10.2015
Part 1: Introduction and Outline
page 2
Part 2: Surgery notes
page 6
Part 3: Nursing/Anaesthesia
page 10
notes
page 14
Part 4: Hospital Standards
page 18
Part 5: Patient Care Standards
page 19
Part 6: Assessment Forms 6A: Trainee assessment sheets 6B: Trainer flank spay records
Part 1: INTRODUCTION AND OUTLINE This manual provides guidelines and a structure for trainers certified by VBB to deliver comprehensive training sessions to other vets. Each training session should be a minimum of 3 days so that the trainee can understand and practise the theoretical and practical elements at your clinic or at a more formal training session. Before the training starts, each of the trainees should be provided with a trainee reference manual that provides more details, charts, etc to help them after they have finished the training. The trainer should also use it during the training to guide the trainee to relevant parts of the reference manual. In this document we have mentioned the specific points where these references can be mentioned. Assessment sheets have been provided (see Part 6A). These should be used for each participant, and you will need to update these regularly during the training. These sheets will help you determine if your trainee has learnt everything in your session, and can also help you when you are mentoring them after the session is over. Trainees also have a copy of these assessment sheets in their manual so that they can monitor their own work - TRM 46. As a trainer, you have certain obligations, which are outlined below. We welcome feedback on this manual to make it easier for you to train new vets.
OBLIGATIONS OF CHINESE VBB VET TRAINERS 1. Agree to give 5 days per annum to participate as a trainer (accompanied by a trained assistant) for the VBB-ACTAsia programme. This may involve training within their city or outside. Trainers are requested to organize their training sessions and coordinate with ACTAsia. 2. Agree to mentor the trainees that they trained the year before for a minimum of 1 year. The method of mentoring is as outlined below in points 6, 7 and 8. 3. Trainers must fully train their own assistants for the work of patient handling, aseptic techniques and anaesthetic monitoring to the standards set by the Training. A fully trained Vet Assistant must always accompany the Trainer when Training a New group of Trainees
4. Continue the flank spay technique in clinic on stray cats and dogs where appropriate (ie excludes fat, pregnant and large dogs or pregnant cats). There should be a minimum of 4 desexing surgeries (spay or castration) performed on stray animal on a monthly basis The surgeon must comply with the minimum standards set out in the Training 5. The trainer vet surgeon and anaesthetist must impart their new skills and knowledge to the other staff in their clinic. All the staff at the Trainers hospital must adhere to the minimum standards set by the Training. 6. The trainer's clinic must adhere to the standards in the following areas as outlined in the training guidelines and as taught in the practical sessions: A) B) C) D)
Patient examination pre-operation Correct animal handling technique Preparation and sterilisation of kits Adequate drugs used - including approved general anaesthetics, pain relief and long acting antibiotics and insecticide treatment E) Surgical scrub solutions prepared correctly and used on the patient in the correct manner F) Correct surgeon scrubbing technique 3
G) H) I) J) K) L)
Appropriate head cover, gown and masks Correct technique of gowning and gloving Anaesthetic monitoring Anaesthetic recording Patient post-operative care Hospital standards
7. The trainer must report to their VBB mentor (the trainer who trained them) at least every 2 months by email or by phone regarding their progress in the clinic in the above areas. Trainers with language difficulties should try to get translations using their own resources, but in cases of exceptional importance they may seek ACTAsia's assistance. Each trainer will mentor 2 trainees. The Trainer and the assistant must read the MANUAL at least annually to update on the procedures and protocols. 8. The trainer can contact the VBB trainer any time by email, phone or directly to ask for assistance or guidance over the next 12 months after the initial training by VBB. 9. The trainer must report and ask for guidance if they have any difficulties or have any queries. 10. The mentoring will expire 12 months from the initial training date. However, it is up to the trainer/mentor if he/she is willing to extend the mentorship. 11. The trainer shall report to ACTAsia and VBB after 6 months and again after 12 months: The number of spays (flank or midline) performed on stray animals Record the condition of the animal when it came in The number of successes and the number of complications (including deaths) The type of anaesthetic used and other drugs used on each animal (including rabies vaccinations)
The recovery rate Where the animals ended up eg foster carer, released (Note: Progress recording forms have been provided - Part 6B) Trainers should also report the following: total numbers of customers to clinic whose animals receive treatment and how many of these were from NGOs numbers of known Rabies cases in their area (animal) how many of their trainees didn't use proper GA before training how many of their trainees didn't use pain relief before training how many of their trainees didn't do a full spay before training 12. The trainers shall be reassessed by the VBB trainers the following year. 13. The trainer will receive the benefits of extra training free of charge every year from General and Specialist Australian and AmericanVets, in all aspects of feline and canine medicine and surgery, which will be beneficial to their own practice and business 14. The Trainer shall help identify potential good Trainers from the Vet trainees, based on the trainees keenness to learn, skills and knowledge and report to Act Asia
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TRAINING PROCESS NOTES Theory session The first step in a training session is to cover the basic theory so that the trainee understands why sterilisation is important, and why a vet is responsible not just for treatment, but also the welfare of the animals under his/her care. As it is unlikely that you, the trainer, will be able to do a complete theory day for your trainees, we suggest that you ask them to study the presentations (Trainee Reference Manual - called TRM foir the rest of this document - 2, 3, 9, 16, 21, 22) and background study material (TRM 4, 6, 7, 10, 11, 13, 17, 18,19, 23, 24, 26, 47, 48) before they start the workshop. You can then have a two or three hour session with them to answer their questions and test their knowledge of the subject matter. Ultimately the aim of all continuing education is to teach sound Principles to all Vets and these principles enable Vets to apply high standards of practice in their clinic and in their treatment of all animals, including strays and owned animals From 2016 onwards VBB and ACTAsia are introducing 4 levels of Vet Trainers for the program: o Advanced Trainers are those who continually improve their standards and go above and beyond the basic guidelines and obligations set out by VBB. o Trainers are the VBB trainers who fulfil all the criteria set out in the VBB guidelines and whose assistants all hold the same standards. o Trial Trainers are the vets who have received basic training from VBB but have not yet been certified as trainers. o Potential Trainers are vets who have received no training from VBB but who exhibit interest for knowledge and a potential for professional development.
Unless the trainer does a workshop for a few vets, it is likely that there will be only one trainee with his/her assistant at a time. The diagram below shows you how to go through material so that you can cover everything.
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Note: Training must always be performed in pairs. The Trainers and Trainees must have
a fully trained Assistant Vet each. The Assistant Vet role is critical especially in the area of Patient monitoring during anaesthesia, as well as pre and post operative care
Essential Procedures • Vaccination, injectable medications (antibiotics, analgesics), ear clipping
•
Essential Procedures Vaccination, injectable medications (antibiotics, analgesics), ear clipping
Step 1 - Q&A session on presentations Step2 - non-surgical demonstrations by trainer (include hospital and patient care standards with tour through trainer's clinic) Step 3 - surgical demonstration by trainer with assistant Step 4 - trainees do operation with trainer monitoring Step 6 - trainees do anaesthesia/monitoring with trainer monitoring Step 7 - trainer takes trainees through post-operative care steps, and monitors trainee's care of the animal until release 6
Concurrent TRAINING of Trainers assistant VET assistants training summary (Pre, During and Post surgery) 1. 2. 3. 4. 5. 6.
Preparation of surgical instruments, drugs, operating room, anaesthetic records) Animal handling Skills Pre surgery comfort and care (bedding, water, toileting) Handling patient for examination and for IV drip placement Anaesthetic monitoring- Refer to Notes on Patient MONITORING in manual Post anaesthesia comfort and care
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Part 2: SURGERY NOTES Minimum Standards: Guidelines for Surgery Check Minimum equipment: 1. Autoclave or pressure cooker with flat bricks or Pressure cooker with a separate dryer to dry kits 2. Surgical drape (with key hole or 4 drapes) - sizes must be appropriate 3. Kits- minimum-2 drape clamps, 2 carmalts, 1 appropriately sized spay hook, 2 artery forceps. 1 rat toothed forceps and needle driver, cutting needle and round needle, absorbable sutures e.g. catgut ( appropriate sizes- e.g. 0 for large dog, 2-0 for medium dog 3-0 for cat and puppy) scalpel blade 4. Autoclave indicator strip and autoclave tape 5. Hand towels for drying hands 6. Scrubbing brushes for hands - double draped for autoclaving 7. Scrub solution for hands 8. Disinfectants for patient - see recipes for Chlorhexidine or Betadine (TRM 26) 9. Clipper blades- sharp and disinfected 10. Vacuum or small broom to remove fur 11. ET tubes of sizes 3- 4 for cats (cuff less for cats if possible)sizes 3 -10 for dogs, and string for tying 12. Cap and masks for anaesthetist/assistant for surgeon 13. Cap, masks, sterile gowns and sterile gloves 14. Enough drapes for double wrapping of surgical drapes , hand towels, scrub brushes 15. Surgery kits and gowns for autoclaving
Minimum Drugs Note: drug dosage charts for cats and dogs are available - TRM 27-39
Suitable Premeds: • • • • •
Acepromazine Xylazine Domitor Diazepam Butorphanol or other sedatives approved in manual
Suitable general anaesthetic: Must provide surgical anaesthesia - ie totally unconscious, muscle relaxation and pain relief see TRM 17. One of the following combinations should be used for acceptable surgical anaesthesia: • Xylazine/Zoletil • Xylazine/Ketamine • Xylazine/isoflurane gas • Thiopentone/isoflurane gas • Alfaxan/isoflurane gas • Propofol/isoflurane gas
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Minimum Recording Admission form and Anaesthetic monitoring chart use is mandatory (TRM 43 and 44} Demonstrate usage.
Minimum Pain Relief Use one of the following pain relief drugs by injection: • • • •
Meloxicam Tolfedine Carprofen Butorphanol
Other Peri-Operative Injections Long acting Antibiotics By Injection: • Cefovecin • Duplocillin LA or similar (procaine penicillin G and benzathine penicillin G - see TRM 36 for proportions to create LA penicillin) •
Clavulox
Other injections: • Rabies vaccine ( for dogs) • Ivermectin injection if possible for internal and external parasites
Demonstrations > > > > >
Procedure for surgical scrubbing of hands (TRM 11 p.68) Procedure for drying hands (TRM 11 p.69) Procedure for gowning and gloving (TRM 11 p.71) Principles for operating room - minimal personnel, minimal movement (TRM 3 p.2) Surgical techniques: • Knot tying- square knot ( use shoe laces) • Ovariohysterectomy procedures using the model uterus (TRM 4, 5. Appendix 1) • Demonstrate location of incision (TRM 3 p.14) • Demonstrate gentle handling and minimise tissue trauma • Demonstrate 3-clamp technique using 2 clamps • Demonstrate inspection of knot prior to release • Demonstrate stitching - selection of sutures, amount of tension to be applied and principles • Application of super glue • Tattooing or ear notching technique
Fluids chart Have dose rate charts displayed (TRM 40 and 41) 9
Selection of ET tubes and procedure for placement and inspection, and cleaning To be available and on display.
Juvenile desexing protocols (TRM 7 and 8) Make sure all trainees read this protocol Key areas Defined as any kitten or puppy patient under 800 gms of bodyweight or less than 4 months old They must not be fasted- about a 1/3 rd of the normal food to be fed about 2 hours before surgery commences Food must be given as soon as possible after recovery Pay attention to ensure the patient does not develop hypothermia Warm IV Fluids must be given
Emergencies Resuscitation procedure (TRM 20 and 42) these p^ro'tocols must be kno^~n be;fo^e surgery commences Minimum Drugs: AdrenalineDopram (Doxapram) or Ambi bag ET tubes IV catheters
Handling & Exam (surgeons and anaesthetist) • • • • •
Have everything prepared before getting patient from ward e.g. gloves, premed, scales, stethoscope, towels, thermometer. Ensure door is shut before opening cage. Keep noise to a minimum. Assess patient for ease of handling and temperament before opening cage. Ensure handler has towel ready and gloves on. 10
• • • • •
If patients permits, do a clinical examination. Heart rate, respiration rate, temperature. It is important to have a pre-anaesthetic heart rate so you know what is normal for this patient. Once weighed and pre-medication given, place cats and dogs back into cage covered with towel. Do not disturb unless necessary, but continue to monitor. Note time, TPR (temperature, pulse and respiration), weight and drug doses given - enter onto anaesthetic chart. Continue to keep noise to a minimum whilst final surgery preparation is performed.
Handling for anaesthetic • When patient is placed on the table ready for induction of anaesthetic, it must not be left alone; although sedated it could fall off the table • Assistant restrains patient whilst surgeon places catheter, gives induction anaesthetic, and starts on i/v fluids • ET tube is to be inserted, make sure cuff is down and if patient is a cat that the larynx has been sprayed with local anaesthetic, then tie in correctly and inflate cuff • Check by cotton wool technique or by a gentle chest compression to hear air expelling • Anaesthetic monitoring commences immediately • Check respiratory rate, body temperature, heart rate, mucous membrane colour and capillary return, eye position, etc. • This should continue throughout surgery, noting every 5 minutes, making adjustments to anaesthetic in conjunction to any fluctuations in TPR's • Also note any top ups of anaesthetics etc. • All small patients must have a heating pad. Ensure there is a thick towel on top of the heating pad to avoid burns. Check that the heating pad does not over heat, by placing hands under the patient, regularly. Do not rely on the thermostat. Remember burns do happen and can be extremely serious. • Assistant must watch the patient not the surgery • Lay patient on left side down for flank spay • Clip surgical site remembering landmarks, do not overclip, the least amount of passes the clippers make on the same area of skin, the less likely the chance of clipper rash • Vacuum, prepare surgical site for surgery • Keep monitoring patient •
* Attention : do not over inflate ET tube cuffs- Too much air can lead to Pneumothorax (use very small syringes for cats- eg 1-2 mls)
Surgery • • • •
When the surgeon is ready to commence make sure they check anaesthetic depth Trainer to demonstrate the first surgery, then supervise remaining surgeries Communicate with anaesthetist during surgery be aware of top ups and pain that may be inflicted during this time. Check that all injections and procedures have been completed by anaesthetist
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Post Operative Care • • • • • •
Once surgery has finished, continue to monitor patient, it is ultimately the surgeon's responsibility that his/her patient recovers well. Ensure correct hospital record stays with patient All patients must lie on a warm soft bed (blanket/towel) and place a towel as a blanket on top and kept in warm and quiet room Do not leave a hot water bottle under a patient unless there is a thick blanket between the patient and the hot water bottle, as an unconscious patient cannot move away from the heat , and could suffer 3rd degree burns As soon as possible - instruct carer when to give water, feed and release Have post operative care instructions for carers (TRM 45)
Although these items are predominantly the responsibility of the anaesthetist/assistant, the Surgeon should always be aware of his/her patient's progress.
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Part 3: Nursing/Anaesthesia notes Assess Autoclaving Procedures and Standards • • •
Implement use of pressure cooker and brick if there is no autoclave available (TRM 11 p.6365) Alternatively, kits can be pressure cooked and placed in a separate dryer Instruct on correct preparation of kits and drapes (TRM 11 p. 55-58 and TRM 3 p. 8) Ensure adequate quantity of drapes available for surgeries to be performed and that the drapes are of a suitable quality i.e., if held up to light, no light passes through them.
Assess Surgical Area (TRM 3 p. 2) Ensure adequate room for trainees attending, allowing room for surgeon to move around unencumbered 乂 Remove anything not essential to surgery (minimise hiding places for pathogens) 乂 Scrub up area suitable (TRM 3 p.5) and scrub solutions prepared (TRM 26) 人 Surgical table prepared (TRM 3 p. 12) 乂 No through traffic 乂 Secure - doors and windows can be closed, but allowing adequate ventilation. 乂 Adequate lighting and ventilation 人 Free from contamination 乂 Adequate rubbish disposal available including sharps disposal. 乂
Discuss Order Of Day Trainer to discuss with all present the order of surgeries to be performed, who will be performing the surgery and who their assistant will be. Once this is established ensure all equipment is available for these surgeries, specifically check: • Drugs - Emergency (TRM 42) Anaesthetics, pain relief, antibiotics, vaccinations reversing agents. • Equipment: ID equipment, syringes, needles, scalpel blades, instruments, scrubs, monitoring equipment, IV fluids, giving set and extension set ready and flushed through, catheters, emergency equipment etc.
Take Trainees to Hospital Wards to Ensure Pre-op and Post-op Areas are Ready and Adequate for the Day’s Requirements. (TRM 3 p. 40 & 41, TRM 11 p.2,3,4 &5) • •
Check that the wards are secure and that the thoroughfare from the ward to the surgery is secured. The patients must be in a cage or on a lead during transportation from ward to theatre.
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Discuss with Trainees the General Health and History of the Patients •
Have each animal's hospital information and anaesthetic sheet on hand for reference and to add any information (TRM 43, 44). Take this opportunity to go through the emergency procedures (TRM 20) • Has the patient been fasted? How long? • How old is the patient? Is it a geriatric or juvenile? Does it have special fasting or surgery requirements? (TRM 7 and 8) • Is it of adequate weight? • Is it healthy enough to perform surgery on? • Is the patient pregnant or in season?
Animal Handling Procedure • • • • • •
• • • •
Show the trainees how to correctly handle the patient (TRM 11, pages.9-18. TRM 14, 15 ) Trainer to assist person retrieving patient from hospital ward and show how to safely and gently remove animals from cages and how to securely transport to theatre (in cage if cat, on lead if dog), remembering to read the animal's mood signals and transport accordingly. Use a crush cage if necessary - always consider the safety of your trainees (if they get bitten or scratched whilst under your watch you are responsible). If patient permits, do a clinical examination - heart rate, respiration rate and temperature It is important to have a pre-anaesthetic heart rate so you know what is normal for the patient. Show the trainees how to handle the patient for its premed. Show how to transfer the patient from a carry cage to a crush cage. Alternatively an aggressive cat can be brought into the clinic in a pillow case, whereby the sedatives can be injected through the soft cloth Aggressive dogs should be muzzled When premed given make sure it is put in a quiet place (but not too far away as it requires monitoring). Cover the cage so as not to disturb the patient. If the patient is a cat make sure the cage is not sitting on the floor. Note the time that the TPR, weight, drug and dose were given on patient's anaesthetic record. Continue to keep noise to a minimum.
First Surgery > It is a requirement that the trainer performs the first surgery, while the trainee observes. > The trainee performs the next surgery with the trainer assisting and supervising
Checking Theatre before Commencement of Surgery > > > > > > > >
Show the trainees how to do pre-surgical checks of the surgery area. Show that kits and drapes are in position and that the autoclave tape has changed colour. Make sure all the surgeon's needs are catered for - mask, hat, gown, gloves. Double check that all drugs required are in position and that emergency drugs are at hand. Check that all present have hats and masks on - remember no hat, no mask, no entry. Make sure there are stethoscopes, thermometers, towels and gloves available. Check that a range of ET tubes are available for the size you may require Have string ready to tie tubes in place. 14
> > > >
Have catheter ready. Have bandaging ready to hold catheter and line in place If patient hasn't already been weighed have some scales on hand Check clippers are working and that there is a vacuum cleaner ready.
Induction and Fluids • Check area is secure - doors and windows closed before removing patient from cage(sometimes they are not as sedated as they first appear!). Keep noise to a minimum. • Remove patient from cage when sedation has become effective. • Place patient on prepared surgical table (check padding and warmth are suitable) • Do not EVER leave patient unattended on the table even under anaesthetic as they can revivequickly and may fall off the table. • If you didn't get the opportunity to do a clinical exam before the premed do one now. • Place catheter in vein • Induce with chosen anaesthetic agent • Place endotracheal tube into position (if the patient is a cat, spray larynx with local anaesthetic lightly before tubing waiting a couple of minutes for this to take effect) • Always double check the sex before clipping, and take advantage of this time to do an abdominal palpation. • Flush anaesthetic agent through. • Check TPR's • Attach purged drip line and run at surgical rate (TRM 40 and 41) (Ensure trainees understand the principles and importance of correct fluid rates. Overdose of fluids can kill a patient)
Patient Surgical Preparation • • • • • • • •
For the first surgery the Trainer will show the trainees how to proceed. Place the patient in the correct position for a flank spay.(TRM 3 p.14) Outline the area that you are going to prepare and explain why. When clipping tell the trainees about clipper rash and how to avoid it and the reason for clipping the site and the size of the clip. Show the trainees how to do a three stage surgical site preparation scrub.(TRM 11 p.72) Whilst preparing the surgery site you will need to attend to the surgeon at the same time. Helping with their gowning process. (TRM 11 p.66-71) Show the trainees how to aseptically open sterile packets and drapes as you are going along.(TRM 11 p.73) Before the surgeon proceeds with the surgery check the patient is in an adequate plane of anaesthesia (TRM 19 p.5-7)
Anaesthetic Monitoring • •
Trainer to demonstrate correct monitoring procedure (this includes interpretation of any changes of variables) on the first surgery, then supervise nurse/assistant during the remaining surgeries and assist as required. (TRM 18, TRM 19 p. 1-3) 5-minute TPRs are to be entered on the patient's anaesthetic record (TRM 43) - this does not mean that the patient is only checked every 5 minutes, the patient must be constantly monitored for respiration, heart rate and anaesthetic plane. The nurse/assistant must pay full attention to the monitoring process and not the surgery, and evaluate all aspects of the 15
anaesthetic.
Peri-operative Injections and Requirements • • • • •
Ensure pain relief is given early in the surgery as this will minimise the amount of anaesthetic required (the patient must first be given fluids). All medications administered must be recorded on the patient's anaesthetic record along with the dose rate and time given. Show the trainee how to tattoo/notch the animal's ear/s as required by governing body (TRM 6) . When top ups are required, make sure fluids are turned back down to correct rate (TRM 41)once the drug is flushed through, and record on anaesthetic sheet. During surgery ensure everybody present maintains asepsis (TRM 12)
After Surgery • • • • • • •
Assistant to continue monitoring the patient when the surgeon has finished surgery. Prepare to remove the ET tube - deflate cuff and untie when the patient is showing signs of strong jaw tone. They may cough initially but do not remove the tube until the patient swallows. (TRM 19, pages 5-7) If a cat should go into laryngeal spasm on removing the tube, be prepared to spray the larynx with a small amount of the local anaesthetic that was used before the cat was entubated. Proceed to monitor closely. Monitor the patient closely for the first 5 minutes after surgery, do not put straight into postoperative ward. Remove i.v. line and thermometer if kept in situ during surgery. Clean surgical site, removing as much antiseptic as possible (with sterile water), being careful not to wet incision or cool the patient down too much. Record surgery finishing time and check that all intra surgical medications and procedures have been entered onto anaesthetic sheet.
Post Operative Care • •
• • • • • • • • •
Once patient is showing signs of consciousness take them to the post-op ward. Ensure ward is warm and if patient's body temperature is low place a warming apparatus in the cage with the patient (hot water bottles, or heating pads - make sure they are padded so that the animal does not get burnt, this is a very important point to reiterate to the trainees) Patient must have a blanket or towel to lie on. Cover patient with blanket or towel. Cover cage with blanket or towel to minimise stimulation from outside sources Nominate somebody to continue observations until the patient is in sternal recumbency Hospital record must be on patient's cage One animal per cage As soon as the patient is able, instruct the carer to give water and food (the patient must be ambulant and steady before releasing, a general rule would be a minimum of six hours before release) If the recovery is slow notify the surgeon who may give a reversing agent. Prepare a convalescent care sheet to give to the carer (TRM 45) 16
•
Remember to check the patient at regular intervals to make sure their recovery is going well.
Preparing for the next Surgery • • • • • • • •
The theatre is to be cleaned for the next operation. Clean and scrub instruments Kits and drapes must be double wrapped before sterilisation Sterilisation date and contents to be recorded on outside tape Store in a dry cupboard for up to 3 months Re-set theatre with all requirements. Complete a thorough check of the surgical area before bringing out the next patient to make sure the patient spends as little time as possible in theatre. An organised surgery makes for a faster and more efficient surgery and anaesthetic.
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Part 4: HOSPITAL STANDARDS Minimum equipment The equipment below is the minimum that must be available for surgery 1. Autoclave or pressure cooker with flat bricks 2. Surgical drape (with key hole or 4 drapes) - sizes must be appropriate to the surgery being performed 3. Kits- minimum - 2 x drape clamps, 2 x carmalts, 1x appropriate sized spay hook, 2 x artery forceps, 1x rat toothed forceps, 1x needle driver, cutting needles and round needles of various sizes, absorbable sutures e.g. catgut ( appropriate sizes- e.g. 0for large dog, 2-0for medium dog, 3-0for cat and puppy), 1x scalpel blade. 4. Autoclave indicator strip and autoclave tape 5. Hand towels for drying hands 6. Scrubbing brushes for hands - double draped for autoclaving 7. Scrub solution for hands 8. 3 x disinfectantsfor patient- see recipesfor Chlorhexidine or Iodine (TRM 26) 9. Clipper blades - sharp and disinfected 10. Vacuum or small broom to remove fur 11. ET tubes - sizes 3-4for cats, sizes 3-10for dogs - and string for tying 12. Cap and masks for anaesthetist and assistant for surgeon 13. Cap, masks, sterile gowns and sterile gloves 14. Enough drapes for doublewrapping of surgical drapes , hand towels, scrub brushes 15. Surgery kits and gowns for autoclaving
Hospital infrastructure requirements Wards • • • • • •
• • • • • •
Secure holding/waiting area for patients being brought into the clinic. Clean and tidy, free from odours, quiet, comfortable temperature for patients. If possible, separate waiting area and hospital ward for cats and dogs. Ward areas to be clean, secure, uncluttered, ventilated, no odour, bedding provided for all patients, water and food supplied. Segregate animals from their neighbours, if walls are not solid then line with newspaper or towels. Cat cages to be elevated off the floor, preferably 1 meter, but at least 50cm. There must be adequate space in cage for the dog or cat to be comfortable - room for a bed and bowls, enough room to stand and turn around. If the patient is a cat, the cage should have room for a litter tray. No animal should be on wire floors or bare floors. All patients must have a towel, newspaper or blanket to sit on (cats and dogs) Rabbits must not be on wire flooring One animal per cage unless litter mates. Litter trays to be kept free of urine and faeces Dog cages to be cleaned regularly. Faeces - Clean inside cages and pens thoroughly Washing machine must have hot water for washing towels and bedding material
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Theatre (TRM 13) • • •
Free from clutter, dust, blood, or debris. The theatre is not to be used as a ward or storage room Regularly cleaned
Drugs and Equipment Suitable Premeds: • • • • •
Acepromazine Xylazine Butorphanol Domitor
•
Diazepam
•
Anaesthetics
• • • • • • • •
Minimum anaesthetics for all animals: Xylazine/Zoletil Domitor/Zoletil Xylazine/Ketamine Xylazine/isoflurane gas Thiopentone/isoflurane gas Alfaxan/isoflurane gas Propofol/isoflurane gas
Antibiotics •
Cefovecin
•
Duplocillin LA or similar (procaine penicillin G and benzathine penicillin G )
•
CLavulox
•
Minimum pain relief :
• • • •
Meloxicam Tolfedine Carprofen Butorphanol
Procedures Must follow VBB training guidelines and VBB's essentials to surgery 19
• •
No body bandaging - if the patients are spayed according to Protocol, there is no reason to bandage them. It is unnecessary to tie the animal down if the correct anaesthetics are used in the correct manner - they are only used for positioning
Suture Material • •
Skin sutures - Only use absorbable suture material for internal suturing (silk and cotton must NOT be used internally for any animal). Non-absorbable suture material on skin is fine for owned pets
Radiology safety • •
X-ray gowns, gloves and thyroid protectors to be used and stored hanging, not folded. (This damages the lead lining which allows entry for radiation.) Hands and other human body parts are to be kept away from the x-ray beam (even if wearing gloves).
Autoclave/Pressure Cooker > If no autoclave is available, use pressure cooker with brick placed in bottom. Once contents have gone through the correct sterilisation time and pressure, release lid but leave cooker on, slightly ajar, for approximately one hour. Then check if contents are dry - if not, check again in half hour. You can only use dry kits for an aseptic surgery. > Indicator strips and Autoclave tape must be used > Double wrap all sterilised equipment. > Adequate area for preparing surgical kits and equipment.
Scrubbing up > Appropriate scrubbing up area, large enough to lay out gowns, caps, masks, gloves and to put on this equipment without breaking asepsis. > Surgical gowns, gloves, hats and masks to be used for surgery - must always be available for use. > NO DIPPING BUCKETS - these are not to be used, correct scrubbing technique should be used both for the surgeon and the animal. Dipping pails are obsolete and unacceptable, and poses a huge risk of developing a resistant soup of bacteria.
Staffing • • •
Staff ratios are to be adequate for the work load. If there are not enough staff the animals cannot be properly cared for. Staff must be adequately trained
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Records • •
Records are kept up to date for animals in hospital, including admission forms and anaesthetic charts and convalescent care sheets Anaesthetic charts are to include all peri-operative injections and procedures
Sharps Disposal •
Adequate safe sharps disposal. A minimum standard is a plastic drink bottle.
Fluid treatment • Must be able to calculate accurate drip rates for maintenance, surgery, dehydration and shock • Follow IV drip rate chart (TRM 40 and 41)
Isolation Ward Clinic needs an area where infectious animals can be treated and hospitalised. Leaving an infectious animal in with the general hospitalised population is negligent and inhumane. Ensure the Isolation Ward Protocols below are followed.
Isolation Ward Protocols (TRM 25) Who goes in: • 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 人 Suspect parvovirus, distemper - if tested positive should be euthanised 人 Euthanasia should be performed if patient not improving after 2 days of intensive treatment 人 You must not let patients die slowly 人 It is not acceptablefor patients to be left without eating and not improving after 2-3 days another veterinary is needed
Care Whilst in Isolation Ward: • • •
Syringe feed 6 times per day Puppies and kittens in isolation room must be checked at least every hour I.V. drips must be checked every 2 hours during day shift and every 4 hours during the night
Entering, Exiting and Equipment for Isolation Ward: 1. 2. 3. 4. 5. 6. 7. 8.
Put on gown and gloves before examination and treatment Step in foot bath (disinfectant to be changed twice daily) Examine and treat Throw all gloves in the rubbish after examination of patient Wash hands with chlorhexidine or Iodine scrub or soap and then an alcohol based disinfectant rub Put on gloves before you touch another patient All rubbish are bagged and thrown out This room has its own bin, bowls, mop (and bucket) and sponge 21
9. All food and water bowls to soak in bleach for 10 min. after washing then rinsed 10. Gown soaked in bleach for 1 hour before washing and drying in dryer or sun Cleaning Isolation Ward: • • • •
Pick up all faeces with “pooper scooper” or newspaper, throw all soiled material including any to^wels into rubbish bin for burning Clean all surfaces with soap and water using mop and sponge to remove ALL organic matter Use only designated mop/sponge for that room Disinfection: spray all surfaces with bleach at a dilution of 250 ml bleach to 5 litres of water, do not rinse, allow to air dry
Note Bleach is inactivated by all organic matter (food, faeces, urine, blood and soil) All areas must be cleaned thoroughly before apply bleach. Quaternary Ammonium compounds are inactivated by Woven cotton, gauze material and soap Use only mops that are unwoven cotton. Do not mix with soap – Sop is an anion, Quatenary ammonium compound cleaners are cations - will neutralize each other
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Part 5: PATIENT CARE STANDARDS Patient Care Standards • • • • • • • • •
•
Individual care and attention to be shown to all animals staying in the hospital. Appropriate bedding, warmth, food, water and cleanliness to be supplied All patients must have comfortable bedding to lie on - even if it is newspaper or a small towel Keep animals in a warm, secure and quiet area during recovery Patients are to stay in hospital for as little time as possible. (But long enough to assess that they can be released safely) Cats and dogs are not to be body bandaged Stray animals can be released within 48 hours if there are no complications ( i.e. alert, eating, no fever, flank spay stitches look good) Owned pets can be sent home the same day with convalescent care information (TRM 45) Pay attention to PRE, DURING AND POST operative care (see protocols TRM 11, 13) 1. Anaesthetic monitoring, 2. Temperature (methods to keep warm) 3. Correct fluid rates 4. Ensure good recovery 5. Ensure drinking and eating 6. Toileting needs taken care of- litter tray for cats. Newspaper for dogs or walked outside 7. Keeping cages clean at all times Juvenile desexing protocol followed (TRM 7)
Animal Handling • • • • • • • •
All staff trained to handle dogs and cats safely Safety paramount to staff and animals When handling cats, have welding gloves and large towel ready Gentle handling and restraint Assess methods of holding patients for injections, IV drip and for taking blood Do not hold or pick up animals by their legs Do not handle cats in front of dogs Do not leave animals unattended when on the table or if not in a cage
Euthanasia (TRM 47) • • • •
The most humane way to euthanise an animal is with an overdose of barbiturates, if available All animals must be sedated heavily before potassium chloride is administered (A heavy dose of 846 anaesthetic is acceptable as a heavy sedative before euthanasia) Humane handling and restraint are also necessary for humane euthanasia
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Part 6: ASSESSMENT FORMS 6A: Trainee assessment sheets: Trainers to use these forms to assess the trainees during surgical training and assess the trainees clinics. äš‚ These forms will be used as part of the selection criteria for trainees to be recommended to become certified VBB/ACTAsia trainers. äš‚
Form 1: Husbandry Date:
Time of arrival:
Assessor: Husbandry Bedding provided
Cleanliness
Temperature
Ambience
Organisation
Secure
Other Comments
Noise Level
Other Comments
Kennel Cattery Other Safe secure table Treatment area Recovery Consult rooms Autoclave - Type
Theatre 1
Set-Up
Through traffic
Theatre 2
Theatre 3
Pre~op Processing Fluidity
Weighed
TPRs
Physical Assessment
Admission Pre-med stage
Post-op Warmth
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Caged condition
Form 2: Surgery preparation, handling and monitoring Transporting from
Date: Patient 1
ward
Preparation of
Handling
surgical table
for induction
Clipping: size, ET tubing & securing
Handling positioning
for
position and technique
Person responsible: Assessment rating: 1 (poor) to 5 (exceptional) Name: Comment:
Patient 2 Person responsible: Assessment rating: 1 (poor) to 5 (exceptional) Name: Comment:
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Surgical area scrub
Aseptic technique
Anaesthetic Monitoring
TPRs & interpretation
Body After Care
temp. &
correction
Form 3: Final trainee assessment sheets (to be completed at the end of the training) Please rate the trainee's ability from 1-5. (1 being poor and 5 being exceptionally good.) Trainee Nam e: Surgeon
Rating
Date: Comments
Pre surgery check I.V. Catheter placement and site preparation Animal handling technique Scrub technique Intubation Surgical ability Suturing technique Gentle handling of tissue Asepsis (includes checking autoclaving) Communication with Assistant After care
Assistant
Comments
Preparation of theatre Preparation of drugs and equipment for surgery Transporting patient from ware Animal handling technique I.V Catheter placement and site preparation Fluid rate calculation and monitoring of flow rate Intubation Positioning for surgery Site clipping Site scrub Assisting surgeon with gowning Asepsis Communication with Surgeon Monitoring and recording Body temperature monitoring and correction Ability to judge anaesthetic depth Tattooing/ear tipping Administering “top-ups� and medications Cleaning patient post surgery Extubation Monitoring post surgery After care Cleaning of instruments and preparation of autoclaving Cleaning of theatre
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Assessor:
6B: Trainer flank spay records 乂
These records are to be used in conjunction with the appropriate anaesthetic, admission and discharge forms provided by VBB.
乂
It forms part of the joint training program and is a record of progress and outcomes of flank spays performed during the year.
乂
Trainers will be required to perform at least 100 spay or castration surgeries every 12 months (owned and stray patients) to be considered for ongoing training.
乂
These records will form the basis for assessment and issuing of ongoing certification by VBB and ACTAsia.
乂
Please fill in details as each surgery is completed and have these records available for assessment upon request by VBB or ACTAsia.
乂
If you require assistance with completion , please get in touch with VBB or ACTAsia for instructions.
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SUMMARY OF FLANK SPAY CASES TIME TAKEN DURING DATE OF SURGERY NAME OF SURGEON NAME OF ASSISTANT SURGERY
ANAESTHETICS USED (ATTACH COPY OF ANAESTHETIC RECORD)
PAIN RELIEF USED
ANTIBIOTICS USED
AGE OF PATIENT
PROBLEMS/ANY OTHER INFORMATION DURING SURGERY:
RECOVERY TIME (TO STERNAL RECUMBENCY):
TIME WHEN EATING
PROBLEMS AFTER SURGERY:
FOLLOW UP INFORMATION :
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DISCHARGE/RELEASE TIME:
GENERAL HEALTH
Appendix 1: How to make a model uterus
Procedure for creating a model uterus. This model can be use to teach female reproductive anatomy and to practice clamping and ligation techniques when performing routine ovariohysterectomy surgery By Carolyn Maguire BSc Veterinary Nurse
You will need: •
No more than 1 metre of basic non stretch material, any type of cotton/cotton blend or similar material. (The amount of material will be determined by how big you would like your uterus to be.)
•
H Metre of mesh or netted type material
•
H m of red bias binding or ribbon
•
Cotton thread for sewing
•
Cushion stuffing material
The main body of the model is made from the non stretch material. The connective tissue between the uterus and the blood vessel is represented by the mesh. Blood vessels are represented by red bias binding/ribbon. It is best to have all materials in different colours to distinguish between anatomical structures.
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• •
Fold the material in half so you will have TWO pieces after the shape is drawn and cut. Copying the design in the graphic above, trace the Y shaped design on to your fabric, remembering to draw half circles at the top of the branches (these circles represent the ‘ovaries’）
Pin your fabric along the pattern line and cut out
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Sew as close as possible to the outside edge of the material all the way from points A to point B, (ie the red line) do not sew across the bottom of the “cervix5. See below.
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Turn the model inside out (will be quite difficult due to the “ovaries”)； hiding the seams and readying the model to be stuffed.
Cut 2 lengths of mesh/net 1.5cm wide, the same length as your ‘Y5 (not including the ‘ovaries5).
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Pin the red bias binding onto the side of the mesh (two pieces, one for each side). Once in position, sew bias binding onto mesh. These now represent the ‘blood vessels’.
Pin the mesh side of the “blood vessels” to the side of the uterine body up the outside of both horns, again stopping before the ovaries.
Sew into place.
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Fill the model with toy filling/toy stuffing (cushion filling material) until plump and then seal the “cervix� end with one final line of stitching. Neaten with scissors.
Your model should look something like this:
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