Today's Veterinary Technician, May 2016 by davidpsu

DENTISTRY WHEN EXTRACTION IS NOT AN OPTION

NUTRITION FEEDING PUZZLES FOR FOOD AND ENRICHMENT

EMERGENCY/CRITICAL CARE URETHRAL OBSTRUCTION IN MALE CATS

CLINICAL PATHOLOGY SAMPLE VARIABLES AND TEST RESULTS

INTERNAL MEDICINE MOTION SICKNESS IN DOGS

TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN |

An Official Journal of the NAVC

| todaysveterinarytechnician.com | Volume 1, Number 3 | May/June 2016 |

WELLNESS

HELPING PETS ENJOY THEIR GOLDEN YEARS

Smart is…

6-in-1 protection. Take parasite protection further with a broad coverage chewable dogs will love.

†

Offer chewy, tasty, and easy coverage against both internal and external parasites. To order, contact your distributor or call your Virbac representative at 1-844-4-VIRBAC (1-844-484-7222).

Dogs should be tested for heartworm prior to use. Mild hypersensitivity reactions have been noted in some dogs carrying a high number of circulating microfilariae. Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention. Please see full product label for more information, or visit www.virbacvet.com. References: 1. Trifexis® [product label]. Indianapolis, IN: Elanco; 2014. 2. Heartgard® Plus [product label]. Duluth, GA: Merial Inc; 2011. * A. caninum. † Prevents flea eggs from hatching; is not an adulticide. © 2015 Virbac Corporation. All Rights Reserved. SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation. TRIFEXIS is a registered trademark of Elanco. HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. 8/15 15724

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TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

MAY/JUNE 2016

VOLUME 1, NUMBER 3

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

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

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*Qualifying Subscribers: veterinary technicians, veterinary assistants, veterinary technician students and other members of the veterinary healthcare team in the United States. Eastern States Veterinary Association, Inc (NAVC) reserves the right to determine eligibility for a free subscription.

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

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

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An Official Journal of the NAVC

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

MAYJUNE2016

Volume 1, Number 3

PEER-REVIEWED CE Urethral Obstruction in Male Cats COURTNEY BEITER, RVT, VTS (ANESTHESIA AND ANALGESIA)

Urethral obstruction is a relatively common and potentially life-threatening emergency. Prompt, appropriate treatment and supportive care can give patients a good prognosis.

When Extraction Is Not an Option JEANNE R. PERRONE, CVT, VTS (DENTISTRY)

Treatment of periodontal disease typically involves tooth extraction. However, in some circumstances, the client may wish to avoid extraction. Learn about some of the alternative periodontal therapies.

FEATURES Helping Pets Enjoy Their Golden Years: The Technician’s Role HEATHER LYNCH, LVT

With improved wellness care, more pets are reaching their senior years. To help ensure good quality of life for aging pets, veterinary technicians should be knowledgeable about signs of emerging chronic illnesses and special nursing considerations for geriatric patients.

Preanalytic Variables: Effects on CBC and Serum Chemistry Results KATIE FOUST, BS, CVT, and MARGI SIROIS, EdD, MS, RVT, LAT

Complete blood counts (CBCs) and serum chemistry testing results can be influenced by several factors. This article gives an overview of some of the most common factors pertaining to sample handling.

Preventing Motion Sickness in Dogs AMY NEWFIELD, CVT, VTS (ECC)

In animals, motion sickness may be a behavior issue rather than a physical one. This article describes the potential causes of motion sickness in dogs and available therapeutic options.

Iron Toxicosis ERIN FREED, CVT

Many common household items contain elemental iron, which can be toxic if consumed in great enough quantities. Learn how to calculate ingested amounts and the steps of decontamination and treatment in affected animals. 2

TODAY’SVETERINARYTECHNICIAN

An Official Journal of the NAVC

May/June 2016

www.todaysveterinarytechnician.com

Cats take enough risks on their own. Why add adjuvanted vaccines to the list? Trust PUREVAX® Feline vaccines – the only complete line of nonadjuvanted feline vaccines. Ask your Merial representative about our Satisfaction Guarantee.

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VaccinateYourPet.net

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Contents

TODAY’S VETERINARY TECHNICIAN

Caution Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian.

An Official Journal of the NAVC

Indications SENTINEL® SPECTRUM® (milbemycin oxime/lufenuron/praziquantel) is indicated for the prevention of heartworm disease caused by Dirofilaria immitis; for the prevention and control of flea populations (Ctenocephalides felis); and for the treatment and control of adult roundworm (Toxocara canis, Toxascaris leonina), adult hookworm (Ancylostoma caninum), adult whipworm (Trichuris vulpis), and adult tapeworm (Taenia pisiformis, Echinococcus multilocularis and Echinococcus granulosus) infections in dogs and puppies two pounds of body weight or greater and six weeks of age and older.

MAYJUNE2016 COLUMNS Editor’s Letter | The Power Trip LYNNE JOHNSON-HARRIS, LVT, RVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Guest Editorial | Looking Forward, Looking Back: The Veterinary Technology Profession

Dosage Schedule

HAROLD DAVIS, BA, RVT, VTS (ECC, ANESTHESIA AND ANALGESIA).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Career Challenges | So You’ve Been Promoted to Management… Now What? SANDY WALSH, RVT, CVPM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

My Favorite Things | Feeding Puzzles for Nutrition and Enrichment ANN WORTINGER, BIS, LVT, VTS (ECC, SAIM, NUTRITION). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

ESTHER KLOK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

What Moves You? | Making a Difference SAMMIE THIBODEAUX, CVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Final Thoughts | An Attitude of Gratitude JULIE SQUIRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

56 68 70

CLIENT HANDOUT Brushing Your Dog’s Teeth............................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53

ON THE COVER

Autumn Ruiz, RVT, takes Emme for a walk at Hinckley Animal Hospital in Hinckley, OH. Cover image by Lars Sahl.

CONNECT WITH US todaysveterinarytechnician.com

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, May/June, Jul/Aug, Sep/Oct, Nov/Dec (6x per year) by NAVC, PO Box 390, Glen Mills, PA. 19342.

TODAY’SVETERINARYTECHNICIAN

TVET-2016-0506_Contents.indd 4

Lufenuron per chewable

2 to 8 lbs.

2.3 mg

46 mg

22.8 mg

One

8.1 to 25 lbs.

5.75 mg

115 mg

57 mg

One

25.1 to 50 lbs.

11.5 mg

230 mg

114 mg

One

50.1 to 100 lbs.

23.0 mg

460 mg

228 mg

One

Body Weight

Over 100 lbs.

Administer the appropriate combination of chewables

SENTINEL SPECTRUM may be offered to the dog by hand or added to a small amount of dog food. The chewables 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 a few minutes after administration to ensure that no part of the dose is lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended. Contraindications There are no known contraindications to the use of SENTINEL SPECTRUM. Warnings Not for use in humans. Keep this and all drugs out of the reach of children. Precautions Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention. Prior to administration of SENTINEL SPECTRUM, dogs should be tested for existing heartworm infections. At the discretion of the veterinarian, infected dogs should be treated to remove adult heartworms. SENTINEL SPECTRUM is not effective against adult D. immitis. Mild, transient hypersensitivity reactions, such as labored breathing, vomiting, hypersalivation, and lethargy, have been noted in some dogs treated with milbemycin oxime carrying a high number of circulating microfilariae. These reactions are presumably caused by release of protein from dead or dying microfilariae. Do not use in puppies less than six weeks of age.

Advertiser Index. . .................. 6

Praziquantel per Number of chewable chewables

Milbemycin Oxime per chewable

To ensure adequate absorption, always administer SENTINEL SPECTRUM to dogs immediately after or in conjunction with a normal meal.

What Moves You? | From Holland: Looking Back on a GREAT Adventure

Dosage and Administration SENTINEL SPECTRUM should be administered orally, once every month, at the minimum dosage of 0.23 mg/lb (0.5 mg/kg) milbemycin oxime, 4.55 mg/lb (10 mg/kg) lufenuron, and 2.28 mg/lb (5 mg/kg) praziquantel. For heartworm prevention, give once monthly for at least 6 months after exposure to mosquitoes.

An Official Journal of the NAVC

Do not use in dogs or puppies less than two pounds of body weight. The safety of SENTINEL SPECTRUM has not been evaluated in dogs used for breeding or in lactating females. Studies have been performed with milbemycin oxime and lufenuron alone. Adverse Reactions The following adverse reactions have been reported in dogs after administration of milbemycin oxime, lufenuron, or praziquantel: vomiting, depression/lethargy, pruritus, urticaria, diarrhea, anorexia, skin congestion, ataxia, convulsions, salivation, and weakness. To report suspected adverse drug events, contact Virbac at 1-800-338-3659 or the FDA at 1-888-FDA-VETS. Information for Owner or Person Treating Animal Echinococcus multilocularis and Echinococcus granulosus are tapeworms found in wild canids and domestic dogs. E. multilocularis and E. granulosus can infect humans and cause serious disease (alveolar hydatid disease and hydatid disease, respectively). Owners of dogs living in areas where E. multilocularis or E. granulosus are endemic should be instructed on how to minimize their risk of exposure to these parasites, as well as their dog’s risk of exposure. Although SENTINEL SPECTRUM was 100% effective in laboratory studies in dogs against E. multilocularis and E. granulosus, no studies have been conducted to show that the use of this product will decrease the incidence of alveolar hydatid disease or hydatid disease in humans. Because the prepatent period for E. multilocularis may be as short as 26 days, dogs treated at the labeled monthly intervals may become reinfected and shed eggs between treatments. Manufactured for: Virbac AH, Inc. P.O. Box 162059, Ft. Worth, TX 76161 NADA #141-333, Approved by FDA © 2015 Virbac Corporation. All Rights Reserved. SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation. 02/15

May/June 2016

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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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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: 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

ADVERTISER INDEX American College of Veterinary Internal Medicine

2016 Forum.....................................ACVIMForum.org............................55

Ceva Animal Health

Adaptil.............................................adaptil.com/US................................17

HEARTGARD Plus is recommended for dogs 6 weeks of age and older. For dogs over 100 lb use the appropriate combination of these chewables.

IDEXX

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.

SNAP Test.......................................idexx.com/idexxsnap2......................27

International Society of Feline Medicine

Free subscription............................icatcare.org/nurses...........................67

Merial

Frontline Gold................................frontline.com.............................. Insert

Heartgard Plus................................heartgard.com...............................5, 6

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.

NexGard..........................................nexgardfordogs.com.................42, 43

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.

Tresaderm.......................................merial.com..........................Back cover

PureVax...........................................vaccinateyourpet.net.........................3

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.

NAVC

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. 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.

2017 Conference............................NAVC.com........................................25

Nestle

UR Urinary Ox/St Canine Formula....purinaproplanvets.com....................37

Penn Foster

Diploma Programs.........................pennfoster.edu.................................58

PNC Bank

Financial Services...........................pnc.com...................Inside back cover

VetFolio

VetFolio...........................................VetFolio.com....................................63

Virbac

Sentinel Spectrum..........................virbacvet.com...... Inside front cover, 4

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. 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.

Correction In the article “Pain Management for Dental Patients,” in the March/April 2016 issue of Today’s Veterinary Technician, the lower end of the range for the dose of medetomidine was inadvertently omitted on page 21. The dose range should have read “1–10 ug/kg.”

TODAY’SVETERINARYTECHNICIAN

May/June 2016

Editor’s Letter

The Power Trip

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

ecently, a story on a television morning show caught my attention. The premise of the story was that women own about one-third of the businesses in the world; however, the percentage of those at the “top” of a corporation (e.g., CEO, COO) is much lower. Why did this story catch my attention? Veterinary technicians in leadership roles— whether male or female—probably fit the same profile. A leading fashion magazine brought 200 top female leaders—representing industries from fashion to technology—to its Power Trip Summit to share their secrets to success. Below are a few of the insights I found particularly relevant to our profession. Follow your passion. Whatever it is in your life that makes you want to lead, follow it. Lead, and don’t be afraid to fail. Veterinary technicians have a true passion for what we do. With that passion, we can become great leaders. Many times, however, we are afraid to follow our passion because we are afraid to fall down. It’s okay to fall. Just get up, and shake it off. There are so many opportunities in our chosen career to lead with passion. It might be in management, or in obtaining a VTS, or advocating for animals in your own community. It’s also okay for your passions to change over time. Following your passion and becoming a leader go hand in hand. Dare to be the first. Just do it! For example, if you see that your practice needs a good client education program, be the one to develop and implement it. (If you need an inspirational role model for developing initiatives, read Esther Klok’s “What Moves You?” column starting on page 56.) Or maybe you want to be the first to become a

VTS in your working group. My election as the president of the NAVC Board in 2013 was a first not only for me, but also for the NAVC. Up to then, the president of the board had always been a veterinarian. Delegate and empower. As a leader, when you give others responsibilities that allow them to shine and lead, you empower them. Delegation of responsibilities enables those around you to show off their talents, helps build their confidence, and ultimately lets them follow their passion and, perhaps, become a “first.”

If you stumble, consider it a “power trip”— an opportunity to help make you stronger, more passionate about what drives you, and a better leader. Be hopeful for the future. You can’t be a good leader without faith in where you are going and why you are going there. Myself, I am hopeful for the future of the veterinary technician profession. We are in for some change as our leaders in NAVTA actively work on our behalf to protect our title and strive for national credentialing. It will be challenging; however, I am hopeful they will succeed. Become a local leader and get involved in the campaign to gain recognition for who we are and what we do. Visit the NAVTA website (navta.net) and read the position statement on the term “veterinary nurse” for more information. And remember: no one said it was easy. It’s okay to fall, fail, and feel fear. Chances are very good that, at some point, you will. So if you stumble, consider it a “power trip”—an opportunity to help make you stronger, more passionate about what drives you, and a better leader. 

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

TVET-2016-0506_Editor-Letter.indd 7

An Official Journal of the NAVC

May/June 2016

www.todaysveterinarytechnician.com

4/7/16 5:54 PM

Peer-Reviewed

Helping Pets Enjoy Their Golden Years: The Technician’s Role Heather Lynch, LVT

“O

BluePearl Veterinary Partners Gilbert, Arizona

ld age” is neither a disease nor a reason not to treat a patient for illness, yet it is a reason commonly cited by clients who are reluctant to treat their senior pets. As we become better at recognizing and managing age-associated issues in companion animals, it is increasingly common to see dogs and cats reaching—and thriving in—their golden years. The fact remains, however, that few veterinary professionals have received any kind of training in the specific care or needs of geriatric patients. This article outlines what it means to be “geriatric,” provides general guidelines for managing aging patients and specific recommendations for nursing care in hospitalized geriatric patients, and discusses the role of the veterinary technician in ensuring quality of life for older patients.

Heather is the supervising technician at BluePearl Veterinary Partners in Gilbert, Arizona. She is a frequent lecturer at state and national veterinary conferences and is the author of several articles on nutrition, patient care, and management of diabetes.

WHAT IS A GERIATRIC PATIENT? Geriatric medicine in humans is a recognized and well-studied specialty. This is much less true in veterinary medicine, although awareness of the specific needs of geriatric patients has been increasing steadily over the past decade. Perhaps the most complicated aspect of working with geriatric animals is that it can be difficult to agree on when a patient is considered “geriatric” because of broad variations among species and breeds. It is important to note that there is a difference between natural aging and being considered geriatric. In humans, aging is defined as the inevitable and irreversible decline in organ function that occurs over time even in the absence of illness, injury, or poor lifestyle choices.1 8

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A geriatric patient, on the other hand, is an older person who also has some type of impaired function. There is no set age when a person is considered geriatric, but he or she is usually older than 75 years, with at least one chronic illness, physical impairment, and/or cognitive impairment. With regard to animals, perhaps it is best to think in terms of “senior” for a healthy older pet and “geriatric” for a pet that is senior and has health or behavior concerns.

RECOGNIZING SENIOR VERSUS GERIATRIC PATIENTS The challenge for veterinary professionals is to help owners identify when their senior pet has become geriatric. Ideally, this happens early, when emerging health issues can be addressed and managed to preserve quality of life for as long as possible. As noted previously, distinguishing “senior” from “geriatric” is especially difficult considering the broad variety in lifespan and health considerations among breeds and species. For instance, 8 years old may be a reasonable age for a golden retriever to be considered senior, but a Great Dane of the same age would likely be geriatric, and a toy poodle may be in the prime of its life. These variations make it extremely difficult to develop generalized answers for owners about age. Individualized communication with clients on the part of the veterinary health care team is necessary. Perhaps what is more important than age is the pet’s general health status and whether the pet has emerging chronic issues that need to be managed. Many educational

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Helping Pets Enjoy Their Golden Years: The Technician’s Role

Photography by Lars Sahl

Taking some extra time to interact with each patient while on walks or during treatments helps to allay stress, anxiety, and fear.

tools are available to help owners make this distinction (BOX 1), such as an age wheel or a questionnaire about possible age-related changes. The American Animal Hospital Association (AAHA) and American Association of Feline Practitioners (AAFP) offer senior care guidelines for veterinary professionals that can serve as a great starting point for creating practice-specific senior care information for clients: ÆÆ AAFP Senior Care Guidelines: jfm.sagepub.com/content/11/9/763.full.pdf+html ÆÆ AAHA Senior Care Guidelines for Dogs and Cats: aaha.org/public_documents/professional/guidelines/ seniorcareguidelines.pdf As with humans, prevention, early recognition, and management of health concerns are the best ways to provide pets with excellent quality of life. TODAY’SVETERINARYTECHNICIAN

EDUCATED OWNERS ARE SUCCESSFUL OWNERS Putting Knowledge into Action British philosopher and sociologist Herbert Spencer once wrote that, “The great aim of education is not knowledge, but action.”2 To keep older pets healthy for as long as possible, owners must be able to recognize when it is necessary for them to act for their pet’s well-being. No matter how good veterinary medicine becomes at diagnosis and treatment, we still rely on owners—who see and care for their pets every day—to recognize changes and seek medical advice on their pets’ behalf. In my opinion, the single most important thing veterinary professionals can do for their patients is to educate owners to recognize signs of potential health

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concerns and know when to call or visit their veterinarian. Ideally, this education should begin from the pet’s puppy or kitten visit and continue every year during the patient’s annual veterinary examination. Understanding the Annual Examination Over the past several years, the entire veterinary community has been advocating for annual examinations. When it comes to helping owners make the distinction between “normal” aging and initial signs of illness, annual examinations are important. Many issues that develop over time and may go unnoticed by pet owners may in fact be signs of an emerging health concern (BOX 2). The American Veterinary Medical Association (AVMA) Partners for Healthy Pets program (partnersforhealthypets. org/) is designed specifically to help practices develop and promote the importance of annual examinations to help improve compliance. The AAFP, AAHA, and many other organizations also offer resources to help the veterinary team educate owners about the importance of preventive health care. Whether your hospital uses existing resources or develops something unique, educating clients about the importance of regular physical examinations by a veterinarian will certainly improve and maintain their pet’s quality of life. Many treatment options can be employed at the annual examination to mitigate clinical signs and improve the patient’s quality of life. Dental prophylaxis, growth removal, and medical therapy for arthritis or other chronic issues are becoming more routine in senior and geriatric pets. The increase in owner education and willingness of pet owners to pursue medical care for older pets strengthens the need for veterinary technicians to gain a fuller understanding of senior and geriatric nursing.

TECHPOINT 

With training, compassion, and proactive pet owner education, veterinary technicians are integral in helping older pets live longer with excellent quality of life. NURSING CONSIDERATIONS FOR HOSPITALIZED SENIOR OR GERIATRIC PETS Physical and mental changes associated with aging often require special nursing care. They may include orthopedic changes, changes in body condition, and changes in perception or mentation.3 Recognizing health issues that may influence the course of treatment and addressing those issues are also important. A nursing plan that proactively addresses these concerns and is appropriate for the patient can be extremely helpful in improving outcomes. First and foremost in nursing care are the basics: In any ward, all patients should always be clean, warm, and dry. Beyond that, it is important to keep patients moving, ensure their comfort, provide good nutrition, and interact with them. Fulfilling Basic Needs ÆÆ Movement: Patients should not be left to lie immobile in cages or runs for long periods. Movement influences many body systems, affecting

BOX 1 Educating Owners About Their Aging Pets  AAHA has produced multiple resources to help put its senior care guidelines into practice, including client brochures and a client-facing website about cognitive dysfunction in older pets: aaha.org/professional/resources/senior_care.aspx?type=resources  AAFP has produced an excellent brochure for owners of senior cats: catvets.com/public/PDFs/ClientBrochures/FriendsforLifeBrochure-Purina.pdf  The AVMA offers a number of resources for the veterinary team to share with pet owners, including a FAQ, podcasts, and other links: avma.org/public/PetCare/Pages/Caring-for-an-Older-Pet-FAQs.aspx  Veterinary Economics (dvm360.com) offers these downloadable client education tools:  Wellness for the older pet (senior wellness testing handout)  Behavior screen for dogs and cats (behavior questionnaire that clients can use to prepare for wellness visits)

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Helping Pets Enjoy Their Golden Years: The Technician’s Role

blood pressure, gastrointestinal (GI) motility, edema, orthopedic pain, body temperature, and muscle strength. The most obvious way to promote movement is walking the pet. If walking is not an option, providing basic physical therapy in the form of passive range of motion exercises, massage, and assisted changes in position (such as standing the patient up for a short time and then helping the patient to lie down again) has been shown in human medicine to improve outcome and shorten hospital stays for a variety of medical issues.4,5 Providing either walks or therapy every 4 hours at a minimum is usually a good starting point in a nursing plan. ÆÆ Comfort: Senior patients often have lower muscle mass and reduced mobility than younger pets. They may also have difficulty navigating hard cage or run floors. Additionally, patients with lower body condition scores or those that have friable skin may be at risk for developing pressure-associated injuries when left to lie in a hard cage. Nonslip mats and thicker blanketing may be required to allow these patients to rest comfortably. Purpose-built antipressure cage beds are available, but thick blankets, egg crate foam, or other forms of padding can provide patients with increased comfort. ÆÆ Nutrition: Senior pets may have GI changes or disease processes that affect their ability to process nutrients. Loss of lean muscle mass occurs naturally with aging and may increase with confinement and lack of sufficient nutrients.6 These patients may require a diet adjustment or even a feeding tube if they are not able to eat on their own. Recognizing issues that may be interfering with eating, such as nausea, food aversion, or pain, is key in helping patients continue to eat voluntarily. ÆÆ Interaction and engagement: Hospitalized patients are often stressed, anxious, and frightened. It is incumbent on veterinary technicians to ease their discomfort, even if that discomfort is more mental than physical. Taking some extra time to interact with each patient while on walks or during treatments helps to allay stress, anxiety, and fear. Patients that feel comforted by their caregiver often eat better, accept physical therapy and other treatments more readily, and are more willing to move and walk than patients that do not share a bond with their caregiver. Addressing Physical Challenges Physical changes related to normal aging in senior and geriatric patients may pose some challenges to nursing. TODAY’SVETERINARYTECHNICIAN

ÆÆ Increased skin fragility/friability: Senior patients

may be at an increased risk for skin tears from clippers or other instruments. They may also have small skin masses or other abnormalities or lesions that may be exacerbated by inadequate bedding, clippers, or even restraint. Recognizing these issues and using extreme care when handling these patients often help prevent injury. ÆÆ Changes in body condition: Senior patients may present in poor body condition. Whether obese or thin, these patients are at risk for developing hospital-induced injuries such as pressure sores, increased stiffness or joint pain, weakness, decreased mobility, hypothermia, or hyperthermia. Recognizing poor body condition and providing adequate cushioning (both in cages and on surgery or dental tables), regular temperature monitoring, and appropriate nutritional support are key.

BOX 2 Potential Signs of Emerging Disease in Older Pets3  Decreased appetite, with or without weight loss  Increased thirst  Increased urination  Decreased or no urination  Poor hair coat  Vomiting  Sore mouth  Increased urination/spotting “accidents” in the house  Weakness  Coughing  Decreased exercise tolerance  Favoring a limb  Difficulty sitting or standing  Sleeping more  Seeming to have stiff/sore joints  Hesitancy to jump/run or climb stairs  Weight gain/weight loss  Decreased activity or interest in play  Attitude or behavior changes (including increased irritability)  Being less alert

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ÆÆ Changes in perception: Patients with poor eyesight

and/or hearing may startle easily or not adapt well to the hospital environment. They may be injured by falling or walking off examination tables or cages or bumping into things they are unable to perceive. At times, these pets may be more reactive and may strike out at their caregivers in the hospital because of apprehension about restraint. It is important to proceed slowly with these patients and give them time to adjust to restraint and/or treatment. ÆÆ Orthopedic changes: Almost all senior patients that present to a veterinary hospital have some degree of arthritis or orthopedic issues. Although they may be well tolerated at home, orthopedic issues may be exacerbated in the hospital by manipulation (e.g., restraining legs for radiography) or long periods of inactivity. The resulting pain may cause the pet to resist handling or to become fractious. Providing regular walks, physical therapy, and gentle manipulations as well as appropriate pain control for these patients helps them better tolerate hospitalization and treatments. ÆÆ Changes related to organ function and/or chronic disease: Senior pets are at a higher risk than their adult counterparts for organ dysfunction, which may or may not be evident. Thorough evaluation by the veterinarian, along with diagnostic testing, is important to help the veterinary health care team recognize organ dysfunction or chronic disease and address its potential effect on the patient’s treatment. To achieve optimum results, any of these concerns should be well communicated and understood by the technician providing nursing care. This enables the technician to better monitor the patient and recognize changes that may be significant to the veterinarian and the patient’s treatment plan.7 DISCUSSING QUALITY VERSUS QUANTITY OF LIFE There are myriad theories and opinions about how best to approach end-of-life care. Many veterinary hospitals are developing formal hospice care programs to help owners navigate the end of their pet’s life, including maintaining the pet’s quality of life and recognizing when it has degenerated. The decision to begin hospice care or to euthanize a pet is intensely personal and individual, and every veterinarian has opinions about what constitutes appropriate care. 12

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TECHPOINT 

To effect the best outcome for senior and geriatric pets, veterinary technicians need to be aware of the changes that occur with natural aging and with chronic health issues and to address them when managing a pet’s nursing care. The veterinary technician’s role often becomes one of providing validation and comfort to the owner. One of the most important aspects of this role is having a thorough understanding of the veterinarian’s and hospital’s policies and procedures so that correct and consistent information is delivered to clients. Evaluating quality of life is often subjective and difficult for owners. In an attempt to provide a standardized evaluation, Dr. Alice Villalobos has developed a Quality of Life Scale to help owners and veterinarians have these discussions (TABLE 1).8 While veterinary technicians are not responsible for making quality of life determinations, understanding the criteria that veterinarians are using and being able to support the veterinarian’s recommendations help to comfort owners in the decision-making process. CONCLUSION Senior patients are becoming a larger segment of the general practice population. Veterinary technicians are often the primary communicators with owners. As such, technicians shoulder much of the responsibility for educating and informing clients about their pet’s care. Training and positive messaging about preventive health care enables veterinary technicians to be more successful in gaining owner compliance. Proactively communicating with owners of young pets about the pet’s ongoing preventive health care needs, appropriate home care, and early signs of illness gives owners the

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Educating clients about the importance of regular physical examinations by a veterinarian will certainly improve and maintain their pet’s quality of life.

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Helping Pets Enjoy Their Golden Years: The Technician’s Role

TABLE 1 The HHHHHMM Quality of Life Scale Evaluate each of the following areas on a scale of 0 to 10, with “0” being unacceptable and “10” being ideal. A total score of 35 or higher is considered an acceptable score for quality of life. SCORE (0–10)

CRITERION Hurt: Is the pet receiving adequate pain control (including breathing ability)? Hunger: Is the pet eating enough on its own? Does the pet require hand feeding or tube feeding? Hydration: Is the pet hydrated? Does it need subcutaneous fluids? Hygiene: Is the pet brushed and cleaned regularly, especially after elimination? Happiness: Does the pet express joy or interest? Does it respond to its environment? Does the pet show signs of boredom, loneliness, anxiety, or fear? Mobility: Can the pet get up without assistance? Does the pet want to go for a walk? Is the pet experiencing seizures or stumbling? More Good Than Bad: Do good days outnumber bad days? Total Score: Adapted from Villalobos and Kaplan.8

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tools they need to avoid some problems, identify health concerns when they occur, and seek appropriate care. To effect the best outcome for senior and geriatric pets, veterinary technicians need to be aware of the changes that occur with natural aging and with chronic health issues and to address them when managing a pet’s nursing care. With training, compassion, and proactive pet owner education, veterinary technicians are integral in helping older pets live longer with excellent quality of life.  References 1. Besdine RW. Introduction to geriatrics. 2013. Merck Manuals website (professional version). http://www.merckmanuals.com/professional/geriatrics/approach-to-thegeriatric-patient/introduction-to-geriatrics. Updated July 2013. Accessed January 2016. 2. Spencer H. Essays on Education and Kindred Subjects. 2005. Project Gutenberg website. gutenberg.org/files/16510/16510-h/16510-h.htm. Accessed January 2016. 3. Epstein M, Kuehn NF, Landsberg G, et al. AAHA senior care guidelines for dogs and cats. JAAHA 2005;41:81-91. 4. Valenza DG, Valenza MC, Cabrera-Martos I, et al. The effects of a physiotherapy programme on patients with a pleural effusion: a controlled trial. Clin Rehabil 2014; 28(11):1087-1095. 5. Labraca NS, Castro-Sanchez AM, Mataran-Panarrocha GA, et al. Benefits of starting rehabilitation within 24 hours of primary total knee arthroplasty: randomized clinical trial. Clin Rehabil 2011;25(6):557-566. 6. Churchill JA. Nutrition for senior dogs: new tricks for feeding old dogs. In: Critical Updates on Canine & Feline Health. 2015 NAVC/WVC Symposia Proceedings. 2015. www.cliniciansbrief.com/sites/default/files/attachments/Nutrition%20for%20 Senior%20Dogs.pdf. Accessed March 2016. 7. Pittari J, Rodan I, Beekman, G, et al. American Association of Feline Practitioners senior care guidelines. J Feline Med Surg 2009;11:763-778. 8. Villalobos A, Kaplan L. Palliative care: end of life “pawspice” care. In Canine and Feline Geriatric Oncology: Honoring the Human-Animal Bond. Ames, IA: Blackwell Publishing, 2007, Table 10.1.

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Guest Editorial

Looking Forward, Looking Back: The Veterinary Technology Profession Harold Davis, BA, RVT, VTS (ECC, Anesthesia and Analgesia) The William R. Pritchard Veterinary Medical Teaching Hospital University of California, Davis

If you want to know your past, look into your present conditions. If you want to know your future, look into your present actions. —Chinese proverb

The first journal for veterinary technicians debuted almost 40 years ago.

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recently returned from the 2016 NAVC (North American Veterinary Community) Conference, where the theme for this year was “What Moves You?” I reflected on this theme and thought about what moves me. I considered my career over the past few decades, the role of veterinary technicians, and the changes I have witnessed in the profession. During my time as a veterinary technician (formerly called animal health technician [AHT]), I have seen many changes. The original American Veterinary Medical Association (AVMA) terminology for a veterinary technician was animal technician. In 1965 the AVMA Executive Board decided not to allow the use of the adjective veterinary with the nouns technician or assistant. The article “What’s in a Name?” appeared in the May 1968 issue of Modern Veterinary Practice. It discussed various terms to describe veterinary technicians, such as animal hospital nurse, animal hospital technologist, and nonprofessional assistant. Does this debate sound familiar? We are currently having a similar discussion—should we be called veterinary nurses? Then and now, the topic sparked debate and was controversial. It was not until 1989 that the AVMA approved the use of the term veterinary technician. One of the ways veterinary technicians have been able to keep abreast of the latest in professional and medical advancements is through professional journals. The first journal published in North America for AHTs, Methods: The Journal for Animal Health Technicians, debuted in 1976. It was published by an AHT for AHTs. It was followed in 1980 by Compendium on Continuing Education for the Animal Health Technician (eventually renamed Veterinary Technician). Neither of those journals is still in print, but articles from the January 2005 to August 2013 issues of Veterinary Technician may be found on VetFolio.com (vetfolio.com/veterinarytechnician-archives). Fortunately, two publications for veterinary technicians are currently available: Today’s Veterinary Technician (published by the NAVC; todaysveterinarytechnician.com) and NAVTA Journal, published by the National Association of Veterinary Technicians in America (NAVTA). Both journals have veterinary technicians as editors in chief. When I started in the profession, technician utilization was a major issue. Technicians believed their skills were not being used to the fullest, and many states were struggling to determine what tasks AHTs and veterinary assistants would be allowed to perform. The discussion about

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Guest Editorial

Looking Forward, Looking Back: The Veterinary Technology Profession

ADVANCES IN PRODUCTS AND TECHNOLOGY Technologically speaking, great strides have been made since I started in this profession. Back then, in-hospital laboratory tests were limited. Leukocyte counts were obtained using a hemocytometer and Unopette system. If you were fortunate, your practice had an electronic cell counter, such as the Clay Adams Accu-Stat Blood Cell Counter or a Coulter counter. The dipstick or test strip method (e.g., Azostix, which is still used today, or the Urograph/Bun-O-Graph, which used chromatographic techniques to estimate blood urea nitrogen) was widely used. Blood chemistry analyzers included liquid reagent instrument-based units (e.g., the Mallinckrodt Serometer, the IL Clinicard, a spectrophotometer), which used the principles of photometry to perform the analysis. Today, dry chemistry units (e.g., Heska’s Element system, Abaxis VetScan, Idexx Catalyst) are common. Sodium thiamylal (Surital or Bio-Tal), a thiobarbiturate, was a common anesthetic induction agent 25 years ago. Intramuscular ketamine–diazepam, acepromazine, or xylazine was used as an induction agent in cats. Methoxyflurane was on the way out as an inhalation agent, and halothane was becoming more common. We now have a variety of induction agents. Today’s options for inhalation anesthetics include isoflurane and sevoflurane. Patient anesthetic monitoring focused on vital signs, eye position, jaw tone, and the use of cardiamps and respiratory/apnea monitors. The cardiamp was essentially an amplifier attached to an esophageal stethoscope, allowing heart and breath sounds to be heard without an earpiece. Respiratory/apnea monitors beeped when the patient took a breath and sounded an alarm if the patient became apneic. Blood pressure monitoring was essentially limited to teaching hospitals. Today, we have a great deal more in our anesthetic monitoring armamentarium: electrocardiography, capnography, pulse oximetry, arterial blood gas measurements, gas agent monitors, oscillometric or Doppler blood pressure, and thermistor temperature probes. At one time, imaging was mostly limited to radiography and fluoroscopy. Today, our options include ultrasonography, computed tomography (CT), magnetic resonance imaging (MRI), flexible and rigid endoscopy, and laparoscopy. Technicians often are responsible for operating and/or maintaining this specialized equipment. Have I dated myself yet?

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Peter Olson Photography

veterinary technician utilization continues today. Working in a small animal practice was—and still is—a challenge for technicians. While we may be seeing some of the same types of medical conditions today that we saw back when I started, our understanding of the disease process has advanced. This advancement carries over into how we think and provide nursing care to our patients. It is important for veterinary technicians to have critical thinking skills as well as hands-on technical skills. Critical thinking is not innate; fortunately, it is being emphasized in veterinary technology curricula. Looking back, the highlight of my day was holding an animal for the veterinarian for catheter placement or tracheal intubation; both tasks are now routinely performed by veterinary technicians.

“I enjoy sharing what I know with other technicians. I speak about things I’m passionate about and perhaps my passion comes through.”

May/June 2016

— Harold Davis

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Guest Editorial

Looking Forward, Looking Back: The Veterinary Technology Profession

TECHNICIAN SPECIALIZATION No one even dreamed of technician specialization when I started as an AHT. We were busy trying to establish our profession. In 1994, NAVTA created the Committee on Veterinary Technician Specialties (CVTS). The CVTS was charged with overseeing the development of specialty academies. There was a bit of pushback from the veterinary community. A letter appeared in the September 1994 JAVMA Practitioner Exchange in response to the question, “Is it a good idea to form veterinary technician specialty boards?” It read, “What is the profession coming to? Why would any general practice want a technician who is advanced trained in fluid therapy, anesthesiology or clinical pathology? These are the domains of the veterinarian.” Ultimately, the first technician academy, the Academy of Veterinary Emergency and Critical Care Technicians (AVECCT), was recognized, and I am proud to have been one of three founding members. We worked closely with NAVTA’s CVTS to develop the process of specialty certification and recognition. I believe our academy has laid the foundation for many others. We were first recognized in 1996, and this year marks our 20th anniversary. Today, there are 12 nationally recognized veterinary technician specialties. EDUCATIONAL OPPORTUNITIES Educational opportunities are better than ever. Whereas only a handful of annual continuing education (CE) meetings were offered years ago, today a major technician CE meeting is held practically every month. Distance learning is another option now available to veterinary technicians. It used to be that veterinarians spoke to technicians at CE meetings; now veterinary technicians are speaking to veterinary technicians at these conferences. Many technicians like me lecture at conferences internationally, enthusiastically sharing knowledge. Likewise, many of us have published journal articles, contributed chapters to textbooks, and edited our own text. The first textbook geared toward AHTs, Animal Hospital Technology—A Textbook for Veterinary Aides, was published in 1971. In 1995, McCurnin’s Clinical Textbook for Veterinary Technicians was published; it is currently in its 8th edition and is perhaps considered the bible for veterinary technicians. Many books are now available for veterinary technicians. PROFESSIONAL ORGANIZATIONS Before 1981, there was no national technician association. Then the North American Veterinary Technician Association (now the National Association of Veterinary Technicians in America) was established. There were,

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however, numerous strong state and local technician associations, many of which are still in existence today. Presently, technicians serve on committees of the AVMA and the American Animal Hospital Association, as board members in professional organizations (e.g., the Veterinary Emergency and Critical Care Society, Western Veterinary Conference, and NAVC), and on veterinary medical boards or their subcommittees. This demonstrates that technicians have a voice in our profession. I was delighted to be elected as the first nonveterinarian president of the Veterinary Emergency and Critical Care Society, a 4000-member organization. I am also honored to be a board member for the NAVC, one of 3 veterinary technicians who have served on this board. THE FUTURE At 56 years, we are still a relatively young profession. Looking back, we have come a long way in a short time; however, we still have some growing to do. A name change is still being debated. The profession is investigating a national credentialing process. There are also some rumblings of an advanced-level veterinary technician on par with a physician assistant. There are at least 3 or 4 specialty groups hoping to receive NAVTA recognition as academies. The issues facing us today are not so different from those of the past. I’m sure these issues will be vigorously debated. It is important to remember that it will take careful listening to all sides, thoughtful planning, and the willingness to find common ground. In the end I believe we all want what is best for our profession; with teamwork, we can achieve it. WHAT MOVES ME After all my years in the profession, I can’t help but be moved. I have had wonderful opportunities to connect with others who share my interests. I have seen and been a part of the change in our profession. I have helped a lot of patients and their owners. I have contributed to the training of future veterinarians at the number-one school of veterinary medicine in the world, UC Davis. I have had and continue to have the privilege of traveling the world and sharing my knowledge with others. So, what moves me? Being a witness to change, my passion for this profession, the contributions I have made and hope to make, and my enthusiasm to see what the future holds. Oh, and in case you’re wondering: I celebrated my 40th anniversary as a veterinary technician in February 2016. I hope I have shared with you a glimpse of the past with an eye to the future. 

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HELP REDUCE SIGNS OF STRESS WITHIN A WEEK* Adaptil® is clinically proven* to help reduce or eliminate stress-related behaviors by mimicking the natural pheromones pets use to communicate. Recommend Adaptil® to your clients to help reduce signs of stress in their dogs. Adaptil® may help with these stress-related issues: • Excessive Indoor barking • Noise phobias • Adapting to a new home

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ARTICLE 1 1 CR E DIT

Urethral Obstruction in Male Cats Courtney Beiter, RVT, VTS (Anesthesia and Analgesia)

The Ohio State University Veterinary Medical Center

rethral obstruction is a potentially life-threatening emergency. Male cats are more prone to obstruction than female cats.1 When the urethra becomes partially or completely blocked, urine is unable to drain from the bladder, resulting in fluid, electrolyte, and acid–base abnormalities.2 Feline urethral obstruction is a relatively common condition, accounting for up to 10% of feline cases presented to small animal referral and emergency clinics.3,4

Courtney works at The Ohio State University Veterinary Medical Center in the Small Animal Emergency and Critical Care department. She graduated from Columbus State Community College in 2006 and obtained her VTS in Anesthesia and Analgesia in 2005. Courtney has several publications to her credit. She enjoys spending her free time with her husband and two daughters.

ETIOLOGY The urethra—the tubular passage through which urine is discharged from the bladder to outside the body—can become obstructed for several reasons. The urethra is longer and narrower in male cats than in female cats; therefore, male cats are more likely to develop an obstruction. The most common cause of obstruction is a urethral plug, which consists of mineral crystals (e.g., struvite, calcium oxalate), white blood cells, red blood cells, protein (mucus), and epithelial cells.5 The underlying cause of urethral plugs is unknown; however, plugs have been linked to struvite crystalluria — suggesting that diet may play a role — and idiopathic cystitis.6 Other causes of urethral obstruction include urethral edema and spasm associated with lower 18

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urinary tract inflammation and pain.7 Uroliths, neoplasms, and urethral strictures can also lead to urethral obstruction; however, they are reported less frequently than other causes.5 HISTORY AND CLINICAL SIGNS Cats with a history of lower urinary tract disease—particularly interstitial cystitis—are at an increased risk for developing urethral obstruction.8 Some patients may have a history of obstruction.9 Clinical signs of urethral obstruction can vary depending on the severity and duration of the obstruction. Initially, the most common clinical sign is stranguria, which is sometimes mistaken by the owner as constipation.8 Affected cats may urinate frequently, strain to urinate, urinate inappropriately, and pass small volumes of blood-stained urine (hematuria).10 Lethargy, anorexia, vomiting, and other signs of systemic illness are also common.1 Signs of discomfort or pain caused by an inflamed urethra and increased bladder size include vocalization, inappetence, and hiding. Affected cats can be observed frequently licking their genital region.10 Vomiting and lethargy may also be noted.1 In addition, the patient’s mucous membranes will be pale, and capillary refill time is prolonged.4

Updated from Veterinary Technician July 2008 (Vol 29, No 7), by the author and peer reviewed by Today’s Veterinary Technician. Used with permission from VetFolio, LLC. Veterinary Technician articles published from January 2005 through August 2013 can be accessed without subscription at vetfolio.com/veterinary-technician-archives.

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Feline urethral obstruction is a relatively common condition, accounting for up to 10% of feline cases presented to small animal referral and emergency clinics. On abdominal palpation, the urinary bladder is often large and firm and cannot be expressed easily. Caution should be used when attempting to express a possibly obstructed bladder. If too much pressure is applied to the distended bladder, it can rupture. If bladder rupture is suspected, the goal is to immediately stabilize the patient so that the clinician can perform emergency surgery. If the urethral obstruction goes untreated for more than 24 to 48 hours, the resulting uremia can lead to hypothermia, bradycardia, tachypnea, altered levels of consciousness (including coma), and death.4 DIAGNOSIS A common finding associated with urethral obstruction is a large, firm bladder on abdominal palpation. Urine should be collected for urinalysis, culture, and sensitivity testing.10 Blood work (i.e., complete blood count and serum chemistry profile, including serum potassium levels) should also be obtained. Serum potassium levels can be used to assess cardiotoxicity associated with hyperkalemia.10 An electrocardiogram (ECG) should be obtained to evaluate cardiac function and identify abnormalities consistent with hyperkalemia. Signs of hyperkalemia include diminished to absent P waves, widened QRS complexes, prolonged PR intervals, and tall, “tented” T waves.11 These abnormalities, which most often appear on lead II tracings when serum potassium concentration is >7 mEq/L, are the result of a raised (more positive) resting membrane potential that slows depolarization and exaggerates repolarization.12 Abdominal radiographs can help determine the presence of cystic or urethral calculi. Identification of calculi (stones) affects how an obstruction is treated. The presence of calculi can make it much more difficult to use a urinary catheter to remove the obstruction and can result in additional urethral trauma. If bladder stones are TODAY’SVETERINARYTECHNICIAN

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Urethral Obstruction in Male Cats

present, a cystotomy should be performed after the urethral obstruction has been removed and the patient is stable enough to undergo anesthesia. Voiding urohydropulsion is another method that can be used to remove bladder stones.13 TREATMENT Address Metabolic Abnormalities When treating a cat with a urethral obstruction, it is important to quickly stabilize the patient’s vital signs and address metabolic abnormalities so that urethral catheterization can be performed to remove the obstruction. Administering IV fluids is the initial step in therapeutic management. Traditionally, 0.9% NaCl has been the fluid of choice because it does not contain potassium and has the greatest dilutional effect on hyperkalemia; however, a balanced electrolyte solution, such as Normosol-R, Plasmalyte 148, or lactated Ringer’s solution, can be administered as an alternative. Although these solutions contain some potassium, the concentrations are 5 mEq/L or less,14 which may also make the solutions effective in treating concurrent metabolic acidosis. Fluid rate and quantity should be determined based on the patient’s clinical signs and physical examination findings. Aggressive fluid therapy is indicated in patients that are markedly depressed or unresponsive. A shock dose of 60 mL/kg should be administered to these patients and titrated to effect.15 Hydration and cardiovascular status must be reevaluated after each bolus is administered. In patients with stable vital signs, the percentage of dehydration should be used to calculate the fluid rate and quantity required to correct hydration status (BOX 1).

BOX 1 How to Calculate Replacement Fluids Dehydration + Maintenance + Ongoing losses = Amount of replacement fluids needed Example: For a 5 kg cat that is 5% dehydrated:  Dehydration fluid rate:  0.05 × 1000 = 50 mL (to replace over 12 hours)  50 mL ÷ 12 hr = 4 mL/hr  Maintenance fluid rate: 12 mL/hr (60 mL/kg/day)  Ongoing losses: Urine output is 40 mL/4 hr (10 mL/hr) 4 mL/hr + 12 mL/hr + 10 mL/hr = 26 mL/hr total fluid rate

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If results of the serum biochemistry profile indicate a potassium concentration that is life threatening (>6 mEq/L),12 and/or if ECG findings suggest hyperkalemia, 10% calcium chloride at 0.1 mg/kg IV should be administered immediately to protect the heart from the effects of hyperkalemia.12 This dose should be given slowly over 5 to 10 minutes while monitoring the patient’s cardiac status on an ECG for conversion to a normal sinus rhythm. To decrease serum potassium concentration, a combination of regular insulin and dextrose can be administered. Insulin drives potassium into the intracellular space, and dextrose helps prevent hypoglycemia that may result from insulin administration. Regular insulin should be given at a dose of 1 U/cat.a Blood glucose concentration should be monitored every 4 hours after administration of insulin and dextrose. If the glucose concentration decreases to 60 to 70 mg/dL or less, a dextrose constant-rate infusion should be initiated at the fluid rate already being administered. Dextrose 50% can also be administered without insulin to stimulate the release of endogenous insulin. The dose is 0.5 g/kg diluted 1:1 with NaCl or sterile water.5 The dextrose should be diluted 1:1 to decrease the osmolarity and should be administered with caution to avoid extravasation, since it can cause skin sloughing.

BOX 2 How to Perform Cystocentesis To perform cystocentesis, a 22-gauge needle should be attached to a flexible IV extension set, 3-way stopcock, and large-capacity syringe (≥20 mL)16 using aseptic technique. The needle should be inserted into the bladder through the ventrolateral wall at a 45° angle (FIGURE A).11 It is important to properly insert the needle into the bladder wall to minimize trauma to the bladder.16

FIGURE A. Performing cystocentesis.

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The short-term prognosis for cats treated for urethral obstruction is good when appropriate treatment and supportive care are provided as soon as an obstruction is suspected. Alternatively, sodium bicarbonate (1 mEq/kg given slowly over 10 minutes) can be used to drive potassium into the intracellular space. Administration of sodium bicarbonate may result in ionized hypocalcemia, hypernatremia, alkalosis, and seizures; therefore, its use should be restricted only to patients with severe hyperkalemia (potassium concentration >10 mEq/L) or acidemia (pH <7.1). Remove the Obstruction Urethral catheterization is the method most commonly used to remove a urethral obstruction.1 If urethral catheterization cannot be performed immediately, or if the patient is too unstable or in too much pain, the urinary bladder can be emptied through cystocentesis to help stabilize vital signs and to relieve discomfort (BOX 2). Cystocentesis should be performed with caution because the bladder wall is friable and prone to tearing. A caudal epidural (BOX 3) can facilitate the deobstruction, help decrease the amount of inhalation anesthesia required, and provide analgesia during the recovery period. Various medications can be used for the epidural injection. Lidocaine 2% without epinephrine at a dose of 0.1 to 0.2 mL/kg can be used (approximately 0.5 mL/cat).17 Bupivicaine 0.75% can also be used at the same dose18; its duration of action is approximately 2 hours. Astramorph (Fresenius Kabi, USA; preservative-free morphine) can also be used at a dose of 0.1 mg/kg, with a duration of action of 10 to 24 hours.18 Administration of a sedative before the collection procedure may be required in fractious patients or patients with severe pain. Detailed information on the catheterization procedure as well as sedation is provided in BOX 4. a

Cooper E, VMD, MS, DACVECC. Personal communication. The Ohio State University Teaching Hospital, 2008.

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POSTOBSTRUCTION CARE Medical Care Acepromazine (0.03 to 0.1 mg/kg IV q6-8h)14 can be administered following urethral catheterization to provide sedation and decrease urethral spasms. It can be administered with buprenorphine (0.006 to 0.01 mg/kg IV q6-8h).20 (In the author’s clinic, doses of 0.01 to 0.03 mg/ kg IV have been used q6-8h.) Buprenorphine should be administered to provide analgesia. Buprenorphine solution can be administered orally and should be placed on the oral mucosa, where it has been shown to have excellent bioavailability. Following urethral catheterization, urine output should be measured every 4 hours to ensure that output equals 1 to 2 mL/kg/hr. IV fluids should be recalculated every 4 hours to match urine output plus the maintenance fluid rate for that individual patient. Packed

Urethral Obstruction in Male Cats

cell volume and serum concentrations of total protein, electrolytes, blood urea nitrogen, and creatinine should be measured once or twice a day to assess hydration status and resolution of metabolic abnormalities. In some patients with significant azotemia, postobstructive diuresis occurs as a result of medullary washout, osmotic diuresis, pressure necrosis, or antidiuretic hormone resistance. Diuresis should be suspected if urine output exceeds 2 mL/kg/hr. Diuresis can cause rapid dehydration and electrolyte depletion. Urine output of these patients should be monitored closely. Serum potassium concentration should also be measured regularly and potassium supplementation provided as needed. The urinary catheter should be left in place for 24 to 48 hours after urethral catheterization. Once urine output and results of blood and serum studies are normal, the catheter can be removed. A sterile urine sample for

BOX 3 Caudal Epidural Technique 1. Place the cat in sternal recumbency and palpate the space between the sacrum and first coccygeal vertebra or the first and second coccygeal vertebrae. The first coccygeal vertebra will be mobile when the tail is moved. 2. Clip a small square over the area and aseptically prepare the skin. Sterile gloves should be worn after the area is prepped. 3. Wearing sterile gloves, again palpate the location of the most mobile joint caudal to the sacrum. If the patient is awake, have an assistant keep the tail from moving to preserve sterility. Use the nondominant index finger to identify this space, while the dominant hand is kept sterile for handling the needle. 4. Once the space has been identified, use a 25-gauge × 1-inch needle to penetrate the skin at midline. The index finger may remain near the injection site as a guide for needle placement. The needle is directed at a 30° to 45° angle and advanced through the interarcuate ligament/ligamentum flavum. A palpable “pop” may occur when the ligament is penetrated. As the needle is advanced, there should be a little resistance upon entering the epidural space. If bone is encountered, establish if the needle is superficial to the spinal canal or if it has been advanced through the epidural space to the floor of the vertebral canal. If the needle is superficial it should be kept underneath the skin, repositioned slightly either cranially or caudally, and walked off the bone until the space is entered. The needle should then feel more firmly seated. If the bone encountered is thought to be deep, back the needle out slightly and continue with the injection. 5. Once the needle is properly placed, attach and aspirate a syringe to confirm the absence of blood. If blood is encountered, the needle should be removed and another attempt made. If no blood is aspirated, infuse the medication being used for injection into the epidural space. There should be minimal resistance to injection. Air is not injected into this space because the potential space is small and air bubbles may result in an incomplete block. If resistance is encountered toward the end of the injection, the injection may be subcutaneous and the block may not be efficacious. 6. Once the injection is completed, withdraw the needle and observe the rectum and tail for relaxation. Relaxation does not need to be complete, but some relaxation should be observed before attempting catheterization. Pinching the tail or perianal region can be used to further confirm proper placement of the injection. 7. If relaxation is not observed within 5 minutes, the block may have been injected outside the epidural space. A second dose may be attempted using the same technique. It is not recommended to attempt more than 2 injections because of the risk for excessive cranial spread of the local anesthetic, which may result in paralysis of necessary spinal structures. In cases in which a higher dose or repeat injections are administered, some hindlimb weakness may be appreciated.

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BOX 4 Urethral Catheterization in Male Cats Anesthesia When vital signs are stable, urethral catheterization should be performed with the patient under sedation or general anesthesia. Sedation is indicated in patients that are not stable enough for anesthesia. Moribund patients can be catheterized without any sedation. The anesthetic protocol should include a premedication, induction agent, and gas inhalant. The premedication provides sedation and reduces the amount of induction agent required. Acepromazine, a phenothiazine, can be administered at 0.03 to 0.1 mg/kg IV, IM, or SC for premedication.14 Although doses at the low end of this range produce minimal cardiovascular effects, high doses can cause marked hypotension and reflex tachycardia; therefore, high doses should be used with caution in debilitated or hypotensive patients. Acepromazine may protect the heart against catecholamine-induced arrhythmias.19 Acepromazine can be combined with buprenorphine at 0.006 to 0.01 mg/ kg.20 Hydromorphone and fentanyl can also be combined with acepromazine. When given as a premedication, hydromorphone and acepromazine provide sedation and analgesia. Fentanyl, given as a constant-rate infusion, provides additional analgesia during catheter placement and allows for a decreased amount of inhalant to be used. Hydromorphone is administered at 0.025 to 0.1 mg/kg IV, IM, or SC.14 Fentanyl is given initially as a bolus dose of 2 to 5 mg/kg IV; a constant rate infusion of 1 to 5 mg/kg/hr is then initiated to maintain a level plane of sedation.14 Hydromorphone and fentanyl can cause respiratory depression at higher doses; therefore, debilitated

patients should be given doses only at the low end of the range.14 The induction agent enables intubation of the patient for administration of inhalant anesthetic gas. Ketamine and diazepam, or propofol alone, can be used for induction.21 Ketamine increases heart rate and contractility while maintaining blood pressure.22 Diazepam produces minimal effects on the cardiovascular system and provides skeletal muscle relaxation.20 Ketamine at 4 to 6 mg/kg and diazepam at 0.3 mg/kg can be combined in the same syringe and administered intravenously to effect.23 This combination should not be used alone in patients that are not stable enough for general anesthesia. If propofol is used for induction, the dose is 2 to 8 mg/kg IV administered to effect; 4 mg/kg is usually sufficient for induction of a premedicated patient.23 The inhalant gas provides maintenance of anesthesia. Following induction, the patient is intubated and isoflurane or sevoflurane is administered. Blood pressure and heart and respiratory rates should be monitored closely during the administration of anesthesia. If insulin and dextrose were administered before anesthesia, blood glucose concentration should be tested every 4 hours. Catheterization The area around the penis and prepuce is clipped and prepared using standard aseptic technique following induction and maintenance of anesthesia. A solution of sterile water and sterile lubricant is mixed at a 1:1 ratio, and two 20-mL syringes are filled with the solution (FIGURES A and B). A sterile 3.5-Fr open-ended tomcat

FIGURES A and B. Two 20-mL syringes attached to a 3-way stopcock. One syringe contains 0.9% NaCl; the other contains sterile lubricant. While attached to the stopcock, the syringes are flushed back and forth to mix the NaCl and lubricant. A syringe filled with the resulting solution is attached to an extension set and then to the urinary catheter that is being passed. The syringe contents are “pulsed” into the catheter while it is advanced into the urethra to help with flushing.

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catheter is then attached to extension tubing and a 3-way stopcock, and one syringe of the sterile solution is attached to the stopcock. Before insertion in the urethra, the catheter should be filled with the sterile solution. Before the catheter is inserted in the urethra, the penis is extruded and extended dorsally until the long axis of the urethra is parallel to the vertebral column.20 The catheter tip is then seeded in the distal urethra, and the prepuce is pulled caudally to straighten the urethral flexure and facilitate passage of the catheter (FIGURES C and D). The catheter is advanced slowly while the plunger of the syringe containing the sterile solution is pulsed at regular intervals. This process flushes the obstruction into the bladder. Once the catheter can be advanced easily through the urethra and all the sterile solution has been pulsed into and then aspirated from the bladder, the catheter is removed. A sterile indwelling 3.5- or 5.0-Fr urinary catheter should be inserted in the urethra and sutured in place (FIGURE E).

Urethral Obstruction in Male Cats

system is attached to the indwelling urinary catheter for monitoring of urine output (FIGURE F). For difficult obstructions, ensure that the patient is positioned in dorsal recumbency with its legs pointing cranially. One the penis is extruded, a 22-gauge IV catheter can be used. This catheter takes the place of the tomcat catheter. Using the same technique mentioned above, seed the catheter in the distal urethra and flush the catheter with sterile lubricant and 0.9% NaCl while trying to advance it further into the urethra. Red rubber catheters (3.5 and 5 Fr) can also be used if other urinary catheters are unavailable. They are pliable enough that they can be used for the deobstruction as well as left in place and sutured. If they are not rigid enough for the initial placement, they can be stored in the freezer.

Some sterile indwelling catheters (e.g., MILA, Erlanger, KY) can be used for deobstruction and then left in place and sutured. This can help decrease urethral trauma from multiple catheterizations. A closed urinary collection

FIGURE E. Patient with a catheter sutured in place.

FIGURE C. Extruding the penis.

FIGURE D. Urinary catheter being placed in the urethra.

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FIGURE F. Urinary drainage system consisting of a sterile Viaflex bag (Baxter, Deerfield, IL) and fluid administration set.

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culture should be obtained from the urinary catheter just before removal. After the urinary catheter has been removed, the patient should be monitored closely during the next 24 hours to ensure that urination is normal. Home Care Following discharge to the owner, a patient treated for urethral obstruction should continue to receive treatment with acepromazine at 0.5 mg/kg PO and buprenorphine at 0.01 mg/kg PO for 5 to 7 days to provide continued sedation and analgesia as well as to decrease urethral spasms. Antibiotics should be administered based on the results of culture and susceptibility testing of the urine sample obtained immediately before urinary catheter removal. Other medications can be used in the hospital or at home after discharge to help to decrease urethral spasms. Phenoxybenzamine, for example, is used mainly to decrease internal urethral sphincter tone, at a dose of 0.5 mg/kg PO q24h. The dose can be increased by 2.5 mg/kg to a maximum of 10 mg. The initial dose should be used for 5 days before reevaluation and then increased, if needed.14 Prazosin can also be used at a dose of 0.5 mg/cat PO q12h.24 Recently, Cosequin for Cats (Nutramax Laboratories, Lancaster, SC) has been used as a symptomatic treatment in cats with FLUTD (feline lower urinary tract disease). This medication, which contains glucosamine and chondroitin sulfate, is a nutritional supplement indicated for cats with arthritis. In cats with FLUTD, it helps to create a water barrier that protects the cells of the urinary tract, which in turn helps prevent bacteria and crystals from adhering to their surface. Some studies show no significant effect compared with placebo; however, some cats in the treatment group showed dramatic improvement when given the medication. The capsule can be opened and the contents sprinkled over the cat’s food.25

References 1. Shaw D, Ihle S. Urinary tract disease and fluid and electrolyte disorders. In: Small Animal Internal Medicine. Baltimore, MD: Williams & Wilkins; 1997:323-377. 2. Drobatz KJ. Critical care aspects of urethral obstruction. WVC Proc 2005. 3. Lawler DF, Sjolin DW, Collins JE. Incidence rates of feline urinary tract disease in the United States. Feline Pract 1985;15(5):13-16. 4. Lee JA, Drobatz KJ. Characterization of the clinical characteristics, electrolytes, acidbase, and renal parameters in male cats with urethral obstruction. J Vet Emerg Crit Care 2003;13(4):227-233. 5. The Ohio State University College of Veterinary Medicine. Unpublished data. Columbus, OH; 2002. 6. Sparkes AH. Feline lower urinary tract disease. World Small Anim Vet Assoc World Congr Proc 2006. 7. Hostutler RA, Chew DJ, Dibartola SP. Recent concepts in feline lower urinary tract disease. Vet Clin North Am Small Anim Pract 2005;35(1):147-170. 8. Bartges JW, Finco DR, Polzin DJ, et al. Pathophysiology of urethral obstruction. Vet Clin North Am Small Anim Pract 1996;26(2):255-265. 9. Bexfield NH. Urinary obstruction: can’t pee, won’t pee. Br Small Anim Vet Congr Proc 2007.

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LONG-TERM DIETARY AND ENVIRONMENTAL MANAGEMENT Long-term management should be geared toward decreasing the recurrence of interstitial cystitis, which may lead to another obstruction. Patients with a history of bladder or urethral stones should be placed on a urinary care prescription diet that keeps pH neutral to help prevent the crystals from returning. These patients can also benefit from increased water intake, with access to fresh running water. Although not ideal, water can be added to their canned food. Cats that are prone to cystitis need environmental enrichment. Scratching posts and toys can help increase their activity. They also need to be in an environment that has reduced levels of stress, and they need a quiet place for their food and litterbox. CONCLUSION The short-term prognosis for cats treated for urethral obstruction is good when appropriate treatment and supportive care are provided as soon as an obstruction is suspected. Cats that have had one urethral obstruction are at increased risk for reobstruction. In addition, cats that develop urethral obstructions multiple times may require perineal urethrostomy to widen and shorten the urethra. This procedure should drastically reduce the chances of another obstruction from occurring; however, stones or calculi could possibly cause another obstruction. 

Acknowledgment The author thanks Edward Cooper, VMD, MS, DACVECC, who is affiliated with The Ohio State University Veterinary Medical Center, for his help in reviewing the original article.

10. Senior DF. Urinary disorders. In: Schaer M, ed. Clinical Medicine of the Dog and Cat. Ames, IA: Iowa State Press; 2003. 11. Plunkett S. Urogenital and reproductive emergencies. In: Emergency Procedures for the Small Animal Veterinarian. Philadelphia, PA: Harcourt Publishers Limited; 2000:224-225. 12. Greene SA, Grauer GF. Renal disease. In: Tranquilli WJ, Thurmon JC, Grimm KA, eds. Lumb & Jones’ Veterinary Anesthesia and Analgesia. 4th ed. Ames, IA: Blackwell Publishing Professional; 2007:915-919. 13. Ettinger SJ, Feldman EC, eds. Urolithiasis, urethroliths, and urethral plugs. In: Textbook of Veterinary Internal Medicine. 6th ed. St. Louis, MO: Elsevier Saunders; 2005. 14. Plumb D. Veterinary Drug Handbook. 3rd ed. White Bear Lake, MN: Pharma Vet Publishing; 1999. 15. Kirby R, Rudloff E. Fluid and electrolyte therapy. In: Textbook of Veterinary Internal Medicine. Philadelphia, PA: Saunders; 2000:335. 16. Sanderson S. Urethral obstruction: techniques to relieve obstruction and management of the patient. Proc 30th World Congr World Small Anim Vet Assoc 2005. 17. O’Hearn AK, Wright BD. Coccygeal epidural with local anesthetic for catheterization and pain management in the treatment of feline urethral obstruction. J Vet Emerg Crit Care 2011;21(1):50-52.

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CE Test Article 1 Urethral Obstruction in Male Cats 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/tvt.aspx. A $5 fee applies. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval. 1. What is thought to be the most common cause of urethral obstruction in male cats? a. Uroliths b. Neoplasia c. Urethral plugs d. Urethral strictures 2. The initial treatment for urethral obstruction is a. cystocentesis. b. deobstruction. c. calcium chloride. d. intravenous fluids. 3. On an electrocardiogram, what are the signs of hyperkalemia? a. Diminished to absent P waves b. Diminished to absent T waves c. Narrow QRS complexes d. Shortened PR intervals 4. What immediate treatment should be administered if the potassium value is thought to be life threatening (>6.0 mEqL)? a. Calcium chloride 10%: 0.1 mg/kg IV b. Calcium gluconate 10%: 100 mg/kg IV c. Regular insulin 1 U/cat IV d. Dextrose 2.5% CRI 5. When should a cystocentesis be performed? a. Immediately upon presentation b. Only if urethral catheterization and decompression cannot be performed soon after presentation c. Only before induction of anesthesia d. It is never appropriate to perform a cystocentesis on a cat with a urethral obstruction 18. Muir WW, Hubbell JAE, Skarda RT, Bednarski RM. Lumbosacral epidural anesthesia. In: Schrefer JA, ed. Handbook of Veterinary Anesthesia. 3rd ed. St. Louis, MO: Mosby, Inc; 2000:108. 19. McKelvey D, Hollingshead KW. The preanesthetic period. In: Duncan LL, ed. Mosby’s Fundamentals of Veterinary Technology: Small Animal Anesthesia Canine and Feline Practice. Baltimore, MD: Mosby 1994:41. 20. Thurmon JC, Tranquilli WJ, Benson JG, eds. Preanesthetic and anesthetic adjuncts. In: Lumb & Jones’ Veterinary Anesthesia. 3rd ed. Baltimore, MD: Williams & Wilkins; 1996:183-209. 21. Tindall B. Anesthesia for patients with cardiac disease. In: Bedford PCG, ed. Small

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A premedication is necessary to a. help to sedate the patient. b. reduce the amount of induction drug needed. c. aid in performing a cystocentesis. d. All of the above

7. Urethral obstruction lasting _______________ hours can result in severe metabolic derangement. a. 12–24 b. 24–48 c. 24–36 d. 48–72 8. Traditionally, _______________ has been considered the fluid of choice in treating hyperkalemia associated with urethral obstruction. a. Lactated Ringer’s solution b. Plasmalyte-148 c. 0.9% NaCl d. 0.45% NaCl + 2.5% dextrose 9. After deobstruction, the patient’s urine output should be _______________ mL/kg/hr, assuming there is no postobstructive diuresis. a. 0.5–1 b. 1–2 c. 2–3 d. 3–4 10. Postobstructive diuresis can result in a. rapid dehydration. b. worsening azotemia. c. hyperkalemia. d. antidiuretic hormone resistance.

Animal Anesthesia: The Increased Risk Patient. Philadelphia, PA: WB Saunders; 1991:77. 22. Lin HC. Dissociative anesthetics. In: Thurmon JC, Tranquilli WJ, Benson JG, eds. Lumb & Jones’ Veterinary Anesthesia. 3rd ed. Baltimore, MD: Williams & Wilkins; 1996:241–296. 23. Thurmon JC, Tranquilli WJ, Benson JG, eds. Injectable anesthetics. In: Lumb & Jones’ Veterinary Anesthesia. 3rd ed . Baltimore, MD: Williams & Wilkins; 1996:210–240. 24. DeBartola SP, Westropp JL. Obstructive and nonobstructive feline idiopathic cystitis. In: Nelson RW, Couto GC, eds. Small Animal Internal Medicine. 5th ed. St. Louis, MO: Elsevier; 2014:701. 25. Plotnick A. Feline lower urinary tract disease (FLUTD). manhattancats.com/Articles/ FLUTD.html. Accessed March 2016.

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Preanalytic Variables: Effects on CBC and Serum Chemistry Results Katie Foust, BS, CVT

Katie Foust, BS, CVT Katie earned an associate’s degree in science from Pima Community College in 2004 and a bachelor’s degree in veterinary science from the University of Arizona in 2008. She has been a certified veterinary technician in the state of Arizona since 2010 and has over 10 years of clinical experience in small and large animal practice and 5 years’ experience as a veterinary technician educator. As a board member of the Animal Welfare Alliance of Southern Arizona, she organizes and volunteers for community service events that provide free or low-cost preventive veterinary care for local pets. She also promotes pet health care awareness by speaking at public events, including community workshops and conventions. Currently, she is the clinical director for the veterinary technology program at Pima Medical Institute in Tucson, Arizona.

Margi Sirois, EdD, MS, RVT, LAT Ashworth College Norcross, Georgia

n both human and veterinary medical practice, current trends indicate a move toward increased point-of-care capabilities. When point-of-care technologies are used efficiently, this translates into better customer service and enhances the practice of medicine. It also leads to improvements in practice financial health. However, these technologies depend on the skill and knowledge of the user to give 28

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Margi Sirois, EdD, MS, RVT, LAT Margi received her doctorate in instructional technology and distance education from Nova Southeastern University. She also holds an associate in applied science degree in veterinary technology, and bachelor’s and master’s degrees in biology. She is certified as a veterinary technician and a laboratory animal technician and has over 25 years of experience as a veterinary technician educator in both traditional and distance education programs. Dr. Sirois is program director for the veterinary technology program at Ashworth College and a frequent speaker at veterinary technician education conferences. She has numerous publications, including several textbooks for veterinary technicians. She is past-president of the Kansas Veterinary Technician Association and co-chair of the proposed Academy of Veterinary Technician Specialists in Education.

Pima Medical Institute Tucson, Arizona

accurate results. In veterinary medicine, one of the most critically important steps in laboratory analysis is blood sample collection. Determining the levels of the various cellular and chemical constituents of blood can provide valuable diagnostic information when test results are accurate. Many preanalytic factors other than disease influence the results of diagnostic tests.1 Veterinary technicians must

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Preanalytic Variables: Effects on CBC and Serum Chemistry Results

Veterinary technicians should alert the veterinarian about any sample characteristics that may interfere with analysis so that the veterinarian may better interpret the results. be familiar with each test methodology used to avoid errors caused by improper sample handling. This article covers a few of the preanalytic factors most commonly encountered in clinical practice. The preanalytic period begins with the preparation of patients and materials for the sampling procedure and continues through sample collection and specimen handling up to beginning the specific laboratory analyses. Preanalytic factors may be biological or nonbiological. Biological variables are factors that are inherent to the patient, such as breed, age, and sex. Because these cannot be controlled, they must be considered when evaluating test results.

Other biological variables involve factors that can be controlled when drawing the blood sample, such as ensuring the animal is properly fasted. Nonbiological variables are related to sample collection and handling. Preanalytic errors are significantly more common than analytic errors.2 The impact of preanalytic factors on test results depends on the analyzer and methods used (TABLE 1). LIPEMIA Lipemia, the presence of excessive lipoproteins in the blood, is common in postprandial blood samples. Lipemic blood samples are turbid (FIGURE 1) because of the presence of large lipid particles, which can absorb or scatter most wavelengths of light and thus interfere with many spectrophotometric test methods. Lipemia can also create a phenomenon known as volume displacement, in which lipoproteins comprise a larger FIGURE 1. The turbidity of lipemic samples can interfere with several spectrophotometric assays.

TABLE 1 Effects of Sample Compromise SAMPLE CHARACTERISTIC

EFFECT

RESULT

Lipemia

Light scattering



Volume displacement



Hemolysis*



Release of analytes

Hemolysis/blood substitutes



Release of enzymes*

Icterus

Hyperproteinemia

Medications



Reaction inhibition



Increased optical density (absorbance)



Release of water



Spectral interference



Chemical interaction



Hyperviscosity



Analyte binding*



Volume displacement



Reaction interference*



*Variable effect, depending on the analyte and test method used. Courtesy of Elsevier. From Sirois M. Laboratory Procedures for Veterinary Technicians. 6th ed. St. Louis, MO: Mosby; 2015.

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If a technician notices a sample to be lipemic or hemolyzed, it should be noted in the patient’s medical record. Varying intensities of lipemia or hemolysis can be described as slight, moderate, or marked.

than normal fraction of plasma, which reduces the fraction of plasma composed of water. This falsely decreases electrolyte levels when using analyzers that measure electrolyte concentration from the total plasma volume. Because lipoprotein concentrations in blood plasma can quickly reach levels that interfere with laboratory testing and persist for several hours after a patient eats, it is recommended that patients be fasted for 12 hours before blood collection.3 HEMOLYSIS Hemolysis is perhaps one of the most commonly encountered sources of sample compromise and has an array of effects on both hematologic and clinical chemistry assays (FIGURE 2). Hemolysis increases the light absorbance of blood serum or plasma, which particularly interferes with chemistry tests that read in the ultraviolet/ visible wavelengths.4 Increased free hemoglobin in plasma can also directly inhibit some chemical reactions. Additionally, hemolysis results in release of analytes and enzymes from red blood cells (RBCs), which can falsely elevate many test results.5 Destruction of RBCs yields a lower RBC count.1 Excess fluid released from the lysed RBCs also creates a dilution effect in serum and can result in an artifactually decreased packed cell volume. Many factors can destroy RBCs; while nearly all are a result of improper collection and handling, some may be a result of patient disease processes, such as immunemediated hemolytic anemia. Administration of certain blood products, such as hemoglobin-based oxygen carriers, can also cause hemolysis. This must be considered when choosing test methods because most chemistry analyzers are incapable of providing accurate readings on samples from these patients. To avoid the common causes of hemolysis, blood should be collected and handled as atraumatically as possible. Repeated attempts to draw blood from the same vessel are undesirable. However, if this cannot be avoided, there are other methods to reduce physical trauma to the sample. Such practices include using FIGURE 2. Hemolyzed samples can yield erroneous results from both blood serum chemistry and hematologic assays. 30

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TECHPOINT 

the largest-gauge needle that the patient can tolerate, limiting the amount of negative pressure created when drawing back on the syringe plunger, and, most importantly, removing the needle from the syringe and the cap from the collection tube before transferring blood. Additionally, because isopropyl alcohol can cause sample hemolysis, collection sites should be clipped and excess alcohol allowed to evaporate before venipuncture is performed. Veterinary technicians should alert the veterinarian about any sample characteristics that may interfere with analysis so that the veterinarian may better interpret the results. If a technician notices a sample to be lipemic or hemolyzed, it should be noted in the patient’s medical record. Varying intensities of lipemia or hemolysis can be described as slight, moderate, or marked. ANTICOAGULANT Veterinary technicians must ensure that the anticoagulant chosen does not interfere with the blood constituent(s) being assayed. Citrate and oxalate anticoagulants can be used for plasma samples but interfere with some biochemical testing and damage RBCs. Fluoride inhibits in vitro glycolysis by RBCs and is a useful anticoagulant when preservation of glucose is critical.4 Ethylenediaminetetraacetic acid (EDTA) preserves cellular components for CBC and morphologic evaluation but falsely decreases calcium, phosphorus, and alkaline phosphatase levels and elevates potassium levels; therefore, EDTA plasma samples should not be used for chemical analysis. Conversely, lithium heparin is a generally safe anticoagulant for plasma chemistry and electrolyte analysis, but it distorts blood cells and should not be used for evaluation of cell morphology in samples from mammals.6

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Preanalytic Variables: Effects on CBC and Serum Chemistry Results

CLOTTING, CENTRIFUGATION, AND SEPARATION To prevent the initiation of blood clotting processes, several guidelines should be followed when collecting whole blood or plasma samples. The coagulation cascade can be triggered by excess venous stasis (>1 minute) or by excessive probing with the needle. Excess venous stasis also alters the composition of the sample as a result of water and electrolytes moving from the intravascular to the extravascular space.3 It is important that samples be collected with minimal trauma to avoid these common errors. Anticoagulant tubes should be gently mixed by inverting several times immediately after collection. Failure to follow these guidelines can result in platelet clumping, which yields low platelet counts by automated machines and also makes it impossible to accurately estimate platelet numbers on a blood film. Additionally, formation of clots in a blood sample may reduce other cell counts. Whole blood samples with evidence of clotting should not be used for testing when the test utilizes whole blood. When collecting blood for the purpose of obtaining serum, blood should be allowed adequate time to clot. If a blood sample is centrifuged before the clotting process has completed, the serum may retain fibrin strands that can alter analyzer readings.4 Unless the blood collection

tube contains clot accelerators, the sample should be left undisturbed at room temperature for 20 to 30 minutes while the clot is forming. Immediately after clotting, a wooden applicator stick should be used to gently separate the clot from the walls of the tube (FIGURE 3) and the sample should then be centrifuged for 10 to 20 minutes at 1000g. Immediately after centrifugation, plasma or serum should be removed with a pipette, transferred to a plain tube, and labeled. Numerous blood constituents will be affected if the cells are allowed to remain in contact with serum or plasma. Generally, decreases are seen in glucose and calcium levels while phosphorus and potassium are increased in affected samples.7 Even though barrier gels separate blood cells from fluid components, they are capable of absorbing certain hormones and drugs, such as progesterone and phenobarbital.8 In addition, centrifuging samples using a fixed-head rotor centrifuge can allow gaps to develop in the gel barrier.4 This is why it is recommended to separate serum and plasma samples after centrifugation regardless of whether a separator gel is present in the tube. When multiple types of samples are required, the samples should always be collected with the vacuum system, as it ensures that an appropriate volume of each

FIGURE 3. Gently separating the clot from the walls of the collection tube before centrifugation helps to increase serum yield. TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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TABLE 2 Order of Draw for Commonly Used Blood Collection Tubes ORDER

CAP COLOR

ADDITIVE

PRIMARY USE

Blue

Sodium chloride

Coagulation studies

Red

Glass: no additive Plastic: silicon coated

Serum for blood chemistry

Red/gray or red/black “tiger top”

Gel separator and clot activator

Serum for blood chemistry

Green

Heparin

Plasma for blood chemistry

Lavender

EDTA

Hematology

Gray

Potassium oxalate or sodium fluoride

Coagulation testing and glucose testing

First

Last Courtesy of Elsevier. From Sirois M. Laboratory Procedures for Veterinary Technicians. 6th ed. St. Louis, MO: Mosby; 2015.

sample type is obtained. EDTA is hypertonic, and excess EDTA results in crenation of RBCs, which in turn drastically reduces the RBC count. The correct-size tube must be used to minimize damage to the sample and the possibility of collapsing the patient’s vein. If using the vacuum system, the tubes must be filled in a specific order to avoid the potential contamination of samples with additives from other tubes (TABLE 2).

BOX 1 Recommended Resources  Overview of collection and submission of laboratory samples. The Merck Veterinary Manual [online]. merckvetmanual.com.  Sample collection. Cornell University College of Veterinary Medicine EClinPath website. eclinpath.com/chemistry/sample-collection-chem/.  Sirois M. Laboratory Procedures for Veterinary Technicians. 6th ed. St. Louis, MO: Mosby; 2015.  Yagi K. Top 5 tips for diagnostic blood collection. Veterinary Team Brief [online]. veterinaryteambrief.com. July 2015.

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STORAGE If processing is delayed, samples should be refrigerated or frozen according to laboratory protocols and type of tests ordered. Storing at cooler temperatures is generally preferred as it slows in vitro reactions of chemical components. However, all samples should be allowed to warm to room temperature before processing because cold temperatures can inhibit certain chemical reactions necessary for blood analysis. Additionally, chemistry samples should also be stored away from ultraviolet light because prolonged exposure reduces bilirubin levels.4 CONCLUSION A variety of factors can influence the quality of CBC and serum chemistry results. Intrinsic patient factors, such as age, breed, and presence of disease, cannot be controlled with human intervention. This strengthens the argument for exercising all reasonable methods to reduce nonbiological preanalytic errors. Blood sample collection and handling protocols should be implemented and followed by all practice personnel to avoid variation in the accuracy of laboratory results. For example, to avoid lipemia, staff should not feed or offer treats to patients

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Veterinary technicians must ensure that the anticoagulant chosen does not interfere with the blood constituent(s) being assayed. that may require blood testing during their visit. When scheduling appointments, receptionists should instruct owners to fast patients when necessary. Protocols to reduce hemolysis of samples should require staff to use appropriately sized needles when drawing blood and to remove needles from syringes before transferring samples to collection tubes. Consistency in preparation of samples can be enhanced with the use of automated instruments

Preanalytic Variables: Effects on CBC and Serum Chemistry Results

(FIGURE 4). Other guidelines related to method of collection, sample handling, and storage of collected samples should be followed to further help minimize effects of preanalytic errors on hematology and serum chemistry results (BOX 1).  References 1. American Society for Veterinary Clinical Pathology (ASVCP). Quality Assurance for Point-of-Care Testing in Veterinary Medicine. Available at asvcp.org/pubs/qas/index. cfm. Accessed August 2015. 2. Baron JM, Mermel CH, Lewandrowski KB, Dighe AS. Detection of preanalytic laboratory testing errors using a statistically guided protocol. Am J Clin Pathol 2012;138(3):406-413. 3. Narayanan S. The preanalytic phase: an important component of laboratory medicine. Am J Clin Pathol 2000;113:429-452. 4. Humann-Ziehank E, Ganter M. Pre-analytical factors affecting the results of laboratory blood analyses in farm animal veterinary diagnostics. Animal 2012;6(7):1115–1123. 5. Bell R, Harr K, Rishniw M, Pion P. Survey of point-of-care instrumentation, analysis, and quality assurance in veterinary practice. Vet Clin Path 2014;43(2):185-192. 6. Harvey JW. Veterinary Hematology. St. Louis, MO: Saunders; 2012. 7. Joshi A. Variations in serum glucose, urea, creatinine and sodium and potassium as a consequence of delayed transport/processing of samples and delay in assays. J Nepal Med Assoc 2006;45(161):186-189. 8. Dasgupta A, Dean R, Saldana S, et al. Absorption of therapeutic drugs by barrier gels in serum separator blood collection tubes. Volume- and time-dependent reduction in total and free drug concentrations. Am J Clin Path 1994;101:456-461.

FIGURE 4. This Microview system automates the process of smearing, staining, and viewing blood smears and other types of samples and captures a digital image of the slide. Photo courtesy of Revo Squared. TODAY’SVETERINARYTECHNICIAN

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Career Challenges

So You’ve Been Promoted to Management… Now What?

wenty-five years ago, the concept of having a supervisor in every department or a practice manager was new to veterinary practices. Practice owners wanted some level of management support but often did not know how to go about achieving that goal. Veterinary practice management continuing education (CE) opportunities were just emerging and frequently involved travel. Therefore, new veterinary practice managers were limited to general management seminars on customer service and communication that were marginally beneficial. The lack of veterinary management training and resources meant that we had to learn from our mistakes—and we made a lot! The practice manager profession has come a long way. Today, many practices have multiple levels of supervision and management. Robust veterinary practice management groups, management resources, associations, and an abundance of CE offerings are available. However, for those who did not consciously set out to be practice managers, the transition into a management role can still be a rocky one. If you have been promoted to a management role within your practice and are still wondering how to tackle your new position—or if you think you might be

Sandy Walsh, RVT, CVPM PetOps, LLC Sandy is a veterinary practice management consultant, instructor, speaker, and advisor. With over 30 years of experience in the veterinary field, she brings her “in the trenches” experience directly to you. She is dedicated to improving hospital operations through coaching and sharing appropriate practice management techniques with the whole team.

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Sandy still works in a small animal practice and is an active member of the Veterinary Hospital Managers Association, NAVTA, VetPartners, Sacramento Valley Veterinary Practice Managers Association, Sacramento Valley Veterinary Technician Association, and the California Veterinary Medical Association. She is an instructor for Patterson Veterinary Management University and a former hospital inspector for the California Veterinary Medical Board.

THE BEST MANAGERS AND LEADERS see themselves as capable of bringing positive change and energy to the practice as a whole. They accomplish goals and drive the practice in the right direction, not on their own, but with the combined efforts of their team. 34

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Honesty, ethics, and integrity are important characteristics for anyone in a leadership role. Even more importantly, they must be seen in action. on that path—don’t panic! Know that there are many resources to help you learn management skills, and even your mistakes can be opportunities to improve. WHY ARE YOU HERE? What is it that motivates one to want a management role in a veterinary practice? Most of us never considered it as an option when we entered the profession as a veterinary technician, a receptionist, a pet care attendant, or even a doctor. So how does it happen? Sometimes, it is simply a matter of being in the right place at the right time to consider the offer. Although outside candidates can bring great experience with them, many practice owners look to their current team when selecting managers and supervisors. Promoting from within allows for upward movement and growth within the practice, and practice leadership can be the appropriate progression for many who have worked their way through multiple positions in the practice, have earned more responsibility, and have a desire to manage. Perhaps, if you are a newly promoted manager, you have served in another role in the practice for a long time—a role you were probably very good at. You have a lot of experience, but not in your new field of management. Maybe you’re asking yourself: What exactly is my new role? What does “management” really mean? As a manager, you are now a practice leader. Practice leaders have a high level of responsibility: achieving the goals and vision of the practice. The practice owner may be the one setting the goals and vision, but the manager and leadership team are the ones leading the effort.

Career Challenges

Promoted to Management

SO YOU’VE BEEN PROMOTED…NOW WHAT? Learn the Ropes Training, guidance, authority, and support are necessary for any manager to succeed. Unfortunately, these tools are not always automatically included with promotion. If you’ve been given the job without the background, you may need to take charge of educating yourself and asking for help from your supervisor. BOX 1 lists some useful resources to get you started, and BOX 2 provides several tips that you can put into practice immediately. Show Your Integrity It can be difficult to transition into a role where you are managing peers and coworkers with whom you already have personal relationships. You now have a responsibility to hold them accountable, making sure their performance, attendance, and conduct meet the expectations of the practice owner. To succeed, you need to gain their trust and respect, not just for your veterinary knowledge, but as a person and a leader. Respect is something you earn, and it takes time. Gaining the respect of a team is an issue every new manager faces, but in your case, it may be complicated by the challenge of changing your existing bonds with team members and the way they perceive you. Perception goes a long way in shaping your success when managing people. The team’s perception of you as a person may be even more important than your skills and technical knowledge when it comes to respect. Honesty, ethics, and integrity are important characteristics for anyone in a leadership role. Even more importantly, they must be seen in action. Be Firm, Fair, and Consistent Favoritism, whether perceived or real, can be a challenge for any manager. Especially as someone who has worked in the practice before becoming a manager, you are likely to relate to some employees better than others—those with whom you have connected on a personal level. You need to be aware of how you address and treat your friends and make sure that you deal with all the people you manage consistently. Even the fairest of managers can

BOX 1 Resources for New Practice Managers  Ackerman L. Blackwell’s Five-Minute Veterinary Practice Management Consult. Wiley-Blackwell; 2013.  Heinke M. Practice Made Perfect: A Complete Guide to Veterinary Practice Management. AAHA Press; 2012.  Opperman M, Grosdidier S. The Art of Veterinary Practice Management. Advanstar Communications; 2014.  Veterinary Hospital Managers Association. VHMA.org.

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BOX 2 Tips to Help New Managers Adjust and Succeed  Ask for a complete and comprehensive job description. It should detail your roles and responsibilities as well as the expectations of the practice owners. Clearly defined authority and autonomy are required to do your job effectively.  Master the practice management software as soon as possible. You need to be fully proficient in every aspect.  Learn the job of every employee in every department you manage. You will have a better understanding of the challenges in each department, get to know each employee, and be able to step in and help out when needed.  Carve out uninterrupted management time. It is very difficult to fulfill all of the duties of a manager when you are a full-time veterinary technician. Your clients and patients will always come first while important management duties are neglected. If you have to split your time, schedule yourself appropriately. You don’t want to have the feeling that wherever you are that day, you should be somewhere else.  Lead by example. Put yourself on the schedule and show up on time. Don’t be a “do as I say, not as I do” manager.  Dress the part. Don’t wear scrubs to work when you are not scheduled to be on the floor. Doctors and coworkers will be less likely to pull you away from your management duties if you are dressed in a “business professional” manner.

be perceived as “playing favorites.” Do your best to keep your work and personal lives separate. On the other side of the coin, it is important to be friendly with the people you work with, but you don’t have to be everyone’s friend. Inevitably, you will be called on to resolve an employee conflict. Depending on your personal relationship with individual employees, you may be tempted to avoid the conflict or confrontation in the hope that it will resolve with time. This generally doesn’t happen, and as the manager, it is your responsibility to address the issue head on. The longer you wait, the more difficult the solution will be. Although it can be difficult to hold coworkers accountable, especially those with whom you have a good relationship, you cannot ignore problem employee performance or behavior, no matter who the employee is. You need to be firm, fair, and consistent in upholding the values and rules of the practice to achieve its goals and vision. 36

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 Acknowledge your team. Make sure to give credit where credit is due.  Learn to delegate. You can’t do it all. Identify those on the team who are willing and capable. You will never feel comfortable taking time off if you feel like you are the only one who can get the job done.  Don’t overdo it. Except in cases of a true emergency, go home at the end of your shift. Learn to prioritize, and remember that everything will be there when you get back the following day. Working excessive hours week after week will lead straight to burnout.  Establish ground rules regarding phone calls at home after hours. If it is a true emergency, staff can call you at any time. If it can wait until the next day, or if there is nothing you can do about the situation at that time, a call is likely not appropriate. Train your team to know the difference.  Take advantage of veterinary practice management and leadership CE opportunities whenever possible. National, state, and local conferences and meetings, webinars, and online courses and programs are all options.  Read as many veterinary practice management articles, journals, and books as you can get your hands on.  Get involved with your local practice managers’ group and national associations such as the Veterinary Hospital Managers Association.

Be a Leader, Not “the Boss” Good managers take a genuine interest in the people in their organization. Without that interest, you will have a difficult time keeping people and their performance in perspective. The best managers and leaders see themselves as capable of bringing positive change and energy to the practice as a whole. They accomplish goals and drive the practice in the right direction, not on their own, but with the combined efforts of their team. Ultimately, your success as a manager shows in the team’s performance. Don’t think of yourself as “the boss,” but rather as the leader of a cohesive team. CONCLUSION Management is not for the faint of heart. It will likely be the hardest—and, potentially, the most rewarding—job you have ever had. Be the type of manager you would respect and follow, and you will find success in your new and exciting role within the practice. 

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My Favorite Things

Feeding Puzzles for Nutrition and Enrichment

ver the past few years, the indoor environment that we offer our pets has garnered increasing attention. While our current preventive health initiatives have greatly reduced the number of pets that die from preventable problems, we have not addressed our petsâ&#x20AC;&#x2122; mental health to the same degree.

Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition) Belleville, Michigan

BATTLING BOREDOM While we routinely leave our residences for work and socialization, we confine our pets (for their own safety) to our homes, often strictly to the indoor environment. This substantially limits the variety of stimuli, both mental and physical, available to them. When dogs and cats are confined indoors without adequate mental stimulation, trouble can ensue. Ensuring that they have housemates and toys can help, but many animals do not engage in play when humans are not around to share in it. Pets may express boredom in the form of aggression to housemates and owners, destruction of furniture and other household items, and anxietyrelated issues.1 A study done by Beth Strickler, DVM, DACVB, looked at owner engagement and 6 specific behavioral issues in cats.2 Strickler was able to demonstrate that the more involved owners were in engaging their cats daily, the fewer behavior-related issues they reported. Owner engagement primarily consisted of playing with the cats. Owners who played with their

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.

FIGURE 1. A variety of dog feeding puzzles used for an active dog. Image courtesy of Judy Conley, LVT 38

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Hunting behavior provides exercise, mental stimulation and, if engaged in as part of playing with a person, social interaction. What benefit does a bowl of food provide? Easy calories. cat for 5 minutes each day reported fewer behavior problems than those who did not. The two most frequently reported behavior problems were aggression directed at the owners (36%) and periuria (24%).2 Even if owners are lucky enough for their pets to choose a nondestructive activity to relieve boredom, trouble can still ensue. For example, boredom-related eating can result in obesity, especially when combined with decreased activity levels. All animals evolved to acquire their food through activity, whether hunting, scavenging, or grazing. Wild canids, such as wolves, foxes, and coyotes, can spend up to 60% of their day searching for food.3,4 No animal evolved to acquire its food from walking up to a full bowl! We’ve all seen our pets and patients engage in hunting behavior, from a dog chasing a ball to a cat stalking a toy mouse. These activities provide exercise, mental stimulation and, if engaged in as part of playing with a person, social interaction.1 What benefit does a bowl of food provide? Easy calories.

My Favorite Things

Feeding Puzzles for Nutrition and Enrichment

WHY USE FEEDING PUZZLES? Feeding puzzles offer a way for owners to provide enrichment for their pets, encourage mental stimulation, and decrease overeating. Feeding puzzles can also make eating an interactive activity rather than just a source of nutrition.5 A feeding puzzle can be any toy or object that can contain food and requires the pet to work to find a way to get to that food.3 A wide variety of commercial feeding puzzles from companies such as Kong, Premier, and Nina Ottosson is available at pet stores and online, ranging from relatively simple toys that scatter food as they are “hunted” to complex, expensive models that require problem solving (FIGURE 1). It is also fairly easy to make many of these toys at home, keeping both owner and pet engaged. BOX 1 provides a list of links to instructions for do-it-yourself feeding puzzles. Feeding puzzles work well with the way cats prefer to eat, in multiple small meals daily. Even when a cat eats dry food from a bowl, it usually only takes a couple of kibbles at a time. This feeding pattern is ideal for a puzzle, which then makes the cat work for its food! For dogs, using a puzzle can slow down mealtime and provide mental stimulation. Who doesn’t like to solve a puzzle and get a reward at the end? GETTING STARTED So you’ve made the commitment to start feeding a pet using a feeding puzzle—or convinced an owner to try it. How can you introduce this concept to the animal? It is easier to introduce a puzzle if the pet is hungry and to begin with the simpler toys. Most people are familiar with Kong toys, which are hollow rubber toys that can be stuffed with food or treats. The goal is for this type of feeder to release the food slowly, with some effort on the animal’s part. If the animal gets to the food too quickly, freezing the filled toy can slow the pet down and prolong

BOX 1 Do-It-Yourself Puzzle Resources  Enrich feeding time for your cat. Make a puzzle feeder. purinaone.com/cats/enrich-feeding-time-for-your-cat-make-a-puzzle-feeder  Make your own DIY dog toys and puzzles. livewellnetwork.com/Deals/episodes/Make-Your-Own-DIY-Dog-Toys-and-Puzzles/9498449  Six DIY food puzzles with stuff around the house. rover-time.com/six-diy-food-puzzles-stuff-around-house/  Why does my cat need a puzzle feeder? catbehaviorassociates.com/why-does-my-cat-need-a-puzzle-feeder/

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My Favorite Things

Feeding Puzzles for Nutrition and Enrichment

the activity (FIGURE 2). When filling toys with canned food or soft treats, it is usually a good idea to offer them to the pet inside a crate or on a harder, easy-to-clean surface. A mess is guaranteed! Start by placing some fragrant treats inside the toy to attract initial attention. For some animals, using peanut butter or baby food can help with this step.3 The pet may need assistance in understanding that the food it smells is inside the toy. As the pet perfects the technique involved in getting the treats out, slowly switch over to placing food in the puzzle instead of the food bowl (BOX 2). Some animals may need increasingly difficult puzzles. Closing off

BOX 2 No Such Thing as a Free Lunch For many animals, feeding puzzles can be used to provide all their food, not just treats. A friend of mine provides every kibble to her dog throughout the day in response to work. Her puzzles are in the form of training. There is no free food in her house! For this method to work, portion control is important. Determine what the desired volume of food is per day, and divide this amount into 2 or 3 smaller daily feedings dispensed in one or multiple puzzles.

FIGURE 2. A Kong toy for dogs filled with frozen canned food, pursued by Cali the Labrador. Image courtesy of Judy Conley, LVT

How I Do It My cats have a selection of 4 puzzles. I put all their dry food in these puzzles twice daily. Canned food is provided in bowls because I mix specific medications for each cat into each portion, and using bowls allows me to ensure the right cat consumes at least some part of the right medication…before the inevitable bowl switch. Half of my puzzles are homemade, and half were bought off the clearance rack at the pet store. Each of my cats has her favorite puzzle, but when they’re hungry, they will check them all! A note about food puzzle balls: Personally, I don’t use them because my cats would inevitably knock them under the furniture or in a corner, making it harder for me to find them at feeding time. I prefer my puzzles to be less mobile, or confined to a specific area for use.

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A SPIRAL COMMERCIAL DOG FEEDER, USED FOR CATS. The cats use their paws to remove the food. Dogs could

use their paws or their tongues.

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My Favorite Things

FIGURE 3. Cali with a Premier Barnacle feeding puzzle. Cali likes the harder rubber ones for the oral stimulation—a Labrador needs to stay out of trouble! Image courtesy of Judy Conley, LVT

Feeding Puzzles for Nutrition and Enrichment

FIGURE 4. Cali with a Premier tug with golf ball puzzle. Image courtesy of Judy Conley, LVT

A SMALL PLASTIC TRASHCAN BOUGHT AT A DOLLAR STORE.

A BALL TOY FOR CATS. The balls have been removed, and the cats reach through the holes to get the food. For energetic cats, the holes can be covered up to make them smaller, and/or balls can be put back in to increase the difficulty of this toy.

A ½” hole has been drilled into it halfway up the side. The advantage of this toy is that although it rolls, the cats cannot roll it under the furniture, where retrieval is difficult. This is my cats’ favorite puzzle.

A HOMEMADE FEEDING PUZZLE using 2 x 4 lumber and the bottoms of 4 different-sized plastic bottles. The bottles are held in place with a screw through the bottom into the wood. Attaching the bottle bottoms to the wood makes this puzzle harder to flip over. The cats eat from the bottles by using their paws to remove each kibble individually.

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Food puzzles are a wonderful way to increase environmental enrichment, control food portions, and provide mental stimulation for a pet. or narrowing treat openings can help increase the difficulty in some cases. For overachieving pets, there are some puzzles that are quite difficult and can challenge even a herding dog’s brain.3,5 To increase the pet’s mental stimulation, have a selection of puzzles and rotate them daily (FIGURES 3 and 4). To further increase the stimulation, hide them around the house so even more hunting is involved. This is a wonderful way to increase environmental enrichment, control food portions, and provide mental stimulation for a pet. Tell your clients to go out and find the puzzle that makes their pet happy!  References 1. Becker M. Want happier, healthier cats and dogs? Use food puzzles. Vetstreet.com. vetstreet.com/dr-marty-becker/want-happier-healthier-cats-and-dogs-use-foodpuzzles. Accessed October 2015. 2. Strickler BL. An owner survey of toys, activities and behavior problems in indoor cats. J Vet Behavior 2014;9(5):207-214. 3. Tripp R. Food puzzles. The Animal Behavior Network. animalbehavior.net/LIBRARY/ AllPets/PPM/PetFoodPuzzles.htm. Accessed October 2015. 4. Becker M, Becker Shannon M. Food puzzles: unleash your pet’s wild side. dog.com/ dog-articles/unleash-your-pets-wild-side/2125/. Accessed March 2016. 5. Smith JL. Five tips for perfect play with cat food filled puzzle feeders. Pet360.com. pet360.com/cat/lifestyle/five-tips-for-perfect-play-with-cat-food-filled-puzzle-feeders/ V5CdjIFS9k6U36rUo_6uqA. Accessed October 2015.

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

% (n=415) 4.1 3.1 3.1 1.7 1.2

Oral active control

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

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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

ARTICLE 2 1 CR E DIT

When Extraction Is Not an Option

Jeanne R. Perrone, CVT, VTS (Dentistry)

reating teeth with periodontal disease is a regular practice at most veterinary clinics. When advanced periodontal disease is present, extraction of the affected tooth or teeth is recommended. However, there are patients for which extraction of a tooth is not the only option. In young patients with a long life expectancy, keeping the tooth can be beneficial to the animal and a good investment for the client. Show dogs need a complete dentition within their breed standard while they are in competition. There are also owners who insist that teeth not be extracted, even when preservation of the teeth is not in the patient’s best interest. Often, these owners fear that tooth extraction will adversely affect the pet’s ability to eat or its appearance. This article presents techniques other than extraction that can be used to treat teeth with moderate or advanced periodontal disease. These procedures are generally performed in dogs. Many of the procedures discussed are to be performed by veterinarians. They require advanced training, usually with a veterinary dentist. If these procedures are not within the clinic’s scope of practice, appropriate patients can easily be referred to a veterinary dentist. A list of dental training courses and a directory of veterinary dentists can be found on the American Veterinary Dental College (AVDC) website (avdc.org). In practices that do provide these treatments, all staff members who interact with owners should be 44

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knowledgeable enough about the procedures to effectively and efficiently answer or refer questions that arise after the veterinarian has gone over the initial treatment options. Client education is critical in these cases, which have progressed beyond gingivitis to periodontitis and may involve multiple treatments and extra costs. For owners who are concerned about cosmetic or functional effects of tooth extraction, education about the benefits of extraction compared with tooth preservation is especially important. Veterinary technicians, in particular, need to be able to handle follow-up questions about the treatment plan. It is important for technicians to know the anatomy of the periodontium and to be able to explain the steps of the procedures, as well as the reasoning behind each step. If available, the use of models or drawings can be helpful.

VT Dental Training, Plant City, Florida

Jeanne earned her associate in applied science degree in veterinary technology from Parkland College in Champaign, Illinois. From 2006 to 2015, she worked as a dentistry technician at Tampa Bay Veterinary Specialists in Largo, Florida, and The Pet Dentist of Tampa Bay in Wesley Chapel, Florida. She is currently self-employed as a consultant, trainer, and educator for technicians in veterinary dentistry. In addition, she is an adjunct instructor for the BAS VT program in dentistry at St. Petersburg College and an online instructor of dentistry courses at VetMedTeam.com.

ANATOMY OF THE PERIODONTIUM The structures that make up the periodontium are illustrated in FIGURES 1 and 2. The gingival sulcus is the space between the tooth surface and the unattached crest of the gingiva that surrounds the tooth (the free gingiva).1 The normal gingival sulcus depth ranges from 0 to 3 mm in dogs and 0 to 0.5 mm in cats.2 Below the free gingiva is the attached gingiva, which extends to the alveolar mucosa.1 The point where these two tissues meet is indicated by the mucogingival line.1 These soft

A founding member and former president of the Academy of Veterinary Dental Technicians, Jeanne is also the editor of Small Animal Dental Procedures for Veterinary Technicians and Nurses.

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FIGURE 1. Cross-section of the periodontium. Reproduced with permission from Niemiec B. Small Animal Dental, Oral and Maxillofacial Disease: A Color Handbook. CRC Press; 2011. tissue structures are visible to the naked eye and can be easily pointed out to clients. Underlying the gingiva and mucosa are the periodontal attachment tissues: the cementum, a layer of bonelike connective tissue that covers the tooth root; the periodontal ligament, a layer of connective tissue that surrounds the cementum and connects to the alveolar bone; and the alveolar bone itself, which is the maxillary or mandibular bone that surrounds the root of the tooth.1 Periodontal therapy often involves procedures that affect

FIGURE 2. Buccal aspect of the maxillary gingiva showing delineations. TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

these structures. Clients need to understand that even if extraction is not being performed, surgery is necessary to reach these tissues. THE NEED FOR PERIODONTAL TREATMENT Within hours after toothbrushing or a professional dental cleaning, plaque bacteria accumulate on tooth surfaces. Left alone, the bacteria continue to multiply and move apically. As calcium deposits from the saliva bond to form calculus, the bacteria infiltrate the roughened surface of the calculus and become pathogenic. At this point, depending on the patientâ&#x20AC;&#x2122;s immune system, periodontal pockets form as the apical migration of plaque bacteria causes destruction of both soft and bony periodontal structures (FIGURES 1 and 2). Damage to any of these structures causes loss of attachment of the tooth and requires treatment, whether periodontal therapy or periodontal surgery. Attachment loss >50% carries a guarded to poor prognosis for tooth-preserving therapies, and loss >75% carries a poor prognosis for long-term success. The success of any nonextraction therapy relies on the use of professional treatments and rigorous home care.3 Owners who are unable to provide home care should not be given options other than extraction.

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TOOLKIT FOR DIAGNOSIS Proper staging of periodontal disease requires a periodontal probe and dental radiographs. The periodontal probe is used to measure the depth of the gingival sulcus (FIGURE 3). A depth >3 mm in dogs and >0.5 mm in cats is considered pathologic; namely, a periodontal pocket representing attachment loss. The periodontal probe is also used to determine if a tooth is mobile or has furcation exposure. The presence of either of these conditions is also proof of attachment loss. These conditions should be specifically noted on the dental chart.4 Dental radiographs should be obtained either before or after probing. Dental radiographs confirm the degree of attachment loss by showing alveolar bone destruction and loss of periodontal ligament. Combined, periodontal probing and dental radiographs are used to stage periodontal disease (BOX 1).4 Once periodontal disease is diagnosed, periodontal treatment or tooth extraction is necessary. PERIODONTAL THERAPIES The AVDC defines periodontal therapy as “… treatment of diseased periodontal tissues that includes professional dental cleaning […] and one or more of the following: root planing, gingival curettage, periodontal flaps, regenerative surgery, gingivectomy/gingivoplasty, and local administration of antiseptics/antibiotics.”4 The goals of periodontal therapy are threefold: the first is the reduction of periodontal pockets or the elimination of soft tissue or bony lesions; the second is to slow or stop the progress of periodontal lesions; and the third is to return the tissues to a more normal environment.5

Root Planing and Subgingival Curettage When exposed in a periodontal pocket, the cementum covering the tooth root provides an irregular surface in which calculus can become embedded. If dentinal tubules are exposed, they can become infected. Removal of the calculus requires the root surface to be cleaned and smoothed by root planing. This process also removes a small amount of cementum, root surface, and possibly some dentin.6,7 In dogs, periodontal pockets between 3 and 5 mm in depth with no pathology such as mobility, furcation exposure, or root caries can be treated with scaling, closed root planing, and subgingival curettage to remove plaque, calculus, and granulation tissue and disrupt the bacterial colonies. If periodontal pockets are deeper than 5 mm with pathology (mobility, furcation exposure), direct root visualization and open root planing are necessary for adequate cleaning. Direct root visualization requires periodontal flap surgery to move the gingiva aside and gain better access to the tooth root. The curette used for root planing must be sharp. To be most effective, the working end should be placed at a 90° angle to the tooth surface. Slight pressure is applied, and short, firm, overlapping strokes are used to remove debris

BOX 1 Periodontal Disease Classification4  Normal (PD 0): No gingival inflammation or periodontitis is evident.  Stage 1 (PD 1): Gingivitis is present without attachment loss.  Stage 2 (PD 2): Early periodontitis. Attachment loss is <25%, or stage 1 furcation involvement is present. In stage 1 furcation involvement, a periodontal probe can be extended less than halfway under the crown of a multirooted tooth.  Stage 3 (PD 3): Moderate periodontitis. Attachment loss is 25% to 50%, or stage 2 furcation involvement is present. In stage 2 furcation involvement, a periodontal probe can be extended more than halfway under the crown of a multirooted tooth.

FIGURE 3. Periodontal probes. Increments can be notched directly into the metal tip (top) or indicated by color change (bottom). Increments are usually shown at 1, 3, and 5 mm. 46

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 Stage 4 (PD 4): Advanced periodontitis. Attachment loss is >50%, or stage 3 furcation involvement is present. In stage 3 furcation involvement, a periodontal probe can be extended through a furcation under the crown of a multirooted tooth from one side to the other.

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For periodontal therapy to be successful, a complete physical examination, blood chemistry testing, and a full history are needed to assess the patient’s suitability for anesthesia. and clean the surface (FIGURE 4).4 Large deposits of debris/calculus should be removed in small sections to reduce the risk of trauma to the surrounding tissues. Open root planing can also be performed using a power scaler fitted with an ultrasonic tip on a low setting. A combination of both power and hand instrumentation is recommended to ensure removal of all calculus in open root planing.6,7 Subgingival curettage removes the infected epithelial lining of the pocket along with the granulation tissue apical to the pocket to the level of the alveolar crest. Removal of this tissue helps reestablish attachment. A Gracey or Universal curette is used.6 After root planing, the debrided pocket can be treated with a perioceutic product to enhance healing. Perioceutics used in this circumstance are locally applied, slow-release, flowable antibiotic gels (e.g., clindamycin, doxycycline) that are injected into the periodontal pocket. A drop of water is added to hasten solidification of the material. The prepared material can then be better manipulated in the pocket.8 In some cases, the gingiva may need to be readapted with digital pressure and possibly interdental sutures to hold it in place.6 The owner should not brush the treated area for 14 days and should instead use an oral rinse or gel to keep the area clean during the healing process, along with the appropriate antimicrobial and pain management therapy.8 The localized application of these medications helps avoid adverse systemic and gastrointestinal effects.9 Periodontal Flaps A flap is a section of tissue that has been cut and raised with a pedicle still attached. Flaps are useful in TODAY’SVETERINARYTECHNICIAN

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When Extraction Is Not an Option

periodontal therapy because they allow exposure of the root surface while maintaining the attached gingiva and allow the gingiva to be sutured in such a way that the pocket can be treated.10 The objective of flap surgery is to allow adequate access to, and visualization of, the diseased area. The base of the flap should be 1.5 times as wide as the coronal aspect to allow adequate blood flow. When the therapeutic procedure is complete, the flap must be sutured closed to prevent displacement, bleeding, hematoma formation, and infection.10 Types of Flaps There are two types of flaps: full thickness and partial thickness. Most periodontal flaps are full thickness. Full-thickness flaps are used to gain access to bony areas for procedures such as root planing and pocket elimination. To create a full-thickness flap, a periosteal elevator is placed under the periosteum and rocked until the periosteum (attached gingiva) is peeled away from the bone. Partial-thickness flaps leave the periosteum attached to the bone. Partial-thickness flaps are used in areas where lateral sliding flaps are needed, where there are thin, bony plates, where dehiscence is present, where bone must be protected, or where bone loss is permanent.10 Envelope flaps are created along the arcade with or without vertical releasing incisions. The gingiva is stretched to allow visualization. The flap should extend to one tooth on either side of the diseased area. Closing sutures are placed interdentally.3,10

FIGURE 4. In closed root planing, the dental curette is inserted under the gingiva before being angled to remove debris. Image drawn by David Crossley and reproduced with permission from The BSAVA Manual of Small Animal Dentistry, 2nd edition. ©BSAVA

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Recheck examinations are needed to make sure healing is taking place and the owner is comfortable giving medications and providing home care.

Full mucoperiosteal flaps involve the addition of one or two vertical releasing incisions on one or both sides of the lesion to allow exposure without stretching the gingiva excessively. The horizontal or sulcal incision is made just below the diseased gingival margin, being careful to maintain as much of the attached gingiva as possible. This excises the diseased pocket epithelium and granulation tissue. The collaret of diseased gingival margin tissue is removed, and the edges of the flap are sutured closed at each releasing incision and interdentally (FIGURES 5A and 5B).3,10 Regenerative Periodontal Therapy/Guided Tissue Regeneration Although periodontal ligament cells can regenerate to restore tooth attachment, the gingival soft tissues grow faster and can recolonize the pocket with junctional epithelium first.11 This temporarily heals the problem and resolves the infection, but in these cases, the infection does come back. When repairing bony pockets, it is therefore necessary to slow the growth of the gingival tissues long enough to allow the periodontal attachment tissue time to regrow. This procedure is called guided tissue regeneration or regenerative therapy. The ultimate goal of this type of therapy is to reduce a periodontal pocket as well as recreate normal periodontal attachment. Various materials, described below, are used to keep the faster-growing alveolar mucosa and gingival connective tissue out of the lesion while encouraging the growth of periodontal ligament and bone. A

TECHPOINT ď Ź

Barrier Membranes Barrier membranes contain components that stimulate regeneration of the periodontium. First-generation (nonresorbable) membranes used in regenerative therapy are usually made of cellulose or Teflon. They have been shown to promote regeneration of alveolar bone, cementum, and periodontal ligament, although bone augmentation is not consistent. These membranes must be removed in 3 to 6 weeks, which adds another anesthesia episode.11 Second-generation (resorbable) membranes come in prepackaged sheets that must be trimmed to size. These membranes can also serve as carriers for substances that can improve attachment, which makes them similar to perioceutics. They are usually made of a combination of polylactic acid, polyglycolic acid, and trimethylene B

FIGURE 5. (A) Full-thickness flap made to provide better visualization for open root planing. (B) Fullthickness flap after closure. Note the interdental sutures. Courtesy of R. Michael Peak, DVM, DAVDC 48

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carbonate. This material stays intact for 16 to 24 weeks before being absorbed.11 A bovine Achilles tendon collagen membrane is also available; it lasts 4 to 18 weeks.11 Lastly, there is a bilayer porcine-derived collagen membrane. This material has been effective in the regeneration of infrabony pockets and is the easiest to use. Demineralized laminar bone sheets and flowable customizable membranes are also available (FIGURE 6). The longer a membrane lasts, the longer the attachment tissues have to grow, and the better the chance of success; however, a correspondingly longer period of home care is needed. Bone Graft Materials Graft materials are used to regenerate the periodontium by reforming the periodontal ligament and growing new bone.11 They are also used to increase healing in jaw fracture repair and tooth extraction. They have shown a positive effect as the treatment for stage 2 and 3 furcation exposure.11 When combined with a barrier membrane, the attachment gain is more significant. Bone graft materials augment bone growth through one or more of 3 processes: osteogenesis, osteoinduction, and osteoconduction. Materials that promote osteogenesis contain cells that cause the synthesis of new bone. Osteoinductive materials convert the surrounding stromal or progenitor cells into osteoblasts, which release growth factor and produce native bone. This accelerates bone production and speeds healing. Osteoconductive products form a scaffold that bone can form around and significantly contribute to the production of new bone.

FIGURE 6. Barrier membrane placed to repair a maxillary defect. Image used by permission: Ossiflex Bone Membranes – Veterinary Transplant Services, Kent, WA

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When Extraction Is Not an Option

There are 4 types of bone graft materials. Three— autografts, allografts, and xenografts—are derived from animal tissue; non–animal-based products comprise the fourth.11 Autografts are bone materials taken directly from the patient, usually from the oral cavity. A large cutting bur is used to turn the harvested bone into dust. The dust is then mixed with the patient’s blood or saline and placed into the defect. This material has the best outcome, but harvested quantities are small, so large defects cannot be repaired using this method. Autografts are osteogenic, osteoinductive, and osteoconductive. Allografts are the most commonly used bone material in human dentistry. The material comes from cadavers of the same species and can be demineralized and freezedried, which allows for a longer shelf life. It contains bone morphologic proteins that recruit the patient’s osteoblasts, making it osteoinductive. One downside to demineralized allografts is the inability to see the material on radiographs to assess the fill (FIGURE 7).

FIGURE 7. Allograft material placed after a feline mandibular canine extraction. Image used by permission: Periomix and Synergy – Veterinary Transplant Services, Kent, WA

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FIGURE 8. Periodontal pocket treated with a synthetic bone graft particulate. Courtesy of R. Michael Peak, DVM, DAVDC Xenografts are also commonly used in humans. Xenograft bone material and components come from different species. Bovine materials are most commonly used. These materials are osteoconductive but may also be osteoinductive. Non-animal products are ceramic-based materials made of calcium phosphate, calcium sulfate, and bioactive glass. They are available in larger quantities, inexpensive, and osteoconductive; however, more fibrous connective tissue than bone may grow into the scaffold, making the repair somewhat weaker than bone.11 These products can be used for regeneration of alveolar bone (FIGURE 8).

Preparation and Follow-Up For regenerative therapy to be successful, all debris and granulation tissue must be removed to leave clean, healthy bone or tooth surface before any of the above materials are placed. Removal of any diseased marginal gingiva is also beneficial. The alveolar bone needs to be remodeled to allow the soft tissue flap to eventually attach to the underlying bone.11 Rotary instruments such as carbide or diamond burs and hand instruments such as rongeurs, chisels, and interproximal files are used for remodeling. A full-thickness flap that includes attached gingiva may be necessary to close the lesion without tension. Pre- and postoperative radiographs should be taken. Antibiotic and antiseptic therapy is crucial to the success of regenerative therapy. If the owner is unable to perform home care, regenerative therapy is likely to fail. The therapeutic site should be rechecked at 10 to 14 days with a follow-up cleaning, dental examination, and radiographs 3 to 4 months later.3 PERIODONTAL SPLINTING Mobile teeth decrease the effectiveness of the guided tissue regeneration procedure, so splinting is used to temporarily stabilize teeth with mild or moderate disease and/or mobility while bone tissue regenerates.11 However, it has been performed for long-term maintenance of a tooth; for example, in a show dog that needs full dentition to compete. This technique can also be used after a traumatic luxation or subluxation of a tooth. The teeth are cleaned and polished, and any debris or

FIGURE 9. Maxillary incisors being treated for advanced periodontal disease using periodontal splinting. Courtesy of Jan Bellows, DVM, DAVDC 50

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granulation tissue is removed. A regenerative material is placed in the defect, which is sutured closed. A band of dental acrylic is placed around the teeth in the area of the defect, with a stable tooth on either side. The acrylic bonds the teeth together for stabilization (FIGURE 9).10 Interdental wiring may also be used to provide additional strength and support (FIGURE 10). When wire is used, shallow grooves may need to be made in the enamel to keep the wire from slipping off the tooth. Splinting has its drawbacks. It is not recommended for mandibular incisors across the symphysis. The splint is difficult to keep clean and can become a nidus for infection. The anchor teeth that hold the splint in place can also be damaged by the constant pulling. The splinted area must be cleaned daily using rinses. A softened diet is required, and hard toys or treats must be avoided to prevent breakage of the acrylic. A regular recheck must follow the procedure, with a full oral examination and radiographs at 3 to 4 months.11 If the radiographs show healing, the splint is gently cracked using calculus forceps and removed in small pieces using hand scalers and curettes.

When Extraction Is Not an Option

CONCLUSION For periodontal therapy to be successful, a complete physical examination, blood chemistry testing, and a full history are needed to assess the patient’s suitability for anesthesia. Discussing all treatment options with the pet owner is crucial to determine if the owner is committed and able to provide home care. Doctors and staff must be trained and prepared to perform all necessary treatments or give the owner the option of referral to a veterinary dentist. An itemized treatment plan needs to be presented and reviewed with the owner. Contact phone numbers must be collected the day of surgery in order to keep the owner updated. Finally, recheck examinations are needed to make sure healing is taking place and the owner is comfortable giving medications and providing home care. The owner should be able to contact staff by phone or e-mail with questions or problems. Extraction does not have to be the only option if all parties are prepared, committed, and equipped to provide the best therapies to achieve a successful outcome. 

FIGURE 10. Avulsed mandibular canine tooth treated with an acrylic splint. Note the figure-8 wire around the canines (arrow). TODAY’SVETERINARYTECHNICIAN

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References 1. Lobprise HB. Glossary. In: Blackwell’s Five Minute Veterinary Consult Clinical Companion Small Animal Dentistry. 2nd ed. Ames, IA: Wiley-Blackwell; 2012:467482. 2. Niemiec B. The complete dental cleaning. In: Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2013:129-153. 3. Lobprise HB, Wiggs, RB. Periodontal disease. In: The Veterinarian’s Companion for Common Dental Procedures. Lakewood, CO: AAHA Press; 2000:47-62. 4. American Veterinary Dental College. Nomenclature. www.avdc.org/nomenclature. html#perio. Accessed February 2016. 5. Holmstrom SE, Frost Fitch P, Eisner ER. Periodontal therapy and surgery. In: Veterinary Dental Techniques for the Small Animal Practitioner. 3rd ed. Philadelphia, PA: Saunders; 2004:233-290.

6. Niemiec B. Advanced non-surgical therapy. In: Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2013:154-169. 7. Niemiec B. Treatment of the exposed root surface. In: Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2013:249-253. 8. Lobprise HB. Root planing: periodontal pocket therapy. In: Blackwell’s Five Minute Veterinary Consult Clinical Companion Small Animal Dentistry. 2nd ed. Ames, IA: Wiley-Blackwell; 2012:69-78. 9. DeBowes L. Problems with the gingiva. In: Niemiec B. A Color Handbook: Small Animal Dental, Oral and Maxillofacial Disease. London: Manson; 2010:159-182. 10. Bellows J. Periodontal equipment, materials, and techniques. In: Small Animal Dental Equipment, Materials, and Techniques: A Primer. Ames, IA: Blackwell; 2004:115-173. 11. Niemiec B, Furman R. Osseous surgery and guided tissue regeneration. In: Veterinary Periodontology. Ames, IA: Wiley-Blackwell; 2013:254-288.

CE Test Article 2 When Extraction Is Not an Option 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/tvt.aspx. A $5 fee applies. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval. 1. True or false: Advanced periodontal therapies can be performed by all veterinarians. 2. Which of the following should rule out advanced periodontal therapy as an option? a. Attachment loss >25% b. Inability of owner to provide home care c. Presence of an avulsed tooth d. Presence of stage 1 furcation involvement 3. The gingival sulcus is the a. crest or edge of the gingiva that is unattached. b. line that separates the attached gingiva from the alveolar mucosa. c. space between the tooth and the free gingiva. d. layer of bony tissue that covers the root. 4. The two tools needed for staging periodontal disease are a. dental elevators and curettes. b. periodontal probe and dental radiographs. c. periodontal probe and dental explorer. d. dental scalers and dental radiographs. 5. In a cat, a periodontal pocket depth of ___________ is considered normal. a. 0–0.5 mm b. 0.5–3 mm c. 3–5 mm d. >5 mm 6. What dental instrument is used to perform subgingival curettage? a. Dental elevator b. Gracey curette c. Periodontal probe d. Dental explorer

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7. Flaps are used when a. exposure of the tooth root is needed. b. maintenance of the attached gingiva is desired. c. gingival sutures are needed to treat the periodontal pocket. d. All of the above 8. A successful outcome with regenerative therapy depends on a. antibiotic and antiseptic therapy. b. owner compliance with home care. c. a properly cleaned and debrided surgical site. d. All of the above 9. An allograft is made of a. a nonanimal product that forms a scaffold for bone to grow around. b. freeze-dried material from cadavers of the same species as the patient. c. material taken directly from the patient, usually from the oral cavity. d. bone material and components from a different species than the patient. 10. How do osteoconductive bone graft materials work? a. Cells within the material cause synthesis of new bone. b. Surrounding stromal and progenitor cells are converted into osteoblasts. c. They provide a scaffold that allows bone to form around them. d. They surround the root and connect it to the alveolar bone.

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CLIENT HANDOUT

Brushing Your Dog’s Teeth  Periodontal disease can lead to tooth loss and affects most dogs by the time they are 3 years old.  Depending on your dog’s overall health, bacteria from periodontal disease can spread to affect other organs.  Have your dog’s teeth checked by your veterinarian before you start brushing them.  Make toothbrushing enjoyable for your dog by rewarding him or her immediately after each session.  Be very patient when teaching your dog to accept toothbrushing.  If your dog won’t tolerate toothbrushing, your veterinarian can recommend plaque-preventive products for your dog.

Periodontal Disease—Why Brush? Periodontal (gum) disease can lead to tooth loss and affects most dogs by the time they are 3 years old. Depending on your dog’s overall health, bacteria from periodontal disease can spread to affect other organs. One of the best ways to help prevent periodontal disease is to brush your dog’s teeth daily, or at least multiple times a week. Dogs are never too young to start having their teeth brushed at home; in fact, the younger they are, the better.

Have your dog’s teeth checked by your veterinarian before you start brushing them. Your veterinarian may recommend a dental cleaning to remove any existing plaque and tartar, which contribute to periodontal disease. If your dog has severe dental disease, extraction of the affected teeth may be recommended. Follow your veterinarian’s recommendation on how long to wait after dental cleaning or extraction before brushing your dog’s teeth.

What You Need  Baby toothbrush or pet toothbrush that is an appropriate size for your dog; if your dog won’t tolerate a toothbrush, a small piece of washcloth can be used  Pet toothpaste  Treat or other reward your dog really likes

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Note: Do not use toothpaste for people or baking soda to brush your dog’s teeth. Human toothpaste is made with ingredients that can cause stomach upset if swallowed (e.g., detergents, fluoride). Dog toothpaste comes in different flavors (e.g., poultry, beef,

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Brushing Your Dog’s Teeth continued

vanilla mint). You may need to try a couple flavors to find the one your dog likes the best. The more your dog likes the toothpaste, the easier it will be to train him or her to accept brushing.

Technique

Signs of Dental Problems  Bad breath  Sensitivity around the mouth  Loss of appetite and/or weight  Yellow or brown deposits on the teeth  Bleeding, inflamed, and withdrawn gums  Loose or missing teeth  Pawing at the mouth or face  Difficulty chewing

 Toothbrushing should be a bonding experience that is constantly reinforced with praise and rewards. Be very patient—teaching your dog to accept toothbrushing may take weeks. Make toothbrushing enjoyable for your dog by rewarding him or her immediately after each session. Y ou only need to brush the outside of your dog’s teeth—the side facing the cheek. Only do as much at a time as your dog allows. You may not be able to do the whole mouth at first.  I f you are ever worried about being bitten, stop. Ask your veterinarian about how best to care for your dog’s teeth. S tart by letting your dog get used to the toothbrush and toothpaste. Put them out and let your dog sniff them. You can let your dog taste the toothpaste to see if he or she likes it.

 Also, get your dog used to you touching his or her mouth. Lift his or her lips, and slowly and gently rub your dog’s teeth and gums with your finger  When your dog is comfortable with you touching his or her mouth and is familiar with the toothbrush and toothpaste, gradually switch to putting the toothpaste on your finger, and then to putting the toothpaste on the toothbrush. At first, let your dog lick the paste off the brush to get used to having the brush in his or her mouth. If your dog won’t tolerate a toothbrush, a small piece of washcloth can be used. Place a small amount of toothpaste on the washcloth, and rub it over the outside surfaces of your dog’s teeth.  Brush your dog’s teeth along the gum line. Work quickly—you don’t need to scrub. Work up to at least 30 seconds of brushing for each side of the mouth every other day.  If you notice any problems as you brush, like red or bleeding gums or bad breath, call your veterinarian. The earlier problems are found, the easier they may be to treat.

Other Ways to Control Plaque Although there’s no substitute for regular toothbrushing, some dogs just won’t allow it. If you can’t brush your dog’s teeth, ask your veterinarian about plaque-preventive products. Feeding dry food may also help keep your dog’s teeth and gums in good condition. The Seal of Acceptance from the Veterinary Oral Health Council appears on products that meet defined standards for plaque and tartar control in dogs and cats. You can find a list of these products at www.vohc.org. 

© 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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COLORADO CONVENTION CENTER DENVER JUNE 8-11, 2016 Join more than 3,300 specialists, primary care practitioners, and technicians to explore the leading edge of veterinary care at the 2016 ACVIM Forum, home of the AIMVT and AVNT annual meeting. Whether you are highly experienced or a newcomer to veterinary medicine, you'll have opportunities to communicate with internationally-known leaders in the field and learn about the most informative and educational advances in veterinary care through sessions specifically targeting veterinary technicians.

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What Moves You? From Holland: Looking Back on a GREAT Adventure Esther Klok Dierenkliniek Winsum Winsum, The Netherlands 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.

When I graduated 22 years ago as a veterinary technician from the only school for technicians in the Netherlands, I would never have thought that this girl would travel at least 10 times to the United States—and definitely not 10 times to one of the biggest veterinary conferences in the world! I’ve always felt like the girl next door! Just doing my job. But my life has become so much more. For me, the motto of the NAVC Conference this year, “What Moves You?”, was something that put a big smile on my face. This conference has resulted in big changes in my life.

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!

“Sometimes, when I’m running from one thing to another, I feel like SUPERWOMAN! You probably recognize this adrenaline kick.” —Esther Klok

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SUPERWOMAN AT WORK I have worked for 21 years in the same veterinary hospital, a mixed practice in the Netherlands. At this practice, it’s still normal for a vet tech to do “all the jobs” that have to get done. You probably know what I mean: I have to be a front desk superstar, then work in the operating room, and then put time in at our lab, or take radiographs of seals at the Seal Centre Pieterburen. Or I might work with wild Konik horses or Scottish Highland cattle. Then, every Wednesday afternoon, I have my own “vet tech appointments,” where I see puppies and kittens, perform dental checks, and assist animals with weight problems or arthritis. Sometimes, in the middle of a day, when I’m running from one thing to another, I feel like SUPERWOMAN! You may recognize this adrenaline kick. The only thing we vet techs are missing is a tight black bodysuit! In one of these Superwoman moments a few years back, I even signed myself up for a Hill’s Pet Nutrition weight loss competition for dogs and cats. When I helped 23 animals lose more than 10% to 42% of their body weight (keeping it off for more than 1 year), I won! The prize? A trip to the NAVC Conference in Orlando, Florida. I became lost in, in love with, and addicted to the NAVC Conference. I won the trip 3 more times, and after that, I decided to save money so I could go every 2 years (with a little bit of help from my boss). So I did, which made 2016 a celebration because it was my 10th visit. For me, it’s always been a big adventure.

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What Moves You?

From Holland: Looking Back on a GREAT Adventure

In 2012, we placed in the national Dutch team for single horse carriage driving, and we were very happy to be part of the Dutch team that competed at two World Championships. ESTHER, RUDOLF, AND DIESEL in international competition in Chablis, France, where they took second place.

NAVC CONFERENCE? POINT THE WAY! My NAVC adventure starts many weeks before the conference, as I look at the program and try to decide which lectures I will attend. Sometimes I fall asleep in the evening with the program in my hand and the lectures of my choice circled in red. But when I wake up, with the program still on my pillow, I change my choices again. There is so much I want to do, and so much to look forward to. The fun of the NAVC has already started! Next, my colleague Annelies van Zutphen (a veterinarian) and I travel across the world, and the excitement builds. She and I do not want to lose lecture time, so we always go to the Gaylord to get our badges the day before the conference starts. And—promise you won’t laugh at me—when I take the big elevator upstairs and walk through the long hall, and I see all the signs, it feels like coming home! My heart beats faster because I know what’s coming: days with the best teachers and colleagues from all over the world, with whom I can share ideas. I love learning about new products and just walking around and seeing all the attendees who share my beautiful profession. The fact that I have the chance to be a part of that makes me very happy. Then the days are flying by, and before I know it, I’m on the plane back to the Netherlands, full of ideas and plans. I learn so much each time I attend the NAVC Conference, and I take home many ideas to share with my practice. But implementing

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them when I get home is not so simple! On the airplane, I promise myself not to overfill the rooms of the practice with all my stories and ideas, because that would drive the whole team NUTS. Instead, I tell it week by week, little parts at a time. And that works! I have the best colleagues a person could wish for. They are always enthusiastic and always helping make my ideas into real plans. Some of my ideas we’ve implemented are: ÆÆ My clinic started the first vet tech appointments in the Netherlands. ÆÆ We were the first American Association of Feline Practitioners (AAFP)–approved cat-friendly practice in the Netherlands. Our whole team is working to understand cats better, and appointments with cats are now much easier. Cats, clients, and staff love it. ÆÆ We now include exercise therapy in our clinic with a vet-physiotherapist for postoperative patients, arthritis patients, and large-breed puppies. ÆÆ From what I learned about public relations and marketing, I have been able to get our clinic mentioned in the press, including magazines, newspapers, radio, and television. This year, what I want to do is really easy because I fell in love with the Fear Free practice initiative. We already do a lot with reducing patient stress because of being a cat-friendly practice, but this initiative is for all animals. I can’t wait!

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What Moves You?

From Holland: Looking Back on a GREAT Adventure

SUPER COMPETITOR AT PLAY But back to the question: What Moves You? I want to feel happy, useful, and appreciated. I want to make a difference, and I need a challenge. That is what happens at my job. All the new things we have developed at our clinic and which we, as vet techs, are doing every day, results in happy clients and healthy animals, as well as more income for the practice. It makes my job more interesting and exciting. But also, in my private life, I feel more secure about myself because knowledge is power. That is important not only in relationships and work, but also in sports. For me, competing in sports is very important. My boyfriend Rudolf and I love carriage driving. We started our sport with a Haflinger named Arriba. Because Arriba was too tall for the pony division, we had to compete against horses. Thanks to this awesome, hard-working pony, we became the Dutch champions. After that, with our Dutch Warmblood horse (KWPN) Diesel, we became Dutch champions 6 more times. In 2012, we placed in the national Dutch team for single horse carriage driving, and we were very happy to be part of the Dutch team that competed at two World Championships. It is like a dream, or better yet, a rollercoaster. It’s a lot of hard work in addition to having a full-time job. When competing, I want to feel the same as I do in my job. I want to feel happy, useful, and appreciated. I want to make a difference, and I need a challenge. I want to WIN. Most vet techs know that it is hard to compete on a high level in addition to having a full-time job like ours. After work, Rudolf and I have to take care of the horses, eat dinner, and then start to train the horses and ourselves. Most times, it’s dark, raining, and cold in the Netherlands, and we sometimes train until 11:00 pm. In the summer, we compete all over Europe, so we travel far with the horses in the truck. The real problem is time! In 2015, in the midst of all these competitions, I didn’t have a single day of my job where I did “nothing.” Still, I love it. I love working with the animals, I love the adrenaline, and I still want to perform and win. For me it’s perfect that I can combine my work and sports. For example, in our clinic, I work quite often with horses, and we have created a sports coaching program for horses to keep them fit. We do lactate testing and make training schedules for jumping, dressage, and carriage horses. So now I’m spoiled, because I get to travel to other countries to help people with the coaching program. It is so satisfying to see the horses getting healthier and to make the owners happy. Still, I sometimes need an extra challenge. I have started to give in-house training at vet clinics to show them how to implement programs in their practices. Also, I give lectures for veterinarians and veterinary technicians for Hill’s and Merck (and for Pfizer and Waltham, in the past). 58

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T ECHPO INT 

I believe that we, as veterinary technicians, are a “special breed.” We can do everything we want. And most of the time, even more than that! So, what moves me? It’s the same throughout my life: I want to feel happy, useful, and appreciated. I want to make a difference, and I need a challenge. I believe that we, as veterinary technicians, are a “special breed.” We can do everything we want. And most of the time, even more than that!  We asked Esther to share the secrets of her success in getting her practice on board with new ideas and turning them into reality. Expect to hear more from her in future issues!

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Updated from Veterinary Technician July 2009 (Vol 30, No 7), by the author and peer reviewed by Today’s Veterinary Technician. Used with permission from VetFolio, LLC. Veterinary Technician articles published from January 2005 through August 2013 can be accessed without subscription at vetfolio.com/veterinary-technician-archives.

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Preventing Motion Sickness in Dogs Amy Newfield, CVT, VTS (ECC)

BluePearl Veterinary Partners

f you work in a veterinary clinic, you likely know who the “car-sick” dogs are. They are the ones whose owners walk in and ask for a roll of paper towels and a bucket of water or need you to hold their dog while they go back outside, defeated, to clean up their car. According to a 2006 pet owner market research study, approximately 7.2 million dogs suffered from motion sickness (kinetosis) that year, but only 25% of the dogs received veterinary treatment for the condition.1 Motion sickness typically manifests as signs of nausea and discomfort, such as excessive drooling, pacing, panting, swallowing, or lip licking.2 In some cases, these signs progress to abdominal heaving followed by vomiting.3 The nausea should fade once the car stops moving. Because of pharmacologic advances and a better understanding of how to prevent emesis, pet owners have more viable options for helping nauseated dogs.

Amy is currently employed with BluePearl Veterinary Partners as the National Technician Training Manager. In 2003, she became boarded as a veterinary technician specialist in emergency and critical care. She currently sits on the Academy of Veterinary Emergency & Critical Care Technicians board as the president-elect. Amy is well published in more than 15 subjects, is an international speaker, has received numerous awards, and is highly involved in her community. Most recently, Amy was awarded Speaker of the Year at the 2014 NAVC Conference as well as the 2015 Western Veterinary Conference. She lives in Massachusetts with her wonderful furry kids.

WHAT CAUSES MOTION SICKNESS? Although the cause of motion sickness is not fully understood, it is generally thought that it occurs when the inner ear is disturbed from repeated motion, such as the movement of a car, plane, or boat.4 TODAY’SVETERINARYTECHNICIAN

Motion sickness is most commonly reported in puppies and young dogs, many of which outgrow it.5 Unfortunately, many more do not outgrow it, and it becomes a lifelong problem. The most popular hypothesis about the cause of motion sickness is that humans and animals become nauseated when mixed sensory signals are transmitted to the brain, such as when the eyes tell the brain that the body is not moving, but the inner ears sense motion.2 For example, when a person is on a boat, he or she may be at ease on the top deck because the horizon provides a solid visual reference indicating that the boat is moving, which matches the sensation in the inner ears. However, when the individual steps below deck, he or she may become seasick because the inner ears still sense motion, but the visual reference is now lacking. The confusion between the two simultaneous signals can lead to a vestibular emesis response.2 Another hypothesis suggests that the sensory confusion signals the brain to respond in the same way as it would to ingestion of a neurotoxin.2 When the brain receives the mixed signals, it decides to ignore the discrepancy between the visual sense and proprioception, and accepts toxin ingestion as the culprit.

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This triggers a stress response of the sympathetic nervous system, which causes the stomach to empty its contents in an attempt to rid itself of a toxin.2 In dogs, motion sickness may lead to a behavior problem.6 Feeling nauseated and vomiting every time it is put in a car can cause a dog fear and anxiety. Some dogs anticipate the nausea they normally experience and may start to vomit even before the car is in motion.6 This can lead to a learned response, so even if the dog stops suffering from motion sickness, it may still continue to vomit in the car. Certainly, some dogs may be fearful of the car for reasons such as noise, traffic, or the association of going to “scary” places (e.g., the veterinary clinic).6 Dogs that are fearful may vomit because they are frightened, not necessarily because of motion sickness.6 This is why it is important to desensitize puppies to car rides. If an older dog is fearful, it may be difficult to determine whether the vomiting is from motion sickness or from fear. A behavior evaluation may be necessary to determine why the dog is vomiting.6 Regardless of the cause of motion sickness, the vestibular system is always involved. Numerous studies have been performed trying to induce motion sickness in both people and animals whose vestibular pathway had been interrupted or removed.4 In these studies, motion sickness could not be induced.4

ALL DOGS THAT ARE FEARFUL of transport should be slowly desensitized to the car (or other vehicle) by first allowing them in it for “fun” time while the car is stationary. 60

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When an animal becomes nauseous, certain receptors in the brain are stimulated. All vomiting stimuli, including those from the vestibular system, ultimately converge in the emetic center. The emetic center receives input from the gastrointestinal tract, the vestibular apparatus, and the chemoreceptor trigger zone (CRTZ).3 The emetic center has 4 receptors: neurokinin-1 (NK1), serotonin, adrenergic, and glucocorticoid.3 The vomiting associated with motion sickness involves M1-cholinergic receptors (located in the autonomic nervous system, central nervous system, and gastric glands) and H1-histaminergic receptors (located in the smooth muscles, heart, and central nervous system) that ultimately send signals to the emetic center, causing vomiting.3 Ideally, treatment should be aimed at preventing signals from both receptor types.3 Unfortunately, little research has been performed regarding dogs and motion sickness, which may be related to the poor results when attempting to treat dogs. Luckily, newer advances in veterinary medicine have given hope to many pet owners. EARLY INTERVENTION Owners can do simple things at home to help set up their dog for success. First, it is important that any dog suspected of having motion sickness not be fed for at least a couple of hours before a car trip, as vomiting food becomes more likely if food is in the stomach.7 Once in the car, simply allowing fresh air in or allowing the dog to see out may help alleviate motion sickness in some dogs.7,8 This is particularly true for puppies, who tend to be either fearful or motion sick more often than older dogs.8 All puppies and adult dogs that are fearful should be slowly desensitized to the car (or other vehicle) by first allowing them in it for “fun” time while the car is stationary. Eventually, the car should be turned on while the owner offers a couple of treats or the dog’s favorite toy. The owner should then drive for 30 seconds to test for reactions and stop and reward the dog’s behavior if it tolerated the ride well. The time spent while the car is moving is gradually increased so the pet associates the car with positive experiences. During this time, it is important for the owner to teach the dog appropriate car riding etiquette (i.e., not jumping up or running around). If, at any point, the dog shows signs of fear or nausea, the training should be stopped and resumed at a level the dog can tolerate. Appropriate desensitization takes many weeks to months, depending on the individual pet, and occurs so slowly that the dog barely notices a change.7 Owners looking to create a systematic desensitization protocol can always reach out to a trained specialist. Finding a

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ď Ź

TE CHP O I N T ď Ź

Some dogs anticipate the nausea they normally experience and may start to vomit even before the car is in motion. This can lead to a learned response. board-certified veterinary behaviorist is a great start (dacvb. org/resources/for-the-public). Systematic desensitization works well for any puppy or dog that vomits because of anxiety or fear.8 However, an estimated 15% of all dogs suffer from true motion sickness.9 Behavior modification using systematic desensitization will likely not help a dog with a vestibular issue.8 When dealing with a dog with true motion sickness, owners have options in pharmaceuticals and alternative medicine. Each motion-sick dog is different, and what may work for one dog may not work for another. PHARMACEUTICAL OPTIONS Acepromazine and chlorpromazine, both phenothiazine drugs, are sometimes prescribed to treat motion sickness in dogs. While acepromazine is labeled for the prevention of motion sickness, chlorpromazine is not. Acepromazine is a sedative/tranquilizer and is generally prescribed to help reduce anxiety or fear.10 Chlorpromazine is generally used as an antiemetic and occasionally as a tranquilizer.10 While both drugs offer antiemetic properties, they also can cause a significant amount of sedation. Depending on the dosage, this sedation can last for a prolonged period.10 These drugs can also cause states of confusion and decreases in blood pressure.10 While they have been used to sedate dogs that travel, they are generally no longer recommended to prevent motion sickness.10 Dimenhydrinate and diphenhydramine are antihistamines that block the H1-histaminergic receptor of the vomiting center.10 When an H1-histamine blocking agent (diphenhydramine) is used, combination with a M1-cholinergic receptor blocker (compazine) is suggested to obtain control of emetic signals originating from the vestibular apparatus.2 The most common adverse reactions seen with many antihistamines are central nervous system depression (sedation) and anticholinergic TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

Preventing Motion Sickness in Dogs

effects (dry mouth, urinary retention).10 Diarrhea, vomiting, and anorexia are less common.10 Antihistamines are not recommended for use in pregnant dogs.10 Administration of these medications about 30 minutes before the car ride is recommended, and the effects last 3 to 6 hours.10 Meclizine is an antihistamine and has antiemetic properties.10 In the past 3 years, it has increased in popularity as a treatment for vestibular disease.10 Its use as a treatment for motion sickness in dogs is considered off label, and its exact mechanism of action for the prevention of motion sickness is not understood.10 If used, the recommendation is to administer it 30 to 60 minutes before travel.10 Sedation has been reported as the most common side effect.10 Maropitant citrate (Cerenia; Zoetis, Florham Park, NJ) is used for the treatment and prevention of acute vomiting and the prevention of vomiting due to motion sickness in dogs. Cerenia is the first FDA-approved drug for preventing nausea and vomiting associated with motion sickness in dogs. It works by blocking the action of substance P, found in the highest concentration in the emetic center.11 Substance P is a neuropeptide that helps regulate mood, anxiety, stress, respiratory rhythm, pain, nausea, and vomiting.11 The receptor for substance P is NK1.11 NK1 receptors are found in both the CRTZ and the emetic center.11 When substance P binds to the NK1 receptor, vomiting occurs.12 Blocking the binding of substance P to NK1 receptors interrupts vomiting stimuli. Several studies in dogs have shown that blocking substance P from the NK1 receptor is very effective in preventing vomiting due to motion sickness.5 In a study of 122 dogs with a history of motion sickness dosed 2 hours before travel, only 7% vomited after being administered maropitant; in contrast, 55% of dogs in a placebo group vomited.11 Approximately 2 hours before the car ride, the pet should be given the oral dose of maropitant in a small amount of food such as deli meat or peanut butter. If the patient has to take an unexpected car ride, maropitant may still be effective if given only 1 hour before the ride. In a clinical trial, many dogs dosed 1 hour before travel (86%) did not vomit.13 The most common side effect was hypersalivation, which affected approximately 12% of the dogs in the study.13 Unlike most other drugs used to help prevent motion sickness, maropitant does not cause sedation. It is not currently approved for use in pregnant or lactating dogs.11 ALTERNATIVE OPTIONS It has been suggested that acupressure and acupuncture may help treat motion sickness; however, their efficacy is unknown.14,15 More studies in humans show the benefit

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of acupuncture than of acupressure.15 For many owners, however, acupuncture can be cost prohibitive. To date, no research has been conducted on continuous acupressure treatment methods in dogs. While some owners use pressure wristbands on the dog’s carpal area as an acupressure zone, there has been no positive research supporting the role of acupressure in decreasing motion sickness. More positive studies have shown that ginger may be effective in dealing with motion sickness in humans. Several studies have shown a reduction in motion sickness when ginger was used.16,17 The use of ginger appears to have some benefit in veterinary medicine as well,18 but how efficacious it is remains unknown. It does appear that ginger extracts must be administered, as opposed to consumption of products that contain some ginger (e.g., gingersnap cookies, ginger ale), for the effect to be seen.19 Other natural herbs, such as Panax ginseng, black horehound, chamomile, fringe tree, peppermint, meadowsweet, and lemon balm, may help with nausea as well.19 There is little to no published information regarding the safe and effective use of these herbs in dogs.19 THE ROLE OF VETERINARY TECHNICIANS Because veterinary technicians are often the first (or last) staff members to speak to clients, they may be asked to clarify information about motion sickness. The client may have already tried some treatments and found them to be ineffective and may be unaware that new medications and options have become available. During the initial puppy visit and annual visits, motion sickness can be addressed by asking the owner if the dog

References 1. Pfizer Animal Health US Market Research Report. 2006. 2. Benchaoui H, Siedek E, Puente-Redondo V, et al. Efficacy of maropitant for preventing vomiting associated with motion sickness in dogs. Vet Rec 2007;161:444-447. 3. Encarnacion H, Parra J, Mears W, Sadler V. Vomiting. Compend Contin Educ Pract Vet 2009;31(3):122-131. 4. Park E. Motion sickness. In: General Medical Officer (GMO) Manual: Clinical Section. Wilmette, IL: Brookside Press; 1999. 5. Twedt D. Vomiting. In: Ettinger E, Feldman C. Textbook of Veterinary Internal Medicine. 7th ed. Philadelphia, PA: WB Saunders; 2010:195-200. 6. Overall K. Clinical Behavioral Medicine for Small Animals. St. Louis, MO: Mosby; 1997. 7. Dogs and motion sickness. WebMD.com. pets.webmd.com/dogs/dogs-and-motionsickness. Accessed March 2016. 8. Dogs and motion sickness. PetMD website. http://www.petmd.com/dog/conditions/ digestive/c_dg_motion_sickness. Accessed March 2016. 9. Robinson N. Evidence-based practice of acupuncture. WVC Proc 2004. 10. Dowling P. GI therapy: when what goes in won’t stay down. WVC Proc 2003 11. Zoetis Inc. Cerenia® package insert. October 2015. https://www.zoetisus.com/ products/pages/cerenia/cerenia_pi.pdf. Accessed March 2016.

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became sick in the car on the way to the clinic. If the answer is yes, the veterinary technician can alert the veterinarian so he or she can speak to the owner about the options for treating motion sickness. If a puppy has motion sickness, it is important to speak to the owner about systematic desensitization to avoid a learned fear of the car later in life. Owners often assume that puppies will outgrow motion sickness, but without early intervention and treatment, motion sickness may become worse. 

Glossary Acupuncture: The treatment of disorders by inserting small needles into the skin at points where the flow of energy is thought to be blocked Acupressure: The treatment of disorders by using manual pressure at points on the skin Antihistamine: A drug that blocks the action of histamine Desensitization: To make an animal less responsive to an overwhelming fear by repeated exposure to the feared situation or object in a controlled situation Histamine: A compound released by immune cells that produces allergic reactions Neuropeptide: A peptide released by the nervous system that carries communication between nerves

12. Washabau RJ, Elie S. Antiemetic therapy. In: Kirk RW, Bonagura JD, eds. Kirk’s Current Veterinary Therapy XII Small Animal Practice. Philadelphia, PA: WB Saunders; 1995:679-684. 13. Conder G, Sedlacek H, Boucher J, Clemence R. Efficacy and safety of maropitant, a selective neurokinin1 receptor antagonist, in two randomized clinical trials for prevention of vomiting due to motion sickness in dogs. J Vet Pharmacol Ther 2008;31(6):528-532. 14. Ehrlich S. Motion sickness. University of Maryland Medical Center website. umm.edu/ health/medical/altmed/condition/motion-sickness. Accessed March 2016. 15. Silver R. The 10 herbs your clients most want to know about. WVC Proc 2005. 16. Chen Y, Zhang C, Zhang M, Fu X. Three statistical experimental designs for enhancing yield of active compounds from herbal medicines and anti-motion sickness bioactivity. Pharmacogn Mag 2015;11(43):435-443. 17. Lien H, Sun W, Chen Y, et al. Effects of ginger on motion sickness and gastric slow-wave dysrhythmias induced by circular vection. Am J Physiol Gastrointest Liver Physiol 2003;284(3):G481-G489. 18. Mowrey D, Clayson D. Motion sickness: ginger and psychophysics. Lancet. 1982;20:655-667. 19. Plumb D. Plumb’s Veterinary Drug Handbook. 8th ed. Wiley-Blackwell; 2015.

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Peer-Reviewed

Iron Toxicosis

Erin Freed, CVT

ron, a heavy metal, is the most abundant trace mineral in the body.1-3 Although iron is essential for the transport of oxygen, the presence of excess iron in the blood can lead to iron toxicosis. The most common cause of iron overdose is accidental ingestion of iron-containing compounds; however, iatrogenic overdose via injection of agents to treat iron deficiency (e.g., iron dextran complex) is possible.4,5 Iron-containing items that animals may accidentally ingest include multivitamins, birth control pills, fertilizers, hand and foot warmers, heat patches or wraps, some slug and snail baits, and oxygen absorber sachets.6-9

Erin has been employed with the ASPCA Animal Poison Control Center (APCC) since 2006. She earned her associate’s degree in applied science in veterinary technology from Parkland Community College and is currently pursuing a bachelor’s degree in applied science in veterinary business management from St. Petersburg College. Erin’s interests include toxicology, but her true passion is sharing knowledge and educating veterinary staff. She has been an instructor for a toxicology continuing education (CE) course for the Veterinary Support Personnel Network and has spoken at several APCC CE conferences. Erin has had peer-reviewed articles published in Veterinary Technician, the NAVTA Journal, and Veterinary Medicine and has authored a chapter on the renal system in Small Animal Toxicology Essentials.

PATHOPHYSIOLOGY Iron can exist in two ionic states— ferrous (Fe2+) and ferric (Fe3+)—within the body.1,3 Although ferrous iron is more readily absorbed by the body, both forms can be absorbed if they are ionized.1,2 Metallic iron and iron oxide (i.e., rust) do not readily ionize; therefore, these forms are typically not problematic if ingested.1,6 After iron is ionized, most of it is absorbed by mucosal cells in the duodenum and upper jejunum.1,2 However, in cases of overdose, the entire intestinal tract may absorb iron.1 Absorption is also increased in the presence of vitamin C.1,3 The iron is then transported across cell membranes to the blood, where it binds to transferrin, which is the primary iron transport molecule.1,4,6 Transferrin is produced in the liver and is normally 25% to 30% saturated with iron.3,4 Most iron is transported by transferrin to the bone marrow for the 64

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production of hemoglobin.1,3 The body absorbs 2% to 15% of ingested iron, but only 0.01% is eliminated daily;1,3,5 the remainder is bound to ferritin, an iron storage protein, and is stored in the liver, spleen, and bone marrow.1,3,5 When iron toxicosis occurs, transferrin becomes saturated so that the total serum iron (SI) concentration exceeds the transferrin iron-binding capacity; therefore, the amount of free circulating iron in the blood increases.1,6 This free iron enters cells of the liver, heart, and brain, where it binds to cell membranes and stimulates lipid peroxidation, in which free radicals remove electrons from the lipid in cell membranes, resulting in cell damage.1,2,6,9 The development of toxicosis also depends on the amount of iron already in the body.1 Animals that have a large amount of stored iron may develop signs of toxicosis even when the level of iron ingested causes no problems in other animals.1

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TOXICOSIS AND CLINICAL SIGNS Toxicosis is not expected in healthy dogs and cats that ingest <20 mg/kg of elemental iron.1,6,9 Ingestion of 20 to 60 mg/kg of elemental iron may cause toxicosis with mild gastrointestinal (GI) signs.1,6,9 Ingestion of >60 mg/kg of elemental iron is considered potentially serious and may result in GI hemorrhage as well as metabolic Updated from Veterinary Technician July 2008 (Vol 29, No 7) by the author and peer reviewed by Today’s Veterinary Technician. Used with permission from VetFolio, LLC. Veterinary Technician articles published from January 2005 through August 2013 can be accessed without subscription at vetfolio.com/ veterinary-technician-archives.

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Iron Toxicosis

acidosis and elevated liver enzyme values.1,4,6,9 Death may result if an animal ingests 100 to 200 mg/kg of elemental iron and does not receive treatment.1,6,9 TABLE 1 lists the elemental iron content of commonly ingested iron salts; BOX 1 describes how to calculate the amount of elemental iron ingested. Toxicosis can be characterized as peracute, subacute, or chronic.4,5,8 In peracute toxicosis, such as that occurring after an iron injection, clinical signs develop within minutes

TABLE 1 Iron Salts and Their Elemental Iron Content 3,4,a IRON SALT

ELEMENTAL IRON (%)

Ferrocholinate

Ferrous gluconate

Ferric ammonium citrate

Ferroglycine sulfate

Peptonized iron

Ferrous sulfate (hydrate)

Ferrous lactate

Ferric pyrophosphate

Ferrous fumarate

Ferric chloride

Ferrous sulfate (anhydrous)

Ferric phosphate

Ferrous carbonate (anhydrous)

Ferric hydroxide

to a few hours after exposure.4,5,8 Signs are similar to those of an anaphylactic reaction and may include hypovolemic shock followed by sudden death as a result of vascular collapse.4,5,8 At the injection site, the skin may be discolored and edema may develop.4,8 Subacute toxicosis, such as that occurring after oral ingestion, can be grouped into four phases.1,2,6-8 During the first phase, signs develop up to 6 hours after exposure

BOX 1 Calculating Ingested Iron Most products that contain iron include it as a salt compound. To calculate the amount of iron ingested, it is important to determine the amount of elemental iron (i.e., the amount of iron without a salt compound). TABLE 1 lists various iron salts and the percentage of elemental iron in each salt. For example, if a cat has ingested 10 tablets, each containing 32.5 mg of ferrous fumarate, the calculations would be performed as follows: 1. To calculate the total amount of ferrous fumarate ingested, multiply 10 by 32.5, which equals 325 mg of ferrous fumarate. 2. To calculate the amount of elemental iron ingested, multiply 325 by 0.33 (the factor that represents the percentage of elemental iron in ferrous fumarate; see TABLE 1), which equals 107 mg of elemental iron. 3. To calculate the amount of iron ingested per kilogram of body weight, divide 107 by the animalâ&#x20AC;&#x2122;s weight in kilograms.

Williams RJ. Biomineralization: iron and the origins of life. Nature 1990;343:213-214.

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and include lethargy and bloody vomiting and diarrhea caused by GI hemorrhage.1,2,6-8 In the second phase, which develops within 6 to 24 hours after exposure, the patient’s condition appears to improve.1,2,6-8 During the third phase, about 12 to 96 hours after exposure, GI signs recur, along with depression, shock, hypotension, tachycardia, cardiovascular collapse, metabolic acidosis, coagulopathy, liver failure, or even death.1,2,6-8 Acute renal failure secondary to shock may also develop.1,7,8 Animals that survive this phase may enter a fourth phase 2 to 6 weeks after exposure.1,2,7,8 In this phase, gastric obstruction may develop secondary to gastric or pyloric stenosis.1,2,6-8 Chronic toxicosis occurs when iron is repeatedly ingested at low levels that individually do not have adverse effects. Long-term iron exposures may lead to the development of hemochromatosis, a pathologic accumulation of iron in the tissues that can cause organ damage, often resulting in fibrosis.2,5 DIAGNOSIS If a patient has ingested an iron salt–containing substance in amounts sufficient to cause toxicosis, the veterinary staff should observe the patient’s clinical signs and measure the SI level and total iron-binding capacity (TIBC).1,6 Testing an animal’s SI level is the best method of confirming a tentative diagnosis of iron toxicosis and may be performed at most human hospitals if needed.1,2,6 The SI test measures bound and free SI, whereas the TIBC test assesses the total amount of iron that the transferrin can bind.1 SI testing should be conducted within a few hours of ingestion to obtain a baseline level1,6 and then repeated 4 to 6 hours after the first assays as SI levels may vary widely within the first few hours after ingestion.1,6 Normal ranges for SI and TIBC vary from animal to animal and the type of laboratory test used.1,2 Veterinary technicians should check the range of the specific test to determine whether results are abnormal. Toxicosis can be confirmed if the SI value is greater than the TIBC value.1,2,7 If a patient has ingested radiopaque iron-containing tablets, it may be useful to obtain abdominal radiographs within a few hours of ingestion.1,4,7 Radiographs should be repeated after GI decontamination.8 TREATMENT If an animal has ingested <20 mg/kg of elemental iron, the veterinary staff should observe the patient and provide treatment based on clinical signs.1 Animals that remain asymptomatic for 6 to 8 hours are unlikely to develop clinical signs.2 A single oral dose of magnesium hydroxide or calcium carbonate tablets may reduce iron absorption by 30% to 40%10 and can be administered to asymptomatic animals.1,4,6-8 66

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TECHPOINT 

Veterinary technicians should educate owners about the signs of iron toxicosis and instruct them to keep iron-containing products away from pets. If an animal has ingested >20 mg/kg of elemental iron, GI decontamination through induced vomiting with 3% hydrogen peroxide or apomorphine should be considered up to 1 to 2 hours after ingestion, unless the animal is already vomiting.1 Activated charcoal is not indicated because it does not bind well to iron.6-9 In animals that are already vomiting, emesis can be managed with antiemetics (such as maropitant or ondansetron).7,8 GI protectants such as sucralfate, along with an H2 blocker (such as famotidine, cimetidine, or ranitidine) or a proton pump inhibitor, such as omeprazole, may be administered.1,2,7-9 Intravenous fluid support—which helps manage shock and hypotension— can be offered.1,2,7,8 Gastric lavage can be performed when emesis is contraindicated or when pill bezoars are identified.7-9 Emergency gastrotomy may be indicated if lavage fails to remove pills adhered to the stomach wall or bezoars.2,5,7 A complete blood cell count and chemistry profile should be obtained to assess liver and kidney function, coagulation, dehydration, leukocytosis, and hyperglycemia.1,2,6-9 Electrolyte level and acid–base status should also be monitored in patients exhibiting clinical signs.1,2,7,8 Supportive care should be provided as needed. When the SI value is greater than the TIBC value or is above 300 to 500 mcg/dL, excess iron must be removed from the blood.1,2,4,6-8 The drug of choice for this purpose is deferoxamine mesylate, an iron chelator.1,2,4,6-8 This agent is best given within the first 24 hours after exposure, at a rate of 40 mg/kg IM q4–8h or 15 mg/kg/h IV.1,2,6-9 Deferoxamine is excreted primarily by the kidneys and can cause hypotension2,4,6,8 or cardiac arrhythmias.2,6,7,9 It should be infused slowly, and care must be taken when administering it to animals that are in shock or have renal insufficiency.2,5 Administering ascorbic acid after the gut has been cleared of iron increases the effectiveness of the drug.2,8 Use of deferoxamine mesylate causes the urine to become reddish-brown if SI is elevated.1,4 Treatment is usually continued until the urine is no longer discolored, clinical signs start to resolve, or the SI value is <300 mcg/dL.1,2,4,7,8

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Making a Difference Sammie Thibodeaux, CVT The Woodlands, Texas

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!

“I realized that I was not in this for the income, I was in it for the outcome.” —Sammie Thibodeaux, CVT

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Ever since I was a little girl, I have been surrounded by animals. My parents tell me that from the time that I could walk, I was always in the boarding kennel my grandmother owned. I would walk up to the cages, no matter what kind of dogs were in them, and even the ones who were snarling and scared would start wagging their tails and lick my face. I loved it! I think from that point on, my career working with animals was destined to be. When I turned 9, my parents got me a boxer puppy named Briggs, who would forever touch my heart. He was my best friend, and with him, I really began to notice my love for animals. I had a bond with him like no other, and in a way, he taught me about how sacred an animal’s life can be. When I was 17, my mother helped me land my first job as a kennel technician at the veterinary hospital where she worked as a receptionist. There, I learned that there was so much more to owning a pet than just feeding it and playing with it! While my job was part time and really only involved handling the animals that were being boarded, I was intrigued by what was happening in the veterinary side of the hospital. After I turned 18 and graduated from high school, I became a full-time staff member and started to be trained as a veterinary technician. My coworkers taught me how to hold animals properly for doctors in examination rooms and how to prep patients for surgery. I caught on so quickly that they moved me on to drawing blood and running SNAP tests. Eventually, I started talking with clients and educating them on proper animal care. Clients were impressed with me and how I handled their animals with such care and passion for what I was doing. The doctors I worked for noticed all my hard work and dedication, and after 3 years, they paid for my schooling and I became a certified technician. I saw so much in those years, from dogs that had been shot and were still able to trust people, to dogs that had been left out in the Texas summer heat and were too far gone to save, that my passion for my job only grew greater. I realized that I was not in this for the income, I was in it for the outcome. Fast forward to me now, at 26. I am working as a full-time veterinary technician in a high-paced small animal clinic, and I have started my own petsitting company because of how much I am in love with what I do. I am moved by each animal I have encountered and will encounter because of how they persevere no matter what they are going through. I have seen animals fight with all they have to get better. I have seen animals in more

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What Moves You?

Making a Difference

shutterstock.com/Poprotskiy Alexey

I am moved by each animal I have encountered and will encounter because of how they persevere no matter what they are going through.

appalling conditions than I have ever seen any human in, and they still have trust for people and want to please and love. For every hurt animal that comes through the doors of my clinic, I feel an obligation to help make it better and reassure

its distressed owners. Whether I’m placing a catheter in a dehydrated parvo pup or simply giving an annual FVRCP vaccine to a cat, I feel as though I am making a difference. And that is what moves me. 

Iron Toxicosis, continued from page 66

and how much time has elapsed since the exposure. To help the veterinary staff calculate the amount of elemental iron ingested and administer the appropriate treatment, the client should bring the packaging that contained the ingested product (e.g., multivitamins, birth control pills, fertilizer). Although severe iron toxicosis, with the need to chelate, is infrequent, iron ingestions are common in pets and the veterinary staff should be knowledgeable about how to manage affected patients. 

Chelation of excess iron may require 2 to 3 days of treatment.1,2 Patients should be monitored for at least 4 to 6 weeks after exposure for evidence of GI obstruction caused by scarring of the tract.1,2,7 PROGNOSIS The patient’s outcome depends on the amount of iron ingested and how quickly the owner seeks medical attention for the pet. If signs do not develop within 6 hours of exposure, or if the patient receives early decontamination, the prognosis is good.1,6,8 The prognosis is guarded after signs have developed,1,6,8 and it is poor when the SI level is >500 mcg/dL and a chelator is not available.1,8 THE ROLE OF VETERINARY TECHNICIANS Veterinary technicians should educate owners about the signs of iron toxicosis and instruct them to keep iron-containing products away from pets. However, if a product containing iron is ingested, the owner should immediately contact the hospital or an animal poison control center. When a client contacts the hospital to report that his or her pet has ingested a product containing iron, the technician should determine what type of product was ingested (e.g., multivitamins), how much the pet ingested (e.g., 10 tablets),

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References 1. Albretsen JC. The toxicity of iron, an essential element. Vet Med 2006;101:82-90. 2. Greentree WF, Hall JO. Iron toxicosis. In: Bonagura JD, ed. Kirk’s Current Veterinary Therapy XII: Small Animal Practice. Philadelphia, PA: WB Saunders; 1995:240-242. 3. Liu J, Goyer RA, Waalkes MP. Toxic effects of metals. In: Klaassen CD, ed. Casarett & Doull’s Toxicology: The Basic Science of Poisons, 7th ed. New York: McGraw-Hill; 2008:954-955. 4. Beasley VA. Iron. In: A Systems Affected Approach to Veterinary Toxicology. Urbana, IL: University of Illinois; 1999:544-547. 5. Hooser SB. Iron. In: Gupta RC, ed. Veterinary Toxicology: Basic and Clinical Principles, 2nd ed. Waltham, MA: Academic Press; 2012:517-520. 6. Hall JO. Iron. In: Peterson ME, Peterson PA, Talcott PA, eds. Small Animal Toxicology, 3rd ed. St. Louis: Elsevier; 2013:595-600. 7. Hall JO. Iron toxicosis. In: Tilley LP, Smith FWK, eds. Blackwell’s Five-Minute Veterinary Consult: Canine and Feline, 6th ed. Ames, IA: John Wiley and Sons; 2016:769. 8. Merola V. Iron toxicosis. In: Côté E, ed. Clinical Veterinary Advisor: Dogs and Cats, 3rd ed. St. Louis: Mosby; 2015:572-574. 9. Poppenga RH. Metals and minerals. In: Poppenga RH, Gwaltney-Brant SM, eds. Small Animal Toxicology Essentials. Ames, IA: Wiley-Blackwell; 2011:276-277. 10. (Iron) (Drug-Drug Combinations). In: DRUGDEX® System (electronic version). Truven Health Analytics, Greenwood Village, CO. Available at: micromedexsolutions.com. Accessed February 2016.

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Final Thoughts An Attitude of Gratitude When I started counting my blessings, my whole life turned around. —Willie Nelson Clients are a paradox. They contribute to both our compassion satisfaction and our compassion fatigue: in essence, both the good and not-so-good parts of our job. Sometimes it feels as though no matter how hard we try, we just can’t satisfy some clients. We are lucky if we even get a “thank you” from them. I know we didn’t come to veterinary medicine for the thanks and praise, but it sure would be nice sometimes, wouldn’t it? It seems like everywhere you turn, the public is suspicious of veterinarians (and their practices). You know those commercials: “Don’t pay those high prices at your vet when you can get the same meds here for a fraction of the price!” I even hear it from my family and friends. “Wow, I can’t believe how much it cost for me to take my dog to the vet. The surgery was over $3000!” I want to say, “Yes, but your dog is still alive, isn’t he? Where’s the gratitude?” Gratitude can be defined as “an emotion expressing appreciation for what one has, as opposed to what one wants.”1 Robert Emmons, PhD, professor of psychology at the University of California, Davis, the founding editor-in-chief of The Journal of Positive Psychology, and the world’s leading scientific expert on gratitude, puts it this way: “It’s an affirmation

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.

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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.

YOUR PATIENTS can’t tell you what is wrong, yet you decipher their signs, symptoms, and nonverbal communication to figure out what is wrong and then make it better. 70

TODAY’SVETERINARYTECHNICIAN

An Official Journal of the NAVC

May/June 2016

www.todaysveterinarytechnician.com

Final Thoughts

An Attitude of Gratitude

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BEING GRATEFUL with our coworkers can completely transform a workplace. Let it begin with you.

of goodness. We affirm that there are good things in the world, gifts and benefits we’ve received…[and] we recognize that the sources of this goodness are outside of ourselves.”2 It’s not just our clients who could use a lesson in gratitude. Sometimes we need one too. Accepting Gratitude On a recent trip to Cornell, a veterinary student, Nick, said to me, “Perhaps we are looking for gratitude from the wrong place. Instead of wishing the client was more grateful, maybe we should be looking for it from our patients?” But how in the world can we ever know if an animal is grateful for the care we have provided? I think it’s easier than you might think. First of all, think about the amazing skill you have to communicate with a nonverbal patient. It’s a true superpower. Your patients can’t tell you what is wrong, yet you decipher their signs, symptoms, and nonverbal communication to figure out what is wrong and then make it better. Superpower? No doubt. We have all seen animals express gratitude. Social media is full of videos like the shelter dog that gets adopted and goes crazy jumping up and down and licking his new owner. Maybe you’ve had a cat that, after recovering from a urethral blockage, purred his face off and rubbed himself all over you. Even farm animals display gratitude. I guide weekend tours at a farm animal sanctuary, and we see it all the time. For example, Jersey calves Emerson, Calvin, Russell, and Bernard were just 3 days old when they arrived at the sanctuary. They were all extremely sick with Giardia and Escherichia coli and required round-the-clock bottlefeeding. TODAY’SVETERINARYTECHNICIAN

These little calves spent their first few months living in a barn stall because they were too weak and too sick to be outside. But then the day came when they were turned out into their “big boy” field, and the gratitude and joy they expressed was undeniable. You can see it on YouTube: youtube.com/ watch?v=si4ijr-KRho. So while we have all seen grateful animals, have we taken that gratitude in? Have we accepted it? Have we let it recharge us? Cultivating Gratitude According to Dr. Emmons’ studies, we can deliberately cultivate gratitude, which has the power to3: ÆÆ Heal ÆÆ Energize ÆÆ Change lives When we’re appreciating something, we let go of our ego and connect with the present, which has benefits of its own. Remembering to be grateful for these things—be they objects, experiences, or people—can increase not only our pleasure in them, but our own energy and harmony with the rest of the world.4,5 Here are some ways to bring more gratitude into your experience and your life. Create a gratitude journal: Spending a few minutes every morning or evening to write down the things for which you are grateful can go a long way in reminding you about what is good in your life. Find 3 things a day: At bedtime, before drifting off into dreamland, my husband and I like to rattle off 3 things from the day that made us grateful. Some days, there are big things like a new speaking engagement, but other days, it

An Official Journal of the NAVC

May/June 2016

www.todaysveterinarytechnician.com

Final Thoughts

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An Attitude of Gratitude

might be smaller things like the feel of clean sheets. They are all worthy of gratitude. Make a gratitude bulletin board: Whether at home or at work, make a space to hang up the thank-you cards you receive, notes that came with a plate of goodies from a client, cards that came with flowers, badges from conferences you attended, and items from family and friends that are significant to you and for which you are appreciative. Write a thank-you letter: Many of us know someone who at some time made a difference in our lives, and who we never really thanked or told how they inspired us. This person may be a college roommate, certain professor, coach, colleague, friend, or family member. Write them a letter, and (if possible) read it to them face-to-face. Bring gratitude into your family: While families eating meals together has become scarcer over the years, when your whole family does sit down for a meal, exchange high and low points of your day. Sharing low points teaches children resiliency and how to manage the difficulties life throws at us. Pay it forward: I wish I had told my grandmother how much I appreciated her and her wisdom before she died many years ago. But since I can’t, I instead show my gratitude by extending kindness to other senior citizens I encounter in the world. It may be just a smile, or a conversation, or a door held open, but it is all infused with appreciation for the elders of our society. Have gratitude reminders: If you have trouble remembering to connect to gratitude, then link something

T ECHPO INT 

We often forget to take the time to recognize the people who are working right alongside us—the ones who care just as much as we do. Take the lead, and see for yourself what a difference a daily attitude of gratitude can make in your life. you do—be it driving, brushing your teeth, making coffee, washing your hands, leaving work, or some other everyday task—with the act of bringing to mind things you are grateful for. Right this moment, think of something you are grateful for and spend a few seconds thinking about it. Do you feel that shift in your energy and your mood? I always do. Gratitude at Work Being grateful with our coworkers can completely transform a workplace. Let it begin with you. The next time someone calms a fractious cat, hits a rolling vein, helps with a difficult client, volunteers for the euthanasia, cleans up the operating room, offers to do data entry, or otherwise helps with an unenviable task, express your heartfelt gratitude with a sincere thank you. We often forget to take the time to recognize the people who are working right alongside us—the ones who care just as much as we do. We all want to feel appreciated. Take the lead, and see for yourself what a difference a daily attitude of gratitude can make in your life. 

References 1. Gratitude. The benefits of gratitude. Psychology Today [website]. psychologytoday. com/basics/gratitude. Accessed March 2016. 2. What is gratitude? Greater Good [website]. greatergood.berkeley.edu/topic/ gratitude/definition. Accessed March 2016. 3. Emmons R. Thanks!: How Practicing Gratitude Can Make You Happier. Boston, MA: Houghton Mifflin; 2008. 4. Cultivate the healing power of gratitude. The Chopra Center [website]. chopra.com/ ccl/cultivate-the-healing-power-of-gratitude. Accessed March 2016. 5. Squires J. Be with what is. Today’s Vet Tech 2016;1(1):80-81. shutterstock.com/Ozgur Coskun

TODAY’SVETERINARYTECHNICIAN

An Official Journal of the NAVC

May/June 2016

www.todaysveterinarytechnician.com

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TRESADERM (thiabendazole-dexamethasoneneomycin sulfate solution) Dermatologic Solution CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: Dermatologic Solution (thiabendazole-dexamethasoneTRESADERM® neomycin sulfate solution) contains the following active ingredients per ml: 40 mg thiabendazole, 1 mg dexamethasone, 3.2 mg neomycin (from neomycin sulfate). Inactive ingredients: glycerin, propylene glycol, purified water, hypophosphorous acid, calcium hypophosphite; about 8.5% ethyl alcohol and about 0.5% benzyl alcohol. INDICATIONS:Dermatologic solution TRESADERM is indicated as an aid in the treatment of certain bacterial, mycotic, and inflammatory dermatoses and otitis externa in dogs and cats. Both acute and chronic forms of these skin disorders respond to treatment with TRESADERM. Many forms of dermatosis are caused by bacteria (chiefly Staphylococcus aureus, Proteus vulgaris and Pseudomonas aeruginosa). Moreover, these organisms often act as opportunistic or concurrent pathogens that may complicate already established mycotic skin disorders, or otoacariasis caused by Otodectes cynotis. The principal etiologic agents of dermatomycoses in dogs and cats are species of the genera Microsporum and Trichophyton. The efficacy of neomycin as an antibacterial agent, with activity against both gram-negative and gram-positive pathogens, is well documented. Detailed studies in various laboratories have verified the significant activity thiabendazole displays against the important dermatophytes. Dexamethasone, a synthetic adrenocorticoid steroid, inhibits the reaction of connective tissue to injury and suppresses the classic inflammatory manifestations of skin disease. The formulation for TRESADERM combines these several activities in a complementary form for control of the discomfort and direct treatment of dermatitis and otitis externa produced by the above-mentioned infectious agents. DOSAGE AND ADMINISTRATION: Prior to the administration of Dermatologic Solution TRESADERM, remove the ceruminous, purulent or foreign materials from the ear canal, as well as the crust which may be associated with dermatoses affecting other parts of the body. The design of the container nozzle safely allows partial insertion into the ear canal for ease of administration. The amount to apply and the frequency of treatment are dependent upon the severity and extent of the lesions. Five to 15 drops should be instilled in the ear twice daily. In treating dermatoses affecting other than the ear the surface of the lesions should be well moistened (2 to 4 drops per square inch) with Dermatologic Solution TRESADERM twice daily. The volume required will be dependent upon the size of the lesion. Application of TRESADERM should be limited to a period of not longer than one week. PRECAUTIONS: On rare occasions dogs may be sensitive to neomycin. In these animals, application of the drug will result in erythema of the treated area, which may last for 24 to 48 hours. Also, evidence of transient discomfort has been noted in some dogs when the drug was applied to fissured or denuded areas. The expression of pain may last 2 to 5 minutes. Application of Dermatologic Solution TRESADERM should be limited to periods not longer than one week. While systemic side effects are not likely with topically applied corticosteroids, such a possibility should be considered if use of the solution is extensive and prolonged. If signs of salt and water retention or potassium excretion are noticed (increased thirst, weakness, lethargy, oliguria, gastrointestinal disturbances or tachycardia), treatment should be discontinued and appropriate measures taken to correct the electrolyte and fluid imbalance. Store in a refrigerator 36°-46°F (2°-8°C). WARNING: For topical use in dogs and cats. Avoid contact with eyes. Keep this and all drugs out of the reach of children. The Material Safety Data Sheet (MSDS) contains more detailed occupational safety information. To report adverse effects in users, to obtain an MSDS, or for assistance call 1-888-637-4251. HOW SUPPLIED: Product 55871Dermatologic Solution TRESADERM Veterinary is supplied in 7.5-ml and 15-ml dropper bottles, each in 12-bottle boxes.

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CLEARS UP ALMOST ANYTHING HOT SPOTS

RINGWORM

OTITIS EXTERNA

Trust TRESADERM Dermatologic Solution as your solution to aid in the treatment of: ®

3 Otitis Externa

3 Flea Allergy Dermatitis

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3 Mycotic Dermatosis

3 Focal Pyoderma

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Approved for use on dogs and cats

IMPORTANT SAFETY INFORMATION: TRESADERM is for topical use only in dogs and cats. On rare occasions, application of the product may result in erythema or discomfort in the treated area. Discomfort in the treated area can last from 24 hours to 48 hours. ®TRESADERM is a registered trademark of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved. TRE15TRADEADD (01/16).

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