Today's Veterinary Technician, March 2016 by davidpsu

OPHTHALMOLOGY THE HAIRY EYEBALL

ANESTHESIA PURR-FECT FELINE ANESTHESIA

PAIN MANAGEMENT DENTISTRY AND CRITICAL CARE

REHABILITATION GETTING STARTED IN REHABILITATION

ZOONOSIS WHAT’S ALL THE FUSS ABOUT?

TODAY’SVETERINARYTECHNICIAN |

An Official Journal of the NAVC

| todaysveterinarytechnician.com | Volume 1, Number 2 | March/April 2016 |

KIM HORNE

TAKING THE BITE OUT OF FELINE MITES

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TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

MARCH/APRIL 2016

VOLUME 1, NUMBER 2

Today’s Veterinary Technician is proudly published by the NAVC

Chief Executive Ofﬁcer Thomas M. Bohn, MBA, CAE

Editor in Chief

Vice President of Content and NAVC Medical Director Beth Thompson, VMD BThompson@NAVC.com Publisher Nick Paolo, MS, MBA NPaolo@NAVC.com

Lynne Johnson-Harris, LVT, RVT LJohnson@NAVC.com

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Brenda K. Feller, LVT, CVT, VTS (Anesthesia) Animal Specialty Hospital of Florida, Naples, Florida

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Rosemary Lombardi, CVT, VTS (Emergency and Critical Care) Director of Nursing, University of Pennsylvania Matthew J. Ryan Veterinary Hospital

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Staff Editors Cheryl Hobbs, Maureen McKinney

Jeanne R. Perrone, CVT, VTS (Dentistry) VT Dental Training, Plant City, Florida

NAVC Board of Directors President Melinda D. Merck, DVM

Heidi Reuss-Lamky, LVT, VTS (Anesthesia & Analgesia, Surgery) Oakland Veterinary Referral Services, Bloomfield Hills, Michigan

Immediate Past President Christine Navarre, DVM, MS, DACVIM (Large Animal Internal Medicine) President-Elect Gail Gibson, VMD

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Directors Paige Allen, MS, RVT Harold Davis, Jr, BA, RVT, VTS (Emergency and Critical Care) (Anesthesia) Cheryl Good, DVM

Daniel J. Walsh, MPS, RVT, LVT, VTS (Clinical Pathology) Purdue University (Retired)

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

MARCHAPRIL2016

Volume 1, Number 2

PEER-REVIEWED CE Pain Management for Dental Patients ANNIE MILLS, LVT, VTS (DENTISTRY)

Pain management is a critical component of a comprehensive dental service. This article gives an overview of the physiology of pain, offers a discussion of a variety of analgesic agents, and provides information to help create an effective pain management protocol for dental patients.

Purr-fect Feline Anesthesia HEIDI REUSS-LAMKY, LVT, VTS (ANESTHESIA & ANALGESIA, SURGERY)

Anesthetizing cats can present several challenges, from managing patient stress to administering anesthetics to monitoring during the procedure. Read this article for information that can help you improve the anesthesia experience for your feline patients.

FEATURES Taking the Bite out of Feline Mites KIM HORNE, AAS, CVT, VTS (DERMATOLOGY)

Zoonosis: What Is All the Fuss About? ANNE WORTINGER, BIS, LVT, VTS (ECC, SAIM, NUTRITION)

Pain Recognition and Management in Critical Care Patients BRANDY TABOR, CVT, VTS (ECC)

37 Getting Started in Physical Rehabilitation MARY ELLEN GOLDBERG, BS, LVT, CVT, SRA, CCRA

The Hairy Eyeball: What’s Your Culprit? SHANNON DALEY, BS

TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

March/April 2016

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! A H w

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Give dogs and their owners an enjoyable vaccine experience — only with BRONCHI-SHIELD ORAL. Bronchi-ShieldORAL.com Reference: 1. Data on file, BRONCHI-SHIELD ORAL package insert, Boehringer Ingelheim Vetmedica, Inc.

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

MARCHAPRIL2016

Volume 1, Number 2

COLUMNS Editor’s Letter | Zoobiquity: For Me, It’s Personal

LYNNE JOHNSON-HARRIS, LVT, RVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

CONNECT WITH US

You Said… | Letters to the Editor

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WE WELCOME YOUR THOUGHTS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Career Challenges | Creating Altitude in Your Career JENNIFER YURKON, CVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

What Moves You? | The Resilience of Animals WENDY DAVIES, CVT, CCRA.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Final Thoughts | What Monkeys Can Teach Us: Letting Go JULIE SQUIRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Children and Hygiene: Tips for Reducing Zoonotic Disease Risk. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51

CLINIC RESOURCES Canine Acute Pain Scale.. .......................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 Feline Acute Pain Scale. . ............................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45 Advertiser Index. . ............................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

ANESTHESIA PURR-FECT FELINE ANESTHESIA

PAIN MANAGEMENT DENTISTRY AND CRITICAL CARE

REHABILITATION GETTING STARTED IN REHABILITATION

ZOONOSIS WHAT’S ALL THE FUSS ABOUT?

TODAY’SVETERINARYTECHNICIAN |

CLIENT HANDOUT

OPHTHALMOLOGY THE HAIRY EYEBALL

An Official Journal of the NAVC

| todaysveterinarytechnician.com | Volume 1, Number 2 | March/April 2016 |

KIM HORNE

TAKING THE BITE OUT OF FELINE MITES

ON THE COVER

Kim Horne, AAS, CVT, VTS (Dermatology), presented the following sessions at the NAVC Conference 2016 on allergies in dogs: “The Allergic Dog: Is It Fleas, Food or Environmental?,” “Diagnostic Plan for the Allergic Dog,” and “Treating and Managing the Allergic Dog.” Read her CE article, “Scratching the Surface of Allergies in Dogs,” in our January/February issue on TodaysVeterinaryTechnician.com. Cover image by Lester Austin/ universalimage.net.

26 51

Today’s Veterinary Technician (ISSN 2162-3872 print and ISSN 2162-3929 online) does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products and claims contained therein. The publisher, Eastern States Veterinary Association, Inc (NAVC), disclaims any liability for any damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective authors and do not necessarily represent the opinions of the NAVC nor its Editorial Advisory Board. NAVC does not guarantee nor make any other representation that the material contained in articles herein is valid, reliable, or accurate; nor does the NAVC assume any responsibility for injury or death arising from any use, or misuse, of same. There is no implication that the material published herein represents the best or only procedure for a particular condition. It is the responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly available. Today’s Veterinary Technician is published Jan/Feb, Mar/Apr, July/August, Jul/Aug, Sept/Oct, Nov/Dec (6x per year) by NAVC, PO Box 390, Glen Mills, PA. 19342.

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An Official Journal of the NAVC

March/April 2016

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Editor’s Letter

Zoobiquity: For Me, It’s Personal

Lynne Johnson-Harris, LVT, RVT | Editor in Chief

“Zoobiquity springs from a simple but revelatory fact. Animals and humans get the same diseases, yet physicians and veterinarians rarely consult with one another. Zoobiquity explores how human and non-human animal commonalities can be used to diagnose, treat, and heal patients of all species.” —Dr. Barbara Natterson-Horowitz, author of the best-selling book Zoobiquity

Emme, our 13-year-old golden retriever, during one of her mellow moments (after romping in the lake).

n October 2014, my veterinarian husband noticed a swelling on the left side of our sweet, old golden retriever’s face. Emme showed no outward sign of pain or discomfort and, being a golden, kept her great attitude and appetite. Maybe it’s nothing serious, we reassured ourselves as we proceeded with the diagnostics and removal of the mass we located on her gum line. The histopathology results were devastating. Emme had a malignant melanoma. As a reader of this journal, you know the score. Historically, in both humans and dogs, these tumors are hardly affected by chemotherapy. Surgery and radiation help debulk the main tumor but do not stop progression. Average survival time for a human with advanced malignant melanoma is less than a year. In dogs, it’s about 4 months. Luckily for us, because of a chance meeting between a veterinary and a human oncologist at a social event, history is changing. Phil Bergman, DVM, told a surprised Jedd Wolchok, MD, that yes, dogs do get malignant melanoma. That sparked a collaboration and research study that ultimately led to a DNA-based melanoma vaccine. Released by Merial in 2009, Oncept, a human DNA-based vaccine for dogs, was an option for Emme. We started her treatment as soon as possible. Well over a year after that dreadful diagnosis, our old girl is still with us and going strong. She is asymptomatic, happy, and playful, thanks to the vaccine created jointly by physicians and veterinarians. Such a wonderful outcome makes me aware of how much more may be possible at the intersection of animal and human medicine. When professionals start to talk each other and exchange ideas, new possibilities could open up for all species. Clinical trials, which are so hard to accomplish in humans, could be done with real pets that experience environments identical to those of humans with the same disease. Findings of long-term health studies, such as the 50-year Framingham Heart Study in nurses, could be enhanced and expanded on by lifetime studies in a shorter-lived species, such as dogs. The Zoobiquity concept is taking off, and some of us think it’s long overdue. Join in when you can. Read the book, look to see if one of the nationwide Zoobiquity conferences is happening near you, and talk to your fellow human professionals. Maybe the pediatric nurse you know has some insights that will help with your patients. Maybe it’s the other way around. Perhaps insights into your clients’ questions about diseases you both see, like ringworm or Lyme disease, will help you both be better health educators. You never know what can happen. I just know that my husband, I, and Emme are happy that it did. 

Do you have a story you’d like to share? Write me at ljohnson@navc.com. 6

TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

March/April 2016

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Letters to the Editor

You Said... Thank You

M We’d like to know what you think about Today’s Veterinary Technician. Drop us a line at LJohnson@NAVC.com or RHenry@NAVC.com. Letters to the editor may be published in a future issue of the journal.

“It is refreshing to see that there are still so many of us dedicated career techs out there.”

TODAY’SVETERINARYTECHNICIAN

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y name is Ren, and I’m an LVT from Nevada. I just got done reading through Today’s Veterinary Technician, which I received in the mail tonight. I must say I’m impressed. This journal is specifically designed for credentialed technicians, and even though I enjoy reading several other publications, I found this one to be more able to connect to me as a technician, a simple footsoldier in the trenches. It is refreshing to see that there are still so many of us dedicated career techs out there—I have found that there are fewer and fewer of us long-timers. This is a very demanding career and it’s not easy to remain steadfast in our resolve, but your editor’s note, as well as several other articles, really gave me a sigh of relief that there are not only just a few of us, but a lot of us that feel blessed by being a tech, and none of us would ever consider quitting. I’ll be honest with you, the only reason I received the journal is because it was an option prompted to me when I accepted to do a small case report at the NAVC this year. Otherwise, I may not have had the chance to subscribe, but I am very glad that I did. There comes a point in one’s career where it is our duty to pass the torch to the next generation of our counterparts, and this journal is a perfect avenue to do so. Although the experiences and skill set that we gather as we work through the

An Official Journal of the NAVC

March/April 2016

years belong to us as individuals, the knowledge which we gain does not—it belongs to our patients, to be used to their benefit. It is our duty to pass the torch and help inspire other techs to continue to strive forward. If I can be instrumental in igniting the spark of dedication, motivation, and innovation in a single technician, I have done my job. I just wanted to thank you for your contribution to our profession and hard work in getting this journal up and running. I have no doubt it is an enormous task, but you need to know that even though not many techs will take the time to provide you feedback on this accomplishment, I felt it was important that you know you are being heard. Veterinarians may be the brains of a practice, but we techs are the lifeblood of a practice.  Sincerely yours, Renaud “Ren” Houyoux, LVT Baring Boulevard Veterinary Hospital, Reno-Sparks, Nevada

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FLEA AND TICK control dogs run to, not from… NexGard® (afoxolaner) for dogs is: POWERFUL so it keeps killing fleas and ticks all month long EASY to give because it’s soft and beef-flavored

Dogs love it! 1

Data on file at Merial.

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IMPORTANT SAFETY INFORMATION: NexGard is for use in dogs only. The most frequently reported adverse reactions included vomiting, dry/flaky skin, diarrhea, lethargy, and lack of appetite. The safe use of NexGard in pregnant, breeding, or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures. For more information, see full prescribing information or visit www.NexGardForDogs.com.

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Peer-Reviewed

Taking the Bite out of Feline Mites Kim Horne, AAS, CVT, VTS (Dermatology)

University of Minnesota

esides fleas, lice, and ticks, a number of ectoparasites can affect cats. Some are common, some are rare, and some are seen more often in different regions of the country. Veterinary technicians should be aware of the many ectoparasites that can cause skin disease in cats, be proficient in performing the necessary diagnostic tests, and understand the various available treatment options in order to educate cat owners. It is important to note that many of the treatments used for ectoparasitic infestations are considered off-label; therefore, client consent should be obtained before beginning treatment with these products.

Kim is a member of the dermatology service at University of Minnesota Veterinary Medical Center. She is a charter member of the Academy of Dermatology Veterinary Technicians and its current president. Kim is also an active member of the Minnesota Association of Veterinary Technicians and NAVTA, actively participating in committees. She has spoken at many national meetings, has several publications to her credit, and is currently working on a dermatology text for veterinary technicians. Kim received her degree from University of Minnesota’s Technical College of Waseca. In her spare time, she enjoys hiking, kayaking, and spending time with her family.

OTOACARIASIS Otoacariasis, or otodectic mange, is the most common mite infestation in cats and is highly contagious.1 In younger cats, it is the most common cause of otitis externa.2 Otodectes cynotis mites are found primarily in the external ear canal, although they can also be seen around the face and neck. These mites can survive off the host for several days to months,2 with adults having a life span of about 2 months.3 Because transmission often occurs via direct contact during the neonatal period, otodectic mange is more commonly seen in kittens and young cats. Transient lesions have been reported in humans.4 10

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An Official Journal of the NAVC

Diagnosis Clinical features of otoacariasis include otitis externa, which is usually bilateral and may have minimal to extensive, dark-brown to black ceruminous exudate (composed of cerumen, blood, and mite feces). Cats with this condition often have pruritus, which can be severe, with self-inflicted excoriations common. Diagnosis is made with microscopic evaluation of ear cytology, confirming the presence of the Otodectes mites (FIGURE 1). When the body is affected, skin scrapings may also be performed, although fewer mites are obtained with this method.1 Conditions to be ruled out include otitis caused by bacteria and/or yeast, pediculosis, notoedric mange, and chigger bites.2,3 Treatment A number of standard topical otic and systemic products are used to treat otodectic mange. Treatment selection should take into account the number of animals that need to be treated, the severity of clinical signs, the patient’s temperament, and the owner’s ability and willingness to administer medication. All products should be used with caution in kittens. Treatment options include the following:

March/April 2016

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

CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Description: NexGard® (afoxolaner) is available in four sizes of beef-flavored, soft chewables for oral administration to dogs and puppies according to their weight. Each chewable is formulated to provide a minimum afoxolaner dosage of 1.14 mg/lb (2.5 mg/ kg). Afoxolaner has the chemical composition 1-Naphthalenecarboxamide, 4-[5- [3-chloro-5-(trifluoromethyl)-phenyl]-4, 5-dihydro-5-(trifluoromethyl)-3-isoxazolyl]-N-[2-oxo-2-[(2,2,2-trifluoroethyl)amino]ethyl. Indications: NexGard kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of Black-legged tick (Ixodes scapularis), American Dog tick (Dermacentor variabilis), Lone Star tick (Amblyomma americanum), and Brown dog tick (Rhipicephalus sanguineus) infestations in dogs and puppies 8 weeks of age and older, weighing 4 pounds of body weight or greater, for one month. Dosage and Administration: NexGard is given orally once a month, at the minimum dosage of 1.14 mg/lb (2.5 mg/kg). Dosing Schedule: Body Weight 4.0 to 10.0 lbs. 10.1 to 24.0 lbs. 24.1 to 60.0 lbs. 60.1 to 121.0 lbs. Over 121.0 lbs.

Afoxolaner Per Chewables Chewable (mg) Administered 11.3 One 28.3 One 68 One 136 One Administer the appropriate combination of chewables

NexGard can be administered with or without food. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused. If it is suspected that any of the dose has been lost or if vomiting occurs within two hours of administration, redose with another full dose. If a dose is missed, administer NexGard and resume a monthly dosing schedule. Flea Treatment and Prevention: Treatment with NexGard may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with NexGard should continue the entire year without interruption. To minimize the likelihood of flea reinfestation, it is important to treat all animals within a household with an approved flea control product. Tick Treatment and Control: Treatment with NexGard may begin at any time of the year (see Effectiveness). Contraindications: There are no known contraindications for the use of NexGard. Warnings: Not for use in humans. Keep this and all drugs out of the reach of children. In case of accidental ingestion, contact a physician immediately. Precautions: The safe use of NexGard in breeding, pregnant or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures (see Adverse Reactions). Adverse Reactions: In a well-controlled US field study, which included a total of 333 households and 615 treated dogs (415 administered afoxolaner; 200 administered active control), no serious adverse reactions were observed with NexGard. Over the 90-day study period, all observations of potential adverse reactions were recorded. The most frequent reactions reported at an incidence of > 1% within any of the three months of observations are presented in the following table. The most frequently reported adverse reaction was vomiting. The occurrence of vomiting was generally self-limiting and of short duration and tended to decrease with subsequent doses in both groups. Five treated dogs experienced anorexia during the study, and two of those dogs experienced anorexia with the first dose but not subsequent doses. Table 1: Dogs With Adverse Reactions. Treatment Group Afoxolaner

Vomiting (with and without blood) Dry/Flaky Skin Diarrhea (with and without blood) Lethargy Anorexia

N1 17 13 13 7 5

Oral active control

% (n=415) 4.1 3.1 3.1 1.7 1.2

N2 25 2 7 4 9

% (n=200) 12.5 1.0 3.5 2.0 4.5

1 Number of dogs in the afoxolaner treatment group with the identified abnormality. 2 Number of dogs in the control group with the identified abnormality. In the US field study, one dog with a history of seizures experienced a seizure on the same day after receiving the first dose and on the same day after receiving the second dose of NexGard. This dog experienced a third seizure one week after receiving the third dose. The dog remained enrolled and completed the study. Another dog with a history of seizures had a seizure 19 days after the third dose of NexGard. The dog remained enrolled and completed the study. A third dog with a history of seizures received NexGard and experienced no seizures throughout the study. To report suspected adverse events, for technical assistance or to obtain a copy of the MSDS, contact Merial at 1-888-6374251 or www.merial.com/NexGard. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth. Mode of Action: Afoxolaner is a member of the isoxazoline family, shown to bind at a binding site to inhibit insect and acarine ligand-gated chloride channels, in particular those gated by the neurotransmitter gamma-aminobutyric acid (GABA), thereby blocking preand post-synaptic transfer of chloride ions across cell membranes. Prolonged afoxolaner-induced hyperexcitation results in uncontrolled activity of the central nervous system and death of insects and acarines. The selective toxicity of afoxolaner between insects and acarines and mammals may be inferred by the differential sensitivity of the insects and acarines’ GABA receptors versus mammalian GABA receptors. Effectiveness: In a well-controlled laboratory study, NexGard began to kill fleas four hours after initial administration and demonstrated >99% effectiveness at eight hours. In a separate well-controlled laboratory study, NexGard demonstrated 100% effectiveness against adult fleas 24 hours post-infestation for 35 days, and was ≥ 93% effective at 12 hours post-infestation through Day 21, and on Day 35. On Day 28, NexGard was 81.1% effective 12 hours post-infestation. Dogs in both the treated and control groups that were infested with fleas on Day -1 generated flea eggs at 12- and 24-hours post-treatment (0-11 eggs and 1-17 eggs in the NexGard treated dogs, and 4-90 eggs and 0-118 eggs in the control dogs, at 12- and 24-hours, respectively). At subsequent evaluations post-infestation, fleas from dogs in the treated group were essentially unable to produce any eggs (0-1 eggs) while fleas from dogs in the control group continued to produce eggs (1-141 eggs). In a 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of NexGard against fleas on the Day 30, 60 and 90 visits compared with baseline was 98.0%, 99.7%, and 99.9%, respectively. Collectively, the data from the three studies (two laboratory and one field) demonstrate that NexGard kills fleas before they can lay eggs, thus preventing subsequent flea infestations after the start of treatment of existing flea infestations. In well-controlled laboratory studies, NexGard demonstrated >97% effectiveness against Dermacentor variabilis, >94% effectiveness against Ixodes scapularis, and >93% effectiveness against Rhipicephalus sanguineus, 48 hours post-infestation for 30 days. At 72 hours post-infestation, NexGard demonstrated >97% effectiveness against Amblyomma americanum for 30 days. Animal Safety: In a margin of safety study, NexGard was administered orally to 8 to 9-week-old Beagle puppies at 1, 3, and 5 times the maximum exposure dose (6.3 mg/kg) for three treatments every 28 days, followed by three treatments every 14 days, for a total of six treatments. Dogs in the control group were sham-dosed. There were no clinically-relevant effects related to treatment on physical examination, body weight, food consumption, clinical pathology (hematology, clinical chemistries, or coagulation tests), gross pathology, histopathology or organ weights. Vomiting occurred throughout the study, with a similar incidence in the treated and control groups, including one dog in the 5x group that vomited four hours after treatment. In a well-controlled field study, NexGard was used concomitantly with other medications, such as vaccines, anthelmintics, antibiotics (including topicals), steroids, NSAIDS, anesthetics, and antihistamines. No adverse reactions were observed from the concomitant use of NexGard with other medications. Storage Information: Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F). How Supplied: NexGard is available in four sizes of beef-flavored soft chewables: 11.3, 28.3, 68 or 136 mg afoxolaner. Each chewable size is available in color-coded packages of 1, 3 or 6 beef-flavored chewables.

NADA 141-406, Approved by FDA Marketed by: Frontline Vet Labs™, a Division of Merial, Inc. Duluth, GA 30096-4640 USA Made in Brazil. ®NexGard is a registered trademark, and TMFRONTLINE VET LABS is a trademark, of Merial. ©2015 Merial. All rights reserved. 1050-4493-03 Rev. 1/2015

TECHPOINT 

Veterinary technicians should be aware of the many ectoparasites that can cause skin disease in cats, be proficient in performing the necessary diagnostic tests, and understand the various available treatment options in order to educate cat owners. ÆÆ Fipronil spot-on formulation: 2 drops instilled into

each ear canal, with the remaining drug applied topically, as directed, to prevent further cutaneous involvement; treatment should be repeated in 2 weeks1 ÆÆ Selamectin: 1 or 2 treatments applied topically given 30 days apart4 ÆÆ Ivermectin: 300 mcg/kg SC every 2 weeks for 1 or 2 treatments, or applied topically (0.5 mL/ear) for 1 or 2 treatments4 ÆÆ Imidacloprid (10%) and moxidectin (1%): 1 or 2 doses applied topically, given 30 days apart2

FIGURE 1. Microscopic image of an Otodectes mite. Image courtesy of Dr. Sheila Torres at the University of Minnesota. TODAY’SVETERINARYTECHNICIAN

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All in-contact animals should be treated. Ideally, the environment (including bedding and grooming equipment) should be cleaned using an acaricidal agent. TROMBICULIASIS Trombiculiasis is an infestation caused by chigger mites (Trombicula spp) and is typically seen in the summer and autumn. The mites live in rotting organic material, and their life cycle is completed in 50 to 70 days. Only the larval stage is parasitic and feeds on animals, including humans (in whom it can cause papular, pruritic lesions, often on the limbs and trunk). Clinical features of trombiculiasis in cats include erythema, hair loss, excoriations, erosions, scaling, and crusts. Areas involved are mainly on the head, occurring at the base of the pinnae, Henry’s pocket, and the neck. They can also be found around the digits of the feet. Pruritus is severe and persists even after the larvae are gone.1 Diagnosis Although the mites are not always present at the time of the examination, they can be observed with the naked eye, with a magnifying glass, or microscopically (removed from host and mixed with mineral oil on a microscope slide). They are orange-red and therefore can be easily distinguished from Otodectes mites. Treatment Treatment of trombiculiasis requires 1 or 2 applications of a parasiticide. If pruritus is present, a short (2- to 3-day) course of corticosteroids may offer relief.3 Clients should be advised to treat the outdoor environment by removing yard debris and possibly using pesticide sprays and to prevent the cat from roaming outdoors. CHEYLETIELLOSIS Cheyletiellosis, a dermatosis caused by the parasitic mite Cheyletiella, is seen in cats (Cheyletiella blakei), dogs (Cheyletiella yasguri), and rabbits (Cheyletiella parasitivorax). It is a highly contagious disease and may be seen more often in young animals, as well as in cats living in shelters or catteries. The mite lives on the skin surface (in a pseudotunnel in epidermal debris) and typically affects the animal’s dorsal area. Cheyletiella mites are large and can appear as “dandruff” that is observed moving on the patient. The mites periodically attach to the epidermis and pierce the skin. Eggs are attached loosely to the hair. The life cycle is completed on the host in about 21 days.3 Although cheyletiellosis has zoonotic importance, the mites do not reproduce on humans. People in the 12

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TECHPOINT 

Because Cheyletiella mites can be killed by flea products, cheyletiellosis is diagnosed less often in temperate climates where year-round flea control is the norm. household can be infested, which should be determined while obtaining the patient history. Humans may have skin irritation or a papular rash, which usually resolves once the cat and environment have been treated. Affected clients should be advised to seek advice from their physician. Diagnosis Scales are the most common clinical sign. Other presentations are variable and may include erythema, papules, crusts, and hair loss. Cats may or may not be pruritic. Scales may be removed as a result of cats’ grooming behavior; therefore, this clinical sign may go unnoticed by the pet owner. Because Cheyletiella mites can be killed by flea products, the disease is diagnosed less often in temperate climates where year-round flea control is the norm.3,5 The mites may also be difficult to find because asymptomatic carriers exist, further allowing the incidence of this disease to be underestimated. The diagnosis is made by confirming the presence of mites or eggs, which can be accomplished through a variety of methods. Sometimes the mites can be found on direct examination of the patient using a handheld magnifying glass. Another method is to collect scale and hair, using a flea comb or acetate tape, and then examine the material collected with a magnifying glass or microscopically. A trichogram can also be performed to look for Cheyletiella eggs attached to the hair. Superficial skin scrapings can also be done. When performing superficial skin scrapings, using broad strokes over a large area will yield more success in finding mites. Fecal flotation may be used to identify mites or eggs that cats have ingested while grooming. Cheyletiella mites are easy to identify by their mouthparts, which terminate in hooks (FIGURE 2). If no mites are found on the patient, other pets in the household

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Taking the Bite out of Feline Mites

BOX 1 Information for Clients About Lime Sulfur Dip Although lime sulfur dip is a very safe and effective treatment, it can be difficult to dip cats. The product is malodorous, will temporarily stain pets’ haircoat yellow, will stain porous surfaces (e.g., concrete), and will tarnish jewelry. Owners should be advised to wear gloves and protect eyes and skin from contact with the solution. Ideally, the dip application should be performed in a well-ventilated area. After dipping, the cat should be kept warm and allowed to dry naturally. To prevent accidental ingestion of dip solution, an Elizabethan collar may be used until the cat is dry.

should be examined. Finally, if no mites or eggs are found, a therapeutic trial should be performed using miticidal therapy. If the patient fails to respond to this treatment, then cheyletiellosis may be ruled out as a diagnostic differential. Other diagnostic differentials include diabetes mellitus and liver disease if seborrhea is present.3 Otherwise, fleabite hypersensitivity, notoedric mange, pediculosis, atopic dermatitis, and food hypersensitivity2 should be considered for cats that present with pruritus. Treatment Although cheyletiellosis can be challenging to diagnose, it is fairly easy to treat in single-cat households and is curable. All in-contact pets should be treated and, in some cases (severe and/or chronic infestation, multiple pets in the household, affected humans in the household), environmental treatment is recommended.1 Although no veterinary products are labeled for the treatment of Cheyletiella dermatitis, a variety of topical and systemic drugs have been found to be effective.

FIGURE 2. Microscopic image of a Cheyletiella mite. Note the mouthparts that terminate in hooks. Image courtesy of Dr. Sheila Torres at the University of Minnesota. TODAY’SVETERINARYTECHNICIAN

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Topical products include the following: ÆÆ Lime sulfur dip: Weekly for 4 to 6 treatments5 (BOX 1) ÆÆ Fipronil 0.25% spray: 1 or 2 pumps/lb every 2 weeks

for 3 or 4 treatments5 ÆÆ Fipronil 10% spot-on formulation: Every 3 to 4 weeks for 2 or 3 applications or every 2 weeks to resolve clinical signs more quickly5 ÆÆ Selamectin: Applied topically every 30 days for 3 treatments4 Cats with medium to long coats may be clipped to enable easier application and penetration of topical products. Systemic treatment involves ivermectin 300 mcg/kg SC every 2 weeks for 3 treatments4 or PO every 7 days for 6 treatments.5 If environmental treatment is needed, recommendations include cleaning and washing pet bedding, grooming equipment, toys, cat carriers, collars, and other pet items with hot water and spraying with insecticide spray.2,5 This cleaning regimen should be performed every 2 weeks throughout the treatment period. Any items that cannot be disinfected should be discarded. Although the mites are thought to die soon after leaving the host, it has been reported that mites may live off the host for 10 days or longer.2 Ideally, treatment should continue for 2 to 4 weeks after resolution of clinical signs. A recheck examination should be scheduled after 4 to 6 weeks of treatment. A physical examination should be performed and, if clinical signs persist and mites or eggs were found previously, diagnostic tests should be repeated. Moreover, the owner should be asked to describe his or her treatment regimen to determine whether recommendations were followed. If they were not, the veterinary technician should use this opportunity to provide additional client education for owners of patients that have not improved as anticipated. NOTOEDRIC MANGE Notoedric mange (sometimes referred to as feline scabies) is caused by the Notoedres cati mite, which lives in the epidermis. N. cati is very contagious via direct contact and has a life cycle similar to that of Sarcoptes scabiei

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Taking the Bite out of Feline Mites

Typically, if demodicosis is present, a positive response will be seen after 3 treatments.

(17 to 21 days).1 Notoedric mange is a pruritic disease; signs often involve the face and pinnae (FIGURE 3) and can spread to the feet and perineum (possibly from cats’ grooming behavior and sleeping positions).3 Diagnosis Clinical features of notoedric mange include alopecia, erythema, scales, and crusting, which can become very thick and yellow to gray in color. Self-trauma from pruritus may also be seen, and these excoriations may become secondarily infected. Peripheral lymphadenopathy is common. Fortunately, N. cati is usually present in large numbers and can be found easily with a skin scraping.1 It is similar in appearance to Sarcoptes mites, but smaller. This mite also infests foxes, dogs, and rabbits,2,3 and humans may also have transient lesions. Notoedric mange is rare in some areas of the country and common in others.3 Conditions to rule out include otoacariasis, cheyletiellosis, atopic dermatitis, food hypersensitivity, pemphigus (foliaceus or erythematosus), and systemic lupus erythematosus.3 Treatment Treatment options include: ÆÆ Lime sulfur dip: Performed weekly until resolution (6 to 8 treatments)3 (BOX 1) ÆÆ Selamectin: Applied topically every 2 weeks for 3 treatments5

FIGURE 3. Kitten with severe crusted lesions on the ears and neck due to Notoedres infestation. Image courtesy of Dr. Sheila Torres at the University of Minnesota. 14

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TECHPOINT 

ÆÆ Ivermectin: 200 to 300 mcg/kg SC every 2 weeks for

2 to 3 treatments5 ÆÆ Doramectin: 0.2 to 0.3 mg/kg SC administered once3 All in-contact cats should be treated, and the environment should be cleaned with an acaricidal agent. Response is usually good provided all cats are treated and reexposure is prevented. DEMODICOSIS Demodicosis is being recognized more often in cats and can be difficult to manage. Cats can have either localized or generalized demodicosis and can be infested with either the Demodex cati or Demodex gatoi mite. Additionally, a third, as yet unnamed Demodex mite has been identified (it resembles D. gatoi but is larger, with other anatomic differences).3 The localized form of demodicosis appears to be rare; generalized demodicosis may be more common in purebred Siamese and Burmese cats.1,3 Cats with diagnosed demodicosis should have a minimum database performed, including a complete blood count, serum biochemistry profile, fecal exam, feline leukemia virus (FeLV) test, and feline immunodeficiency virus (FIV) test. Often, an associated underlying immunosuppressive disease, such as FIV, FeLV, diabetes mellitus, hyperadrenocorticism, toxoplasmosis, systemic lupus erythematosus, or squamous cell carcinoma in situ is present in patients with generalized disease.3 Diagnosis D. cati is similar in appearance to Demodex canis (long, slender tail), lives in the hair follicles and sebaceous glands, and can be found in healthy cats as normal flora. The ova of this mite also differ in appearance from those of D. canis; D. cati ova are slimmer and oval versus the spindle-shaped D. canis ova. All other life stages are narrower. Clinical signs of D. cati infestation include alopecia, patchy erythema, scaling, crusting, and ceruminous otic discharge (especially in FIV-positive cats). These cats may or may not be pruritic; however, if pruritus is present, it can be intense. Demodicosis caused by D. cati typically affects middleaged or older cats. When localized, the most common

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areas affected are the head and neck—specifically the pinnae, chin, and periocular areas. When generalized, the trunk and limbs may also be involved. The proliferation of mites may be related to an underlying systemic condition or immunosuppression. Multiple deep skin scrapings should be performed. Co-infestation with D. gatoi or the unnamed mite has been reported.3 D. gatoi is a short-bodied, more superficial mite that inhabits the stratum corneum. This species is considered

FIGURE 4. Bilaterally symmetric alopecia in a cat infested with Demodex gatoi. Image courtesy of Dr. Sheila Torres at the University of Minnesota. 16

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contagious to other cats.6 Clinical signs of D. gatoi infestation are usually related to pruritus, which can be moderate to severe, and include alopecia (sometimes bilaterally symmetric; FIGURE 4), scaling, and excoriations. Pruritus may have a sudden onset and may not be responsive to steroids. Multiple superficial skin scraping samples should be obtained using broad strokes and may be more successful if taken from areas less likely to have been self-groomed by the patient. In patients that are nonpruritic, the mites are usually found. Other methods of diagnosis include tape prep samples and fecal flotation. When viewing skin scrapings microscopically, using a 10× objective with increased contrast will help to see the small, translucent mites. Negative test results do not rule out this disease, however, and a treatment trial may be warranted (especially as the clinical signs associated with demodicosis caused by D. gatoi can mimic allergic disease and self-inflicted alopecia). Examination and diagnostic testing of other cats in the household may be warranted, even if the cats are not showing clinical signs. Treatment Localized demodicosis caused by D. cati may be selflimiting and resolve spontaneously.6 In general, cats respond well to treatment, which can include lime sulfur dip, ear medications containing pyrethrin, or amitraz (1:9) in mineral oil.3 Along with miticidal therapy for generalized demodicosis, treatment for any underlying conditions should be included. Unless the underlying disease is identified and managed, demodicosis will be difficult to cure. The most commonly recommended therapy is lime sulfur dip. A 2% concentration is applied weekly for a minimum of 6 weeks.4 Treatment should be continued until 2 negative skin scrapings taken 4 to 6 weeks apart are obtained (D. cati). With D. gatoi infestation, all cats in the household should be treated. The affected cat(s) should be reevaluated after the third dip; if significant improvement is noted, treatment should be continued for another 3 to 5 dips. If this treatment is to be used at home, owners should be informed of product drawbacks (BOX 1). The following treatment options have been used in cases of D. cati infestation. However, use of these products is considered off-label, and more information is needed to understand their efficacy. Cats given these treatments should be monitored closely for adverse effects. ÆÆ Amitraz: Dips (125 or 250 ppm) are applied every 5 to 7 days for 4 to 6 weeks.5

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Taking the Bite out of Feline Mites

EXPERIENCE THE PURINA DIFFERENCE ®

ÆÆ Doramectin: Doses of 400 to 600 mcg/kg SC are

given weekly until 2 negative skin scrapings taken 4 to 6 weeks apart are obtained; treatment is then continued for an additional 4 weeks.4 ÆÆ Ivermectin: An injectable form of ivermectin is used, but it is administered orally. Recommended dosing is 200 to 400 mcg/kg q24–48h until 2 negative skin scrapings taken 4 to 6 weeks apart are obtained; treatment should then be continued for an additional 4 weeks.4 Although ivermectin toxicity is rare in cats, if seen, it is usually in kittens within 1 to 12 hours after administration and can manifest as abnormal behavior, lethargy, ataxia, weakness, apparent blindness, coma, and death.3 For cats with D. gatoi, besides the recommended lime sulfur dip, the following treatment options have been used. However, such use is considered off-label, and more information is needed to understand their efficacy. Cats given these treatments should be monitored closely for adverse effects, and all in-contact cats should be treated. ÆÆ Amitraz: Dips (either at 125 or 250 ppm) applied weekly for 12 weeks3,4 ÆÆ Ivermectin: Given every other day3,5 ÆÆ Moxidectin 10% and imidacloprid 2.5%: Applied topically every 7 to 14 days7

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It is important to rule out other feline dermatoses that involve excessive grooming as a clinical sign, such as fleabite hypersensitivity, notoedric mange, atopy, food hypersensitivity, and psychogenic alopecia.3 A therapeutic trial for demodicosis may be performed before more aggressive diagnostic testing for these other dermatoses. Typically, if demodicosis is present, a positive response will be seen after 3 treatments. 

References 1. Guaguere E. Ectoparasitic skin diseases. In: Guaguere E, Prelaud P, eds. A Practical Guide to Feline Dermatology. Duluth, GA: Merial;1999: 3.1-3.14. 2. Curtis C. Ectoparasites. In: Jackson HA, Marsella R, eds. BSAVA Manual of Canine and Feline Dermatology. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2012:153-163. 3. Miller WH, Griffin CE, Campbell KL. Parasitic skin disease. In: Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Elsevier; 2013:284-342. 4. Koch SN, Torres SMF, Plumb DC. Canine and Feline Dermatology Drug Handbook. Ames, IA: Wiley-Blackwell; 2013. 5. Ghubash R. Parasitic miticidal therapy. Top Companion Animal Med 2006;21(3):135144. 6. Forsythe P. Demodicosis. In: Jackson HA, Marsella R, eds. BSAVA Manual of Canine and Feline Dermatology. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2012:164-172. 7. Moriello KA. Chronic pruritus in a household of cats. Clin Brief June 2013:29-31.

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ARTICLE 1 1 CR E DIT

Pain Management for Dental Patients Annie Mills, LVT, VTS (Dentistry)

n the past 10 years, the delivery of quality veterinary care in general practices, particularly with regard to professional dental care, has made great strides. The increased prevalence of dental radiology in general practices is just one example of the forward progression of veterinary dentistry. Continuing education in veterinary dentistry is in great demand as veterinarians and veterinary technicians strive to provide the best care for their patients. Courses offered by veterinary dental experts include instruction in dental radiology, surgical extraction, and periodontal therapy, as well as basic prophylactic and charting skills. All of these skills are crucial to maintaining a high standard of care for dental patients. Pain management is also a critical component of a comprehensive dental service. This article gives an overview of the physiology of pain, offers a discussion of a variety of analgesic agents, and provides information to help create an effective pain management protocol for dental patients.

Atlanta Veterinary Dentistry and Oral Surgery Orlando Veterinary Dentistry Florida Veterinary Dentistry

Annie is a 1983 graduate of Macomb Community College in Macomb, Michigan. She currently serves on the board of the Academy of Veterinary Dental Technicians as President. Annie has published several articles in professional journals and is coauthor of a textbook, Small Animal Dental Procedures for Veterinary Technicians and Nurses. She has also presented dentistry lectures and wet labs at national conferences and has worked with many teams to organize, create, and teach comprehensive dental programs. Currently, Annie is working with Brett Beckman, DVM, FAVD, DAVDC, DAAPM, in a mobile dental referral practice. “Nothing gives me more satisfaction than to see the enthusiasm of other technicians engaged in learning something new and being able to implement it within their own hospitals. As technicians, we are driven to provide the best care for our patients. Learning a new skill to achieve that is a wonderful thing.”

THE IMPORTANCE OF MANAGING DENTAL PAIN Effective pain management before, during, and after a dental procedure can significantly improve care and raise the bar for dentistry services

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provided in general practices. A number of positive outcomes are achieved when the patient is comfortable and pain free. During the procedure, benefits of pain management, specifically regional nerve blocks,1 include the ability to maintain the patient at a lighter plane of anesthesia, significantly reducing the anesthetic risk to the patient. Pain management after the procedure, including medications administered at home, promotes a smooth postoperative recovery for the patient and can increase client compliance with continued, regular professional prophylactic dental cleaning and evaluation. Client compliance with follow-up care is especially important for patients with periodontal disease, which occurs in approximately 80% of dogs and 70% of cats over the age of 2 years.2 These patients require frequent (every 4 to 6 months in some cases) professional cleaning, assessment, and treatment to successfully manage periodontal disease. If a patient undergoes oral surgery and is not properly treated for pain, it will likely exhibit obvious signs of pain at home after the procedure. These signs may include whining, groaning, excessive drooling, and inappetence. It is highly unlikely that the owner will continue with follow-up professional

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CE Article 1

Pain Management for Dental Patients

shutterstock.com/Julie Keen

Effective pain management before, during, and after a dental procedure can significantly improve care during dentistry services.

care after seeing their pet in pain. Lack of follow up will lead to undue patient suffering as dental disease progresses without professional assessment and treatment. CLASSIFICATIONS OF PAIN Pain is classified based on the origin of the pain impulse or its physiologic importance.

Clinical pain occurs when peripheral nerves or the spinal cord are injured, subjecting nociceptors (pain-sensing neurons) to repeated impulses without the benefit of analgesia, ultimately resulting in central sensitization, also called the wind-up phenomenon (BOX 1). Peripheral pain can include either visceral (thoracic or abdominal) or somatic pain involving the joints and muscles.

BOX 1 Preventing the Wind-Up Phenomenon Central sensitization, or wind up, occurs when the spinal cord is subjected to repeated and uncontrolled painful stimuli (clinical pain). This phenomenon can begin within as little as 1 hour of unmanaged pain. Several physiologic changes occur when a patient is experiencing wind up. Excitatory neuropeptides, including substance P and glutamate, are released. These chemical substances bind with and stimulate the N-methyl-D-aspartate (NMDA) receptor. When this receptor is activated, pain impulses are intensified, essentially lowering the patient’s pain threshold. This is also known as hyperalgesia, a heightened response to a mildly painful stimulus. This chemical response also results in allodynia, a painful response to a nonpainful stimulus. In addition, mu and alpha-2 receptors become less susceptible to the effects of analgesics, rendering them ineffective while the patient is in this state. To prevent the wind-up phenomenon, an NMDA antagonist is administered to block substance P and glutamate from binding with the NMDA receptor. Ketamine is most often used for this purpose. However, ketamine is not an analgesic agent, so it is best delivered in conjunction with an opioid to provide simultaneous pain relief. Constant-rate infusion (CRI) is the most practical method of administering these agents appropriately. When given via CRI, ketamine can be delivered at a small enough dose to block the NMDA receptor without the dissociative effects associated with higher doses.3 For best results, the CRI should be started 1 to 3 hours before the surgical procedure, maintained throughout the procedure, and continued postoperatively for 1 to 4 hours, based on the patient’s response.

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Visceral pain is characterized by a cramping sensation and is poorly differentiated. Somatic pain, on the other hand, is localized and manifests as an aching or throbbing sensation. As an example, patients experience somatic pain after a spay surgery or other abdominal surgical procedure. Neuropathic pain occurs when peripheral nerves or the spinal cord are damaged and is felt as an intermittent burning sensation. Cancer patients that are treated with radiation therapy and patients that have undergone limb amputation experience this type of pain. Idiopathic pain exists without a definitive cause and is often associated with stress and behavioral changes in the patient. Physiologic pain is caused by a painful stimulus introduced at the peripheral nerves. This type of pain is also known as teaching pain.4 It is immediate and sharp and “teaches” the patient to protect itself from whatever is causing the pain. To illustrate, imagine a 2-year-old child who touches a hot burner on the stove and pulls his hand back quickly to avoid further injury. Oral pain, whether caused by dental disease or by treatment of dental disease, falls into this category; therefore, this type of pain will be discussed further in this article. Physiologic pain, if not managed successfully, can quickly become clinical pain.4 SIGNS OF PAIN The physiology of pain in animals is very similar to that in humans; that is, animals experience and feel pain similar to the way humans do.5 However, animals typically do not exhibit pain responses as humans do. They can be stoic, or hide their reaction to pain. When an animal sustains an acute injury, obvious pain behaviors such as vocalization (e.g., whining, groaning) are easily recognized. Patients may limp or flinch when palpated. Patients with dental pain can be much more difficult to assess because they tend to suffer in silence. Dental conditions like fractured teeth can be excruciating, but these patients may not show any signs of pain or may exhibit very subtle changes in behavior. Slight changes in posture, drooling, squinting, staring, hiding, lethargy, and even purring can indicate oral discomfort. Recognizing these signs can be challenging, and they are sometimes missed as pain responses. Changes in behavior in older pets, such as decreased appetite and activity, are often perceived by owners as the pet “just slowing down” in its later years. However, in many cases, these patients have long-term oral pain secondary to prolonged, untreated dental disease. Once the disease is treated and pain is managed or eliminated, these patients exhibit many positive behavioral changes, as described by many owners during recheck appointments. 20

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TECHPOINT 

Client compliance with follow-up care is especially important for patients with periodontal disease, which occurs in approximately 80% of dogs and 70% of cats over the age of 2 years. Almost all procedures that are used to treat dental conditions can induce varying degrees of pain. Dental procedures as minor as ultrasonic scaling or root planing can cause mild to moderate pain. More involved procedures, including surgical extraction, en bloc resection, and mandibulectomy, can cause severe pain. If postoperative pain is not managed well during recovery and the days following the procedure, it can be detrimental, especially in older patients or patients with mildly compromised organ function such as liver or kidney disease.6 However, in patients with preexisting chronic conditions like renal or liver disease, drug choices can be limited. For instance, nonsteroidal anti-inflammatory drugs (NSAIDs) should be used with caution or avoided in these cases. All scenarios from mild to severe pain must be addressed appropriately for the overall well-being of the patient. PHYSIOLOGY OF PAIN To implement successful analgesic protocols, it is helpful to know how pain is transmitted and eventually perceived by the patient. Understanding this “pain pathway” is the key to providing effective pain management. The physiologic process of the pain response consists of 3 main components culminating in perception of pain by the cerebral cortex, essentially recognition of pain by the patient, or nociception. It begins with the noxious stimulus or, more simply put, the painful event at the site of injury or surgical site. The stimulus is translated from physical energy into an electrical impulse at the peripheral nerves. This process is known as transduction. Transmission then takes place as the electrical energy is transmitted by nerve fibers through the peripheral nervous system. Two primary nerve fibers are involved in transmission. A-delta fibers conduct fast pain, recognized

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by the patient as the first sharp, stabbing pain sensation. C fibers conduct slow pain, recognized as a dull, throbbing pain. As the painful stimulus is transmitted and eventually reaches the spinal cord, modulation can take place. Endogenous systems located within the spinal dorsal horn, including opioid, serotonergic, and noradrenergic systems, can inhibit or lessen pain. In other words, modulation enables the patient to lessen its own pain to some degree. Perception of pain by the patient is the end result of transduction, transmission, and modulation.7 Each of these processes of the pain pathway is susceptible to the effects of a variety of analgesic agents available to veterinarians. PAIN MEDICATIONS Classes of analgesic agents include opioids, alpha-2 agonists, NSAIDs, local anesthetics, and adjuvant analgesics. Opioids Opioids are classified by the effect they have on specific receptors. Mu receptors, located on the second-order neuron within the spinal cord (where modulation takes place), are responsible for the most profound analgesia within the body. When an agonist—an agent that enhances a receptor—is introduced and binds with the receptor, the analgesic effect is significantly increased, thereby relieving pain for the patient. The most common examples of pure mu agonists available are listed in TABLE 1. These agents are used for more severe pain or as a premedication before surgical procedures and can be administered intravenously, intramuscularly, transdermally, or orally. However, these opiates can produce dysphoria (anxiety) and/or hyperthermia, and caution should be used when using pure mu agonists in cats. Buprenorphine (0.005–0.02 mg/kg) is considered a partial mu agonist (i.e., it only partially stimulates the

Pain Management for Dental Patients

receptor), making it less effective than the pure mu agonists, and is used for mild to moderate pain. This drug is used more commonly for cats to avoid the adverse effects of pure mu agonists. Buprenorphine can be administered intravenously, intramuscularly, subcutaneously, or orally.8 Butorphanol (0.2–1.0 mg/kg) is a mu agonist/antagonist. It simultaneously enhances and blocks the mu receptor, making it less effective than a pure mu agonist. In addition, the duration of this agent is relatively short, lasting only 1 to 3 hours. More involved dental procedures often last up to 2 hours. If butorphanol is used as a premedication, the surgical procedure could potentially outlast the analgesic, causing the patient to recover without the benefits of analgesia. Because of its lesser efficacy and short duration, butorphanol is not recommended as an effective analgesic for dental procedures.8 Alpha-2 Agonists Alpha-2 agonists include xylazine (0.1–0.5 mg/kg) and medetomidine (–10 ug/kg), which enhance the alpha-2 receptor on the first-order neuron. These agents can sometimes cause adverse cardiac effects, specifically severe bradycardia. Medetomidine should be used with caution or even avoided, especially in patients with underlying cardiac issues.8 NSAIDs NSAIDs prevent the formation of prostaglandins by targeting the cyclooxygenase enzyme responsible for prostaglandin production. Prostaglandins are known to lead to inflammation and pain as well as to affect peripheral nociceptors, causing peripheral pain. Carprofen (4.4 mg/kg once daily), meloxicam (0.2 mg/kg initially; 0.1 mg/kg once daily), and ketoprofen (1.0–2.0 mg/kg) are the more commonly used NSAIDs in veterinary medicine. They are available as injectable and oral formulations.8

TABLE 1 Pure Mu-Agonist Opioids Used in Dental Patients DRUG

DOSAGE (DOGS AND CATS)

Morphine

0.5–2 mg/kg7 IV, IM, or SC as a premedication 5–15 min induction

Hydromorphone

0.05–0.3 mg/kg8 IV, IM, or SC

Fentanyl transdermal patch

<7 kg: 25 mcg patch for 3 days 7–18 kg: 50 mcg patch for 3 days 8–27 kg: 75 mcg patch for 3 days >27 kg: 100 mcg patch for 3 days8

Codeine

1–2 mg/kg8 PO postoperatively

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Pain management needs to continue in the days following the dental procedure.

Local Anesthetics Local anesthetics prevent the conduction of nerve impulses from the surgical site. Lidocaine (7 mg/kg maximum per site)8 and bupivicaine (1.0 mg/kg)8 can be used alone or simultaneously. However, it is important to note that lidocaine has a much shorter duration of action (1–2 hours) than bupivacaine (up to 6 hours). Adjuvant Analgesics Adjuvant analgesics are agents that are used for other applications but have been found to have beneficial effects in relieving certain painful conditions. Antidepressants, neuroleptics, and anticonvulsants are a few examples. N-methyl-D-aspartate (NMDA) receptor antagonists also fall into this group. Ketamine (injectable) and gabapentin (oral) are commonly used as NMDA antagonists. ANALGESIC STRATEGY FOR DENTAL PATIENTS Anesthetic Premedication The first step to an effective analgesic strategy starts with what is known as preemptive analgesia, in which an analgesic is introduced before the patient is exposed to

TECHPOINT 

noxious stimuli. A narcotic such as an opiate, along with an NSAID in some instances, is usually administered as preemptive analgesia. Proactive administration of an analgesic before the dental procedure begins can help the patient avoid postoperative clinical pain. Increasing the modulation taking place in the spinal dorsal horn more effectively controls pain, thereby preventing central sensitization or wind up, which can otherwise occur during recovery (BOX 1). Regional Nerve Blocks Regional nerve blocks deliver the anesthetic agent in or near a foramen where the target nerve bundle is located to block sensation in a specific region in the oral cavity. The most widely used sites for placing a nerve block

BOX 2 Sample Balanced Analgesia Strategy 1. Preemptive Analgesia

 Administer an opioid before induction. Administration can be intravenous, intramuscular, or subcutaneous, depending on the time frame that works best for the dentistry service. The administration of an opiate enhances the modulation process and creates a pain-free state for the patient before surgery begins, setting the stage for a pain-free recovery and prevention of postoperative wind up.

 A benzodiazapine (e.g., diazepam, midazolam) can also be given if more sedation is preferred and to avoid postoperative dysphoria.

 An NSAID can be given to prevent peripheral nerve sensitization (transmission), if desired.

2. Intraoperative Analgesia

 Induce the patient and maintain gas anesthesia.

 After the oral evaluation (full-mouth radiography, probing, and charting to determine the appropriate treatment plan) is complete, perform regional nerve blocks to prevent transduction and subsequent transmission of the pain impulse. Placing nerve blocks early allows the maximum amount of time for them to take effect before any surgical procedures begin.

 An NSAID can be given to prevent peripheral nerve sensitization, if desired.

3. Postoperative Analgesia

 An NSAID can be given to prevent peripheral nerve sensitization, if desired.

 A narcotic used with an NSAID creates a synergistic effect and provides more effective analgesia than an NSAID alone.

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during dental procedures are the infraorbital foramen, the caudal maxillary region, the inferior alveolar foramen, the middle mental foramen, and the inferior alveolar foramen. The technique is as simple as giving an injection. Proper placement of the needle to deliver the agent to bathe the nerve bundle sufficiently is where most of the challenge exists. However, with proper instruction in a wet lab setting, and with additional practice on cadaver specimens, this skill can be relatively easy to master. Regional nerve analgesia is absolutely essential to the dentistry service for quality patient care. To illustrate this point, consider that when a patient feels pain while under anesthesia, its heart rate, respiratory rate, and blood pressure increase. The patient may even attempt to move if the anesthesia is too “light.” The anesthetist is alerted by these changes and immediately reacts by increasing the gas inhalant to produce a deeper plane of anesthesia for the patient so that the procedure can be completed. Deeper planes of anesthesia can compromise cardiac output, blood pressure, and respiration. When nociception is prevented with an efficiently placed nerve block, the patient does not experience changes in heart rate, respiratory rate, or blood pressure and, consequently, can be maintained at a much lighter plane of anesthesia. Balanced Analgesia The bulk of a successful analgesic strategy consists of a multimodal or “balanced” approach. Balanced analgesia is defined as using agents from two or more drug classifications simultaneously to modulate the pain impulse as it travels the pain pathway. By interrupting transduction and transmission as well as heightening the effects of modulation within the spinal cord, balanced analgesia provides optimum pain relief. BOX 2 outlines a specific plan of when and where to use analgesic agents in a successful pain management strategy, keeping in mind the pain pathway processes and the interruption of the pain stimulus. Patients that have a pain-free recovery are less likely to experience central sensitization. Pain behaviors during recovery, including vocalization and thrashing, are also eliminated. Client Communication Anesthesia of a pet is a substantial fear and source of anxiety for most pet owners when dental procedures are recommended and is often the reason why owners do not follow recommendations for professional dental cleaning, assessment, and treatment. Educating clients on the positive effects of the practice’s comprehensive analgesia strategy, including the benefits of regional nerve analgesia (i.e., use of a lighter plane of anesthesia), can reduce these fears. TODAY’SVETERINARYTECHNICIAN

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Pain Management for Dental Patients

Home Care In most cases, regional nerve blocks will most likely still be in effect during recovery and even when the patient returns home. In addition, any injectable NSAID administered will also still be providing analgesia, as the duration of action of injectable NSAIDs can last up to 24 hours. Owners are pleasantly surprised when their pet eats and remains comfortable throughout the evening following its dental procedure. Again, this can increase client compliance with the follow-up professional dental care necessary to successfully manage periodontal disease. Pain management needs to continue in the days following the dental procedure. Several options, including chewable tablets, oral liquids, and transdermal patches, are available to administer postoperative analgesics. An opiate given in conjunction with an NSAID creates a synergistic effect, providing a more profound analgesia for the patient.7 CONCLUSION Implementation of a pain management protocol should involve the entire veterinary team. Although this article provides an introduction to many aspects of pain physiology and management, a complete discussion of pain management in the dental setting is beyond the scope of a single article. Continuing education courses, including lectures, wet labs, and online webinars, are offered for this particular subject, as well as for other disciplines in veterinary dentistry. To maintain a high level of care for dental patients, veterinary technicians should take advantage of available continuing education opportunities. Ultimately, the patient reaps the benefits of implementing an effective analgesic protocol. 

References 1. Beckman B. Regional nerve blocks key to delivering quality dental care. DVM360, September 2007. veterinarynews.dvm360.com/regional-nerve-blocks-key-deliveringquality-dental-care. Accessed January 2016. 2. Wiggs R, Lobprise H. Veterinary Dentistry Principles & Practice. Philadelphia, PA: Lippincott-Raven; 1997:187. 3. Stein B. Analgesic constant rate infusions. October 2005. vasg.org/constant_rate_ infusions.htm. Accessed January 2016. 4. Tranquilli W, Grimm K, Lamont L. Pain Management for the Small Animal Practitioner. 2nd ed. Jackson, WY: Teton New Media; 2000:2. 5. Tranquilli W, Grimm K, Lamont L. Pain Management for the Small Animal Practitioner. 2nd ed. Jackson, WY: Teton New Media; 2000:6. 6. Holmstrom S. Veterinary Dentistry for the Technician & Office Staff. Philadelphia, PA: Saunders; 2000:142. 7. Tranquilli W., Grimm K., Lamont L., Pain Management for the Small Animal Practitioner. 2nd ed. Jackson, WY: Teton New Media, 2000, ppg. 4-8, 13 8. Kuehn N. North American Companion Animal Formulary. 10th ed. Port Huron, MI: North American Compendiums; 2013.

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CE Test Article 1 Pain Management for Dental Patients The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval. 1. The percentage of dogs over the age of 2 years with periodontal disease is a. 10% b. 20% c. 60% d. 80% 2. Purring can be a sign of pain. a. True b. False 3.

Nociception is defined as a. the transmission of pain impulses b. recognition of pain by the patient c. central sensitization d. a painful stimulus

4. C fiber peripheral nerves are responsible for a. allodynia b. conduction of fast or first, sharp pain c. prostaglandin production d. conduction of slow or dull, throbbing pain 5. The ____receptor is responsible for the most profound analgesia within the body. a. alpha-2 b. NMDA c. mu d. opioid

An agonist is defined as a. an analgesic that enhances a receptor b. an analgesic that blocks a receptor c. an opioid receptor d. a response to a painful stimulus

7. Central sensitization occurs with the stimulation of the ________ receptor. a. mu b. alpha 2 c. dorsal horn d. NMDA 8. NSAIDs prevent the formation of prostaglandins by a. targeting the cyclooxygenase enzyme b. initiating the release of substance P c. preventing transduction d. binding with the NMDA receptor 9. Somatic pain would be experienced after which of the following? a. acute fracture of the tibia b. radiation therapy c. surgical tooth extraction d. abdominal exploratory surgery 10. Patients with dental disease often show outward signs of pain. a. True b. False

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What Moves You? shutterstock.com/InBetweentheBlinks

The Resilience of Animals Wendy Davies, CVT, CCRA University of Florida Animals have always been a huge part of my life. Growing up on a dairy farm in upstate New York, I was the kid who brought stray animals home in the hope I could keep them. As I got older, I knew that a job working with animals was what I wanted. I graduated from college as a zookeeper and initially worked in a small, private zoo until an injury prevented me from continuing such hard physical labor. I then worked at a couple of private veterinary practices for a few years until I got a job at the University of Florida Veterinary School, where I have worked in several different services for the past 16 years. I love what I do! The best part of my job as a rehabilitation technician is the bond I form with my patients and the ability to watch them heal. One special patient was Natalia. I first met Natalia, a saluki, in September 2014. She had been a street dog from Qatar, in the Middle East, that was lucky enough to get rescued by an amazing group there. Her journey from Qatar to the United States through Alabama Sighthound Adoptions was a long one, but eventually, she arrived at the University of Florida Small Animal Hospital. When Natalia arrived at the university, she was severely lame in her right forelimb with accompanying muscle atrophy, and the plan was to perform an ovariohysterectomy and imaging studies. Radiography and computed tomography showed that the extent of her injuries was shocking. She had a

For its 2016 Conference, the NAVC asked veterinary professionals to share their stories: What drives you? What inspires you? What moves you? Throughout the year, Today’s Veterinary Technician will be publishing veterinary technicians’ answers to these questions. What moves you? Do you have a story you’d like to share? Send it to us at TVTech_submissions@NAVC.com. Submissions should be approximately 500 words or less and may be posted on our website or edited for publication in the journal. Tell us your story!

SWIMMING was just one of the many therapies used to help Natalia regain strength and function in her atrophied muscles. Wendy says, “You don’t typically think of sighthounds as swimmers, but Natalia taught me she could swim just as well as a Labrador!“ 26

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TECHPOI NT 

“It never ceases to amaze me how animals can go through such great trauma and still remain trusting and loving.” fractured pelvis and acetabulum, a chronic, healed left ulnar fracture that still contained bullet fragments, a comminuted right olecranon avulsion fracture, and several shrapnel pieces throughout her body. Despite all that, Natalia remained the sweetest dog imaginable. She walked around and greeted everyone as if they were her best friends. Our goal was to help Natalia be more comfortable and able to use her right forelimb. Because the muscle was severely atrophied and the triceps tendon severely contracted in the right forelimb, we needed to build muscle mass and increase her range of motion. Surgery to repair her avulsion fracture was initially considered, but the extent of the triceps contracture was too great to have a successful outcome, so we had our work cut out for us.

We used everything we had in our rehabilitation arsenal. For 7 months, I worked closely with Natalia, performing laser therapy, therapeutic ultrasound, swimming, underwater treadmill exercises, passive range of motion exercises, massage, transcutaneous electrical nerve stimulation, and neuromuscular electrical stimulation to prepare her for surgery. She was an amazing patient and never once complained or refused any of her treatments. Eventually, she was able to have surgery to repair the avulsion fracture, and since then, she has healed very well and been adopted by her foster mother. I guess that’s the part that really sticks with me, how resilient Natalia is. Despite beginning her life dodging bullets and thrown rocks on the streets of Qatar, she is still a wonderful dog. I would’ve expected her to be a cowering, timid girl when approached by people, but she is just the opposite. She loves people and attention. It never ceases to amaze me how animals can go through such great trauma and still remain trusting and loving. Working as a rehabilitation technician has allowed me to help many animals over the years, and all of them have their own stories, but one thing always remains consistent: they never give up. 

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ARTICLE 2 1 CR E DIT

Purr-fect Feline Anesthesia Adapted with permission from the Michigan Association of Veterinary Technicians, Vet Tech Insider, December 2015.

Heidi Reuss-Lamky, LVT, VTS (Anesthesia & Analgesia, Surgery)

nesthetizing cats can pose unique challenges for veterinary technicians. Not only are cats problematic to monitor under anesthesia, but their small size, interesting metabolism, variable temperament, and predisposition to particular health ailments can also complicate anesthetic administration and monitoring. Advanced preparation, skills, and knowledge allow astute technicians to anticipate patient requirements under a variety of circumstances, thereby improving the odds of a successful anesthetic procedure.

Oakland Veterinary Referral Services Bloomfield Hills, Michigan

Heidi graduated from Michigan State University’s Veterinary Technology Program in 1984. After many years in private practice, she became affiliated with Oakland Veterinary Referral Services in 2006.

PATIENT CONSIDERATIONS Preoperative Assessment Thorough patient assessment is paramount. Patient signalment and history typically include patient name, species, breed, age, weight, and sex (intact, neutered, or pregnant), as well as discovery of recent health issues, current medications, and details surrounding the reason for presentation.1 Other important factors may include diet and housing conditions (indoor versus outdoor), preventive health status (e.g., date of most recent vaccine administration, fecal examination, feline leukemia virus test), and prior anesthetic episodes. Whenever possible, a good physical examination is essential; all abnormalities should be further investigated. Preoperative blood analysis, radiography, and other diagnostic tests, such as blood 28

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She became board-certified through the Academy of Veterinary Technicians in Anesthesia and Analgesia in 2003 and served on the credentials committee from 2005 to 2009. She served in the president’s role on the Executive Board of the Michigan Association of Veterinary Technicians from 2007 to 2009. She was a founding member of the Academy of Veterinary Surgical Technicians and currently sits on the executive board. She is an accomplished author and lecturer and was presented with the 2013 NAVC Dr. Jack L. Mara Memorial Lecturer award.

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pressure measurement, electrocardiography (ECG), echocardiography, and/or abdominal ultrasonography, may be necessary to completely define common feline health problems, such as obesity, diabetes, hyperthyroidism, renal insufficiency, hepatic lipidosis, hypertrophic cardiomyopathy, and asthma. Minimizing Stress Fear-free feline handling techniques are recommended by and available from the American Association of Feline Practitioners (catvets.com). Although not always easy, every attempt should be made to minimize stress in cats to avoid the release of catecholamines in the perioperative period. The use of pheromone products (e.g., Feliway diffusers and sprays; ceva.us) in the examination room, feline wards, and on employees’ hands and clothing and creation of dedicated feline wards help create a quiet, warm, clean, stress-free environment.1 Moreover, tender, loving care, when combined with pheromones (especially during mealtimes), can greatly reduce anxiety and promote food intake.2 It is imperative to minimize stress whenever handling feline patients, using feline-friendly techniques when possible. Mildly stressed cats may be amendable to the use of “clipnosis” cat clips and/or air muzzles. However, sometimes the safest option for both patient and handler entails the use of chemical restraint and/or general anesthesia.

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One sedation technique described for average-sized cats (3–4 kg) is administration of ketamine (1 mL PO) into the cat’s mouth via a urinary catheter attached to the ketamine syringe.1,3 The ketamine is rapidly squirted into the mouth when the cat attempts to bite the catheter. This technique results in a salivating, slower-moving, recumbent, and somewhat catatonic patient. PREOPERATIVE CONSIDERATIONS Numerous factors should be considered before anesthetizing cats. Severity of preexisting health problems guides the anesthetist in the choice of premedications, crystalloid fluid type and rate, induction agents, inhalant, and analgesic. For example, a typical feline hypertrophic cardiomyopathy patient requires careful titration of low-sodium intravenous fluid therapy (range, 2–5 mL/kg/hr)4 to prevent fluid overload and pulmonary edema, while a patient with renal disease may benefit from preoperative diuresis, with particular attention to maintaining blood pressure, and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs). The primary objective of premedication is to reduce the overall dosage of induction and maintenance agents while providing preemptive analgesia and anxiolytic effects. To this end, sedatives like acepromazine and/or midazolam can be combined with alpha-2 agonists or partial or pure mu opioid agonists for analgesia. Other preoperative considerations include the type of procedure being performed (elective versus emergent, short versus prolonged), patient factors that can adversely affect surgical positioning (e.g., large abdominal masses or gross obesity that compromises breathing), and expected level of discomfort associated with the procedure. MONITORING AND EQUIPMENT CONSIDERATIONS Ensure that emergency drug dosages have been calculated, surgical supplies are ready, and additional trained staff members are available to help should a crisis situation arise. Critical Patients Feline patients in shock may present with bradycardia, hypothermia, and hypotension. Because it is speculated that adrenergic receptors are down-regulated in hypothermic cats, aggressive warming measures and small volume resuscitation are advised (to a systolic blood pressure up to 60 mm Hg) to prevent fluid overload once the patient becomes normothermic. Therefore, intravenous fluid doses should always be administered “to effect.”5 Volume overload is more widespread in small patients and may manifest in anesthetized patients as serous nasal discharge, chemosis, TODAY’SVETERINARYTECHNICIAN

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pulmonary crackles, and, in severe cases, frothy fluid emanating from the endotracheal tube (ET). Alternative therapies for hypotensive patients include the use of hetastarch or positive inotropic drugs (e.g., dopamine, dobutamine). When blood loss exceeds 20% of the total blood volume (or if the packed cell volume is <20% and total solids is <4 g/dL),3 a whole blood transfusion should be considered. The patient should be blood typed in advance, as fatal reactions may occur when feline patients are administered incompatible blood products. The most common sign of a transfusion reaction in an anesthetized patient is hypotension. Anesthetic Administration Preoxygenation should be considered before induction whenever a difficult intubation is anticipated (such as when intubating feline patients), but it is considered particularly valuable for brachycephalic patients, patients with lung disease (e.g., asthma, heart disease), and patients with reduced functional residual capacity (e.g., pregnant females). Preoxygenating via flow-by, face mask (if tolerated), or induction chamber/oxygen cage for ≥5 minutes increases the reservoir of the lungs and replaces the air in the lungs with 100% oxygen. In the event of airway obstruction, difficult intubation, or apnea, preoxygenation permits a lapse of 3 to 4 minutes before the patient becomes hypoxic, compared with the 90 seconds it takes a nonpreoxygenated patient breathing room air to become hypoxic.1 Patient induction can be achieved via induction chamber, mask, or chemical routes. A mask or induction chamber should be considered only if an injectable agent is not an option. Chamber and mask induction are least desirable for several reasons: ÆÆ Monitoring patients in an induction chamber is more difficult. ÆÆ Staff members are exposed to high levels of waste anesthetic gases. ÆÆ Excessive stress can be induced by pungent odors and a prolonged induction period. ÆÆ Stress-induced cardiac arrhythmias can be severe, causing increased morbidity and mortality. ÆÆ Postoperative analgesia is not provided by inhalants alone. If chamber induction cannot be avoided, provide oxygen while allowing fractious cats to become calm before administering the inhalant. During chamber induction, monitor the patient frequently to evaluate level of sedation, and transfer the cat to a mask as soon as possible to better assess anesthetic depth.3

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A laryngoscope eases visualization of the feline laryngeal area during intubation. If necessary, use of a stylet can keep the ET rigid during the intubation process. However, laryngeal tissue trauma and tracheal tears may occur if the end of the stylet extends past the end of the tube or if the ET cuff is overinflated. Never force intubation. If laryngeal spasm impedes intubation, lidocaine spray, 1% or 2% lidocaine solution drawn into a syringe, or a cotton swab impregnated with 2% lidocaine gel can be applied to desensitize the arytenoids.1 It is important to note that the use of benzocaine sprays to assist with intubation in cats can cause acute death due to the development of methemoglobinemia. Using a v-gel (docsinnovent.com) supraglottid tube (which covers the larynx) can provide an acceptable airway access alternative for some anesthetic procedures in cats (FIGURE 1). Nonrebreathing circuits (e.g., Bain, Jackson-Reese) are typically used for maintenance of anesthesia in small patients (<7 kg; FIGURE 2). This type of circuit is advantageous in small patients because it decreases resistance to breathing. In addition, most nonrebreathing apparatuses are simple, inexpensive, and lightweight. The disadvantages of nonrebreathing circuits include dependence on high oxygen flow rates (200–500 mL/kg/min), increased cost of anesthetic agent(s) and oxygen, accelerated onset of hypothermia due to high oxygen flow rates, and potential for barotrauma if the pop-off valve is accidentally left closed.

ECG monitoring is common during general anesthesia for small animal patients. It is important to ensure good contact of leads to skin by using ECG paste or alcohol when placing ECG leads. In addition, avoid wetting large areas of the skin and allowing the leads to come into direct contact with the table. Exact lead locations are not as important as ensuring that all waves are present (even if they are inverted). Because the ECG tracing does not provide information about chamber size or how efficiently the heart is ejecting blood, ECG should be used strictly for detection of dysrhythmias during the perianesthetic period.1,6 Blood pressure monitoring is important during general anesthesia because all patients experience some degree of hypotension during general anesthesia. Blood pressure is determined by cardiac output and total peripheral resistance. Total peripheral resistance is defined as the resistance to blood flow created by the peripheral arterial system and capillary beds. Cardiac output is determined by a combination of the heart rate and stroke volume. Normal arterial blood pressure values for cats are a systolic measurement of 120 to 170 mm Hg and a diastolic measurement of 70 to 120 mm Hg. See BOX 1 for further information on blood pressure measurement.

Patient Monitoring Pulse palpation is useful in evaluating heart rate (unless an arrhythmia is present) and is determined by the difference between the systolic and diastolic phase. The normal heart rate for anesthetized cats should range from 100 to 220 beats per minute. Bradycardia in cats should be avoided, as it can result in reduced cardiac output and hypotension. Similarly, tachycardia does not allow adequate time for cardiac filling, which also leads to decreased cardiac output and hypotension. Tachycardia can also increase the oxygen demand of the myocardium, inducing arrhythmias.

FIGURE 2. This nonrebreathing Bain block includes a pressure manometer. Note that the breathing circuit on this unit cannot be used in conjunction with an end-tidal carbon dioxide (ETCO2) dead space adapter.

FIGURE 1. v-gel supraglottid tube. 30

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CE Article 2

Purr-fect Feline Anesthesia

BOX 1 Methods for Measuring Blood Pressure Two methods can be used to measure blood pressure indirectly—Doppler blood flow measurement and oscillometry. Doppler methods use a “return-to-flow” principle to detect systolic blood pressure. Use of a Doppler device can prove advantageous to obtain periodic readings in anesthetized cats if oscillometric devices fail to record blood pressure readings. In cats, it is hypothesized that the resultant reading probably represents the mean arterial pressure (MAP).1,7,8 As such, a correction factor of 14 mm Hg is added to the obtained reading to more accurately reflect the actual feline femoral systolic pressure.8 Several readings should be obtained in a conscious patient and the results averaged. Oscillometric methods detect intracuff changes caused by the pulse wave and calculate heart rate and systolic, diastolic, and MAP measurements. The author has had good experiences measuring blood pressure in cats while using a petMAP device (petmap.com), and satisfactory results with other oscillometric devices by placing the cuff around the proximal tail or over the distal humeral area, proximal to the elbow. Patient movement, smaller patient size (<5 kg), hypothermia or vasoconstriction, or patients with short legs or excessive skin all adversely affect results.9 Regardless of the method used, selection of the correct-sized blood pressure cuff is imperative to obtain the most accurate results. Although, in general, the width of the cuff should extend 40% around the circumference of the limb, in cats it is acceptable to use a cuff that is only 30% of the limb’s circumference.9,10 Acceptable cuff locations include the forelimbs, tail, and hindlimbs; the areas proximal to the carpus and tarsus work best, but the ventral tail can also work well.10 The cuff should be snug, but not too tight. Selection of an inappropriate cuff size is the most common source of error.

Pulse oximetry provides continuous and noninvasive heart rate monitoring and an estimate of arterial hemoglobin saturation (SpO2). Often, after extended periods of use, the clip-on tongue sensor causes blanching of the local blood supply, impeding accurate SpO2 readings. The author has had success disarming the spring assembly of the clip and creating a modified clip that merely holds the probe ends opposed. This modification results in a clip incapable of producing pressure on the local blood supply (FIGURE 3). End-tidal carbon dioxide (ETCO2) monitoring measures the level of carbon dioxide in the expired gases from the alveoli. An abrupt decrease in ETCO2 can be an early and

reliable indication of impending cardiovascular collapse or cardiac arrest. Consequently, ETCO2 can be used to assess effectiveness of cardiopulmonary cerebral resuscitation techniques because delivery of carbon dioxide from the lungs requires blood flow, cellular metabolism, and alveolar ventilation. Capnometers and capnographs monitor ETCO2 by evaluating samples of exhaled gases taken from the anesthetic circuit via an adapter placed on the end of the patient’s ET.8 This adapter must be placed precisely at the end of the patient’s nose to eliminate excessive dead space and prevent rebreathing of carbon dioxide. Cutting the ET

FIGURE 3. SpO2 clip with the spring assembly disarmed.

FIGURE 4. ETCO2 dead space adapter (surgivet.com).

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

Peer-Reviewed

to a shorter length allows this placement, with the tube cuff situated immediately distal to the larynx, but no further than the thoracic inlet.1,11 In smaller patients with sidestream ETCO2 sample collection tubing, it may be advantageous to eliminate excessive dead space by using a special ETCO2 adapter, which is a substitute for the connection of the ET to the wye hose interface (FIGURE 4). Alternatively, sidestream ETCO2 sample collection tubing can be attached to a 22-gauge needle that has been inserted directly into the lumen of the proximal section of the patient’s ET. In the absence of intracranial pathology, normal ETCO2 values should be maintained between 35 and 45 mm Hg.1 It is prudent to avoid hyperventilation, which can result in ETCO2 values <25 mm Hg. Values in this range may reflect decreased cerebral blood flow and oxygen delivery to the brain. ANESTHETIC COMPLICATIONS Hypothermia Hypothermia is one of the most common anesthetic complications. Almost all anesthetized or sedated patients lose body heat under general anesthesia, but small patients are at the greatest risk, largely because of their small body surface-to-mass ratio. Hypothermia is exacerbated during prolonged surgical procedures, especially those that expose body cavities or use cold irrigation solutions. Hypothermia itself is considered a form of general anesthesia because it increases the solubility of inhalants in the body, effectively increasing the dose delivered. Critically ill or otherwise compromised patients may face challenges if their core body temperatures decrease by as little as 2°F.1

FIGURE 5. At least 60% of the patient’s body surface should be covered with an external heat source for maximum effect; a heating block is pictured. 32

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TECHPOINT 

Although anesthetizing cats can be somewhat difficult and challenging, it can be a very rewarding experience with a positive outcome. Obviously, prevention is key when addressing hypothermia, and rewarming should be considered if patient temperature drops to ≤97.6°F.12 Warmed irrigation fluids can be used to help restore core body temperature. There are also several ways to maintain an envelope of warm air around perioperative patients. Convection-type warm air devices, such as BAIR Huggers (3m.com) and electrically conductive fabric warmers, such as the HotDog Warmer (augustinebiomedical.com) are the most effective, followed by warming units such as carbonbased conductive polymers (inditherm.co.uk) and circulating warm water blankets.1,11 At least 60% of the body surface area must be in contact with the external heat source for rewarming efforts to be most effective (FIGURE 5).11 If latex gloves or bottles of warm water are used for smaller patients, they must be initially warmed to a temperature of ≤107°F, not placed in direct contact with the patient, and removed once they cool to the temperature of the patient because, at that point, they contribute to heat loss rather than heat gain.1,11 Commercially available wire electric heating pads and heat lamps have been associated with uneven heating, thermal injury, and/or electrocution and should be avoided. Furthermore, use thermometers carefully, as they may not always provide accurate results when used close to the surgical site. Bradycardia and Tachycardia Bradycardia is common in patients undergoing general anesthesia8 and is defined as a heart rate of <100 beats per minute in cats. There are numerous causes of bradycardia, including drug side effects (e.g., opioids), excessive vagal tone, hypertension, hyperkalemia (e.g., in blocked cats), uremia, hypothermia, increased intracranial pressure (e.g., head trauma), profound hypoxemia, and deep-level inhalants. Tachycardia is defined as >200 beats per minute in cats.9 Causes of tachycardia include drugs (e.g., ketamine;

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CE Article 2

anticholinergics; positive inotropes, such as dopamine; sympathomimetics, such as epinephrine), pain (e.g., inadequate plane of anesthesia), hyperthermia, anaphylactic reactions, hypovolemia, early-stage hypercarbia, and numerous disease states (e.g., hyperthyroidism, heart failure, central nervous system disease, anemia, hypokalemia). Induction agents (e.g., barbiturates, alpha-2 agonists) and disease processes (e.g., splenic disease) may predispose patients to cardiac arrhythmias.9 ANALGESIC OPTIONS Signs of pain in cats can be quite variable and, at times, subtle—ranging from purring to self-mutilation or from fractious behavior and hissing to being withdrawn and quiet. Confounding interpretation of pain in cats are inconsistent observations of heart and respiratory rates, systolic blood pressure, and temperature. A better indication of adequate pain management in cats may be evidenced by the return of normal behaviors, such as grooming and attention seeking, and return of appetite.2 In the Hospital Although historically somewhat controversial, pure mu-agonist opioid analgesics (e.g., morphine, methadone, hydromorphone, fentanyl) have been used with great success in cats as they provide the most reliable form of analgesia for severe pain in cats. Paradoxical excitement (typically observed at higher opioid doses) can be avoided by addition of a sedative agent, such as acepromazine. Mild to moderate pain may be treated with butorphanol or, preferably, buprenorphine. Alternatively, low doses of alpha-2 adrenergic agonists (e.g., dexmedetomidine, xylazine) may be combined with opioids in otherwise healthy patients.3 Ketamine (an N-methyl-D-aspartate [NMDA] receptor antagonist) may be administered via constant-rate infusion in conjunction with opioids for adjunctive analgesic effects.1,2 Local anesthetics, such as lidocaine and bupivacaine, may be employed for local, incisional, and ring (for onychectomy) blocks. Epidural analgesia, pain catheters, References 1. Greene S. Veterinary Anesthesia and Pain Management Secrets. Philadelphia, PA: Hanley & Belfus, Inc; 2002:1-3, 17-19, 39-41, 53-54, 67-68, 113-119, 121-126, 135, 139, 141-143, 149-153, 239-244, 335-338, 342. 2. Mathews K. Management of acute pain in cats. Proc Am College Vet Surg 2007:676682. 3. Mathews K. Trauma patient triage. Part 2. Proc Am College Vet Surg 2007:635-638. 4. Shelby A, McKune C, Fitzgerald N. Anesthesia in patients with concurrent disease. In: Shelby A, McKune C, eds. Small Animal Anesthesia Techniques. Ames, IA: WileyBlackwell; 2014:147. 5. Sigrist N. Cats are not dogs--not even in the OR. IVECCS Proc 2008:175. 6. Glerum L. Anesthetic monitoring: interpreting the data. Proc Am College Vet Surg 2005:652-655.

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Purr-fect Feline Anesthesia

and transdermal fentanyl and lidocaine are other pain management techniques that can be used in the perioperative period. At Home Pain management may be indicated after the patient has been discharged from the hospital. The pH of the feline oral cavity allows buprenorphine to be absorbed sublingually, making this drug a good analgesic choice for acute or long-term use. Simbadol (zoetisus.com) is a recently approved injectable buprenorphine formulation that lasts 24 hours in cats. NSAIDs are another excellent analgesic option: robenacoxib (Onsior, elanco.com) can be used in healthy cats for up to 3 treatment days. Meloxicam is currently approved for one dose in the United States but has been used for extended periods of time in other countries, using a gradually tapering dosage.1,2,13 CONCLUSION Although anesthetizing cats can be somewhat difficult and challenging, it can be a very rewarding experience with a positive outcome. 

Would you like to read more about anesthesia and analgesia in feline patients? Read Feline Anesthesia & Analgesia: Recent Developments in the March/April 2016 issue of Today’s Veterinary Practice, available with the print edition of Today’s Veterinary Technician or at tvpjournal.com. An Official Journal of the NAVC

7. Valverde A. Monitoring the anesthetized patient: what do the numbers mean? Proc Am College Vet Surg 2003. 8. Cunha AF, Saile K, Beaufrere H, et al. Measuring level of agreement between values obtained by directly measured blood pressure and ultrasonic Doppler flow detector in cats. J Vet Emerg Crit Care 2014;24(3):272-278. 9. Seahorn J. Monitoring the anesthetized small animal patient. NAVTA J Winter 2004:53-58. 10. Durham HE. Arterial blood pressure measurement. Vet Tech 2005;26(5):324-339. 11. Lukasik V. Anesthesia of the pediatric patient. NAVTA J Fall 2006: 52-57. 12. Mathews K. Accidental hypothermia & frostbite. NAVTA J Winter 2005: 60-64. 13. Lascelles D. Postoperative pain management in cats. Proc Am College Vet Surg 2003.

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CE Test Article 2 Purr-fect Feline Anesthesia The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval. 1. The most common sign of a transfusion reaction in anesthetized cats is a. hypothermia b. hypotension c. pulmonary crackles d. bradycardia 2. ECG monitoring during anesthesia allows veterinary technicians to a. identify dysrhythmias b. determine cardiac output c. assess oxygenation d. detect heart murmurs 3. Why are nonrebreathing circuits used for small patients? a. They use low oxygen flow rates. b. They use lower gas inhalant rates. c. They provide less resistance to breathing. d. They help keep the patient normothermic. 4. In cats under anesthesia, bradycardia is defined as a heart rate less than _____ bpm. a. 100 b. 120 c. 150 d. 140 5. One method that can be used to determine the femoral systolic blood pressure in cats is to add a correction factor of ___ mm Hg to Doppler readings. a. 1.5 b. 6.8 c. 14 d. 20

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6. To provide the most effective warming, external heat sources should cover at least ____ of the bodyâ&#x20AC;&#x2122;s surface area. a. 25% b. 30% c. 45% d. 60% 7. Which class of analgesic is the most effective for severe pain in cats? a. pure mu-agonist opioids b. NMDA antagonists c. NSAIDs d. alpha-2 agonists 8.

Pulse oximeters measure a. end-tidal carbon dioxide b. arterial hemoglobin saturation c. cardiac output d. total peripheral resistance

9. What triad is associated with shock in feline patients? a. tachycardia, hypothermia, and hypertension b. bradycardia, hypothermia, and hypotension c. tachycardia, hyperthermia, and hypertension d. bradycardia, hyperthermia, and hypotension 10. Which of the following parameters can promptly detect an impending cardiac arrest? a. arterial hemoglobin saturation b. blood pressure c. heart rate d. end-tidal carbon dioxide

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Buster’s playmates miss him.

It won’t be for long, because you prescribe PREVICOX.® Who isn’t sad when a dog is in too much osteoarthritis pain to play? So trust PREVICOX as your go-to NSAID because PREVICOX: • Provides efficacy both pet owners and veterinarians notice In a field study, after 30 days of use: – 96% of pet owners saw improvement in their dogs1 – In 93% of dogs, veterinarians saw improvement1 • Rapidly absorbed—detected in plasma levels within 30 minutes2 • Convenient with once-daily dosing

PUT RELIEF IN MOTION

Important Safety Information As a class, cyclooxygenase inhibitory NSAIDs may be associated with gastrointestinal, kidney or liver side effects. These are usually mild, but may be serious. Pet owners should discontinue therapy and contact their veterinarian immediately if side effects occur. Evaluation for pre-existing conditions and regular monitoring are recommended for pets on any medication, including PREVICOX. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided. Refer to the full Prescribing Information for complete details. REFERENCES: 1. Pollmeier M, Toulemonde C, Fleishman C, Hanson PD. Clinical evaluation of firocoxib and carprofen for the treatment of dogs with osteoarthritis. Vet Rec. 2006;159(17):547-551. 2. Data on file at Merial. ®PREVICOX is a registered trademark of Merial. ©2014 Merial, Inc. Duluth, GA. All rights reserved. PVX15TRADEADC (07/15).

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CHEWABLE TABLETS Brief Summary: Before using PREVICOX, please consult the product insert, a summary of which follows: Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Indications: PREVICOX (firocoxib) Chewable Tablets are indicated for the control of pain and inflammation associated with osteoarthritis and for the control of postoperative pain and inflammation associated with soft-tissue and orthopedic surgery in dogs. Contraindications: Dogs with known hypersensitivity to firocoxib should not receive PREVICOX. Warnings: Not for use in humans. Keep this and all medications out of the reach of children. Consult a physician in case of accidental ingestion by humans. For oral use in dogs only. Use of this product at doses above the recommended 2.27 mg/lb (5.0 mg/kg) in puppies less than seven months of age has been associated with serious adverse reactions, including death (see Animal Safety). Due to tablet sizes and scoring, dogs weighing less than 12.5 lb (5.7 kg) cannot be accurately dosed. All dogs should undergo a thorough history and physical examination before the initiation of NSAID therapy. Appropriate laboratory testing to establish hematological and serum baseline data is recommended prior to and periodically during administration of any NSAID. Owners should be advised to observe for signs of potential drug toxicity (see Adverse Reactions and Animal Safety) and be given a Client Information Sheet about PREVICOX Chewable Tablets. For technical assistance or to report suspected adverse events, call 1-877-217-3543. Precautions: This product cannot be accurately dosed in dogs less than 12.5 pounds in body weight. Consider appropriate washout times when switching from one NSAID to another or when switching from corticosteroid use to NSAID use. As a class, cyclooxygenase inhibitory NSAIDs may be associated with renal, gastrointestinal and hepatic toxicity. Sensitivity to drug-associated adverse events varies with the individual patient. Dogs that have experienced adverse reactions from one NSAID may experience adverse reactions from another NSAID. Patients at greatest risk for adverse events are those that are dehydrated, on concomitant diuretic therapy, or those with existing renal, cardiovascular, and/ or hepatic dysfunction. Concurrent administration of potentially nephrotoxic drugs should be carefully approached and monitored. NSAIDs may inhibit the prostaglandins that maintain normal homeostatic function. Such anti-prostaglandin effects may result in clinically significant disease in patients with underlying or pre-existing disease that has not been previously diagnosed. Since NSAIDs possess the potential to produce gastrointestinal ulceration and/or gastrointestinal perforation, concomitant use of PREVICOX Chewable Tablets with other anti-inflammatory drugs, such as NSAIDs or corticosteroids, should be avoided. The concomitant use of protein-bound drugs with PREVICOX Chewable Tablets has not been studied in dogs. Commonly used protein-bound drugs include cardiac, anticonvulsant, and behavioral medications. The influence of concomitant drugs that may inhibit the metabolism of PREVICOX Chewable Tablets has not been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy. If additional pain medication is needed after the daily dose of PREVICOX, a non-NSAID class of analgesic may be necessary. Appropriate monitoring procedures should be employed during all surgical procedures. Anesthetic drugs may affect renal perfusion, approach concomitant use of anesthetics and NSAIDs cautiously. The use of parenteral fluids during surgery should be considered to decrease potential renal complications when using NSAIDs perioperatively. The safe use of PREVICOX Chewable Tablets in pregnant, lactating or breeding dogs has not been evaluated. Adverse Reactions: Osteoarthritis: In controlled field studies, 128 dogs (ages 11 months to 15 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27mg/lb (5.0 mg/kg) orally once daily for 30 days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed adverse reactions during the study. Adverse Reactions Seen in U. S. Field Studies Adverse Reactions Vomiting Diarrhea Decreased Appetite or Anorexia Lethargy Pain Somnolence Hyperactivity

PREVICOX (n=128) 5 1 3 1 2 1 1

Active Control (n=121) 8 10 3 3 1 1 0

PREVICOX (firocoxib) Chewable Tablets were safely used during field studies concomitantly with other therapies, including vaccines, anthelmintics, and antibiotics. Soft-tissue Surgery: In controlled field studies evaluating soft-tissue postoperative pain and inflammation, 258 dogs (ages 10.5 weeks to 16 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27 mg/ lb (5.0 mg/kg) orally approximately 2 hours prior to surgery and once daily thereafter for up to two days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study. Adverse Reactions Seen in the Soft-tissue Surgery Postoperative Pain Field Studies Adverse Reactions Vomiting Diarrhea Bruising at Surgery Site Respiratory Arrest SQ Crepitus in Rear Leg and Flank Swollen Paw

Firocoxib Group (n=127) 5 1 1 1 1 1

Control Group* (n=131) 6 1 1 0 0 0

*Sham-dosed (pilled) Orthopedic Surgery: In a controlled field study evaluating orthopedic postoperative pain and inflammation, 226 dogs of various breeds, ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group were evaluated for safety. Of the 226 dogs, 118 were given PREVICOX Chewable Tablets at a dose of 2.27 mg/lb (5.0 mg/kg) orally approximately 2 hours prior to surgery and once daily thereafter for a total of three days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study. Adverse Reactions Seen in the Orthopedic Surgery Postoperative Pain Field Study Adverse Reactions Vomiting Diarrhea Bruising at Surgery Site Inappetence/ Decreased Appetite Pyrexia Incision Swelling, Redness Oozing Incision

Firocoxib Group (n=118) 1 2** 2 1 0 9 2

A case may be represented in more than one category. *Sham-dosed (pilled). **One dog had hemorrhagic gastroenteritis.

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Control Group* (n=108) 0 1 3 2 1 5 0

Post-Approval Experience (Rev. 2009): The following adverse reactions are based on post-approval adverse drug event reporting. The categories are listed in decreasing order of frequency by body system: Gastrointestinal: Vomiting, anorexia, diarrhea, melena, gastrointestinal perforation, hematemesis, hematachezia, weight loss, gastrointestinal ulceration, peritonitis, abdominal pain, hypersalivation, nausea Urinary: Elevated BUN, elevated creatinine, polydypsia, polyuria, hematuria, urinary incontinence, proteinuria, kidney failure, azotemia, urinary tract infection Neurological/Behavioral/Special Sense: Depression/lethargy, ataxia, seizures, nervousness, confusion, weakness, hyperactivity, tremor, paresis, head tilt, nystagmus, mydriasis, aggression, uveitis Hepatic: Elevated ALP, elevated ALT, elevated bilirubin, decreased albumin, elevated AST, icterus, decreased or increased total protein and globulin, pancreatitis, ascites, liver failure, decreased BUN Hematological: Anemia, neutrophilia, thrombocytopenia, neutropenia Cardiovascular/Respiratory: Tachypnea, dyspnea, tachycardia Dermatologic/Immunologic: Pruritis, fever, alopecia, moist dermatitis, autoimmune hemolytic anemia, facial/muzzle edema, urticaria In some situations, death has been reported as an outcome of the adverse events listed above. For a complete listing of adverse reactions for firocoxib reported to the CVM see: http://www.fda.gov/AnimalVeterinary/SafetyHealth/ProductSafetyInformation/ucm055394.htm Information For Dog Owners: PREVICOX, like other drugs of its class, is not free from adverse reactions. Owners should be advised of the potential for adverse reactions and be informed of the clinical signs associated with drug intolerance. Adverse reactions may include vomiting, diarrhea, decreased appetite, dark or tarry stools, increased water consumption, increased urination, pale gums due to anemia, yellowing of gums, skin or white of the eye due to jaundice, lethargy, incoordination, seizure, or behavioral changes. Serious adverse reactions associated with this drug class can occur without warning and in rare situations result in death (see Adverse Reactions). Owners should be advised to discontinue PREVICOX therapy and contact their veterinarian immediately if signs of intolerance are observed. The vast majority of patients with drug-related adverse reactions have recovered when the signs are recognized, the drug is withdrawn, and veterinary care, if appropriate, is initiated. Owners should be advised of the importance of periodic follow up for all dogs during administration of any NSAID. Effectiveness: Two hundred and forty-nine dogs of various breeds, ranging in age from 11 months to 20 years, and weighing 13 to 175 lbs, were randomly administered PREVICOX or an active control drug in two field studies. Dogs were assessed for lameness, pain on manipulation, range of motion, joint swelling, and overall improvement in a non-inferiority evaluation of PREVICOX compared with the active control. At the study’s end, 87% of the owners rated PREVICOX-treated dogs as improved. Eighty-eight percent of dogs treated with PREVICOX were also judged improved by the veterinarians. Dogs treated with PREVICOX showed a level of improvement in veterinarian-assessed lameness, pain on palpation, range of motion, and owner-assessed improvement that was comparable to the active control. The level of improvement in PREVICOX-treated dogs in limb weight bearing on the force plate gait analysis assessment was comparable to the active control. In a separate field study, two hundred fifty-eight client-owned dogs of various breeds, ranging in age from 10.5 weeks to 16 years and weighing from 7 to 168 lbs, were randomly administered PREVICOX or a control (sham-dosed-pilled) for the control of postoperative pain and inflammation associated with soft-tissue surgical procedures such as abdominal surgery (e.g., ovariohysterectomy, abdominal cryptorchidectomy, splenectomy, cystotomy) or major external surgeries (e.g., mastectomy, skin tumor removal ≤8 cm). The study demonstrated that PREVICOXtreated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with soft-surgery. A multi-center field study with 226 client-owned dogs of various breeds, and ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group was conducted. Dogs were randomly assigned to either the PREVICOX or the control (sham-dosedpilled) group for the control of postoperative pain and inflammation associated with orthopedic surgery. Surgery to repair a ruptured cruciate ligament included the following stabilization procedures: fabellar suture and/or imbrication, fibular head transposition, tibial plateau leveling osteotomy (TPLO), and ‘over the top’ technique. The study (n = 220 for effectiveness) demonstrated that PREVICOX-treated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with orthopedic surgery. Animal Safety: In a targeted animal safety study, firocoxib was administered orally to healthy adult Beagle dogs (eight dogs per group) at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated dose of 5 mg/kg, there were no treatment-related adverse events. Decreased appetite, vomiting, and diarrhea were seen in dogs in all dose groups, including unmedicated controls, although vomiting and diarrhea were seen more often in dogs in the 5X dose group. One dog in the 3X dose group was diagnosed with juvenile polyarteritis of unknown etiology after exhibiting recurrent episodes of vomiting and diarrhea, lethargy, pain, anorexia, ataxia, proprioceptive deficits, decreased albumin levels, decreased and then elevated platelet counts, increased bleeding times, and elevated liver enzymes. On histopathologic examination, a mild ileal ulcer was found in one 5X dog. This dog also had a decreased serum albumin which returned to normal by study completion. One control and three 5X dogs had focal areas of inflammation in the pylorus or small intestine. Vacuolization without inflammatory cell infiltrates was noted in the thalamic region of the brain in three control, one 3X, and three 5X dogs. Mean ALP was within the normal range for all groups but was greater in the 3X and 5X dose groups than in the control group. Transient decreases in serum albumin were seen in multiple animals in the 3X and 5X dose groups, and in one control animal. In a separate safety study, firocoxib was administered orally to healthy juvenile (10-13 weeks of age) Beagle dogs at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated (1X) dose of 5 mg/kg, on histopathologic examination, three out of six dogs had minimal periportal hepatic fatty change. On histopathologic examination, one control, one 1X, and two 5X dogs had diffuse slight hepatic fatty change. These animals showed no clinical signs and had no liver enzyme elevations. In the 3X dose group, one dog was euthanized because of poor clinical condition (Day 63). This dog also had a mildly decreased serum albumin. At study completion, out of five surviving and clinically normal 3X dogs, three had minimal periportal hepatic fatty change. Of twelve dogs in the 5X dose group, one died (Day 82) and three moribund dogs were euthanized (Days 38, 78, and 79) because of anorexia, poor weight gain, depression, and in one dog, vomiting. One of the euthanized dogs had ingested a rope toy. Two of these 5X dogs had mildly elevated liver enzymes. At necropsy all five of the dogs that died or were euthanized had moderate periportal or severe panzonal hepatic fatty change; two had duodenal ulceration; and two had pancreatic edema. Of two other clinically normal 5X dogs (out of four euthanized as comparators to the clinically affected dogs), one had slight and one had moderate periportal hepatic fatty change. Drug treatment was discontinued for four dogs in the 5X group. These dogs survived the remaining 14 weeks of the study. On average, the dogs in the 3X and 5X dose groups did not gain as much weight as control dogs. Rate of weight gain was measured (instead of weight loss) because these were young growing dogs. Thalamic vacuolation was seen in three of six dogs in the 3X dose group, five of twelve dogs in the 5X dose group, and to a lesser degree in two unmedicated controls. Diarrhea was seen in all dose groups, including unmedicated controls. In a separate dose tolerance safety study involving a total of six dogs (two control dogs and four treated dogs), firocoxib was administered to four healthy adult Beagle dogs at 50 mg/kg (ten times the recommended daily dose) for twenty-two days. All dogs survived to the end of the study. Three of the four treated dogs developed small intestinal erosion or ulceration. Treated dogs that developed small intestinal erosion or ulceration had a higher incidence of vomiting, diarrhea, and decreased food consumption than control dogs. One of these dogs had severe duodenal ulceration, with hepatic fatty change and associated vomiting, diarrhea, anorexia, weight loss, ketonuria, and mild elevations in AST and ALT. All four treated dogs exhibited progressively decreasing serum albumin that, with the exception of one dog that developed hypoalbuminemia, remained within normal range. Mild weight loss also occurred in the treated group. One of the two control dogs and three of the four treated dogs exhibited transient increases in ALP that remained within normal range. Made in France Marketed by: Merial Limited, Duluth, GA 30096-4640, U.S.A. 1-877-217-3543 NADA 141-230, Approved by FDA Rev. 07-2012 ®PREVICOX is a registered trademark of Merial. ©2015 Merial. All rights reserved.

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Pain Recognition & Management in Critical Care Patients Brandy Tabor, CVT, VTS (ECC)

ain management is crucial in critical care patients. Pain has multiple negative effects that can delay or prevent healing, and veterinary technicians play a central role in pain management. Understanding pain, its consequences, and how it can be addressed increases veterinary technicians’ ability to work with veterinarians to ensure that patients are comfortable both during hospitalization and when they go home. PHYSIOLOGY OF PAIN Nociceptors are unmyelinated peripheral neurons sensitive to noxious stimuli. They are found throughout the body and are triggered by mechanical, chemical, or thermal stimuli.1 When a stimulus activates a nociceptor, a nerve impulse is produced. This impulse is transmitted to the dorsal horn of the spinal cord, where it causes the release of neurotransmitters (e.g., aspartate, glutamate γ-aminobutyric acid [GABA]) and neuropeptides (substance P). Some of these are excitatory and continue to send the signal up the spinal cord to the brain, while others are inhibitory and inhibit the signal from traveling further. Inflammation causes an increase in excitatory neurotransmitters while reducing inhibitory neurotransmitters.2 There are three types of nerve fibers: A-delta, A-beta, and C fibers. A-delta fibers are medium to small, TODAY’SVETERINARYTECHNICIAN

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thinly myelinated, and conduct at a speed of 6 to 30 m/sec. A-beta fibers are larger, myelinated, and conduct at a speed of 30 to 70 m/sec. C fibers are small, unmyelinated, and conduct at a speed of 0.5 to 2 m/sec.1 A fibers are sensitive to thermal or mechanical stimulation, causing a sharp, localized pain, while C fibers can be sensitive to thermal, mechanical, or chemical stimuli, causing a dull, aching pain that is more diffuse.1,3

Brandy Tabor, CVT, VTS (ECC), is a senior emergency/ critical care technician at Animal Emergency & Specialty Center in Parker, Colorado. She is also chair of the Academy of Veterinary Emergency and Critical Care Technicians Credentials Committee, a board moderator with Veterinary Support Personnel Network, and an instructor of several courses at VetMedTeam.com. While pursuing her bachelor’s degree in equine science at Colorado State University, Ms. Tabor worked as an assistant in the critical care unit at the CSU Veterinary Teaching Hospital. There, the talented and knowledgeable nursing staff inspired her to become a veterinary technician specialist in emergency and critical care.

PATHOPHYSIOLOGY OF PAIN Pain, whether from injury or surgery, can have many detrimental effects if left untreated. The release of catecholamines in response to a painful stimulus results in tachycardia, hypertension, and an increase in oxygen consumption by the myocardium. If prolonged, this can lead to left ventricular dysfunction, ischemia, and possible infarction. An increase in the release of cortisol and glucagon can cause insulin resistance and hyperglycemia. Stress caused by pain increases the activity of clotting factors, leading to an increased risk for developing a coagulopathy. Stress also suppresses the immune system, leading to an increased risk for infection.4 If thoracic pain is present, the patient may be unwilling to breathe normally, leading to atelectasis. Decreased gastrointestinal motility and the development of ileus and urine retention after abdominal surgery (secondary to pain and an

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unwillingness to posture to urinate) can cause decreased bladder function. The patient may also be anxious, agitated, and unable to rest, prolonging the recovery period.4 RECOGNITION OF PAIN Recognition of pain has always been difficult in veterinary patients. Some patients are stoic and do not demonstrate obvious signs of pain, while others are very sensitive and will react to the slightest touch. The patient may be hunched, splint (stiffen its muscles) with abdominal palpation, vocalize (growl, hiss), refuse to lie down, stretch (FIGURE 1), be restless or agitated, be tachycardic or hypertensive, refuse to rise, or walk stiffly. If measures taken to relieve pain seem unsuccessful, it is helpful to ask the owner about the patientâ&#x20AC;&#x2122;s normal behavior and attitude. While pain management is a team effort, the veterinary technician plays a large role in recognition and treatment of pain. The patient should be assessed at the beginning of the shift so that any changes can be noted throughout the day.

A soft, thick bed can keep older patients more comfortable, while other patients prefer a thin blanket and refuse to lie down if the bed is too thick or soft. Cats often prefer a bed, although occasionally they prefer to lie in the litterbox. Cats that will not use a standard bed may be happier with a blanket placed in a second litterbox or no bed at all. Some canine breeds are normally vocal (e.g., beagles, Northern breeds). Veterinary technicians should be able to differentiate between normal vocalization and vocalization secondary to pain or discomfort.

Pain Versus Anxiety It is important to be able to distinguish between pain and anxiety because both can cause tachycardia, hypertension, and changes in posture. Removing the patient from its kennel or taking it out for a short walk may alleviate some anxiety. If an outside area is available, it is often advantageous to assess the patient outdoors to see if it is more relaxed out of the hospital environment. Patient comfort while in the kennel is equally important to reducing anxiety; however, individual preferences vary.

Assessing Pain Gentle palpation of the abdomen can reveal abdominal pain. Some patients become tense immediately on being touched, and it is helpful to place your hands on either side of the abdomen, wait for the patient to relax, and then slowly palpate the abdomen. If the patient tenses, leave your hands where they are until the animal relaxes again; then continue palpating. If the patient does not relax or is vocal, pain is likely present, and the veterinarian should be notified. If the patient is tachycardic when auscultated, it is advantageous to leave the stethoscope in place for a minute or two to give the patient a chance to relax and the heart rate to normalize. Pain is only one cause of tachycardia and other causes (e.g., hypovolemia, anxiety, excitement) should be ruled out. Painful patients are reluctant to move and often refuse to lie down or stand up because they anticipate pain associated with changing position (FIGURE 2). If a patient does not appear painful but refuses to lie down, it may be

FIGURE 1. This type of stretch, called prayer posture, can be a sign of pain. This dog presented for vomiting. He was later taken to surgery and underwent foreign body removal.

FIGURE 2. This dog was admitted to the hospital after being hit by a car. He is showing signs of pain, including refusing to lie down, panting, and an anxious expression. After receiving a bolus of fentanyl, he lay down and slept for several hours.

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

Pain Recognition and Management in Critical Care Patients

Pain has multiple negative effects that can delay or prevent healing, and veterinary technicians play a central role in pain management.

anticipating pain. It is often helpful to physically lay the patient down and sit with it until it has relaxed. Pain scales can be used to ensure pain assessment remains consistent. Colorado State University has developed pain scales for dogs and cats that assess behavior as well as response to environment and palpation (see pages 44 and 45). Cats Cats are often difficult to assess. They may be fractious by nature, and so hissing or growling may not indicate pain. Tachycardia and increased respiratory rate may be signs of anxiety rather than pain, and hiding, while a possible sign of pain, can also be caused by simple fear. To decrease stimuli that may contribute to fear and anxiety, covering the cage with a blanket may be beneficial. If possible, keeping feline patients in quieter surroundings (e.g., away from noisy dogs) may also help. A painful cat may be quiet while refusing to move or may become aggressive and growl or hiss while rolling in its kennel.5 It is worthwhile to try observing the cat from a distance in case your presence causes anxiety. When palpating for pain, it is recommended to palpate the area several times and watch for a repeatable pain response. If you are unsure whether the patient is painful, it is always best to assume that it is and administer analgesics. Team Communication If the veterinary technician believes a patient is in pain, he or she should approach the clinician to discuss additional pain management. It is in the patient’s best interest to obtain as much information as possible before going to the clinician with concerns (BOX 1). When talking to the

BOX 1 Pain Assessment Checklist  Observe the patient for behaviors associated with pain, such as anxious expression, restlessness, panting, and reluctance to move/change position.  Obtain the patient’s heart rate, blood pressure, and respiratory rate.  Palpate the patient to identify signs of abdominal pain or the need to urinate. Elevated heart rate, respiratory rate, and blood pressure and signs of anxiety may all be caused by the need to urinate and the patient’s unwillingness to soil its kennel.  Ensure that the intravenous catheter is patent and that the patient is receiving its prescribed analgesics at the proper dose.

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TECHPOINT 

clinician, technicians should be ready to discuss observed signs of pain, what has been done to address other possible causes of discomfort (e.g., walking the patient, checking the bedding, ensuring the intravenous catheter is patent), and what analgesics the patient is receiving, including the dose, frequency, and time of last administration. Of equal importance is communication between veterinary technicians. Rounds at the end of the shift should include information on the patient’s pain status as well as any concerns and opinions, including whether the patient is more anxious than painful or how it is responding to new analgesics. The same information given to the clinician should be given to the technician taking over care. PAIN MEDICATIONS It is vital that veterinary technicians be knowledgeable about the different types of pain medication available and the mechanism of action for each drug. TABLE 1 lists the most common pain medications used in veterinary medicine, the level of pain relief they provide, and their standard dosages. Opioids Several opioids are used in veterinary medicine. Opioids are classified based on the receptor they bind to as well as the effect of binding on receptor activity.6 Some opioids bind to only one receptor, while others bind to multiple receptors. There are three primary opioid receptors6: ÆÆ Mu—located in multiple areas, including the brain (thalamus and cortex) and spinal cord ÆÆ Delta—located in the brain ÆÆ Kappa—located in the brain and spinal cord When an opioid binds to a receptor, it may cause increased receptor activity with a maximum effect (agonist), increased receptor activity that plateaus at an effect lower than maximum (partial agonist), or decreased receptor activity (antagonist).6

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TABLE 1 Common Analgesics Used in Dogs and Cats6,7 PAIN LEVEL

CANINE DOSAGE

FELINE DOSAGE

COMMENTS

Tramadol

Mild to moderate

2–4 mg/kg PO BID–TID

 Synthetic analog of codeine that acts as a weak mu receptor agonist  Potency: 0.10  Often used for pain management in the home setting  Dogs: Analgesic properties are assumed secondary to serotoninergic and noradrenergic effects because of inability to convert to active metabolite8  Cats: Opioid effects8

Morphine

Severe

0.5–2.0 mg/kg IV q2–4h

0.2–0.5 mg/kg IV q3–4h

 Mu receptor agonist  Potency: 1  Can cause histamine release leading to vasodilation, hypotension, and pulmonary edema; also may cause cardiac and respiratory depression8  Contraindicated in patients in shock or undergoing mast cell tumor removal

Butorphanol

Mild to moderate

0.1–0.4 mg/kg IV/ IM q1–4h

0.1–0.4 mg/kg IV/ IM q2–6h

 Mu receptor antagonist  Kappa receptor partial agonist  Potency: 5  Duration of action: 30–45 min9  Can be used to reverse sedation and respiratory depression associated with pure mu agonists

Hydromorphone

Severe

0.05–0.2 mg/kg IV q1–4h

Contraindicated in cats because of potential for hyperthermia10

 Mu receptor agonist  Potency: 5  Does not cause the histamine release associated with morphine  Dogs: Can be given on presentation at 1 mg/kg

Oxymorphone

Severe

0.05–0.4 mg/kg IV q2–4h

0.2–0.5 mg/kg IV q3–4h

 Mu receptor agonist  Potency: 7  Does not cause the histamine release associated with morphine  May cause bradycardia, increased sensitivity to sound, and decreased ability to thermoregulate8

Buprenorphine

Moderate to severe

0.005–0.02 mg/kg IV/IM q6–8h

0.005–0.02 mg/ kg IV/IM/PO q8–12h

 Mu receptor partial agonist  Kappa receptor antagonist  Potency: 33  Dogs: PO administration is ineffective and not recommended in this species11  Cats: Transmucosal administration provides 100% bioavailability and quick onset of action in this species12

Fentanyl

Moderate to severe

2–5 mcg/kg/h CRI

 Mu receptor agonist  Potency: 100  Short duration of action  Has few cardiovascular effects  Can have mild respiratory effects  May lower body temperature through decrease in temperature set point6

Adjunct

0.0005 mcg/kg/h CRI

0.0005–0.0008 mcg/kg/h CRI

 Exerts effects in brain and dorsal horn of the spinal cord  Works well in conjunction with opioids  Higher doses are associated with notable cardiovascular and respiratory effects13

DRUG Opioids

Alpha-2 Agonist Dexmedetomidine

N-Methyl-D-Aspartate (NMDA) Agonist Ketamine

Adjunct

20 mcg/kg/min CRI

5–10 mcg/kg/min CRI

 Decreases sensitization of the central nervous system and increases activity of inhibitory neurons14

Adjunct

25–75 mcg/kg/ min CRI

10–40 mcg/kg/ min CRI, but use with caution in this species

 Sodium channel blocker  Dogs: Can be used systemically in dogs to block neuropathic pain and pain associated with inflammation15 as well as to decrease hyperalgesia and required opioid dose16  Cats: Has been shown to cause cardiac depression without any benefit17,18

Gabapentin

Moderate

2.5–10 mg/kg PO q8–12h17

2.5–5.0 mg/kg PO q12h17

 Binds to voltage-gated calcium channels that are upregulated in response to a noxious insult to inhibit calcium influx, thereby inhibiting release of excitatory neurotransmitters  Can be used while the patient is still on injectable analgesics to provide a smooth transition from intravenous to oral analgesics

Carprofen

Mild alone; moderate with opioid

2.2 mg/kg SC or PO BID 4.4 mg/kg SC or PO q24h

Contraindicated in cats

 NSAID

Local Anesthetic Lidocaine

Oral Analgesics

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Pain Recognition and Management in Critical Care Patients

Understanding the physiology and pathophysiology of pain, as well as being aware of the options available, can only serve to elevate patient care.

The potency of each opioid is compared with that of morphine (TABLE 1).6 The greater the potency, the smaller the dosage required for the drug to be effective. NSAIDs Nonsteroidal anti-inflammatory drugs (NSAIDs) inhibit cyclooxygenase (COX), an enzyme involved in the production of prostaglandins, some of which are mediators of the inflammatory response. There are two forms of COX: COX-1 and COX-2. COX-1 produces prostaglandin E2 (PGE2), which plays a role in several functions involving the gastrointestinal system, such as increasing mucus and bicarbonate secretion, decreasing gastric acid secretion, and increasing the rate of turnover of gastric mucosa cells. COX-1 is also indirectly involved in coagulation processes. In addition to PGE2, COX-2 produces prostacycline (PGI2), which causes vasodilation, inhibits platelet aggregation, and is involved with inflammation. PGE2 and PGI2 also decrease blood flow to the kidneys. Carprofen is a COX-2 specific NSAID, meaning it inhibits COX-2 without blocking the activity of COX-1. As a result, it has fewer gastrointestinal side effects, is less likely to cause bleeding secondary to platelet inhibition, and is less likely to cause renal disease.19 Dose Calculation Veterinary technicians are usually the ones calculating drug dosages and constant-rate infusions. It is important for technicians to be comfortable with these calculations and to be able to perform them accurately. Often, multiple calculations are required for a single drug, as shown in the case example on page 42.

TECHPOINT 

If the patient is on a constant-rate infusion (such as with fentanyl), a dose range allows the veterinary technician to make adjustments based on the patient’s pain level. This gives technicians the freedom to address pain quickly. Assessing Response to Medication Veterinary technicians play an important role in pain management. Often, because technicians monitor patients through their hospital stay, they are more able to recognize changes in patients’ behavior and can quickly tell if a patient is showing signs of pain or appears more comfortable. Changes in patient attitude, such as willingness to lie down or a decrease in anxiety, indicate whether pain management is adequate (FIGURE 3). Normalized heart rate, respiratory rate, and blood pressure are also signs that pain is well controlled. OTHER METHODS OF MINIMIZING PAIN It is also helpful to combine treatments so the patient is disturbed as little as possible. Bloodwork can be scheduled during normal treatment times, as can subcutaneous or intramuscular injections. If the patient is recumbent, taking it outside on a gurney can brighten its spirits. Depending on the cause of the pain, warm or cold compresses can be helpful. CONSIDERATIONS IN SPECIAL PATIENT POPULATIONS

FIGURE 3. This cat presented for a urethral obstruction 24 hours earlier. He is on oral buprenorphine and is very comfortable. When approached, he rolls over on his back, and he purrs when his belly is rubbed. TODAY’SVETERINARYTECHNICIAN

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Patients with Thoracostomy Tubes Thoracostomy tubes are known to cause severe pain that prevents the patient from fully expanding its lungs, which can lead to atelectasis. These patients are also reluctant to lie down and unable to rest. While systemic analgesia (primarily opioids) does address this pain, these patients benefit greatly from additional analgesia, including intercostal blocks or intrapleural analgesia.

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Case Example: Pain Management After Foreign Body Surgery Emma, a 22-kg, 6-year-old, spayed mixed-breed dog, presented with a 3-day history of vomiting and anorexia. On physical examination, Emma was tachycardic, panting, and anxious. When her abdomen was palpated, she splinted and whined. To address her pain, an intravenous (IV) catheter was placed and 0.1 mg/kg of hydromorphone was administered IV. Abdominal radiographs were highly suspicious for a foreign body. Emma was admitted to the hospital and started on a constant-rate infusion (CRI) of fentanyl (50 mcg/mL) to control her pain. The clinician ordered a CRI of 2 to 4 mcg/kg/hr. The CRI was started at a rate of 3 mcg/kg/hr. The delivery rate was calculated as follows: 22 kg × 3 mcg/kg/hr = 66 mcg/hr 66 mcg/hr 50 mcg/mL

= 1.32 mL/hr

Emma’s CRI was delivered at a rate of 1.3 mL/hr. Emma required an intestinal resection and anastomosis. Surgery went well, and the fentanyl CRI was continued postoperatively at 3 mcg/kg/hr. The following morning, the veterinary technician caring for Emma noted that she was quiet and reluctant to leave her kennel. She had urinated in her kennel and had not moved away from the soiled bedding. Once Emma was up, she moved slowly and was disinterested in her surroundings. When walked outside, Emma was unwilling to posture to urinate and consistently adopted a prayer

Intercostal blocks are performed by injecting bupivacaine (0.5%) caudal to the head of the ribs surrounding the insertion site of the thoracostomy tube. The bupivacaine dose should not exceed 5 mg/kg. If the patient and the volume of the dose are both small, the dose can be diluted with 0.9% saline. The total amount can be divided between several injection sites and can be given every 6 to 12 hours.20 Intrapleural analgesia may be more effective because the medication is injected directly into the pleural space. At the author’s hospital, bupivacaine at a dose of 1 mg/kg is injected into the thoracostomy tube, followed by 0.9% saline to ensure the drug reaches the pleural space. This is followed by injection of 1 mg/kg of lidocaine into the thoracostomy tube, and the tube is again flushed with 0.9% saline. This procedure is performed every 6 hours until the thoracostomy tube is removed. Neonatal, Pregnant, and Lactating Patients Drug absorption is disrupted in pregnant animals because of a decrease in gastrointestinal motility, increases in cutaneous blood flow, low-normal serum albumin levels, rapid renal 42

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FIGURE A. Emma in prayer posture.

posture, which allowed her to stretch her abdomen in an attempt to relieve her pain (FIGURE A). When the attending clinician palpated her abdomen, Emma splinted (arched her back) and tried to look around at her abdomen. She was tachycardic, panting, and appeared anxious. To address her pain, the clinician ordered an additional CRI of lidocaine at a rate of 25 mcg/kg/min. He asked that the lidocaine be placed in a 1 L bag of 0.9% sodium chloride and delivered at a rate of 25 mL/hr. The infusion rate was calculated as follows: 22 kg × 25 mcg/kg/min = 550 mcg/min Because the CRI would be delivered as mL/hr, the dose had to be converted to mcg/hr: 60 min/hr × 550 mcg/min = 33,000 mcg/hr

secretion, and increases in total body water.21 Drugs that are lipophilic will cross the placental barrier. Ionized, polar, or protein-bound drugs are less likely to do this.21 Drugs that are highly lipid soluble or non-ionized are excreted in milk and should be avoided in nursing animals. Current estimates state that nursing neonates will receive 1% to 2% of the drug dose.21 Pediatric patients may not be affected by some medications (e.g., ketamine) due to their underdeveloped N-methyl-D-aspartate (NMDA) system.21 NSAIDs should be avoided in pregnant patients because they block the production of prostaglandins. This can cause fetal abnormalities (orofacial cleft, ductus arteriosus, and underdeveloped kidneys). Fetuses and neonates may also eliminate some drugs more slowly due to their increased body water, increased tissue perfusion, lower plasma protein level, and immature hepatic system.21 CONCLUSION Veterinary technicians must act as patient advocates. Because technicians have the most contact with patients,

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Pain Recognition and Management in Critical Care Patients

1,320 mg

A 2% solution of lidocaine was used, meaning the concentration of lidocaine was 20 mg/mL. To calculate the delivery rate, it was first necessary to convert 33,000 mcg to mg: 33,000 mcg/hr 1000 mcg/mg

33 mg/hr 20 mg/mL

Calculate how many hours the bag of fluids will last: 1000 mL = 40 hr 25 mL/hr Then calculate the amount of lidocaine needed to provide 1.65 mL/hr for this period of time: 1.65 mL/hr × 40 hr = 66 mL For Emma’s CRI, 66 mL of lidocaine was added to 1 L of fluids, which was delivered at 25 mL/hr, to deliver 25 mcg/kg/min of lidocaine. This math can be double-checked by going backward: 66 mL of lidocaine × 20 mg/mL = 1,320 mg

they are in an ideal position to monitor and address pain. Understanding the physiology and pathophysiology of pain, as well as being aware of the options available, can only serve to elevate patient care.  References 1. Bourne S, Machado AG, Nagel SJ. Basic anatomy and physiology of pain pathways. Neurosurg Clin N Am 2014;25(4):629-638. 2. Reardon DP, Anger KE, Szumita PM. Pathophysiology, assessment, and management of pain in critically ill adults. Am J Health Syst Pharm 2015;72(18):1531-1543. 3. Steeds CE. The anatomy and physiology of pain. Surgery (Oxford) 2013;31(2):4953. 4. Dunwoody CJ, Krenzischek DA, Pasero C, et al. Assessment, physiological monitoring, and consequences of inadequately treated acute pain. J Perianesth Nurs 2008;23(1 suppl):S15-S27. 5. Taylor PM, Robertson SA. Pain management in cats—past, present and future. Part 1. The cat is unique. J Feline Med Surg 2004;6(5):313-320. 6. KuKanich B, Clark TP. The history and pharmacology of fentanyl: relevance to a novel, long-acting transdermal fentanyl solution newly approved for use in dogs. J Vet Pharmacol Ther 2012;35(suppl 2):3-19. 7. Gaynor SG, Muir WW. Handbook of Veterinary Pain Management. 3rd ed. St. Louis, MO: Elsevier; 2015. 8. Epstein ME. Opioids. In: Gaynor JS, Muir W, eds. Handbook of Veterinary Pain Management. 3rd ed. St. Louis, MO: Elsevier; 2015:161-195. 9. Mathews KA, Dyson DH. Analgesia and chemical restraint for the emergent patient.

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= 1.32 mg/mL

1.32 mg/mL × 25 mL/hr = 33 mg/hr

= 1.65 mL/hr

If the lidocaine were to be administered alone, it would be delivered at a rate of 1.65 mL/hr. However, the clinician had asked that it be added to 1 L (1000 mL) of 0.9% saline and delivered at a rate of 25 mL/hr. The veterinary technician therefore had to determine how much lidocaine to add to the liter of saline to deliver 25 mcg/kg/min when the fluids were running at 25 mL/hr. This was calculated as follows:

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1000 mL

33 mg/hr × 1000 mcg/mg = 33,000 mcg/hr 33,000 mcg/hr 60 min 550 mcg/min 22 kg

= 550 mcg/min

= 25 mcg/kg/min

Emma did well with this combination. After 24 hours, her lidocaine CRI was discontinued and the veterinary technician watched her closely for any signs indicating pain (tachycardia, panting, anxiety, restlessness, or an unwillingness to lie down). Emma continued to be pain free. When it was time to switch Emma to oral pain medications, she was given gabapentin at a dose of 9 mg/kg (200 mg total) PO TID. Her fentanyl CRI was discontinued several hours later, at which time she was started on tramadol at a dose of 4.5 mg/kg (100 mg total) PO TID. She did very well on this combination of drugs and was sent home the following morning. This case shows how a combination of analgesics can be used to control postoperative pain, as well as the multiple roles veterinary technicians play in pain management.

Vet Clin North Am Small Anim Pract 2005;35(2):481-515, viii. 10. Hansen B. Analgesia for the critically ill dog or cat: an update. Vet Clin North Am Small Anim Pract 2008;38(6):1353-1363, vii. 11. Ko JC, Freeman LJ, Barletta M, et al. Efficacy of oral transmucosal and intravenous administration of buprenorphine before surgery for postoperative analgesia in dogs undergoing ovariohysterectomy. JAAHA 2011;238(3):318-328. 12. Robertson SA, Taylor PM. Pain management in cats—past, present and future. Part 2. Treatment of pain—clinical pharmacology. J Feline Med Surg 2004;6(5):321-333. 13. Hansen BD. Analgesia and sedation in the critically ill. J Vet Emerg Crit Care 2005;15(4):285-294. 14. Berry SH. Analgesia in the perioperative period. Vet Clin North Am Small Anim Pract 2015;45(5):1013-1027. 15. Terkawi AS, Sharma S, Durieux ME, et al. Perioperative lidocaine infusion reduces the incidence of post-mastectomy chronic pain: a double-blind, placebo-controlled randomized trial. Pain Physician 2015;18(2):E139-E146. 16. Dyson DH. Analgesia and chemical restraint for the emergent veterinary patient. Vet Clin North Am Small Anim Pract 2008;38(6):1329-1352, vii. 17. Lamont LA. Adjunctive analgesic therapy in veterinary medicine. Vet Clin North Am Small Anim Pract 2008;38(6):1187-1203, v. 18. Quandt J. Analgesia, anesthesia, and chemical restraint in the emergent small animal patient. Vet Clin North Am Small Anim Pract 2013;43(4):941-953. 19. KuKanich B, Bidgood T, Knesl O. Clinical pharmacology of nonsteroidal antiinflammatory drugs in dogs. Vet Anaesth Analg 2012;39(1):69-90. 20. Pavlidou K, Papazoglou L, Savvas I, Kazakos G. Analgesia for small animal thoracic surgery. Compend Contin Educ Pract Vet 2009;31(9):432-436. 21. Mathews KA. Analgesia for the pregnant, lactating and neonatal to pediatric cat and dog. J Vet Emerg Crit Care 2005;15(4):273-284.

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Date Time Colorado State University Veterinary Medical Center

Canine Acute Pain Scale Animal is sleeping, but can be aroused - Not evaluated for pain Animal canâ&#x20AC;&#x2122;t be aroused, check vital signs, assess therapy

Rescore when awake

Pain Score

Example

Psychological & Behavioral

Response to Palpation

Comfortable when resting Happy, content Not bothering wound or surgery site Interested in or curious about surroundings

Nontender to palpation of wound or surgery site, or to palpation elsewhere

Content to slightly unsettled or restless Distracted easily by surroundings

Reacts to palpation of wound, surgery site, or other body part by looking around, flinching, or whimpering

Looks uncomfortable when resting May whimper or cry and may lick or rub wound or surgery site when unattended Droopy ears, worried facial expression (arched eye brows, darting eyes) Reluctant to respond when beckoned Not eager to interact with people or surroundings but will look around to see what is going on

Flinches, whimpers cries, or guards/pulls away

Unsettled, crying, groaning, biting or chewing wound when unattended Guards or protects wound or surgery site by altering weight distribution (i.e., limping, shifting body position) May be unwilling to move all or part of body

May be subtle (shifting eyes or increased respiratory rate) if dog is too painful to move or is stoic May be dramatic, such as a sharp cry, growl, bite or bite threat, and/or pulling away

Constantly groaning or screaming when unattended May bite or chew at wound, but unlikely to move Potentially unresponsive to surroundings Difficult to distract from pain

Cries at non-painful palpation (may be experiencing allodynia, wind-up, or fearful that pain could be made worse) May react aggressively to palpation

Body Tension

0 Minimal

Mild

Mild to Moderate Reassess analgesic plan

Moderate Reassess analgesic plan

Moderate to Severe May be rigid to avoid painful movement Reassess analgesic plan

Tender to palpation Warm Tense RIGHT

LEFT

Comments ÂŠ 2006/PW Hellyer, SR Uhrig, NG Robinson Reproduced with permission from Colorado State University

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Supported by an Unrestricted Educational Grant from Pfizer Animal Health

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lth

Date

Your Clinic Name Here

Time

Feline Acute Pain Scale

Rescore when awake

Pain Score

Example

Animal is sleeping, but can be aroused - Not evaluated for pain Animal canâ&#x20AC;&#x2122;t be aroused, check vital signs, assess therapy

Psychological & Behavioral

Response to Palpation

Content and quiet when unattended Comfortable when resting Interested in or curious about surroundings

Not bothered by palpation of wound or surgery site, or to palpation elsewhere

Signs are often subtle and not easily detected in the hospital setting; more likely to be detected by the owner(s) at home Earliest signs at home may be withdrawal from surroundings or change in normal routine In the hospital, may be content or slightly unsettled Less interested in surroundings but will look around to see what is going on

May or may not react to palpation of wound or surgery site

Decreased responsiveness, seeks solitude Quiet, loss of brightness in eyes Lays curled up or sits tucked up (all four feet under body, shoulders hunched, head held slightly lower than shoulders, tail curled tightly around body) with eyes partially or mostly closed Hair coat appears rough or fluffed up May intensively groom an area that is painful or irritating Decreased appetite, not interested in food

Responds aggressively or tries to escape if painful area is palpated or approached Tolerates attention, may even perk up when petted as long as painful area is avoided

Constantly yowling, growling, or hissing when unattended May bite or chew at wound, but unlikely to move if left alone

Growls or hisses at non-painful palpation (may be experiencing allodynia, wind-up, or fearful that pain could be made worse) Reacts aggressively to palpation, adamantly pulls away to avoid any contact

Prostrate Potentially unresponsive to or unaware of surroundings, difficult to distract from pain Receptive to care (even aggressive or feral cats will be more tolerant of contact)

Body Tension

Minimal

Mild

Mild to Moderate Reassess analgesic plan

Moderate Reassess analgesic plan

Moderate to Severe May not respond to palpation May be rigid to avoid painful movement

May be rigid to avoid painful movement Reassess analgesic plan

Tender to palpation Warm Tense RIGHT

LEFT

Comments ÂŠ 2006/PW Hellyer, SR Uhrig, NG Robinson

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Zoonosis: What Is All the Fuss About? Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition)

Belleville, Michigan

oonosis is defined medically as â&#x20AC;&#x153;a disease that can be transmitted from animals to people or, more specifically, a disease that normally exists in animals but that can infect humans.â&#x20AC;?1 Currently, there is no legal definition of zoonosis. For those who live and work with animals, zoonoses are occupational hazards that most other professionals do not encounter. These hazards extend to pet owners, and humans can also transmit disease to their companion animals. By their very nature, zoonotic diseases exist in the animal population; this source is referred to as a disease reservoir. A reservoir can be an animal or an inanimate object; the latter is referred to as a fomite. Soil, water, and plants can also serve as reservoirs.2 More than 800 zoonotic pathogens are known to affect humans, with 20 to 30 of these resulting from contact with dogs and/or cats.3,4 An estimated 75% of emerging infectious diseases are zoonotic, primarily of viral origin.5 Normal microbial changes can influence the spread of a zoonotic disease from a wildlife reservoir; this is of particular concern for veterinary professionals who work directly with wildlife, as well as for clients who live in more rural areas, where their animals may come in contact with infected wild animals or fomites.

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Ann is a 1983 graduate of Michigan State University. She has worked in general, emergency, and specialty practice, as well as education and management. Ann is active in her state, national, and specialty organizations and served on the organizing committees for the internal medicine and nutrition veterinary technician specialties. She has mentored over 15 fellow veterinary technician specialists. She has published over 45 articles in professional magazines, as well as book chapters, and is a coauthor of Nutrition and Disease Management for Veterinary Technicians and Nurses, now in its second edition.

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Microbial changes include mutations (e.g., genetic drift in viruses), activation and silencing of individual genes, genetic recombination, and conjugation, transformation, and transduction of bacteria.6 TRANSMISSION Three elements are required for successful disease transmission: (1) a source of infection, (2) host susceptibility, and (3) a route of transmission. Animal sources of infection include endogenous microflora that are pathogenic to humans, such as Salmonella spp in chickens; environmental sources include contaminated walls, floors, counters, cages, bedding, equipment, supplies, feed, soil, and water. Host susceptibility to infection varies greatly among the general population, with increased susceptibility seen in humans who are unvaccinated, very young or elderly, immunosuppressed, or pregnant or who have injuries (e.g., scratches, bite wounds) that pose a break in the normal defense mechanisms.3 The three main routes of pathogen transmission are contact, aerosol, and vector-borne transmission.3 BOX 1 outlines some of the more common zoonotic pathogens encountered in veterinary practice and their routes of transmission.

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Zoonosis: What Is All the Fuss About?

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Zoonosis is a disease that normally exists in animals but that can infect humans. Humans can also transmit disease to their companion animals.

BOX 1 Common Zoonotic Pathogens in Veterinary Practice and Routes of Transmission Direct/Indirect Contact Transmission  Fungi (cause several diseases, such as sporotrichosis)  Mites  Dermatophytes  Hookworms (cause cutaneous larval migrans)  Roundworms (cause visceral larval migrans)  Pasteurella spp  Bartonella spp  Salmonella spp  Escherichia coli O157:H7  Rabies virus Aerosol Transmission  Bordetella spp  Influenza viruses (specific strains)  Mycobacterium tuberculosis Vector-borne Transmission  Borrelia burgdorferi (causes Lyme disease)  Yersinia pestis (causes plague)  Bacillus anthracis (causes anthrax)  Rickettsia rickettsii (causes Rocky Mountain spotted fever)

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Direct contact can be through ingestion of the pathogen (usually via the fecal–oral route), puncture wounds (e.g., needlesticks, bites), or mucous membrane exposure. Indirect contact transmission can happen through exposure to fomites, such as when cleaning cages and equipment or handling dirty laundry. Aerosol transmission is possible when a pathogen travels through the air, whether via large droplets deposited on mucous membranes or smaller particles that can be inhaled. Large droplets can be generated by patient coughs, sneezes, and vocalization and by veterinary personnel during such procedures as lancing of abscesses and dentistry procedures. Particles may also become aerosolized through the use of suction units, during bronchoscopy, and when sweeping, vacuuming, and using high-pressure spray washers. In general, the risk of aerosol transmission increases with proximity and duration of exposure to the source; however, once aerosolized, certain pathogens may remain infective over long distances, depending on particle size, the nature of the pathogen, and such environmental factors as temperature and humidity.3 Vector-borne transmission occurs when vectors such as fleas, mosquitoes, and ticks transmit disease as a result of their normal feeding activities. Working outdoors may

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increase the risk of exposure to insects and other biologic vectors.3 Each vector may have the ability to transfer more than one disease during each period of contact. EDUCATION Preventing zoonoses starts by understanding the ways diseases can be transmitted between humans and animals. The next step is education of veterinary personnel and clients. A 1999 study surveyed 327 veterinarians and 322 physicians about how often they encountered zoonotic diseases to suggest the appropriate role each profession should play in educating the public on zoonotic diseases, prevention, and precautions.7 The findings indicated that veterinarians encounter zoonotic diseases in their practices or discuss them with their clients more frequently than physicians. Small animal practitioners encountered zoonotic disease more frequently than large animal veterinarians; however, the small animal veterinarians indicated they encountered or discussed zoonotic diseases on a weekly rather than a daily basis.7 Physicians indicated that they felt that “veterinarians should play an equal or greater role in advising patients about zoonotic diseases” and that “veterinarians should be involved not only in controlling zoonotic disease pathogens in animals, but also in providing information for patients and physicians.” However, despite these feelings, there was almost a complete lack of communication between physicians and veterinarians about zoonotic disease issues.7 If physicians are not asking patients about the pet population in their homes and veterinarians are not asking clients about the health status of humans in the household, it is difficult, if not impossible, to advise clients about the zoonotic risks associated with pet ownership as well as measures that can be taken to mitigate those risks. Veterinary technicians can begin the educational process by asking clients about elderly people living in the home and whether their pets interact with individuals who are on immunosuppressive drugs. LEGAL ISSUES As the incidence of zoonotic disease rises, the legal impact on the veterinary health care team could become significant.4 Concern among veterinarians is increasing because of the threat of legal liability for a practice’s failure to diagnose and treat an animal with a zoonotic disease and educate owners about the risks of these diseases.4 The Companion Animal Parasite Counsel (capcvet.org) provides excellent, up-to-date resources to help practitioners, and the American Animal Hospital Association’s Parasite Counselor Program (aaha.org/ 48

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TECHPOINT 

More than 800 zoonotic pathogens are known to affect humans, with 20 to 30 of these resulting from contact with dogs and/or cats. professional/education/parasite_counselor.aspx) aids in training staff on zoonosis and parasite transmission. Lawyers can also become involved in liability surrounding infection with zoonotic disease.8 In the 1990s, a child in New Haven, Connecticut, sustained permanent vision loss due to ocular larval migration of Toxocara spp acquired from a puppy. The pet store that sold the puppy to the family settled out of court for $1.5 million.8 To help avoid legal action against the veterinary health care team, a proactive approach is best. The practice should identify resources to educate the entire staff about zoonotic diseases, especially parasites. Clients must be educated about the health risks of zoonotic diseases in their pets. Client handouts (see p. 51) help reinforce these messages. Preventive parasite control programs should be developed and recommended. It is important to record all medical treatments provided and to note treatments and tests that were recommended but declined by owners. To be certain that the parasite monitoring system is as accurate as possible, the staff must ensure that samples used are fresh and representative of the animal in question, use the most accurate method (centrifugation of samples rather than gravity floatation), and be well trained to accurately identify what is found under the microscope. Clients should sign consent forms releasing the veterinary practice from liability if they decline recommended diagnostic procedures such as deworming.9 PREVENTION Veterinary Standard Precautions Because the most common mode of transmission is direct/ indirect contact, the best way to prevent transmission is through the use of Veterinary Standard Precautions (VSPs). VSPs are guidelines designed to minimize the risk of zoonotic infections from recognized and unrecognized sources and should be used whenever personnel may be exposed to potentially infectious materials, including feces,

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Zoonosis: What Is All the Fuss About?

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Clients must be educated about the health risks of zoonotic diseases in their pets. Client handouts help reinforce these messages.

blood, body fluids, and exudates, or when skin is not intact.3 VSPs include strategies to reduce the potential for bites and other traumas that may result in exposure to zoonotic pathogens. Each practice should develop VSPs to fit its individual risks and exposures. Model plans can be found in the Compendium of Veterinary Standard Precautions for Zoonotic Disease Prevention in Veterinary Personnel.3 Injury Prevention Dog and cat bites, kicks, scratches, and crush injuries account for most occupational injuries among veterinary personnel. According to one source, up to 18% of dog bites and up to 80% of cat bites become infected with a mix of aerobic and anaerobic bacteria.3 Measures to prevent bite injuries include physical restraints, bite-resistant gloves, muzzles, sedation or anesthesia, and reliance on experienced veterinary personnel rather than owners for restraint. A note should be made in the medical record about animals with aggressive tendencies or a history of biting or that are unpredictable, and this should be communicated to attending personnel. Veterinary professionals cannot rely on clients to provide this information before a bite has occurred. Needlestick injuries are the most frequent accidents in the veterinary workplace.3 They usually involve inadvertent injection of vaccines but could also result in inoculation of bacteria from fine-needle aspirates or blood draws. Handwashing and Disinfectant Use Consistent, thorough handwashing is the single most important measure to reduce the risk of disease transmission.3 In veterinary practice, handwashing is preferred over the TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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use of alcohol-based lotions or rubs because of routine contamination with organic materials such as blood, feces, urine, and saliva. Most disinfectants do not penetrate organic material; therefore the contamination would still be present on the skin under the material if only a lotion or rub is used. Handwashing with plain (not antibacterial) soap and running water mechanically removes organic material and reduces the number of bacterial organisms on the skin. To help reduce the opportunity for cross-contamination, liquid or foam soap is recommended over bar soap. Refillable containers should be emptied and cleaned before being refilled to prevent creation of a bacterial reservoir. The use of moisturizing soaps can help improve compliance as well as maintain skin integrity by reducing dry, cracked skin.3 The handwashing process should take at least 20 seconds. Alcohol-based rubs and lotions are highly effective against bacteria and enveloped viruses but should only be used if hands are not visibly soiled with organic matter. These products are not as effective against nonenveloped viruses such as parvovirus, bacterial spores such as Clostridium spp, or protozoal parasites such as coccidia and cryptosporidia. When using a rub or lotion, the product should be applied to one hand and then rubbed to cover all surfaces of both hands and fingers. Hands should continue to be rubbed together until the product has dried completely.3 Personal Protective Equipment Wearing gloves helps reduce the risk of pathogen transmission by providing a physical barrier between the skin and the pathogen. Gloves are not a substitute for handwashing. While wearing gloves is not necessary when handling healthy

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animals, gloves should be worn when handling an animal with evidence of disease or whose medical history is unknown.3 Gloves should always be worn when contact with feces, blood, body fluids, secretions, excretions, exudates, and the handler’s nonintact skin is likely, including when cleaning cages, tabletops, litterboxes, and environmental surfaces such as keyboards and telephones.3 Gloves should be changed between examinations of individual animals or animal groups such as litters of puppies or kittens, between clean and dirty procedures performed on a single patient, and whenever they become torn or their integrity is in question. Dirty gloves should be removed promptly after use, and contact between the skin and the outer glove surface should be avoided during removal. Prompt glove removal before touching objects such as cage doors, medical equipment, and supplies can help to prevent surface (fomite) contamination. Disposable gloves should not be reused. Hands should be washed as soon as gloves are removed to eliminate any potential contamination. Facial protection prevents the mucous membranes in the eyes, nose, and mouth from contact with infectious materials and should be worn whenever exposure to splashes or sprays is likely, such as during lancing of abscesses, flushing of wounds, dentistry procedures, nebulization of medications, suction or lavage of wounds, and necropsies. Adequate facial protection includes a surgical facemask and goggles or a face shield. A surgical facemask provides adequate protection during most veterinary procedures that generate potentially infectious large droplets.3 The type of shield selected depends on the extent of anticipated droplet generation. For example, a dental procedure would be expected to generate more droplets than would emptying a suction container during surgery. Protective outerwear such as laboratory coats and coveralls are designed to protect street clothes or scrubs from contamination. Unless designed to be fluid resistant, they should not be used when splashing or soaking with potentially infectious material is likely. Wet clothes should be promptly changed whenever they become visibly soiled or contaminated with feces or body fluids. Clothes should be changed daily and not worn outside of the work environment.3 References 1. Zoonotic. www.medicinenet.com. Accessed October 1, 2015. 2. Romich JA. Zoonotic disease history. In: Understanding Zoonotic Diseases. Clifton Park, NY: Thomson Delmar Learning; 2008:1-9. 3. National Association of State Public Health Veterinarians Veterinary Infection Control Committee. Compendium of veterinary standard precautions for zoonotic disease prevention in veterinary personnel. JAVMA 2015;247(11):12521277; correction JAVMA 2016;248(2):171. http://www.nasphv.org/Documents/ VeterinaryStandardPrecautions.pdf. Accessed February 2016. 4. Ford R. Zoonoses: how real the threat? Proc AAHA 75th Conf Tampa, FL, 2008. 5. Chomel BB, Belotto A, Meslin FX. Wildlife, exotic pets and emerging zoonoses.

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Nonsterile procedure gowns provide a better moisture barrier than laboratory coats and can be used for general care of animals in isolation. Impermeable gowns should be used when splashes or large quantities of fluids are present or anticipated. Disposable gowns should not be reused. Reusable fabric gowns may be worn repeatedly for the same animal in isolation but should be laundered between contact with different animals or when soiled. Gloves and gowns should be removed and placed in the garbage or laundry bin before leaving the animal’s environment. Hands should be washed immediately after leaving the area. Vector Control For vector-borne diseases, effective vector control is an integral part of any intervention strategy.6 Integrated pest management is a comprehensive approach used to prevent and control various pests that can transmit diseases.3 This approach uses several strategies. Physical barriers to infestation include sealed building entry and exit points, window screens, and metal or thick plastic containers for food storage. Rodent traps should be maintained and monitored, and potential vector nesting materials and breeding sites should be eliminated. For example, standing water should be regularly removed, and/or mosquito dunks should be used in standing water tanks or rain barrels.3 Use of insecticides and pesticides should be part of a whole plan, not the only tactic used to control pests. CONCLUSION This article cannot provide a complete or exhaustive list of standard precautions regarding zoonoses, but it addresses the most relevant points for veterinary personnel and pet owners. Public education and behavioral changes are important factors in successful control of disease transmission. Zoonoses should be discussed as part of client education. Pet owners should be provided with gloves (and possibly surgical masks) when appropriate to help prevent exposure at home. It is in everyone’s best interest to keep some areas of our lives separate from our animals—especially the more pathogenic ones. 

7. 8. 9.

Emerg Infect Dis 2007;13(1):6-11. wwwnc.cdc.gov/eid/article/13/1/06-0480_article. Accessed October 2015. Kruse H, Kirkemo AM, Handeland K. Wildlife as source of zoonotic infections. Emerg Infect Dis 2004;10(12):2067-2072. wwwnc.cdc.gov/eid/article/10/12/04-0707_article. Accessed October 1, 2015. Grant S, Olsen CW. Preventing zoonotic disease in immunocompromised persons: the role of physicians and veterinarians. Emerg Infect Dis 1999;5(1):159-163. Hawn R. Zoonosis: how lifestyle alters risks to people and pets. Vet Tech 2006;27(8A):4-6. Bowman D, Lucio-Forster A. Focus on companion animal zoonosis. https:// vetmedteam.com/class.aspx?ci=238. Accessed February 2016.

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CLIENT HANDOUT

Children and Hygiene: Tips for Reducing

Zoonotic Disease Risk  Keeping your own pets healthy and parasite-free is a great way to reduce the risk of zoonotic disease. This includes scheduling regular veterinary visits, staying current on vaccines, and using effective parasite control.  Frequent and thorough handwashing is critically important in preventing transmission of many zoonotic organisms.  Petting zoos and other interactive animal habitats are valuable educational tools, but children (especially infants and children younger than 5 years) must be properly supervised to help reduce their risk for exposure to zoonotic diseases.

What Are Zoonotic Diseases? Zoonotic diseases are illnesses caused by organisms such as viruses and bacteria (also called pathogens) that can be transmitted between animals and humans. Direct contact with a sick animal is not always necessary for a zoonotic pathogen to be transmitted. For example, humans can be exposed to roundworms through contact with feces-contaminated soil, even if the infected animal is nowhere around. Some zoonotic diseases, like rabies and salmonellosis, are relatively well known, whereas others, like leptospirosis, are less familiar. Although rabies is a very frightening disease because it causes fatal illness in humans and animals, there are many other zoonotic diseases that can make a person sick but not necessarily cause death.

Why Are Children at Risk for Exposure to Zoonotic Diseases?

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Anyone can contract a zoonotic infection, even a healthy adult, but children are understood to be at greater risk for several reasons. Compared with adults, children tend to have more direct contact with areas that can be contaminated by animal waste, such as the ground, grass, sandboxes, and

standing water. Children are also less likely to wash their hands before eating, and they are more likely to put their hands into their mouths (nail biting, thumb sucking, etc.) during the course of regular daily activities. Additionally, the immune system of a child may not be able to effectively fight off an infection if exposure occurs. The same may be true for adults whose immune systems are compromised by disease (e.g., AIDS), immunosuppressive treatment (e.g., chemotherapy), or other causes (e.g., pregnancy, advanced age).

What Types of Animals Can Transmit Zoonotic Pathogens? Any animal is capable of transmitting a zoonotic pathogen. For example, the rabies virus can be transmitted by cats, dogs, goats, sheep, and a variety of other domestic and wild animals. Certain animals, however, tend to be associated with specific zoonotic diseases. Cats, for example, can transmit Bartonella bacteria that cause “cat-scratch disease.” Salmonella bacteria can be transmitted to humans through contact with several animal species, most notably reptiles (like turtles and lizards), birds, and some rodents. Dogs and cats can have

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Tips for Reducing Zoonotic Disease Risk continued intestinal parasites, like roundworms and hookworms, that can be transmitted to humans and cause illness. Because it can be difficult to know exactly which animals can put a person at risk, it is best to exercise good hygiene and some other important preventive measures when around any animals—even your own pets.

How Can Children Be Protected from Zoonotic Diseases? Petting zoos, classroom pets, and other interactive animal habitats are valuable educational tools for children, but the potential risk for exposure to zoonotic diseases in these environments should not be dismissed. Because children are particularly vulnerable, it may be safest to prevent their contact with certain animals, such as amphibians, reptiles, baby chicks, and ducklings, to help reduce the risk of exposure to pathogens potentially carried by these animals. In fact, the Centers for Disease Control and Prevention (CDC) has recommended this precaution for children under the age of 5 years. However, avoidance is not always possible or practical, so organizations like the CDC, National Association of State Public Health Veterinarians, and American Veterinary Medical Association (AVMA) are trying to educate the public about the best ways to protect children, adults, and pets from exposure to zoonotic diseases.

Want more information? The CDC and AVMA offer advice about proper handwashing procedure and other ways to protect your family from zoonotic diseases:  AVMA: Pets and Zoonotic Diseases (FAQ)  CDC: Infants and Young Children—Animal Safety Tips  CDC: Wash Hands When Leaving Animal Exhibits

The good news is that you don’t necessarily have to get rid of your pet lizard or abandon trips to farms or petting zoos to protect your loved ones from zoonotic diseases—although, if your home contains young children or immunocompromised people, you should consult

your veterinarian about the potential risks. Some basic precautions can significantly reduce the risk of anyone becoming ill:  Apparently healthy animals can still transmit certain zoonotic diseases, but keeping your own pets healthy is a great place to start. This means scheduling regular wellness visits with your veterinarian, keeping vaccines up-to-date, and staying on top of parasite prevention. Preventive medications for fleas, roundworms, and other parasites are highly recommended for your pets. Discuss these points with your veterinarian to make sure your pet is being adequately protected.  Wash hands thoroughly after handling pets, before eating or drinking, before preparing food, after using the restroom, after removing dirty shoes or clothes, and after leaving an area where animals are kept— even if you don’t remember touching anything. Children should be taught when and how to properly wash their hands.  Handwashing with soap and water is preferable to using alcohol-based sanitizers, especially when your hands are visibly dirty. Alcohol-based sanitizers can be used if your hands are free of visible dirt.  After washing your hands, don’t dry them on your clothing or previously used towels.  Teach children to avoid direct contact with wild animals. Wild animals should not be approached or touched, and they certainly should not be kept as pets.  Keep litterboxes clean, and pick up after your dog. Ideally, wear gloves when handling animal urine or feces.  Don’t eat or drink in areas where animals are kept.  Don’t let animals lick your mouth, and don’t share your food with them.  When at a petting zoo or other place where touching animals is encouraged, always remind children to (1) wash their hands afterward (even if they didn’t touch anything), (2) not eat or drink anything until they have left the animal area and washed their hands, and (3) avoid putting anything into their mouths. Children younger than 5 years should be closely supervised, and toys and pacifiers should not be permitted into areas where animals are housed. 

© 2016 Today’s Veterinary Technician. Created by Vetstreet and peer-reviewed by Today’s Veterinary Technician. Brought to you by VetFolio. Today’s Veterinary Technician grants permission to individual veterinary clinics to copy and distribute this handout for the purposes of client education. For a downloadable PDF, please visit www.todaysveterinarytechnician.com.

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STAY ON GARD against heartworm disease PLUS hookworms and roundworms.

Data on file at Merial.

PREVENTS HEARTWORM DISEASE

TREATS AND CONTROLS 3 SPECIES OF HOOKWORMS

TREATS AND CONTROLS 2 SPECIES OF ROUNDWORMS

#1 RECOMMENDED HEARTWORM DISEASE PREVENTIVE 1

SAFE FOR PUPPIES AT 6 WEEKS

IMPORTANT RISK INFORMATION: HEARTGARD® Plus (ivermectin/pyrantel) is well tolerated. All dogs should be tested for heartworm infection before starting a preventive program. Following the use of HEARTGARD Plus, digestive and neurological side effects have rarely been reported. For more information, please visit www.HEARTGARD.com.

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Adapted with permission from the 2015 Tampa AAHA Yearly Conference Proceedings (c) American Animal Hospital Association (aaha.org).

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Getting Started in Physical Rehabilitation Mary Ellen Goldberg, BS, LVT, CVT, SRA, CCRA Canine Rehabilitation Institute, Wellington, FL

Mary Ellen is a graduate of Harcum College and the University of Pennsylvania. She has been an instructor of anesthesia and pain management for VetMedTeam since 2003. In 2007, she became a surgical research anesthetist certified through the Academy of Surgical Research. In 2008, she became the executive secretary of the International Veterinary Academy of Pain Management. In addition, she is on the Proposed Organizing Committee for the Academy of Physical Rehabilitation Veterinary Technicians for the formation of a NAVTA recognized VTS-physical rehabilitation program.

s veterinary technicians, we vow to further our knowledge and competence through a commitment of lifelong learning.1 Physical rehabilitation is an exciting and challenging field in which veterinary technicians can develop new skills and grow in their career development. Over the past decade, awareness of animal physical rehabilitation has increased, and rehabilitation has become a rapidly growing service within veterinary specialty hospitals, referral centers, and primary care practices. Every day, we hear more about laser therapy and underwater treadmills, equipment not traditionally covered in the veterinary technician college curriculum. Learning more about rehabilitation enables veterinary technicians to better assist supervising veterinarians when physical rehabilitation therapies are recommended. This article aims to answer some basic questions about rehabilitation and how to become certified to work in this field as a veterinary technician.

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Mary Ellen has written several books and contributed to numerous chapters regarding anesthesia, pain management, and rehabilitation. She has worked in various aspects of veterinary medicine ranging from small animal to zoo animal medicine.

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OVERVIEW OF WORKING IN PHYSICAL REHABILITATION The greatest asset for effective physical rehabilitation is an educated veterinary team.2 A rehabilitation veterinary technician should work under the direct supervision of a credentialed rehabilitation veterinarian who directs therapy. The larger team may be made up of a credentialed physical therapist, the referring veterinarian, a veterinary specialist (e.g., surgeon, neurologist), a veterinary chiropractor, an acupuncturist, hospital support staff, the owner, and other trained veterinary professionals.3 The duties of a rehabilitation veterinary technician include assisting the supervising therapist in evaluating patients and performing prescribed therapies, keeping patient records up-to-date and accurate, and educating clients on how to perform home exercises. The American Association of Rehabilitation Veterinarians strongly discourages anyone working as a rehabilitation veterinary technician unless the

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Getting Started in Physical Rehabilitation as a Veterinary Technician

person has graduated from a certified rehabilitation school. Credentialed rehabilitation veterinary technicians can apply prescribed therapeutic exercises and physical modalities, some of which are described below.

chewables

CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. INDICATIONS: For use in dogs to prevent canine heartworm disease by eliminating the tissue stage of heartworm larvae (Dirofilaria immitis) for a month (30 days) after infection and for the treatment and control of ascarids (Toxocara canis, Toxascaris leonina) and hookworms (Ancylostoma caninum, Uncinaria stenocephala, Ancylostoma braziliense). DOSAGE: HEARTGARD® Plus (ivermectin/pyrantel) should be administered orally at monthly intervals at the recommended minimum dose level of 6 mcg of ivermectin per kilogram (2.72 mcg/lb) and 5 mg of pyrantel (as pamoate salt) per kg (2.27 mg/lb) of body weight. The recommended dosing schedule for prevention of canine heartworm disease and for the treatment and control of ascarids and hookworms is as follows:

Therapeutic Exercises Therapeutic exercises are a daily part of the rehabilitation veterinary technician’s routine. The therapist chooses the exercises, and the technician carries them out. Exercises may focus on improving proprioception, balance, speed, endurance, focal strength, pelvic limb function, forelimb function, neurologic function, or land treadmill endurance training.4 Therapeutic exercise equipment includes physioballs, cavaletti rails, balance blocks and discs, weights, tunnels, rocker boards, wobble boards, and treadmills (FIGURES 1 AND 2).5

Dog Weight

Chewables Per Month

Ivermectin Content

Pyrantel Content

Color Coding 0n Foil Backing and Carton

Up to 25 lb 26 to 50 lb 51 to 100 lb

1 1 1

68 mcg 136 mcg 272 mcg

57 mg 114 mg 227 mg

Blue Green Brown

HEARTGARD Plus is recommended for dogs 6 weeks of age and older. For dogs over 100 lb use the appropriate combination of these chewables. ADMINISTRATION: Remove only one chewable at a time from the foil-backed blister card. Return the card with the remaining chewables to its box to protect the product from light. Because most dogs find HEARTGARD Plus palatable, the product can be offered to the dog by hand. Alternatively, it may be added intact to a small amount of dog food. The chewable should be administered in a manner that encourages the dog to chew, rather than to swallow without chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes after administration to ensure that part of the dose is not lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended. HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors), potentially carrying infective heartworm larvae, are active. The initial dose must be given within a month (30 days) after the dog’s first exposure to mosquitoes. The final dose must be given within a month (30 days) after the dog’s last exposure to mosquitoes. When replacing another heartworm preventive product in a heartworm disease preventive program, the first dose of HEARTGARD Plus must be given within a month (30 days) of the last dose of the former medication.

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If the interval between doses exceeds a month (30 days), the efficacy of ivermectin can be reduced. Therefore, for optimal performance, the chewable must be given once a month on or about the same day of the month. If treatment is delayed, whether by a few days or many, immediate treatment with HEARTGARD Plus and resumption of the recommended dosing regimen will minimize the opportunity for the development of adult heartworms. Monthly treatment with HEARTGARD Plus also provides effective treatment and control of ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). Clients should be advised of measures to be taken to prevent reinfection with intestinal parasites. EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development of the adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). ACCEPTABILITY: In acceptability and field trials, HEARTGARD Plus was shown to be an acceptable oral dosage form that was consumed at first offering by the majority of dogs. PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult heartworms and microfilariae before initiating a program with HEARTGARD Plus. While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level, HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due to dead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials with ivermectin alone after treatment of some dogs that have circulating microfilariae.

FIGURE 1. Balance discs are used to help patients improve proprioception.

Keep this and all drugs out of the reach of children. In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans. Store between 68°F - 77°F (20°C - 25°C). Excursions between 59°F - 86°F (15°C - 30°C) are permitted. Protect product from light. ADVERSE REACTIONS: In clinical field trials with HEARTGARD Plus, vomiting or diarrhea within 24 hours of dosing was rarely observed (1.1% of administered doses). The following adverse reactions have been reported following the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions and hypersalivation.

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SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability of ivermectin. The dose regimens of HEARTGARD Plus and HEARTGARD are the same with regard to ivermectin (6 mcg/kg). Studies with ivermectin indicate that certain dogs of the Collie breed are more sensitive to the effects of ivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds. At elevated doses, sensitive dogs showed adverse reactions which included mydriasis, depression, ataxia, tremors, drooling, paresis, recumbency, excitability, stupor, coma and death. HEARTGARD demonstrated no signs of toxicity at 10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies, support the safety of HEARTGARD products in dogs, including Collies, when used as recommended.

FIGURE 2. Wobble boards are another type of equipment that can be used for proprioception exercises. TODAY’SVETERINARYTECHNICIAN

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HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant or breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea collars, dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with HEARTGARD Plus in a heartworm disease prevention program. In one trial, where some pups had parvovirus, there was a marginal reduction in efficacy against intestinal nematodes, possibly due to a change in intestinal transit time. HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (See DOSAGE section) for dogs of different weights. Each strength comes in convenient cartons of 6 and 12 chewables. For customer service, please contact Merial at 1-888-637-4251.

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FIGURE 3. Massage may involve tapping, stroking, kneading, wringing, or skin rolling motions, either parallel to the muscle fibers or at an angle, and can be performed at a range of pressures.4

FIGURE 4. Cryotherapy is an adjunct physical modality typically indicated for management of acute injury or inflammation.

Patient considerations such as motivation, footing, assistive devices, and leash/harness control must be assessed before beginning any exercise program, and therapist/handler body mechanics must be monitored to prevent injury.5 Exercises are designed to address specific impairments, and each is described with a goal, a technique, and a progression.5 Details of therapeutic exercises can be found in recent textbooks (BOX 1); however, to fully understand and perform these therapies, certification in rehabilitation is necessary.

Manual Techniques Specialized manual techniques are used extensively in evaluating and treating rehabilitation patients.4 Credentialed technicians are trained in these techniques, which include massage, range of motion (ROM) exercises, and stretching. Massage may involve tapping, stroking, kneading, wringing, or skin rolling motions, either parallel to the muscle fibers or at an angle, and can be performed at a range of pressures (FIGURE 3).4 ROM exercises may be normal, in which a joint moves through its full ROM, or passive. Passive ROM exercises use an external force to move a joint without muscle contraction through its available ROM.6 Stretching techniques are often performed in conjunction with ROM exercises to improve flexibility of the joints and extensibility of periarticular tissues, muscles, and tendons.6

BOX 1 Recommended Reading  Marcellin-Little DJ, Levine D, Millis DL, eds. Rehabilitation and physical therapy. Vet Clin North Am Small Anim Pract 2015;45(1).  Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014.  Zink MC, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: John Wiley and Sons; 2013.

Physical Modalities Rehabilitation physical modalities are used as adjuncts to the patient’s treatment plan (FIGURE 4). Physical modalities are used as tools to alleviate pain; improve strength, flexibility, and joint ROM; and aid in tissue healing.7 A brief list of these modalities is presented in BOX 2. Recordkeeping Proper documentation of treatments should be completed each day. Any member of the rehabilitation team should be able to refer to the record and understand the needs and past treatments of each patient. Because pain plays a role in any patient’s willingness and motivation, each patient’s pain score should be assessed and documented in the medical record during each visit.11

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Getting Started in Physical Rehabilitation as a Veterinary Technician

Veterinary assistants who are interested in becoming certified, licensed, or registered veterinary technicians should investigate the State Practice Act of their home state to see what practicing as a veterinary technician encompasses.

A detailed history should indicate the degree of pain, the disability,12 and how the patient copes with the disability. If changes in a patient’s pain level are noted, the supervising veterinarian should be notified. It is very important for the rehabilitation veterinary technician to remain in open communication with his or her supervisor about anything abnormal or any changes in a patient’s progress. (Pain scales from Colorado State University are reprinted on pages 44 and 45.) Client Communication Clear client communication and education are also essential to successful rehabilitation. The owner/handler must be well educated on the exercise program, especially the home exercise program.5 However, each client’s needs and expectations can vary depending on the time available for home exercises. The client needs guidance for home exercises, and the completion (or not) of home exercises should be documented in the record. Often, printed instructions, as well as verbal and physical directions, need to be provided for the client to completely understand what each exercise entails. This is also documented in the record.

BOX 2 Selected Physical Modalities  Superficial thermal agents7,8  Heat (thermotherapy): Stimulates vasodilation and causes increases in extensibility, thus reducing joint stiffness and leading to increased range of motion  Cold (cryotherapy): Typically indicated for management of acute injury or inflammation  Neuromuscular electrical stimulation: Usually used to address muscular weakness7  Transcutaneous electrical nerve stimulation: Used for pain relief7  Therapeutic ultrasound: Deep heating technique used for rehabilitating musculoskeletal conditions9  Low-level laser therapy: Used for many applications, including acceleration of wound healing; promotion of muscle regeneration; treatment of acute and chronic pain, chronic and acute edema, and neurologic conditions; and postoperative care10  Extracorporeal shock wave therapy: Used for increased bone, tendon, and ligament healing; accelerated wound healing; antibacterial therapy; and pain relief 7

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TECHPOINT 

Specialized Areas Additional areas of education include topics such as aquatic therapy, canine orthotics and prosthetics, orthopedic and neurologic rehabilitation, canine sports medicine, pain management, nutrition, and working with geriatric patients. HOW TO BECOME A CERTIFIED REHABILITATION VETERINARY TECHNICIAN A certified rehabilitation veterinary technician is a certified, licensed, or registered veterinary technician who has completed a prescribed curriculum to receive the designation of CCRA (Certified Canine Rehabilitation Assistant), CCRP (Certified Canine Rehabilitation Practitioner), Certified Equine Rehabilitation Assistant (CERA), or CVMRT (Certified Veterinary Massage and Rehabilitation Therapist). Currently, 4 certification programs in the United States offer these respective titles (BOX 3). Each program involves formal educational courses and wet labs, and each school has its own curriculum. The cost is relatively expensive for a veterinary technician, but certification allows veterinary technicians to command a higher salary. Only certified, licensed, or registered veterinary technicians are accepted into the existing rehabilitation certification programs. In the approximately 40 states and provinces in which veterinary technicians are certified, registered, or licensed, candidates are tested for competency through an examination that may include oral, written, and practical portions. This process is regulated by a state board

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BOX 3 US Veterinary Rehabilitation Certification Programs  The Animal Rehabilitation Institute offers the Certified Equine Rehabilitation Assistant (CERA) program for veterinary technicians and physical therapist assistants. Classes are held in Florida. animalrehabinstitute.com  The Canine Rehabilitation Institute offers the Certified Canine Rehabilitation Assistant (CCRA) program for veterinary technicians at training facilities in Florida and Colorado. A 40-day internship is required as part of the program. caninerehabinstitute.com/CCRA.html  Healing Oasis offers the Certified Veterinary Massage and Rehabilitation Therapist (CVMRT) program for licensed or certified veterinary technicians, licensed veterinarians, licensed physical therapists, licensed nurses, and licensed or certified massage therapists at its facility in Wisconsin. healingoasis.edu/veterinary-massage-rehabilitation-therapy-program/  NorthEast Seminars offers the Certified Canine Rehabilitation Practitioner (CCRP) and Certified Equine Rehabilitation Practitioner (CERP) programs for veterinary technicians, veterinarians, and physical therapists at The University of Tennessee. vet.utk.edu/clinical/rehab/programs.php

What Next for Credentialed Rehabilitation Veterinary Technicians? For those who are already credentialed in physical rehabilitation, the formation of the Academy of Physical Rehabilitation Veterinary Technicians (APRVT; aprvt.com) is under way. APRVT (proposed) is a group of credentialed rehabilitation veterinary technicians working toward forming a veterinary technician specialty (VTS) recognized by the North American Veterinary Technician Association (NAVTA). APRVT is a nonprofit organization dedicated to supporting CCRAs/CCRPs in the field of veterinary sports medicine and rehabilitation. This board certification will allow veterinary technicians to possess the credential VTS (Physical Rehabilitation). The academy’s mission statement is, “We are credentialed rehabilitation veterinary technicians providing assistance in physical rehabilitation, encouraging veterinary technicians to further education, while improving the quality of animals’ lives.” For information about the Academy, please contact the following members of the Proposed Organizing Committee:  Kristen Hagler, President | goldengaitk9@gmail.com  Wendy Davies, Vice President | k9guru13@gmail.com  Deana Cappucci, Secretary | dcapps13@yahoo.com  Lis Conarton, Treasurer | lis@vmccny.com  Mary Ellen Goldberg, Exam Committee Chair | mewhitester@gmail.com

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T E C HP O I N T 

Getting Started in Physical Rehabilitation as a Veterinary Technician

A rehabilitation veterinary technician’s job is complex and fulfilling. There are advancements in veterinary medicine daily, and animal physical rehabilitation is on the cutting edge.

define the responsibilities of veterinary technicians. These responsibilities and duties depend in part on the type of employment the individual chooses. Standards for practice acts can be found on websites of the North American Veterinary Technician Association (navta.net) and the American Association of Veterinary State Boards (aavsb.org). Veterinary assistants who are interested in becoming certified, licensed, or registered veterinary technicians should investigate the State Practice Act of their home state to see what practicing as a veterinary technician encompasses. CONCLUSION A rehabilitation veterinary technician’s job is complex and fulfilling. There are advancements in veterinary medicine daily, and animal physical rehabilitation is on the cutting edge. Many conferences offer specific tracks of learning in physical rehabilitation, such as the North American Veterinary Community Conference, WVC, and the American Animal Hospital Association Conference. If you enjoy exercise, training, massage, and recovery, then you may want to consider this field. 

of veterinary examiners or the appropriate state agency. Every state is unique and maintains its own regulations with respect to the practice of veterinary medicine. Practice acts, legislated by states and provinces, often References 1. North American Veterinary Technician Association. Veterinary Technician Code of Ethics. 1987. https://c.ymcdn.com/sites/www.navta.net/resource/ collection/946E408F-F98E-4890-9894-D68ABF7FAAD6/navta_vt_code_of_ethics_07. pdf. Accessed January 2016. 2. Sprague S. Introduction to canine rehabilitation. In: Zink MC, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: John Wiley & Sons; 2013:83. 3. Levine D, Adamson CP. Conceptual overview of physical therapy, veterinary medicine, and canine physical rehabilitation. In: Millis DL, Levine D, Taylor RA, eds. Canine Rehabilitation and Physical Therapy. St. Louis, MO: Saunders/Elsevier; 2004:18. 4. Coates J. Manual therapy. In: Zink MC, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: John Wiley & Sons; 2013:100. 5. McCauley L, Van Dyke JB. Therapeutic exercise. In: Zink MC, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: John Wiley & Sons; 2013:132156. 6. Millis DL, Levine D. Range of motion and stretching exercises. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014:431-446. 7. Niebaum K. Rehabilitation physical modalities. In: Zink MC, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: John Wiley & Sons; 2013:115128. 8. Hanks J, Levine D, Bockstahler B. Physical agent modalities in physical therapy and rehabilitation of small animals. Vet Clin North Am Small Anim Pract 2015;45:29-44. 8. Levine D, Watson T. Therapeutic ultrasound. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014:328339. 9. Millis DL, Saunders DG. Laser therapy. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014:359378. 10. American Association of Rehabilitation Veterinarians. Model Standards for Veterinary Physical Rehabilitation Practice. 2011. rehabvets.org/model_standards.lasso. Accessed January 2016. 11. Davies L. Chapter 11. In: Egger CM, Love L, Doherty T, eds. Canine Rehabilitation in Pain Management in Veterinary Practice. Ames, IA: John Wiley and Sons; 2014:134.

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Career Challenges

Creating Altitude in Your Career

hat does the longevity of your current job position look like? Do you have a plan for your retirement? What about when you are unable to carry that 60-pound dog across the room to get him into surgery? The veterinary technician profession is not only emotionally and mentally challenging, it also takes a physical toll. Many of us concentrate so hard on being a great veterinary technician that we don’t think about the physical demands until it is too late. Fortunately, there are opportunities for advancement within our profession that allow us to escape some of the physical stress, yet still work closely with clients, pets, and our team. One such avenue is to develop your business acumen and become a certified veterinary practice manager (CVPM). Sound interesting? Veterinary practice managers assist in all aspects of day-to-day practice operations, including team culture, human resources, financial reporting, inventory control, expense management, client interactions, and much more. All too often, practice owners become overburdened with trying to manage all these responsibilities in addition to practicing medicine. For many, their first instinct is to move their head veterinary technician into a management position—ready or not. Unfortunately, this promotion often comes with little guidance, training,

Jennifer Yurkon, CVT Altitude Veterinary Consulting Wellington, Colorado Jennifer grew up on a dairy farm in Western New York, where she quickly learned that she loved to take care of animals. In SUNY Delhi’s Veterinary Science Technology program, she discovered that she not only enjoyed being part of a nursing team, but also had a knack for leading one. Since that time, she has taken on many leadership roles in veterinary medicine. Currently, she is studying to take the Certified Veterinary Practice Manager examination.

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Jennifer and her husband are owned by an Australian shepherd, Roo; a Boston terrier, Zoom; two cats, Stinger and Chewy; and a “very boisterous” guinea pig, Miss Piggy. They are both active in the Larimer County 4-H program, especially with meat quality assurance and dairy cattle projects, and attend numerous continuing education meetings for veterinary medicine. VETERINARY PRACTICE MANAGERS assist in all aspects of day-to-day practice operations, including team culture, human resources, financial reporting, inventory control, expense management, and client interactions. 60

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There are opportunities for advancement within our profession that allow us to escape some of the physical stress, yet still work closely with clients, pets, and our team. or support, which typically does not work out well for either party. CVPMs are trained to take the daily responsibility of running the practice off the owner–veterinarian’s plate, allowing him or her to focus on medicine and thereby improving the efficiency and profitability of the practice. HOW DO I BECOME A CVPM? The Veterinary Hospital Managers Association (VHMA) created the CVPM certification program in 1989. The VHMA website, vhma.org, contains useful information about all aspects of practice management, including support for those willing to pursue certification. The VHMA has been instrumental in helping veterinarians and managers improve veterinary businesses since 1981. What does it take to become a CVPM? Candidates for this certification must meet the following education and experience requirements: ÆÆ 48 continuing education (CE) credits specific to management topics ÆÆ 18 management-based college credits in areas such as accounting and leadership ÆÆ Minimum of 36 months in clinical practice management ÆÆ Demonstrated proficiency in at least 26 of 30 areas in veterinary practice management ÆÆ 4 extensive professional reference letters Candidates who have completed all the prerequisites can apply for the opportunity to sit for the national certification exam. As you can see, becoming certified is not an easy process. It requires dedication and persistence. Instead of looking at these requirements as hurdles, consider them stepping stones to becoming one of the few who can call themselves a CVPM. Currently, only about 400 professionals throughout the entire world have successfully achieved CVPM certification. TODAY’SVETERINARYTECHNICIAN

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Career Challenges

Creating Altitude in Your Career

WHAT ARE THE ADVANTAGES OF BECOMING A CVPM? Besides being an elite group, CVPMs have more professional opportunities. Personally, I find the most rewarding aspect of the process of becoming a CVPM is having the ability to benefit more patients because I am further immersed in the day-to-day operations of my practice. Another valuable aspect is access to the CVPM networking community. You can communicate with your peers to seek advice, bounce ideas around, and form lasting friendships. In addition to the improved job satisfaction, there is a potential financial gain in becoming a CVPM.1 Are you ready to get started on advancing your career? HOW DO I START THE CERTIFICATION PROCESS? Where can you find opportunities to obtain 48 CE credits in management? Options for CE range from local events to large national conferences such as those run by the American Animal Hospital Association (AAHA), American Veterinary Medical Association (AVMA), CVC, North American Veterinary Community (NAVC), and WVC. If you haven’t yet had the opportunity to attend one of the larger national veterinary conferences, you should consider investigating the possibility, as you may be able to acquire most of your credits at one time. I had the opportunity to attend the AVMA conference in July 2014 in Denver, Colorado. It was an incredible experience. Between the classes taught by experts from all over the world to the numerous networking opportunities, it was great! If you can’t attend a large national conference, webinars and practice management classes taught by CVPMs are also available, and the VHMA website has registered practice management groups for many states. Check to see if you have a practice managers’ group nearby. Attending these local meetings is a great way to network with managers in your area, and the CE can be applied toward your needed credits. In addition to obtaining CE credits, you will need to take appropriate management classes. If you already have college credits, you can submit your unofficial transcripts to the VHMA office for review to get a better idea of what classes you need. I was fortunate enough to find a local community college that offered various business and management classes at an affordable price. Additionally, I took online classes at my own pace while working as an active practice manager. Once you have completed all the requirements and submitted your application with all the necessary

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Career Challenges

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The CVPM examination tests your knowledge of employment regulations, the AVMA Model Veterinary Practice Act, inventory control, drug calculations, financial reporting, and other aspects of veterinary medicine and business.

documentation and deposit, the approval process begins. Use this time to prepare for the actual examination. HOW DO I PREPARE FOR THE EXAMINATION? Prepping for your CVPM examination is a challenging process. The examination requires you to be knowledgeable in many areas, including employment regulations, the AVMA Model Veterinary Practice Act, Drug Enforcement Agency regulations, Occupational Safety and Health Administration standards, inventory control, drug calculations for usage, financial reporting, and various other aspects of veterinary medicine and business. Where do you start? Several resources for CVPM test preparation exist (BOX 1). You can attend veterinaryspecific management curricula, such as those offered by Veterinary Management Consultation (VMC), Purdue, and AAHA, in a classroom setting. The VHMA also offers The CVPM Preparation Workbook and webinars. The workbook can be an essential resource to assist you through the entire process of CVPM certification. It provides candidates with the tools they need to prepare for, and to streamline the process of eligibility to sit for, the exam. For me, as someone who has recently submitted my CVPM application, it’s challenging to break away from the day-to-day operations of the practice and find classroom time to study and prepare for the examination. My plan is to use self-paced, online courses such as those on vetmedteam.com and vspn.org as much as possible. Additionally, I have a phone app (see BOX 1) that provides sample questions for study purposes. Now that you have a better understanding of what it takes to become a CVPM, are you ready to change your

TECHPOINT 

altitude and consider a new avenue for your career in veterinary management? I am looking forward to the career changes, benefits, challenges, and new opportunities I anticipate as a CVPM. I am also excited to build a fabulous network as I meet more CVPMs in my future. As I have been told, “You never know who the next person may know.” 

Reference 1. Shupe C. The VHMA files: results from the 2013 compensation and benefits survey. Firstline February 1, 2014. Accessed December 23, 2015. veterinaryteam.dvm360. com/vhma-files-results-2013-compensation-and-benefits-survey?rel=canonical

BOX 1 Selected CVPM Examination Preparation Resources Practice Management Programs

 AAHA Veterinary Management School | aaha.org/professional/education

 Purdue University Veterinary Practice Management Program | vet.purdue.edu/vpmp

 VMC School of Veterinary Practice Management | vmc-inc.com/vmc-school.html

Publication

 VHMA CVPM Preparation Workbook | vhma.org

 VetMedTeam | vetmedteam.com

 Veterinary Support Personnel Network (VSPN) | vin.com/ce

shutterstock.com/Inga Ivanova

Online CE

Phone App

 CVPM Veterinary Practice Manager | dynamicpath.com

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The Hairy Eyeball: What’s Your Culprit? Shannon Daley, BS

Portland Veterinary Specialists Portland, Maine

hen presenting a pet for a physical ailment, owners often provide vague descriptions of clinical signs and misleading theories about their causes. It is the job of veterinary professionals to help decipher the underlying problem through detailed history taking and examination so that patients can be treated appropriately. Ocular problems are often described as “red” and “irritated” eyes. Myriad problems can present as “red eye.” Commonly missed causes of red eye are irritants that arise from the eye itself. Surprisingly, in practice, it seems that the most common causes are not external irritants or trauma, but rather abnormal hairs arising from the eyelids or periocular region. Taking a thorough history and performing an ocular examination help determine whether the hair irritant is normal hair growth in an abnormal position or abnormal growth (misplaced hair).

Shannon’s love for animals started long before she got into veterinary medicine. She attended University of Southern Maine to earn her bachelor’s degree in biology. Shortly after graduation, she started working in the animal field and became a veterinary technician with onthe-job learning. Her veterinary career began 6 years ago in a general practice, and she has been with Portland Veterinary Specialists for the past 2 years. Shannon says, “I couldn’t be happier in the field I have chosen. I get to have animals as patients throughout the day, aiding in their care, and also get to come home to my personal 4-legged kids. Life in the veterinary medicine field, in my opinion, is as good as it gets.”

NORMAL HAIR GROWTH Sometimes, normal hairs from the eyelid tissue can evert or roll inward, irritating the cornea. This is called entropion. It can either be caused by a primary, hereditary condition or develop secondary to pain and spasticity of the eyelids. When it is a primary problem, surgical correction is needed to reposition the eyelids. TODAY’SVETERINARYTECHNICIAN

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When it is a secondary problem, such as from a corneal ulcer, fixing the primary problem often corrects the spastic entropion. Another source of irritation is trichiasis, which refers to a normal hair that is misplaced and touches the cornea or conjunctiva, causing irritation. Trichiasis can arise from any point along the eyelid or nasal fold region and is most commonly observed in brachycephalic breeds. If the irritation arises from the nasal folds, grooming may fix the issue, but nasal fold resection may be needed.1 Medial canthal trichiasis (FIGURE 1) is hair that specifically arises from the inside corner of the eyelid (i.e., the medial canthus). It is more prevalent in specific breeds, such as Shih Tzus, Pekingese, and other brachycephalic breeds, although many breeds can be affected.2 To examine for medial canthal trichiasis, position the patient to the side to enable a lateral view of the medial canthus; then locate the medial caruncle, a small raised area of conjunctival tissue where the upper and lower eyelids join deep within the medial corner of the eye. Medial canthal trichiasis often arises from hair follicles in the caruncle.3 Once it is confirmed that hairs are emerging from the caruncle, treatment options can be considered. These hairs are a constant source of

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FIGURE 1. Medial canthal trichiasis arising from caruncle. Image courtesy of Portland Veterinary Specialists irritation and predispose the patient to corneal irritation and possible ulceration. For patients that are poor candidates for anesthesia or whose owners have financial concerns that preclude a surgical option, periodic epilation can relieve some or most of the irritation. It is important to educate clients that the hairs regrow and the process will need to be repeated. For owners who want to pursue a more permanent treatment, surgical options include cryosurgery and medial canthoplasty. Cryosurgery tends to be less invasive and does not alter the pet’s conformation, but the potential for hair regrowth remains. In this procedure, which requires general anesthesia, a probe is used to freeze the region from which the hair arises, which discourages regrowth.3 Medial canthoplasty is a permanent fix. The caruncle in the medial canthus containing the trichiasis is surgically excised, and the inner corner of the eyelids is reformed.4 This procedure shortens the eyelid margins and can alter the patient’s appearance, but the irritant will be permanently removed. The choice of procedure typically depends on the client’s comfort level, and both options are adequate. Some clients prefer to start with cryosurgery; if the trichiasis regrows, medial canthoplasty can be pursued. These procedures are routinely performed by veterinary ophthalmologists. 64

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ABNORMAL HAIR GROWTH Distichiasis Abnormal or aberrant hairs are often missed as a cause of ocular irritation. Distichiasis is an aberrant hair growth in which abnormal cilia (distichia) arise along the eyelid margin, originating from the meibomian glands. These glands are designed to supply the ocular surface with an oily substance that protects the surface of the eye by preventing evaporation of the tears. Hairs are not supposed to arise from these glands.5 FIGURE 2 shows a canine eyelid margin with distichiasis. Distichia tend to be soft, but they rub and irritate the cornea as the pet closes its eye. Distichiasis can range from mild to severe, and certain breeds tend to have higher degrees of distichiasis. Depending on the severity, a variety of clinical signs may be noted, including hyperemia, epiphora, and/or blepharospasm.3 The important task is to determine the best way to treat the underlying problem. If there are only a few stray hairs, they can be epilated fairly easily, but this is not a permanent fix and the hairs typically grow back at various rates. Cryosurgery offers a more permanent

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The Hairy Eyeball: Whatâ&#x20AC;&#x2122;s Your Culprit?

FIGURE 2. Distichia contacting a cornea. Image courtesy of Portland Veterinary Specialists solution, typically for patients that have multiple distichia on more than one eyelid. There is still the chance that a few hairs may grow back, but generally not enough to cause the degree of irritation initially noted. After cryosurgery, some mild to moderate swelling is to be expected, and the potential for some eyelid depigmentation exists; both should resolve in time but can be startling to the owners at first.4 Veterinary technicians should therefore prepare owners for these temporary effects. Resection of the affected area of eyelid is another procedure to treat clusters of distichia; however, because of the potential scarring and loss of functional eyelid margins, this tends not to be the preferred treatment. The decision of how to treat distichiasis varies among veterinarians but is often based on the severity of the problem.1 TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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Ectopic Cilia Ectopic cilia (FIGURE 3) are another type of abnormal hair growth that can cause irritation. These cilia arise from the palpebral conjunctiva, most commonly on the upper eyelid. Whereas distichia tend to brush the cornea, ectopic cilia are more perpendicular to the cornea. Ectopic cilia tend to be sharper than distichia and, because of their location and orientation, contact the cornea more directly and aggressively. As a result, ectopic cilia typically cause corneal abrasions. To discover ectopic cilia on examination, it is important to rotate/evert the eyelid margin outward and look along the conjunctiva. Sometimes, ectopic cilia are not as obvious as distichia. The tissue around the cilium can become irritated, causing conjunctival swelling that can obscure and hide the cilium. If this is the case, ectopic cilia can be missed. If ectopic cilia are suspected, it is important to palpate the

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T E CHP O I N T 

Determining the source of ocular irritation can be a frustrating battle, especially when dealing with abnormal hairs. It is important to conduct a thorough examination, taking into account the animal’s breed and age. area in question under topical anesthetic using a sterile cotton swab. Often, veterinary technicians may observe a raised red area and occasionally a small spot of pigment. Ectopic cilia are often noted in younger dogs, especially in retriever breeds, but can be seen in any breed. Surgical excision is needed to provide relief from an ectopic cilium. Some veterinarians choose to apply

The Hairy Eyeball: What’s Your Culprit?

cryosurgery to the site after the cilia are removed, but such decisions are made on a case-by-case basis. Ectopic cilia tend to be a more hidden source of ocular irritation but should remain on the differential diagnosis until the cause of irritation is determined.4 CONCLUSION Determining the source of ocular irritation can be a frustrating battle, especially when dealing with abnormal hairs. It is important to conduct a thorough examination, taking into account the animal’s breed and age. Also, a diagnosis should never be limited to a single cause until the possibility of multiple causes has been eliminated. The eye and its supporting structures are complex, and irritation can come from numerous sources.  References 1. Turner S. Veterinary Ophthalmology. A Manual for Nurses and Technicians. New York: Elsevier; 2005. 2. Lim CC. Small Animal Ophthalmic Atlas and Guide. Ames, IA: John Wiley & Sons; 2015: 73-74. 3. Martin CL. Eyelids. In: Ophthalmic Diseases in Veterinary Medicine. London: Mason; 2005:145-182. 4. Stades FC, Gelatt KN. Diseases and surgery of the canine eyelids. In: Gelatt KN, ed. Veterinary Ophthalmology. 4th ed. Ames, IA: Blackwell; 2007:563-617. 5. Turner SM. Eyelids. In: Saunders Solutions in Veterinary Practice. Small Animal Ophthalmology. Toronto, ON: Saunders Elsevier; 2008.

FIGURE 3. Ectopic cilium arising from palpebral conjunctiva after eversion of eyelid. Image courtesy of Portland Veterinary Specialists 66

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Final Thoughts What Monkeys Can Teach Us: Letting Go There’s an ancient parable about how hunters used to trap monkeys. Coconuts were hollowed out, filled with bananas or other monkey delicacies, and then tied to a tree. A hole big enough for a monkey’s hand was cut in each coconut. The monkeys would come and reach into the coconuts for the food, but the holes were crafted such that although a flexible hand could fit in, a fist could not be pulled out. By holding on to the food, the monkeys essentially became trapped—trapped by their attachment and clinging to the food. All they had to do was let go to free themselves, but their minds trapped them. When we cling or become attached to an idea, a feeling, or a desired outcome, we too become trapped by our minds. Recently, I conducted a compassion fatigue workshop in a large veterinary practice. At the end of the workshop, a veterinary technician named Katie (not her real name) confided in me that it was an “aha” moment for her. “I try to take away all the pain from my patients and the clients and it’s killing me,” she said. “I just realized how badly I need to let go and how it’s not my pain to take on.” She hugged me and went on to tell me how she could feel so much weight being lifted from her with that single realization.

Julie Squires Rekindle, LLC Julie is a compassion fatigue specialist who brings a unique perspective and approach to support the sustained energy and passion of animal workers. Her company, Rekindle LLC, offers on-site compassion fatigue training to veterinary hospitals, animal shelters, and other animal organizations. Julie has more than 20 years of experience within the veterinary field and with leading organizations. She has developed and executed training, workshops, and 1:1 coaching for major companies in the animal health industry. She obtained her certification as a compassion fatigue specialist through the Green Cross Academy of Traumatology and has also completed training from The Figley Institute and Traumatology Institute. Julie’s clients also gain from her experience as a certified health and wellness coach and corporate wellness specialist.

Letting Go with the Four Noble Truths Twenty-five hundred years ago, the Buddha identified how suffering comes from patterns of thinking and behaving. These insights are referred to as The Four Noble Truths. The first noble truth: In life, there is suffering because of the impermanent nature of things. While we all understand on some level that things are always changing and death is inescapable, we still vehemently resist change in all forms. To end suffering caused by uncontrollable change, we need to accept the change. Resistance is futile. The second noble truth: Suffering is caused by attachments and expectations, by grasping and clinging. Just like the monkeys and their refusal to let go of the coconuts, we pay a hefty price for our attachments. The third noble truth: It’s possible to end suffering by giving up attachments (clinging) and expectations (grasping). In my experience, and in my workshops, practicing and embodying the concept from mindfulness of being with what is has provided me and so many others with not only relief from suffering but also implicit freedom.

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What Monkeys Can Teach Us: Letting Go

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Final Thoughts

We tend to resist whatever is happening that we don’t like. As long as life is going the way we like, we’re fine. But the minute a coworker is curt with us, or a patient dies unexpectedly, or our car breaks down, we find ourselves expending a ton of energy to push away what we don’t like or trying to change the unchangeable. What being with what is offers is to stop fighting with reality. The freedom results from acceptance. That does not mean we have to like it, but we do have to accept it. The fourth noble truth: The way to end suffering from clinging and grasping is through balance and living in the present. Here is where we get the opportunity to practice over and over again, every day! In my life, I try to constantly give myself the chance to acknowledge my thoughts and emotions and, with that, find balance. By being “present,” or self-aware, I allow myself to feel what I’m feeling and lean in rather than pull away, resist, or cling. I’m not perfect, but I don’t try to be. I treat myself the way I would treat a good friend, reminding myself to let go of the what-ifs and the if-onlys and see where I am right now and what it’s like. Am I happy? Yes. Savor it! Am I suffering? Yes. Why? Let it go. Where in your life are you holding on, attached, or clinging to a thought or feeling that is trapping you? Is it an unrealistic expectation of yourself, or anger or resentment against a client or coworker? Wherever it is, see if you can find the self-compassion and kindness that you so easily give to others and gift it to yourself. Jon Kabat-Zinn, founder of the renowned “MindfulnessBased Stress Reduction” program, reminds us that our breath teaches us this very lesson of letting go. When we take in a breath, we then have to let it go, otherwise there is no room for the next breath.1 Breathing is a constant rhythm of taking in (receiving) and letting go. And this rhythm we practice over and over again, every single day.  Reference 1. Kabat-Zinn J. Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life. New York, NY: Hachette Books; 2005.

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C o n fi d e n c e i n eve r y d ro p.

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®FRONTLINE is a registered trademark, and TMSATISFACTION PLUS GUARANTEE is a trademark, of Merial. ®TERMINIX is a registered trademark of the Terminix International Company Limited Partnership Terminix International, Inc. ©2015 Merial, Inc., Duluth, GA. All rights reserved. FLE16TRADEAD4 (01/16).

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Straubinger RK, Chang YF, Jacobson RH, Appel MJ. Sera from OspA-vaccinated dogs, but not those from tick-infected dogs, inhibit in vitro growth of Borrelia burgdorferi. J Clin Microbiol. 1995;33(10):2745-2751. Rice Conlon JA, Mather TN, Tanner P, Gallo G, Jacobson RH. Efficacy of a nonadjuvanted, outer surface protein A, recombinant vaccine in dogs after challenge by ticks naturally infected with Borrelia burgdorferi. Vet Ther. 2000;1(2):96-107. Probert WS, Crawford M, Cadiz RB, LeFebvre RB. Immunization with outer surface protein (Osp) A, but not OspC, provides cross-protection of mice challenged with North American isolates of Borrelia burgdorferi. J Infect Dis. 1997;175(2):400-405.

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