Today's Veterinary Technician, July 2016 by davidpsu

BEHAVIOR HELPING CLIENTS CARE FOR OLDER CATS

EMERGENCY/CRITICAL CARE FLUID THERAPY BASICS: WHAT, WHY, AND HOW

TOXICOLOGY HOW TO HANDLE “MY PET JUST ATE…”

CAREER CHALLENGES TIPS TO IMPROVE CLIENT SATISFACTION

IDEAS INTO PRACTICE VETERINARY TECHNICIAN APPOINTMENTS

SURGERY

HOW TO PREPARE FOR THE BEST OUTCOME

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FRIENDS

LIFE

Protect all that matters with the ONLY 6-IN-1 PARASITE PROTECTION POWERED BY LUFENURON. Help preserve their special connection with parasite protection that can’t be imitated. SENTINEL® SPECTRUM® (milbemycin oxime/lufenuron/praziquantel) covers 6 different parasites and is the only heartworm preventive that uses the power of lufenuron to stop flea infestations before they start. To order, contact your Virbac representative or call 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.

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TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

JULY/AUGUST 2016

VOLUME 1, NUMBER 4

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

JULYAUGUST2016

Volume 1, Number 4

PEER-REVIEWED CE Preoperative Roles and Responsibilities of the Veterinary Surgical Nurse DANIELLE BROWNING, LVMT, VTS (SURGERY), and KAREN TOBIAS, DVM, MS, DACVS

Successful surgical outcomes rely on more than the operative procedures themselves. Veterinary surgical nurses play critical roles in preparing the patient, the surgical suite, and the owner.

FEATURES Go With the Flow: The Basics of Fluid Therapy for Small Animal Veterinary Technicians LIZ HUGHSTON, MEd, RVT, CVT, VTS (SAIM, ECC)

Fluid therapy is one of the most common therapies in small animal medicine, and knowing what, why, and how to deliver it is a core competency for veterinary technicians. This article provides a brief overview of each aspect.

Behavioral Aspects of Caring for Elderly Cats VICKY HALLS, RVN, DIP COUNS MBACP

This article from the British journal Feline Focus reviews common behavioral changes in senior and geriatric cats and provides recommendations that clients can use in enriching and adapting the home environment for their older pets.

Crash Carts: Preparation and Maintenance PAULA PLUMMER, LVT, VTS (ECC, SAIM)

Emergencies cannot be predicted, but they can be anticipated. Learn how to create and stock a crash cart to prepare for the kinds of emergencies your clinic typically handles.

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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.

JULYAUGUST2016 COLUMNS Editor’s Letter | Advice From a New Puppy LYNNE JOHNSON-HARRIS, LVT, RVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

What Moves You? | Being in the Driver’s Seat

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.

Dosage Schedule

RENAUD HOUYOUX, LVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Toxicology Talk | How to Take a Toxin Exposure History JENNIFER A. SCHUETT, CVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Career Challenges | Tips and Tricks to Rev Up Your Client Service Game HEATHER PRENDERGAST, RVT, CVPM. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Ideas Into Practice | Starting Veterinary Technician Appointments ESTHER KLOK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Final Thoughts | The Space Between Us

18 31

46 49

Praziquantel per Number of chewable chewables

Milbemycin Oxime per chewable

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

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

CLIENT HANDOUTS

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.

Common Household Poisons................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Contraindications There are no known contraindications to the use of SENTINEL SPECTRUM.

JULIE SQUIRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Why Do I Need to Vaccinate My Pet?. . ................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

TECHNICIAN RESOURCE Toxin Triage Sheet............................................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 Advertiser Index. . .................. 53

ON THE COVER University of Guelph student Mari Bessell prepares a patient for a bilateral mandibular and retropharyngeal lymph node excision via a ventral midline approach. Cover image by Dean Palmer Photography.

Correction In Table 2 of the May/June 2016 article “Preanalytic Variables: Effects on CBC and Serum Chemistry Results,” the additive for the blue-cap collection tube was mistakenly identified as sodium chloride. The correct additive for this tube is sodium citrate.

Today’s Veterinary Technician (ISSN 2472-209X print and ISSN 2472-2103 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

An Official Journal of the NAVC

July/Aug 2016

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. 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

Editor’s Letter Advice From a New Puppy Lynne Johnson-Harris, LVT, RVT | Editor in Chief

ur new puppy family member is Quinn, a playful prankster. Our trustworthy and faithful golden retriever, Emme, passed away recently, and our home was just too empty and too quiet. We couldn’t stand it. I’m sure you know the feeling. You also know that a puppy may be the quickest and most decisive way to go from quiet stillness to peripatetic energy; a way to go from sadness to all-encompassing attention to “now”; a way to pay proper tribute to the dog that made it impossible to live without a dog. I wanted to tell you about our old girl, but I find it very hard. She was extraordinary—as your special dogs have been—a golden with a good heart, smart, and so easy to love. Our grief over Emme’s death was such I wasn’t sure I’d find any meaningful description that didn’t sound clichéd and overworn. When I searched for inspiration, I found a webful of beautiful tributes, quotes, and tearyeyed stories about dogs that have crossed the Rainbow Bridge. What could I say that would sound new? So I searched for stories about puppies, expecting to find tales and tributes to new life, new possibilities, and the joy of living. Instead, the hits were all about containing youthful energy and getting the puppy to adjust to home life, to a life with boundaries. Is that odd? Maybe, but it’s understandable. Without limitations, without clear expectations, life becomes chaotic and uncomfortable. Aha, I thought. Just like Julie Squires says in this issue’s Final Thoughts, boundaries are essential for us all— human or not. They may not be established easily, but the reward comes when little victories add up to a huge and positive difference. It’s work for Quinn to learn how to function in our home and our veterinary practice. Julie references some great resources for the ground rules we all need in order to thrive. I asked Quinn for his 12-week-old golden retriever perspective on the subject. Here’s what he “said.”

“Know your values. Food, toys, getting petted, giving kisses, getting tummy rubbed. Did I say toys? Did I say food? Being loved and giving love. Sleep— but only when you can’t keep your eyes open anymore. Maybe for people, it’s more like human family, honesty, nursing animals, volunteer activities? Make time for all of those. Spend time on what matters most to you. Did I say food? “Communicate clearly. I see your nonverbal cues, even when they don’t match your verbal ones. Understand my cues: my soulful, expressive ‘look’; that little head turn when I don’t understand. “Create structure and stick to it. Wake up, go out, eat, play, meet/greet everyone, nap. Repeat. Endlessly. It’s better when you are consistent and I know what to expect and what not to expect from you. “Bring up boundary violations right away. Older dogs give me a quick growl when I’ve gone too far, so I learn what not to do. I get it. (The hospital cat is still a mystery.) I look pathetic and go to my food bowl if a meal is late. You get it, and then you feed me. Say something when someone’s gone too far, but stick to the subject at hand. Did I mention the food bowl? “I’ll lean in, on, and next to you. Just tell me when I’ve gone too far. And expect great things from me!” Losing Emme and our other golden girl, Rudder, has been difficult; however, as you can tell, Quinn is joyfully exploring and learning while reminding me how worthwhile it is to be open and to try something different. It’s been a very long time since we have had a playful puppy, and I know that Quinn will provide us with many happy memories. New puppy. Spring turns to summer again. Life goes on. Isn’t that great? 

For all the adorable pictures you can stand, visit our Facebook page: facebook.com/todaysveterinarytechnician. Do you have a story you’d like to share? Write me at ljohnson@navc.com. TODAY’SVETERINARYTECHNICIAN

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PATIENT POSITIONING is key for any surgery, and communication with the surgeon is important to ensure proper placement of the patient and team.

TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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CE ARTICLE 1 CR E DIT

Preoperative Roles and Responsibilities of the Veterinary Surgical Nurse Danielle Browning, LVMT, VTS (Surgery)

Danielle Browning, LVMT, VTS (Surgery)

University of Tennessee College of Veterinary Medicine

Danielle is a senior veterinary technician who currently works in the Department of Small Animal Clinical Services at the University of Tennessee College of Veterinary Medicine, where she has been employed since September 2000. She is the ward nurse for soft tissue surgery. She currently serves on the American College of Veterinary Surgeons continuing education committee as the technician seminar/session chair and is a member-at-large of the Academy of Veterinary Surgical Technicians.

TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

Karen Tobias, DVM, MS, DACVS University of Tennessee College of Veterinary Medicine

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Karen Tobias, DVM, MS, DACVS Dr. Karen Tobias is a professor and board-certified surgeon at the University of Tennessee College of Veterinary Medicine. She received her DVM from the University of Illinois and completed an internship at Purdue University and her surgery residency and masterâ&#x20AC;&#x2122;s degree at Ohio State University. Dr. Tobias has published more than 100 scientific articles and book chapters. She is the author of the Manual of Small Animal Soft Tissue Surgery, co-editor of Veterinary Surgery: Small Animal, and co-author of Atlas of Ear Diseases of the Dog and Cat. Dr. Tobias resides in Knoxville, Tennessee, with one faithful dog and one annoying cat.

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uccessful surgical outcomes rely on more than the operative procedures themselves. They also depend on patient health; preparation of the patient, surgical suite, and owner; and anticipation and prevention of perioperative complications. Veterinary surgical nurses (VSNs) play critical roles in all these areas. TEAM COMMUNICATION Effective communication throughout the veterinary team is imperative to ensure a successful surgical outcome. Because owner compliance is also crucial to a successful outcome, the patient’s caregiver must be considered part of the veterinary team. Before Admission The VSN might be responsible for recording a complete patient history. The client should be asked about any concurrent health issues the pet has, previous anesthetic episodes or surgeries, prior and current medications, any episodes of allergies or adverse reactions to medications, past or recent infections, unexpected bleeding, difficulty breathing or exercise intolerance, and vaccination and preventive health care status. Breed-specific questions, such as von Willebrand status in Doberman pinschers and palate surgery in brachycephalic breeds, are also important. The owner must be properly advised on the surgical procedure and associated potential risks. Gathering information about the patient’s environment (e.g., does the animal live outdoors, are there other pets in the home) helps the veterinary surgeon outline appropriate instructions for postsurgical home care. Even the caregiver’s profession may be significant: for example, colonization with antimicrobial-resistant bacteria is more common among health care workers, pig farmers, competitive sports participants, and military personnel,1,2 and these bacteria can be transmitted to pets. Most medications can be given on the morning of surgery, but a good guideline is for the VSN to provide the veterinary surgeon with a list of the patient’s medications several days before the scheduled procedure. This allows the surgeon to determine whether any medications should be discontinued before surgery. For example, if a dog undergoing a palate resection is expected to receive dexamethasone at the time of surgery, nonsteroidal antiinflammatory drugs (NSAIDs) should be discontinued several days before the procedure. Dogs that have received glucocorticoids and NSAIDs within 24 hours of each other have an increased risk for gastrointestinal tract perforations.3 Additionally, the VSN should specifically ask the owner what medications were administered the morning of surgery, 8

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since abrupt discontinuation of some medications (e.g., glucocorticoids) could be life threatening.4 Typically, the VSN relays appropriate fasting instructions to owners before their arrival. Some patients, such as those that are diabetic, hypoglycemic, or pediatric, need special feeding instructions as determined by the veterinary surgeon. These patients should be scheduled for the first operative time of the day to minimize effects of fasting. Diabetic patients may also require adjustment of morning insulin doses. In one study, a reduced dose of insulin (25% of normal) before surgery was shown to decrease the risk of postoperative hypoglycemia in dogs undergoing cataract removal.5 Veterinary literature supports the notion that an overnight fast before anesthesia is outdated. In one study, prolonged preoperative fasting was associated with increased gastric acidity and risk of reflux: none of the dogs that were fed 2 to 4 hours before anesthetic induction had reflux, while reflux was noted in 15% of dogs fasted 12 to 18 hours.6 In another study, dogs that ate a small meal of canned food (half their daily ration) 3 hours before anesthesia had gastric volumes similar to dogs that had fasted for 10 hours, and they had higher gastric pH than dogs receiving kibble or low-protein canned dog food 10 hours before anesthesia.7 A more updated protocol is to withhold food for 6 hours before surgery but to continue offering water until the patient has been premedicated. Antiemetic and prokinetic drugs can be administered to aid in gastrointestinal motility and help relieve nausea during premedication; for instance, administration of maropitant (Cerenia; 1 mg/kg IV) 45 minutes to 1 hour before premedication with hydromorphone and acepromazine reduced the incidence of vomiting and retching in dogs at the time of sedation, although it did not prevent gastroesophageal reflux during surgery.8 The veterinary surgeon should establish the hospital’s standard presurgical fasting instructions for patients that are not diabetic, hypoglycemic, or pediatric. At Admission The importance of introducing the veterinary team to owners and their pets should not be underestimated, and every effort should be made to mitigate stress in veterinary patients in the preoperative period. Human literature has reported better surgical outcomes in patients with lower anxiety levels.9 Use of family-centered preoperative behavioral intervention reduces children’s anxiety before surgery and decreases postoperative delirium, hospital stays, and analgesic consumption.10 Such programs consist of distribution of instructions and preparation materials in

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CE Article

Preoperative Roles and Responsibilities of the Veterinary Surgical Nurse

Dean Palmer Photography

Intubation allows for protection of the airway and delivery of inhalant anesthesia during the procedure.

the preoperative visit, telephone coaching calls 1 and 2 days before surgery, and presence of a parent during induction and recovery. Family dogs read and react to the nonverbal signals exhibited by their owners,11 so reducing owner anxiety may help to decrease the stress perceived by the pet. Characteristics of canine anxiety include trembling, cowering, lip licking, yawning, dilated pupils, and increases in heart rate, cortisol levels, and adrenocorticotropic hormone concentrations.12 Stress in dogs can be reduced by gentle stroking and petting; in a study of young and adult shelter dogs, dogs that were petted had lower cortisol concentrations during venipuncture than those that were not.13 For some animals, an urgent need to void can also be a source of stress. Before anesthesia induction, dogs should be walked to encourage urination and defecation, but manual bladder expression under anesthesia is occasionally required to help alleviate postoperative discomfort and prevent inadvertent soiling and/or contamination of bedding, fur, and (sometimes) bandages or wounds. Nevertheless, some patients will require anxiolytic medications (e.g., trazodone), which can be administered before admission or anesthesia to decrease anxiety. In terms of perioperative cardiovascular effects, no difference is seen in healthy dogs receiving acepromazine or trazodone before undergoing elective TODAY’SVETERINARYTECHNICIAN

surgery.14 Trazodone also facilitates canine tolerance to postsurgical confinement.15 Before or during admission, all owners should be educated about the risks of anesthesia and should give written consent to the procedure. The VSN should also document the patient’s resuscitation code. In the event cardiopulmonary resuscitation (CPR) is required, owners must choose which code status they want assigned to their pets: ÆÆ Red—DNR (do not resuscitate) ÆÆ Yellow—Full resuscitation with closed-chest CPR ÆÆ Green—Full resuscitation with open-chest CPR A detailed estimate should be provided so the client is well informed about all anticipated costs associated with the surgical procedure and subsequent rechecks. Before the client departs, the VSN should direct the owner to the client service representative, who will ensure financial deposits have been collected, contact information is up-to-date, and all required documents have been signed. At admission, the patient should be fitted with an identification neck band and placed in appropriate housing (cage/run) labeled with the patient’s identifying and pertinent medical information. The VSN should use the identification band to verify the patient’s identity before administering any premedication drugs or preparing the animal for surgery. Critical information (e.g., known

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

Peer-Reviewed

TECHPOINT 

Effective communication throughout the veterinary team is imperative to ensure a successful surgical outcome. are not missed. The VSN should also confirm that preoperative diagnostic images are readily available in the OR for viewing before or during the procedure. Once in the OR, before the first skin incision is made, the circulating VSN facilitates a conversation between anesthesia and surgery personnel referred to as a timeout. The purpose is for the team to collaborate, making sure all members are briefed on the procedure and possible critical events. During the time-out session, each member introduces him- or herself and his/her role (e.g., “Danielle Browning, circulating nurse”; “Karen Tobias, head surgeon”). After introductions are completed, the patient and procedure are once again verified, including confirmation that the proper side/area has been prepped.

Dean Palmer Photography

After Admission A surgical checklist is invaluable for tracking preoperative diagnostics and procedures. Use of surgical checklists has been shown to improve preoperative teamwork and patient outcomes, thereby increasing patient safety and reducing morbidity.16 Checklists are used at 3 points: before anesthesia induction, before making the incision, and before leaving the operating room (OR). Each checklist should be completed within 60 seconds to encourage compliance and effectiveness.17 Surgical checklists may encompass topics such as special pre- or intraoperative diagnostics (e.g., laryngeal function examination), anesthetic requests (e.g., administration or avoidance of local blocks or epidural), sample collection (e.g., culture, biopsy), or perioperative requirements (e.g., jugular or arterial catheter, feeding tube placement) so that critical tests and treatments

A LAB COAT or other covering should be worn during clipping to prevent hair contamination of the scrubs to be worn in the surgical suite. 10

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allergies to medications) should be clearly documented in the record, on the patient, and/or on its flow sheet or cage. The VSN may also ask the owner to confirm masses to be removed or surgical site locations, such as appropriate limb to be amputated; the appropriate area(s) can be identified by permanent marker or by shaving a very small area over the location.

CLEAN SURGICAL SCRUBS and a cap and mask are worn during patient preparation.

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Verifications are also obtained regarding administration of the first dose of antibiotics (if applicable), completion of the final aseptic patient skin prep, and counts of all gauze and laparotomy pads.

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DIAGNOSTIC TESTS Diagnostic blood tests are determined by the surgeon, and the VSN is often responsible for obtaining the blood sample. It is important to confirm that the venipuncture site will not compromise the surgical field. For example, blood should not be collected from a jugular vein in a patient undergoing thyroidectomy or parathyroidectomy because hematoma formation in that area may distort normal tissue architecture. This knowledge is also helpful before placing intravenous catheters: a peripheral catheter should be avoided in the affected limb in patients undergoing orthopedic procedures or digit or limb amputation. All patients should undergo a complete physical examination on the day of surgery. Each patient’s record should contain current weight, temperature, heart rate, respiratory rate, pain score (e.g., on a numerical rating scale, whereas 0 = no pain and 10 = most severe pain), body condition score, mucous membrane color, capillary refill time, and results of heart and lung auscultation.

THE NURSING TEAM plays a vital role in the administration and monitoring of general anesthesia.

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Patients with heart murmurs may require additional imaging of the thorax or an echocardiogram to evaluate the structure and function of the heart. Patients at risk of hypertension, such as those with an adrenal mass, may require a blood pressure reading before anesthesia. Ideally, blood pressure measurements should be performed by the same person each time, in a quiet room, and using the same instrument and cuff size. The cuff should be at the level of the heart and, ideally, placed in the same location on the same limb (i.e., proximal or distal to tarsus/carpus) to ensure consistent, accurate results.18 Presurgical assessment and diagnostic testing can be routine among certain groups of patients, including those undergoing elective procedures such as ovariohysterectomy or castration. These patients are often young, healthy animals, and evaluating packed cell volume, total protein, blood glucose, and blood urea nitrogen (using a reagent strip) may be adequate. However, to determine an increased anesthetic risk associated with a particular breed, additional diagnostic tests and/or procedures may be necessary. For example, toy breeds such as Yorkshire terriers have an increased risk for portosystemic shunts or other congenital liver diseases19 and thus may warrant a more complete diagnostic evaluation. It is not the responsibility of the VSN to decide what laboratory work is appropriate; however, the VSN often performs the ordered test(s) and must be able to recognize abnormal values so the surgeon may be properly informed. Although blood loss is a potential complication associated with any surgery, it can have devastating consequences in patients with preexisting anemia or coagulopathies (e.g., those associated with von Willebrand or hepatobiliary disease). Additional blood work considerations for these patients may include a platelet count, prothrombin and activated partial thromboplastin times, von Willebrand factor measurement, and buccal mucosal bleeding time. Normal buccal mucosal bleeding times range from 34 to 105 seconds in cats,20 100 to 285 seconds in non-greyhound dogs, and 53 to 235 seconds in greyhounds.21 If significant blood loss is possible or the animal is severely anemic, a crossmatch should be performed beforehand and results logged in the patient’s record. The VSN is responsible for ensuring that any anticipated blood products or autotransfusion supplies are available and in-date before the patient is anesthetized. Predicting and preventing postoperative hemorrhage in greyhounds presents a special conundrum. Retired racing greyhounds have a 26% to 30% risk for delayed postoperative bleeding (36–48 hours after surgery) despite

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having normal preoperative platelet counts and coagulation times.22,23 However, the rate of delayed postoperative bleeding is reduced to 10% for greyhounds treated with epsilon-aminocaproic acid, a potent antifibrinolytic agent, for 3 days after surgery.23 Each patient should be assigned an American Society of Anesthesiologists (ASA) status grade (TABLE 1).24 Knowledge of ASA status may help the surgical team predict and prepare for perioperative complications. For example, cats with an ASA status III or greater are 4 times as likely to develop serious perianesthetic complications as those with a lower ASA status,25 and, in one study, dogs and cats with an ASA status III or greater had a perioperative mortality rate 40 times that of pets with ASA status I or II.26 CLIPPING AND SKIN PREPARATION If an inadequate area of hair is removed, hair may creep into the sterile field after the patient has been draped. However, the VSN must always confirm the correct surgical site before removing any hair. The VSN is responsible for preparing the surgical site and must anticipate the needs of the surgeon by ensuring that the clip margins are wide enough for expected, and even unexpected, procedures (e.g., an extension of the incision, placement of drains, need for skin flaps). Hair removal the day before surgery has been associated with surgical site infections (SSIs). Clipping produces tiny nicks in the skin in which bacteria can embed and proliferate over time; ideally, hair removal should be performed after induction of anesthesia or no more than 1 hour before surgery.27,28 Clipping should always be performed outside of the OR, with loose hair thoroughly vacuumed from the patient and gurney so it is not brought into the OR during transport. A clean #40 electric clipper blade is ideal for

TECHPOINT 

Because owner compliance is crucial to a successful outcome, the patient’s caregiver must be considered part of the veterinary team. removing hair from most surgical sites; electric clippers can harbor infectious agents and contaminate other patients, so the blades should be cleaned and disinfected with an approved clipper disinfectant before and after each use.29 Safety razors cause microlacerations that can lead to infection and therefore should be used sparingly, if at all.30 Clipping should be performed in slow precise strokes, with the flat surface of the blade touching the skin. The blade should be checked frequently during clipping to make sure it does not get too hot, which could result in burns. During clipping, the VSN should inspect the skin for evidence of pyoderma (skin infections) on or around the incision site. At the discretion of the surgeon, patients with pyoderma may need to be recovered from anesthesia and have their procedure postponed until the condition resolves. Once the hair is removed, the skin must be aseptically prepped. A preliminary scrub of the patient is performed before entering the OR to remove organic debris and allow adequate contact time of antiseptics. Patient skin preparation is important because many SSIs result from contamination of the incision from the patient’s own resident bacterial flora. The bacteria typically associated

TABLE 1 American Society of Anesthesiologists Status Grades24 GRADE

DEFINITION

POSSIBLE EXAMPLES

Normal, healthy patient

No discernible disease; animals undergoing ovariohysterectomy, ear trim, castration

Mild systemic disease

Skin tumor, fracture without shock, uncomplicated hernia, cryptorchidectomy, localized infection, compensated cardiac disease

III

Severe systemic disease

Fever, dehydration, anemia, cachexia, moderate hypovolemia

Severe systemic disease that is a constant threat to life

Uremia, toxemia, severe dehydration and hypovolemia, anemia, cardiac decompensation, emaciation, high fever

Moribund patient not expected to survive without surgery

Extreme shock and dehydration, terminal malignancy or infection, severe trauma

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with SSI are Staphylococcus pseudintermedius, Enterococcus spp, and Escherichia coli.27 Proper preparation of the skin is an important step in avoiding such infections.

Povidone–iodine is a broad-spectrum, fast-acting bactericide with a residual activity of up to 6 hours. Povidone–iodine is thought to work by affecting protein synthesis and altering the cell wall of bacteria. It is deactivated by organic debris and blood. Povidone–iodine requires a 2-minute contact time and should be allowed to dry thoroughly on the skin. The use of povidone–iodine with alcohol lowers the necessary contact time but shortens residual activity. Clinically, effectiveness of povidone–iodine is comparable to that of chlorhexidine in veterinary patients.28 Povidone–iodine is often used for prepping around the ears and eyes. When used as an ophthalmic preparation, the 10% solution is diluted with sterile saline to create a 0.1% or 0.2% concentration.28 Povidone–iodine can stain the skin, and adverse skin reactions have been noted in up to 50% of canine patients.28 Isopropyl alcohol (60%–90% concentration) rapidly kills bacteria but is not effective against bacterial spores. It has no residual activity and is harsh to mucous membranes. Because of its limited residual activity, alcohol is best used in conjunction with povidone–iodine or chlorhexidine. It is often avoided when prepping skin because of its potential to cause hypothermia, especially in smaller patients.33 Additionally, it is extremely flammable and thus must be used with caution, if at all, when lasers, electrocautery, or vessel-sealing devices will be used.28,34 Commercial one-step preparations containing alcohol and either chlorhexidine or povidone–iodine are available to “paint” on the skin and leave to dry. One-step preparations are applied to the skin after a preliminary scrub to remove surface contaminants; manufacturer recommendation guidelines must always be followed for application and dry times.

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Antiseptic Choice Ideally, antiseptics should be nonirritating, be effective against multiple pathogens, and require only a short contact time. Prolonged residual activity, which is necessary in long surgeries, ensures the prevention of bacterial regrowth.28 Chlorhexidine, povidone–iodine, and isopropyl alcohol are the most common surgical antiseptics used to prepare surgical sites. Chlorhexidine, a biguanide, is a broad-spectrum antiseptic effective against both gram-positive and gram-negative bacteria, as well as viruses and fungi. Chlorhexidine has a fast onset but requires a minimum 2-minute contact time when used as a 4% concentration.31 Organic debris must be removed before contact time is measured because chlorhexidine may be inactivated by organic debris. Chlorhexidine can cause corneal damage, deafness, and other neurotoxicities and therefore should be avoided around the eyes or in patients with ruptured eardrums or exposed meninges.32

CAREFUL ORGANIZATION of the surgical table is important to ensure all important equipment is accessible and available as needed.

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Antiseptic Application The antiseptic is usually applied to the skin using a concentric circle (target) pattern that starts in the center of the proposed incision and works outward to the edges (cleanest to dirtiest). It may be necessary to use a towel clamp to hold loose skin off the table when prepping a wide area ventrally and laterally. Surgeries involving the perineal region may require a purse-string suture or gauze packing in the anus to prevent fecal contamination; such procedures should be performed outside of the OR, before the preliminary prep. Antiseptic scrubs (soaps) are irritating to mucous membranes, so when the preputial cavity of a male dog or the vaginal region of a female is included within or near the surgical site, use of diluted solutions is recommended to flush the genital area. When using a hanging leg prep, an impervious layer (e.g., examination glove) is placed on distal limb, which is then

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suspended for the prep. The VSN should ensure the distal limb wrap and suspended tape are free of hair, which could fall into the surgical field. In the Surgical Suite Once the VSN has completed the preliminary surgical scrub in the prep room, the patient is transported on a gurney to the surgical suite. The VSN should ensure that the OR table has the desired warming device and, if monopolar electrocautery is to be used, the contact plate is in place and moistened as required. Contaminants can be circulated in the OR by air movement, such as during transport or with warming devices, or introduced during hookup of monitoring equipment. Often these breaks in asepsis go unrecognized, increasing the risk for SSIs. A final antiseptic prep is performed in the OR after the patient has been positioned and monitoring equipment hooked up. Areas treated with alcohol should be allowed to dry completely (at least 3 minutes) before draping because use of electrocautery equipment near alcohol can spark a fire.28,34 Hot-air warming devices are usually left off until after the patient has been completely draped to avoid the potential increase in surgical site contamination from moving air.

TECHPOINT 

Family dogs read and react to the nonverbal signals exhibited by their owners, so reducing owner anxiety may help to decrease the stress perceived by the pet. PERIOPERATIVE ANTIBIOTICS Assuming the surgical site has been prepared properly, patients with healthy immune systems should be able to resist infection by most surface contaminants. VSNs can help reduce the incidence of SSIs by preventing hypothermia, using proper atraumatic hair removal techniques, and administering any prescribed antibiotics.35 Prophylactic perioperative antibiotics are recommended in patients receiving an implantable device, (e.g., bone plate, pacemaker), undergoing prolonged (≥90 minutes) surgery,

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A preliminary scrub of the patient is performed before entering the OR to remove organic debris and allow adequate contact time of antiseptics.

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or undergoing a contaminated procedure (e.g., enterotomy). For patients undergoing clean procedures, the risk of infection is increased when antibiotics are given incorrectly (e.g., at the wrong time, using the wrong drug).27 Furthermore, previous antimicrobial treatments increase the likelihood of colonization with antimicrobial-resistant bacteria,36 and dogs with previous clinically apparent infections of methicillin-resistant S. pseudintermedius can carry those bacteria for 11 months or more, even when the infection has resolved.37 If perioperative antibiotics are given, they should be administered within 1 hour before the first incision to ensure that peak blood and tissue concentration are reached before the incision is made. Most surgeons will readminister antibiotics every 90 to 120 minutes during

References 1. Aubry-Damon H, Grenet K, Sall-Ndiaye P, et al. Antimicrobial resistance in commensal flora of pig farmers. Emerg Infect Dis [serial online] 2004;10. wwwnc.cdc.gov/eid/ article/10/5/03-0735. Accessed April 2016. 2. Weber JT. Community-associated methicillin-resistant Staphylococcus aureus. Clin Inf Dis 2005;41:S269-S272. 3. Lascelles DX, Blikslager AT, Fox SM, et al. Gastrointestinal tract perforation in dogs treated with a selective cyclooxygenase-2 inhibitor: 29 cases (2002-2003). JAVMA 2005;227:1112-1117. 4. Plumb DC. Plumb’s Veterinary Drug Handbook. 8th ed. Ames, IA: Wiley-Blackwell; 2015. 5. Kronen PWM, Moon-Massat PF, Ludders JW, et al. Comparison of two insulin protocols for diabetic dogs undergoing cataract surgery. Vet Anaesth Analg 2001;28:146-155. 6. Galatos AD, Raptopoulos D. Gastro-esophageal reflux during anesthesia in the dog: the effect of preoperative fasting and premedication. Vet Rec 1995;137:479-483. 7. Savvas I, Rallis T, Raptopoulos D. The effect of pre-anesthetic fasting time and type of food on gastric content volume and acidity in dogs. Vet Anesth Analg 2009;36:539-546. 8. Johnson RA. Maropitant prevented vomiting but not gastroesophageal reflux in anesthetized dogs premedicated with acepromazine-hydromorphone. Vet Anaesth Analg 2014;41:406-410. 9. Komolafe C, Csernus M, Fülöp E. Patients’ anxiety during the perioperative care from the point of view of the nursing staff and patients. Kontakt 2015;17(2):e80-e88. 10. Kain ZN, Caldwell Andrews AA, Mayes LC, et al Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007;106:65-74. 11. Gyori B, Gascsi M, Miklosi A. Friend or foe: context dependent sensitivity to human behavior in dogs. Appl Anim Behav Sci 2010;128:69-77. 12. Beaver BV. Canine Behavior. 2nd ed. Philadelphia, PA: Elsevier; 2009. 13. Hennessy MB, Williams MT, Miller DD, et al. Influence of male and female petters on plasma cortisol and behavior: can human interaction reduce the stress of dogs in a public animal shelter? Appl Anim Behav Sci 1998;61:63-77. 14. Mathews L, Reichl L, Graham L, et al. Comparison of the cardiovascular effects of acepromazine versus trazodone pre-medications in dogs anesthetized for TPLO or TTA surgical procedures. Int Vet Emerg Crit Care Symp 2011. 15. Gruen ME, Roe SC, Griffith E, et al. Use of trazodone to facilitate postsurgical confinement in dogs. JAVMA 2014;245:296-301. 16. Gasson J. Improving patient safety in the perioperative period: surgical safety checklists. Vet Nurse 2013;4:322-327. 17. Gawande A. The Checklist Manifesto: How to Get Things Right. New York, NY: Metropolitan; 2010. 18. Bosiack AP, Mann FA, Dodam JR, et al. Comparison of ultrasonic Doppler flow monitor, oscillometric, and direct arterial blood pressure measurements in ill dogs. J Vet Emerg Crit Care 2010;20:207-215.

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anesthesia based on the half-life of the antibiotic. Prophylactic antibiotics should be discontinued within 24 hours after surgery.27 CONCLUSION The VSN plays a major role in successful surgical outcomes. Responsibilities begin with effective communication with owners before their pet’s appointment and gathering a complete history and patient information. The VSN must adequately perform the patient’s aseptic preparation and understand the associated surgical risks, including anticipated bleeding and infection. The VSN can reduce the risk for SSIs with the effective administration of antibiotics and improve overall patient safety by using a surgical checklist. 

19. Tobias KM, Rohrbach BW. Association of breed with the diagnosis of congenital portosystemic shunts in dogs: 2400 cases (1980-2002). JAVMA 2003;223:1636-1639. 20. Alatzas DG, Mylonakis ME, Kazakos GM, et al. Reference values and repeatability of buccal mucosal bleeding time in healthy sedated cats. J Feline Med Surg 2014;16:144-148. 21. Sato I, Anderson GA, Parry BW. An interobserver and intraobserver study of buccal mucosal bleeding time in greyhounds. Res Vet Sci 2000;68:41-45. 22. Lara-Garcia A, Couto CG, Iazbik MC, et al. Postoperative bleeding in retired racing greyhounds. J Vet Intern Med 2008;22:525-533. 23. Marin LM, Iazbik MC, Zaldivar-Lopez S, et al. Epsilon aminocaproic acid for the prevention of delayed postoperative bleeding in retired racing greyhounds undergoing gonadectomy. Vet Surg 2012;41:594-603. 24. Grimm KA, Lamont LA, Tranquilli WJ, et al, eds. Veterinary Anesthesia and Analgesia, The Fifth Edition of Lumb and Jones. Ames, IA:Wiley-Blackwell; 2015:12. 25. Hosgood G, Scholl DT. Perianesthetic morbidity and mortality in the cat. J Vet Emerg Crit Care 2002;12:9-15. 26. Bille C, Auvigne V, Libermann S, et al. Risk of anesthetic mortality in dogs and cats: an observational cohort study of 3546 cases. Vet Anaesth Analg 2012;39:59-68. 27. Brown DC. Wound infections and antimicrobial use. In: Tobias KM, Johnston SA, eds. Veterinary Surgery: Small Animal. Philadelphia, PA: Elsevier; 2012:135-139. 28. Renburg WC. Preparation of the patient, operating team, and operating room for surgery. In: Tobias KM, Johnston SA, eds. Veterinary Surgery: Small Animal. Philadelphia, PA: Elsevier; 2012:164-166. 29. Mount R, Schick AE, Lewis II TP, Newton HM. Evaluation of bacterial contamination of clipper blades in small animal private practice. JAAHA 2016;52(2):95-101. 30. Alexander JW, Solomkin JS, Edwards MJ. Updated recommendations for control of surgical site infections. Ann Surg 2011;253:1082-1093. 31. Stinner DJ, Krueger CA, Masini BD, et al. Time-dependent effect of chlorhexidine surgical prep. J Hosp Infect 2001;79(4):313-316. 32. Harrop JS., Styliaras JC, Ooi YC, et al. Contributing factors to surgical site infections. J Am Acad Orthop Surg 2012;20(2):94-101. 33. Redrode S. Soft tissue surgery of rabbits and rodents. Semin Avian Exotic Med 2002;11:4:231-245. 34. Batra S, Gupta R: Alcohol based surgical prep solution and the risk of fire in the operating room: a case report. Patient Saf Surg 2008;2:10. 35. Brendle TA. Surgical Care Improvement Project and the perioperative nurse’s role. AORN J 2007;86(1):94-101. 36. Leite-Martins L, Mahu MI, Costa AL, et al. Prevalence of antimicrobial resistance in faecal enterococci from vet-visiting pets and assessment of risk factors. Vet Rec 2015;176:674. 37. Windahl U, Reimegard E, Stron Holst B, et al. Carriage of methicillin-resistant Staphylococcus pseudintermedius in dogs—a longitudinal study. BMC Vet Res 2012;8:34.

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CE Test Preoperative Roles and Responsibilities of the Veterinary Surgical Nurse 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. A presurgical fast of 10 hours or more would be most appropriate for a(n) a. diabetic poodle undergoing cataract removal. b. 7-year-old Labrador undergoing a thyroid mass removal. c. 6-week-old kitten undergoing wound debridement. d. adult rabbit undergoing a dental procedure. 2. Which one of the following statements is true? a. Yawning can be a sign of stress and anxiety in dogs. b. Stroking and petting increases cortisol concentrations during venipuncture. c. Trazodone is more likely to lower blood pressure during surgery than acepromazine. d. Diabetic dogs should receive their full dose of insulin the morning of surgery. 3. Which professional is least likely to be colonized with an antimicrobial-resistant bacterial strain? a. Pig farmer b. Nurse c. Football player d. Waitress 4. Which of the following is a normal buccal mucosal bleeding time for a greyhound? a. 50 seconds b. 150 seconds c. 250 seconds d. 350 seconds 5. The rate of delayed postoperative ___________ is reduced to 10% for greyhounds treated with epsilon-aminocaproic acid for 3 days after surgery. a. infection b. bleeding c. pain d. regurgitation

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6. A dog with an uncomplicated inguinal hernia is usually considered an ASA grade ____ patient. a. I b. II c. III d. IV 7. Which antiseptic is best recommended for ophthalmic preparations? a. Chlorhexidine gluconate b. Povidone–iodine c. Isopropyl alcohol d. Baby shampoo 8. Which of the following statements is true with regard to prophylactic perioperative antibiotics? a. They are recommended for patients receiving implants or undergoing long surgeries. b. They should be administered 90 minutes before the incision is made. c. They should be repeated every 60 minutes during the operation. d. They should be continued for 48 hours after surgery. 9. Which of the following statements about antiseptic skin preparations is true? a. Chlorhexidine is effective when organic debris is present. b. Povidone–iodine has a 6-hour residual activity. c. A 10% povidone-iodine solution can be used for ophthalmic preparation. d. Isopropyl alcohol is effective against bacterial spores. 10. Risk of gastrointestinal perforation is increased in dogs that receive NSAIDs and _____________ within 24 hours of each other. a. maropitant b. hydromorphone c. trazodone d. glucocorticoids

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want to shine a light on your top-dog team? Nominate your practice’s brightest stars and reward their com-paw-ssionate care! Your nominee could be our next:

★ Veterinary Practice of the Year

★ Veterinarian of the Year

★ Veterinary Technician of the Year

★ Practice Manager of the Year

★ Veterinary Receptionist of the Year

★ Pet Parent of the Year

nominate your picks in every category at: www.GoPetplan.com/Vet-Awards Winners receive cash, prizes and a trip to Orlando to attend the black-tie 2017 Veterinary Awards Dinner, held in concert with the NAVC Conference on February 4! Visit www.GoPetplan.com/Vet-Awards for full details, terms and conditions.

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What Moves You?

Being in the Driver’s Seat Renaud “Ren” Houyoux, LVT Baring Boulevard Veterinary Hospital and Wellness Center Reno, Nevada “What moves you?” At first, this seems like a simple question, and answering it seems like it should be just as simple. Strangely enough, though, it is not a common question, so when I really started to think about it, it became apparent that my answer would be much more involved than I originally anticipated. In 1998, I passed the Veterinary Technician National Examination after graduating from an American Veterinary Medical Association–accredited program and was on my way to do my part in veterinary medicine. My first job as a credentialed technician was at an American Animal Hospital Association (AAHA)–accredited specialty practice, and the norm for this level of patient care has remained my baseline in doing my job. (Looking back, the people that trained me may have been a little over the top, but they were effective.) I was both excited and scared to death when, after I completed my internship, the owner offered me a position to work the overnight critical care/emergency shift. I voiced my enthusiasm—and concerns—and he told me, “Ren, you’re going to find out real quick whether or not you’re cut out for the job. Do you want the position?” I said yes, and the rest is history. I quickly discovered that I was one of the lucky few to have found my true passion. I have found that if you are passionate about something, everything will fall into place. Good schooling is an important foundation, but the technician you become is the one you make of yourself by keeping your nose to the grindstone as the years accumulate. There are times when it is very difficult to remain steadfast, but at the end of the day it has been a blessing to me to be a veterinary technician.

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!

“Good schooling is an important foundation, but the technician you become is the one you make of yourself by keeping your nose to the grindstone.” —Renaud “Ren” Houyoux

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A Cornucopia of Motivation So, what moves me as a technician? Well, everything! We as technicians are responsible in so many aspects of veterinary medicine that a virtual cornucopia of elements moves me. Technicians are the foot soldiers in the trenches, carrying out the doctors’ orders. At any given time, we can be instrumental in reducing pain, delivering therapeutics, keeping a patient safe under anesthesia, cleaning teeth, triaging emergencies, providing client education on how to give subcutaneous fluids or insulin, going over the discharge instructions with a client after a spay, keeping cancer in remission, cleaning that explosive blowout from a parvovirus patient, or just rocking a cat gently as he recovers from a surgical procedure. There are simply too many things we do as technicians to be able to list them all. However, we all have areas we naturally gravitate to as we work. I am lucky enough to have worked at excellent practices, including general practice and specialty facilities. Currently, I am grateful to be in a practice where we are very progressive. We are able to provide optimal care for our patients with cutting-edge medicine, so I will narrow down my areas of interest to two: laser therapy and chemotherapy.

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What Moves You?

Being in the Driver’s Seat

A feline patient is fitted with laser-safe goggles to receive antinausea laser therapy before chemotherapy.

Laser Therapy: In the Driver’s Seat My primary devotion is the use of laser therapy delivery platforms. Only approved in the United States for about 10 years, laser therapy has proven itself to be a godsend for our patients. While I understand the limitations of the current science and the physical limitations of individual patients, this modality has shown its value in practice to me. I am a hard sell but also a pragmatist—I want to see results. I have seen those results with laser therapy: a noninvasive, painless tool that minimizes pain, reduces inflammation, and potentiates active tissue healing. We’re not just attenuating symptoms, we are inducing a physical cascade resulting in tissue normalization. Treatments are usually short and require no sedation. The best part about laser therapy is that the veterinary technician is in the driver’s seat. Just like an ultrasonic scaler, the laser is our tool! We get to educate the client on the modality, we get to perform the treatments, and we get hands-on with patients as we guide them through treatment courses. Laser therapy is doctor-ordered but technician-driven. I believe that veterinary technicians will be instrumental in the rapid evolution of this aspect of veterinary medicine. TODAY’SVETERINARYTECHNICIAN

While it’s come a long way in the past few years, there remains a lot of untapped potential. We may come to find some benefit in treating malignancy sites, immunemediated diseases, epilepsy, and many other conditions that are currently untreated for lack of clinical data as to benefit—there are no proven clinical data confirming that laser treatment would do harm in these cases. Laser therapy remains on the cutting edge of medicine and will continue to evolve as we continue to treat patients and share our successes and failures. This is a unique time to be a veterinary technician—we can help pioneer this technology. In years to come, laser therapy will be mainstream medicine, and it will be a standard of care. For example, AAHA and the American Association of Feline Practitioners recently added laser therapy to their pain management guidelines. Although few veterinary technicians currently perform these treatments, our ability to deliver better treatments will rise as the number of laser operators continues to grow. Chemotherapy: Treatment Victories My second area of special interest is chemotherapy. Cancer remains one of the biggest causes of death in

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What Moves You?

Being in the Driver’s Seat

veterinary medicine. We must be very careful when dealing with cytotoxic agents, but they can be very useful when handled and delivered appropriately. There is nothing easy about chemotherapy—it is financially taxing, emotionally taxing, and potentially very hazardous to both the patient and the veterinary technician. If I can keep a cancer in remission to buy any amount of time for a patient while promoting the human–animal bond, I’ll take it as a victory. We as technicians need to be the anchor for clients who are at a loss when presented with the fact that their beloved pet has a terminal disease. Clients inevitably refer to what they know of chemotherapy: hair loss, anemia, oral ulcers, etc. We must reassure them that we would not consider a patient a valid candidate to undergo a chemotherapy protocol unless we believed we could avoid side effects that would reduce quality of life—and yet we are prepared to deal with potential sequelae. We will not sacrifice quality of life for quantity of life, but we will take each and every successful treatment as a victory. Giving All the Best Care to Animals in Need Being a veterinary technician can be just as rewarding as it can be absolutely heartbreaking. I try to focus on the positive while dealing with the negative, even when that includes euthanasia. Euthanasia never gets easier, but we learn to deal with it. My rationale is that if it is the last thing that I can do for a patient, then I’m going to make darn sure it is done right. I will not walk away from my patient in its time of greatest need. So there you have it. What moves me? It’s all providing the best possible medical care for creatures that are better than us. Humans dwell on things and over-rationalize their situation, while our patients will never feel sorry for themselves. They never question why things are the way they are. They just live in the moment and accept everything for what it is. In my mind, this makes them better than us, and I plan on continuing to help them the best I can for as long as I can. Veterinary technicians should feel blessed to do what we do. Veterinary medicine continues to evolve, and we as technicians are on the forefront of potentiating its applications. The rise of technician specialty academies also shows the way our work is becoming more recognized by the veterinary community. The things we do affect countless lives, including children—some of whom will be our future counterparts. Be prepared. Adapt, improvise, and overcome. But first and foremost, keep your nose to the grindstone. Ad astra per aspera.  20

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

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

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

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

N1 17 13 13 7 5

% (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

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. 1

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

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.

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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Go With the Flow:

The Basics of Fluid Therapy for Small Animal Veterinary Technicians

Liz Hughston, MEd, RVT, CVT, VTS (SAIM, ECC)

luid therapy is one of the most common therapies provided in small animal medicine. Patients are given fluids for many reasons, and the number of available fluids is growing. Knowing why fluids are ordered, the goals and limitations of fluid therapy, and how fluids are chosen is a key competency for veterinary technicians. This article reviews some of the reasons fluid therapy may be ordered for a patient, how to administer and monitor fluid therapy, and the fluid types available in the United States.

Liz practices as a relief veterinary technician and consultant in the San Francisco Bay Area for both general and emergency/specialty practices. She graduated from Foothill College in 2006 and went on to earn her certification as a veterinary technician specialist in both small animal internal medicine and emergency and critical care in 2012. Liz is dedicated to advancing veterinary nursing through training and mentorship and is a frequent and sought-after national and international speaker. In 2013, Liz was awarded the California Registered Veterinary Technician’s Association’s inaugural RVT of the Year Award, recognizing her efforts to improve veterinary nursing in California and beyond.

BODY WATER COMPARTMENTS To understand fluid therapy and its applications, one must first understand the distribution of fluid and water in the body (FIGURE 1). Total body water (TBW) comprises approximately 60% of a patient’s body weight.1 Approximately 67% of TBW is found inside the body’s cells and is referred to as intracellular fluid (ICF). The remaining 33% of TBW is the extracellular fluid (ECF), which is further divided as follows: ÆÆ Interstitial fluid, which bathes cells and tissues (~24% of TBW) ÆÆ Plasma, the liquid portion of blood, which constitutes most of intravascular volume (~8%–10% of TBW) ÆÆ Transcellular fluid, which comprises of synovial joint fluid, cerebrospinal fluid, bile, and the fluid in the linings of the peritoneal cavity, pericardium, and pleural space (~2% of TBW) 22

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A helpful rule of thumb to simplify the distribution of fluids in the body is the 60:40:20 rule: 60% of a patient’s body weight is water, 40% of body weight is ICF, and 20% of body weight is ECF.1 The body is considered a closed system, meaning that any fluid lost must come from one of the compartments listed above. In the case of hemorrhage, for example, fluid is lost from the intravascular space (i.e., plasma) but also from the ICF in the cells lost (e.g., red blood cells, white blood cells). In addition to losses, fluid can and does move between compartments in a dynamic and ever-changing fashion. When providing fluid support to patients, technicians must keep in mind which compartment needs to be replenished or what derangement needs to be corrected. This knowledge helps guide both fluid choice and the method used to administer fluid therapy. REASONS FOR FLUID THERAPY Veterinary professionals provide fluid therapy to patients for many reasons, including correction of dehydration, expansion and support of intravascular volume, correction of electrolyte disturbances, and encouragement of appropriate redistribution of fluids that may be in the wrong compartment (e.g., peritoneal effusion).2 The first step in determining whether a patient needs fluid therapy is a full physical examination, including collection of a complete history. The

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Go With the Flow: The Basics of Fluid Therapy

FIGURE 1. Fluid compartments in the body. Total body water (TBW) is 60% of a patient’s body weight and can be thought of as separated into distinct compartments, as represented here.

Patient’s body weight

Interstitial fluid ~24% of TBW

TBW 60% of body weight

Intravascular fluid ~8%–10% of TBW Transcellular fluid ~2% of TBW

Intracellular fluid ~67% of TBW

veterinary staff must assess whether the patient is perfusing its tissues well, check for dehydration, and evaluate losses from any of the fluid compartments.3 Inadequate Perfusion Patients that cannot adequately perfuse their tissues require immediate intervention with fluid therapy to restore perfusion and correct shock. Shock is defined as the critical imbalance between the delivery of oxygen and nutrients (carried by blood) to tissues and the tissues’ demand for these components. If allowed to persist, this imbalance can lead to acute decompensation and death. Restoring perfusion and, subsequently, oxygen and nutrient delivery to tissues is crucial to survival in these patients.1 Shock is a life-threatening emergency and must be recognized and treated immediately on presentation. Patients may present with several clinical signs (BOX 1), and owners may report a history of recent fluid loss, such as intractable vomiting, severe diarrhea, or hemorrhage. Once shock is recognized, access to the intravascular compartment must be achieved and fluid resuscitation initiated as soon as possible (see Ways to Provide Fluid Therapy), with the goal of restoring intravascular volume TODAY’SVETERINARYTECHNICIAN

and flow, thus improving perfusion and delivery of oxygen and nutrients to starving tissues (FIGURE 2). Oxygen delivery to the tissues (DO2) depends on cardiac output and arterial oxygen content. Cardiac output

BOX 1 Clinical Signs of Shock  Vasoconstriction  Pale mucous membranes  Prolonged capillary refill time  Peripheral temperature < core temperature  Reduced urine output  Decreased mentation  Tachycardia (cats may present with bradycardia)  Hypotension (poor pulse quality)  Reduced oxygen saturation (low SpO2)  Lactate >2 mmol/L  Metabolic acidosis

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FIGURE 2. Oxygen delivery to the tissues (DO2), which is crucial for maintaining cellular metabolism and preventing cellular death, depends on many factors.

Blood volume

Contractility

Heart rate

Afterload

Stroke volume

Saturation of oxygen

Hemoglobin

Arterial oxygen content (CaO2)

Cardiac output

Oxygen delivery to the tissues

is the product of stroke volume and heart rate. Stroke volume is defined as the amount of blood ejected from the left ventricle during systole and is a product of preload (the amount of blood entering the heart), afterload (the amount of resistance in the vasculature to the flow of blood from the heart), and contractility (the heart’s ability to contract). Once perfusion and, by extension, DO2 is restored, homeostasis can be reestablished and the shock state will be remedied. Correction of perfusion deficits is demonstrated by normalization of the forward perfusion parameters, listed in BOX 2.1 Dehydration Loss of fluid from the intracellular and interstitial compartments leads to dehydration. If severe, dehydration can be detected in derangements in forward perfusion parameters1 as well as by the tests listed below. Any patient determined to be more than 10% dehydrated is considered severely dehydrated4 and requires immediate fluid resuscitation and careful monitoring.5 Dehydration 24

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must not be confused with hypovolemia: dehydration describes a water deficit in the interstitial and intracellular compartments, whereas hypovolemia describes a loss of fluid in the intravascular space.4 Hydration status can be assessed using several simple tests. One of the easiest to perform is a skin tent test to check the turgor, or moisture level, of the skin. To perform

BOX 2 Forward Perfusion Parameters  Heart rate  Pulse quality  Respiratory rate  Mucous membrane color  Capillary refill time  Mentation  Temperature and color of digits

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

TE C HP O I N T 

The skin tent test can be confounded by age, emaciation, and body condition and must be considered in relation to other parameters and physical examination findings. this test, the skin over the thorax or lumbar region is pulled away from the back. In a well-hydrated animal, the skin immediately returns to its normal resting position. If the tent formed remains standing, it can be an indication of dehydration.1,5 When performing this test, veterinary technicians can often appreciate a “tacky” or “sticky” feeling in the underlying tissue, which is further evidence of dehydration. The skin tent test can be confounded by both emaciation (decreased turgor even if euhydrated) and obesity (increased turgor in the face of dehydration) and must be considered in relation to other parameters and physical examination findings. Age is another factor to consider: loss of skin turgor progresses with increasing age, and neonates exhibit very little skin tenting even when dehydrated. Another way to check for dehydration is to feel for moistness on the mucous membranes. This is most easily accomplished by sliding a finger along a patient’s gum line or inside the cheeks. If the membranes themselves are dry or sticky, it may indicate dehydration. In the case of vomiting animals, it is necessary to differentiate excess saliva in the mouth from mucous membrane moisture. In patients with normal kidney function, oliguria can indicate dehydration, and the small amount of urine produced will likely be concentrated (urine specific gravity [USG] >1.030).5 Other laboratory parameters that change with dehydration include packed cell volume and total protein (PCV/TP) levels, which demonstrate hemoconcentration (high PCV) and hyperproteinemia (high TP) in dehydrated patients5 due to the loss of the fluid portion of the blood as the body tries to maintain fluid balance and homeostasis. Serial measurements of both USG and PCV/TP can help the veterinary care team evaluate the effectiveness of fluid resuscitation efforts, as both levels should decrease as intravascular volume is restored and the interstitial fluid and ICF compartments are replenished. TODAY’SVETERINARYTECHNICIAN

Go With the Flow: The Basics of Fluid Therapy

Previous, Ongoing, and Anticipated Losses Consideration of fluid losses is an important part of determining a fluid therapy plan. These losses may have occurred before presentation to the clinic—such as animals with a history of protracted vomiting or diarrhea— or may be anticipated after treatment has been instituted, as is often seen in cases of postobstructive diuresis in cats with urinary obstruction. These losses must be factored in when deciding the type, amount, and route of fluid therapy. When calculating fluid losses, veterinary technicians should include urination, defecation/diarrhea, vomiting, removal of effusions or gastric contents, fluid loss from drains, and insensible losses (such as from panting). WAYS TO PROVIDE FLUID THERAPY Even veterinary technicians who have been in practice for only a short while have likely seen fluids given several ways. Oral, subcutaneous, intravenous, intraosseous, and even intraperitoneal routes are all used, depending on the species receiving fluid therapy and why it is needed. Oral Route By far the simplest mode of fluid therapy, providing water per os can correct some conditions, including mild salt toxicity and mild cases of dehydration. Providing water via the oral route is as simple as offering the patient a bowl with a premeasured volume of water on a set schedule and measuring the amount consumed. However, in patients that have gastrointestinal pathology (i.e., parvovirus infection) or are unable to consume adequate amounts of water to maintain normal urine production or to establish and maintain fluid homeostasis, other means of fluid resuscitation must be used. Subcutaneous Route Subcutaneous fluids are a mainstay of veterinary therapy. Subcutaneous fluid administration is used for many disease conditions, including cases of mild vomiting and diarrhea or mild dehydration, or to support kidney function in animals with chronic kidney disease. It is relatively simple to provide fluids via the subcutaneous route, and many owners can be trained to provide this therapy at home, mitigating the need for hospitalization. As with other therapies given subcutaneously, it takes time for subcutaneous fluids to be absorbed into the bloodstream; thus the subcutaneous route is not appropriate to treat life-threatening conditions such as severe dehydration or shock.

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Intravenous Route IV fluid therapy is very common in veterinary practice and allows practitioners to restore intravascular volume, correct dehydration, and administer IV medications. IV catheter placement is a core nursing competency for veterinary technicians and allows for IV fluid therapy in emergency presentations and hospitalized patients alike. In addition, access to the vascular space allows for other therapies, including transfusions, medications, and parenteral nutrition. In emergency situations or when a large volume of fluid is needed over a short amount of time, selecting a catheter with a large bore and a short length is preferable to allow for rapid infusion of fluids. This is a function of Poiseuille’s law, which governs the flow of fluid through a tube: essentially, the shorter the tube, the smoother the flow, and the larger the tube’s diameter, the faster the flow, meaning that large-bore, short catheters are the best choice when a large volume of fluid must be delivered quickly, such as in cases of hypovolemic shock.6,7 T-ports and additional tubing (e.g., extension sets) may decrease both the amount of fluid and the speed of delivery. In an emergency situation, it is best to minimize any extra IV accessories that might impede flow. In addition to peripheral access, IV fluid therapy can be delivered through central line catheters. These catheters are longer than typical peripheral IV catheters and reach the central circulation via the vena cava. Central lines are commonly placed in the jugular vein, with the tip of the catheter sitting just outside the entrance to the right atrium to facilitate measurement of central venous pressures, if desired. Jugular central line catheters can be placed with a guidewire (i.e., Seldinger technique) or a peel-away introducer. They are available with multiple lumens to enable sampling, concurrent administration of incompatible fluids, and administration of hypertonic solutions that may cause phlebitis if given peripherally (e.g., dextrose concentrations >7.5%). The central circulation can also be reached with a long, through-the-needle catheter (e.g., Intracath) placed in either the lateral saphenous vein or the medial femoral vein or a peripherally inserted central catheter (PICC) in the same vessels. Because of their long length, smaller bore, and longer time usually required for placement, central catheters are not recommended for emergency fluid therapy, but can be maintained for long periods, making them well-suited to longer-term fluid therapy. Intraosseous Route Intraosseus (IO) catheters are an excellent choice for providing drugs and fluids to patients in which IV access is difficult—if not impossible—to obtain in a timely fashion. Patients with severe hypotension or complete cardiovascular collapse (i.e., patients in cardiac arrest), that are severely dehydrated, or in which IV access is not obtainable (as in patients with edema, burns, thrombosis, or obesity) can benefit from placement of a catheter in the medullary cavity of a bone (IO). This route is also very useful in tiny patients, such as neonates and pocket pets (e.g., hamsters, gerbils). The materials are readily available in most, if not all, veterinary practices, and placement may mean the difference between life and death. The IO route is fast and has been proven8,9 to provide access to the central circulation comparable to the access provided by central venous catheterization, making it the first choice for administration of drugs and fluids when IV access cannot be achieved. For all of the advantages of the IO route, there are several limitations. Fluid cannot be provided at a rate equivalent to that of IV access, and the needles are not designed for long-term use. Most sources1,2,4,7,10 recommend removal of IO 26

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access devices within 72 to 96 hours of placement to avoid the development of osteomyelitis or bone infections, as long as IV access can be obtained.

compartment syndrome. A patient who becomes tachypneic, develops clear nasal discharge, or is found to have crackles on thoracic auscultation while receiving fluid therapy should be suspected of becoming overhydrated. If these signs are noted, particularly in combination with an increase in body weight, IV fluid therapy should be stopped and the veterinarian should be notified immediately.11 Chemosis (swelling of the conjunctiva) is a late sign of fluid overload and requires urgent treatment (FIGURE 3), including cessation of IV fluids and potential administration of diuretic agents.

MONITORING Veterinary technicians are responsible for providing therapies in as safe a manner as possible; this includes fluid therapy. Safety can be maintained with vigilant monitoring. To monitor a patient’s perfusion status, technicians should observe forward perfusion parameters (BOX 2). Normalization of these parameters is a good indication that fluid therapy is being provided successfully. In the laboratory, technicians can perform serial measurements of PCV/TP and USG. In patients that presented in a state of dehydration with increased PCV/TP, lowering of these values indicates a return to normal fluid levels in the intravascular space and an improvement in overall hydration. Increasingly dilute urine means that the patient’s kidneys have detected an increase in intravascular volume and a restoration of overall fluid balance. One of the easiest and most sensitive ways to monitor fluid therapy in patients is with multiple weight checks throughout the course of therapy. Since TBW is 60% of a patient’s body weight, increases in any fluid compartment lead to a commensurate increase in the patient’s overall weight. However, an increase >10% from baseline admission weight should prompt an investigation of the possibility that the patient is becoming overhydrated, also known as becoming fluid overloaded. Fluid overload is a major complication of fluid therapy and can lead to pulmonary edema, ascites, and peripheral edema with the potential for development of

FLUID TYPES AVAILABLE Several types of fluids are available, ranging from crystalloids to synthetic colloids to natural colloids (i.e., blood products). Each type has its place in the treatment of various conditions and pathologies found in veterinary patients. It is easiest to differentiate fluids based on their purpose: maintenance or replacement therapy. TABLE 1 outlines the components of common maintenance and replacement fluids available to veterinary practitioners in the United States. The resources listed in the Recommended Reading box can provide more detailed explanations of fluid types and their effects. Crystalloids Patients presented as an emergency often require immediate intravascular expansion in the form of crystalloid boluses, or large volumes of crystalloid fluids. Crystalloid fluids move quickly from the intravascular space into other fluid compartments, primarily the intracellular compartment. Less than one-third of the crystalloid volume administered

TABLE 1 Composition of Common Veterinary Fluids COMPONENT (unit) FLUID TYPE

BUFFER(S)

PRIMARY USE

308

None

Replacement

154

None

Maintenance

294

Acetate (27 mEq/L) Gluconate (23 mEq/L)

Replacement

363

None

Maintenance

294

Acetate (27 mEq/L) Gluconate (23 mEq/L)

Replacement

363

Acetate (16 mEq/L)

Maintenance

6.5

130

109

2.7

273

Lactate (28 mEq/L)

Replacement

5.5

154

309

None

Colloid

Sodium (mEq/L)

Chloride (mEq/L)

Potassium (mEq/L)

Magnesium (mEq/L)

Calcium (mEq/L)

Osmolarity (mOsm/L)

0.9% Saline

5.5

154

0.45% Saline

5.6

Plasmalyte A

7.4

140

Plasmalyte 56

5.0

Normosol-R

7.4

140

Normosol-M

5.0

Lactated Ringer’s solution (LRS) Hetastarch

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Go With the Flow: The Basics of Fluid Therapy

intravenously persists in the vasculature 1 hour after administration,4 making these fluids an excellent choice for treating dehydration and electrolyte derangements and correcting free water deficits. Crystalloid fluids can be categorized as follows: ÆÆ Free water: 5% dextrose in sterile water or 0.45% saline. This hypotonic (i.e., containing fewer solutes than ICF) solution replenishes the interstitial fluid and ICF compartments. ÆÆ Replacement solutions: These balanced, isotonic solutions are designed to replenish the ECF compartments, including increasing intravascular volume and restoring perfusion. Isotonic fluids contain a solute concentration that approximates that of ICF, and crystalloids that are considered “replacement” fluids (TABLE 1) have compositions that closely match the electrolyte balance and pH of ECF,1 making them ideal to replace losses from that fluid compartment (e.g., dehydration). ÆÆ Maintenance solutions: These balanced, isotonic solutions have less sodium and more potassium than replacement fluids and may be more suitable for long-term fluid therapy after restoration of intravascular volume and correction of electrolyte

derangements. Maintenance fluids are rarely used alone—they are usually combined with a ratio of 0.9% sodium chloride1 (aka “normal” or “isotonic” saline) to more closely match the composition of the fluid in the intravascular space, preventing unwanted fluid shifts between compartments. ÆÆ Hypertonic solutions: 7% to 23.4% saline. These fluids contain a solute concentration higher than that of ICF and rapidly expand intravascular volume by drawing water from the interstitial and intracellular compartments. Because of this oncotic pull, hypertonic solutions should never be used in cases of severe dehydration. Colloids Many practitioners also use colloids (either synthetic or natural) in an emergency to expand the intravascular compartment without the risk of fluid overload posed by infusing large volumes of crystalloid fluids. Colloids contain large, osmotically active particles that work to hold fluid in the vasculature after administration. Synthetic colloids are fluids with large molecules designed to provide oncotic pressure support within the intravascular space. Natural colloids are blood products such as whole blood, packed red blood cells (pRBCs), plasma, and albumin. Whole blood and pRBCs have the added benefit of providing oxygen-carrying capacity, helping to prevent and treat hypoxia. The use of colloids is highly controversial in human medicine and becoming so in veterinary medicine as well,12 with recent research13 implicating a link between the use of a synthetic colloid and the development of acute kidney injury in dogs.

BOX 3 Appropriate Fluid Choices for Selected Disease Processes  Cardiac disease: Low-dose maintenance crystalloid, such as 0.45% saline with dextrose (may require potassium and or magnesium supplementation)  Vomiting/diarrhea: Replacement crystalloid, such as lactated Ringer’s solution, Normosol-R, or Plasmalyte-A

FIGURE 3. Swelling of the conjunctiva without signs of inflammation or irritation is known as chemosis. This is a late sign of fluid overload; it is incumbent on veterinary technicians to recognize earlier signs such as increased respiratory rate and effort, increased breath sounds (e.g., crackles), or clear nasal discharge. TODAY’SVETERINARYTECHNICIAN

 Diabetic ketoacidosis: Replacement crystalloid, such as lactated Ringer’s solution, Normosol-R, Plasmalyte-A  Hemorrhage: Natural colloid, such as plasma, whole blood, pRBCs

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Go With the Flow: The Basics of Fluid Therapy

DEVELOPING AND IMPLEMENTING A FLUID THERAPY PLAN There is a helpful guideline when it comes to fluid therapy: Replace like with like. This means if a patient has lost blood, that fluid should be replaced with plasma, pRBCs, or whole blood. If a patient has lost body fluids through diarrhea, vomiting, or excessive urination, replacement should be with similarly constituted isotonic crystalloid fluids. While development of the fluid plan is ultimately the veterinarian’s purview, it is important for veterinary nurses and technicians to understand the fluids available and for what conditions they might be used in clinical practice. Fluid therapy in the veterinary hospital or clinic has 3 primary phases, which can overlap and alternate, depending on how a patient presents and the progression of its disease process. The resuscitation phase refers to correcting shock and other life-threatening fluid deficits; the replacement phase is the time taken to replace dehydration deficits; and the maintenance phase covers

fluids provided during hospitalization to support and maintain homeostasis. BOX 3 provides examples of fluid choices in some specific disease processes. The amount of fluid to be provided to a patient must be calculated carefully, taking into account the need for intravascular volume expansion, the profundity of perfusion deficits, the degree of dehydration, and the severity of electrolyte derangements, among other considerations. BOX 4 lists common fluid therapy calculation formulas. CONCLUSION Understanding the need for fluid therapy, methods of providing fluids, types of fluids available, and how to keep patients safe while providing this vital treatment is a big part of being a veterinary technician. Go with the flow and help patients feel better! 

BOX 4 Fluid Therapy Formulas Recommended Reading

Calculation of Dehydration Deficit1

 Davis H, Jensen T, Johnson A, et al. 2013 AAHA/ AAFP fluid therapy guidelines for dogs and cats. JAAHA 2013;49(3):149-159.

Body weight (kg) × % dehydration as a decimal = liters of fluid required to correct dehydration

 DiBartola SP, Bateman S. Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice. 3rd ed. St. Louis, MO: Saunders Elsevier; 2006. Chapters 14 and 23.

Dogs: Body weight (kg)0.75 × 132 = 24-hour fluid requirement in milliliters

 Pre-Hospital Push. IV catheter size: How much of a difference does it make? http://www. prehospitalpush.com/2016/03/04/iv-cathetersize-how-much-of-a-difference-does-it-make/. Accessed March 30, 2016.

References 1. DiBartola SP, Bateman S. Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice. 3rd ed. St. Louis, MO: Saunders Elsevier; 2006. 2. Creedon JM, Davis H. Catheterization of the venous compartment. In: Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care. Chichester, West Sussex, UK: Wiley-Blackwell; 2012:51-68. 3. Davis H, Jensen T, Johnson A, et al. 2013 AAHA/AAFP fluid therapy guidelines for dogs and cats. JAAHA 2013;49(3):149-159. 4. Silverstein DC, Hopper K. Small Animal Critical Care Medicine. 2nd ed. St. Louis, MO: Saunders/Elsevier; 2015. 5. Macintire DK, Haskins SC. Manual of Small Animal Emergency and Critical Care Medicine. 2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2005. 6. Reddick AD, Ronald J, Morrison WG. Intravenous fluid resuscitation: was Poiseuille right? Emerg Med J 2011;(28):201-202. 7. Hackett TB, Mazzaferro EM. Professional intraosseous catheterization. In Veterinary Emergency and Critical Care Procedures. Ames, IA: Blackwell; 2006:263-267.

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Calculation of Maintenance Fluid Requirements*

Cats: Body weight (kg)0.75 × 80 = 24-hour fluid requirement in milliliters Ongoing losses (e.g., from diarrhea, vomiting, or polyuria) must be calculated and added to the total maintenance requirement obtained from these formulas. *UC Davis School of Veterinary Medicine fluid therapy formula.

8. Spivey WH, Malone D, Unger HD, et al. Comparison of intraosseous, central, and peripheral routes of administration of sodium bicarbonate during CPR in pigs. Ann Emerg Med 1985;14(5):514. 9. Stack AM. III. Intraosseous infusion. In: Wolfson AB, Wiley II JF, eds. Textbook of Pediatric Emergency Procedures. 2nd ed. Philadelphia, PA: Wolters Kluwer Health/ Lippincott Williams & Wilkins; 2008:281-288. 10. Wingfield WE, Raffe MR. Emergency vascular access and intravenous catheterization. In: The Veterinary ICU Book. Jackson Hole, WY: Teton NewMedia; 2002:58-67. 11. Mazzaferro EM. Fluid therapy: the critical balance between life and death. Clinician’s Brief 2006:73-75. 12. Cazzolli D, Prittie J. The crystalloid-colloid debate: consequences of resuscitation fluid selection in veterinary critical care. J Vet Emerg Crit Care 20105;25(1):6-19. 13. Hayes G, Benedicenti L, Mathews K. Retrospective cohort study on the incidence of acute kidney injury and death following hydroxyethyl starch (HES 10% 250/0.5/5:1) administration in dogs (2007-2010). J Vet Emerg Crit Care 2015;26(1):35-40.

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Toxicology Talk

How to Take a Toxin Exposure History

y pet just ate this! What do I do?” Pets tend to eat anything and everything. Some exposures may be more of a concern than others. Getting the details of the exposure is very important. Learning how to take an exposure history will help in gathering the information necessary to determine what treatments are needed. The triage form on page 35 can be used to record the information outlined in this article.

Jennifer A. Schuett, CVT ASPCA Animal Poison Control Center, Urbana, Illinois Jennifer worked in a small animal practice for 6 years before considering toxicology. She went to Joliet Junior College for her associate’s degree in veterinary medical technology, graduated in May 2010, and became a certified veterinary technician by August 2010. She has been with the ASPCA Animal Poison Control Center for a little over 5 years. Jennifer has written several protocols for her workplace and articles for an online veterinary magazine, as well as being an active board moderator on the Veterinary Support Personnel Network (VSPN).

shutterstock.com/Dmitri Ma

THE PATIENT When a pet owner calls about a pet ingesting a potentially toxic substance, first ask how the animal is doing. If the animal is bleeding, not breathing, or is having a seizure, medical attention is needed right away. Nothing can be done over the phone in these situations. Advise the owner to remain calm and bring their pet in immediately or take the pet to the nearest open general or emergency veterinary facility. If the pet is not experiencing these life-threatening symptoms, the next questions to ask are the pet’s breed, age, weight, and health history. The signalment is important when assessing a potential toxic exposure.

PRODUCT DETAILS ARE IMPORTANT when collecting the exposure history. Details from the product label provide the most helpful and reliable information. If the owner no longer has the label but purchased the product, ask if they can go back to the store to possibly identify the product. TODAY’SVETERINARYTECHNICIAN

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In her spare time, Jennifer likes to garden, craft, and spend time with friends and family. When Halloween season comes around, she is also an actor/makeup artist for a local haunted house. Jennifer and her husband Tom celebrated their first wedding anniversary in June 2016.

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Toxicology Talk



How to Take a Toxin Exposure History

The form of the medication can affect the absorption time and onset of clinical signs. Liquids tend to get absorbed very quickly, and some tablets can be extended release.

Emesis is commonly recommended after an ingestion of a possible toxic substance; however, emesis may or may not be indicated based on the animal’s signalment and current status. Emesis is generally not recommended if the pet is already vomiting or showing clinical signs, if a corrosive substance was ingested, if the pet had recent abdominal surgery, or if the pet has a poor health history (e.g., seizures).

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THE SUBSTANCE Product details are important when collecting the exposure history. Details from the product label, if the pet owner has it, provide the most helpful and reliable information. In the United States, products that are regulated by the Environmental Protection Agency (EPA) list a registration number (EPA Reg number) on their labels. In Canada, these products have a PCP number instead. Some common products that have an EPA Reg or PCP number are fertilizers, pesticides, herbicides, rodenticides, and some household products. The owner can find the EPA Reg number on the label around the manufacturer details or the ingredients. If the owner no longer has the label but purchased the product, ask if they can go back to the store to possibly identify the product. If the product was placed by a pest control operator or landscaper, ask if the owner has a receipt for the services that contains information on what product was used. EPA Reg and PCP numbers are important when contacting an animal poison control hotline. If a human-use medication, either over the counter or prescription, was involved, the name and strength are important details to collect. The owner can find this information on the bottle label. The form of the medication is also important because it can affect the absorption time and onset of clinical signs. Some common forms of

IF PRESCRIPTION MEDICATION was involved, the name and strength are important details to collect. The owner can find this information on the bottle label. 32

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TECHPOINT 

medication are tablets, capsules, softgels, chewables, liquids, topicals, and powders. Liquids tend to get absorbed very quickly, and some tablets can be extended release. If the label is no longer available or legible and the medication was prescribed, the owners can call the prescribing pharmacy to determine the medication details. If that is not an option or the product was an over-thecounter medication, the imprint code (the numbers and letters that are printed on the pill) can be used to help in identification of the product. The staff at a poison control center or local pharmacy may be able to identify the product based on the imprint code, which can be used to look up medication name and strength. Many medications contain multiple active ingredients (e.g., multivitamins, cold and flu medications, supplements), so ask the owner to read you all of the ingredients. If the product is a cold medication, it may contain pseudoephedrine, which can cause serious cardiovascular and central nervous system stimulation. Identification is required to purchase pseudoephedrine, so ask the owner if they remember having to show any identification when they bought the medication. Some medications that are flavored, chewable, or compounded may contain xylitol, which can cause severe hypoglycemia and liver failure in dogs. Ask the owner to look specifically for xylitol listed as an ingredient in these types of medications. If a veterinary-prescribed medication was involved, the name, strength, and prescription history are important in determining the risk assessment. Ask whether the pet is currently on the medication or has been in the past. If the owner has been giving the medication as prescribed, knowing the prescribed dosage can help determine how much may be missing. If multiple medications are involved, drug interactions could also be a concern.

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Toxicology Talk

How to Take a Toxin Exposure History

shutterstock.com/Hans Engbers

If the pet was outside, many things could have been ingested such as fertilizers, gopher baits, or mushrooms.

EARLY CLINICAL SIGNS OF MUSHROOM INGESTION include vomiting, diarrhea, depression, tremors, and seizures. If the client is reporting mushroom ingestion, have them collect all the pieces of the mushroom in a bag labeled “DO NOT EAT! POISONOUS!” for identification purposes. Educate clients to scour their yards frequently and get rid of any mushrooms they find. Once product details are available, the amount ingested is needed to determine the risk for toxicosis. Try having the pet owner estimate the worst-case scenario. If some of the product is left, it could be weighed to estimate the amount missing (e.g., fertilizers, chocolate, rodenticides). Some liquid substances are dispensed with syringes, droppers, or cups to be used in measuring the dose. These are helpful tools when estimating the amount of liquid missing. If the pet ingested a plant, identification of the plant is necessary to determine the risk. Plant identification can be difficult when the pet owner is not sure what the plant is. Pet owners can look for pictures online, but information obtained this way may not always be accurate. Garden nurseries can sometimes help with identification. THE EXPOSURE In addition to information about the pet and the product, other important details should be collected, such as the timing of the exposure. Ask when the exposure happened and whether anyone saw it. Unfortunately, exposures

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often occur when the owner is not with the pet (e.g., when the owner is sleeping or at work). If the exposure wasn’t witnessed, ask about the time frame of the exposure, including the earliest and latest times it may have happened. Comparing the exposure time frame to the expected onset time for development of clinical signs can help determine the course of treatment for the animal. For example, if a dog ingested chocolate 24 hours ago, emesis would no longer be effective, and if an animal ingested a rapid-acting medication many hours earlier but has not developed clinical signs, treatment may not be needed. Also ask the owner if more than one pet was involved. Multiple pets can drastically change the exposure and treatment plan. If pets may have shared what was ingested, the worst-case scenario must be determined for each pet and the treatment plan customized accordingly. If the owner suspects poisoning but doesn’t know what may have been ingested, ask the owner where the suspected exposure took place. If the pet was outside, many things could have been ingested (e.g., fertilizers, mole/gopher baits, mushrooms).

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TE C HP O I N T 

Some liquid substances are dispensed with syringes, droppers, or cups to be used in measuring the dose. These are helpful tools when estimating the amount of liquid missing. THE PLAN Once all the above information has been collected, a treatment plan can be developed. Any medical treatment that has already been administered by the pet owner at home, such as inducing emesis, needs to be taken into account. Commonly, inducing emesis and/or administering activated charcoal is recommended in cases of possible toxicant exposure. These treatments may not be needed depending on the situation and patient. As many veterinary professionals know, cats sometimes do not vomit when we want them to. Hydrogen peroxide (3%) is commonly recommended for inducing emesis in dogs but has not been shown to be effective in cats. Inducing emesis in cats at home should never be recommended. Additionally, rodents, rabbits, birds, horses, and ruminants cannot safely vomit, so emetics should not be used in these cases. Medications that can be used for emesis at the veterinary clinic include apomorphine hydrochloride and xylazine. Activated charcoal is like a magnet; it attracts and holds toxins to its surface to carry them through the gastrointestinal tract without being absorbed by the body. Activated charcoal is administered when an animal ingests certain products such as organic poisons, chemicals, or bacterial toxins. Toxins that undergo enterohepatic recirculation may require multiple doses of activated charcoal. Hypernatremia is a possible downside of activated charcoal administration, so serum sodium must be monitored when giving activated charcoal. Cathartics enhance the elimination of activated charcoal from the body. If cathartics are not used, the toxin bound by the activated charcoal can eventually be released and absorbed, delaying the development or prolonging the course of clinical signs. Cathartics would not be recommended if the animal has diarrhea or is dehydrated.

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Toxicology Talk

How to Take a Toxin Exposure History

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

IF THE PET INGESTED A PLANT, identification of the plant is necessary to determine the risk. Plant identification can be difficult when the pet owner is not sure what the plant is. Garden nurseries can sometimes help with identification. Once the exposure details are collected and the animal has been stabilized, other diagnostics and treatments can be considered. Blood work, radiographs, and fluid therapy may be recommended, depending on the exposure information. Calling a professionally staffed animal poison control hotline can help hospital staff develop a treatment plan.  Toxicology Talk is written and reviewed by members of the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center (APCC). The mission of the APCC is to help animals exposed to potentially hazardous substances, which it does by providing 24-hour veterinary and diagnostic treatment recommendations from specially trained veterinary toxicologists. It also protects and improves animal lives by providing clinical toxicology training to veterinary toxicology residents, consulting services, and case data review. The ASPCA APCC includes a full staff of veterinarians, including board-certified toxicologists, certified veterinary technicians, and veterinary assistants, and its state-of-the-art emergency call center routinely fields requests for help from all over the world, including South America, Europe, Asia, and the Pacific Islands.

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TECHNICIAN RESOURCE

Toxin Triage Sheet Animal-related emergency? Call 888-426-4435 For non-emergency information about our services, call Customer Service at 888-426-4911 Monday–Friday, 9am to 5pm, CST We do our best to answer your calls quickly, and having all necessary information at hand can expedite handling your call. Here’s what we’ll need:

1. I nformation on the exposure The best way to get this is for the pet owner to bring in original packaging/label information. Many products such as rodenticides, lawn care products, cleaning supplies, etc. have an EPA REG registration number (these are all numbers with dashes) tied to ingredient information. The ASPCA Animal Poison Control Center has an extensive database of these numbers which can help accurately identify the product in question. If the product is a pill, most pills have codes on them that can also help.

Print out the triage sheet on the next page and fill it in by hand. ASPCApro.org ASPCApro.org/poison

2. Patient’s medical record (signalment) We always ask about breed, sex, reproductive status (altered, pregnant, lactating) along with age and weight of the patient. Pre-existing medical conditions about the patient are also important and will potentially dictate treatment recommendations.

3. Detailed history of the exposure Information such as when and where the exposure happened and the worst-case scenario (how many pills are missing or how much fertilizer might be missing, for example) will all dictate assessment and treatment recommendations. Information will also be needed on the time frame when exposure occurred (time owner left and returned, for example) and if any packing was ingested.

4. Signs and when they started What signs is the patient showing and when did they begin? Have any treatments already been done? Depending on the patient’s current status, particular treatment recommendations (like inducing vomiting) may not be recommended.

This form is reproduced with the permission of the American Society for the Prevention of Cruelty to Animals (ASPCA).

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TECHNICIAN RESOURCE

Toxin Triage Sheet Owner Information Owner name: _____________________________________________________________________ Address: ________________________________________________________________________ __________________________________________________________________________________ Phone number: ___________________________________________________________________

Payment Information (check applicable and fill in relevant blanks)

Patient Information (check applicable and fill in relevant blanks) Name: ___________________________________________________________________________

 Clinic credit card on file

Breed: _____________________________________________________ Sex: ________________

C linic credit card not on file (have info at hand)

 Spayed

 Owner’s credit card Credit card number: _______________________________

 Neutered

Age ____________

 Intact

 Immature

 Pregnant

 Lactating

Weight ____________

Significant Health History Current medication list: __________________________________________________________________________________

Expiration date:

__________________________________________________________________________________

_______________________________

__________________________________________________________________________________

Security code on back

 Vaccination history up to date

_______________________________

 Vaccination history not up to date

Exposure Information Product (trade name/generic name): _______________________________________________ Milligram strength/concentration: __________________________________________________ Number of pills involved/worst-case scenario range: ________________________________ Time frame range: ______________ EPA regulation number (if applicable): _____________ Ingredients (if known): ____________________________________________________________ __________________________________________________________________________________ Story of the exposure: ____________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

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Any Treatments Already Completed __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________

© 2016 Today’s Veterinary Technician. This form is reproduced with the permission of the American Society for the Prevention of Cruelty to Animals (ASPCA). For a downloadable PDF, please visit www.todaysveterinarytechnician.com.

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CLIENT HANDOUT

Common Household Poisons  Many common food items or household products can sicken or even kill animals.  Be aware of what substances may be toxic to your pet, and store and use them safely.  If you think your pet has eaten something poisonous, call your veterinarian or an animal poison hotline immediately.

Top 10 Pet Poisons The ASPCA Animal Poison Control Center handles more than 180,000 cases of pet poisonings every year. Based on those cases, the top 10 offenders are:  Over-the counter medications  Human prescription medications  Insecticides

The Basics

Chocolate

Your home can hold a lot of unrecognized dangers for your pet. However, a few simple precautions can help keep your pet safe. Pets are not “mini people.” Animals react to substances in food and medicines differently than people do, so just because something doesn’t make a person sick doesn’t mean it is okay for a pet. Also, most pets are much smaller than people, so what may seem like a harmless amount of a food or drug can make them ill. Pets are curious. If something smells good, they’ll eat it. If they can get into a container, they will. Be aware of what substances may be toxic to your pet, and store and use them safely.

If you suspect that your pet has consumed any amount of any chocolate, call your veterinarian. However, not all chocolate is equally dangerous to pets. In general, the darker the chocolate, the more toxic it is to animals. Baker’s chocolate and cocoa powder are the most dangerous because they contain the highest concentration of substances called methylxanthines. Pets that eat too much of these substances can have vomiting, diarrhea, excessive thirst and urination, hyperactivity, and in severe cases, increased heart rate, abnormal heart rhythms, tremors, and seizures.

Other Food

 Human foods  Household items (e.g., cleaning products, fire logs, paints)  Veterinary medications (e.g., wrong medication, wrong amount, wrong animal) shutterstock.com/ Dream79

 Chocolate  Plants  Rodenticides  Lawn and garden products

It is generally not a good idea to give your pet table food. Many human foods can cause digestive upset or pancreatitis, which can be severe. Even if the food is not known to be toxic, it can still contain mycotoxins, which are substances produced by mold that can cause neurologic signs. Also, several common ingredients in human food can be toxic to pets. Just a few are:  Avocados  Grapes and raisins. These are sometimes recommended as treats for dogs. However, cases of serious kidney damage have been reported in dogs, cats, and ferrets that consume them.  Macadamia nuts  Onions, garlic, and chives

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Common Household Poisons continued Cleaning Products Read the warning labels on the household cleaning products you use, and store as directed.

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Outdoor Hazards

In an Emergency… If your pet does eat something he or she shouldn’t, time is critical. Call your veterinarian or an animal poison hotline immediately and be prepared to describe the following:  What your pet ate  How long ago  How much The ASPCA Animal Poison Control Center’s hotline number is 888-426-4435. The Pet Poison Helpline number is 855-764-7661. (Note: Callers will be charged a consultation fee.) If possible, bring some of the substance, including any available packaging, with you if you are asked to bring your pet in for an examination.

 Xylitol. This is a common sugar-free sweetener, often found in chewing gum, foods (including peanut butter), dental products, and medications and supplements. Xylitol can lower the blood sugar in the body and cause life-threatening liver failure. Y east dough S ome beverages, such as coffee and alcohol In general, do not store or leave food meant for you and your family in a place where your pet may be able to get to it. Take special care during holiday seasons and festive occasions, when it is very easy to become distracted and leave food or drinks on a counter or coffee table.

Medicines Never give your pet a medicine meant for people unless you’ve been told to by a veterinary professional. Many common over-the-counter drugs can be extremely toxic to pets. Don’t leave medicine bottles out where pets can reach them (a determined dog can chew through a childproof cap), and pick up any dropped pills immediately. Use the same caution with dietary supplements or with products you buy at a health food store.

If you have a garage, shed, or garden, you probably have at least some of the following:  Plants: Learn which plants can be toxic to pets and under what circumstances. Tomatoes, for example, are in the nightshade family. Many lilies, flowers, and common ornamental shrubs can be toxic. The American Society for the Prevention of Cruelty to Animals (ASPCA) maintains a comprehensive online list (www.aspca.org/apcc).  Pest poisons: Poisons meant to kill rodents, insects, or weeds are very common causes of poisoning in pets. Be very careful how you apply and store any poisons around your home.  Garden products: Cocoa mulch, fertilizers, and compost piles are also unsafe for pets. Make sure any mulch or fertilizer you apply to your yard is safe for pets to play in (and possibly eat). Keep your pet out of areas treated with toxic products. Compost piles can grow bacteria and fungi that are highly toxic to pets, so if you have a compost pile, make sure your pet cannot get into it, and don’t compost dairy or meat items.  Garage chemicals: Any chemical in your garage can be dangerous to pets. Antifreeze, in particular, can be deadly. Store all chemicals out of reach of your pet (just as you would for children), and carefully mop up any spills. 

© 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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WELCOME

HOME PURRFECT LOCATION Attending the NAVC Conference 2017 at the Orange County Convention Center will feel like your homecoming. Our new fully-inclusive venue features all of your conference excitement in one spot. Get ready for a bigger, better and more exhilarating experience than ever before! Register today at NAVC.com.

NEW LOCATION ORANGE COUNTY CONVENTION CENTER

ORLANDO, FL â&#x20AC;¢ FEB 4-8, 2017 For more details, please visit NAVC.com/OCCC

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Peer-Reviewed

Behavioral Aspects of Caring for Elderly Cats Vicky Halls, RVN, Dip Couns MBACP United Kingdom

alf of the cats in the United Kingdom are over 8 years old, and it is not uncommon for cats to live into their early 20s. This aging cat demographic is likely representative of cat populations in other countries. Veterinary nurses and technicians can play a key role, through clinics and nurse consultations, in assisting owners of older cats to manage their changing needs and monitor for the subtle signs of disease to ensure early identification and treatment. Environmental modifications for older cats can be easily made and improve the quality of life for older cats. There is no specific age at which cats become elderly, as the aging process is very individual, but 3 older life stages have been identified1: ÆÆ Mature (7–10 years) ÆÆ Senior (11–14 years) ÆÆ Geriatric (15+ years)

Vicky Halls is a registered veterinary nurse and full member of the Association of Pet Behaviour Counsellors, consulting widely as a feline specialist. She is a member of the International Cat Care behavior and welfare panels and the author of a number of best-selling books. She was also voted The Nation’s Favourite Cat Behaviour Author in the United Kingdom.

This article discusses the changes that come with aging, common behavioral problems in this group of cats, and how veterinary nurses and technicians can educate owners on caring for their cat during their advancing years.

HOW DOES AGING AFFECT A CAT? With increasing age there are many physical changes that take place, all of which potentially impact on a cat’s normal patterns of behavior, including2: ÆÆ Reduced:  Ability to smell and taste food  Ability to digest fat and protein  Hearing  Immune function (making the elderly more vulnerable to infections)  Skin elasticity  Heart and lung function  Tolerance to distress (chronic stress) ÆÆ Changes to eyes, such as iris pigment changes and nuclear sclerosis ÆÆ Brittle nails

Common behavior patterns observed in the elderly may all be attributed to these physiologic changes; these include: ÆÆ Reduction in hunting ÆÆ Reduction in general activity levels

This article was originally published in the October 2015 issue of Feline Focus and is reprinted with permission from International Cat Care. Feline Focus is the online veterinary nursing journal of the International Society of Feline Medicine. Subscription is free for all veterinary technicians. Find out more at icatcare.org/nurses/membership.

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Behavioral changes in older cats can indicate physical illness, especially if combined with other clinical signs, for example, litter tray accidents or weight loss. ÆÆ Less time spent outdoors ÆÆ Sleeping for longer periods ÆÆ Reduced appetite; fussier about food ÆÆ Playing and grooming less ÆÆ Altered sociability ÆÆ Increased insecurity ÆÆ Lack of adaptability to change ÆÆ Increased vocalization ÆÆ Increased dependency on, or attachment to, the owner

It is important that owners appreciate that behavioral changes can occur as a direct result of illness. For example, increased thirst and appetite are commonly seen in cats suffering from diabetes mellitus. Other signs that may indicate a physical problem include: ÆÆ Stiffness, lameness, or difficulty in jumping up ÆÆ Lethargy ÆÆ Lumps or swellings ÆÆ Balance problems ÆÆ Toilet accidents ÆÆ Difficulty passing urine or feces ÆÆ Disorientation or distress ÆÆ Weight loss ÆÆ Uncharacteristic behavior (e.g., hiding, aggression, excessive vocalization) GENERAL TIPS FOR ELDERLY CAT MAINTENANCE This is the time, more than any other, when a cat needs essential care and regular monitoring at home. As cats get older they will find it more difficult to maintain their own cleanliness. The owners can assist them by regularly trimming claws (FIGURE 1) and grooming gently in areas that the cat can no longer reach. Early identification of problems leads to improved healthcare if owners check their cat’s teeth regularly, monitor their toilet habits, and check for general warning signs such as loss of appetite, weight loss, excessive drinking, etc. TODAY’SVETERINARYTECHNICIAN

Behavioral Aspects of Caring for Elderly Cats

Stimulating the Older Cat Caring for an elderly cat is not all about monitoring for signs of disease. Many owners believe that physical and mental exercise is no longer beneficial, yet encouraging activity can maintain and prolong good health. It is arguably more important at this age as time spent hunting and patrolling territory will decrease, often resulting in more sleep to fill the void. Regular activity helps to retain muscle mass (which can decrease pain from osteoarthritis) and aids circulation; it is also useful to assist bladder and bowel function in the elderly. Exercise can be interactive or solitary and take the form of predatory play, exploration of new objects, patrolling, or foraging for food. The nature of the activity undertaken should be appropriate for the cat’s age and mobility;3 gentle and regular playtime for short periods is the most suitable regimen. Large toys for self-play can be useful to encourage the elderly cat to grab and kick, giving important “range of movement” exercise for stiff hindlimbs (FIGURE 2). Cardboard boxes, a favorite for many cats, can be adapted for the elderly to take into account lack of flexibility. Larger boxes on their side, or those with a shallow entrance, will be easier to access. If part or all of the cat’s diet consists of dry kibble, then they may enjoy a challenge to acquire some of their daily ration. Placing kibble or biscuits inside cardboard egg boxes, tubes, or paper bags requires some paw dexterity to remove them.

FIGURE 1. Older cats need more attention to grooming and claw care, which owners should be taught to do at home, if possible.

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Making the Home and Garden Elderly Cat Friendly Home Small adaptations to an elderly cat’s existing resources can make a significant difference to quality of life. If they are finding stairs difficult to negotiate, then they may be spending prolonged periods on one level, either up- or downstairs. Ensuring that all their needs are met on that one level will avoid any risk of being unable to access important resources. Social Contact Many cats become increasingly insecure as they get older, and this may lead to greater demands of the relationship with their owners. Routine activities and predictable social contact will help the older cat feel more secure. Food and Water Food bowls should be located well away from litter trays, thoroughfares, full-length glass windows, and cat flaps. Ideally, they should be placed so that the cat can approach the bowl from any direction, thereby avoiding the need to have their back to any other cats that may be in the household. If the bowl is positioned on a raised platform, the cat will not need to lower its head in order to drink or eat and this will make it easier to do so for those with stiffness or discomfort in the neck, shoulders, or forelimbs. Elderly cats are more likely to become dehydrated, so the availability of attractive sources of water is essential. Water bowls should be placed away from the feeding areas.

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Advise clients on adapting an older cat’s home. Does the cat have difficulty climbing stairs? Ensure cats have all the resources they need on their preferred level. Litter Trays Many behaviorists recommend that litter trays be provided in the formula of one per cat (or one per identified social group) in the household plus one extra.4 They should be located in different areas so that it is not possible for one cat to prevent another from having access to a litter tray. In the case of a single-cat household, two trays can be positioned in close proximity to each other. For the very elderly, or those cats suffering from cognitive dysfunction, it is appropriate for all of the cat’s resources to be located in easy reach of the cat to avoid confusion. Covered trays (those with hoods and flap entrances) can be difficult to negotiate. Open trays with low sides are ideal,5 and they should be firmly fixed to prevent them from being tipped up if the cat is clumsy when using a tray. Polythene litter tray liners should be avoided as they can catch in a cat’s claws. Indoor trays should be cleaned regularly (BOX 1).4

BOX 1 Cleaning Regimen for a Clumping Substrate  Remove clumps of urine and solids once or twice a day and top off with fresh litter if necessary to an optimum depth of approximately 3–4 cm (1½ inches). If the cat is producing copious urine, then this level should be increased to 5–6 cm (2½ inches) to accommodate.  Once a week, empty the entire contents of the tray and wash with hot water and mild non-toxic detergent. Once dry, fill to the original depth with fresh litter.  If a non-clumping litter is used, it is difficult to remove urine, so solids should be removed once or twice a day and all the litter changed 2–3 times a week.

FIGURE 2. Polly (aged 20) playing. 42

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Elderly cats should have the option of a private, accessible, comfortable, and warm resting place away from the family and any interruptions.

Behavioral Aspects of Caring for Elderly Cats

BOX 2 Elderly Cat Behavior Survey

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Scratching Posts Elderly cats are less likely to use vertical scratching posts, so alternative surfaces must be provided that enable the cat to scratch and exercise on horizontal surfaces. Activity centers may still be appealing as high perches, but gradual steps should be placed alongside for ease of access. Flooring Laminate, wood, or tile floors can be slippery and loop pile carpet may get caught in a cat’s claws. Cut pile carpets are less problematic, so strategic use of runners for those cats having difficulty will be helpful.

The author conducted a large-scale survey in 1995 (unpublished) on elderly cat behavior and health; in total, more than 1200 owners participated in the research. Owners of cats aged 12 years or over were invited to complete detailed surveys asking questions about how their cat’s behavior had changed since they had reached the age of 12 years.

Steps Cats love to view outdoors, and most enjoy sitting on high windowsills. Jumping up can prove difficult if not impossible for some, so provision should be made for easy access up to and down from these favorite lookouts. A series of shallow steps offers the best solution.5 If steps are built to reach a particular area, the distance should be measured and the height of each step calculated based on a 3-step

The results of the elderly cat survey showed:  Around half of the cats had become fussy with food.  Around half of the cats were drinking more.  Around half of the cats were not going outdoors as much as they had done.  Just over 40% of the cats were sleeping more than 75% of the time.  About a third of the cats soiled in the house (passing urine and/or feces outside the litter tray).  About a quarter of the cats had either reduced or stopped grooming.  The cat’s social interactions had changed:  80% of the cats were more sociable and affectionate towards their owner and/or demanded more attention.  Two-thirds of the cats were more vocal, a third crying for attention at night.  A quarter of the cats had become less tolerant of other animals in the home, while a similar number had become more tolerant.

FIGURE 3. Steps giving access to a favored resting place. TODAY’SVETERINARYTECHNICIAN

 About a third of cats had one or more chronic illness or disability; the most commonly reported were chronic kidney disease, osteoarthritis, and deafness.

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TABLE 1 Favorite Places to Sleep from the Elderly Cat Survey FAVORITE PLACE TO SLEEP

No. (%)

Warm (e.g., in the sun; airing cupboard; by the radiator, boiler, or fire; on lap)

356 (27.7)

Owner’s bed

340 (26.5)

Soft furnishings (e.g., chair, sofa)

273 (21.2)

“Cat” bed/basket/cradle/hammock

87 (6.8)

Garden or outside

83 (6.5)

Window/porch

54 (4.2)

Varies with the weather/cat’s mood

53 (4.1)

Box/cardboard box

39 (3.0)

unit (usually the device becomes bulky if there are any more than 3 steps). The steps should be constructed in such a way that they will support the cat’s weight and be comfortable to use (FIGURE 3). Beds In the 1995 Elderly Cat Survey, owners reported that most of their cats (79.1%) had a favorite place to sleep; and when asked where their cat liked to sleep, almost all owners reported that it was somewhere warm and comfortable (BOX 2 and TABLE 1). If a cat uses the owner’s bed, chair, or sofa, it is useful to provide a thermal blanket that is warm and washable. If a cat likes to sleep on window sills or other narrow platforms, it is advisable to place a soft padded object on the ground underneath to prevent injury, as many older cats have impaired balance and could easily fall; ideally, elderly cats

FIGURE 4. A step to help a cat in and out of a cat flap can encourage them to access the outdoors. 44

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should be encouraged to use secure or wider surfaces for sleep. Heated pads or beds may be beneficial to those elderly cats that are underweight or arthritic. Private Places Cats need to be able to have uninterrupted rest, and occasionally this needs to be in a place well away from children, family, and other pets in the household. These areas should be kept accessible and new ones created if lack of mobility prevents a cat from using those previously favored. Private places, like beds, should be warm and padded, and the cat should not be approached when it is there unless the owner has any concerns about its well-being. Cat Flaps Some elderly cats will reduce the frequency of excursions outside purely as a result of difficulty negotiating the cat flap. It may be helpful to build a step, inside and outside (FIGURE 4), to make it easier to use the flap, but eventually the cat flap may be replaced by escorted trips into the garden. When this occurs, if no other cats in the household are using the flap, it would be advisable to block off or remove it to prevent invasion from other cats outside, which can distress the elderly resident. Garden Other cats in their territory may deter the older cat from going outside. If the garden can be secured, it will exclude other cats and contain the resident cat within the safety of its own property. Most systems for securing a garden require 6-foot fencing or boundary walls of an equivalent height to be

FIGURE 5. Gardens can be fenced to secure the garden. (picture courtesy of FeliSafe)

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Elderly cats benefit from careful thought on how to improve and enrich their environment to meet their needs. Veterinary nurses can provide excellent advice and make a real difference to the lives of geriatric cats. present along the entire perimeter (FIGURE 5). Trees and sheds may also be an issue as many are positioned in close proximity to boundary fences, and this can provide an entry route for cats from outside. There are several commercially available systems that may be suitable for the elderly. With any securing system, gates that give access to the garden will have to have similar treatment to ensure the area really is cat proof. Gaps below the fence, holes in fencing, and holes that are dug under fencing by wildlife all represent possible escape or entry routes and must be identified and blocked accordingly. Once the owner is satisfied that their garden is secure, or they wish to escort their cat outside and supervise excursions, they can then concentrate on ensuring that the area provides everything the cat needs. Positioning a selection of pots and tubs near the exit and entry point to the house (e.g., near the cat flap or door) provides

BOX 3 Making an Outside Cat Toilet  Locate the outside cat toilet in a flower bed as near to the house as possible to ensure the cat feels secure.  Dig a section of border to a depth of 30–45 cm (12–18 inches), ideally choosing a patch that is against a fence or wall and surrounded by shrubbery.  Place shingle or hard core in the bottom to act as drainage and top up to ground level with sand suitable for a child’s sandpit mixed with equal amounts (or less) of compost.  Remove and replace as needed.

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Behavioral Aspects of Caring for Elderly Cats

immediate protection for an elderly cat to allow it to survey the area before moving away from the safety of the home. Borders should be stocked with a variety of plants and dense shrubbery to provide the cat with private areas, shade in hot weather, and protection from rain. A weatherproof container can be left outside to collect rainwater, which the cat can use as a water bowl. Any fishponds should be protected with cat-proof netting and, ideally, a small fence around its perimeter. If the garden does not have a lawn, then grass can be grown in pots. In good weather conditions, the elderly cat may appreciate an attractive outdoor toilet near to the house (BOX 3). COMMON BEHAVIORAL PROBLEMS IN THE ELDERLY Over a quarter of cats aged 11 to 14 and half of cats over 15 develop at least one age-related “problem behavior.”6 Those behaviors that, in the author’s behavior referral practice, are seen most commonly in elderly cats include: ÆÆ Urination and defecation outside of any provided litter facilities (house soiling) ÆÆ Excessive night-time vocalization ÆÆ Attention-seeking behaviors motivated by or resulting from over-attachment ÆÆ Abnormal/unusual/unacceptable behavior associated with disease Most behavioral problems seen in elderly cats have a physical origin and, therefore, a thorough veterinary examination is essential to rule out disease before referring the patient to a suitably qualified behaviorist with a particular interest in cats. CONCLUSIONS The elderly cat population has specific requirements, for both preventive and general health care, that take into consideration the physical and emotional changes that take place as a result of the aging process. Veterinary nurses are well equipped to provide their clients with support and guidance regarding the best way to care for these cats.  References 1. Vogt AH, Rodan I, Brown M, et al. AAFP-AAHA feline life stage guidelines. J Feline Med Surg 2010;12:43-54. 2. Pittari J, Rodan I, Beekman G, et al. AAFP senior care guidelines. J Feline Med Surg 2009;11:763-778. 3. Ellis SLH, Rodan I, Carney HC, et al. AAFP and ISFM feline environmental needs guidelines. J Feline Med Surg 2013;15:219-230. 4. Carney HC, Sadek TP, Curtis TM, et al. AAFP and ISFM guidelines for diagnosing and solving house soiling behavior in cats. J Feline Med Surg 2014;16:579-598. 5. Bennett D, Zainal Ariffin SM, Johnston P. Osteoarthritis in the cat 2. How should it be managed and treated? J Feline Med Surg 2012;14:76-84. 6. Moffat KS, Landsberg GM. An investigation of the prevalence of clinical signs of cognitive dysfunction syndrome (CDS) in cats [abstract]. JAAHA 2003:39:512.

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Career Challenges

Tips and Tricks to Rev Up Your Client Service Game

ften, veterinary technicians and assistants miss opportunities with clients that could enhance the client relationship and bond, ultimately leading to better patient care. It is up to each individual to capture the moment and create a positive experience for every client and patient every time they visit the practice. For many, these opportunities could lead to an improved practice culture and job satisfaction.

Heather Prendergast, RVT, CVPM Heather has spent over 25 years in small animal practice, teaches veterinary technology and assistance programs, and is the author of Front Office Management for the Veterinary Team. She lectures on topics ranging from grief management for health care professionals to nutrition, inventory, communications, and veterinary team management. She has also written several articles and participated in published roundtable discussions on these topics.

EDUCATE; DONâ&#x20AC;&#x2122;T SELL! Veterinary technicians and assistants often feel they are salespeople in the examination room. Flip this attitude and put a positive spin on it! Become a teacher and educate clients how to care for their pets in the best way possible. In veterinary medicine, recommendations are made because they are in the best interest of the pet. If the goal is to provide the best medicine possible for every patient that walks in the door, we must make recommendations that the owner understands and is willing to accept. Therefore, educating every client on the importance of what, why, and how is crucial. When every message delivered incorporates

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Currently, Heather provides consulting services for veterinary hospitals and is an instructor for Patterson Veterinary University and VetMedTeam. She serves on several advisory committees and is the Program Chair of the Technician Program at the North American Veterinary Conference. Heather was named the 2014 Veterinary Technician of the Year and Continuing Educator of the Year for 2016 at the Western Veterinary Conference. BECOME A TEACHER AND EDUCATE CLIENTS how to care for their pet in the best way possible. An educated client perceives the value of the services being delivered and is willing to pay for it. 46

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Tying together education, communication, and stress reduction enhances clients’ experience in the practice. what, why, and how, the client begins to trust the practice and is more willing to accept the recommendation(s) being made. An educated client perceives the value of the services being delivered and is willing to pay for it. DEVELOP RELATIONSHIPS WITH CLIENTS Developing relationships with today’s veterinary consumers is crucial. Gone are the days of rushing the client in and out of the examination room. In addition, many clients are no longer loyal to one veterinarian in the practice, but rather to an entire team that builds a solid brand. Veterinary practice brands are established when consistent medical and customer services are delivered repeatedly. Therefore, time must be given to create relationships, starting with the initial phone call to create the appointment. In the examination room, let clients tell their story. If they don’t start out with a story, ask them a question to get it started, before you make any recommendations. Make a connection. For example, compliment the owner on something they have done for their pet. Clients are proud of their pets, yet team members rarely compliment them on the pet’s excellent body condition, haircoat, or spectacular grooming job. These connection moments only take seconds, yet build a year of trust. Add education into the formula, and relationship building gets on the fast track. COMMUNICATE Many people think they are phenomenal at communication; yet “lack of communication” is a common grievance to veterinary state medical boards. Every veterinary technician can rev up their game in communication for the sake of their patients. Messages have three critical components. Verbal, paraverbal, and nonverbal communication each play a significant role in how the message is interpreted by the client. Verbal Communication Historically, veterinary team members rely on the verbal component of communication, or the word choice. Sadly, TODAY’SVETERINARYTECHNICIAN

Career Challenges

Tips to Rev Up Your Client Service Game

the words used only account for 7% of the message the client receives.1 Granted, word choice is important, and team members do need to use professional words that clients can understand. For example, clients often use the term “shots” in place of “vaccines”; however, they understand what vaccines are. Therefore, team members are encouraged to use the term “vaccines” to enhance their professional image. However, consider the word “um.” How many times do you use “um” in a sentence when speaking with clients? Words such as “um”, “like,” or “uh” are fillers used while the speaker is gathering his or her thoughts, and are often used unconsciously. Filler words distract the listener, keeping him or her from absorbing the entire message, and decrease his or her confidence in the speaker. To overcome the use of filler words, ask colleagues to become aware of how often they use them. One way of doing this is to have team members count the fillers they hear each other use, then role play with each other to demonstrate the hurdle these fillers present and help overcome it. Paraverbal Communication Paraverbal communication refers to the tone of voice used to relay a message, as well as the enunciation and emphasis of words, and accounts for 38% of the message received.1 The tone of voice that a person uses when speaking can have a positive or negative effect on the conversation. For example, when team members are busy and trying to handle multiple clients at one time, their tone of voice may be short and abrupt, which may be perceived as rude. Rudeness—even if only perceived— ruins the client service experience. Paraverbal communication is particularly important in telephone conversations because the listener cannot see the body language of the speaker. Words must be enunciated clearly; words that are jumbled together or “mumbled” decrease the confidence the client has in the team member. Placing emphasis on particular words is also important. A monotone message does not educate clients; the listener easily becomes bored, disengaged, and distracted by something more interesting. Nonverbal Communication Nonverbal communication includes body posture, facial expressions, eye contact, and professional appearance, and accounts for 55% of the message received.1 Team members who keep their hands in their pockets appear unmotivated, shy, or unconvinced of what they are saying. Folded arms may signal rejection of information, while lack of eye contact may be seen as having something to hide

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Tips to Rev Up Your Client Service Game

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Veterinary practice brands are established when consistent medical and customer services are delivered repeatedly.

or lacking confidence. Slouching and moving slowly can project lack of motivation and caring in the eyes of the client. When clients perceive these nonverbal messages, their satisfaction can drop significantly. Overcome negative nonverbal messages by dressing professionally (matching, unwrinkled, unstained scrubs), standing tall and proud, and maintaining eye contact while educating clients. Communicating Diagnostic Plans If veterinary technicians want to drive patient care, then learning how to communicate diagnostic plans to clients is the number-one area in which to rev up the game. Be a teacher when delivering these plans; integrate what, why, and how with exceptional communication skills, focusing on the paraverbal and nonverbal components. Role-play with other team members if needed to gain confidence in delivery and education. If you need to recommend a procedure or service that you don’t have confidence in, obtain more information from the veterinarian as to why it

is being recommended. The nonverbal messages clients receive when a team member does not understand the why of what they are saying are exceptionally clear (to the client), and will most likely cause the client to decline the recommended service. Clients should ask questions when you present a diagnostic plan. If they don’t, they likely do not understand what you are saying. Clients who do not understand do not accept recommendations and have a poor perception of service value. One study found that most clients who do not accept recommendations decline because they lack understanding, not finances.2

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DEVELOP RELATIONSHIPS WITH PATIENTS Did you think that client service was only about the client? Not any more! Today, pets must also have an exceptional experience in the hospital for clients to feel they received exceptional customer service. When pets love coming to the vet, clients love bringing them to the vet. So, what are you doing to promote low-stress patient handling in your clinic? If you need some ideas on where to start, check out the Fear Freesm initiative at fearfreepets.com.

DEVELOPING RELATIONSHIPS with today’s veterinary consumers is crucial. Make a connection by complimenting the owner on something they have done for their pet, such as the pet’s excellent body condition, haircoat, or spectacular grooming job. These connection moments only take seconds, yet build a year of trust.

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CONCLUSION Tying together education, communication, and stress reduction will enhance the experience clients have in the practice. When clients feel they have received 5-star service, they post reviews on social media and brag to their family, friends, and colleagues. The practice retains and gains exceptional clients, and the pets receive the best care possible because the clients believe in the practice culture. Last, but not least, veterinary technicians can excel at their duties and enjoy their job, because they get to care for animals the best way possible, every time.  References 1. Windle R, Warren S. Communication skills. directionservice.org/cadre/section4.cfm#THE %20THREE%20COMPONENTS%20OF%20COMMUNICATION. Accessed May 2016. 2. Lue TW, Pattenburg DP, Crawford PM. Impact of the owner-pet and clientveterinarian bond on the care that pets received. JAVMA 2008;232(4):531-540.

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Ideas Into Practice

Starting Veterinary Technician Appointments What inspired your idea to establish veterinary technician appointments, and why did you follow through with it? After a long day of listening to presentations at the NAVC Conference in Orlando, in a language other than my own, I was lying on the bed in my hotel room, thinking about how I, a young vet tech, had ended up in the United States, far from home. This was an amazing country that I had seen often on television. All the movies and television series I watched were from here too, so I felt like I knew quite a bit about the American way of life. Now I was here! The conference was so big and had so many people and lectures. It also had so many new ideas. I had listened to lectures about animal weight, behavior, and dentristy, and had learned about puppies and their problems, public relations and marketing for veterinary clinics, pet diets, and much more. Also, I talked with a number of veterinarians and heard them describe how their veterinary technicians took so much work off their hands. That was the moment I began to think

Esther Klok Dierenkliniek Winsum The Netherlands Esther Klok, a veterinary technician at Dierenkliniek Winsum in the Netherlands, described her passion for bringing new ideas back from the NAVC Conference to her clinic in ”What Moves You? From Holland: Looking Back on a GREAT Adventure” (Today’s Veterinary Technician May/June 2016). In this article, she discusses her inspiration to initiate veterinary technician appointments, as well as how she introduced and implemented her plan.

TEACH CLIENTS AND CHILDREN the correct schedule for applying flea control products. Let children help you with a demonstration. For example, for a spot-on product, have the child hold some food very low so that the pet has to bend its head to eat. You—or the client—can then easily apply the product. Children love to do this, and they will help remind their parents of the schedule. TODAY’SVETERINARYTECHNICIAN

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When puppies come in from a young age, they love you for life. They are not afraid because they trust you and feel relaxed at your practice. about the idea of vet tech appointments. They would keep clients in our practice, get some work off the vets’ “plate,” and do something good for the animals. That’s exactly what our job is all about. Most importantly, it involved what I love to do! How did you approach your boss with this concept? On the plane ride home, I was thinking of a way to introduce my ideas to my colleagues and boss. I did not want to scare them with too many big ideas. I am a really busy, enthusiastic person, and often, my biggest problems are that I am too busy and too enthusiastic! But then, at a staff meeting, my boss told us we all must create a plan that would benefit the practice. None of the vet techs knew what to do, so I asked them if they wanted to help me with a big plan we could all take part in. Needless to say, they loved this joint plan. Also, I have the best boss! He always listens to ideas and gives opportunities to try new things. More importantly, he lets people make their own mistakes and learn from them. Not everything you try will work out perfectly, but you can only improve yourself when you can make your own decisions and mistakes. How did you choose what practice areas were best for vet tech appointments? The areas a practice chooses to focus on for vet tech appointments should be areas the whole team is comfortable with, and that’s why it’s important to talk to the whole team about it. In my practice, we ordered pizza and dessert, and all the vet techs sat around a table. We discussed what we were talking about with clients the most at the front desk, in the waiting room, and on the phone. Then we settled on the following areas: ÆÆ Puppy and kitten care ÆÆ Overweight pets ÆÆ Dentistry ÆÆ Food 50

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Starting Veterinary Technician Appointments

We decided these should be the subjects we should build our program on because (1) people want this information from us, and (2) we knew a great deal about it and were accustomed to talking about it. Did you have any resistance from your colleagues? If so, how did you overcome it? Yes, there was resistance from colleagues, but I learned an important strategy from the lectures at the NAVC conference:

Before you create a new plan, think about what people in the team love to do. People will be resistant when they are afraid they cannot do something. So, one should try to create a plan that makes everyone comfortable. I knew the skills of our team and what they loved, and I tried to make a plan where everybody was in the saddle of the right horse. For example, I knew that one of my colleagues hates to create new programs, but she is the best receptionist because she knows the clients and animals by name, knows about their lives, and has a really special bond with most of them. So we decided she should be the one to inform them of our new service. My computer skills are subpar, so another colleague did the computer work and designed the flyer to give away at the front desk. And one of the vets really loved this idea, so she took on the task of convincing the other vets of the benefits of the program. The plan we presented was that the animals would be scheduled to come in more frequently, sometimes about 10 times a year, so they would get used to being spoiled in our practice, get more accustomed to being loved on the table, and feel fear free with all the staff. Nothing “bad” was scheduled during these appointments—only TLC. The idea was, when owners saw that their animals were happy in the clinic, they would begin to come more often and enjoy visiting the practice. So, in addition to everybody on the team having a task they loved, the little problems that came up were solved in no time, because everyone wanted to start doing it. I will say this about opposition to a new idea. Because I also give in-house training at clinics, I sometimes hear about resistance to innovative ideas. What I hear most is, “How about time? We are already so busy. How will we do this?” I understand. But when you want to make your work more interesting, and you want a practice with more income, take the chance! When a new plan such as providing vet tech appointments is working well, you can

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Ideas Into Practice

hire an extra vet tech, because the appointments will bring more clients into the practice, providing more work and more money. I also hear about space problems. But where there is a will, there is a way! When we were renovating our practice, I had to do the vet tech appointments in the quarantine area. I was afraid of what the owners would think of this, but they were so happy that we made an effort to enable them to come to appointments that we even received boxes of chocolate as a token of appreciation. Don’t look for problems; always look for solutions. Owners will see this and put more trust in you and your team. When you implement new things in your practice, you are developing the practice, the team, and all the individual team members. How did you initially set up the vet tech appointments? We started by offering vet tech appointments in the evening, after our normal closing time of 6 pm. This way, we did not have to hire an extra vet tech to start the program. Instead, I scheduled appointments after my normal working hours. It was also a great way to start because many people are free from their jobs in the evening and have time to come. The only issue was that there were no vets in the building after 6 pm, but I could always make a phone call when I needed to consult with them. This further developed trust between me and my boss, because he knew I would not do things that a vet tech is not allowed to do. After a few months, the clients, my colleagues, and my boss were so enthusiastic that my boss asked me to start scheduling appointments on Wednesday afternoons.

Starting Veterinary Technician Appointments

We were also able to hire an extra vet tech to take my place on Wednesday in the operating room. This is how a vet tech appointment looks at our practice: 15 minutes Time is important, because I let all the animals walk freely so I can observe how they move and behave. Even more importantly, I take time to listen to the owners and then give advice. It’s free Vet tech appointments are free for clients who buy food, get vaccinations, or purchase medicines from our practice (regular customers), and for all puppies and kittens every month until they are adults. For other customers, we charge about 30 euros (a little over $30). Soon we noticed we were selling more deworming and flea control products, food, radiographs, spay/neuter procedures, and dental services because of the vet tech appointments. More importantly, we were building stronger relationships with clients because they came in so many times. Our clients were less inclined to go to the supermarket to buy food or to change veterinarians. When puppies come in from a young age (every month for about 10 months), they love you for life. Even years later, they come running into your practice. They are not afraid because they trust you and feel relaxed at your practice. That is worth so much, even if it is not directly measurable! It’s important that every visit be a party for the pet, which also makes it a party for the owner. Having a

ENCOURAGE CLIENTS TO BRING THEIR CHILDREN with them to veterinary technician appointments. The children will learn a lot, and the owner can, too. You can examine the pet with the owner to show them what is normal (or not), so they can learn what they can check at home, like teeth, haircoat, and skin. Here, a child watches as his puppy’s teeth are checked. The puppy has a double fang…while the boy is missing some teeth! TODAY’SVETERINARYTECHNICIAN

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TE C HP O I N T 

When owners saw that their animals were happy in the clinic, they would begin to come more often and enjoy visiting the practice. relaxed animal is your first priority. Besides, who can give more TLC than a vet tech? Here’s a good tip for initiating your first vet tech appointment: Start by seeing puppies and kittens. People love these appointments, and you will feel really good about yourself and your team after the first day! It will give you the self-confidence you need to move on to areas like dental checks and overweight appointments.

Ideas Into Practice

Starting Veterinary Technician Appointments

How do you “sell” veterinary technician appointments to clients? ÆÆ Every member of the team must provide information about the appointments to owners! Our whole team is proud of our program, so this is not a problem for us. ÆÆ Give people flyers with all the information. ÆÆ Try to schedule appointments immediately. ÆÆ Reach out to newspapers and radio and television stations to promote your clinic. The press loves covering subjects like happy puppies and “before and after” pictures of dogs losing weight. How has the client response been? What, if any, obstacles might someone have to overcome to initiate a program like this? Clients love these types of programs and tell others about them. So the only obstacle is…you. First, you need to be positive. If you have a negative attitude, owners will feel it immediately. Of course, there will always be challenges to overcome. Once, half our staff

PUPPIES AND KITTENS can come to the clinic just to be adored. Let them explore and get comfortable with the space. Owners love it when you let their pets do a little “sightseeing,” and you can watch the animal move to see if its gait and balance are normal. Treats help pets relax and teach them that the clinic is a pleasant place to be. In my clinic, we always have a supply of Kongs filled with meat paste in the freezer. 52

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TE C HP O I N T 

Ideas into Practice

When you implement new things in your practice, you are developing the practice, the team, and all the individual team members.

Is the program a success at your practice, and what, if anything, would make you “give up” on this idea? In a couple ways, it is easy to measure the results of the program. For one, we simply look at what we sell to the clients who come for these appointments. For another, the appointments have been very satisifying for my boss, and because of his enthusiasm and support, we now have 2 days of vet tech appointments. Other results are harder to measure. Have we kept clients loyal to our practice with this program? We can’t be sure. But we do see happy pets and owners, and a good relationship is so important! What’s perhaps most important for me is that it adds value to my job to have my own appointments, and it gives so much satisfaction! Helping animals become fear free, giving owners a great experience, and seeing the health benefits make it worth it. When animals run straight from the car to the appointment room, when I am almost hugged to death, when an owner loves to come in every month, when a frightened animal becomes fear free, when a dog that almost couldn’t walk because of its weight loses so many kilos that he can run around, or when a cat can wash herself again after losing 2 kilos of fat—I feel like Superwoman! It gives me energy to do this job even after 22 years. It’s why I’m a vet tech! So, would I ever give up on this idea? No way! In fact, I give lectures to inspire veterinarians and veterinary technicians to start their own programs at their clinics! I say, “Go for it and make your own success story.”  |

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Veterinary Technician Appointments

Advertiser Index

had the flu and we did not have enough people to handle our 10 vet tech appointments, forcing us to cancel them at the last minute. But the same thing can affect a practice’s surgical or walk-in vet appointments. That’s not a problem with the program, it’s just life. Also, you will always have difficult owners. Just talk to a colleague about it, share the frustration, and help each other when necessary.

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Updated from Veterinary Technician March 2013 (Vol 34, No 3) by the author and peer reviewed by Todayâ&#x20AC;&#x2122;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.

Peer-Reviewed

Crash Carts: Preparation and Maintenance Paula Plummer, LVT, VTS (ECC, SAIM)

Texas A&M University

any different types of emergencies can present at veterinary practices at any time of day. Having a centrally located station for emergencies with a crash cart that is stocked and ready to use is essential for saving time, which is crucial in emergencies and should not be wasted by scrambling to gather supplies. A crash cart can be designed to fit the needs of any hospital and can help stabilize critically ill or injured patients.

A crash cart can be as simple as a mobile, compact cart equipped with medical equipment and supplies for various emergencies. The size of the cart depends on the number and types of emergencies a hospital manages. Multiple-doctor, highvolume hospitals typically have larger, more complete crash carts than smaller, low-volume hospitals. Paula has been at Texas A&M University since 2007, first working in the small animal intensive care unit and then moving to the feline internal medicine service in 2011. She graduated from Murray State College in Tishomingo, Oklahoma, and has been a registered veterinary technician since 2000. In 2011, she earned her veterinary technician specialty in emergency and critical care, and in 2014, she earned her second specialty in small animal internal medicine. Paula is also involved in teaching technicians in online programs and as a guest lecturer and lab instructor at local, regional, and national continuing education symposiums. When she is not working, Paula enjoys spending time with her husband and furry 4-legged family.

FIGURE 1. A commercially available crash cart. 54

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FIGURE 2. A toolbox that serves as a crash cart.

FIGURE 3. A look inside the toolbox. |

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Crash Carts: Preparation and Maintenance

Brian Walski/Colorado Visions

A crash cart can be designed to fit the needs of any hospital and can help stabilize critically ill or injured patients.

Crash carts are commercially available (FIGURE 1), but hospitals can prepare their own using a large or a small toolbox (FIGURES 2 and 3) or even a cabinet drawer. The same equipment can be used for canine and feline emergencies, so the same crash cart can be used for both species. Lidocaine is the only emergency drug with different doses for feline and canine patients. The different doses are noted in TABLE 1, which is an example of an emergency drug chart. A hospital’s crash cart should be located in the central treatment area and in areas where patients are anesthetized. The station should be near oxygen and suction sources to increase cardiopulmonary resuscitation (CPR) success rates. Hospitals that have separate wards or treatment areas should consider maintaining multiple crash carts to cover all areas. Studies have shown that environmental factors (e.g., location of the crash station); availability of up-to-date checklists, flow charts, and easy-to-follow aids; and maintenance of a well-stocked, organized cart can help improve the success rate of CPR. In human medicine, it has been proven that a pre-stocked station that includes the proper crash cart and CPR aids such as flow charts and algorithms improves the outcome of cardiopulmonary arrest. Crash carts should include emergency medications, intravenous catheters and fluids, and a defibrillator. Carts should be fully stocked and in date at all times, and each TODAY’SVETERINARYTECHNICIAN

drawer should be labeled. All staff members should know what is in the cart and where to find each item. BOX 1 lists common supplies in a crash cart.

BOX 1 Common Equipment and Supplies in a Crash Cart  Laryngoscope  Endotracheal tubes (various sizes)  Syringes (various sizes)  Needles (various sizes)  Ambu bag  Monitoring equipment (e.g., electrocardiograph, pulse oximeter, capnograph, oscillometric or Doppler blood pressure unit)  Intravenous fluids  Dextrose 50%  Intravenous catheters and the supplies for placing them  Emergency drug table  Emergency drugs (e.g., epinephrine, atropine, naloxone, calcium gluconate, furosemide, vasopressin)

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All personnel should know how to use all the equipment in a crash cart. Staff training can be essential in saving a patient’s life.

All personnel should know how to use all the equipment in a crash cart. Staff training can be essential in saving a patient’s life. Scenario-based training should be conducted regularly to train new employees and refresh the skills of the established staff. Written emergency protocols and quick-reference guidelines on how to use the crash cart should be posted, and the team leader should ensure that all staff members understand them. ORGANIZING A CRASH CART Organizing a crash cart requires understanding of how a life-threatening emergency progresses. In human medicine, most crash carts have 5 to 9 drawers. In veterinary medicine, most crash carts can be organized into 5 drawers. An example system for organizing crash carts follows. Top of the Cart The top of the crash cart could include an electrocardiograph, a defibrillator, a capnograph, a pulse oximeter, Ambu bags

TECHPOINT 

of various sizes, and a blood pressure unit. A multiparameter unit can be used instead of individual monitors. Keep examination gloves on top of the cart or nearby. All patients arriving as emergencies should be handled with gloves. In trauma cases, patients may be covered in their own or the owner’s blood or have undiagnosed infectious diseases. Bloodborne pathogens can be transmitted to staff members.

TABLE 1 Sample Emergency Drug Chart* DOSE (in milliliters) PER BODY WEIGHT OF PATIENT DRUG

DOSE

Epinephrine 1:1000 1 mg/mL Low dose

0.01 mg/kg; 0.005 mg/lb

0.02

0.05

Epinephrine 1:1000 1 mg/mL High dose

0.1 mg/kg; 0.05 mg/lb

0.25

Atropine 0.5 mg/mL

0.05 mg/kg; 0.02 mg/lb

Lidocaine (dogs) 20 mg/mL

2.5 kg; 5 lb

5 kg; 10 lb

7.5 kg; 15 lb

9 kg; 20 lb

11 kg; 25 lb

14 kg; 30 lb

16 kg; 35 lb

18 kg; 40 lb

23 kg; 50 lb

27 kg; 60 lb

32 kg; 70 lb

36 kg; 80 lb

41 kg; 90 lb

45 kg; 100 lb

0.07

0.09

0.11

0.14

0.16

0.18

0.23

0.27

0.32

0.36

0.41

0.45

0.5

0.75

0.9

1.1

1.4

1.6

1.8

2.3

2.7

3.2

3.6

4.1

4.5

0.25

0.5

0.75

0.9

1.1

1.4

1.6

1.8

2.3

2.7

3.2

3.6

4.1

4.5

2 mg/kg; 1 mg/lb

0.25

0.5

0.75

1.0

1.25

1.5

1.75

2.0

2.5

3.0

3.5

4.0

4.5

5.0

Lidocaine (cats) 20 mg/mL

0.2 mg/kg; 0.1 mg/lb

0.02

0.05

0.07

0.09

Dexamethasone sodium phosphate 4 mg/mL

4 mg/kg; 2 mg/lb

2.5

5.0

7.5

Calcium gluconate 100 mg/mL

10 mg/kg; 5 mg/lb

0.25

0.5

0.75

0.9

1.1

1.4

1.6

1.8

2.3

2.7

3.2

3.6

4.1

4.5

Vasopressin 0.4 U/mL

0.8 U/kg; 0.4 U/lb

Defibrillator (external)

2 joules/kg; 1 joule/lb

100

Defibrillator (internal)

1 joule/kg; 0.5 joule/lb

2.5

7.5

*All doses are for intravenous and intraosseous administration in dogs and cats; separate lidocaine doses for dogs and cats are noted. For epinephrine and atropine, double the dose for intratracheal administration. NA = not applicable. This chart appears courtesy of Dorothy Black, DVM, MPVM, DACVECC, who created it.

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Crash Carts: Preparation and Maintenance

Top Drawer The top drawer could contain intubation supplies, including endotracheal tubes (at least one of each size), laryngoscope handles, blades of various sizes, and umbilical tape or something else for tying endotracheal tubes in place. Second Drawer The second drawer could contain emergency drugs. Which drugs to include may be a matter of preference. Ideally, only drugs used in emergencies, such as those listed in BOX 2, should be included. All doctors in the hospital should agree on the drugs and doses to be used in an emergency. The drawer could also include a small supply of preassembled needles and syringes as well as a chart of drug doses per body weight. TABLE 1 is an example of a drug chart; alternatively, a chart can be purchased from the Veterinary Emergency and Critical Care Society. Third Drawer The third drawer could contain intravenous catheters of various sizes and the supplies for placing them (e.g., T-ports, tape, surgical scrub, needles, syringes, scalpel blades). Every emergency patient requires placement of an intravenous catheter for administering medications and fluids, so it saves time to keep catheters centrally located in a crash cart. Fourth Drawer The fourth drawer could contain intravenous fluids and administration sets. One or two bags of each type of intravenous fluid stocked by the hospital could be kept in the crash cart; suggestions include sodium chloride 0.9%, Normosol-R (Hospira, Lake Forest, IL), lactated Ringer’s solution, and hetastarch. Fifth Drawer The fifth drawer could contain miscellaneous items to help

BOX 2 Common Emergency Drugs to Include in a Crash Cart  Aminophylline

 Dextrose 50%

 Atipamezole

 Diphenhydramine

 Atropine

 Epinephrine

 Calcium gluconate

 Naloxone

 Dexamethasone

 Vasopressin

TODAY’SVETERINARYTECHNICIAN

treat cardiac arrest. All items could be organized in labeled bins to facilitate access. This drawer could also include anything that might be needed in an emergency. To decide what to include, each hospital should determine which types of emergencies it typically sees. Suggested supplies include suction catheters, internal and/or pediatric defibrillator paddles, conducting gel, intravenous pressure administration bags, chest tubes, and sterile thoracocentesis packs consisting of a butterfly catheter, a three-way stopcock, and a 60-mL syringe. Supplies for thoracocentesis can be sterilized and preassembled to save time in an emergency. MAINTENANCE Crash carts should be checked daily and monthly against checklists to ensure that they are fully stocked at all times. When an item from the cart is used, it should be replaced immediately after the emergency. A daily check would include ensuring that the cart has all the necessary supplies in the proper place and that all its electronic equipment is fully charged. A monthly check would include checking drug expiration dates as well as sterilization dates for endotracheal tubes if they are reused. CONCLUSION A crash cart can be very helpful in saving lives, but staff members must be properly trained to successfully use a crash cart. It is very important for a crash cart to contain the appropriate equipment and supplies and to be centrally located. Being prepared and organized can make a significant difference in an emergency. 

Suggested Reading  Devey J. CPCR: how to set up a ready area. Proc Latin Am Vet Emerg Crit Care Soc 2010. Available at ivis.org. Accessed November 2012.  Fletcher D. Advances in CPR: guidelines & simulations for educational and clinical training. Proc Int Vet Emerg Crit Care Soc 2011.  McMichael M, Herring J, Fletcher DJ, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 2: Preparedness and prevention. J Vet Emerg Crit Care 2012;22 (Suppl 1):S13-S25.  Quintana A. What’s new in CPCR? Proc World Small Anim Vet Assoc 2009. Available at ivis.org. Accessed November 2012.

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CLIENT HANDOUT

Why Do I Need to Vaccinate My Pet?  Vaccination is an important weapon against infectious diseases.  Some diseases, like rabies, are transmissible to humans, so protecting your pets also protects your family members and community.  Pets that stay indoors also can be exposed to infectious diseases, so even indoor cats can benefit from vaccinations.  Vaccines are safe and generally well tolerated by most pets.  Vaccine selection and scheduling should be an individualized choice that you and your veterinarian make together.

Companion animals today have the opportunity to live longer, healthier lives than ever before, in part due to the availability of vaccines that can protect pets from deadly infectious diseases. Over the past several decades, the widespread use of vaccines against diseases like rabies has saved the lives of millions of pets and driven some diseases into relative obscurity. Unfortunately, infectious diseases still pose a significant threat to dogs and cats that are unvaccinated; therefore, although vaccine programs have been highly successful, pet owners and veterinarians cannot afford to be complacent about the importance of keeping pets up-to-date on their vaccinations.

How Do Vaccines Work? Although there are many types of vaccines, they tend to work through a similar principle. Most vaccines contain a very small portion of the virus or bacterium that is the infectious agent. Some vaccines contain small quantities of the entire virus or bacterium, whereas others contain particles that are part of the infectious organism. When this material is introduced into the body in a vaccine, the body’s immune system responds through a series

of steps that include making antibodies and modifying other cells that will recognize the target organism later. When the vaccinated individual encounters the “real” organism later, the body recognizes the organism and reacts to protect the vaccinated individual from becoming sick by activating the immune system.

Why Does My Pet Need Vaccines? Vaccines protect your pet. Vaccines are one of our most important weapons against infectious diseases. Some diseases, such as “kennel cough” in dogs and rhinotracheitis in cats, can be transmitted directly from pet to pet. If your pet is ever around other animals, such as at a kennel, dog park, grooming salon, or daycare facility, exposure to infectious disease is possible. Even pets that look healthy on the outside may be sick, so keeping your pet’s vaccines up-to-date is a good way to help prevent illness.

Even primarily indoor pets can be exposed to diseases. Even if your pet doesn’t have direct contact with other animals, some diseases can be transmitted indirectly. For example,

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Why Do I Need to Vaccinate My Pet? continued So, even pets that spend most of their lives indoors or have very limited contact with other animals are not completely safe from exposure to infectious diseases.

Vaccines protect your family and community.

shutterstock.com/Nina Buday

Some infectious diseases, such as leptospirosis in dogs and rabies in dogs and cats, are zoonotic diseases. That means humans also can become infected. In the case of rabies and leptospirosis, both diseases can cause serious illness and death in infected individuals— including humans. Protecting your pets against these diseases also protects the rest of your family members, as well as other pets and people in your community.

Are Vaccines Safe? parvovirus infection, which is potentially fatal, is spread through contact with feces from an infected dog. Even if your dog never has contact with a dog infected with parvovirus, exposure to the virus can occur through contact with feces from an infected dog, such as in a park or on a beach. Lyme disease—a dangerous infection that is carried by ticks—is another disease that your dog can be exposed to without coming into contact with other dogs. In cats, panleukopenia infection is potentially fatal and spread through contact with body fluids (mostly urine and feces) from an infected cat. Once a cat is infected with panleukopenia, it may shed virus in body fluids for a few days or up to 6 weeks. Panleukopenia can live in the environment (such as on contaminated bedding, food bowls, litter boxes, and other items) for a very long time, so contact with contaminated objects can spread the infection to other cats. Additionally, if a pet owner is handling an infected cat, failure to change clothes and wash hands thoroughly with the correct disinfectant can expose other cats to the disease.

All of the available vaccines for dogs and cats have been thoroughly tested and found to be safe when administered as directed. Most pets tolerate vaccines very well, although reactions can occur in some cases. Some pets can seem a little “tired” after receiving vaccines. Notify your veterinarian if your pet develops breathing problems, facial swelling, vomiting, hives, redness on the skin, or other unusual changes after receiving a vaccine. You also should tell your veterinarian if your pet has ever had a problem in the past after receiving a vaccine.

Which Vaccines Does My Pet Need? Many vaccines are available for dogs and cats, but every pet does not need to receive every available vaccine. So how do you know which vaccines your pet should have? The American Animal Hospital Association (AAHA) and the American Association of Feline Practitioners (AAFP) have summarized vaccine recommendations to help veterinarians clarify how to best protect dogs and cats through the use of vaccine programs.

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Why Do I Need to Vaccinate My Pet? continued AAHA and AAFP evaluated the available vaccines and categorized them to provide guidelines on how commonly they should be used. Vaccines are categorized as core, non-core, or not recommended. A core vaccine is one that all pets should receive. The core vaccines for dogs are rabies, distemper, adenovirus-2, and parvovirus; and the core vaccines for cats are rabies, rhinotracheitis (feline herpesvirus-1), panleukopenia (feline distemper), and calicivirus. Non-core vaccines are optional ones that pets can benefit from based on their risk for exposure to the disease. Examples include the vaccines against Lyme disease and leptospirosis in dogs, and the vaccines against feline leukemia virus and feline immunodeficiency virus (or feline AIDS) in cats. Categorization of a vaccine as “not recommended” does not mean that the vaccine is bad or dangerous. This designation simply means that widespread use of the vaccine is not currently recommended. Because core vaccines are recommended for all pets, your veterinarian will recommend keeping these vaccines up-to-date at all times. The decision regarding non-core vaccines should be made after you and your veterinarian have discussed the vaccines in question and whether your pet might benefit from receiving them. Factors to consider include your pet’s lifestyle (how much time your pet spends outside), where you live, where you travel with your pet, and how often your pet has contact with other animals. Bear in mind that vaccine recommendations and your pet’s lifestyle can change. Your veterinarian may want to discuss modifying the vaccine recommendations to ensure that your pet is well protected.

What Is the Recommended Schedule for Vaccines? Puppies and kittens generally receive their first vaccines when they are around 6 to 8 weeks of age (depending on the vaccine and manufacturer’s recommendations). Booster vaccines are generally given during your puppy or kitten checkup visits; your veterinarian can discuss the recommended schedule with you. Vaccines are generally repeated a year later. Although puppies and kittens are considered especially vulnerable to some diseases, it is also very important for adult pets to be up-to-date on vaccines. Traditionally, many vaccines were repeated yearly, during regular checkup examinations. However, research has shown that some vaccines can protect pets for longer than 1 year. In light of these findings, the AAHA and AAFP guidelines note that some vaccines don’t need to be repeated more frequently than every 3 years. The decision regarding how often your pet needs vaccine boosters depends on several factors, including your pet’s overall health status and risk for exposure to the diseases in question. Your veterinarian may recommend annual boosters after considering your pet’s lifestyle and disease exposure risk. The decision regarding how often to administer any vaccine (annually, every 3 years, or not at all) should be an individualized choice that you and your veterinarian make together. Vaccination remains one of the most important services your veterinarian offers, and although vaccination is a routine procedure, it should not be taken for granted. It also allows a regular opportunity for your veterinarian to perform a physical examination, which is very important for keeping your pet healthy. Protecting patients is your veterinarian’s primary goal, and developing an appropriate vaccine protocol for your pet is as important as any other area of medicine. 

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Final Thoughts The Space Between Us I remember the first time I felt my body image violated. I was 13 years old, and my mother told me I had better “watch it” in regard to my weight. I had started to gain weight, as any normal prepubescent girl does, but to her it was unacceptable. I felt like I had been punched in the stomach, and for the first time, I felt that I was unacceptable. That moment changed my life forever. It was the moment that other people’s opinion of me took precedence over my own.

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.

Soon after, my brother started bullying me, relentlessly calling me “Blimp” and “Thunder Thighs.” I felt humiliated, embarrassed, and deeply encroached upon. Not knowing where I began and my family ended, I internalized what they thought of me as Truth and eventually decided I would rebel against the Truth they imposed on me. I developed anorexia. My eating disorder was an attempt to put space between me and others, to create separation and ultimately protect myself from the pain I felt for not being “okay.” I didn’t know it at the time, but I was trying to enforce my boundaries. True, it was not in a healthy or sustainable way, but I can see the twisted logic in it now. When we know better, we do better.

shutterstock.com/Monkey Business Images

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.

ENFORCING OUR BOUNDARIES is how we demonstrate respect for ourselves, whether by telling others it’s not okay to comment on our weight or our parenting style or that we won’t accept being spoken to in a certain manner. 62

TODAY’SVETERINARYTECHNICIAN

An Official Journal of the NAVC

July/August 2016

www.todaysveterinarytechnician.com

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Boundaries are an ultimate act of self-love and self-care. Boundaries are a way of not only respecting but also protecting ourselves. What Are Boundaries? Boundaries are where one thing ends and another begins; the place where two things become different, where you end and I begin. According to Drs. Henry Cloud and John Townsend in their New York Times bestseller Boundaries: When to Say Yes, How to Say No To Take Control of Your Life, “Boundaries impact all areas of our lives: Physical boundaries help us determine who may touch us and under what circumstances—Mental boundaries give us the freedom to have our own thoughts and opinions— Emotional boundaries help us to deal with our own emotions and disengage from the harmful, manipulative emotions of others.” Boundaries are how we protect ourselves from emotional harm. This harm can come in many forms, such as always picking up the slack from lazy coworkers, allowing clients to have our cell phone numbers, not saying “no” when we want to, allowing clients to be disrespectful to us, and being touched when we don’t want to be. Enforcing our boundaries is how we demonstrate respect for ourselves, whether by telling others it’s not okay to comment on our weight or our parenting style or that we won’t accept being spoken to in a certain manner. Boundaries are an ultimate act of self-love and self-care. Without them, we become ineffective at caring for others because we end up feeling immensely depleted and sometimes even contaminated by others. And we are. Boundaries are a way of not only respecting but also protecting ourselves. Euthanasia comes to mind. There are simply times when assisting in euthanasia is not in our best emotional interest. When we are struggling with other heavy-hearted circumstances in our lives, we have to recognize that we can’t do it, enforce our boundary, and ask for a reprieve. “But I could never do that. What would my coworkers think? What would my boss think?” I’m sure a version of this is going through your mind. Remember, boundaries TODAY’SVETERINARYTECHNICIAN

Final Thoughts

The Space Between Us

are about respect and protection. Recognize when you need both. Why Do We Lack Boundaries? We are people pleasers. We want everyone to like us, and we don’t want to “hurt anyone’s feelings.” Know that no one has the power to make another person feel a certain way. Our feelings come from our thoughts and not the circumstance (more on this in the next issue!). If you are a people pleaser, ask yourself: How’s this working out for me? My bet is that it’s not. I would guess that you often feel angry and resentful and wonder why no one is thinking about you, since you are thinking about everyone else and their needs. Here’s a secret: It’s your job to meet your own needs. We lack an understanding of boundaries. Most of us aren’t “taught” about boundaries. Typically, we learn them from our families—or not. When we don’t understand the importance of boundaries, we don’t know why we need them. This was my experience. I didn’t know that it wasn’t okay for others to comment on my body, so I didn’t speak my Truth and enforce my boundaries. What did you learn? Lack of understanding is also true from the other side. For example, if you work with someone who doesn’t understand boundaries, they may very well mistake your enforcing of boundaries for obstinance, refusal to be a “team player,” or, for women, bitchiness. You have to be okay with the risk of misinterpretation to maintain your boundaries. Ask yourself what the cost of not having boundaries is, and I’m sure you will agree that the risk is usually worth it. If you work in a toxic environment where you are penalized for standing up for yourself, then at the very least, recognize this as a workplace/leadership flaw and not a personal one. Even when we understand boundaries, we can inadvertently break them. Boundaries are intensely personal, and we don’t always know when we are violating others’. For example, I love to hug people and was unaware that others are not okay with this until I met a practice manager who—I learned after I hugged her—hated it. We don’t think we’re important. Many of us come with an internal “I’m not good enough” or “I’m not worthy” tape playing on continuous loop. We think, “Who am I to ask people from work to not text me

An Official Journal of the NAVC

July/August 2016

www.todaysveterinarytechnician.com

Final Thoughts

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Without boundaries, we become ineffective at caring for others because we end up feeling immensely depleted and sometimes even contaminated by others.

at home unless it’s a true emergency?” Who are you not to? Your personal life is as important as anyone else’s. Others don’t feel comfortable standing up for themselves, but if you don’t, some people will see how far they can infiltrate your space. We don’t think we can. There is no question that enforcing boundaries requires patience, diligence, and practice, but consider the possibility that it’s these exact boundaries that will help build both your self-esteem and confidence. And as you establish your boundaries, people will begin to recognize where they have to stop before you have to enforce them. Where Do We Begin?

Daring Greatly, uses the mantra “Choose discomfort over resentment” to remind herself to not be pulled into saying “yes” when she really wants to say “no.”

Start small. Find little things to start with, such as telling friends that you put your phone on do-not-disturb at 9 pm, and you won’t be answering texts after that time. Sure, you will likely have to remind them—that’s what it means to enforce boundaries. Once you get good at setting and enforcing small boundaries, then you can move to larger ones like setting boundaries with coworkers, clients, and family.

VETERINARY MEDICINE requires us to be empathetic with our patients, clients, and coworkers. At first, the idea of setting boundaries can seem to be counterintuitive to this need. In fact, healthy boundaries enable us to maintain the space between us and others while being empathetic.

How Do We Stay Connected Through Our Boundaries? Veterinary medicine requires us to be empathetic with our patients, clients, and coworkers. At first, the idea of setting boundaries can seem to be counterintuitive to this need. In fact, healthy boundaries enable us to maintain the space between us and others while being empathetic. As Brené Brown explains in her video “Boundaries, Empathy & Compassion,” “Empathy minus boundaries is not empathy. Compassion minus boundaries is not genuine.” She disagrees with the current belief that empathy can lead to burnout. Instead, she defines empathy not as feeling for someone, but feeling with someone. When approached this way, empathy can actually restore us. I highly recommend watching the whole video at theworkofthepeople.com/boundaries. Boundary setting and enforcing is one of the most powerful tools we have against compassion fatigue and, when practiced, can sustain us indefinitely in our career and our lives. 

shutterstock.com/Bruce Weber

Use a mantra. Brené Brown, a research professor at University of Houston Graduate College of Social Work and author of the New York Times #1 bestsellers The Gifts of Imperfection and

Practice, practice, practice. Start saying aloud (alone or to others) what it is you want to say. The more you become comfortable setting and enforcing your boundaries, the easier it will be. “That sounds interesting, but I can’t make it.” “I don’t give my phone number out to clients.” “I’m not able to assist with this euthanasia, can you?” “No, my plate is already full.” “Thanks for the invitation. My weekend plans are to be with my family, so I won’t be able to attend.” “No, I can’t work that day. I already made plans.”

TODAY’SVETERINARYTECHNICIAN

An Official Journal of the NAVC

July/August 2016

www.todaysveterinarytechnician.com

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