that is associated with all surgical procedures. It is an easy concept to grasp but not so easy to remember to implement. That is because we have become used to treating animal pain on "request", that is, when we see overt signs of pain even though we rationally know that once we see the signs it is already too late. We have already missed the opportunity to effectively manage pain in that patient. Myth # 3. Animals are given post-operative analgesia only when they show evidence of pain This thinking requires the patient to prove he/she is in pain at the time the next dose is scheduled. It is far better to reach a sustained plane of analgesia than to allow pain to return before administering additional drugs. The length of time that pain relief is provided is determined by several factors, including the onset, duration and source of pain. Acute pain is usually most intense during the first 24 hours after tissue injury and routinely responds to treatment. In addition, different drugs have varying durations of action. Op ioids, a diverse group of natural and sy nthetic analgesic drugs widely used in veterinary medicine, are generally reserved for perioperative or short-term inhosp ital use because they tend to have short duration of action. For example, the analgesic properties of butorphenol, the only opioid approved for veterinary use in dogs, cats and horses, may only last about 45-90 minutes. Effective pain management involves perioperative analgesia, ongoing evaluation and use of drugs with different modalities. We must think in terms of managing pain for at least 24 hours with even simple procedures. The central nervous sy stem inversely adapts to repetitive pain impulses. When sp inal neurons are subjected to repeat or high-intensity nociceptive impulses, they become progressively and increasingly excitable, a phenomenon known as windup. Windup is associated with changes in sp ecific neuron cell-membrane receptors that lead to increased neuron excitability that lasts for several hours after the stimulus stops. This condition is known as central sensitization. Instead of producing normal nociceptive signals, these modified neurons distort impulse transmission; therefore, normally harmless sensations are interpreted as pain and noxious stimuli provoke extraordinary pain. This phenomenon is apparent, for example, in the dachshund with disk disease that cries out in pain when any part of its body is touched, or the cocker sp aniel with a chronic ear infection that can no longer tolerate normal petting. This phenomenon highlights the need for preemptive analgesia to treat pain before it begins and at regular intervals post-operatively. Keeping patients out of pain 188

rather than continually rescuing them from it reduces the overall use of analgesics and helps avoid central sensitization. Myth #4. Labradors are made of steel and Yorkies are wimps! This myth illustrates our preconceived notions about variations in breed response to painful stimuli. The inherent danger associated with this belief sy stem is that we may fail to treat patients who are stoic or we may under treat patients whose overt signs seem exaggerated. (We also discriminate against puppies, older animals and aggressive animals). Diagnosis of pain in veterinary medicine is seldom made on the basis of a single observation or laboratory value. Because pain is an individual, subjective experience, assessment depends on a combination of good examination skills; familiarity with species, breed and individual behavior; knowledge of the degree of pain associated with particular surgical procedures and illnesses; and recognition of the signs of stress and pain. Animals likely reach a threshold of pain-induced distress before they show changes in behavior. M oreover, individual animals express pain differently, so we must be observant and knowledgeable enough to interpret a behavioral change as pain. Animals that express more pain than expected may have a low pain threshold and should be managed appropriately. Myth # 5. Elective sur gical procedures don't require take home medication The message is "don't quit till the pain quits". Send pain relief home with the patient. M any professionals agree that most soft tissue procedures such as spay or neuter require 3-4 days of postoperative analgesia while orthopedic procedures probably require a week's supp ly. Of course individual patients may vary and owners should be advised to request additional analgesia if they perceive their pet to be in pain beyond the anticipated period. Myth # 6. Pain is beneficial in limiting a recovering animal's activity Although one of the mostly widely held myths about pain, the type of pain produced by tissue injury, inflammation or direct damage to the nervous sy stem is never beneficial. Aside from being morally questionable, there appears to be little evidence to supp ort this idea. In fact, studies demonstrate that animals in pain tend to be restless, changing position frequently and bite/chew/lick at painful sites whereas analgesed animals tend to rest quietly. Perhaps the most compelling reason to abandon this myth is the deleterious effects of pain itself that far outnumber any possible benefit, real or imagined. Although the nervous sy stem is the main target of painful stimuli and provides the means by which the animal responds to that information, the body's response is not limited to the nervous system. M ost, if not all, of the body's major systems; the cardiopulmonary, gastrointestinal, neuroendocrine, and immune sy stems are affected by unrelieved or improperly treated pain. Pain is a stressor, triggering autonomic reflexes governed by the sympathetic nervous system. This response sets the body's defenses in motion, creating the appropriate internal environment for tissue repair and healing. Unfortunately, the increased cortisol levels that can accompany pain can interfere with tissue healing and reduce the immune sy stem's ability to work effectively. In addition, the classic "stress response" to pain, regardless of the underlying cause, ultimately results in a catabolic state or state of metabolic breakdown. Pain-induced distress that is prolonged sup presses the immune system and promotes inflammation, thereby predisposing patients to infection. Other adverse effects of the stress response include increased blood pressure (which affects organ perfusion and can lead to abnormal heart rhythm), fluid retention, decreased gut motility, and increased likelihood of sepsis.

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Although the stress response is an evolutionary adaptation designed to improve survival following injury, its persistence can be harmful. Enduring distress also affects patient morbidity and recovery. Providing effective analgesia reduces the pain-induced stress response, thereby enhancing patient comfort and recovery.

Myth # 7. The clients won't pay for pain management Owners of ill animals can present a great source of frustration to veterinary staff. But, they can also provide a great sense of accomplishment, mutual trust and emotional satisfaction. Pain management is an area where strategies for success must include the client right from the beginning. We have grown accustomed to viewing the client as the guardian of his or her wallet. In reality , although many clients do have financial concerns, the vast majority are people who love their pets and generally want what is best for them. When our behaviors illuminate pain management as an essential aspect of good medicine clients will agree. It is not a good idea to make pain management optional at the owner's discretion because it gives the wrong message. We do not want to say," we only manage pain if we are asked to". Rather we want to message to be "we care about your pet and that includes our commitment to manage his pain". In most practices this burden will rest largely with technicians and supp ort staff as they provide most of the client contact during patient admissions and discharges. In fact, it is advisable to broach the topic of pain management even as early as the initial phone call to schedule services. The topic is revisited on admission and again at discharge. When handled appropriately, clients will ultimately choose veterinary hosp itals because of their reputation for providing good pain management. Taking the following actions fully engages the client in proper pain management:  The receptionist includes "pain management" when quoting prices over the phone  There is a sign about pain management in the waiting room or staff is wearing buttons when the client arrives  The admitting technician talks about expected level of pain associated with the condition or surgery and explains hosp ital policy/protocol regarding pain management  Pain/comfort level is discussed in phone calls during hosp italization  Expected level of "at home" pain and its recognition is discussed at discharge  App ropriate take home pain relief is routinely provided at discharge  Clients are encouraged to call if pain appears to persist Copyright 1991-2010, WSAVA 2002 Congress http://www.vin.com/proceedings/Proceedings.p lx?CID=WSAVA2002&Category=&PID=17195&O=Generic

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24. AAHA/AAFP Pain Management

Guidelines for Dogs & Cats

Pain management in dogs and cats has undergone a dramatic evolution in the past decade. Current approaches focus on anticipation and prevention of pain, as well as both pharmacologic and nonpharmacologic management techniques. The veterinary team plays an essential role in educating pet owners about recognizing and managing pain in their pets. J Am Anim Hosp Assoc 2007; 43:235-248.

The American Animal Hospital Association and the American Association of Feline Practitioners AAHA/AAFP Pain Management Guidelines Task Force Members Peter Hellyer, DVM, MS, DACVA Ilona Rodan, DVM, DABVP (Feline Practice) Jane Brunt, DVM Robin Downing, DVM, CVA, DAAPM James E. Hagedorn, DVM, DABVP Sheilah Ann Robertson, BVMS (Hons), PhD, DACVA, DECVA, MRCVS The American Animal Hospital Association and the American Association of Feline Practitioners would like to acknowledge and thank the members of the Pain Management Guidelines Task Force for their time and commitment to this project. The Task Force members’ dedication to relieving and, when able, eliminating animal suffering is evidenced by this work. AAHA and AAFP gratefully acknowledge the following for their sponsorship of an educational grant for the AAHA/AAFP Pain Management Guidelines for Dogs & Cats: IDEXX Laboratories, Merial Ltd., Pfizer Animal Health, ScheringPlough Animal Health Corporation and Novartis JOURNAL of the American Animal Hospital Association

Introduction Historically it was thought that animals did not feel pain or that they perceived pain differently than humans. As a corollary to this concept, it was suggested that pain following surgery or injury was beneficial to animals because it limited movement and thus prevented further injury.

Today there is a better understanding of how pain develops and is perpetuated. 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 animals experience pain similarly [Table 1]. Veterinary practitioners also have more insight into how most drugs work to modulate pain and how and why a combination of therapies can benefit patients. Untreated pain decreases quality of life in all patients, and prolongs recovery from surgery, injury, or illness. Today’s analgesic strategies allow people—and now animals—to live more comfortable lives. Preventing and managing pain has become a fundamental part of quality and compassionate patient care in veterinary medicine. As advocates for their patients, the veterinary team has the responsibility to recognize, assess, prevent, and treat pain. Pain should be thought of as the fourth vital sign—after temperature, pulse, and respiration— and integrated into all patient evaluations. Many health conditions and medical procedures cause pain in cats and dogs. Attention to pain is fundamental to every aspect of patient care, regardless of the patient’s condition or reason for presentation to the veterinarian. Managing pain effectively requires looking for its signs and asking the right questions. Because many animals may not show obvious indications of pain, identifying the degree of pain and the amount of suffering associated with it can be a challenge. The most common sign of pain is change in behavior. 235

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Incorporating pain management into the veterinary practice helps everyone. It benefits the patient through improved quality of life and reduced complications. It benefits clients through enhancement of the human–animal bond. It benefits the health care team through increased safety; improved morale, pride, and job satisfaction; and a less stressful environment. Contemporary approaches to pain management enable veterinarians to more effectively fulfill their responsibility to relieve animal suffering as pledged in the veterinarian’s oath. This document was developed by the American Animal Hospital Association and the American Association of Feline Practitioners through a collaborative effort between Task Force members. By their very nature as a consensusbuilt set of guidelines, these recommendations reflect a combination of expert opinion, personal experience, and scientific studies. They are intended to educate and inform members of the veterinary profession and should not be identified as standards of care, AAHA accreditation standards, or considered minimum guidelines, but rather as recommendations from AAHA and AAFP. These guidelines should not be construed as exclusive protocols, courses of treatment, or procedures. The Task Force recognizes that through continuing developments in research, technology, and experience, the information contained herein will be subject to change. Procedures and techniques other than those described in these guidelines may be deemed necessary based on the specific needs of the patient, available resources, and constraints due to the environmental conditions.

Types of Pain

All tissue injury, including that from elective surgery, may cause pain. Pain-induced stress responses, mediated by the endocrine system, are one of the negative consequences of pain. Increased cortisol, catecholamines, and inflammatory mediators cause tachycardia, vasoconstriction, decreased gastrointestinal motility, delayed healing, and sleep deprivation. In addition, trauma causes unseen changes in the central nervous system. Inadequate pain prevention or management can lead to magnification of pain perception and a prolonged pain state. Although traditionally pain has been categorized as acute or chronic based on duration, a more contemporary approach considers pain as adaptive or maladaptive1 [Table 1]. Adaptive pain is a normal response to tissue damage. Adaptive pain includes inflammatory pain. Inflammation is a major component of many pain states (including acute pain following surgery or trauma) and some chronic pain states such as osteoarthritis. Inflammatory mediators sensitize neural pathways, increasing the perception of pain. If adaptive pain is not appropriately managed, physical changes occur in the spinal cord and brain, leading to pain that is termed maladaptive. Examples of maladaptive pain are neuropathic and central pain. For instance, the thalamus typically serves as a relay station sending nerve

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impulses from the periphery to the cortex but may become a spontaneous pain generator if adaptive pain becomes maladaptive, central pain. An awareness that acute and chronic pain can convert from adaptive to maladaptive pain helps veterinarians understand why pain is so difficult to control in some patients. The pain-induced changes in the nervous system cause it to become more sensitive, rather than less sensitive. The longer pain is unmanaged, the more likely the neurophysiologic processes involved will cause a switch from adaptive to maladaptive pain, which is more serious and difficult to control. When that happens, some patients require specific drug therapy—such as N-methyl-D-aspartate (NMDA) receptor antagonists (amantadine) and gabapentin —aimed at restoring normal central transmission. Patients may also require multiple therapies (pharmacological as well as nonpharmacological) to manage their pain. “Wind-up pain” is a heightened sensitivity that results in altered pain thresholds, both peripherally and centrally, such that pain is experienced in areas unrelated to the original source. Wind-up causes a worsening of acute pain and has been used to describe the processes that result in maladaptive pain. Allodynia is pain caused by a stimulus that does not normally result in pain and can be a component of maladaptive pain. For instance, a cat with long-standing, untreated vertebral osteoarthritis may not tolerate even light stroking across its back. Patients may experience both adaptive and maladaptive pain. As an example, a cat undergoing onychectomy (declawing) experiences inflammatory pain with the potential to develop long-term neuropathic or central pain if the pain is inadequately managed during the perioperative and healing periods. Effective, early, multimodal perioperative pain management is essential to minimize the development of these events.a

Anticipation and Early Intervention

An understanding of the underlying conditions that can result in pain better equips the practitioner to anticipate and potentially intervene or modulate pain development. Preventing risk factors early in life reduces the development of pain later in life. For example, providing lifelong dental care reduces the development of oral pain, and preventing obesity reduces the incidence and severity of osteoarthritis.2

Overlooked or Unrecognized Source of Pain

Unintentional pain or discomfort associated with veterinary procedures is easily overlooked. Procedures that might cause discomfort or pain include IV catheterization, ear cleaning, manual stool evacuation, and anal sac expression (especially in cats). Evaluate in-hospital procedures where unintentional pain can occur, and reduce or eliminate those causes. If necessary, use an opioid to reduce the pain or discomfort of some procedures. If an animal must be restrained or handled excessively because of its fear, aggression, or preexisting pain, use anxiolytics, sedation, 192 192 167

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Table 1 Definitions Associated with Pain and Pain Management Type of Pain

Definition

Adaptive pain—inflammatory*

Spontaneous pain and hypersensitivity to pain in response to tissue damage and inflammation. Occurs with tissue trauma, injury, surgery. Causes suffering. Responds to treatment.

Adaptive pain—nociceptive*

Transient pain in response to a noxious stimulus. Small aches and pains that are relatively innocuous and that protect the body from the environment.

Allodynia†

Pain caused by a stimulus that does not normally result in pain.

Analgesia†

Absence of pain in response to stimulation that would normally be painful.

Anesthesia‡

Medically induced insensitivity to pain. The procedure may render the patient unconscious (general anesthesia) or merely numb a body part (local anesthesia).

Distress§

Acute anxiety or pain.

Dysphoria§

A state of anxiety or restlessness, often accompanied by vocalization.

Hospice†

A facility or program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill.

Hyperalgesia†

An increased response to a stimulus that is normally painful.

Maladaptive pain—neuropathic*

Spontaneous pain and hypersensitivity to pain in association with damage to or a lesion of the nervous system.

Maladaptive pain—functional*

Hypersensitivity to pain resulting from abnormal processing of normal input.

Maladaptive pain—central neuropathic pain*

Pain initiated or caused by a primary lesion or dysfunction in the central nervous system. Often called “central pain.”*

Modulation§

Altering or adaptation according to circumstances.

Multimodal analgesia\

Use of more than one drug with different actions to produce optimal analgesia.

Neurogenic pain‡

Pain initiated or caused by a primary lesion, dysfunction, or transitory perturbation in the peripheral or central nervous system.

Nociception¶

Physiologic component of pain consisting of the processes of transduction, transmission, and modulation of neural signals generated in response to an external noxious stimulus.

Pain†

An unpleasant sensory and emotional experience associated with actual or potential tissue damage.

Palliative care†

Care that relieves or alleviates a problem (often pain) without dealing with the cause. (continued on next page) 193 168

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Table 1 (continued) Definitions Associated with Pain and Pain Management Type of Pain

Definition

Peripheral neuropathic pain†

Pain initiated or caused by a primary lesion or dysfunction in the peripheral nervous system.

Preemptive analgesia\

Administration of an analgesic before painful stimulation.

Principle of analogy§#

A similarity of forms having a separate evolutionary origin. Similar structures may have evolved through different pathways, a process known as convergent evolution, or may be homologous.

Wind-up pain**††

Heightened sensitivity that results in altered pain thresholds—both peripherally and centrally.

* Woolf CJ. Pain: Moving from symptom control toward mechanism-specific pharmacologic management. Ann Intern Med 2004;140:1441–1451. † IASP (International Association for the Study of Pain): www.iasp-pain.org. ‡ MSN Encarta Dictionary: www.encarta.msn.com. § Random House Webster’s College Dictionary. New York: Random House, 1997. \ Gaynor J, Muir W. Handbook of Veterinary Pain Management. St. Louis, MO: Elsevier Publishing, 2002. ¶ Vet Clin North Am Small Anim Pract 2000;30(4):704. # Wikipedia: http://en.wikipedia.org/wiki/Main_Page. ** Hansen B. Managing pain in emergency and critical care patients. Proc Atlantic Coast Veterinary Conf. 2005. †† Muir WW, Hubbell JA. Handbook of Veterinary Anesthesia. 4th ed. St. Louis, MO: Elsevier Publishing, 2006.

and/or anesthesia as needed to prevent struggling, subsequent pain or injury, and aversion. Conditions in which it is unclear how much pain the animal experiences include some visceral, gastrointestinal, and urogenital diseases; central nervous system disorders; and dermatologic disease. Table 2 lists conditions and procedures that may be overlooked or underestimated as causes of pain. Specific management for these conditions and procedures may include pharmacologic and/or nonpharmacologic management or simply a different or more careful approach to handling the animal. Some procedures and conditions that are commonly recognized as causing pain in dogs may be overlooked in cats. For example, osteoarthritis, intervertebral disc disease, and spondylosis are common in older cats, and yet many of the behavioral changes related to these diseases have been ascribed to “old age” rather than pain. Cats and dogs with behavior problems often have an underlying medical condition that may be painful. For example, the cat that urinates inappropriately may have painful lower urinary tract disease. In these kinds of cases, pain management plays an important part in the animal’s treatment.

Anticipating and Reducing Surgical Pain

The level of pain associated with surgery can be anticipated to some extent. In general, the more tissue trauma, the more pain, because pain is proportional to increasing levels of circulating cytokines.3 Abdominal surgery generally produces more pain than do superficial soft-tissue procedures, and orthopedic procedures can cause severe and prolonged pain. Keep in mind, however, that even “routine” procedures are painful. Repeat surgeries may be more painful than the original surgery due to the changes that occur in the spinal cord and brain with repetitive and prolonged stimulation (maladaptive pain). Good surgical technique and minimal tissue trauma may help alleviate pain. Resources are available to assist in estimating the degree of pain associated with various conditions and procedures (see page 248). However, the practitioner must be aware that each individual animal will have a unique response to painful stimuli.4 To optimize pain management and improve the safety of anesthesia, use a perioperative approach to pain management. The timing of administration of medications to prevent pain is critical. For example, giving an opioid prior to a surgical procedure is much more beneficial than 194 169

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Table 2 Frequently Overlooked Causes of Pain Type of Pain

Cause

Cardiopulmonary

Congestive heart failure (pulmonary edema and pleural effusion); pleuritis, cerebral vascular accident, thromboembolism (clot).

Oncologic

Any and all cancer.

Dermatologic

Otitis, severe pruritus, burns, chronic wounds; abscess, cellulitis, clipper burns, urine scalding, severe chin acne.

Dental

Oral tumors, feline oral resorptive lesions (â&#x20AC;&#x153;neckâ&#x20AC;? lesions), fractures (no matter how small), tooth abscess, ulcers, stomatitis.

Gastrointestinal

Constipation, obstipation, obstruction, megacolon; anal sac impaction; hemorrhagic gastroenteritis, pancreatitis, gastric dilatation-volvulus (GDV), foreign body.

Musculoskeletal

Most often overlooked in cats. Muscular soreness, arthritis, degenerative joint disease, tendon or ligament injury, intervertebral disc disease, facet pain of spondylosis, osteodystrophy, dislocations.

Ocular

Corneal disease and ulcers, glaucoma, uveitis.

Urogenital

Uroliths, ureteroliths, queening/whelping, feline lower urinary tract disease/interstitial cystitis, acute renal failure, enlarged kidneys (capsular swelling), lower urinary tract infections, urinary obstruction, vaginitis (especially in obese cats).

Hospital procedures

Restraint (examination, obtaining blood and urine samples, radiographs, and ultrasound; even gentle handling and hard surfaces can increase pain in an already painful animal). Urinary/IV catheterization, bandaging, surgery, thoracocentesis, chest tube placement and drainage procedures, abdominocentesis. Manual extraction of stool and anal sac expression (especially in cats).

Surgical procedures

Ovariohysterectomy, castration, onychectomy,* growth removal, and all other surgical procedures.

Neurologic

Diabetic neuropathy.

* Regardless of method used, onychectomy causes a higher level of pain than spays and neuters.

administering the same dose afterward. An opioid administered as an anesthetic premedication not only helps to dampen the pain response but also decreases the doses of anesthetics required for anesthetic induction and maintenance. Providing adequate intraoperative and postoperative analgesia increases patient comfort and facilitates a smoother recovery from anesthesia. It may also prevent the development of maladaptive pain.

Some opioids have a very short duration of action and have a ceiling effect (e.g., butorphanol), whereas others (e.g., buprenorphine) have a longer duration of action but a delayed onset and time to peak effect. Understanding these pharmacologic differences helps to ensure that medications are used appropriately and with the most efficacy. 195 170

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Anticipating Changes in Pain Management

Initial pain management should be followed by ongoing reassessment and revision of pain management, titrating treatments up or down to meet patient needs. Anticipate that increased signs of pain may occur following discharge from the hospital, as (for example) when residual sedation or a local anesthetic wears off after the patient has returned home. Furthermore, some animals may mask behavioral signs of pain while hospitalized, and signs of pain become evident only at home. The client should be counseled about this contingency, and pain medications should be made available. (A later section provides more information on educating clients regarding pain management in their pets.) Analgesic drugs and/or dosages may need to be modified with the patient’s changing status. If a dog with osteoarthritis is on a nonsteroidal anti-inflammatory drug (NSAID) and then undergoes intestinal surgery, a different type of drug must be prescribed if the animal becomes hypovolemic. The practitioner should expect escalating pain management needs in animals with progressive diseases, such as osteoarthritis, cancer, intervetebral disc disease, or spondylosis, as well as in some end-of-life or hospice patients.

Recognition and Assessment Variations in Pain Response

Although all animals experience pain, expression of pain varies with age and species, as well as among individuals. Neonates have intact neural pathways for pain transmission, but both neonates and senior animals may not express their pain as plainly as other animals. Cats and dogs also tend to hide pain as a protective mechanism. However, a lack of expression or outward evidence does not necessarily indicate that these patients are not experiencing the negative consequences of pain. Some animals experience residual pain following a surgery or injury, whereas other animals seem to return quickly to normal function with no obvious residual pain. Responses to surgery and injury or to therapy are unique to each individual, and the differences reflect genetic variation in such factors as the number, distribution, and morphology of opioid receptors. 5,6,7 Anecdotal evidence suggests that certain breeds appear more sensitive to painful stimuli and are more easily aroused than others. Whether this reflects different communication styles, arousal patterns, or actual pain perception is not known. Individual animals undergoing the same procedure may experience or express their pain differently. In addition, an individual animal can experience more than one type of pain at any given time. For example, the senior patient with osteoarthritis that undergoes surgery to remove a mass may experience musculoskeletal pain due to positioning during the procedure, in addition to the pain associated with the surgery itself.

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Differentiating Pain From Other Conditions

Assessing behavior is an integral part of the history-taking and physical examination of any animal [Table 3]. Understanding normal behavior is essential to identifying pain and selecting an appropriate intervention.8,9 The input of the owner is invaluable in determining abnormal behavior that may be linked to pain.4 Behavioral signs of pain, including both loss of normal behavior and development of new and abnormal behaviors, may be subtle and easily overlooked by both owners and the veterinary health care team. A systematic and holistic approach that considers the animal as well as its environment is essential to recognizing changes in behavior and physiologic parameters. Physiologic signs such as increased respiration and heart rate, increased blood pressure, or dilated pupils may be manifestations of pain or stress but should not be relied on as the sole indicators of pain. The line between “discomfort” and “pain” is imprecise. The practitioner must assess the conditions and procedures that cause sensations ranging from skin irritation to severe discomfort and then determine whether pain management is indicated. Tables 2 and 3 summarize often-overlooked causes of pain and signs of pain, respectively. The decision-making process can be facilitated by the pain management algorithm shown in Figure 1, which offers a step-by-step approach to determining whether or what intervention is indicated. If a question persists regarding the presence of pain, administer an analgesic and assess the patient’s response. Response to therapy is an appropriate and important tool in pain assessment. When pain management is needed, formulate a plan, note it in the medical record (and make a copy for the client), and update the plan as needed. Differentiating dysphoria from pain can be challenging, especially in traumatic or surgical cases. Pain and dysphoria can occur simultaneously, complicating the picture. However, the observant practitioner can discern clues to differentiate between dysphoria and pain. Dysphoric animals are difficult to distract or calm by interaction or handling. Administering more opioids does not help the situation, and a source of pain is not readily identifiable. In contrast, animals in pain typically can be temporarily distracted and calmed by interaction or handling. Increased or repeated doses of opioids seem to help, and a source of pain can be identified. Frequency of pain assessment depends on the presenting problem. In patients with surgical or traumatic pain, pain assessment is recommended at least every 2 hours. In patients with chronic pain, assessment is recommended a minimum of every 3 months or whenever control seems to be waning. All patients should be assessed for pain during their regularly scheduled wellness exams. Scoring tools such as identification and recording of behavioral changes and responses to therapy are useful for standardizing pain assessment. No single accepted pain scale has been developed for use in dogs or cats, and scales 196 171

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Table 3 Signs of Pain General Signs

Specific Signs

Loss of normal behavior

Decreased ambulation or activity, lethargic attitude, decreased appetite, decreased grooming (cats). Harder to assess in the hospital.

Expression of abnormal behaviors

Inappropriate elimination, vocalization, aggression or decreased interaction with other pets or family members, altered facial expression, altered posture, restlessness, hiding (especially in cats).

Reaction to touch

Increased body tension or flinching in response to gentle palpation of injured area and palpation of regions likely to be painful, e.g., neck, back, hips, elbows (cats).

Physiologic parameters

Elevations in heart rate, respiratory rate, body temperature, and blood pressure; pupil dilation.

currently in use range from simple to complex.10,11 Whatever pain scale is adopted, it is essential that it fits the practice; otherwise, the scale will go unused. The pain scoring system should be incorporated into overall patient assessment, treatment, and reassessment protocols, as well as staff and client educational materials.

Pharmacological Intervention

The use and choice of pharmacologic agents is based on a thorough patient assessment that includes a physical exam; an evaluation of the patient’s history, underlying or preexisting conditions, and presenting complaint; and a laboratory evaluation of an appropriate database. When choosing medications to send home with patients, client compliance can be enhanced by taking into account such factors as the duration of analgesic action and ease of administration. Classes of analgesic drugs are listed in Table 4. An exhaustive list of drugs and their indications, contraindications, side effects, and doses is referenced and may be found in other sources.12,13,14 A multimodal approach to pain management takes advantage of the different modes and sites of action of various analgesic agents [Table 4]. Lower doses of each analgesic often can be used, reducing the potential for side effects and providing superior analgesia. This approach also utilizes the timing of administration of different agents.15,16

Perioperative Analgesia

Before an elective surgery, use an opioid that also reduces the anesthetic requirement. Before or during surgery, use a local anesthetic at the incision to block the transmission of noxious stimuli. During anesthetic recovery, use an NSAID to decrease the inflammation from the surgical trauma. This

combination of pharmacological agents may help prevent the evolution of maladaptive pain. Regardless of the procedure performed, opioids are anesthetic-sparing and should be used for this effect. Pharmacological pain management must also be addressed by organizations with a high volume of surgical cases (i.e., shelters, ovariohysterectomy–neuter programs, and feral cat programs) or in situations with little to no opportunity for follow-up. Economic considerations may play a role in these circumstances. The question may be, “What is the minimally acceptable degree of analgesia that should be offered for routine surgical procedures, and how is this most economically achieved?” The answer will change as new information becomes available. For instance, even when opioids are unavailable, other options exist. In a recent study, a single dose of carprofen given to shelter dogs undergoing ovariohysterectomy demonstrated good analgesia for up to 24 hours in most dogs.17

Analgesia for Other Procedures and Conditions

Local or topical anesthetics are useful for managing pain or discomfort associated with a variety of conditions such as clipper burns or urine scalding or procedures such as IV catheter placement. Opioid administration for procedures such as manual extraction of stool and anal sac expression, especially in cats, decreases pain and helps prevent fear and anxiety associated with veterinary visits. Since pain is individual for each patient, if the patient is still in pain, additional analgesia and/or anesthesia are indicated. Because anxiety and fear can amplify pain, and physical restraint may contribute to pain, anxiolytics should be used for anxious or fearful animals undergoing hospital procedures. Alprazolam is an excellent antianxiety med197 172

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Is the patient in pain now?

Yes

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Not Sure

Administer test dose of an analgesic.

Why? Diagnose cause source; assess general type of pain (e.g. visceral, neuropathic) and probable cause.

Establish cause and work toward its resolution. Manage pain using appropriate agents and techniques.

Is pain anticipated due to handling, disease, procedure or surgery?

Yes

No management indicated.

Assess time and severity of anticipated pain. Assess physical and physiologic condition, age, species and breed.

Pain not managed.

Assess and monitor response to pain therapy and primary treatment for underlying cause/source of pain.

Utilize appropriate short-acting preemptive agents. Utilize appropriate patient handling and housing.

Pain well-managed.

No pain.

Utilize appropriate intermediate and longer-acting multimodal analgesics.

Continue therapy with periodic reassessment.

Underlying cause corrected.

Continue pain management postoperatively. Continue ongoing assessment of therapy. Monitor laboratory parameters as indicated.

Adjust or titrate medications, treatments and treatment cycles, adding or subtracting modalities up or down to meet patient needs.

Pain resolved.

Discontinue treatment.

Figure 1â&#x20AC;&#x201D;Pain Management Algorithm 198 198 173

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Table 4 Drug Classes and Characteristics*† Drug Class

Comments

Alpha-2 agonists

Analgesic, sedative, muscle relaxant; dose-related duration, reversible.

Anxiolytics

Anti-anxiety (anxiety enhances pain); preappointment or preanesthetic.

Corticosteroids

Analgesic; anti-inflammatory.

Local anesthetics

Analgesic; anesthetic-sparing; blocks pain recognition.

NMDA‡ receptor antagonists Amantadine

Reduces “wind-up”; good for chronic pain management in dogs; typically not used for adaptive pain.

Ketamine

Somatic analgesia; reduces “wind-up.”

NSAIDs§

Analgesic; anti-inflammatory; long duration of action.

Opioids

Analgesic; anesthetic-sparing; reversible; short duration of action.

Topical anesthetics

Dermatologic conditions, anal/genital procedures, hospital procedures (e.g., catheter placement).

Tricyclic antidepressants

Antidepressant and anxiolytic, with analgesic properties. Used as adjunctive analgesic; enhances opioid analgesia. Used in humans to treat chronic and neuropathic pain at lower doses than those used to treat depression.

Miscellaneous Drugs

Comments

Gabapentin

Reduces “wind-up”; good for chronic pain management in dogs and cats; typically not used for adaptive pain.

Tramadol

Analgesic; good for chronic pain management in dogs and some cats.

* Gaynor J, Muir W. Handbook of Veterinary Pain Management. St. Louis, MO: Elsevier Publishing, 2002. † Mayo Clinic Tools Online: www.mayoclinic.com/health/ ‡ NMDA—N-methyl-D-aspartate § NSAID—nonsteroidal anti-inflammatory drug

ication. Tricyclic antidepressants may be indicated when the practitioner suspects persistent, aberrant pain that is refractory to traditional analgesics (e.g., neuropathic pain). Recall that acepromazine is not an anxiolytic but rather a tranquilizer, causing sedation without decreasing anxiety. Acepromazine may disinhibit aggression, making the patient not only more fearful but also more dangerous. Although acepromazine is useful as part of an anesthetic

protocol, it is not indicated for use to control fear or anxiety.18 A synthetic feline facial pheromone (FFP) helps reduce anxiety in unfamiliar surroundings, including the veterinary hospital. FFP diffusers can be plugged into each room and sprayed on tables, towels, and hands. Although this approach is beneficial with many cats, occasionally an individual animal may become more agitated.19,20 199199 174

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Evaluating and Monitoring Drug Metabolism and Effects

It is important to treat all pain for an adequate period of time. Patients receiving pain management must be monitored via reexamination and laboratory testing at prescribed intervals to assess for efficacy and adverse events. Drug metabolism varies among species, breed, and individuals. Specific contraindications of drug classes are noted by their manufacturers (for those drugs that are approved for use in dogs and cats) as well as in many texts. Selection of pain medication for cats requires special attention. Some opioids—such as buprenorphine, meperidine, and methadone—cause fewer behavioral side effects in cats (e.g., less excitement) than do other opioids. With respect to buprenorphine, the oral (transmucosal) route can be as effective as the intravenous route and is more convenient. Hydromorphone has been associated with hyperthermia and agitation in cats at the doses required to provide analgesia.21 There is a misunderstanding regarding the degree and duration of analgesia provided by butorphanol. Butorphanol is not as effective or long-lasting as other opioids (although there are individual variations in response to drugs that target different opioid receptors, such as the mu- and kappa receptors, which has been demonstrated in cats).22,23 Limited uses of butorphanol include anesthetic premedication and prior to minimally invasive procedures. Pets with transdermal fentanyl patches may be easier for owners to manage, but the absorption of the drug is highly variable and may not reach analgesic levels. If the decision is made to send a cat home with transdermal fentanyl, the client should be educated about how to identify whether the cat is still in pain, such that the use of other opioids becomes necessary.24 Because vomiting increases intracranial and intraocular pressure in animals with an eye injury or intracranial mass, opioids such as morphine or hydromorphone should be avoided in these patients. Exercise caution with their use in animals that are obtunded and have an increased risk of aspiration (e.g., brachycephalics).

Nonpharmacological Intervention

Appropriate use of nonpharmacologic therapy as an adjunct to pharmacologic agents can enhance pain prevention, management, and treatment. These methods of pain control typically are used for chronic pain but may also be appropriate adjuncts to treatment of acute pain. Many basic lifestyle changes can reduce pain. For example, controlled exercise and weight management are used to decrease joint stress and improve muscular support of the joints.25,26 Although home care varies with the condition, even simple environmental accommodations can benefit the pet and prevent or reduce discomfort. These include easy access to litter boxes (no hood, ramp, or stairs and a lowentry side); soft bedding; raised food and water dishes; nonslip floor surfaces, especially in food and litter areas; baby gates to prevent access to stairs; modified access to outdoors, especially in hot or cold weather; and appropriate

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warm-up prior to exercise.8 And lastly, positive, consistent interaction with the pet can improve the animal’s demeanor. Quality in-hospital care may include the use of soft padded bedding during illness or surgery to enhance comfort, warm water or air blankets to decrease pain and facilitate recovery from anesthesia, reduction of patient anxiety by minimizing the length of a hospital stay, and gentle and respectful patient handling. It is also beneficial to decrease visual and auditory stimulation and separate dogs and cats within the hospital setting. Shy or anxious cats should have a box or similar structure in their cage to provide a hiding place. An array of medical approaches can be grouped under the umbrella of “complementary and alternative medicine.” Use of some of these methods is controversial, in part because of the lack of scientific study and published evidence about them. Additional research is needed to elucidate both the benefits and uses of complementary and alternative medicine. Of all the complementary procedures used for pain management, acupuncture is most supported by evidence; its use in humans is endorsed by the National Institutes of Health.27 If alternative medical approaches are used, it is essential that the procedure or therapy be performed with the full and informed consent of the client and under applicable state laws. Where training or certification is available, the modality must be administered by individuals trained or certified in its use and limitations.b As with administration of pharmacologic agents, patients receiving alternative modalities should be periodically reassessed to determine the efficacy of treatment. Nutrition is one of the most popular of “alternative” modalities. Nutraceuticals, such as glucosamine and chondroitin, may decrease joint inflammation and assist in cartilage repair, although a large meta-analysis conducted in human medicine indicated the need for further study.28,29,30,31,32 There is evidence that omega-3 fatty acids decrease inflammation in cartilage of dogs with osteoarthritis, and dietary intervention can improve clinical signs in osteoarthritic dogs.33,34,35 Chondroprotective agents such as polysulfated glycosaminoglycans have been demonstrated to modify the progression of osteoarthritis by maintaining chondrocyte viability via the inhibition of cartilage degradation pathways.36,37 At this time, most of the research that has been conducted to assess the roles of nutraceuticals and chondroprotective agents has been conducted in dogs. However, there are anecdotal reports of improved function in cats receiving chondroprotective agents. Rehabilitation therapy (i.e., the application of physical therapy techniques to animals) may be used to return a patient to normal function following surgery or trauma or as a part of a long-term strategy to manage pain. Rehabilitation includes techniques such as cryotherapy, heat therapy, massage, stretching, passive range-of-motion exercise, hydrotherapy, therapeutic exercise, use of dryland or underwater treadmill, and strength-building. 200 200 175

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Additional therapies that fall under the rehabilitation umbrella include low-level laser, ultrasound, and transcutaneous electrical nerve stimulation (TENS). Some veterinary practices have incorporated these therapies on the basis of extrapolation from human medicine and anecdotal reports of their success. Currently there is insufficient published evidence of efficacy in dogs and cats to make specific recommendations about the use of these therapies. Although chiropractic intervention occasionally has been used to treat chronic pain, chiropractic methods potentially can cause injury through the use of inappropriate technique or excessive force. Currently there are no clear standards for when chiropractic intervention should be applied or who is qualified to use chiropractic manipulations. Practitioners who have received formal training in animal chiropractic manipulation (typically 100–140 contact hours) report positive results in their patients experiencing chronic pain. There is currently insufficient published evidence of efficacy in dogs and cats to make specific recommendations about the use of chiropractic intervention.

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Pharmaceutical and nonpharmaceutical intervention can be combined for pain management. For example, a cat with osteoarthritis is given both drug therapy and a reducedcalorie diet for weight loss. The cat also may benefit from acupuncture, massage, physical rehabilitation techniques, and care in handling. In the home, the pet’s quality of life can be enhanced by such environmental modifications as soft bedding, ramps or steps that allow the cat to use its favorite places, nonslip floor surfaces, and food dishes raised to the height of the cat’s elbow.

When Pain Persists: Referrals, Hospice, and Palliative Care

Due to the complex nature of many pain conditions, consultation or referral may be appropriate in some cases. Situations that warrant consultation or referral include a lack of anticipated response or an unsatisfactory response to treatments despite the use of multiple modalities. Patients may also be referred if their condition requires surgical intervention by a specialist or a procedure not provided by the primary practice, e.g., acupuncture, radiotherapy, or advanced

Table 5 Useful Internet Links Name of Organization

Web Address

Type of Information Available

American Animal Hospital Association

www.aahanet.org

Pain management standards; analgesic position statement.

American Association of Feline Practitioners

www.catvets.com

Feline Behavior Guidelines, Appendix 1: behavioral assessment; feeding tips to prevent obesity in your cat; how to help your cat have pleasant veterinary visits; environmental enrichment enhances quality of life.

Center for Veterinary Medicine, Food and Drug Administration

www.fda.gov/cvm

Information about specific approved drugs.

Cornell University College of Veterinary Medicine, Feline Health Center

www.felinevideos.vet.cornell.edu

Giving your cat medication, other cat care.

International Academy of Veterinary Pain Management

www.cvmbs.colostate.edu/ivapm

Information for professionals and pet owners.

International Association for the Study of Pain

www.iasp-pain.org

Terminology, definitions.

United States Pharmacopoeia

www.usp.org

Drug information including modes of action and potential adverse effects. 201 176

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diagnostic workups such as computed tomography (CT) or magnetic resonance imaging (MRI). Practitioners may want to seek consultation for diagnostic confirmation or help in fine-tuning pain management protocols and procedures. Referrals are also recommended for patients requiring more aggressive or complex pain management beyond the scope of most practices. Many pet owners welcome the possibility of being able to provide hospice or palliative care for their pets when it is made available. Hospice is defined as “a system which provides compassionate comfort care to patients at the end of their lives and also supports their families in the bereavement process. Hospice care for terminally ill patients is characterized by recognition that the life expectancy is less than 6 months.”38,39 Palliative care is defined as “the active total care of patients whose disease is not responsive to curative treatment. Control of pain is paramount. The goal of palliative care is achievement of the best quality of life for patients and their families.”40 Palliative care maximizes the pet’s quality of life while managing pain and discomfort. Providing palliative care treats the patient but not necessarily the disease. Examples of palliative care include palliative radiation (e.g., to decrease pain related to osteosarcoma), appropriate analgesics and other pharmacologic agents, and nutritional support (e.g., esophagostomy or gastrostomy tube). With both hospice and palliative care, regular client communication is essential. Create client support systems within the practice, using the veterinary team to assist with client education and the most appropriate means of delivery of medications or treatment modalities at home. It is important to create reasonable expectations for the client. Clients can be helped by the use of decision-making trees and explanations of probable outcomes and by being given choices. Euthanasia can be a gift to relieve pain and suffering and should be included as a reasonable and humane option at some point. A client may not apprehend the level of suffering the pet is experiencing or have any way to gauge quality of life. Quality-of-life indices are being developed to assist pet owners in making these kinds of difficult decisions.41 At the onset of an animal’s terminal condition, it is beneficial to ask the client to remember what activities the pet enjoyed and have the client compare these to the pet’s current status. This process helps to clarify the client’s understanding of quality of life. When possible, these issues should be discussed with the client while the pet is still healthy, before the animal is ill or in pain.

Client and Staff Education

A team approach that involves the client, veterinary team, and patient reinforces the doctor–client–patient relationship and strengthens the human–animal bond. The veterinary team serves as the client’s source of reliable information regarding identification and management of pain for the pet. The client plays an essential role in the ongoing assessment and success of treatment.

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Education is an important component of a comprehensive veterinary practice. Both staff members and clients should be instructed on how to best handle both cats and dogs respectfully and the additional support and respect needed when animals are fearful. It is important to educate owners early in their experiences with their pets. At the first kitten or puppy visit, discuss handling, dental care, weight management, ovariohysterectomy and neuter procedures, semiannual wellness exams, and planned procedures such as ongoing dental prophylaxis, all of which can impact the future onset of pain. Clients generally need help to recognize the subtle signs of pain and should be advised that methods for the alleviation of pain are available, effective, and generally safe. Even subtle changes in behavior are reasons to contact the veterinary clinic because these are the first signs of illness and pain. If a pain management plan is required, the client should be given a copy of the plan as well as written, verbal, and hands-on instruction in how to administer medications. To reinforce verbal information about pain assessment, provide the client with handouts with general information about pain in pets as well as any side effects of medication. Owner compliance will be increased if the administration of the medication is tailored not only to the patient but also to the owner’s abilities, with regard to both schedule and method of administration. Many of the medications used for a variety of canine and feline conditions, including pain, are not approved for such use. For example, on the basis of its clinical performance, gabapentin is becoming more widely used to interrupt the cycle of chronic pain in arthritic dogs and cats, yet the drug is not approved by the Food and Drug Administration (FDA) for such use. Nonetheless, veterinarians should not avoid provision of pain management simply because approved drugs are not available. Legal experts advise that informed consent be obtained in these circumstances and that copies of the signed consent form be kept in the medical record. As treatments for alleviating pain continue to evolve, veterinarians can monitor the peer-reviewed literature, veterinary conferences, and appropriate associations for new information. Team members who are involved in client interactions must be trained to effectively practice active listening. They should be willing and able to address clients’ concerns and answer questions via periodic appointments, email, and/or phone support from the practice. Any discussions with clients about specific patients should be documented in the medical record. In shelters, ovariohysterectomy–neuter programs, and feral cat programs, educating veterinarians and staff members about pain management should be a part of the group’s long-term strategy to raise the standard of care. Education needs to address the various learning styles of clients and team members. Veterinarians, veterinary teams, and clients can find useful information from a variety of sources and in a variety of forms, including written, online (text and video), and video or audio recordings. Written and 202 177

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audio sources include journals and veterinary conference proceedings. Other educational sources include commercial companies, information-sharing groups, and government agencies. Team training resources are available for use both in the veterinary practice and home setting. Veterinarians should be prepared to direct their clients and staff to websites that provide accurate and current information. When possible, videos, CDs, and/or DVDs should be available in the hospital for either viewing on site or loan to pet owners. Industry and FDA-approved information about medications and their adverse effects is available from each drug manufacturer and at the Center for Veterinary Medicine website at www.fda.gov/cvm/default.html. Table 5 offers a list of useful websites and the kind of information they provide. In addition to providing extensive information about pain management, the Internet is a resource for materials related to ancillary procedures. Veterinarians can download legal forms for informed consent and refusal of recommendation, client information forms, pain management handouts, discharge instructions, and instructions on administration of medications — all useful tools for implementing a successful pain management plan.42,43,44,45,46

Summary

Offering and providing adequate pain management enhances patient quality of life, improves the human– animal bond, encourages the team, and benefits the practice. For veterinarians who wish to improve their approach to pain management, the following strategies are a good place to start. Use the pain management algorithm [Figure 1] to aid in pain identification, prevention, and management. Develop anesthetic protocols to include pain prevention, using appropriate agents at specific times. Involve and train the whole veterinary team in pain management protocols. Discuss common case examples. Develop and provide scoring and assessment tools. Teach team members to use open-ended questions during their history-taking with clients to maximize the team’s understanding of each patient’s situation. Educate pet owners as described previously, starting when the animal is young. Develop written materials for client education. Begin developing the client’s awareness of the importance of identifying and treating pain whenever it occurs. The profession’s understanding of pain management is evolving with new agents and techniques and the application of evidence-based medicine. The need to be open to these changes and challenges is essential. It is hoped that this document provides a framework to approaching and managing pain and to understanding the challenges that face the profession in the future. Footnotes

a Declawing is a controversial procedure. However, if it is performed, the procedure should include effective multimodal pain therapy including opioids, an NSAID, and local analgesia, with individualized timing and assessment as described for all surgical patients.

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b For example, the oldest certifying program in canine rehabilitation is located at the University of Tennessee, Knoxville (www. canineequinerehab.com).

References

1. Woolf CJ. Pain: Moving from symptom control toward mechanismspecific pharmacologic management. Ann Intern Med 2004;140:441–451. 2. Smith GK, Paster ER, Powers MY et al. Lifelong diet restriction and radiographic evidence of osteoarthritis of the hip joint in dogs. J Am Vet Med Assoc 2006;229(5): 690–693. 3. Kristiansson M, Saraste L, Soop et al. Diminished interleukin-6 and C-reactive protein responses to laparoscopic versus open cholecystectomy. Acta Anaesthesiol Scand 1999;43(2):146–152. 4. Hunton E, Ascher A, Tokiwa M et al. Animal Welfare Task Force: Guidelines for Preventing, Recognizing, and Treating Pain in the Hospital Setting and Guidelines for Pet Owners for Recognizing Pain in Their Dogs and Cats. New Jersey Veterinary Medical Assoc, 2005. 5. Landau R. One size does not fit all: genetic variability of mu-opioid receptor and postoperative morphine consumption. Anesthesiol 2006;105(2):235–237. 6. Kim H, Mittal DP, Iadarola MJ et al. Genetic predictors for acute experimental cold and heat pain sensitivity in humans. J Med Genet 2006;43(8):40. 7. Janicki PK, Schuler G, Francis D et al. A genetic association study of the functional A118G polymorphism of the human mu-opioid receptor gene in patients with acute and chronic pain. Anesth Analg 2006;103(4):1011–1017. 8. American Association of Feline Practitioners. AAFP Feline Behavior Guidelines. 2004:www.catvets.com. 9. American Association of Feline Practitioners. Healthy Cats for Life— Subtle Signs of Illness. 2006:www.catvets.com. 10. University of Glasgow Faculty of Veterinary Medicine. Glasgow Pain Scale. 2005:www.gla.ac.uk/faculties/vet/ research/cascience/painandwelfare/cmps.htm. 11. Hellyer PW, Uhrig SR, Robinson NG. Canine Acute Pain Scale and Feline Acute Pain Scale. Colorado State University Veterinary Medical Center, Fort Collins CO, 2006: www.cvmbs.colostate.edu/ivapm/ professionals/members/ drug_protocols/ painscalecaninenobandagesPAH.pdf. 12. Gaynor J, Muir W. Handbook of Veterinary Pain Management. St. Louis, MO: Elsevier Publishing, 2002. 13. Flecknell P, Waterman-Pearson, A., eds. Pain Management in Animals. London: WB Saunders, 2000. 14. Tranquilli WJ, Grimm KA, Lamont LA. Pain Management for the Small Animal Practitioner—A Made-Easy Series Book. 2nd ed. Jackson, WY: Teton NewMedia, 2004. 15. Lamont LA, Tranquilli WJ, Grimm KA. Physiology of Pain. Vet Clin North Am Small Anim Pract 2000;30(4):704, 720–723, 753. 16. Tranquilli W, Grimm K, Lamont L. Pain Management for the Small Animal Practitioner. Jackson, WY: Teton NewMedia, 2004. 17. Shih AC, Robertson S, Isaza N et al. A Comparison Between Buprenorphine or Carprofen alone and in Combination for Analgesia After Ovariohysterectomy in Dogs. Vet Anaesth Analg 2007: in press. 18. Bowen J, Heath S. Behavior Problems in Small Animals—Practical Advice for the Veterinary Team. Edinburgh Elsevier Saunders, 2005:51, 81, 87, 89. 19. Kronen PW, Ludders JW, Erb HN et al. A synthetic fraction of feline facial pheromones calms but does not reduce struggling in cats before venous catheterization. Vet Anaesth Analg 2006;33(4):258–265. 20. Pageat P, Gaultier E. Current research in canine and feline pheromones, Vet Clin North Am Small Anim Pract 2003;33(2): 187–211. 21. Niedfeldt RL, Robertson SA. Postanesthetic hyperthermia in cats: a retrospective comparison between hydromorphone and buprenorphine. Vet Anaesth Analg 2006;33(6):381–389. 203 178

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248

JOURNAL of the American Animal Hospital Association

22. Lascelles BD, Robertson SA. Use of thermal threshold response to evaluate the antinociceptive effects of butorphanol in cats. Am J Vet Res 2004;65(8):1085–1089. 23. Lascelles BD, Robertson SA. Antinociceptive effects of hydromorphone, butorphanol, or the combination in cats. J Vet Intern Med 2004;18(2):190–195. 24. Egger CM, Glerum LE, Allen SW et al. Plasma fentanyl concentrations in awake cats and cats undergoing anesthesia and ovariohysterectomy using transdermal administration. Vet Anaesth Analg 2003;30(4):229–236. 25. Mlacnik E, Bockstahler BA, Muller M et al. Effects of caloric restriction and a moderate or intense physiotherapy program for treatment of lameness in overweight dogs with osteoarthritis. J Am Vet Med Assoc 2006;229(11): 1756–1760. 26. Impellizeri JA, Lau RE, Azzara I. Effect of weight reduction on clinical signs of lameness in dogs with hip osteoarthritis. J Am Vet Med Assoc 2000;216: 1089–1091. 27. National Institutes of Health. NIH Panel Issues Consensus Statement on Acupuncture 1997:www.acucouncil.org/ reports/nih_consensus.htm. 28. McCarthy G, O’Donovan J, Jones B et al. Randomised double-blind, positive-controlled trial to assess the efficacy of glucosamine/chondroitin sulfate for the treatment of dogs with osteoarthritis. Vet J 2006; Apr 27. 29. Hardie EM. Management of osteoarthritis in cats. Vet Clin North Am Small Anim Pract 1997;27(4):945–953. 30. Beale BS. Use of nutraceuticals and chondroprotectants in osteoarthritic dogs and cats. Vet Clin North Am Small Anim Pract 2004;34(1):271–289, viii. 31. Richy F, Bruyere O, Ethgen O et al. Structural and symptomatic efficacy of glucosamine and chondroitin in knee osteoarthritis: a comprehensive meta-analysis. Arch Intern Med 2003;163(13):1514–1522. 32. Towheed TE. Published meta-analyses of pharmacological therapies for osteoarthritis. Osteoarthritis Cartilage 2002;10(11):836–837. 33. Wander RC, Hall JA, Gradin JL et al. Ratio of dietary (n-6) to (n-3) fatty acids influences immune system function, eicosanoid metabolism, lipid peroxidation, and vitamin E status in aged dogs. J Nutr 1997;127:1198–1205. 34. Budsberg SC, Bartges JW. Nutrition and osteoarthritis in dogs—does it help? Vet Clin N America Small An Pract 2006;36(6):1307–1323. 35. Neill KM, Caron JP, Orth MW. Role of glucosamine and chondroitin sulfate in treatment for and prevention of osteoarthritis in animals. J Am Vet Med Assoc 2005; 226(7):1079–1088. 36. McNamara PS, Johnston SA, Todhunter RJ. Slow-acting, diseasemodifying osteoarthritic agents. Vet Clin North Am Small Anim Pract 1997;27:863–867. 37. Sevalla K, Todhunter RJ, Vernier-Singer M et al. Effect of polysulfated glycosaminoglycan metabolism in normal and osteoarthritic canine articular cartilage explants. Vet Surg 2000;29:407–414.

September/October 2007, Vol. 43 38. American Association of Human-Animal Bond Veterinarians. What is hospice or End-of-Life care? 2002: http://members.aol.com/guyh7/hospice.htm. 39. American Animal Hospital Association. Hospice Care- Ending Life With Compassion—AAHA Pet Care Library 40. World Health Organization. WHO Definition of Palliative Care. Accessed 2007:www.who.int/cancer/ palliative/definition/en/. 41. Wiseman-Orr ML, Nolan AM, Reid J et al. Development of a questionnaire to measure the effects of chronic pain on health-related quality of life in dogs. Am J Vet Res 2004;65(8):1077–1084. 42. Cornell University, College of Veterinary Medicine, Feline Health Center. Videos. 2007:www.felinevideos.vet. cornell.edu. 43. Wilson J. Legal Consents for Veterinary Practices. Yardley, PA: Priority Press Ltd, 2006. 44. Lifelearn. Client Handouts on CD, Small Animal Series. Newmarket, England: Lifelearn Ltd, 2004/2005. 45. Brock, N. Veterinary Anesthesia Update. 2nd ed. Lakewood, CO: AAHA Press, 2007. 46. American Animal Hospital Association. Pain Management. Client information brochure, Am Anim Hosp Assoc, 2005.

Resources for Assessing Pain Associated with Various Procedures and Conditions Hellyer, P. Objective, categoric methods for assessing pain and analgesia. In Gaynor JS, Muir WW, eds. Handbook of Veterinary Pain Management, St. Louis, Mo.: Mosby, 2002:82-107. Firth AM and Haldane SL. Development of a scale to evaluate postoperative pain in dogs. J Am Vet Med Assoc 1999;(214)651-59. Holton, L, Reid J, Scott EM, Pawson P, Nolan A. Development of a behaviour-based scale to measure acute pain in dogs. Vet Rec 2001 Apr 28;148(17):525-31. Holton, LL et al. Comparison of three methods used for assessment of pain in dogs. J Am Vet Med Assoc 1998; (212):61-66. Reid, J, Scott M, Nolan A. Development of a short form of the Glasgow Composite Measure Pain Scale (CMPS) as a measure of acute Pain in the Dog. Vet Anaesth Analg 2005;32(6):7.

AAHA and AAFP gratefully acknowledge the following for their sponsorship of an educational grant for the AAHA/AAFP Pain Management Guidelines for Dogs & Cats:

204 204 179

25. IS OLATION ROOMS A. Who goes in 1. 2. 3. 4.

Diarrhoea, depressed, anorexia Vomiting, depressed, anorexia Diarrhoea, vomiting, anorexia, depressed Diarrhoea with a lot of blood, depressed but still eating a little Note: all still sitting up and still alert

B. Protocol 1. First, test for Parvo:  If positive: Euthanasia  If negative: Treatment in Isolation Room 2. Treatment  IV fluids (must do) – glucose 5% alternate with Hartmann’s  Tribrissen IV  Kaofectin  Vitamins  Syringe feed 6 times/day  Pupp ies in isolation room must be checked at least every 2 hours  IV drip must be checked every 2 hours in day shift, and every 4 hours after midnight

205

26. Surgical scrub preparations 1ST PREP COTTONWOOL IN SCRUB BOWL

CHLORHEX SCRUB AND DISTILLED WATER (1:100) OR BETADINE SCRUB AND DISTILLED WATER (1:100) OR 4ML 5% POVIDONE IODINE SOLUTION 16ML DETERGENT 980ML DISTILLED WATER OR

1.6MLS 2% POVIDONE IODINE SOLUTION 16ML DETERGENT 982.4ML DISTILLED WATER 2ND PREP 500ML SPRAY BOTTLE 150ML DISTILLED WATER 375ML 70% ISOPROPYL ALCOHOL

SURGICAL SCRUB PREPARATIONS

(Note:Chlorhex Scrub mentioned here is Chlorhexidine gluconate 4% w/v (40 mg/mL) in a detergent base)

(Note: The Betadine Scrub mentioned here is a 10% povidone-iodine solution with detergent – if you are using a different concentration of povidone iodine please adjust dilution accordingly.)

(Note: this could be any detergent, such as dishwashing detergent)

(Note: Tincture of iodine (2% iodine) can be used except in cases where no alcohol is permitted – see below)

206

3RD PREP 500ML SPRAY BOTTLE 50ML CHLORHEX C 75ML DISTILLED WATER 375ML 70% ISOPROPYL ALCOHOL OR 4MLS OF 5% POVIDONE IODINE SOLUTION 200ML DISTILLED WATER 796ML 70% ISOPROPYL ALCOHOL

(Note: Chlorhex C contains Chlorhexidine gluconate 5% w/v (50 mg/mL)

(Note: 1 part Betadine mixed with 9 parts distilled water makes 1% solution) IF USING ON EYES OR MUCOUS MEMBRANE DO NOT ADD ALCOHOL BUT MAKE UP TO ONE LITRE VOLUME BY ADDING 980ML STERILE WATER

IF USING ON EYES OR MUCOUS MEMBRANE DO NOT ADD ALCOHOL BUT MAKE UP TO ONE LITRE VOLUME BY ADDING 996ML STERILE WATER

20MLS 1% BETADINE 196ML DISTILLED WATER 784ML 70% ISOPROPYL ALCOHOL

IF USING ON EYES OR MUCOUS MEMBRANE DO NOT ADD ALCOHOL BUT MAKE UP TO ONE LITRE VOLUME BY ADDING 980ML STERILE WATER

OR 1.6MLS 2% POVIDONE IODINE 200ML DISTILLED WATER 798.4MLS 70% ISOPROPYL ALCOHOL

207

27. PRE-MED DOSAGES (ml) Weight Kgs 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41

ACP 2mg/ml 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 0.2 0.22 0.24 0.26 0.28 0.3 0.32 0.34 0.36 0.38 0.4 0.42 0.44 0.46 0.48 0.5 0.52 0.54 0.56 0.58 0.6 0.62 0.64 0.66 0.68 0.7 0.72 0.74 0.76 0.78 0.8 0.82

Atropine 0.6mg/ml 0.07 0.11 0.15 0.18 0.22 0.26 0.29 0.33 0.37 0.4 0.44 0.48 0.51 0.55 0.59 0.62 0.66 0.7 0.73 0.77 0.81 0.84 0.88 0.92 0.95 0.99 1.03 1.06 1.1 1.14 1.17 1.21 1.25 1.28 1.32 1.36 1.39 1.43 1.47 1.5

AMA 0.13 0.2 0.27 0.33 0.4 0.47 0.53 0.6 0.67 0.73 0.8 0.87 0.93 1 1.07 1.13 1.2 1.27 1.33 1.4 1.47 1.53 1.6 1.67 1.73 1.8 1.87 1.93 2 2.07 2.13 2.2 2.27 2.33 2.4 2.47 2.53 2.6 2.67 2.73

0.84

1.54

2.8

Anamav 0.04 0.06 0.08 0.1 0.12 0.14 0.16 0.18 0.2 0.22 0.24 0.26 0.28 0.3 0.32 0.34 0.36 0.38 0.4 0.42 0.44 0.46 0.48 0.5 0.52 0.54 0.56 0.58 0.6 0.62 0.64 0.66 0.68 0.7 0.72 0.74 0.76 0.78 0.8 0.82

Butorphanol Tartrate 1mg/ml 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8 2 2.2 2.4 2.6 2.8 3 3.2 3.4 3.6 3.8 4 4.2 4.4 4.6 4.8 5 5.2 5.4 5.6 5.8 6 6.2 6.4 6.6 6.8 7 7.2 7.4 7.6 7.8 8 8.2

Temgesic 0.3mg/ml 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 1.05 1.1 1.15 1.2 1.25 1.3 1.35 1.4 1.45 1.5 1.55 1.6 1.65 1.7 1.75 1.8 1.85 1.9 1.95 2 2.05

Morphine 10mg/ml 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1 1.05 1.1 1.15 1.2 1.25 1.3 1.35 1.4 1.45 1.5 1.55 1.6 1.65 1.7 1.75 1.8 1.85 1.9 1.95 2 2.05

0.84

8.4

2.1

ACP dose = 0.04mg/kg (range 0.01mg/kg – 0.05mg/kg) Atropine dose = 0.022mg/kg (range 0.022-0.044mg/kg) AMA = (morphine 3ml (30mg/ml) + atropine 6.75ml + ACP 2.25ml) chart dose is equivalent to – 0.5mg/lg morphine-0.025mg/kg ACP – 0.023mg/kg Atropine. Anamav = chart dose of 0.2ml/10kg is equivalent to 0.04mg/kg ACP - 0.02mg/kg atropine Butorphanol Tartrate= 0.2mg/kg (range0.1 – 0.4mg/kg) 208 Temgesic= (buprenorphine) dose – 0.02mg/kg (range 0.01-0.03mg/kg)

28. Feline xylazine, ketamine, diazepam anaesthetic regime

CATS Xylazine, Ketamine, Diazepam Anaesthetic Regime PRINCIPLES: NICE CATS Premed:

Xylazine 20: 0.3 â&#x20AC;&#x201C; 0.5ml per 4 kg i.m. or s/c

Induction:

Ketamine (100mg/ml) 0.5ml and Diazepam (5 mg/ml) 0.5ml Dose : 1 ml per 10 kg IV

Top Ups:

Ketamine and Diazepam 1:1 mix Dose : give 0.1ml increments IV

*********************************

AGGRESS IVE CATS Premed & Induction: Mix equal volume of ketamine:xylazine 20 Give 1ml per 5 kg IM Top ups:

I.V. as above. (Ketamine/Diazepam)

IF CANNOT FIND VEIN AFTER PREMEDING WITH XYLAZINE: Give 0.5 ml per 5 kg IM Ketamine Top ups:

Try i.v. again, if still cannot locate vein gi ve Ketamine and Diazepam mix i.m.

209

0.5 0.75 1 1.25 1.5 1.75 2

0.4

0.3

0.2

0.35

0.3

0.25

0.2

Benzathine 0.6 million units Ivomec S/C madeup to 10ml Ivermectin vial 10mg/ml

0.5

0.4

0.6

0.45

Procaine Penicillin 0.4 million units made up to 10ml vial

0.7

0.5

0.02 0.03 0.05 0.06 0.075 0.09 0.1

Tolfedine 40mg/ml s/c

Meloxicam 5mg/ml

0.02 0.03 0.04 0.05 0.06 0.07 0.08

0.05 0.075 0.1 0.12 0.15 0.17 0.2

210

Zoletil 100 (mix 10mls sterile water for injection )into vial reconstituted gives 50mg/ml

0.8

29. DRUG DOSE FOR KITTENS < 4 MONTHS

Zoletil Zoletil 50mg/ml I/M 50mg/ml I/M Ml

0.1-0.2 0.15-0.3 0.2-0.4 0.26-0.5 0.3-0.6 0.35-0.7 0.4-0.8

0.05-0.1 0.08-0.2 0.1-0.2 0.15-0.25 0.18-0.3 0.2-0.32 0.2-0.35

Xylazine 20 S/C or I/M 0.05 0.07 0.1 0.12 0.14 0.15 0.2

Zoletil 50 (mix 5mls sterile water for injection)in vial Reconstituted gives 50mg/ml Contains 125mg of Zolazepam/125mg Tiletamine.

1 2 3 4 5 6

PREMED Xylazine 20 S/C or I/M Ml

0.1 0.2 0.3 0.4 0.5 0.6

0.4

Procaine Penicillin Zoletil 50mg/ml Zoletil 50mg/ml 0.4 million units made up to 10ml vial I/V I/M Ml Ml Ml

0.5

0.3

Benzathine 0.6 million units made up to 10ml vial Ml

30. DRUG DOSE FOR ADULT CATS

0.8

1 1.3

0.8 1.9

1.5

Ivomec S/C 10mg/ml Ivermectin Ml

0.05 0.1 0.15 0.2 0.25 0.3

Tolfedine 40mg/ml S/C Ml

0.1 0.2 0.3 0.4 0.5 0.6

Meloxicam 5mg/ml S/C Ml

0.04 0.08 0.12 0.16 0.2 0.24

211

Zoletil 100 (mix 10mls sterile water for injection )Reconstituted gives 50mg/ml

2.3

1.2

0.2-0.4 0.4-0.8 0.6-1.2 0.8-1.6 1.0-2.0 1.2-2.4

1.5

0.1-0.2 0.2-0.3 0.3-0.4 0.4-0.6 0.5-0.75 0.6-0.8

Zoletil 50 (mix 5 mls water for injection) in vial Reconstituted gives 50mg/ml Contains 125mg Zolazepam /125mg Tiletamine

31. Canine xylazine premed im and sc

XYLAZINE 20 PREMED I.M. OR S/C Weight Kg. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40

Xylazine (20mg/ml) ml 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 4

212

32. Canine xylazine, ketamine, diazepam anaesthetic regime DOGS

Xylazine, Ketamine, and Diazepam Anaesthetic Regime PRINCIPLE: Premed:

Xy lazine (20mg per ml)

Induction:

Diazepam (5 mg/ml) 0.5ml + Ketamine(100mg/ml) 0.5ml

1ml per 10-20kg IV

Diazepam + Ketamine (1:1)

0.1 â&#x20AC;&#x201C; 1ml increments IV

Top ups:

1ml per 10kg IM or SC

****************************************

AGGRESSIVE DOGS

Premed and Induction: Xy lazine + Ketamine (1:1)

Top ups

Diazepam + Ketamine

1ml per 10kg IM

(1:1)

0.1 - 1ml increments IV

213

33. Canine ketamine/diazepam IV induction Ketamine/Diazepam IV Induction Protocol 1:1 volume ratio Weight in kilograms (1 to 11 kg) (5 mg/kg Ketamine + 0.25 mg/kg Diazepam) Give to effect Total Weight Kg Ketamine 100 mg/ml Diazepam 5 mg/ml volume ml Total ml dose ml dose 1.00 1.25 1.50 1.75 2.00 2.25 2.50 2.75 3.00 3.25 3.50 3.75 4.00 4.25 4.50 4.75 5.00 5.25 5.50 5.75 6.00 6.25 6.50 6.75 7.00 7.25 7.50 7.75 8.00 8.25 8.50 8.75 9.00 9.25 9.50 9.75 10.00 10.25 10.50 10.75 11.00

0.050 0.063 0.075 0.088 0.100 0.113 0.125 0.138 0.150 0.163 0.175 0.188 0.200 0.213 0.225 0.238 0.250 0.263 0.275 0.288 0.300 0.313 0.325 0.338 0.350 0.363 0.375 0.388 0.400 0.413 0.425 0.438 0.450 0.463 0.475 0.488 0.500 0.513 0.525 0.538 0.550

0.100 0.125 0.150 0.175 0.200 0.225 0.250 0.275 0.300 0.325 0.350 0.375 0.400 0.425 0.450 0.475 0.500 0.525 0.550 0.575 0.600 0.625 0.650 0.675 0.700 0.725 0.750 0.775 0.800 0.825 0.850 0.875 0.900 0.925 0.950 0.975 1.000 1.025 1.050 1.075 1.100

214

Ketamine/Diazepam IV Induction Protocol: Dogs 1:1 volume ratio Weight in kilograms (12 to 50 kg) (5 mg/kg Ketamine + 0.25 mg/kg Diazepam) Give to effect Weight Ketamine 100 mg/ml Diazepam 5 Kg mg/ml 12.00 13.00 14.00 15.00 16.00 17.00 18.00 19.00 20.00 21.00 22.00 23.00 24.00 25.00 26.00 27.00 28.00 29.00 30.00 31.00 32.00 33.00 34.00 35.00 36.00 37.00 38.00 39.00 40.00 41.00 42.00 43.00 44.00 45.00 46.00 47.00 48.00 49.00 50.00

0.600 0.650 0.700 0.750 0.800 0.850 0.900 0.950 1.000 1.050 1.100 1.150 1.200 1.250 1.300 1.350 1.400 1.450 1.500 1.550 1.600 1.650 1.700 1.750 1.800 1.850 1.900 1.950 2.000 2.050 2.100 2.150 2.200 2.250 2.300 2.350 2.400 2.450 2.500

Total volume 1.200 1.300 1.400 1.500 1.600 1.700 1.800 1.900 2.000 2.100 2.200 2.300 2.400 2.500 2.600 2.700 2.800 2.900 3.000 3.100 3.200 3.300 3.400 3.500 3.600 3.700 3.800 3.900 4.000 4.100 4.200 4.300 4.400 4.500 4.600 4.700 4.800 4.900 5.000

215

kg 1 2 3 4 5 6 7 8 9 10

Premed

Xylazine 20 S/C or I/M

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1ml

Ml 0.4 0.8 1.2 1.3 1.9 2.3 2.7 3 3.4 3.8

Procaine Penicillin 0.4 million units made up to 10ml vial

Ml 0.3 0.5 0.8 0.9 1.3 1.5 1.8 2 2.3 2.6

Ml 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5

Ml 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

Benzathine 0.6 Ivomec S/C million units made up to 10 ivermectin10m Tolfedine ml vial g/ml 40mg/ml S/C

34. DRUG DOSE FOR PUPPIES< 4 MONTHS

Ml 0.2-0.4 0.4-0.8 0.6-1.2 0.8-1.6 1.0-2.0 1.2-2.4 1.4-2.8 1.6-3.2 1.8-3.6 2.0-4.0

Zoletil 50mg/ml Zoletil I/V 50mg/ml I/M

0.1-0.2 0.2-0.3 0.3-0.4 0.4-0.5 0.5-0.6 0.6-0.7 0.7-0.8 0.8-0.9 0.9-1.0 1.0-1.2

Meloxicam S/C 5mg/ml

Ml 0.04 0.08 0.12 0.16 0.2 0.24 0.28 0.32 0.36 0.4

216

Zoletil 50 (mix 5mls sterile water for injection) in vial.Reconstituted gives 50mg/ml. Contains 125mg of Zolazepam Zoletil 100 (mix 10mls sterile water for injection) in vial Reconstituted gives 50mg/ml 125mg of Tiletamine

kg 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29

PREMED Xylazine 20 S/C or I/M Ml

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9

35.

0.4 0.8 1.2 1.5 1.9 2.3 2.7 3 3.4 3.8 4.2 4.5 5 5.3 5.7 6 6.4 6.8 7.1 7.6 8 8.3 8.7 9 9.5 10 10.3 10.6 11

0.3 0.5 0.8 1 1.3 1.5 1.8 2 2.3 2.6 2.8 3 3.3 3.6 3.8 4 4.3 4.6 4.9 5.1 5.4 5.6 5.9 6.2 6.4 6.6 6.9 7.2 7.5

Procaine Penicillin 0.4 million units Benzathine 0.6 made up to 10ml million units made up to 10 ml vial vial

DRUG DOSE ADULT DOGS

0.2-0.4 0.4-0.8 0.6-1.2 0.8-1.6 1.0-2.0 1.2-2.4 1.4-2.8 1.6-3.2 1.8-3.6 2.0-4.0 2.2-4.4 2.4-4.8 2.6-5.2 2.8-5.6 3.0-6.0 3.2-6.4 3.4-6.8 3.6-7.2 3.8-7.6 4.0-8.0 4.2-8.4 4.4-8.8 4.6-9.2 4.8-9.6 5.0-10.0 5.2-10.4 5.4-10.8 5.6-11.2 5.8-11.6

Zoletil Zoletil 50mg/ml I/V 50mg/ml I/M

0.1-0.2 0.2-0.3 0.3-0.4 0.4-0.5 0.5-0.6 0.6-0.7 0.7-0.8 0.8-0.9 0.9-1.0 1.0-1.1 1.1-1.2 1.2-1.3 1.3-1.4 1.4-1.5 1.5-1.6 1.6-1.7 1.7-1.8 1.8-1.9 1.9-2.0 2.0-2.1 2.1-2.2 2.2-2.3 2.3-2.4 2.4-2.5 2.5-2.6 2.6-2.7 2.7-2.8 2.8-2.9 2.9-3.0

Zoletil 50 (mix 5mls sterile water for injection)in vial Reconsituted gives 50mg/ml Contains 125mg Zolazepam/125mg Tiletamine.

Ivomec S/C ivermectin 10mg/ml Ml

0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1ml 1.05 1.1 1.15 1.2 1.25 1.3 1.35 1.4 1.45

0.04 0.08 0.12 0.16 0.2 0.24 0.28 0.32 0.36 0.4 0.44 0.48 0.52 0.56 0.6 0.64 0.68 0.72 0.76 0.8 0.84 0.88 0.92 0.96 1 1.04 1.08 1.12 1.16

Tolfedine Meloxicam 40mg/ml S/C 5mg/ml S/C

0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1ml 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2ml 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9

Zoletil 100 ( mix 10mls sterile water for injection) in vial Reconstituted gives 50mg/ml 217

36.

kg 1kg 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Ivomec S/C ivermectin 10mg/ml 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5 0.55 0.6 0.65 0.7 0.75 0.8 0.85 0.9 0.95 1ml

Other treatments Procaine Penicillin 0.4 million units made up to 10ml vial 0.4 0.8 1.2 1.5 1.9 2.3 2.7 3 3.4 3.8 4.2 4.5 5 5.3 5.7 6 6.4 6.8 7.1 7.6

Benzathine 0.6 million units made up to 10ml vial Meloxicam 5mg/ml 0.3 0.04 0.5 0.08 0.8 0.12 1 0.16 1.3 0.2 1.5 0.24 1.8 0.28 2 0.32 2.3 0.36 2.6 0.4 2.8 0.44 3 0.48 3.3 0.52 3.6 0.56 3.8 0.6 4 0.64 4.3 0.68 4.6 0.72 4.9 0.76 5.1 0.8

Rabies Injection : Dogs â&#x20AC;&#x201C; 1ml s/c or i/m : Cats â&#x20AC;&#x201C; 1ml s/c

218

0.1-0.2 0.2-0.3 0.3-0.4 0.4-0.5 0.5-0.6 0.6-0.7 0.7-0.8 0.8-0.9 0.9-1.0 1.0-1.1 1.1-1.2 1.2-1.3 1.3-1.4 1.4-1.5 1.5-1.6 1.6-1.7 1.7-1.8 1.8-1.9 1.9-2.0 2.0-2.1

Zoletil 50 I/V 5mg/kg

0.2-0.4 0.4-0.8 0.6-1.2 0.8-1.6 1-2mls 1.2-2.4 1.4-2.8 1.6-3.2 1.8-3.6 2-4mls 2.2-4.4 2.4-4.8 2.6-5.2 2.8-5.6 3-6mls 3.2-6.4 3.4-6.8 3.6-7.2 3.8-7.6 4-8mls

Zoletil 50 I/M 10-25mg/kg

37. Zoletil 50

kg 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

219

38. Feline anaesthesia XYLAZINE PREMED I/M OR S/C Weight Kg Xylazine 20mg/ml 1 0.08 2 0.15 3 0.23 4 0.3 5 0.38 6 0.45 7 0.53 8 0.6 9 0.68 10 0.75

DIAZEPAM AND KETAMINE 1:1 INDUCTION Weight Kg Diazepam1 ml & Ketamine 1 ml mix 1 0.1 2 0.2 3 0.3 4 0.4 5 0.5 6 0.6 7 0.7 8 0.8 9 0.9 10 1

Top ups I.V.: Diazepam & Ketamine 1:1 mix, in 0.1ml increments ATTENTION Diazepam 5 mg/ml Ketamine 100 mg/ml

220

39. Canine anaesthesia

Canine Anaesthesia I/M premedication

Xylazine per ml)

Kg 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30

(20mg Atropine (0.6mg per ml) 0.1 0.02 0.2 0.04 0.3 0.06 0.4 0.08 0.5 0.1 0.6 0.12 0.7 0.14 0.8 0.16 0.9 0.18 1 0.2 1.1 0.22 1.2 0.24 1.3 0.26 1.4 0.28 1.5 0.3 1.6 0.32 1.7 0.34 1.8 0.36 1.9 0.38 2 0.4 2 0.42 2 0.44 2 0.46 2 0.48 2 0.5 2 0.52 2 0.54 2 0.56 2 0.58 2 0.6

Recommended maximum dose for Xylazine is 2ml.

I/V induction I/M induction Diazepam (5mg per ml) mixed with equal parts Ketamine (50mg per ml) - Ketamine Give to effect (15mg/kg) 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1 1.1 1.2 1.3 1.4 1.5 1.6 1.7 1.8 1.9 2 2.1 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 3

0.3 0.6 0.9 1.2 1.5 1.8 2.1 2.4 2.7 3 3.3 3.6 3.9 4.2 4.5 4.8 5.1 5.4 5.7 6 6.3 6.6 6.9 7.2 7.5 7.8 8.1 8.4 8.7 9

Ketamine stings when given i/m

221

40. IV FLUID CALCULATION 1. Maintenance – 3ml/kg/hour 2. Dehydration - (% dehydrated x 1000 x weight) 24 hours 3. Losses – 50 to 300 mls per day 24 hours For example a 5kg dog with 10% dehydration: 1. Maintenance = 5 x 3 = 15mls/hour 2. Dehydration = 10 x 1000 x 5 over 24 hours = 35mls/hour 3. Losses = 100ml over 24 hours = 4 mls/hour

Total required IV per hour is 15 + 35 + 4 = 54 mls/hour Dehydration: • Beware fat dogs have better skin turgor although dehydrated • Replace ¼ to ½ blood volume in 1-2 hours and remainder over 24 hours (1 blood volume = 8% x weight x 1000) • When hydration restored, reduce to maintenance rate (unless anorexic) • Be very careful with fluid rate; can kill if volume overload • Take special care and reduce rate if patient has concurrent:  Cardiovascular disease  Pulmonary Oedema  Head Trauma

222

FLUID RATES 1. Maintenance - 3 mls/kg/hour 2. Surgery rate - 10mls/kg/hour ( or if no IV pump – 1 drop per 2 seconds on a normal infusion set per 10kg dog.) 3. Hypovolaemic shock – a. Dog = 60 – 90 mls/hour for 1st hour using ISOTONIC SOLUTIONS ONLY b. Cat = 40 – 60 mls/hour i. replace 1 blood volume in 1st hour then reduce rate. 4. Acute Pancreatitis – As for Hypovolaemic shock – in 1st hour

TYPE OF FLUIDS CONDITION

FLUID TYPE

1 .Vomitting (gastric e.g. Pyloric obstruction : alkalotic)

0.9% NACL plus K supplement

2. Duodenal obstruction : acidotic

Hartmanns

3. Diarrhoea (acidotic)

Hartmanns

4. Renal Failure (acidotic)

0.9% NACL plus K supplement (can use Hartmanns after rehydration and if not hyperkalaemic)

5. Dehydration (acidotic)

Hartmanns

6. Pancreatitis (acidotic)

Hartmanns (0.9% NACL plus K supp. if alkalotic.)

7. Intestinal Obstruction Proximal to Duodenum (alkalotic)

NACL (K supp if vomitting)

8. Intestinal Obstruction Distal to Duodenum (acidotic)

Hartmanns

9. Septic Shock/Endotoxic Shock

Colloids Whole blood in cats

10. Blocked Bladder, Urethra and Addisonian Crisis and Renal Failure with Hyperkalaemia

NACL ONLY

223

SUPPLEMENTATION Potassium: Vomitting, inappetance, anorexia • • • •

Add 20 mEq in 1 litre of NACL Do not exceed 0.5 mEQ/kg/hour Do not add if Hyperkalaemic renal failure Mix well in bag before starting drip

Measure Urine Output Oliguria = < 1ml/kg/hour

224

41. Intravenous fluids chart Weight kg

Maintenance 3mls/Kg/Hr

10% Dehydration Maintenance + Loss(10%)

Surgical Rate 10mls/Kg/Hr

0.5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 24 26 28 30 32

1.5 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 66 72 78 84 90 96

3.5 7 14 21 28 35 42 50 57 64 72 79 86 93 100 107 115 122 129 136 143 158 172 186 200 215 229

5 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 160 170 180 190 200 220 240 260 280 300 320

225

42.

Emergency Drug Doses

Drug

Dosage

Action

Dopram

3ml/10kg

Respiratory stimulant

Pamlin (Diazepam)

1ml/5kg

Anti-seizure

Phenobarbitone

0.25ml/10kg over 5 mins. Repeat after 30mins

Anti-seizure

Atropine

1ml/10kg IV

Cardiac stimulant

Adrenaline (Epinephrine)

1ml/10kg IV (Dilute 1 vial in 9ml saline)

Shock Rate Fluids

Dog: 90ml/kg/hr Cat: 60ml/kg/hr

Hypotensive Shock

Crystalloids 10-20ml IV Bolus Colloids 5-10ml IV Bolus

Cerebral Oedema

Colloids 5- 10ml IV Bolus

Cardiac stimulant

226

43. Anaesthetic Record Date: ………………………………………… Client: ……………………………………….. Patient: ………………………………………. Age: ………………………………………….. Weight: ………………………………………

Procedure: ……………………………………… Vet: ……………………………………….. Pre-Anaesthetic Examination HR (heart rate):…………. RR (respiration rate):……………… MM /CRT (mucous membrane/capillary refill time):……………….. Temp:……………..Vulva/testis:………… Pre-M edication:………………….. Induction:……………………… ET Tube: Yes/no

Size:

Fluid Therapy: Yes/no

Type:………..

Time:……………… Time:………………

Rate:………….ml

Surgery start time:………………… Finish:…………………. Time

MM/CRT

Temp

Eye position

Medication

227

44. Surgery Consent Form Date: Client

Patient

Address

Breed

Home phone

Colour

Work phone

Sex

Mobile phone

Age

Preferred contact person

Weight

Surgical Procedure General anaesthesia for _____________________________________________________________ ________________________________________________________________________________ Intravenous fluids help to maintain blood pressure and perfusion to important organs and will aid in a quicker anaesthetic recovery. It is recommended in all animals but is essential for older animals and lengthy procedures. Would you like your pet to receive intravenous fluids? Yes/No $ Time of admission:_____________ Belongings admitted with pet:

Cage □

Collar □

Leash □

Has your pet fasted for 8 hours?

Yes/No

Has y our pet toileted this morning?

Urinated/Defecated

Does y our pet have any known health problems?

Yes/No

Other □..............

If yes, please state:............................................................................................................... Is y our pet currently taking any medications?

Yes/No

If yes, M edication:............................................ Last dose given: _ _/_ _/_ _ at __:__ am/pm Have you brought the medication with y our pet for the duration of hospitalisation? Does y our pet have Health Insurance?

Yes/No

Has y our pet had a pre-anaesthetic blood test?

Yes/No

Additional procedures □M icrochipping □Vaccination □Heartworm test □Proheart Injection □Intestinal worming □Dew claw removal □Deciduous teeth extraction

Yes/No

□Umbilical Hernia □Dental scale and polish □Ear cleaning □Ear cytology □Ear check □Nail trim □Express anal glands

228

I, the undersigned, as the owner/agent for the owner, and over 18 years of age, authorise the ________ Clinic to administer general anaesthesia and perform the above procedure(s). 1. I understand that the Veterinarian will choose an appropriate anaesthetic regime. 2. I understand there are inherent risks associated with any anaesthetic and surgical procedure and understand that adverse circumstances may develop despite intensive monitoring. Adverse reactions are a rarity but may include unexplained death. 3. I accept the risks and release the __________ Clinic and attending Veterinarians from any liability . 4. I authorise the Veterinary Surgeon to p erform any emergency treatment procedures required, and understand additional prescribed fees may be incurred. 5. I understand that where additional procedures need to be undertaken to ensure the best care of my pet, that the clinic will endeavour to contact me first; but if unable to do so then additional costs may be incurred. 6. I understand that the estimation for the above procedures is not a definite quotation and I am responsible for providing full payment on discharge.

Estimate:$.............. to ............. I _________________ hereby agree to the above terms and give consent for the _________ Clinic to provide the above services. Signed:______________________

Date:_____________

Witness:_____________________

Signed:_________________

Date:__________

229

45.

Convalescent Care

Your pet has undergone a general anaesthetic. Procedures performed were. 1) Keep patient. warm and dry 2) On the night after the operation, offer a small amount of food (approximately ½ of usual meal) as patient. may feel nauseous after their anaesthetic. Do not give any bones the night after procedure, otherwise there are no dietary restrictions, unless otherwise advised. Water should be freely available. App etite should be back to normal in 1 – 3 days. 3) No games or exercises for about days. Keep confined either inside the house or in a small sheltered yard. Dogs should be given a short leash walk outside to do toileting, 3 – 6 times per day. Remember to accompany the dog for toileting during the first 24 hrs, as he/she maybe a little unsteady after the anaesthetic. 4) Any bandages must be kept clean and dry at all times. 5) Examine the surgical site twice daily, but do not bathe the wound unless instructed to do so. Check for swelling, bleeding, oozing and that the stitches are intact. 6) Excessive activity or licking may cause swelling and redness of the wound. M inor swelling and inflammation usually settle down after 5 – 7 days However please contact us IMMEDIATELY if a) There is persistent licking b) There is a large amount of swelling c) The stitches/drain tubes are stretched or torn out.

Should you be uncertain or concerned about recovery from this op eration, please make a revisit appointment for examination of the patients' wound.

The advised date for Drain / Skin Stitch / removal is

25/10/2005

Additional Information .................................................................................................................................................... ................................................................................................................................................................ ................................................................................................................................................................

230

Processing Fluidity

Set-Up

Safe secure table

Bedding provided

Warmth

Weighed

TPR's

Cleanliness Temperature

Physcial Assessment

Through traffic

Ambience

Date: Assessor:

Organisation

Caged condition

Time of arrival:

Other Comments

Noise Level Other Comments

Secure

46a. Progress reporting form: Assessment of trainee husbandry - clinic, pre-op, post-op Clinic Name: Husbandry

Kennel Cattery Other Treatment area Recovery Consult rooms Autoclave â&#x20AC;&#x201C; Type Theatre 1 Theatre 2 Theatre 3

Pre-op

Admission Pre-med stage Post-op Recovery Ward Notes

231

Handling for Preparation of surgical table induction ET tubing & securing

Preparation, Handling and Monitoring

Transporting from ward

Handling for positioning

Clipping: size, position and technique

Surgical area scrub

Aseptic technique

Anaesthetic Monitoring

TPRs & interpretation

After Care

46b. Progress reporting forms: Assessment of trainee husbandry - prep, handling, monitoring Surgery

Date: Patient 1 Person responsible: Assessment rating: 1 (poor) to 5 (exceptional) Name: Comment:

Patient 2 Person responsible: Assessment rating: 1 (poor) to 5 (exceptional) Name: Comment:

Body temp. & correction

232

47. Euthanasia Algorithm for Companion Animals

Euthanasia Algorithm for Companion Animals Designed for companion animal veterinarians and animal shelters International Fund for Animal Welfare, China 2009

233

= Yes

= No

= Uncertain

Go to Questions 2 & 3.

Consider euthanasia, particularly if the disease is likely to be dangerous, e.g., rabies

Do you have the resources necessary to contain and treat the disease?

Does the animal have a medical condition that poses a threat to other animals or people?

Question 1: Does the animal have a medical condition that is causing it to suffer?

Does the illness pose a threat to other animals or people?

Does the condition have a poor prognosis?

Consider euthanasia.

Isolate the animal(s) and provide medical treatment. Is the situation improving?

Do you have the resources necessary to continue treatment, ensure safety of animals & people, and ensure welfare of the sick animals?

Continue treatment & management. Reevaluate safety and animal welfare status as the disease condition changes or as resources change.

Treat the condition. Re-evaluate the situation daily and as resources or the animalâ&#x20AC;&#x2122;s condition change.

Do you have the resources necessary to alleviate the suffering and to treat the condition appropriately?

Will the suffering be brief and will the animal have a good quality of life following recovery?

Consider euthanasia. Treat the condition and make the animal as comfortable as possible. Re-evaluate the situation daily and as resources or the animalâ&#x20AC;&#x2122;s condition change.

234

International Fund for Animal Welfare â&#x20AC;&#x201C; China 2009 Principle author: Dr. K. Loeffler

= Yes

= No Question 2: Does the animal have a behavioral problem?

Carefully evaluate the animal for a medical condition that may result in what appears to be a behavioral problem, e.g., inappropriate urination or sudden aggression. Does the animal have a behavioral problem that can be explained by a medical condition and that can be alleviated by treatment of a medical condition?

Ensure that Question 1 has been answered. Proceed to Question 3.

Treat medical condition and re-evaluate.

 Work with owner to manage behavioral problem, - OR  Re-home animal to an owner who can manage the behavioral issue.

 Is the problem likely to result in the animal being abandoned or abused by the owner? --AND/OR- Does the problem result in poor physical or psychological welfare of the animal (e.g., chronic anxiety, self-mutilation)? --AND/OR- Does the behavior pose a threat to other animals, people (e.g., aggression) or the environment?

Is the owner willing and able to learn to manage the animal to reduce the risks above? -- OR --

Proceed to Question 3.

Do you have the resources to safely rescue the animal and to safely and effectively manage the behavioral problem?

Rescue animal, eliminate source of behavior problem, train/desensitize animal. Does the problem persist?

Monitor animal with original owner, or re-home to people able to manage animal appropriately.

235

International Fund for Animal Welfare – China 2009 Principle author: Dr. K. Loeffler

= Yes

= No

Consider euthanasia

Treat any medical conditions. Provide training & necessary additional resources to the owner. Re-evaluate the situation regularly until you are satisfied that the owner will properly care for the animal.

Evaluate animal according to Medical and Behavioral considerations (Questions 1 & 2).

Question 3: Does the animal live under conditions that compromise physical and/or psychological health?

Consider euthanasia

Evaluate the animal according to the Medical and Behavioral algorithms. Is there a medical or behavioral reason to euthanize the animal?

Is there a possibility that the owner will improve the care of the animal if s/he is taught how to do so and if provided with additional resources if needed, and do you have the resources to provide this support?

Did the animalâ&#x20AC;&#x2122;s condition improve?

Is the animal fully rehabilitated?

Is the animal suffering?

Rescue, rehabilitate and re-evaluate the condition of the animal and its prognosis. Consider Medical and Behavioral algorithms.

Do you have the resources to rescue and rehabilitate the animal, and to re-home it following recovery?

Consider euthanasia.

Re-home.

236

International Fund for Animal Welfare â&#x20AC;&#x201C; China 2009 Principle author: Dr. K. Loeffler

Notes for guidance on use of Euthanasia Algorithm Designed for companion animal veterinarians and animal shelters International Fund for Animal Welfare, China 2009 Principle author: Dr. Kati Loeffler IFAW works from the concept of Adequate Guardianship, which requires that an animal‟s basic needs are being met. The algorithm is based on this concept and its criteria, and provides a simplified structure to help local veterinarians and dog/cat shelter staff to think through a decision about euthanasia as objectively as possible. The notes below are meant only to help clarify some of the terminology in the algorithm, and to provide real-life examples to illustrate implementation of euthanasia criteria and the algorithm. Algorithm 1: Euthanasia due to medical condition  Does the animal have a medical condition that is causing it to suffer? An animal is suffering if it is in pain or if it is so ill that it is depressed, does not eat, does not move or respond to people, vocalizes due to pain or discomfort, has wounds that will not heal, etc. 

Prognosis refers to the ability of the animal to recover from its illness or injuries and to live without undue suffering. For example, a dog or cat may have a crushed leg that needs to be amputated. If the missing limb will be the animal‟s only problem, then it is capable of living a very happy life and has a good prognosis. On the other hand, an animal with cancer that cause constant pain and that cannot resolve has a poor prognosis.



Resources & skills for management of a medical condition include: 1) staff competence in knowledge and skills in diagnosing, treating and managing the condition 2) staff availability, e.g., skilled staff who are competent to work with the animal 24 hours a day if necessary 3) finances 4) facilities, e.g., drugs, diagnostics such as radiography and laboratory analyses, cages or isolation areas that ensure the comfort and safety of the animal and staff, proper surgical areas and instruments



Quality of life following recovery or partial recovery. Consider physical pain and discomfort and emotional distress. In example (3) below, the dog has to live in a cage and was isolated almost all day. This is not an acceptable living condition for a dog.



How long should the animal suffer in the hope that it will recover? This depends on the degree of suffering, how well you are able to decrease the suffering, how long the suffering will continue, and the prognosis for the animal‟s future. Consider the following examples. 1) A dog has a broken leg and small wounds on the face and flanks. The leg is very painful but the other injuries are minor and heal quickly once they are cleaned and treated. You have the facilities and surgical skills to repair the bone, the owner is willing to pay for it, and you can give the dog medication against pain. In this case, the suffering that the dog endures is acceptable because: a. the injury has a good prognosis (a full recovery can be expected)

Notes on Euthanasia Algorithm – IFAW-China 2009

Page 1 237

b. you have the resources to manage the problem c. the period during which the dog is in pain will be relatively brief and can be alleviated with drugs d. the owner is willing and able to properly care for the dog during its recovery Make sure to find out why the dog‟s leg was broken. Did the owner beat her? Does the owner let her run loose on the street and she was hit by a car? In this case, further injuries are likely to occur. This is now a case of Medical Condition + Failure of Guardianship (Question 3). 2) A Dachshund is paralyzed in the hind legs due to a prolapsed (or partially prolapsed) disc. He is five years old and overweight. He can only walk by dragging his hind legs across the floor. His attitude is bright, he eats well, and his personality and energy level seem to be normal. He is able to control micturation and defecation. a. Do you have the skills to evaluate the degree of the injury, e.g., radiography and neurologic diagnostic skills? If so, you can determine the severity of the condition and determine a prognosis. If not, you have to treat the condition symptomatically. b. You start the dog on pain medication, instruct the owner how to take care of the dog and how to help the dog lose weight. c. A week later: i. the dog is no better, but it is no worse either. It does not appear to be in pain: attitude and appetite are still good and he drags himself around the house with good energy. The owner seems to be taking good care of the dog. Continue treatment. – OR – ii. the dog is panting, in pain and has not been able to control defection. The prognosis now is much poorer than it was initially. If the owner is taking good care of the dog and wants to keep trying, you can try stronger pain medication and suggest surgery if there is a reliable veterinary neurosurgeon available. If the owner is frustrated and there is no option of surgery, consider euthanasia. d. In the case of (c. i.), recheck the dog every 3 or 4 days. If the attitude is still good and the dog is not developing sores on the dragging limbs and the owner is taking good care of the dog, then you can keep trying. e. If the dog appears to be in pain or the dog develops frequent secondary problems such as urinary tract infections and sores on the dragging body parts, and there is no sign of recovery, then the dog‟s quality of life is decreasing and you should consider euthanasia. f. The owner gets tired of taking care of the dog and begins to neglect him. The dog is in pain and neglected. Consider euthanasia. Note: this is a case of Medical Condition + Failure of Guardianship. g. The dog loses control of micturation and defecation. It lives in a cage because the owner doesn‟t want the whole house soiled. The tail is permanently soiled with faeces. The owner takes the dog to a local vet who amputates the tail. The wound heals poorly because it is always dirty. The dog‟s attitude is bright and he is very happy to see the owner. But he spends 23.5 hours a day in the cage, alone. In this case, you can teach the owner how to provide enrichment for the dog so that he is not so lonely and bored. But the prognosis for the case is poor, and the dog‟s quality of Notes on Euthanasia Algorithm – IFAW-China 2009

Page 2 238

life is not good because of his isolated living condition. Consider euthanasia. 3) Five year old cat with mammary cancer. a. You do not have experience in cancer surgery and you do not have drugs for proper control of pain. There is no one in the town who has better skills or facilities than you do. In this case, consider euthanasia. b. You have learned how to remove this type of tumor from surgical text books. You have the drugs for proper anaesthesia and pain medication following the surgery. The owner is willing to pay for it and will take care of the cat carefully following surgery. In this case, it is worth a try, but keep in mind that the prognosis for the condition may be only a few months. c. The cat recovers from surgery and appears to be healing well. Six weeks later, she has stopped eating and spends a lot of time lying in a corner, isolating herself. She is now in pain and is suffering. You can try to control the pain with medication, but prepare the owner that this will help only for a short time. Consider euthanasia. 4) Dog that survived distemper, but is now paralyzed in the hind legs, twitches constantly, and is very thin. The dog eats well, is alert and responds to people. It cannot walk, however, and is developing decubital ulcers. The owner is willing to feed it carefully and clean up the urine and faeces, but cannot manage the ulcers. The quality of life for this dog is poor, and the prognosis for recovery of good quality of life is poor. Consider euthanasia. 5) Two-year old golden retriever dog with hip dysplasia. a. Dog is limping and doesn‟t want to go on walks. Pain medication improves the condition but the dog‟s liver does not tolerate the medicine. You try a different medication, but the dog doesn‟t tolerate this either. Consider euthanasia. b. Pain medication helps and the dog‟s liver appears to tolerate it. The owner does a good job in walking the dog twice a day to keep the hip muscles strong. Continue medication and controlled exercise until the dog appears to be in more pain. When that happens, re-evaluate the options and make a new decision. c. Pain medication helps and the dog‟s liver appears to tolerate it. But the owner does not walk the dog enough and often forgets to give the dog his medicine. The dog is in pain and lonely. Options: a) encourage the owner to do a better job of taking care of the dog; b) find a new home for the dog with a better owner; c) euthanasia. Note: this is a case of Medical Condition + Failure of Guardianship. 6) Six year old dog with chronic, itchy skin disease. a. The dog scratches constantly, its skin is raw and infected. You have tried a variety of medications but nothing has helped. The owner is frustrated, quality of life for the dog is poor, prognosis is poor: consider euthanasia. b. You have tried several diets to discover if the dog is suffering from a food allergy. This is hard to do because of the lack of hypoallergenic diets available locally. The owner cooks special food for the dog, but the diet is Notes on Euthanasia Algorithm – IFAW-China 2009

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imbalanced. The dog‟s skin improves a little bit, but it still receives antibiotics and steroids and now it is malnourished, thin and constantly hungry. Quality of life is poor, prognosis is poor: consider euthanasia. 7) Nine year old cat with kidney failure. The cat is very thin, vomits daily and is depressed from constant nausea and feeling ill. The owner has to bring the cat to the veterinary clinic every other day for treatment. This causes great stress to the cat and costs the owner considerable time and money. The cat seems to feel better for a few hours, but by the next day is depressed and nauseated again. In this case, the quality of life and prognosis for the cat are poor, and euthanasia should be considered. Algorithm 2: Euthanasia due to behavioral problem  A behavioral problem is a behavior that causes the owner to be frustrated with the animal. Some people are very tolerant, others are less tolerant, so a “problem” behavior in one household may not be a problem in another household.  The frustration of the owner may result in the owner abandoning or abusing the animal. In this case, the issue is Behavior Problem (Question 2) and Failure of Guardianship (Question 3).  Quality of life is an important consideration for management of behavioral problems. If a dog is locked in a cage 23.5 hours a day because he might destroy something in the house, the quality of life for the dog is poor, and the situation needs to be changed. A cat tied to a wall all day so that she does not run away does not have an acceptable quality of life. A dog who wears a muzzle all day so that he doesn‟t bark does not have an acceptable quality of life. An aggressive dog who is chained to the wall 24 hours a day and is choked half to death when a visitor comes does not have a good quality of life.  Resources for managing a behavioral problem essentially means a person with sufficient expertise in animal behavior management and positive reinforcement training to teach pet owners how to manage their animals‟ behavior issues in a humane and effective manner. This may be difficult to find locally. The owner must be patient and committed to solving the problem, and will have to try to find training resources on his or her own, e.g., obtaining foreign expertise through books or advice from qualified people.  Training in behavior management (together with Responsible Pet Ownership) is one of the most valuable educational resources that animal shelters and other animal welfare organizations can provide in China. Example 1. Adult dog begins to urinate all over the house. 1. Examine the animal for medical conditions that may cause it to urinate inappropriately, e.g., urinary tract infection or a condition that causes incontinence. 2. You can‟t find a medical cause for the problem, so you work with the owners to try to figure out what might have changed in the dog‟s environment that is causing it to behave this way. Is it in season? Did another animal join the household so that the dog now feels the need to mark its territory? Did a person join or leave the household? The owners are patient and work with the dog to re-train it, using positive reinforcement techniques. In this case, the prognosis is good: keep working on it. 3. You can‟t figure out a medical cause for the problem and the owners are frustrated and beat the dog. The dog cowers and lives in constant fear, which makes it urinate in Notes on Euthanasia Algorithm – IFAW-China 2009

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the house even more. The owners don‟t want to deal with the dog anymore. Now we have a Behavior Problem + Failure of Guardianship (Question 3). You have the option of a) rescuing the animal, retraining and re-homing it, or b) euthanasia. Example 2. Young dog with separation anxiety who chews up everything it can reach in the house when the owner leaves the house. The owner has been shutting the dog in a box, where it lives all day while the work, crying and distressing the neighbors. 1. Owner is willing to spend time to help the dog but doesn‟t know what to do. In this case, help the owner to understand separation anxiety and teach the owner how to train the dog to overcome the problem. This will require patience and skill in training techniques. 2. Owner is willing to spend time to help the dog but doesn‟t know what to do and there is no one who knows how to teach the behavioral management to help the dog overcome the problem. The dog is living in a box, is isolated, quality of life poor, and the anxiety becomes worse because of the isolation it suffers. The neighbors complain and the owner is in danger of being forced to abandon the dog. You can try to provide something better than a box for the dog to live in and see if the owner or another member of the household can stay home more with the dog. Alternatively, seek options to re-home the dog. Only if these options fail, consider euthanasia. 3. Owner is frustrated, beats the dog, which makes the dog even more anxious and distressed. Now we have a Behavior Problem + Failure of Guardianship (Question 3). You have the option of a) rescuing the animal and re-homing it to someone who is able and willing to care for the dog properly, or b) euthanasia. Algorithm 3: Euthanasia due to Failure of Guardianship  Adequate Guardianship is defined as the resources (e.g. food, water, shelter and health care) and social interactions necessary to meet an individual animal‟s physiological and psychological needs necessary to maintain an acceptable level of health and well-being.  In order to ensure proper guardianship of an animal guardianship, the following criteria must be met: 1. Appropriate food & water to keep animal in good health 2. Housing conditions to protect animal from weather, provide clean, soft sleeping area, provide area for animal to move about and express normal behavior 3. Behavioral management a. Appropriate social environment, e.g., human family & other animals b. Sufficient exercise c. Training to prevent or manage behavioral problems, using only positive reinforcement methods. d. A misbehaved dog indicates that something is missing in the care of the animal or in its environment, or that it has a medical condition that is causing it to behave abnormally. Efforts should be made to determine what these deficits are and to correct them in a humane manner. 4. Never abuse an animal physically or psychologically. Beating or otherwise hurting an animal, isolation, malnutrition and thirst, causing fear and anxiety, punishing an animal for something it does not understand was wrong, all are counterproductive and constitute abuse. Notes on Euthanasia Algorithm – IFAW-China 2009

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5. Maintain the health of the animals a. Prevention of disease: vaccination, deworming, proper nutrition, exercise, behavioral management b. Seek proper veterinary care if animal is ill c. In many cases, it is advisable to neuter pets in order to prevent unwanted puppies & kittens, prevent or manage behavioral problems, and decrease incidence of certain medical conditions. 

Resources for rescue, rehabilitation and re-homing include: 1) Temporary home for the animal – shelter or volunteer guardian 2) Expertise, time and money to treat medical conditions properly 3) Expertise, time and money to manage behavioral issues properly 4) Personnel, time and money to re-home the animal and to monitor the animal in its new home to ensure adequate guardianship there.



Criteria for an appropriate guardian with whom to re-home an animal include: 1) Ability to ensure the 5 criteria listed above.

2) 3) 4) 5)

De-sexing (spay/neuter) the animal is strongly advised Understanding of „responsible pet ownership‟ Will not use the animal for fighting/food/experimentation Relinquishment of the animal back to the shelter if Adequate Guardianship cannot be provided 6) Permanent identification of the animal (in addition to a microchip), ie collar and tag 7) Abide by local laws/regulations/ordinances, eg registration and licensing 8) Must not have a criminal record of animal or human abuse 

“Re-evaluate the situation regularly until you are satisfied that the owner will properly care for the animal.” Re-evaluation should be done twice a week for 2 weeks, then once a week, then monthly until you feel that the situation is under control. If there is any indication that the owner is unable to maintain acceptable conditions of animal welfare, then re-evaluate the situation though the left side of the algorithm, assuming that the animal will need to be rescued and re-homed.

Example 1. A dog lives permanently tied to a wall on a short chain. It must sleep and defecate in the same area and is not taken for daily walks. For shelter it has a broken piece of wood leaning against the wall. Sometimes it has water to drink, but usually this is dirty. Once a day it receives rice gruel and sometimes left-over scraps from the owner‟s meals. The animal is thin, dirty and covered with ticks. Once a year she becomes pregnant (while tied to the wall) and raises her puppies while remaining tied up and without additional water and food to sustain her lactation. This is clearly a case of inadequate guardianship. This animal must either be rescued or the owners must be taught – and then monitored – to take proper care of the dog. Example 2. A dog is kept by the security guards of a factory to help guard the area. The dog runs loose and is not vaccinated. The guards feed it occasionally (not daily) from scraps left over from their own meals. The dog lives primarily on what it can find to eat in the streets. It has a strong cough, is very thin, and sleeps in the garbage litter next to the factory gate. When it meets one of the guards, it cowers in fear, and the guards are often seen to kick it. Notes on Euthanasia Algorithm – IFAW-China 2009

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This is a case of inadequate guardianship and the animal must be rescued. A communally “owned” dog like this is often neglected because no one takes the responsibility to properly care for it. Consider also role of this dog in 1) risk & spread of disease; 2) population control Example 3. A cat is kept tied to the wall by its neck all day. It is fed rice gruel once a day. This is a case of inadequate guardianship. This animal must either be rescued or the owners must be taught – and then monitored – to take proper care of the cat. Example 4. A cat begins to urinate on the owner‟s bed. The owner takes the cat to the veterinarian who cannot find anything medically wrong with the cat. The cat continues the behavior and the owner gets so frustrated that it begins to throw the cat across the room. This is a case of Behavior Problem + Failure of Guardianship. In this case, the owner needs help in identifying the cause of the cat‟s behavior, and then in managing the problem. If he or she is unwilling to do this, the cat must be rescued.

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48. Internet Use for Veterinarians: Useful Links: (All of these links are free with the exception of VIN) Veterinary Information Network (VIN.com) www.vin.com Veterinary Partner (Client Handouts / Forms) www.VeterinaryPartner.com International Vet Information Service (IVIS ) www.ivis.org Bayer Accelerate Veterinarian / Vet Nurse Continuing Education Service (CE Credits) www.BayerAccelerate.com.au 5 Minute Vet consult https://www.vetconnect.com.au/5min/toc/000.htm Veterinary anaesthesia and analgesia support group www.vasg.org Google S cholar (Journal / Publication Search) Scholar.Google.com Merck Veterinary Manual (Free Complete Comprehensive Veterinary Textbook) http://www.merckvetmanual.com/mvm/index.jsp University of Auburn (US A) VetMed Board Exam Review Documents (S pecies Reviews) http://www.vetmed.auburn.edu/index.pl/review_material Case Studies in S mall Animal Cardiovascular Medicine (Cases / ECG / Echo Atlas) http://vmth.ucdavis.edu/cardio/cases/ Animal Insides – General Radiology (Technique Chart / Sedation / Positioning) http://www.animalinsides.com/index.php/Table/General-Radiology-Tutorials/ DVM Insight – Online Radiology Searchable Image Library www.dvminsight.com AS PCA – Animal Poison Control Centre (Poisons Information) www.aspca.org/apcc Colorado S tate University – Poisonous Plants Guide http://southcampus.colostate.edu/poisonous_plants/index.cfm?countno=NO US National Library of Medicine - ToxNet Toxicology Data Network http://toxnet.nlm.nih.gov/ Aqua Vet Medicine & Disease Diagnostic Laboratories http://www.aquavetmed.info/

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World Chelonian Trust Handbook (Turtles / Tortoises) http://www.chelonia.org/ DVM 360 â&#x20AC;&#x201C; Veterinary News & Medical Updates (Daily) http://www.advanstarvhc.com/avhc/ Canine Epilepsy Centre (UK) (Client / Vet Info / Handouts) http://www.canineepilepsy.co.uk/owners/Owners_epi_sites.htm VEIN Website http://vein.library.usy d.edu.au Candidates can use the library catalogue from VEIN to update their reading lists and browse relevant high quality web sites Animal Health Australia www.animalhealthaustralia.com.au Go to the AUSVETPLAN manuals link where you can download articles and summaries of a wide selection of diseases and disease strategy. These contain excellent descriptions of the diseases. You can also op en The"Publications" link to find the annual reports which provide an overview on regulatory, trade and production diseases of livestock Diseases acquired from animals www.avbc.asn.au/documents/GradHndbk2-6-08.pdf The Glass Horse http://www.3dglasshorse.com/ It illustrates the major anatomical features of the abdominal cavity and demonstrates commonly occurring gastrointestinal tract lesions. The ACVC website www.acvs.org It has information on colic for horse owners in the animal owners section under health conditions S ome parasitology websites www.wormboss.com.au www.vein.library.usyd.edu.au/links/parasitology.htm Food hygiene and large animals www.mla.com.au www.wool.com.au Respiratory Sounds http://www.cvmbs.colostate.edu/clinsci/callan/breath_sounds.htm These are human: http://www.wilkes.med.ucla.edu/lungintro.htm http://www.emsvillage.com/learning_center/breath_sounds/index.cfm

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