Today's Veterinary Technician, November 2016 by davidpsu

DERMATOLOGY SIGNS OF PEMPHIGUS FOLIACEUS

ANESTHESIA PEDIATRIC AND GERIATRIC PATIENTS

TOXICOLOGY ORAL DECONTAMINATION IN DOGS AND CATS

RADIOGRAPHIC POSITIONING HEAD, SHOULDERS, AND ELBOWS

PROFESSIONAL GROWTH TIME FOR MIDLEVEL PROFESSIONALS?

Feline Physical Rehabilitation HOW AND WHY

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In a 3-month clinical trial with diabetic cats

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To learn more about DM Dietetic Management with Urinary St/Ox Defense™, visit PurinaProPlanVets.com. 1 Frank et al. “Use of a high-protein diet in the management of feline diabetes mellitus.” Veterinary Therapeutics, Vol. 2, No. 3, Summer 2001. 238-246. 2Based on dollar and unit sales of Purina® Pro Plan® Veterinary Diets DM Dietetic Management formulas as a percentage of total diabetes therapeutic diet sales as reported by GfK Retail and Technology US LLC, Vet Panel Market Database, 52 w/e 8/13/16.

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TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

NOVEMBER/DECEMBER 2016

VOLUME 1, NUMBER 6

Today’s Veterinary Technician is proudly published by the NAVC

Chief Executive Ofﬁcer Thomas M. Bohn, MBA, CAE

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

Senior Vice President of Sales and Publishing Laura C.S. Walker LWalker@NAVC.com Publisher Nick Paolo, MS, MBA NPaolo@NAVC.com Executive Editor Robin Henry RHenry@NAVC.com

Editorial Advisory Board Brenda K. Feller, LVT, CVT, VTS (Anesthesia) Animal Specialty Hospital of Florida, Naples, Florida Rosemary Lombardi, CVT, VTS (Emergency and Critical Care) Director of Nursing, University of Pennsylvania Matthew J. Ryan Veterinary Hospital Jeanne R. Perrone, CVT, VTS (Dentistry) VT Dental Training, Plant City, Florida Heidi Reuss-Lamky, LVT, VTS (Anesthesia and Analgesia, Surgery) Oakland Veterinary Referral Services, Bloomfield Hills, Michigan

Deborah A. Stone, MBA, PhD, CVPM StoneVPM Austin, Texas Daniel J. Walsh, MPS, RVT, LVT, VTS (Clinical Pathology) Purdue University (Retired)

Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition) 4 Cats Consulting Belleville, Michigan

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

NOVEMBERDECEMBER2016

Volume 1, Number 6

PEER-REVIEWED CE Opposite Ends of the Life Cycle, Similar Anesthetic Needs BRENDA K. FELLER, CVT, RVT, VTS (ANESTHESIA and ANALGESIA)

Geriatric patients are generally assumed to be at higher risk than healthy young adults when undergoing anesthesia, but healthy pediatric patients should also be approached as challenges for the anesthetist. This article provides an overview of anesthesia considerations for both old and young patients. To view the CE test for this article, please visit todaysveterinarytechnician.com.

FEATURES Feline Physical Rehabilitation MARY ELLEN GOLDBERG, BS, LVT, CVT, SRA, CCRA

Although rehabilitation is more commonly used for dogs, cats can also benefit from many of the same techniques—even swimming! Learn more about the whats, hows, and whys of feline physical rehabilitation.

How to Recognize Autoimmune Skin Disease: Tips for Spotting Pemphigus Foliaceus JENNIE TAIT, AHT, RVT, VTS (DERMATOLOGY)

Pemphigus foliaceus (PF) is the most common autoimmune skin condition in dogs and cats. Timely diagnosis is essential. This article is intended to help the healthcare team narrow in on a diagnosis of PF at a patient’s initial presentation.

Radiographic Positioning: Head, Shoulders, Knees, and Toes, Part 1 LIANE K. SHAW, BS, RVT and JEANNINE E. HENRY, BA, RVT

This first of two articles on radiographic positioning provides an overview of radiation safety as well as the techniques used to obtain good-quality orthopedic radiographs of the skull, shoulders, and elbows.

The Case for Veterinary Midlevel Professionals KENICHIRO YAGI, BS, RVT, VTS (ECC, SAIM) and MANDY FULTS, BS, LVT, CVPP, VTS (CLINICAL PRACTICE—CANINE/FELINE)

This year, the 13th veterinary technician specialty—ophthalmology— was recognized by NAVTA. Is time for a new level of veterinary technician? This article looks at the parallels in the growth of the veterinary technician and nursing professions.

TODAY’SVETERINARYTECHNICIAN

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Scarlet is why

SDMA

matters

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The IDEXX SDMA Test identifies chronic kidney disease up to 27 months earlier in dogs than creatinine* and up to 48 months earlier in cats.* The IDEXX SDMA Test is more reliable than creatinine in assessing kidney function as it can identify the disease earlier and is not affected by muscle mass and extrarenal factors that impact creatinine.* In fact, the IDEXX SDMA Test has been included in the International Renal Interest Society (IRIS) Chronic Kidney Disease (CKD) Staging and Treatment Guidelines as a useful adjunct for diagnosing CKD and to help determine treatment for the appropriate stage of CKD. With the IDEXX SDMA Test, you can diagnose CKD earlier in cats and dogs, giving you more time for effective treatment options, so you can improve and possibly extend the lives of your patients. The IDEXX SDMA Test is the new standard of care for veterinary medicine and your patients.

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Strengthen the bonds. *To see the proof and a complete list of references, visit idexx.com/5minutes. © 2016 IDEXX Laboratories, Inc. All rights reserved. • 110448-00 All ®/TM marks are owned by IDEXX Laboratories, Inc. or its affiliates in the United States and/or other countries. The IDEXX Privacy Policy is available at idexx.com.

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

NOVEMBERDECEMBER2016 Volume 1, Number 6

COLUMNS

Editor’s Letter | Am I a Veterinary Nurse?

LYNNE JOHNSON-HARRIS, LVT, RVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

What Moves You? | Knowledge and Discovery

KATHI L. SMITH, RVT, VTS (ONCOLOGY).. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Toxicology Talk | Oral Decontamination in Dogs and Cats ERIN FREED, AS, CVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Sidebar | NAVTA National Credentialing and Veterinary Nurse Update HEATHER PRENDERGAST, RVT, CVPM and KENICHIRO YAGI, BS, RVT, VTS (ECC, SAIM). . . . . . . . . . . . .

Final Thoughts | Technician, Heal Thyself JULIE SQUIRES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

60 62

Careers | Employment Opportunities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . 61 Advertiser Index.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . 4 ON THE COVER Wendy Davies, CVT, CCRA, works with a feline patient at the University of Florida Small Animal Rehabilitation and Fitness Center. Photo courtesy of Lyon Duong, University of Florida | UF Photography

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. Postmaster: address corrections to CDS/Today’s Veterinary Technician, 440 Quadrangle Drive, Ste E, Bolingbrook, IL 60440.

Advertiser Index CareCredit Credit card carecredit.com . . . . . . . . . . . . . . . . . . . . . . . . . . 17

IDEXX SMDA test idexx.com/smdaguide . . . . . . . . . . . . . . . . . . 3

BluePearl Veterinary Partners Career opportunities bluepearlvet.com/careers . . . . . . . . . . . . 61

Merial NexGard nexgardfordogs.com . . . 64, back cover

Bluffton Veterinary Hospital Career opportunities . . . . . . . . . . . . . . . . . . 61

NAVC Bookstore navc.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35

Coral Springs Animal Hospital Career opportunities coralspringsanimalhosp.com . . . . . . . . . 61

TODAY’SVETERINARYTECHNICIAN

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Conference navc.com . . . . . . . . . . . . . Inside back cover

2017 Institute navc.com/institute . . . . . . . . . . . . . . . . . . . . . 59 Nestlé Purina DM Dietetic Management formulas purinaproplanvets.com . . . . . . . . . . . . . . . . . . . . . . . . . Inside front cover Veterinary Associates of Manning Career opportunities manningvet.vetstreet.com . . . . . . . . . . . . 61 VetFolio VetFolio vetfolio.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43

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Editor’s Letter

Am I a Veterinary Nurse? Lynne Johnson-Harris, LVT, RVT | Editor in Chief

way that clients can understand, and in my opinion, that means using the term veterinary nurse. NAVTA’s Veterinary Nurse Initiative (VNI) is built on the recommendation to reduce confusion about the role of veterinary technicians by having one title, nationwide, with standardized guidelines and requirements to protect it. On behalf of all veterinary technicians, NAVTA is forging relationships with the American Veterinary Medical Association (AVMA), the AVMA Committee on Education and Activities, the American Association of Veterinary State Boards, the Association of Veterinary Technician Educators, and nursing associations to achieve this goal. (For more information about the VNI, read the update by Ken Yagi and Heather Prendergast on page 60.)

m I a veterinary nurse? For me, the answer is a resounding “YES!” I am proud to say that my role in patient and client care is equal to or greater than that of a human nurse. Let me take you back… I am a 1976 graduate of the veterinary technology program offered by Michigan State University (MSU). My educational journey provided me with the opportunity to work side by side with junior and senior veterinary students through all of the medical rotations in small and large animal medicine. I worked hard to gain all that knowledge. When I received my degree, I knew I was qualified to offer outstanding medical care based on my training in each rotation. I was an anesthesia nurse, a medical nurse, a surgical nurse—and yes, surgical technician—a laboratory technician, and a radiology technician. I could discuss medications, complications, side effects, and home care with both veterinarians and clients. I worked in private practice for a bit and then went back to MSU’s Veterinary Teaching Hospital. I was one of the veterinary nurses managing the medicine wards and teaching the veterinary technician students and veterinary students. We worked side by side. The students experienced working with a team and recognized what each team member brought to overall patient care. When a pet owner asks, “What is a veterinary technician?”, I am proud to say that I am a veterinary nurse. Everyone has had contact with a nurse. Nurses have respect from patients and doctors. Nurses provide outstanding medical care. It is our job as veterinary technicians to answer the question of what we do in a

When a pet owner asks, “What is a veterinary technician?”, I am proud to say that I am a veterinary nurse. It is now our turn! Veterinarians need to recognize the value of credentialed veterinary technicians/nurses. We have the talent and knowledge to do many of the patient care activities that are now being performed by veterinarians, thereby allowing veterinarians to use more of their own hard-earned training. So what should we do? Speak up, stand up, and proudly state, “I can do it all! I have the training and credentials to increase the level of patient care.” Not only to clients, but also to veterinarians. Until veterinarians rally behind us and help us drive change, change will not happen. By educating our clients to expect the level of care a credentialed “veterinary nurse” can provide their furry, scaled, or feathered family member, we can help drive it ourselves. 

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

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Feline Physical Rehabilitation

feline patient is not a canine patient, period. Nonetheless, developing a physical rehabilitation program for a cat, while sometimes challenging, is absolutely possible. The misconception exists that feline patients will not cooperate with therapeutic exercises, especially if there is water involved, but it has been found that, when “asked” correctly, many cats willingly participate.1 (Did that make you smile?) WENDY DAVIES performs range of motion therapy on a cat at the University of Florida Small Animal Rehabilitation and Fitness Center. Photo courtesy of Lyon Duong, University of Florida | UF Photography.

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Feline Physical Rehabilitation

Mary Ellen Goldberg, BS, LVT, CVT, SRA, CCRA Canine Rehabilitation Institute Wellington, Florida

Mary Ellen is a graduate of Harcum College and the University of Pennsylvania. She has been an instructor of anesthesia and pain management for VetMedTeam since 2003. In 2007, she became a surgical research anesthetist certified through the Academy of Surgical Research. In 2008, she became the executive secretary of the International Veterinary Academy of Pain Management. In addition, she is on the Proposed Organizing Committee for the Academy of Physical Rehabilitation Veterinary Technicians for the formation of a NAVTArecognized VTS physical rehabilitation program. Mary Ellen has written several books and contributed to numerous chapters regarding anesthesia, pain management, and rehabilitation. She has worked in various aspects of veterinary medicine ranging from small animal to zoo animal medicine.

TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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Before beginning any rehabilitation therapy, patients must be examined by the rehabilitation veterinarian. This examination should include pain assessment and scoring.

Successful feline physical rehabilitation demands a good understanding of feline behavior, including excellent handling skills. This article gives an overview of several rehabilitation therapies that can be used with cats, as well as insights for dealing with feline patients in potentially stressful situations, such as physical rehabilitation. Pharmacologic treatment is not addressed because of the complexity of the topic; readers are encouraged to pursue further resources in this area (BOX 1). PATIENTS AND PERSONNEL Treatment advances and the high costs involved in veterinary medicine and surgery are leading cat owners to expect postoperative and postinjury care for their pets similar to that offered for dogs. This care often includes physical rehabilitation, or physiotherapy, which is concerned with physical function and considers the value of movement and the optimization of physical potential to be essential to the health and well-being of individuals.1 The most common reasons to perform physiotherapy in feline patients are generally related to injuries sustained as a result of trauma or joint conditions.2 Physical rehabilitation programs for cats should be formulated by a veterinarian and a physical therapist, both of whom should be certified in physical rehabilitation. The veterinarian is responsible for examining the patient and

TECHPOINT 

prescribing the modalities that the credentialed veterinary technician or nurse certified in physical rehabilitation will carry out. Therapies that the certified veterinarian should perform include joint mobilizations, myofascial trigger point needling, chiropractic manipulations, and acupuncture. The certified rehabilitation physical therapist is an expert in joint mobilizations. Cats often make willing patients, but sessions should be kept short and interesting and should be undertaken in a quiet, relaxed environment (see HELPFUL HINTS FOR HANDLING FELINE STRESS AND ANXIETY).3

BOX 1 Suggested Reading Pharmacologic Treatment for Rehabilitation Patients  Epstein M, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain management guidelines for dogs and cats. JAAHA 2015;51:67-84.  Epstein M. The prevention and management of pain in dogs. In: Zink MC, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: John Wiley & Sons; 2013:370-388.  Fox SM, Downing R. Rehabilitating the painful patient: pain management in physical rehabilitation. Canine Rehabilitation and Physical Therapy. 2nd ed. Saunders; 2014:243-253.  Mathews KA, Kronen PW, Lascelles D, et al. WSAVA guidelines for recognition, assessment and treatment of pain. J Small Anim Pract 2014;55:E10-E58. Detailed Techniques for Feline Rehabilitation Modalities  Bockstahler B, Levine D. Physical therapy and rehabilitation. In: Norsworthy GD, ed. The Feline Patient. 4th ed. Ames, IA: John Wiley & Sons; 2011:687-690.  Bockstahler B, Levine D. Physical therapy and rehabilitation. In: Schmeltzer LE, Norsworthy GD, eds. Nursing the Feline Patient. Ames, IA: John Wiley & Sons; 2012:138-144.  Drum MG, Bockstahler B, Levine D. Feline rehabilitation. Vet Clin North Am Small Anim Pract 2015;45:185-201.  Medina C, Robertson S. Non-pharmacological pain management in cats. Feline Focus 2015;1(6):195-199.  Sharp B. Feline physiotherapy and rehabilitation. 1. Principles and potential. J Feline Med Surg 2012;14:622-632.  Sharp B. Feline physiotherapy and rehabilitation. 2. Clinical application. J Feline Med Surg 2012;14:633-645.

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Feline Physical Rehabilitation

CONDITIONS COMMONLY TREATED WITH REHABILITATION THERAPY IN CATS Cats are most often referred to rehabilitation facilities for osteoarthritis,8 fractures, neurologic conditions, femoral head and neck excision, and weight reduction.9 Other conditions that can benefit from rehabilitation therapy are listed in BOX 2. Cats are less commonly affected by developmental orthopedic diseases and orthopedic injuries9 than dogs.

BOX 2 Conditions That Can Benefit from Rehabilitation Therapy10  Traumatic stifle luxation  Femoral fractures  Articular fractures  Spinal cord trauma  Cruciate ligament injury

Osteoarthritis Osteoarthritis, also known as degenerative joint disease, is the most common form of arthritis. Its true prevalence is unknown, but one study suggests that 90% of cats >12 years of age have evidence of osteoarthritis,11 and with

such high numbers being suggested, it is likely that osteoarthritis is underdiagnosed in cats. It frequently affects multiple joints bilaterally, and most cases are primary or

Helpful Hints for Handling Feline Stress and Anxiety In the Hospital

When cats are faced with something stressful, they typically try to alleviate the stress they feel by creating distance between themselves and the stressor; that is, they run away.4 If they cannot run, they may attempt to groom or “waste time,” hoping the stress goes away. As a last resort, they use aggression. When it comes to restraint for feline patients, a general guideline is “less is more.”

Hospital waiting rooms can also be extremely stressful, and using pheromone diffusers (e.g., Feliway, Comfort Zone) in these areas and examination rooms can improve the response feline patients have to being in the facility. Feliway (Ceva) is clinically proven to help reduce stress related to traveling and visiting the veterinarian.6,7 Other strategies to improve the feline experience in the waiting room include keeping waiting times to a minimum, having separate areas for dogs and cats, and providing benches where cat carriers can be placed off the ground, thus helping cats feel less exposed. Examination areas should be quiet and secure, with little or no traffic to cause disruption.

Before Arrival at the Facility Feline patients that need rehabilitation therapy may already be stressed or in pain from whatever condition has prompted the need for therapy, even if it is performed in the patient’s home. If therapy is to be performed in a rehabilitation facility, the stress of transportation to the facility can cause cats to toilet or even vomit in their carrier, which may be particularly unpleasant for these obsessively clean animals.5 Encouraging the owner to bring the patient’s own bedding and toys not only makes the owner feel involved in the treatment, but also can help the patient feel more settled through the retention of familiar scents. The owner should be asked before the first visit what treats the cat enjoys. Having a variety of low-calorie, palatable treats on hand is helpful in bonding with the patient and goes a long way to establishing trust for future rewards after therapeutic exercises.

TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

The cat should be given time to explore the therapy area and become familiar with its surroundings, allowing it to feel more comfortable.

Staff members involved with planned feline rehabilitation therapies should gather any required therapy equipment before getting the cat out of its carrier. The cat should be given time to explore the therapy area and become familiar with its surroundings, allowing it to feel more comfortable. This time spent with the patient helps to develop a rapport between cat and nurse. Sudden or rapid movements, which can be threatening to cats, should be avoided.

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idiopathic. Diagnosis is challenging because of the lifestyle of most cats (e.g., they are not taken for walks) and the feline tendency to conceal pain and illness.12 Some clinical signs of feline osteoarthritis are listed in BOX 3, and tools that can assist in the recognition of pain are described in RECOGNIZING PAIN IN CATS. Veterinary technicians and nurses can help in the diagnosis of osteoarthritis by guiding owners through a questionnaire focusing on changes in behavior and lifestyle. A sample questionnaire can be downloaded at todaysveterinarytechnician.com. After analgesia has been administered, the questionnaire can be repeated to monitor the effectiveness of treatment. Simple range of motion and massage techniques (described under Modalities for Feline Rehabilitation) can be taught to owners, help alleviate muscular pain associated with osteoarthritis, and improve joint mobility.18 These techniques also help promote interaction between owners and their cats. The owner should be encouraged to interact with the cat and engage it in play for several minutes at least 3 times a day (or according to the preference of the individual cat) to encourage exercise and mental stimulation. Using different toys or alternating play techniques and locations is likewise helpful. Some cats may even be amenable to outdoor exercise on a leash or harness. Simple home modifications that can help cats with osteoarthritis are listed in BOX 4. The rehabilitation technician or nurse should be prepared to instruct the owner in a home exercise program for the cat. It is best to provide written and verbal instructions and hands-on demonstrations for clients, then have the clients perform the exercises while still in the facility to ensure they understand the instructions and are performing the exercises correctly.

BOX 3 Clinical Signs of Osteoarthritis12

Several therapies performed in the facility can also be beneficial for osteoarthritis patients, including cold/heat therapy, joint mobilizations (performed by the rehabilitation veterinarian or physical therapist), and electrotherapeutic modalities such as laser therapy or therapeutic ultrasound. When these techniques are used in conjunction with therapeutic exercises, patient outcomes are greatly improved. Therapeutic exercises are described under Modalities for Feline Rehabilitation. Weight Loss/Obesity Management A 2011 study by the Association for Pet Obesity Prevention found that >50% of cats in the United States were either obese or overweight.3 Quantitatively, obesity is generally defined as exceeding ideal body weight by 15% to 20% or more.19 A number of risk factors have been identified for obesity in domestic cats, including physical inactivity, urban dwelling, and increased humanization of the diet (e.g., being fed from the table, eating what the owner eats instead of a well-balanced nutritional plan). Indoor-only cats are less active than cats with access to the outdoors, and, unlike their ancestors, modern domestic cats no longer have to hunt for food. The resulting obesity predisposes cats to a number of medical conditions (BOX 5), as well as an increased risk for orthopedic disease.21 Excess weight also contributes to the development of musculoskeletal diseases and places excessive strain on joints, muscles, tendons, and ligaments, thus aggravating existing health problems. The management of obesity is based on the dual approach of reducing caloric intake and increasing physical activity, which can comprise a combination of land-based and water-based exercise. Activity through play is most effective

BOX 4 Home Modifications to Help Cats with Osteoarthritis17

 Decreased willingness and ability to jump up and down (particularly from previously frequented locations)  Changes in interaction with owners (increased aggression or decreased interaction)  Reduced hunting or outdoor exploration  Reduced grooming or overgrooming a painful joint  Claw overgrowth

 Secure hiding places  Stairs or ramps to alleviate sore joints  Litterboxes that have easy access (cutout section or lower sides)  Scratching posts that are horizontal instead of vertical for patients with abnormal joint motion

 Overt lameness (limp, stiffness, abnormal posture)

 Raised food and water bowls for patients with stiffness in elbows, shoulders, or spine

 Changes in toileting habits

 Padded, comfortable bedding

 Changes in eating habits

 Nonslip flooring (e.g., yoga mats)

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Feline Physical Rehabilitation

with obese cats as, in addition to burning calories, it increases muscle mass, increases resting metabolic rate, improves mobility and mental stimulation, and often improves the cat–owner bond.10 Owners should be encouraged to increase their cat’s activity level at home gradually, based on its needs, starting with 5 to 10 minutes per day of low-intensity activities for sedentary pets (e.g., walking).22 Creativity in activities, such as incorporating food-dispensing toys, placing meals in different parts of the house, and using interactive toys, laser pointers, and electronic mice can also be helpful with a long-term weight loss program.22 Any increase in physical activity is likely beneficial for a cat of any weight. Cats that have long-term exercise restrictions for medical reasons and, therefore, have decreased energy requirements pose a challenge for weight management. It is important to devise a weight maintenance plan for these patients and to switch them to low-calorie foods if needed. Clients who have problems restricting their cat’s food intake as prescribed should be encouraged to use

low-calorie cat foods. The veterinary rehabilitation team can offer suggestions to the client as to which food has the best nutritional value. Premium cat foods contain highquality ingredients with a balanced mixture of all essential nutrients and can help facilitate dietary management considerably for patients with weight loss challenges. In the rehabilitation facility, a variety of therapeutic exercises are used to treat obesity. For example, underwater treadmill therapy decreases joint stress while increasing the metabolic rate for successful weight loss. Numerous body condition scoring systems are used to evaluate obesity in cats, and owners should be instructed on how to regularly use these to assess their pet. MODALITIES FOR FELINE REHABILITATION It is beyond the scope of this article to discuss any techniques in detail, and readers are encouraged to learn more (BOX 1). BOX 6 lists modalities for feline rehabilitation not discussed below.

Use of a validated scoring system will help the physical rehabilitation team to objectively monitor pain scores and address changes in pain states promptly.

Recognizing Pain in Cats

should be evaluated with one of these multifactorial instruments at every visit to view trends in data.13 To date, the instrument specifically used for feline patients is the Feline Musculoskeletal Pain Index (FMPI).17 The validity of the scoring system has been tested, but the conclusion of the paper by Dr. B. D. X. Lascelles’ group was that “responsiveness and criterion validity of the FMPI could not be established in this cohort of cats.”17

Rehabilitation technicians or nurses must be skilled at recognizing pain in feline patients because therapy will have little to no benefit if the patient is in pain. Simple, online, practice-friendly numerical rating scales are available and are slowly helping to improve recognition of feline pain.13 One such scale has been developed (but not yet validated) by Colorado State University.13 A currently validated assessment tool is the UNESP-Botucatu multidimensional composite pain scale, available from animalpain.com.br/assets/ upload/escala-en-us.pdf.14,15 The Glasgow Feline Composite Measure Pain Scale: CMPS – Feline (CMPS-F) has been described as “a valid scale for the measurement of acute pain in cats [that] heralds a new era in the recognition and management of acute pain in cats.”16 The CMPS-F is a 3-page form that may be downloaded from newmetrica.com/ cmps/cats/eng/download/CMP_feline_eng.pdf.

Rehabilitation technicians or nurses who suspect that a patient is in pain should immediately alert the rehabilitation veterinarian and cease all therapies until the cat is no longer painful. Use of a validated scoring system at each visit, if possible, will help the physical rehabilitation team to objectively monitor pain scores and address changes in pain states promptly.

Chronic pain scales that use pet owner observations and input are also available. The Multifactorial Clinical Measurement Instruments are recommended by the American Animal Hospital Association and American Academy of Feline Practitioners in their 2015 guidelines.13 Ideally, patients with chronic pain

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Manual Therapy Manual therapies are commonly used in human therapy programs and may be used on veterinary patients. Credentialed veterinary technicians or nurses may perform massage, range of motion (ROM) exercises, and stretching. Massage Massage is defined as the therapeutic manipulation of the soft tissues of the body1,23 and has mechanical, physiologic, and psychologic effects.24 Massage uses stroking, effleurage, compression (kneading, wringing), friction, and percussion techniques. When massaged, muscle is mechanically stretched, reducing tone and increasing pliability (FIGURE 1). Over time, this can lead to a reduction in muscle soreness and an increase in connective tissue strength.25 Scar tissue is also mobilized and softened, helping to maintain movement between tissues and restore function after injury or surgery.25

BOX 5 Possible Consequences of Obesity in Cats 20  Cardiovascular disease, heart failure, and high blood pressure  Diabetes mellitus  Gastrointestinal problems (e.g., constipation, flatulence)  Loss of liver function  Reproductive disorders (e.g., decreased breeding performance, dystocia)

Physiologically, massage increases interstitial pressure, which in turn increases venous and lymphatic flow. Using massage strokes in a distal to proximal direction is recommended to move fluid from the extremities back to the central circulatory system,24 which becomes vitally important when addressing an edematous extremity. With each massage stroke, the hands should gently squeeze and stretch the tissue. This action creates pressure differences between one area and another, with high pressure pushing old fluid and irritating metabolites into the vasculature and low pressure drawing in new fluid. This flushing effect may be responsible for decreasing inflammation, pain, and muscle fatigue.25 Psychologically, massage decreases stress and anxiety, produces relaxation, and improves emotional well-being.1,23–25 The body and mind are both linked to the skin via the nervous system, and different types of touch elicit different types of mental responses. Range of Motion Exercises Passive ROM (PROM) exercises manually exercise joints through their natural pain-free range without voluntary muscle contraction. PROM exercises are performed by pushing or pulling on the lower part of the limb to induce flexion or extension in a target joint.26 They are typically performed in patients with stiffness secondary to surgery or in patients unable to walk on their own.27 The benefits of PROM include prevention of joint contracture and soft tissue adaptive shortening, maintenance of mobility between soft tissue layers, reduced pain, enhanced

 Increased risk for complications during anesthesia  Higher frequency of skin problems  Greater susceptibility to infection due to decreased immune defense  Shorter life expectancy

BOX 6 Other Modalities for Feline Rehabilitation  Thermotherapy (hot and cold)  Postural management for neurologic patients  Positioning and chest care for intensive care patients  Maintenance exercises for recumbent patients (passive range of motion and massage)

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FIGURE 1. Petrissage being performed on author’s cat. Petrissage is a form of massage that uses compression techniques.

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T E CHP O I N T 

Feline Physical Rehabilitation

Cats often make willing patients, but sessions should be kept short and interesting and should be undertaken in a quiet, relaxed environment.

Electrotherapy Many electrotherapy modalities can be used on feline patients. All possess inherent precautions/ contraindications and should only be used by operators who have received adequate training and wear personal protective equipment.29 Low-Level Laser Therapy or Photobiomodulation LASER is an acronym for “light amplification by stimulated emission of radiation.” Lasers produce electromagnetic radiation (light) that is monochromatic, coherent, and collimated. These qualities allow laser light to penetrate tissue.30 The mechanisms by which low-level laser therapy (LLLT) decreases pain include release of endogenous opioids, changes in conduction latencies of nerves, increased cellular metabolism, increased circulation, promotion of neovascularization, decreased fibrosis formation, and reduction of inflammation.30 Feline conditions that respond well to LLLT include osteoarthritis, degenerative lumbosacral stenosis, fractures, chronic wounds, and stomatitis.31 Most cats tolerate LLLT well, as it is not painful and can be delivered in a relatively short time (FIGURE 2).31

blood and lymphatic flow, and improved synovial fluid production and diffusion.28 Active ROM exercises use unassisted active muscle contraction to achieve joint motion28 and are performed independently by the patient.29 Activities include using cavaletti rails (i.e., a system of rails placed at adjustable heights and widths), climbing stairs, swimming, and walking in water, sand, or tall grass.27 The goals of performing active ROM are increasing strength, coordination between muscle groups, flexibility, weight bearing, and joint motion.

Therapeutic Ultrasound In physical rehabilitation, therapeutic ultrasound heats deep tissues and can be used to improve the extensibility of connective tissues, decrease pain and muscle spasms, promote tissue healing, and improve the quality of scar tissue.30 Therapeutic ultrasound units generate an ultrasound wave by applying an electric field to an array of piezoelectric crystals located on the transducer surface. This stimulation causes mechanical distortion of the crystals, resulting in vibration and production of sound waves (i.e., mechanical energy).32 The biological effects of ultrasound differ depending on the mode used. A continuous mode maximizes thermal effects; this mode is therefore primarily used for tissue heating before stretching.9 Pulsed modes produce decreased thermal effects but are used for other applications, including acceleration of the inflammatory process, increased fibroblast proliferation, and increasing the tensile strength of healing tissues.9

Stretching Stretches are passive movements that help to improve or restore full range to a joint or full length to a muscle. Stretches create change by adding sarcomeres to muscle, thereby increasing the muscle’s length/range.1 Stretching is generally more effective if preceded by light exercise, massage, heat, or therapeutic ultrasound, all of which increase the extensibility of collagen.

Electrical Stimulation Electrical stimulation is a useful therapeutic modality and is often possible in cats. In fact, many cats enjoy it. Nevertheless, cats must be carefully introduced to electrical stimulation to become familiar with it. Principally, this modality can be used for muscle strengthening and pain control. Neuromuscular electrical stimulation is a form of electrical

FIGURE 2. Cat undergoing laser therapy. Courtesy of Wendy Davies, CVT, CCRA TODAY’SVETERINARYTECHNICIAN

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The misconception exists that feline patients will not cooperate with therapeutic exercises, especially if there is water involved, but it has been found that, when “asked” correctly, many cats willingly participate.

stimulation that uses current to stimulate a motor nerve and cause the contraction of a muscle or muscle group. To stimulate a denervated muscle (e.g., in patients with spinal cord injuries), the muscle fibers must be excited directly; this form of therapy is called electrical muscle stimulation. When electrical stimulation is used for pain control, analgesia results from several mechanisms such as release of endogenous endorphins. The type of electrical stimulation most commonly used for pain control is transcutaneous electrical nerve stimulation.9 Therapeutic Exercises Therapeutic exercises are one of the most important parts of the rehabilitation process. The design of the therapy program depends strongly on the needs of the individual patient and should ensure that the exercises can be performed safely without risk of worsening the clinical signs. The exercises should be selected based on the stage of tissue repair; therefore, the rehabilitation veterinarian and therapy team should understand the underlying pathology, expected recovery progress, and biomechanical considerations.33 Exercise is the final element in the process of helping a cat achieve optimum function after injury, surgery, or disease. If the cat is weak, has a neurologic condition, or does not have endurance, then it may need assistance;

FIGURE 3. Proprioception training with a cat after a thrombolytic event. Courtesy of Lynn Nalepa, LVT, CCRP, CVPP 14

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TECHPOINT 

assistance can be provided manually or with the aid of “physio-rolls,” slings, harnesses, or carts. Therapeutic exercise may be used to decrease pain and improve the following1: ÆÆ Aerobic capacity and endurance ÆÆ Agility, coordination and balance (static and dynamic) ÆÆ Gait and locomotion ÆÆ Neuromuscular capability and movement patterning ÆÆ Postural stabilization ÆÆ Range of motion ÆÆ Strength and power

FIGURE 4. Weight shifting exercises after cruciate surgery. Courtesy of Lynn Nalepa

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Feline Physical Rehabilitation

How to Begin Hydrotherapy Exercises for Cats

Rehabilitation technicians should observe individual patients and not push them beyond their comfort zone to where they become stressed or frightened.

the water and, with motivation from a favorite toy stored in catnip or a favorite treat, will gladly perform any task (FIGURE A). Rehabilitation technicians should observe individual patients and not push them beyond their comfort zone to where they become stressed or frightened.

Introducing a cat to hydrotherapy may be facilitated with the help of the owner, either through their reassuring presence during exercise or through accustoming the cat to being in water at home (e.g., bathing). During therapy, the rehabilitation technician or nurse should accompany the patient into the water to provide assistance and reassurance until the patient is accustomed to the activity.1 Underwater Treadmill Begin with a very slow speed (often the slowest speed possible), usually no more than 0.23 m/sec (0.5 mph), depending on the manufacturer settings. Initially, support and encourage the patient until it takes only 1 or 2 steps forward voluntarily or until just before it reaches the back of the exercise chamber; then stop the belt immediately. This process may only take 5 or 10 seconds, but it should be repeated 2 or 3 times. Once the cat is walking voluntarily, it can be challenged with longer durations of up to 1 minute. Many cats will tolerate only 1- or 2-minute intervals for several assisted sessions, regardless of fitness or mobility levels. It may be helpful to vary the water level initially to find the level at which the cat will walk forward voluntarily; then increase the depth slowly to the desired level for therapeutic goals. Many cats will resist and float their hindlimbs or try climbing out of the treadmill at higher water levels. As the patient improves, lowering the water level will increase the effect of gravity, which can be advantageous for increasing range of motion or aerobic activity. Swimming Swimming is very difficult for any land animal, and unfit patients tire quickly. A life jacket is required for initial introduction to the swimming pool and provides a handle to guide and control the patient.9 Allowing the patient to swim to a chosen point and then return to a resting spot is preferred to swimming in place. Initial training sessions should be shortâ&#x20AC;&#x201D;2 to 5 minutes each. Many cats will not tolerate longer sessions.

FIGURE A. This feline patient with unknown neurologic trauma affecting both hindlimbs tolerated underwater treadmill exercises and swimming well. Courtesy of Lynn Nalepa

Each patientâ&#x20AC;&#x2122;s acceptance of swimming as therapy must be judged. Some cats are fine on an underwater treadmill but never accept swimming. Others take to

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Types of Exercise Strengthening. Strength training is a type of physical exercise specializing in the use of resistance to induce muscular contraction, which builds the strength, anaerobic endurance, and size of skeletal muscles. Strengthening exercises include running, uphill and downhill slope work, use of leg or body weights, dancing, wheelbarrowing, and swimming.1 Flexibility (suppleness). Flexibility is defined as a joint’s range of motion or its ability to move freely. It also refers to muscle mobility, which allows for more movement around the joints. Flexibility allows cats to get through difficult spaces and affords some protection from injury. Flexibility exercises can include activities that encourage the cat to reach or stretch or to maneuver around or through obstacles.1 Balance and proprioception. Balance is the ability to move or to remain in a position without losing control or falling. It depends partly on proprioception, which is an animal’s awareness of where its body is in time and space. Age, physical or neurologic injury, and surgery can all negatively affect proprioception. Balance exercises may require cats to respond to rapid changes in a supporting surface (e.g., wobble cushion, balance pad, trampoline) or changes of direction.1 Proprioception exercises may include weight shifting or walking in patterns or over uneven surfaces1 (FIGURES 3 and 4). Endurance (stamina). Endurance is the ability of an organism to exert itself and remain active for a long period of time, as well as its ability to resist, withstand, recover from, and have immunity to trauma, wounds, or fatigue. Endurance exercises, usually in the form of aerobic or anaerobic exercise, allow for cardiovascular changes to occur. Because aerobic exercise sessions often exceed 15 minutes, they are used less often for cats, but they but can be considered as part of a rehabilitation plan.1 Land-Based Exercise Most exercise programs designed for cats primarily consist of exercises performed on land, rather than in water.1 They may involve direct contact with a therapist, such as assisted standing, wheelbarrowing, dancing, or bicycling in lateral recumbency, in which the cat is placed on its side and its legs are put through ROM exercises similar to bicycling. They may also involve activities such as playing with laser lights, toys, and treats; crawling under cavaletti poles; or other creative uses of equipment that the cat navigates on its own. 16

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TECHPOINT 

The credentialed veterinary technician will be interacting a great deal with the owner, carrying out parts of the therapeutic plan, and monitoring comfort levels during therapy. Water-Based Exercise Hydrotherapy (e.g., swimming, underwater treadmill) is a very popular form of rehabilitation therapy for dogs and can be used with cats that will tolerate it. The natural properties of water (e.g., density, buoyancy, resistance) make water-based exercise one of the most useful forms of rehabilitation therapy by reducing the concussive effects of active exercise and helping improve limb mobility, strength, and joint ROM.34 Water aspiration and drowning are real risks during hydrotherapy; therefore, no animal should ever be left unattended during a hydrotherapy session,1 and the patient should wear an appropriately sized lifesaving vest. For more information, see HOW TO BEGIN HYDROTHERAPY EXERCISES FOR CATS. CONCLUSION Physical rehabilitation for cats is different than that for dogs. The basic therapeutic principles remain the same, but the plan must be creative, fun, easy to follow, and include short intervals to accommodate the feline attention span, which is much shorter than that of dogs. Before beginning any rehabilitation therapy, patients must be examined by the rehabilitation veterinarian. This examination should include pain assessment and scoring, in addition to observation of patient stress. The rehabilitation veterinarian is responsible for designing and prescribing the therapeutic plan. The credentialed veterinary technician or nurse trained in physical rehabilitation will most likely be interacting a great deal with the owner, carrying out parts of the therapeutic plan and monitoring comfort levels during therapy. Feline patients can benefit from a rehabilitation program just like canine patients. 

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Feline Physical Rehabilitation

References 1. Sharp B. Feline physiotherapy and rehabilitation 1. Principles and potential. J Feline Med Surg 2012;14:622-632. 2. Millis DL, Drum M, Levine D. Therapeutic exercises: joint motion, strengthening, endurance, and speed exercises. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014:506-525. 3. Price H. Feline physiotherapy. Companion Anim 2014;19(7):374-378. 4. Ellis S. The Veterinary Nurse workshops 2015: feline patients and stress. Vet Nurse 2015;6(2):78-82. 5. Mercado JL. Nursing the feline patient. Vet Nursing J 2009;24(11):21-23. 6. Gaultier E, Pageat P, Tessier Y. Effect of a feline appeasing pheromone analogue on manifestations of stress in cats during transport. 32nd Cong Intl Soc Appl Ethology; 1998:198. 7. Pereira JS, Fragoso S, Lavigne S, Beck A, et al. Proc 2014 Intl Cong Semiochemistry Manag Anim Pop 2014:89-90. 8. Rychel JK. Diagnosis and treatment of osteoarthritis. Topics Companion Anim Med 2010;25(1):20-25. 9. Drum MG, Bockstahler B, Levine D. Feline rehabilitation. Vet Clin Small Anim 2015;45:185-201. 10. Sharp B. Feline physiotherapy and rehabilitation: 2. Clinical application. J Feline Med Surg 2012;14:633-645. 11. Hardie EM, Roe SC, Martin FR. Radiographic evidence of degenerative joint disease in geriatric cats: 100 cases (1994-1997). J Am Vet Med Assoc 2002;220:628-632. 12. Bennett D. Feline osteoarthritis 1: what is it and how can the veterinary nurse help in its recognition? Feline Focus 2015;1(10):349-357. 13. Epstein M, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain management guidelines for dogs and cats. J Am Anim Hosp Assoc 2015;51:67-84. 14. Brondani JT, Luna SPL, Padovani CR. Refinement and initial validation of a multidimensional composite scale for use in assessing acute postoperative pain in cats. Am J Vet Res 2011;72(2):174-183. 15. Brondani JT, Mama KR, Luna SPL, et al. Validation of the English version of the UNESP-Botucatu multidimensional composite pain scale for assessing postoperative pain in cats. BMC Vet Res 2013;9:143. 16. Musk G. Understanding cats. J Small Animal Pract 2014;55:601-602. 17. Benito J, Hansen B, DePuy V, et al. Feline musculoskeletal pain index: responsiveness and testing of criterion validity. J Vet Intern Med 2013;27:474-482. 18. Bennett D. Feline osteoarthritis 2: managing the cat with painful osteoarthritis. Feline Focus 2015;1(11):383-391. 19. Raditic DM, Bartges JM. The role of chondroprotectants, nutraceuticals, and nutrition in rehabilitation. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014: 254-276. 20. Scarlett JM, Donoghue S. Associations between body condition and disease in cats. J Am Vet Med Assoc 1998;212:1725â&#x20AC;&#x201C;1731. 21. Rand JS, Marshall R. Diabetes mellitus in cats. Vet Clin North Am Small Anim Pract 2005;35:211-224. 22. Linder D. How to implement and manage a weight loss plan. Vet Nurse 2014;5(4):216-219. 23. Downing R. The role of physical medicine and rehabilitation for patients in palliative and hospice care. Vet Clin Small Anim 2011;41:591-608. 24. Sutton A, Whitlock D. Massage. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014: 464-483. 25. Corti L. Massage therapy for dogs and cats. Topics Companion Anim Med 2014;29(2):54-57. 26. Millis DL, Levine D. Range-of-motion and stretching exercises. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014:431-432. 27. Siddens AD. Rehabilitation techniques for the veterinary technician. Vet Team Brief August 2014: 8-10. 28. Sprague S. Introduction to canine rehabilitation. In: Zink CM, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: Wiley-Blackwell; 2013:88. 29. Niebaum K. Rehabilitation physical modalities. In: Zink CM, Van Dyke JB, eds. Canine Sports Medicine and Rehabilitation. Ames, IA: Wiley-Blackwell; 2013:115-131. 30. Millis DL, Saunders DG. Laser therapy in canine rehabilitation. In: Millis DL, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Elsevier; 2014:359-380. 31. Medina C, Robertson S. Non-pharmacological pain management in cats. Feline Focus 2015;1(6):195-199. 32. Manbachi A, Cobbold RSC. Development and application of piezoelectric materials for ultrasound generation and detection. Ultrasound 2011;19(4):187-196. 33. Bockstahler B, Levine D. Physical therapy and rehabilitation. In: Norsworthy GD, ed. The Feline Patient. 4th ed. Ames, IA: John Wiley & Sons; 2011:687-690. 34. Jackson AM, Millis DL, Stevens M, Barnett S. Joint kinematics during underwater treadmill activity. Proc 2nd Int Symp Rehab Phys Ther Vet Med 2002:191.

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What Moves You?

Knowledge and Discovery Kathi L. Smith, RVT, VTS (Oncology) Portland Veterinary Specialists Portland, Maine I’ve never considered myself a writer. It’s not something that I’m comfortable doing. So the first time Lynne Johnson-Harris (aka editor in chief of Today’s Veterinary Technician) asked me to write about what moves me as a veterinary technician, my answer was a resounding “NO.” “I’m not a writer,” I said. She said, “Please?” The second time she asked, I said again, “I’m not a writer,” and again, she said, “Please?” Well, Lynne isn’t just the editor in chief, she’s also a great friend to whom I owe a great deal, both personally and professionally. I thought about all the times she has said “yes” to me. So here I am.

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!

“If I hadn’t taken those leaps of faith and stepped out of my comfort zone, none of those opportunities would have been possible.” —Kathi L. Smith

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Love of Learning Learning moves me. Each day I seek to learn something new. That wasn’t always the case. Many times in my past, I didn’t take opportunities that were afforded me, and as the adage goes, you don’t regret the things you did, you regret the things you didn’t do. As veterinary technicians, we can get into a rut of doing the same thing day after day. If we don’t challenge ourselves, push ourselves, and motivate ourselves, boredom, burnout, and regret can set in. For many years, I did my job and did it well, but I didn’t necessarily know the “who, what, when, and whys” of it. Then I had an epiphany. Suddenly, I wanted to know everything. I learned to ask questions—like a 5-year-old. When I started working with my doctor (who is one of the smartest people I know), I asked a million questions. Every day. To the point that she would look at me and say, “Stop talking.” I started reading, voraciously. Journals, texts, online searches, you name it, I read it. It was amazing how things started to click in my head. I started looking at my job in a whole new light. It was more exciting, more interesting, and more personally satisfying. I now have my own library at home that focuses on my favorite specialties. My husband says I’m not allowed to go to the book section at conferences without adult supervision. I have learned to delve into diseases like a detective. When a patient comes in with a condition unfamiliar to me, I read about it to understand it better. I have gained confidence through reading and researching. Learning energizes me. It makes me a better technician and employee. I have more to contribute, I know that my doctor and teammates value my expertise, and I am ready to teach and council clients. Love of Challenges Challenging myself moves me. That wasn’t always the case either. Like I said, it’s easy to get into a rut. However, after having many years of being a technician under my belt, I felt like I needed to do something. I wasn’t quite sure what, but I knew I needed to stoke the old fires. My career was in the “burning ember” phase. I wasn’t unhappy with what I was doing or where I was, I just wanted to add to it. So I decided to jump into the deep end of the pool.

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TECHPOI NT 

What Moves You?

If we don’t challenge ourselves, push ourselves, and motivate ourselves, boredom, burnout, and regret can set in.

Love of the Profession I am grateful to be a dinosaur in the world of veterinary medicine. I’m from an age that used Unopette and hemocytometers to do CBCs; thiopental, Metofane, and esophageal stethoscopes for anesthesia and monitoring; and dunk tanks for developing radiographs. I have witnessed incredible advances in the diagnostics and treatment of diseases that are on par with those in human medicine. Through it all, I’ve never lost my wonder at the field of veterinary medicine. For example, venipuncture never ceases to amaze me. It totally moves me even after all these years. Especially on really hairy or obese patients, when you can’t actually see or feel the vein, but you know where it should be and the needle just slides in like butter. I’d be lying if I didn’t admit that I like having people ask me to “hit the vein” that they either haven’t been able to get or don’t even want to try. Lastly, knowing that I’ve made a difference in a patient’s life moves me. When a client comes in knowing that their beloved pet will most likely succumb to its disease, I want them to know I care. That I’m able to answer their questions, no matter how trivial they seem or how many times they’ve asked the same one. When they aren’t sure how to handle a specific situation, they know that I’m part of a team made up just for them at that moment and help is always there. That I’m able to help provide the best quality of life for as long as possible and, when the time comes, to help them make that difficult decision to humanely intervene, and know I’m still there for them. For these reasons and many more, just being a veterinary technician moves me. 

Love of the Laboratory Laboratory studies move me. When I first moved to Maine in 1992, my husband worked at IDEXX in customer service and tech support. As they developed new products, the hospital I worked at (and still do) had the opportunity to

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Knowledge and Discovery

test all the latest kits and machines. We were able to give instant feedback and play an integral part in the advancement of diagnostics. To this day, all I have to hear is, “Would you be willing…?” and I get excited because I know eventually something valuable will come from it. I love cytology. If I could aspirate masses all day and look at them under the microscope, that would be my perfect job. There is nothing more exciting than getting an excellent diagnostic specimen (to me, anyway). I love looking at cellular characteristics. I love trying to evaluate whether it’s a benign condition or a malignancy. I love knowing that I have a good-quality sample and that I’m helping the doctor give the client a better idea of the diagnosis and prognosis while they wait for the pathologist’s confirmation. I even love the fact that my teammates tease me about my very specific lab procedures. It’s okay—I know why I do things the way I do them. It’s totally logical. As I have always said, “Do you want an answer or the answer?” I stand firm in my neuroses.

The first 12 feet I jumped into was being part of the formation of the Veterinary Technician Cancer Society. I even went on to become the president. Since that time, I’ve also been a charter member in the oncology specialty of the AIMVT (Academy of Internal Medicine for Veterinary Technicians), a member of the AIMVT Executive Board, and the president of the academy in 2010. (Apparently my bossiness can be an asset when it’s used correctly!) The next jump was more like a cannonball. I was asked to speak to a group of Canadian technician students on hematology. At that time, the idea of public speaking was not even on my radar. That was for all the other really smart technicians whose sessions I attended at conferences. Well, I had another epiphany: Public speaking could be a HUGE new challenge. Have you ever have words spill out of your mouth that you were powerless to stop? That was exactly the situation. I said “yes.” Still, although I had a pretty good background in hematology and loved it, I was worried that I had to speak for 4 hours. I felt like I’d been asked to solve world peace. I couldn’t imagine coming up with 4 hours of information and delivering it in a fashion that would keep someone awake. But once I started researching everything I would want to learn about hematology, things just flowed like honey on my oatmeal. Challenge and learning in one fell swoop! Life was good…until I got to Canada and was informed that the students hadn’t had any hematology yet. My 4 hours went really fast, and I did their entire semester on hematology in an afternoon. I have since had the privilege of sharing my love of hematology, cytology, oncology, and infectious diseases with technicians at numerous outstanding national conferences. If I hadn’t taken those leaps of faith and stepped out of my comfort zone, none of those opportunities would have been possible.

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ARTICLE 1 CR E DIT

Opposite Ends of the Life Cycle, Similar Anesthetic Needs

ompared with young adult patients—and with each other—geriatric and pediatric patients have differences in physiology, pharmacology, and anatomy. Yet their anesthetic needs are often very similar to each other. These cases should be considered challenges for the anesthetist. Veterinary technicians should be knowledgeable not only about how to provide the optimum anesthetic experience, but also about the reasons behind these actions. This article outlines special concerns for pediatric and geriatric patients, but it is important to note that all comorbidities in an individual patient must be taken into consideration when assessing anesthetic risk and designing an anesthetic protocol for any patient, regardless of age. A full examination of all aspects of anesthesia is beyond the scope of a single article; interested readers are recommended to consult the cited references for further details.

CLASSIFYING ANESTHETIC RISK IN PEDIATRIC AND GERIATRIC PATIENTS Most veterinary technicians realize that geriatric patients need specialized care under anesthesia. Often, pediatric patients are considered healthy and expected to handle anesthesia well. But nothing could be further from the

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

Brenda graduated from Michigan State University, one of the first veterinary technician programs in the United States. She has worked in private practice, a university anesthesia department, and specialty practices during her career. She is not only a board member at large of the Academy of Veterinary Technicians in Anesthesia and Analgesia, but also a member of the academy’s examination, preapplication, and conference committees. She is married to Doug, a retired veterinarian, with three grown children and a growing number of grandchildren! Doug and Brenda share their house with a rescue Westie mix. Brenda is a frequent speaker at major conferences and teaches online anesthesia classes. In her spare time, she likes to rollerblade and read nonfiction.

To view the CE test for this article, please visit todaysveterinarytechnician.com.

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truth. In reality, the anesthetic needs of both pediatric and geriatric patients are more closely related to those of critical patients, but often for very different reasons. The reason for anesthesia is one factor to consider in determining a patient’s anesthetic risk. Underlying disease that could affect the patient’s reaction to anesthesia is another. All patients scheduled for surgery should be assessed to determine their physical status and corresponding anesthesia risk classification according to the American Society of Anesthesiologists (ASA) classification system (BOX 1). While age is not a disease and, unlike organ dysfunction or comorbid disease, does not automatically place a patient in a higher ASA class, it is a risk factor in morbidity and mortality.1 The argument can be made to classify healthy pediatric and geriatric patients as either ASA I or ASA II, but because of their special needs, pediatric and geriatric patients presenting for routine surgery without any comorbidities are generally classified as ASA II. DIFFERENCES BETWEEN PEDIATRIC AND YOUNG ADULT PATIENTS Pediatric patient is a general term used to describe a puppy or kitten from weaning age (approximately 8 weeks) to around 12 weeks old. Because different breeds mature at different rates, this is a general range. The

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Geriatric and pediatric patients have differences in physiology, pharmacology, and anatomy. Yet their anesthetic needs are often very similar to each other.

shutterstock.com/Vasek Rak

CE Article | Opposite Ends of the Life Cycle, Similar Anesthetic Needs

neonatal period—from birth to weaning, or at least 4 weeks of age—is not covered in this article.

immature respiratory chemoreceptors do not respond to increased carbon dioxide or decreased oxygen levels as mature ones in adult patients do. Pediatric patients are therefore at a respiratory disadvantage. Compared with healthy adults, they have increased respiratory rates, lower functional residual capacity (FRC), and an increased oxygen demand, which makes them prone to respiratory fatigue and hypoxemia while under anesthesia.1

Respiratory The pediatric thoracic cage is still pliable, and the intercostal muscles are immature and weak. As a result, pediatric patients have to work harder and use more pressure to maintain a normal tidal volume.1 In addition,

BOX 1 American Society of Anesthesiologists Physical Status Scalea Class I

Class IV

 Minimal risk

 High risk, significantly compromised by disease

 Normal healthy animal, no underlying disease

 Animal with preexisting systemic disease or disturbance of a severe nature

Class II

 Severe dehydration, shock, uremia, toxemia, high fever, uncompensated heart disease, uncompensated diabetes, pulmonary disease, emaciation present

 Slight risk, minor disease present  Animal with slight to mild systemic disturbance, able to compensate

Class V

 Neonate, geriatric animal, obese animal

 Extreme risk, moribund

Class III

 Animal with life-threatening systemic disease

 Moderate risk, obvious disease present  Animal with moderate systemic disease or disturbances, mild clinical signs

 Advanced case of heart, kidney, liver, or endocrine disease; profound shock; severe trauma; pulmonary embolus; terminal malignancy

 Anemia, moderate dehydration, fever, low-grade heart murmur, or cardiac disease present

“E” denotes emergency.

American Society of Anesthesiologists (ASA) Physical Status Scale. avtaa-vts.org/asa-ratings.pml. Accessed September 2016.

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Veterinary technicians should be knowledgeable not only about how to provide the optimum anesthetic experience, but also about the reasons behind these actions.

Cardiovascular Pediatric patients have naturally lower blood pressure, blood volume, and systemic peripheral resistance than adult patients. Immature baroreceptors depress the ability of the vascular system to constrict in response to lower heart rates to maintain cardiac output, so these patients rely more on heart rate to maintain blood pressure and tissue perfusion than adults.1 Pediatric patients also have a large percentage of noncontractile cardiac mass and low ventricular compliance.2 These characteristics result in a fixed stroke volume, causing increases in preload and afterload to be poorly tolerated. Hepatic Immature hepatic metabolism has several implications for anesthesia in pediatric patients. First, these patients are often hypoalbuminemic; therefore, drugs that are highly protein bound, such as ketamine, opioids, and propofol, have a more profound effect.3 Second, the immature liver decreases the capacity for drug distribution, which may prolong the effect of the drug.3 Because most drugs used in anesthesia are either protein bound or eliminated by the liver, lower dosages of all drugs should be used in pediatric patients. Third, the liver plays a role in regulating insulin,3 so while most pediatric patients have a normal blood glucose level, their glycogen stores are low. If a pediatric patient becomes stressed or is fasted, it can quickly become hypoglycemic.1 Renal The kidneys of pediatric patients have not yet reached the adult glomerular filtration rate (GFR), which decreases their ability to concentrate urine.3 Decreased GFR calls for a higher fluid rate during anesthesia, but pediatric patients may also have limited renal clearance and, as mentioned, preexisting hypoalbuminemia. These two factors require restriction of high fluid rates during surgery because the kidneys may not be able to clear the urine and

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overhydration can cause a dilution of serum protein. Ensuring a normal fluid rate and refraining from administering fluid boluses to combat hypotension are good rules to follow with pediatric patients.2 The American Animal Hospital Association and the American Association of Feline Practitioners have published excellent fluid therapy guidelines for all patients (BOX 2).4 Other Factors Pediatric patients have a naturally lower hematocrit, creating the risk of mild hemorrhage resulting in anemia.2 They also have a high metabolic rate, a low body fat percentage, an immature thermoregulatory system, a high body surface area to mass ratio, and poor vasomotor control.2,5 All of these factors make them very susceptible to hypothermia, which leads to a slower recovery in all patients. Prevention is the key. Steps to avoid hypothermia are outlined during the discussion of anesthetic protocols for geriatric patients. DIFFERENCES BETWEEN GERIATRIC AND YOUNG ADULT PATIENTS At the other end of the life cycle, a patient is considered geriatric when it has completed 75% to 80% of its expected life span.3 Life spans vary greatly between species and among breeds of dogs. A cat or small dog is

BOX 2 Fluid Therapy Guidelines for Dogs and Cats In 2013, the American Animal Hospital Association (AAHA), along with the American Association of Feline Practitioners, published fluid therapy guidelines for dogs and cats. These guidelines stress that the fluid rate for each patient should be calculated according to the patient’s needs, not chosen as a set rate, and that feline patients require less fluid per pound than canine patients because of their lower total body fluid. The 2013 guidelines no longer support the 10 mL/kg/h rate for patients under anesthesia and instead suggest formulas for calculating a rate based on the patient’s specific need. The key is that blood pressure and coexisting conditions should be a guideline to hydrating patients under anesthesia. These guidelines are well worth reading and should be considered when calculating fluid rates. They can be downloaded at no cost from the AAHA website (aaha.org/public_documents/professional/guidelines/fluid_therapy_guidelines.pdf).

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ď Ź

T E C HP O I N T ď Ź

CE Article | Opposite Ends of the Life Cycle, Similar Anesthetic Needs

Pediatric patient is a general term used to describe a puppy or kitten from weaning age (approximately 8 weeks) to around 12 weeks old.

on the list of concerns. Valvular heart disease, dilated cardiomyopathy, pericardial disease, arrhythmias, and systemic hypertension are common in geriatric patients.1 Geriatric cats are prone to hypertrophic cardiomyopathy. Blood pressure concerns in geriatric patients include both hypotension and hypertension. During the history and physical examination, it is important to note any exercise intolerance, arrhythmias, abnormal pulses, murmurs, or other cardiac-related signs. Electrocardiography is advisable if any cardiac abnormalities are noted during the examination. It may be prudent for some patients to undergo a cardiac workup with a cardiologist before anesthesia.

generally expected to have a longer life span than a giant breed of dog. Therefore, the age at which a patient should be considered geriatric depends on the individual. Geriatric patients often require surgery because of a disease process, and this factor needs to be taken into consideration when crafting the anesthesia protocol. Think of a geriatric patient like an old car. It may still be running just fine, but under the hood, there will be some wear and tear. A minor issue can result in a major disturbance.

Hepatic Geriatric patients may have a decrease in liver mass, hepatic blood flow (a result of reduced cardiac output), albumin production, and clotting factors.3 These deficiencies can result in hypoproteinemia, hypoglycemia, hypothermia, and coagulopathies. Renal Hypertension in cats is often associated with chronic renal disease6; therefore, obtaining a preoperative blood pressure is imperative for geriatric cats. Because the kidney has no regenerative capacity, renal reserve decreases with age. Reduced renal blood flow due to cardiovascular changes may result in a lower number of glomeruli and nephrons. This decrease can cause a 50% decrease in GFR. Physiologic tubular changes lead to a decreased ability to concentrate urine, making the patient more dependent on fluid intake and unable to tolerate fluid excess or deficit.6

Respiratory Two of the most common respiratory issues in geriatric patients are weakening of the intercostal muscles and loss of lung elasticity. In addition to pulmonary fibrosis, which is common, this results in decreased elastic recoil of the lungs and chest wall compliance.1 This, in turn, results in a lower lung capacity and FRC and predisposes the patient to atelectasis during prolonged recumbency.1 Atelectasis is a reduced volume or lack of air in all or part of the lung due to collapsed alveoli. Atelectatic lung tissue therefore contains very little oxygen. Some degree of atelectasis is common in anesthetized patients, but because atelectasis can result in hypoxemia, efforts should be made to avoid it. Geriatric patients may also have decreased pulmonary diffusion capacity and capillary blood volume and an increase in airway resistance.1 These changes may lead to hypoxemia due to reduced efficiency for expiration and gas exchange.

Other Factors Geriatric patients have sarcopenia (a decrease in muscle mass) and an increase in the fat to lean muscle ratio. This change in body composition is seen in all geriatric patients regardless of body condition score.3,5 Obesity in geriatric patients poses a challenge because landmarks for epidurals may be hidden under a layer of adipose tissue. If drug doses are not decreased to reflect ideal body weight, the increased fat to lean muscle ratio may prolong drug redistribution.3 Osteoarthritis and spondylosis can also distort anatomy, making it a challenge to find the epidural space and adding to the need for gentle positioning during surgery.3 Geriatric patients should be considered to have arthritis regardless of whether it is recognized and being currently treated.2 They should be given extra padding in cages at all times, and during positioning for surgery, the joints should be handled with care and gentle restraint.

Cardiovascular The heart undergoes changes during the aging process that may include ventricular thickening, valvular calcification, and myocardial fibrosis.1 These changes prevent the heart from moving blood as efficiently as it once did and predispose geriatric patients to cardiac arrhythmias.1 Decreased baroreceptor activity, circulation time, blood volume, and cardiac output all lead to decreased cardiac reserve in these patients.1 Therefore, the potential for cardiopulmonary disease should be high TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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TABLE 1 Physiologic Characteristics of Pediatric and Geriatric Patients and Their Implications for A AFFECTED SYSTEM

PHYSIOLOGIC DIFFERENCE FROM YOUNG ADULT Pediatric

Geriatric

Respiratory

Lung and chest walls are very compliant, predisposing patient to respiratory fatigue Oxygen consumption demand is 2–3 times greater Resting respiratory rate is high (20–36 breaths/min), making patient prone to hypoxia and rebreathing carbon dioxide

Lung elasticity, tidal volume, and minute volume are reduced Intercostal muscles are weaker Protective airway reflexes are reduced

Cardiovascular

Heart has limited ability to increase stroke volume; therefore, cardiac output is heart rate dependent

Cardiac reserve, blood volume, and cardiac output are reduced Underlying arrhythmias may surface due to stress

Hepatic

Plasma protein levels are low Immature hepatic enzyme pathways produce exaggerated effects and longer duration of action of protein-bound drugs

Cardiac output and hepatic blood flow are reduced

Renal

Kidneys have not reached normal capacity

Reduced renal function and blood flow Predisposed to acidosis

Metabolic

Metabolic rate is high Glycogen stores are limited Gluconeogenic ability is poor

Lean body mass is decreased Body fat is increased

Thermoregulatory

Subcutaneous fat stores are low Surface area to body mass ratio is high Thermoregulatory function is poor

Decreased ability to regulate body temperature1

Other

Hemoglobin content is lower

Predisposed to cognitive dysfunction; anxiety is common in unfamiliar surroundings May already be on multiple other drugs Osteoarthritis is likely Ability to protect airway is reduced

The surgery table should be padded, and recovery should take place in a warm area with lots of padding. Many geriatric patients have some degree of cognitive dysfunction that can be exacerbated by unusual surroundings, such as the animal hospital. ANESTHETIC PROTOCOLS Like all patients undergoing anesthesia, both pediatric and geriatric patients require patient-specific anesthetic protocols. One size does not fit all. TABLE 1 summarizes specific considerations that should be taken into account for these patients. 24

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Pediatric Patients Preanesthetic Considerations Pediatric patients have a high metabolic rate; therefore, they should not be fasted for longer than 2 hours.2,5 When they arrive at the clinic, the time of their last meal must be determined, and if surgery will not take place within 2 hours of the last meal, they should be fed a small amount every 2 hours until surgery. Water should not be withheld. The blood glucose level should be measured as part of the preoperative blood work, then followed up every 60 minutes during anesthesia and postoperatively. If the veterinarian determines

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CE Article | Opposite Ends of the Life Cycle, Similar Anesthetic Needs

tions for Anesthesia CLINICAL RELEVANCE Pediatric

Geriatric

Use non-rebreathing systems and reduce dead space to reduce resistance to breathing Avoid barotrauma Intubate gently Provide IPPV Preoxygenate if it does not stress patient Obtain control of the airway quickly

Monitor ventilation, oxygenation, and tidal volume Provide IPPV Preoxygenate if it does not stress patient Obtain control of the airway quickly

Have anticholinergic calculated and ready to administer if needed perioperatively

Avoid drastic changes in heart rate and blood pressure by avoiding or reducing doses of drugs that affect both. Drugs that should be used only with caution include ketamine, anticholinergics, and alpha-2 agonists. Minimize stress Use anticholinergics only if heart rate is too low to support blood pressure

Consider drugs that have a reversal agent and are short acting A pure mu opioid may be sufficient for sedation in premed Use lowest end of dosage range Administer induction agents to effect

Preanesthetic testing of liver function a must Prolonged drug metabolism may occur Clotting time may be increased Avoid drugs that have a long duration of action Reduce dosages of drugs that are protein bound Administer intraoperative fluids and avoid hypotension that would further reduce blood flow to liver

Cannot tolerate fluid overload; consider syringe pump to administer fluids and avoid fluid boluses

Preoperative biochemistry/electrolyte testing a must Avoid drugs cleared by kidneys (ketamine in cats); NSAID use should be cautious Avoid reduction in renal blood flow Monitor urine production IV fluids a must

Do not fast patients more than 2 hours Test blood glucose before and during surgery Consider adding glucose to IV fluids Feed patients as soon as they are alert

Duration of action of drugs may be prolonged; choose drugs that have a short duration of action or a reversal agent and use the low end of the dosage Look for drugs that have few side effects If blood glucose is low, add glucose to IV fluids

All factors contribute to hypothermia; therefore, keep patients warm from their arrival at the hospital until they go home

Ensure the patient has access to warming devices at all times (in cage and during prep, surgery, and recovery)

More likely to need transfusions with small amount of blood loss2 Calculate blood loss, place 2 catheters if hemorrhage is likely, and have blood products on hand to administer2

Sedatives help reduce anxiety; keep patient routine as normal as possible (e.g., send home same day if possible); go slowly when approaching these patients Check for adverse drug interactions (e.g., steroids and NSAIDs) Use lots of padding in the kennel and on the surgery table Be gentle with the joints Do not extubate until the patient has control of its airway, treat any abnormality immediately to prevent decompensation

that the patient is hypoglycemic, dextrose can be added to IV fluids to create a 2.5% or 5% solution. It is important that these patients be fed as soon as they are up and alert. Pediatric patients should be weighed accurately on the day of surgery so drug doses are accurate. Puppies and kittens can grow at an incredible rate during this stage of life. An IV or intraosseous catheter should be placed before surgery.

nonsteroidal anti-inflammatory drugs (NSAIDs). Pure mu opioids provide excellent analgesia and may provide sedation alone in pediatric patients owing to incomplete metabolism by the immature liver.3,5 Opioids are proteinbound drugs, so the low end of the dosage range should be considered and the patient carefully monitored for a reduction in heart and/or respiratory rate. The pros outweigh the cons for this class of drugs, but side effects may need to be addressed. When local blocks are used in small patients, care must be taken to avoid overdosing. NSAID use is acceptable in pediatric patients at 25% to 50% of the

Drug Choices Pediatric patients feel pain and should receive analgesia in the form of pure mu opioids, local blocks, and TODAY’SVETERINARYTECHNICIAN

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adult dose; however, age restrictions for individual drugs should be checked before use. When considering preanesthetic drugs, keep doses on the low end of the dosage range, attempt to avoid drugs that reduce heart rate, and use drugs that have a reversal agent. Additional doses can always be administered to achieve the desired effect if needed. Unlike their effect in adult patients, benzodiazepines often produce sedation. They have little effect on the cardiovascular system and provide good skeletal muscle relaxation. Flumazenil is the reversal agent for benzodiazepines. Many other drugs, such as acepromazine, are not contraindicated, but their side effects must be weighed against their benefits. For example, acepromazine is metabolized by the liver, has no reversal agent, and causes vasodilation, which can lead to hypotension and hypothermia. In the past, it has been recommended that an anticholinergic agent be used as part of the premedication for pediatric patients, but this practice is now under debate. While it is not incorrect to administer an anticholinergic to a pediatric patient, there is currently very little research to support it. If not used in premedication, an anticholinergic can be considered for use during surgery to counteract bradycardia, with a dose precalculated and all equipment ready for administration at a moment’s notice. Inhalant agents are preferred3 because they are noncumulative and anesthetic depth can be easily adjusted.2 Anesthetic depth can change rapidly, and the patient should be monitored vigilantly to ensure adequate depth.2 There has been little research in veterinary patients, but human infants have a larger ratio of alveolar ventilation to FRC, which results in faster induction when gas inhalants are used.1 Respiratory Considerations Pediatric patients have large tongues, can be difficult to intubate, and have a naturally low hemoglobin concentration, so preoxygenation is recommended if it does not stress the patient.2,3 A fast-acting, rapidly distributed induction drug should be used to obtain rapid control of the airway. Commonly used agents include ketamine/midazolam, propofol, alfaxalone, or etomidate. In general, no induction drugs are contraindicated for use in healthy pediatric patients. If the patient has a comorbid condition, this must be taken into consideration when creating the anesthetic protocol. A cuffed endotracheal tube is always recommended to protect the patient’s airway. A 2- to 3-mm endotracheal tube should be adequate for most small pediatric patients.2 The tracheal tissue and larynx are fragile, so care should be taken when intubating these patients.1 26

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The ideal placement of an endotracheal tube is for the distal end to be at the thoracic inlet and proximal end at the level of the incisors. Pediatric patients benefit from the use of nonrebreathing systems, which provide little resistance to breathing by eliminating one-way valves and the carbon dioxide absorbent canister. Dead space should be minimized by trimming the endotracheal tube to size (the ideal placement of an endotracheal tube is for the distal end to be at the thoracic inlet and proximal end at the level of the incisors) and eliminating nonessential extras in the anesthesia circuit such as elbows and respiratory monitors. However, non-rebreathing systems require high oxygen flow rates (150–500 mL/kg/min). This is in contrast to rebreathing, or circle, systems, which typically require an oxygen flow rate of 20 to 22 mL/kg/min. Higher oxygen flow rates can dry and cool the respiratory tract and accelerate temperature loss. Pediatric patients often require intermittent positive pressure ventilation (IPPV).3 They are prone to respiratory fatigue because the thoracic cage is still pliable and the intercostal muscles are not fully developed. Mechanical ventilation is not required, but as few as 1 to 4 assisted breaths per minute can provide adequate oxygen, minimize atelectasis, and remove carbon dioxide from the lungs. Only gentle pressure is needed. If a rebreathing system with a manometer is being used, ensure that the pressure does not exceed 10 to 12 cm H2O. If a manometer is not used, during surgical prep, give the patient a small breath while watching the chest expand to determine an adequate breath, taking care to not overextend the lungs. Monitoring end-tidal carbon dioxide (ETCO2) enables the anesthetist to determine the adequacy of IPPV. Hypothermia Prevention Minimize heat loss! It is much harder to regain body temperature than it is to maintain it. Pediatric patients have little body fat, a high body surface area to mass ratio, and a high metabolic rate. They should have a heat source available before surgery and be on a veterinary-approved

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CE Article | Opposite Ends of the Life Cycle, Similar Anesthetic Needs

Cuff size has a dramatic effect on accurate blood pressure reading; using a cuff with a width that is 30% to 40% of the circumference of the limb will provide a more accurate reading.

adapters, which produce a smaller dead space volume and deliver a more accurate reading, should be used. All patients require IV fluids under anesthesia, including pediatric patients. However, because pediatric patients have low hemoglobin concentrations and immature kidneys, it is especially important to not over- or underhydrate them.2 The heart, which has a stiff myocardium at this stage, cannot respond to fluid loading as an adult heart can.3 Overhydration can therefore lead to pulmonary edema. Monitor the patient, not the monitor. Assess pulses, mucous membranes, and capillary refill time regularly. Always monitor more than one parameter before making a judgment. An esophageal stethoscope can be a very effective monitor to auscult heart and respiratory rates in these small patients.

heat support system during prep, while in surgery, and postoperatively. An adult patient can lose up to 2°F in body temperature during surgical prep, and pediatric patients can lose even more. Ways to can minimize heat loss include wrapping extremities in bubble wrap, warming prep solutions, using appropriate warming devices from premedication through recovery, keeping anesthesia time to a minimum, and warming IV fluids close to the body with inline fluid warmers.

Postoperative Care Postoperative care is essential to a positive outcome. Keeping patients warm during recovery is crucial. Incubators are a good option for pediatric patients; some also supplement oxygen. Other approved veterinary warming devices, such as circulating warm water blankets or warm forced air blankets, should be used if the patient is hypothermic, but care must be taken to avoid thermal burns, which can occur quickly in pediatric patients because of their thin skin and lack of subcutaneous fat. Once the patient is fully alert and able to move about the cage, warm water bottles or similar devices can be used. Treatment of pain is imperative. Food should be offered as soon as the patient is alert and able to eat in a normal manner and at regular intervals until the patient is sent home.

Monitoring Considerations Diligent monitoring is crucial to a positive outcome. Puppies and kittens have higher heart rates (~200 bpm) and respiratory rates (15–35 breaths/min) but lower blood pressures than adult patients.5 A mean arterial pressure of 55 mm Hg is acceptable in pediatric patients.2 It is important to obtain a heart rate and respiratory rate before administration of any drugs to establish what is normal for the individual patient. It can be a challenge to obtain blood pressures in pediatric patients. Doppler readings may show something closer to mean arterial pressure, and many oscillometric units can be unreliable in smaller patients. Cuff size has a dramatic effect on accurate blood pressure reading; using a cuff with a width that is 30% to 40% of the circumference of the limb will provide a more accurate reading. Unless a direct arterial blood pressure is obtained, blood pressure readings are estimates and should be viewed as trends rather than exact numbers. ETCO2 readings can be difficult to obtain because of the small tidal volume and high oxygen flow rates used in pediatric patients. An artificially low ETCO2 is often observed when using high oxygen flow rates or adult monitors on pediatric patients. If possible, pediatric TODAY’SVETERINARYTECHNICIAN

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Geriatric Patients Preanesthetic Considerations At the other end of the spectrum, geriatric patients have their own concerns. These patients often do not hear or see as well as they once did, so they should be approached slowly to avoid startling them. They must be handled gently and require extra time and effort owing to a variety of issues, such as cognitive disorder. Clues to cognitive disorder include owners stating that the pet is suddenly “cranky,” having accidents in house, or becoming lost in its regular surroundings. Geriatric patients thrive on routine, and if possible, these patients benefit from being in the hospital for as little time as medically necessary. They do best in their home surroundings with their normal routine and may recover better at home,3 if their release is not contraindicated because of their individual medical needs. Having them come in early in the morning |

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and scheduling their surgery as the first procedure of the day may allow them to return home the same day. Because of their age, the organs of geriatric patients may not work as efficiently as they once did and may have some degree of irreversible dysfunction. Organ dysfunction that could affect anesthesia should be identified by obtaining preoperative blood test results. A sobering fact to remember is that 60% of kidney function must be lost before renal dysfunction shows up in blood work.5 Preanesthetic liver function tests are essential for geriatric patients. A low total protein necessitates a reduction in doses of protein-bound drugs. If low blood glucose is noted, it may be prudent to start fluids containing dextrose to prevent hypoglycemia. Because reduced cardiac output already reduces hepatic blood flow in these patients, hypotension should be avoided to prevent further liver damage. It is best to stabilize these patients before anesthesia. Drugs with minimal cardiovascular and respiratory side effects are preferable. Reducing drug dosages based on the suspicion of at least some hepatic dysfunction is warranted. Additional drug can be administered if required. Patients with laryngeal paralysis and patients that are nervous and pant are prone to hyperthermia.3 These patients may benefit from a maintenance dose of IV fluids to prevent dehydration while waiting for surgery. IV access in these patients is a must to allow titration of drugs to effect and rapid response in an emergency. Drug Choices As with any patient, balanced anesthesia is the best option, and no one protocol is perfect for every geriatric patient. The patient’s history, physical examination findings, blood work results, hydration status, and blood pressure must be taken into account to design an individual protocol. Decreases in brain size, loss of neurons, increased cerebrospinal fluid volume, and depleted neurotransmitters in geriatric patients require reduced doses for most drugs used in anesthesia.1 Local and regional blocks allow for lower doses of other analgesic and maintenance drugs. Premedication is a must. Extremely low doses of acepromazine (0.01 mg/kg)3 may be acceptable in some anxious pets. However, acepromazine has no reversal agent and can cause splenic engorgement, so it is not the best option for patients undergoing abdominal surgery.2 Another potential adverse effect is vasodilation, which may lead to hypotension, so its use should be evaluated carefully. Although benzodiazepines can provide sedation in some geriatric patients, paradoxical excitement may also 28

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The patient’s history, physical examination findings, blood work results, hydration status, and blood pressure must be taken into account to design an individual protocol. occur. Benzodiazepines have a reversal agent, so adverse reactions can be managed. Opioids are a good choice, and some debilitated patients can be sedated with only an opioid premedication. Alpha2-adrenergic agonists, such as dexmedetomidine, are not absolutely contraindicated in geriatric patients, but they do produce profound cardiovascular effects at any dosage, so their benefits must be weighed against any potential adverse effects.5 Inhalant agents are used for most surgeries. These agents have a dose-dependent negative effect on blood pressure, ventilation, cardiac contractility, and body temperature, so keeping the vaporizer at the lowest possible setting during surgery is beneficial. Administration of additional analgesics during surgery either IV or via constant rate infusion may assist in this goal. As a patient’s body temperature drops, so does the need for gas inhalants. If a patient becomes hypotensive, a reduction of the vaporizer setting should be the first consideration. In very critical cases, the inhalant may be discontinued and the patient kept under a surgical plane of anesthesia using total intravenous anesthesia. Anticholinergics are not warranted as a premedication in adult patients.6 If given, they may cause tachycardia, causing excessive work for the heart and an increase in oxygen consumption. Respiratory Considerations As with pediatric patients, preoxygenation is advised if it will not cause stress to the patient. Geriatric patients may also require IPPV, mechanical or manual, in order to prevent atelectasis and respiratory fatigue, and they benefit from postoperative oxygen supplementation. At induction, drugs should be titrated to effect to quickly secure the airway. When the patient is on inhalant

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CE Article | Opposite Ends of the Life Cycle, Similar Anesthetic Needs

agents, remember that the reduced blood–brain permeability causes rapid changes is anesthetic depth. A variety of induction drugs are appropriate for geriatric patients. The key is to titrate and use only what is needed for intubation. One consideration of concern in geriatric patients is aspiration of fluids into the lungs, especially in breeds that are prone to laryngeal paralysis. While nothing can be done to prevent laryngeal paralysis, close monitoring after premedication and quick induction to get control of the airway are essential to prevent fluids from entering the lungs. These patients may have a diminished ability to protect their own airways, so securing the airway in an efficient manner and ensuring the endotracheal tube cuff is properly inflated will help protect them.

Postoperative Care Recovery is a critical time for the geriatric patient. Postoperative temperature monitoring is essential, and additional heating sources may be required. Remember to provide lots of padding for old joints. Patients with osteoarthritis, diagnosed or not, may need assistance in standing postoperatively. A maintenance rate of IV fluids may benefit these patients until they are able to drink on their own. One often-overlooked postoperative treatment is expression of the bladder at the end of surgery, before the patient is awake. These patients are usually litter/house trained and become agitated if their bladders are full after surgery. Geriatric patients are prone to emergence delirium, due to age-related cognitive dysfunction, but some extra hands-on time postoperatively can work wonders for these patients.3 Returning geriatric patients home as quickly as medically feasible is essential.3 If it is possible for them to go home the same day of the surgery, it is important to contact the owners before the last staff member leaves for the night to ensure these patients are doing well at home.

Hypothermia Prevention Hypothermia is a major concern with geriatric patients. Hypothermia has a negative myocardial outcome for high-risk patients, increases surgical wound infection, delays recovery, and can change the pharmacokinetics of anesthetic agents.1 Hypothermia from a weakened thermoregulatory system can lead to bradyarrhythmias.1 The act of shivering can increase oxygen consumption by 200% to 300%,5 so oxygen is often required postoperatively in these patients.

CONCLUSION So what is the bottom line? Is there a “magic,” specialized anesthesia protocol for pediatric and geriatric patients? Not really. As for any patient, their individual protocols should take into account their special needs and comorbid conditions. However, their needs will also reflect their stage of life, and they require more careful monitoring as a result. Just because a patient wakes up and goes home does not necessarily mean that the anesthesia was successful or optimal. This profession is constantly changing and we must change with it. Adjusting our anesthesia protocols as we educate ourselves is how we provide the best medical care for our patients. Next time you see a geriatric or pediatric patient, remember their needs and treat them with tender loving care. 

Monitoring Considerations Geriatric patients should be monitored diligently and with equipment appropriate to their specific needs. Electrocardiography, pulse oximetry, noninvasive blood pressure monitoring, and temperature monitoring should be the minimum; ETCO2 monitoring should be used if available. It is often beneficial to employ extensive monitoring equipment on these patients during surgical prep. Renal clearance may be limited in geriatric patients, so careful monitoring of fluid administration is needed to avoid fluid overload. If not carefully monitored, overhydration can lead to pulmonary edema and congestive heart failure in patients that have difficulty excreting salt and electrolytes.1 Some cardiovascular depression and hypotension is normal during anesthesia. While young, healthy patients may tolerate these changes well, such effects can be detrimental to geriatric patients. Geriatric patients have a decreased cardiac reserve, which is another reason to avoid fluid overload. Cardiac electrical activity and blood pressure should be closely monitored so any minor changes can be addressed while they are easier to correct. TODAY’SVETERINARYTECHNICIAN

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References 1. da Cunha AF. Neonatal, pediatric, and geriatric concerns. In: Canine and Feline Anesthesia and Co-Existing Disease. Ames, IA: Wiley Blackwell; 2015:310-317. 2. Duke-Novakovski T, deVries M, Seymour C. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Quedgeley; 2016:418-427. 3. Dugdale A. Veterinary Anaesthesia, Principles to Practice. Ames, IA: Wiley-Blackwell; 2010:312-317. 4. Harold BA, Johnson T, Johnson, A, et al. AAHA/AAFP Fluid Therapy Guidelines for Dogs and Cats. 2013. catvets.com/guidelines/practice-guidelines/fluid-therapyguidelines. Accessed September 2016. 5. Grimm KA, Tranquilli WJ, Lamont LA. Essentials of Small Animal Anesthesia and Analgesia. 2nd ed. Ames, IA: Wiley-Blackwell; 2011:490-496. 6. Tranquilli WJ, Thurmon JC, Grimm KA. Lumb & Jones’ Veterinary Anesthesia and Analgesia. 4th ed. Ames, IA: Blackwell; 2007:988.

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Toxicology Talk

Oral Decontamination in Dogs and Cats

Erin Freed, AS, CVT ASPCA Animal Poison Control Center Urbana, Illinois

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

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revention is the best way to decrease pet poisonings, but even with precautions in place, accidental poisonings happen every day. The management of poisoning cases generally consists of decontamination and symptomatic and supportive care because very few antidotes are available, and those that are available can be cost prohibitive or difficult to obtain.1 Therefore, it is important to consider methods of decontamination for a poisoned patient when indicated.1 Decontamination is the process of removing a toxicant from a patient to reduce its absorption or enhance its elimination, thus minimizing or even preventing clinical signs from developing.2 The most common types of decontamination are oral, inhalation, dermal, and ocular.1,2 This article specifically addresses oral decontamination in dogs and cats, including potential adverse reactions and contraindications. Oral decontamination is the process of removing a toxicant from the gastrointestinal (GI) tract through oral rinsing; dilution; induction of emesis; lavage; the use of absorbents, cathartics, and enemas; or endoscopy or gastrotomy.1,2 Before proceeding with oral decontamination, veterinary technicians should consider the following guidelines: ÆÆ If the patient is stressed or symptomatic, it should be stabilized first and then decontaminated if necessary.1 ÆÆ Each poisoning case varies depending on the patient’s species, breed, age, weight, and health history; agent(s) involved; amount ingested; and duration of exposure.2 ÆÆ Decontamination is not required for all poison exposures. ORAL RINSING Oral rinsing is the process of flushing the mouth with water to remove or decrease the amount of toxin ingested or absorbed through the mucous membranes (e.g., a dog that has bitten a toad), thus reducing systemic toxicity. Depending on the toxin, the mouth should be rinsed with tepid water for at least 5 to 10 minutes. The mouth can be flushed using a garden hose, a rinse attachment for a sink, or a detachable shower nozzle. It is best not to squirt the water directly into the back of the throat because of the risk for aspiration. The water source should be positioned at the commissure of the lips and directed rostrally. Preventing a pet from drinking water entering the mouth is impossible, so as long as most of the water runs out of the pet’s mouth and onto the ground, oral rinsing is achieved. Oral rinsing is also used when a patient has developed a taste reaction after licking a product such as a topical insecticide. Offering a small amount of water, milk, canned food, or juice drained from canned tuna or chicken helps rinse a bad taste out of the patient’s mouth.

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Toxicology Talk

Decontamination is the process of removing a toxicant from a patient to reduce its absorption or enhance its elimination, thus minimizing or even preventing clinical signs from developing.

shutterstock.com/Robert Crum

DILUTION Dilution is indicated when an irritating or corrosive substance such as a cationic detergent (e.g., fabric softeners, potpourri oils), acid, or alkali (e.g., cleaners) has been ingested. Offering a demulcent, such as milk or plain yogurt, can soothe and relieve irritation of the mucous membranes; demulcents form a protective film in the mouth.2

MANY DOGS VIEW TOADS AS PREY and catch them in their mouths. All toads can secrete a toxic chemical that is absorbed through the mucous membranes in a dog’s mouth. Some toads, such as the Colorado River (Bufo alvarius) and cane toads (Bufo marinus), secrete toxins that are more potent and pose a higher risk for systemic signs. A dog that has bitten a toad will require oral rinsing.

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Administering too much diluent can cause the stomach to distend or lead to vomiting, which can reexpose the esophagus to the corrosive material and potentially cause aspiration.1,2 A general rule to follow when recommending diluents to dogs and cats is use a volume similar to that recommended for hydrogen peroxide (H2O2) in dogs (1 mL/lb).2 Clients who are not medically trained may feel that more is better, so when speaking to clients, it is important to recommend a specific diluent and amount to administer. Contraindications. A diluent should not be offered to a patient that is vomiting, has an increased risk for aspiration (e.g., cannot swallow or control airway; is brachycephalic), or is unstable (as described above).1,2

Contraindications. Oral rinsing should not be performed in an animal that cannot swallow or that is unstable (e.g., experiencing tremors, seizures, or dyspnea; obtunded; recumbent), unless an endotracheal tube is in place to prevent aspiration.

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INDUCING EMESIS Emesis is the process of removing a substance from the stomach through vomiting. It is generally most effective within 30 to 90 minutes after ingestion, but this time frame depends on the substance ingested (e.g., rapid-release versus time-released medications).2,3 Some toxins act extremely fast and the onset of signs can develop minutes after exposure, making emesis contraindicated.2,3 H2O2, apomorphine, xylazine, and dexmedetomidine are emetics commonly used in veterinary medicine.1 Whether at home or in the clinic, it is best to have the pet vomit in an area that is well lit and easy to clean, such as tile, wood, or concrete flooring. According to one study, approximately 49% (range, 9%–75%) of gastric contents were recovered when emesis was induced in dogs within 30 minutes of a toxin ingestion and approximately 17% to 62% of gastric contents were recovered when emesis was induced within 1 hour of a toxin ingestion.3,4 It is important to note the number of times the pet vomits, the amount of toxic substance, and the presence of food, bile, blood, or other foreign material. The vomit should be cleaned up immediately to prevent reexposure. Once the pet has vomited, it is best not to allow it to drink any water or eat any food (NPO) for at least 30 minutes for small and young animals and up to 2 hours for larger adults.5 If NPO does not control the vomiting, an antiemetic (maropitant, 1 mg/kg SC [not labeled for cats]; ondansetron, 0.1–0.2 mg/kg SC, IM, or IV; or metoclopramide, 0.2– 0.5 mg/kg SC or IM) can be administered.3 Emetics that should be avoided include salt and baking soda (sodium bicarbonate) because of the risk of increasing the sodium level in the body (hypernatremia).2–4 Hypernatremia can lead to central nervous system (CNS) signs such as ataxia, tremors, and seizures, which can put the patient more at risk.2–4 Dish soap is not recommended because of the risk for aspiration pneumonia and severe November/December 2016

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respiratory effects if the pet inhales the soapy bubbles. Washing soda crystals (sodium carbonate) are used in the United Kingdom and Australia to induce emesis,a but this practice should be avoided because the crystals are caustic. Syrup of ipecac was removed from the market and is no longer recommended because vomiting can be delayed up to 40 minutes and it has been reported to cause cardiac issues in humans.2,3 Powdered mustard should be avoided because it can be irritating to the GI tract and is generally not effective.2 2

Dogs Emesis can be performed by veterinary staff or the client at home using fresh (bubbly and nonexpired) 3% H2O2.1,2 H2O2 is the safest over-the-counter emetic; it works by bubbling against the stomach lining, which causes local irritation, and producing oxygen, which stretches the stomach.1,2 If the patient does not vomit, the H2O2 simply breaks down into water and oxygen while it is foaming.2 Before recommending emesis to a client, ask about the pet’s clinical signs, take a brief toxicology history, and consult with a veterinarian.3 All emetics are more effective if the patient eats a small meal first.1,2 The recommended dose for H2O2 is 1 mL/lb body weight but should not exceed 45 to 50 mL, even if the patient exceeds 100 lb.1–3 H2O2 can be administered directly with a medicine dropper or turkey baster, or it can be mixed with milk, peanut butter that does not contain xylitol, or low-sodium chicken or beef broth to entice voluntary ingestion.1 Emesis may be unsuccessful if the product used to entice ingestion exceeds the recommended amount of H2O2, thereby watering it down. Vomiting usually occurs within 10 to 15 minutes, and the dose can be repeated once if emesis is not initially successful.1,5 Light activity between doses increases the effectiveness of H2O2.1,5 Adverse effects such as protracted vomiting, gastritis, and hematemesis are generally the results of overdosing.2,5 If the patient does not vomit within 30 minutes after the administration of H2O2, emesis can be induced with another emetic such as apomorphine. Emesis should be attempted again only if the patient is asymptomatic and the timeframe for emesis is appropriate for the toxin ingested. Apomorphine can be a first-choice emetic in dogs that are in the clinic or if H2O2 is unavailable. Apomorphine is a centrally acting emetic that stimulates the dopaminergic receptors in the chemoreceptor trigger zone (CRTZ).1,3,4 It can be administered by the IV, IM, or conjunctival route.1,3,4 The recommended dosage for IV and IM routes is 0.02–0.04 mg/kg.3,5 Emesis occurs almost a

Wismer T, DVM, DABVT, DABT, MS. Personal communication. 2016.

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The most common types of decontamination are oral, inhalation, dermal, and ocular. immediately after IV injection and usually within 5 minutes after IM injection.1 For conjunctival administration, a portion of an apomorphine tablet can be crushed and dissolved in a few drops of saline.1,3,4 Emesis generally occurs within 4 to 6 minutes; once the patient vomits, the conjunctival sac should be flushed with saline to prevent protracted vomiting.1–3 Adverse effects include CNS and respiratory depression, protracted vomiting, and, rarely, CNS stimulation.1,3,4 Naloxone can be used to reverse the CNS and respiratory effects of apomorphine but will not block the emetic effect.1,3,4 Cats Vomiting is difficult to induce in cats, but xylazine, an alpha2–adrenergic agonist, can be used for emesis induction in this species.1,3,4 The recommended dose is 0.44 to 1 mg/kg IM or SC, and emesis generally occurs within 5 minutes.3,4 Adverse effects can include CNS and respiratory depression, hypotension, and bradycardia.1 These effects, along with the emetic effects, can be reversed with yohimbine, an alpha2-antagonist, at 0.1 mg/kg IM, SC, or IV.1,3–5 Dexmedetomidine, an alpha2-receptor-specific agent, can also be used as an effective emetic in cats.4,5 The recommended dose is 7 mcg/kg IM (median dosage, 0.96–10 mcg/kg) and 3.5 mcg/kg IV.6,7 Sedative and emetic effects can be reversed with an equal volume of atipamezole given via the same route as the dexmedetomidine.4,5 H2O2 is not recommended in cats because they are more likely to develop gastritis.3 Because cats’ CRTZ receptors differ from those of dogs, apomorphine is poorly effective as an emetic and may also result in CNS stimulation.3,5 Contraindications Emesis should not be induced in a patient that is already vomiting or exhibiting clinical signs such as agitation, disorientation, ataxia, obtundation, dyspnea, seizures, recumbency, or coma.1,2,4,5 If the patient is symptomatic, the poison has taken effect and decontamination is inappropriate and can cause further complications (e.g., aspiration pneumonia).1–5 In patients with preexisting health conditions, such as seizures, cardiovascular disorders, recent abdominal surgery, megaesophagus, or collapsing trachea, and in

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Toxicology Talk

During decontamination procedures, veterinary technicians should remember to use proper safety measures and wear personal protective equipment such as gloves, an apron, and goggles.

ACTIVATED CHARCOAL AC is an absorbent that binds to most organic compounds, reduces their absorption into the systemic circulation, and facilitates their excretion in the feces.1,2 AC is beneficial when emesis cannot be induced and for toxins that undergo enterohepatic recirculation. AC comes in powder, gel, and liquid formulations; the recommended dose is 1–3 g/kg.1,2,5 Tablets and capsules found in stores are not likely to be as effective as commercially prepared medical produts.1,3,4 AC can be administered orally with a large syringe or a stomach tube while the animal is anesthetized and a endotracheal tube is in place to prevent aspiration.1,3,5 AC can also be mixed with a small amount of canned food to make it palatable for voluntary ingestion, but this does slightly decrease its effectiveness.1,2 Repeated doses can be given every 4 to 8 hours at half the original dose when enterohepatic recirculation is known to occur.1,2 Additional doses should not contain a cathartic because of the increased risk for dehydration via fluid loss from the GI tract.3 Adverse effects include vomiting, hypernatremia, and aspiration.1–5 The use of antiemetics should be considered before administering AC, especially if the patient is vomiting from induction of emesis.3 Patients should be monitored for evidence of aspiration and hypernatremia for at least 4 hours after administration of AC.1,4,5

GASTRIC LAVAGE Gastric lavage is used to remove ingested toxins from the stomach by irrigation and may be necessary if emesis is unsuccessful or contraindicated.1,3–5 Gastric lavage can be considered in symptomatic patients that are extremely sedate, unconscious, recumbent, or seizing or that have other health concerns, such as a recent abdominal surgery, that increase the risk associated with emesis induction.1,3 Gastric lavage can also be considered when the patient has ingested material that is large in size (but not larger than the diameter of the lavage tube) or has formed a concretion in the stomach (e.g., iron tablets or large amounts of chocolate) or capsules/tablets approaching a lethal dose (e.g., calcium channel blockers, beta-blockers, baclofen, organophosphate and carbamate insecticides).3,4

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Oral Decontamination in Dogs and Cats

During lavage, the patient should be anesthetized unless comatose, and a cuffed endotracheal tube should be placed to protect the airway and prevent aspiration.1,3,4 A large-bore gastric tube with a fenestrated end should be lubricated and inserted into the stomach no farther caudal than the xiphoid process.1,3–5 Body-temperature water (5–10 mL/kg) should be instilled using the gravity method, and the flushing process should be repeated multiple times with copious amounts of water until the lavage fluid runs clear.1,3,4 The patient’s head should be kept lower than the chest and the gravity method used for fluid recovery.1,3,4 The contents should be emptied into a bucket and examined for evidence of the toxic substance.3 Activated charcoal (AC) can be instilled directly into the stomach after gastric lavage has been completed.3 The free end of the tube should be kinked before being removed to help prevent aspiration.1,3,4 Adverse effects with gastric lavage include mechanical injury to the mouth, throat, esophagus, or stomach; hypothermia; and the instillation of fluid into the lungs.1,3–5 Contraindications. Contraindications include ingestion of corrosive substances, because of the risk for esophageal or gastric perforation from the tube placement; hydrocarbons, because of the risk for aspiration; and sharp objects.1,3,4

brachycephalic breeds with known breathing issues, emesis should be induced only under the supervision of a veterinarian because these conditions can make vomiting hazardous.1–5 The veterinarian must weigh the benefits of emesis against the risks.1 Emesis should not be induced in patients that have ingested a strong alkali, acid, or other highly corrosive material.1–5 Emesis with these agents can reexpose the mouth and esophagus, which can lead to ulceration, perforation, and scarring.1–5 Emesis should not be induced if the patient has ingested hydrocarbons or petroleum distillates (e.g., kerosene, paint thinner, solvents, lighter fluid) because these agents are easily aspirated into the lungs.1–5 Extreme caution should be taken when emesis is induced in a patient that has ingested zinc phosphide (e.g., rodenticides).2 In these cases, emesis should be performed in a well-ventilated area or outside because of the emission of phosphine gas, which is also toxic to humans.2

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Contraindications. AC should not be administered to patients that are actively vomiting or that have ingested a caustic material, hydrocarbons, or agents that are known to have excess sodium (sodium bicarbonate, Play-Doh) or that are osmotically active (gummy candies, artificial sweeteners, paintballs, glycerol).1,4,5 AC does not bind to all compounds equally, so it should not be administered to patients that have ingested heavy metals, xylitol, ethanol, or fertiizers.1,3,5 CATHARTICS Cathartics enhance the elimination of a substance by increasing the speed and transit time of the GI tract.1–3 The three types of cathartics used in dogs and cats are bulk, osmotic, and saline cathartics.1,2 Bulk cathartics use a high fiber content to retain water and produce bulkier stools.1,2 Common bulk cathartics include psyllium (Metamucil [no flavors or artificial sweeteners]), plain canned pumpkin (no spices or sweeteners), and whole-wheat bread (no nuts or raisins).1,2 Osmotic cathartics pull electrolyte-free water into the GI tract, which increases the fluid volume, stimulating GI motility.1,2 A saccharide osmotic cathartic such as sorbitol is commonly combined with AC. Sorbitol can be given at 1–2 mg/kg using a 70% solution.1,3 Adverse effects from sorbitol include vomiting, dehydration, secondary hypernatremia, abdominal cramping or pain, and possibly hypotension.3,4 Saline cathartics draw fluid into the intestines through osmosis, which increases the fluid content of feces, thus causing intestinal distention and promoting peristalsis.4 Saline cathartics, such as sodium sulfate (Glauber’s salts) and magnesium sulfate (Epsom salts), can be given at given at 250 mg/kg.1,2,4 The use of magnesium sulfate has led to hypermagnesemia in some cases, which presents as CNS and cardiovascular depression.1 Electrolytes should be monitored very closely for any disturbances with the administration of saccharide and saline cathartics because fluid shifts can occur.1–3 Contraindications. Cathartics should not be administered to patients with diarrhea, dehydration, electrolyte imbalances, ileus, or intestinal obstruction or perforation.1–3,4 Saline cathartics should not be administered to patients with renal insuffiency.1 Mineral oil is no longer recommended as a lubricant cathartic in dogs and cats because it has a higher risk of pulmonary aspiration.3,4 The use of cathartics alone in the management of a poisoned pet is no longer recommended or beneficial.3,4 ENEMAS Enemas are helpful when elimination of toxicants from the lower GI tract is desired (e.g., raisins, extended-release medications).1,2 Warm water or warm soapy water at 10 mL/lb and dioctyl sodium sulfosuccinate (DSS) 34

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Clients should be educated about poison prevention, and the clinic should establish a pet poisoning protocol so the veterinary team knows how to proceed with decontamination when clients call or present a poisoned patient for treatment. single-use syringes (250 mg/12 mL; dogs and cats) are enemas that can be used to move medication and other toxins quickly through the colon and lessen additional systemic effects.1,2,8 Phosphate enemas should be avoided (especially in cats) because of the risk for electrolyte and acid–base disturbances.1,2 Enemas should not be administered to patients with diarrhea.b ENDOSCOPY AND GASTROTOMY Endoscopy requires general anesthesia and a thin flexible endoscope to remove coins, batteries, toys, and other items before they can pass out of the stomach.1,2 If endoscopy is not available, the objects can be removed by gastrotomy. Gastrotomy is a surgical procedure to remove objects from the stomach that are corrosive (e.g., batteries), form bezoars (e.g., iron tablets), expand and cause a foreign body obstruction (e.g., Gorilla glue), or continue to seep their toxic effect into the body (e.g., zinc pennies, fentanyl or nicotine patches).1,3,4 Contraindications. Surgery should not be performed until the patient is stabilized. Before anesthesia, emesis should be controlled with antiemetics, the patient should be properly volume resuscitated with IV fluids, and electrolyte, glucose, or acid–base imbalances should be corrected.3 Before surgery, radiographs should be obtained to verify the presence of the agent or a foreign body obstruction; however, not all agents are radiopaque.3 continued on page 42 b Wegenast C, DVM, CVCT; Cripe E, DVM, CVCT; DeClementi C, VMD, DABT, DABVT. ASPCA Animal Poison Control Center. Personal communication. 2016. ASPCA.

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How to Recognize Autoimmune Skin Disease: Tips for Spotting

Pemphigus Foliaceus Jennie Tait, AHT, RVT, VTS (Dermatology)

imely diagnosis of a medical condition is always in a patient’s best interest. This is especially true when dealing with an autoimmune disease process, which has the potential to spiral out of control, have secondary infections develop, and even cause damage to other organ systems. Reaching a timely diagnosis can be quite a challenge with dermatology cases, since many diseases of the skin present so similarly at first glance. This article is intended to help veterinary technicians in general practice recognize key pieces of information in a patient’s history, physical examination findings, and results of simple, in-house diagnostic tests that can help the healthcare team to narrow in on a diagnosis of pemphigus foliaceus (PF) at the patient’s initial presentation. SKIN HEALTH AND THE IMMUNE SYSTEM Skin health is often a reflection of the health of a patient’s immune system. When the immune system is robust— barring the presence of infectious diseases and ectoparasites—skin problems are rare. When the immune system is compromised, skin disease can run rampant. Skin disease can be further exacerbated by secondary infections, often creating a vicious cycle.1 Primary diseases that manifest when the immune system is not working well fall into two main categories: immune mediated and autoimmune.2 Immunemediated diseases are triggered by foreign antigens, such as drugs 36

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Guelph Veterinary Specialty Hospital Guelph, Ontario, Canada

Jennie is a charter member and the current secretary of the Academy of Dermatology Veterinary Technicians and is currently the only VTS (Dermatology) in Canada. Jennie is also a member of the Ontario Association of Veterinary Technicians, where she holds RVT certificate #4, as well several other veterinary organizations, including the Canadian Academy of Veterinary Dermatology. She has more than 30 years’ experience in veterinary medicine, including 24 years of teaching veterinary students at the Ontario Veterinary College and more than 15 years’ experience specializing in veterinary dermatology. Jennie is an accomplished speaker and is currently waiting on her contribution to a dermatology text for technicians to be published.

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(including vaccines), infectious agents (e.g., bacteria, viruses), environmental substances, and food components.3 Autoimmune diseases are caused by a failure of the immune system to recognize the patient’s own antigens, or “self,” resulting in an attack by antibodies or lymphocytes against normal tissues. Autoimmune conditions also have a trigger that starts the disease process. However, the appearance of clinical signs may be delayed for as long as several months after the trigger event.1 This can make searching for a trigger in a patient’s history baffling. Difficulty is compounded by the fact that it is common for autoimmune disorders to have a history of waxing and waning clinical signs.1 There are many autoimmune dermatoses. The prognosis for each condition depends on the disease process. Some affect only the skin, while others, such as systemic lupus erythematosus,2,3 can affect other organ systems, with serious consequences for the patient. Many dermatoses mimic each other because the skin displays only a limited number of reaction patterns.4 As a result, there is no single dermatologic hallmark of autoimmune disease, but identifying lesions can help to narrow the differential diagnosis. For example, crusting is seen with PF, depigmentation with discoid lupus erythematosus,2 and open fistulas with panniculitis.3

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T E C HP O I N T 

Tips for Spotting Pemphigus Foliaceus

Primary diseases that manifest when the immune system is not working well fall into two main categories: immune mediated and autoimmune.

individual, rounded keratinocytes that have large, dark-staining nuclei. These cells are known as acantholytic cells (FIGURE 3). PF is the most common condition of the pemphigus complex3,8 and is the most frequently occurring autoimmune skin condition in dogs, cats, and horses. The disease usually appears to be idiopathic, although it has been associated with drug administration and can develop subsequent to chronic, usually allergic, skin disease.2 Other, rarer, forms of pemphigus include pemphigus vulgaris, pemphigus vegetans, pemphigus erythematosus, and paraneoplastic pemphigus. In some cases, neutrophilic and/or eosinophilic infiltrate occurs throughout the epidermis in addition to acantholysis; the term panepidermal pustular pemphigus has been suggested for this condition.9

Thorough examination of lesions is essential. For instance, a pustule associated with a superficial bacterial skin infection usually only incorporates one hair follicle, while pemphigus pustules span several follicles. At first glance, they look very similar, but paying attention to these details helps put the veterinarian on the right track for a diagnosis (FIGURES 1 AND 2). Other clinical signs commonly associated with autoimmune disorders are alopecia, erythema, purpura, vesicles, loss of skin architecture (due to the infiltration of plasma cells), and ulcers.1,2,5 Notably, not many diseases involve the nasal planum, so if the nasal planum is affected, suspicion for an autoimmune disease such as pemphigus or lupus should be high.3,6,7 PEMPHIGUS FOLIACEUS The pemphigus complex is a group of uncommon autoimmune dermatoses characterized by acantholysis. Acantholysis is the breakdown of intercellular desmosomal bridges, deep in the epidermis, resulting in the release of

Clinical Presentation and Diagnostic Differentials Since many dermatologic conditions have a similar clinical presentation, breed predispositions can be very helpful in formulating a differential diagnosis.6 For example, Akitas, Chow Chows, and English bulldogs are overrepresented breeds with PF,2 although any breed can be affected. Animals are most often middle aged. The onset of clinical signs can be very rapid or very slow, with a history of waxing and waning being common. Patients with an acute onset may be depressed, anorexic, or febrile or have accompanying lymphadenopathy. Pain and pruritus are variable, and secondary bacterial infections may also be present. PF is a pustular disease, with primary lesions (pustules) starting as erythematous papules. The progression of lesions can be very rapid, and patients may present with widespread areas of pustules, yellow crusts, and erosions. Large pustules spanning multiple hair follicles are characteristic (FIGURE 4). The pustular phase is followed by postinflammatory alopecia and epidermal collarettes, which can be extensive.2

FIGURE 1. Small pustules in superficial pyoderma, with epidermal collarettes. Image courtesy of Yu of Guelph Veterinary Dermatology

FIGURE 2. Large pustules in pemphigus foliaceus. Image courtesy of Yu of Guelph Veterinary Dermatology

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Peer-Reviewed

TECHPOINT 

Since many dermatologic conditions have a similar clinical presentation, breed predispositions can be very helpful in formulating a differential diagnosis.

The head, face, and pinnae are involved in more than 80% of cases, but lesions can progress to becoming generalized and more severe. Lesions are usually symmetrical. This distribution helps differentiate PF from staphylococcal pyoderma, in which the ventrum and trunk are affected without symmetry and cranial lesions are uncommon.2 In dogs, the footpads are often affected with crusting that can lead to fissures.2 In cats, lesions on footpads are common and may be the only lesions present. Hallmarks of PF in cats include papular, crusting lesions around nail beds and nipples (FIGURE 5).3 Nasal depigmentation can occur later in the course of the disease, unlike discoid lupus erythematosus, in which it is usually the first clinical sign noted (FIGURES 6 and 7).2 Oral or mucocutaneous lesions are very rare in PF but can be seen with pemphigus vulgaris and bullous pemphigoid.3 Differentials to rule out are numerous and include demodicosis, dermatophytosis (especially those caused by Trichophyton spp), lupus (systemic lupus erythematosus, discoid lupus erythematosus), dermatomyositis, zincresponsive dermatosis, cutaneous epitheliotrophic lymphoma, superficial necrolytic migratory erythema, other pemphigus diseases, leishmaniasis (in geographic areas where this disease is prevalent), and in cats, mosquito bite hypersensitivity.10 If there is no obvious trigger event, a restricted diet trial should be considered, in the event that a food sensitivity is the culprit. Dietary triggers are well established in human medicine,11–14 so a similar scenario for animals seems likely. In my experience, I have seen several cases of PF maintained in long-term remission with dietary restrictions.

Diagnostic Tests A tentative diagnosis can be readily made when typical clinical signs are present. Performing cytology and skin biopsies are the next steps in confirming PF. Cytology is invaluable when it comes to diagnosing PF, and it can be done quickly and easily in house. If the patient presents with crusts and pustules, a sample can be obtained by lifting a crust and performing an impression smear or by gently rupturing an intact pustule with a sterile, small-gauge needle and then making a touch prep with the contents (Tzanck smear). However, when an autoimmune skin disease is suspected, intact pustules are best left for biopsy samples. Processing samples for cytology is straightforward: slides should be air dried, then fixed and stained with Diff-Quik. Veterinary technicians who are familiar with assessing cytology samples can quickly identify acantholytic cells

FIGURE 3. Acantholytic keratinocytes versus squamous epithelial cells at 100× magnification. Image courtesy of Yu of Guelph Veterinary Dermatology

FIGURE 4. Large pustule incorporating several hair follicles in pemphigus patient. Image courtesy of Yu of Guelph Veterinary Dermatology

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Tips for Spotting Pemphigus Foliaceus

standard for diagnosing PF. Classic histopathology is of a subcorneal pustule with acantholytic cells admixed with neutrophils and variable numbers of eosinophils.3 Multiple punch biopsies should be obtained from representative lesions. If crusting is present, a crusted area should be chosen as a biopsy site, with the crust included in the sample. If pustules are present, a biopsy punch large enough to encompass an entire intact pustule should be chosen. Submission of ulcerated tissue is discouraged, as it will likely lead to a vague diagnosis of ulcerative dermatitis. Special stains can also be ordered, such as PAS (periodic acid–Schiff staining) or GMS (Gomori’s methenamine silver), which can help to rule out any autoimmune disease lookalikes, like dermatophytosis. Ideally, biopsy should be performed before an animal has started any corticosteroid treatment and after any secondary infections have been cleared.15 Corticosteroids can disguise the disease process histologically and delay an accurate diagnosis. Biopsy sites should not be clipped or prepped, as this can remove crusts that often provide vital information for a dermatohistopathologist to make a diagnosis. Results of routine hematology and biochemistry tests are not diagnostic, but these tests should be run to establish baseline parameters before instituting immunosuppressive therapy. Neutrophilia is often present and may be severe.3

FIGURE 5. Crusting of nail beds in a cat with pemphigus. Image courtesy of Yu of Guelph Veterinary Dermatology under the microscope even at lowest power. The presence of acantholytic keratinocytes surrounded by neutrophils is very suggestive of PF.3 In these cases, acantholytic keratinocytes are often seen in “rafts” (i.e., several cells close together). Examination of slides at higher magnification often shows that eosinophils are also present. Pemphigus is a sterile disease process, so bacteria are not usually seen, especially if performing a Tzanck smear on a large pustule that spans more than one hair follicle. Acantholytic keratinocytes can also be seen with deep pyoderma; however, bacteria are also seen in these cases. Acantholytic cells may also found with dermatophytosis (such as Trichophyton mentagrophytes)9 but are usually seen as single cells, as opposed to in rafts. Histopathologic evaluation of biopsy samples from intact pustules by a dermatohistopathologist is the gold

TREATMENT There are two approaches to treating autoimmune dermatoses: immunosuppression and immunomodulation. The type of disease and the severity of the condition are what guide the veterinarian’s choice of treatment. For instance, an animal with PF that has mild focal lesions

FIGURE 6. Nose of a dog that has discoid lupus erythematosus (note loss of cobblestone appearance and depigmentation). Image courtesy of Yu of Guelph Veterinary Dermatology TODAY’SVETERINARYTECHNICIAN

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FIGURE 7. Nose of a dog that has pemphigus foliaceus with crusting of nasal planum. Image courtesy of Yu of Guelph Veterinary Dermatology

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ď Ź

There are 4 phases in the treatment of cutaneous autoimmune diseases: induction, transition, maintenance, and determining cure.

on the pinnae may do well and be maintained on immunomodulatory drugs, while an animal with advanced disease and extensive lesions will need immunosuppressive therapy. The main benefit of immunomodulatory drugs is that they have less serious side effects than immunosuppressive treatments (TABLE 1); however, all treatments carry the risk of adverse reactions. If bacterial secondary infections are present, they should be treated with appropriate antibacterial therapy. If crusts or pustules have not resolved after a 4-week course of appropriate antibiotics, cytology should be repeated.3 Treatment Phases There are 4 phases in the treatment of cutaneous autoimmune diseases: induction, transition, maintenance, and determining cure.2 The induction phase is meant to stop the inflammatory component as quickly as possible and suppress the immunologic response that is attacking the skin. During this phase, higher doses of medications are usually given. In general, immunomodulatory drugs take some time to be effective (around 3 to 4 weeks), so a high dose of glucocorticoids is often given initially to gain control of a disease. If a positive response is not seen in a timely manner, another treatment protocol will be considered. This could involve using alternative medications or adding medications to the current treatment protocol. In the transition phase, drugs are tapered to minimize adverse effects. When combinations of drugs are used, those with the most significant side effects (usually glucocorticoids) are the first to be tapered. Tapering is usually done slowly over several weeks or months, until an acceptable maintenance dose is reached or a relapse occurs. If relapse occurs, medications are increased until remission is achieved (i.e., the induction phase is repeated), then tapered down again to the last dose that kept the patient symptom free. This is the dose used for the maintenance phase. Depending on the trigger for the start of the disease, some patients may be completely weaned off both medications. A patient is considered cured once it has achieved remission, has been successfully controlled with maintenance therapy, and does not have recurrence after treatment has been stopped. However, most patients with PF require lifelong therapy to maintain remission. In severe cases, immunosuppressive drugs may be combined to achieve and maintain remission. Since many of these medications can have adverse effects on the liver and bone marrow, complete blood counts and serum biochemistry panels should be obtained every 2 to 3 weeks for the 40

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TECHPOINT ď Ź

first couple of months. For maintenance, the monitoring frequency can be reduced to every 4 months or so. If blood work reveals adverse effects, the veterinarian may choose alternative medications. Other Treatment Considerations Topical therapies are very useful for localized lesions and for managing flares. They include topical steroids and tacrolimus. Topical steroids allow the veterinary team to gain quick control over localized inflammation and lesions, but may result in thinning of the skin with chronic use. If long-term management is anticipated, switching the patient to tacrolimus can be beneficial. Topical shampoos can also be helpful in removing crusts. Stopping maintenance therapy in a well-controlled patient can be a little disconcerting, especially if the initial disease was severe. In many cases, maintenance therapy is continued for up to a year before considering discontinuation.2 If the risk of recurrence outweighs the benefits of stopping treatment, protocols can be maintained lifelong with appropriate monitoring. Future vaccinations are usually discouraged in patients with autoimmune skin diseases, including PF, even in cases where vaccination is not a known trigger. The concern is that vaccination could cause a generalized immune response, possibly retriggering the autoimmune process.16 In these cases, vaccine titers are recommended. If titer levels are insufficient, then a risk-benefit assessment should be done before considering vaccination.17 The prognosis for patients with PF varies according to the etiology and severity of disease but is considered to be fair to good.3 Regular monitoring of clinical signs, complete blood counts, and serum biochemistry panels with treatment adjustments as needed is essential. CONCLUSION There are many autoimmune skin diseases, with the most likely to be seen in general practice being PF. Veterinary

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Tips for Spotting Pemphigus Foliaceus

TABLE 1 Immunosuppressive and Immunomodulatory Drugs3 DRUG

DOSAGE

ADVERSE EFFECTS IMMUNOSUPPRESSIVE DRUGS

GLUCOCORTICOIDSa Dexamethasone

Dogs and cats: 0.1–0.2 mg/kg q12–24h

Prednisone

Dogs: 1–3 mg/kg q12–24h

Prednisolone

Cats: 2–2.5 mg/kg q12-24h

Triamcinolone

Dogs: 0.1–0.3 mg/kg q12–24h Cats: 0.3–1 mg/kg q12–24h

Symptoms of hyperadrenocorticism, panting, vomiting, diarrhea, hepatic enzyme elevations, pancreatitis, GI ulcers, lipidemias, urinary tract infections, diabetes mellitus, muscle atrophy, behavioral changes

OTHER DRUGS Azathioprine

Dogs:

Induction: 1.5–2.5 mg/kg q24h Maintenance: 1.5–2.5 mg/kg q48h, but can be

Anemia, leukopenia, thrombocytopenia, vomiting, diarrhea, hypersensitivity reactions, pancreatitis, hepatotoxicity, increased risk of infections

tapered to as low as 1 mg/kg q72h Chlorambucil

Anorexia, vomiting, diarrhea, bone marrow suppression

Dogs and cats:

Induction: 0.1–0.2 mg/kg q24–48h Maintenance: 0.1–0.2 mg/kg q48h or less to lowest effective dose Cyclophosphamideb

Cyclosporine

Dogs and cats: 1.5 mg/kg q48h

Sterile hemorrhagic cystitis, bladder fibrosis, teratogenesis, infertility, alopecia, nausea, GI inflammation, increased infections, bone marrow suppression

Dogs and cats:

Vomiting, diarrhea, anorexia, gingival hyperplasia, papillomatosis, hirsuitism, bacteriuria, bone marrow suppression, nephropathy

Induction: 5–10 mg/kg q24h Maintenance: 5–10 mg/kg q48h or less Mycophenolate mofetil

Dogs and cats: 10–20 mg/kg q24h

Nausea, vomiting, diarrhea, bone marrow suppression, increased incidence of infections

IMMUNOMODULATORY DRUGSC Niacinamide

Dogs:

Vomiting, anorexia, lethargy, occasional increased liver enzymes

250 mg/kg q12h for dogs <10 kgd 500 mg/kg q12h for dogs >10 kgd TETRACYCLINES Doxycycline

Dogs: 5 mg/kg q12h

Minocycline

Dogs: 5–10 mg/kg q12h

Tetracycline

Vomiting, diarrhea, anorexia, lethargy, increased liver enzymes

Dogs:

250 mg q8h for dogs <10 kg 500 mg q8h for dogs >10 kg TOPICALS Tacrolimus 0.1%

Dogs: Applied 1 or 2 times/day for induction, then tapered to less frequent use

Localized erythema, irritation, pruritus; owners should wear gloves

Topical glucocorticoids (betamethasone 0.1%, mometasone 0.1%)

Dogs: Applied 1 or 2 times/day for induction, then tapered to less frequent use (ideally down to twice weekly for chronic use)

Dermal atrophy, increased risk of inducing hypothalamic-pituitaryadrenal axis suppression, glucocorticoid effects, development of milia and comedones, local skin reactions

These are induction doses that are then tapered to maintain remission. Rarely used for cutaneous autoimmune diseases; due to adverse effects, often recommended for use in induction phase only. c Tetracyclines are combined with niacinamide for an immunomodulatory effect. d Given q8h if administered with tetracycline. a

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technicians play a vital role in recognizing these patients, often being the first team members to take a patient history and do an initial physical examination. Being able

to spot the clinical signs that point to pemphigus will help ensure that patients get a timely diagnosis and appropriate treatment. 

References 1. Hnilica K. Differential diagnoses. In: Small Animal Dermatology: A Color Atlas and Therapeutic Guide. 3rd ed. St. Louis, MO: Elsevier Saunders; 2011:18. 2. Miller WH, Griffin CE, Campbell KL. Autoimmune and immune-mediated dermatoses. In: Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Saunders; 2013:438-500. 3. Hnilica K. Autoimmune and immune-mediated skin disorders. In: Small Animal Dermatology: A Color Atlas and Therapeutic Guide. 3rd ed. St. Louis, MO: Elsevier Saunders; 2011:189-227. 4. Miller WH, Griffin CE, Campbell KL. Structure and function of the skin. In: Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Saunders; 2013:1-56. 5. Miller WH, Griffin CE, Campbell KL. Differential diagnosis. In: Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Saunders; 2013:57, 61t-65t. 6. Miller WH, Griffin CE, Campbell KL. Regional diagnosis of non-neoplastic dermatoses. In: Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Saunders; 2013:67. 7. Senter D. Diseases of the nasal planum. Proc Central Vet Conf 2011. 8. Beco L. Autoimmune skin diseases: what’s important? Part 2. Proc 21st Fed Eur Companion Anim Vet Assoc EuroCongress Scientific Programme: Dermatology 2015: NEW 14.

9. Olivry T, Linder KE. Dermatoses affecting desmosomes in animals: a mechanistic review of acantholytic blistering skin diseases. Vet Dermatol 2009;6(3):13-326. 10. Hnilica K. Hypersensitivity disorders, mosquito bite hypersensitivity. In: Small Animal Dermatology: A Color Atlas and Therapeutic Guide. 3rd ed. St. Louis, MO: Elsevier Saunders; 2011:183-184. 11. Palmer S. Is there a link between nutrition and autoimmune disease? Today’s Dietitian 2011;13(11):36. 12. Valenta R, Mittermann I, Werfer T, et al. Linking allergy to autoimmune disease. Trends Immunol 2009;30.3:109-116. 13. Ruocco V, Brenner S, Ruocco E. Pemphigus and diet: does a link exist? Int J Dermatol 2001;40:161-163. pemphigus.org/pemphigus-and-diet-does-a-link-exist-2/. Accessed July 2016. 14. Kaimal S, Thappa D. Diet in dermatology: revisited. Indian J Dermatol Venereol Leprol 2010;76(2):103-115. 15. Miller WH, Griffin CE, Campbell KL. Diagnostic methods. In: Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Saunders; 2013:92. 16. Westra J, Rondaan C, van Assen S, et al. Vaccination of patients with autoimmune inflammatory rheumatic diseases. Nat Rev Rheumatol 2015;11(3):135-145. 17. Welborn LV, DeVries JG, Ford R, et al. 2011 AAHA canine vaccination guidelines. JAAHA 2011;47(5):1-42.

Toxicology Talk, continued from page 34

CONCLUSION During the decontamination procedures, veterinary technicians should remember to use proper safety measures and wear personal protective equipment such as gloves, an apron, and goggles. Clients should be educated about poison prevention, and the clinic should establish a pet poisoning protocol so the veterinary team knows how to proceed with decontamination when clients call or present a poisoned patient for treatment. When in doubt, the toxicology professionals at an animal poison control center can assist veterinary staff or clients with the decontamination process.  References 1. DeClementi C. Prevention and treatment of poisoning. In: Gupta RC, ed. Veterinary Toxicology: Basic and Clinical Principles. 2nd ed. Waltham, MA: Academic Press; 2012:1361-1368. 2. Murphy L. Decontamination procedures. In: Poppenga RH, Gwaltney-Brant SM, eds. Small Animal Toxicology Essentials. Ames, IA: Wiley-Blackwell; 2011:51-53. 3. Lee JA. Decontamination and detoxification of the poisoned patient. In: Osweiler GD, Hovda LR, Brutlag AG, Lee JA, eds. Blackwell’s Five-Minute Veterinary Consult: Small Animal Toxicology. Ames, IA: John Wiley and Sons; 2010:5-19. 4. Peterson ME. Toxicologic decontamination. In: Peterson ME, Peterson PA, Talcott PA, eds. Small Animal Toxicology. 3rd ed. St. Louis: Elsevier; 2013:73-83. 5. DeClementi C. Decontamination of patients after oral exposure to toxicants. In: Côté E, ed. Clinical Veterinary Advisor: Dogs and Cats. 3rd ed. St. Louis: Mosby; 2015:1139-1140. 6. Plumb DC. Dexmedetomidine. In: Veterinary Drug Handbook. 7th ed. Ames, IA: Iowa State Press; 2011:298-300. 7. Thawley V, Drobatz K. Assessment of dexmedetomidine and other agents for emesis induction in cats: 43 cases (2009-2014). JAVMA 2015;247(12):1415-1418. 8. Plumb DC. Docusate. In: Veterinary Drug Handbook. 7th ed. Ames: Iowa State Press; 2011:348-349.

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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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Radiographic Positioning: Head, Shoulders, Knees, and Toes PART 1

Liane K. Shaw, BS, RVT Liane grew up in Valparaiso, Indiana, on a small hobby farm with horses, goats, pigs, chickens, geese, cats, a dog, and one duck named Daffy. A 10-year member of 4-H, she followed her passion for animals by applying to the veterinary technology program at Purdue University, where she earned not only an associate’s degree, but also a bachelor’s in applied science, with a minor in organizational leadership and supervision.

Liane K. Shaw, BS, RVT Purdue University

After working as a supervisor in private practice for 6 years, Liane returned to Purdue to pursue her love of teaching. In the past 9 years as Purdue’s Diagnostic Imaging Instructional Technologist, she has completely remodeled the diagnostic imaging curriculum to include many labs for a more hands-on approach. In 2011, she received a Teaching Excellence award from Purdue University and Elanco Animal Health. In 2013, she spoke at Purdue’s fall conference on the topic of dental radiography.

Jeannine E. Henry, BA, RVT Purdue University

ur passion for our patients is what drives our need to be thorough and proficient in our work as veterinary technicians. When it comes to taking radiographs, this means knowing the positioning techniques necessary to achieve diagnostic-quality images in a timely and efficient manner, as well as the safety precautions all staff should follow when working with radiation. |

TODAY’SVETERINARYTECHNICIAN

Jeannine was born and raised in Logansport, Indiana, where she welcomed any opportunity to spend time with animals. In 2005, she earned a bachelor’s degree in English, in pursuit of her passion for reading and writing, but soon realized that something was missing from her life: her love for animals. While working at a private practice, she was introduced to the role of veterinary technician. She graduated from Purdue with an associate’s degree in veterinary technology in 2007. One month after graduation, Jeannine accepted a position at Purdue University as a Versatech, a position created to fill gaps in various departments all over the hospital, including diagnostic imaging. This was how she discovered her love for radiology. She has now been working in diagnostic imaging for 6 years and is PennHIP certified. In her spare time, Jeannine enjoys reading, writing, cooking, and spending time with her husband, son, two dogs, and adopted blood donor cat. She hopes to combine her love for animals and writing in the future to pursue a career in journalism for the veterinary medicine profession.

Liane stays busy by spending the evenings outside with her husband and two sons on their 22-acre farm in Attica, Indiana, which is home to horses, dogs, cats, and a donkey!

Jeannine E. Henry, BA, RVT

In this first of two articles on radiographic positioning, we provide an overview of the principles and guidelines of radiation safety in the workplace as well as the techniques used to obtain good-quality orthopedic radiographs of the skull, shoulders, and elbows with great efficiency and care for the patient. Part 2 will discuss manual versus chemical restraint, the use of positioning

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T E C HP O I N T 

Radiographic Positioning: Head, Shoulders, Knees, and Toes, Part 1

Dosimeter badges should be checked at least quarterly to evaluate the wearer’s cumulative radiation dose.

should be checked at least quarterly to evaluate the wearer’s cumulative radiation dose.3 According to the US Nuclear Regulatory Commission, occupational personnel should not receive a total effective dose of more than 5 rem per calendar year.4 There are more specific limits for skin and eyes (BOX 1). However, different states may have different guidelines. To learn more about your state’s radiation guidelines, go to crcpd.org, and click on Radiation Control Programs on the left-hand side to follow the links to the full map, find your state, and go to the correct website. The exact level of radiation exposure that causes cell death is not known, so all exposure should be treated as if it is going to produce cell death. All veterinary professionals should practice simple methods of keeping exposure as low as reasonably achievable (ALARA), such as increasing distance from the tube head, using short exposure times, and using their knowledge and understanding of positioning to decrease the number of retakes. Other factors that can help in minimizing radiation exposure include using proper exposure techniques from a professionally developed technique chart, sedation for patients that are in pain or anxious, and positioning aids. These concepts will be described in more detail in part 2.

aids, and a step-by-step tutorial to aid in the positioning of the pelvis, stifles, and feet. OVERVIEW OF X-RAYS AND RADIATION SAFETY Were you ever told, “Stay away from the microwave when it is cooking, or you will get irradiated”? Now, people are more aware of the risks posed by repeated exposure to radiation, but that wasn’t always the case. Up until the 1950s, it was possible to go to a shoe store and use x-rays to determine your shoe size.1 Fortunately, the principle of being cautious about radiation has improved over the decades. Although we have advanced in many other ways, the production of x-rays remains the same as when they were first discovered: accelerated electrons interact with a metal target on the anode in the x-ray tube head, heating the target and causing photons to be produced. In this inefficient process, 1% of the electrons’ energy is converted to x-rays and 99% to heat (or waste). The photons (x-rays) are then directed at the patient in what is known as the primary beam. However, some subsequently bounce off or “scatter” in all directions after reaching the patient. Scatter radiation, or secondary radiation, poses exposure risks to radiography personnel.2 X-rays, like radio waves and microwaves, are part of the electromagnetic spectrum. X-rays differ from some other forms of electromagnetic radiation because their very short wavelength allows them to penetrate matter, including cells. Today, we know that x-rays interact with cells in 4 ways2: 1. They can pass through with no damage. 2. They can cause repairable damage. 3. They can cause irreparable damage. 4. They can cause cell death.

PERSONAL PROTECTIVE EQUIPMENT Personnel who work with radiation should protect themselves from all workplace radiation exposure by wearing the appropriate personal protective equipment (PPE). Lead, being a very dense material, is the approved barrier against harmful scatter radiation. It is suggested (but unfortunately not required) that all personnel working with radiation-emitting devices wear a 0.25- to 0.50-mm lead apron or wrap, lead thyroid shield, lead gloves, and even lead-lined goggles.6 These guidelines can vary by state, but most states have adopted the minimum of 0.25-mm lead equivalent.7,8

BOX 1 US Nuclear Regulatory Commission Occupational Dose Limits for Radiation5  Whole body: 5 rem/y  Any organ: 50 rem/y  Skin: 50 rem/y  Extremity: 50 rem/y

RADIATION EXPOSURE LIMITS Most states require that any person working with radiationemitting devices wear a personal radiation exposure monitor. These dosimeter badges, as they are often called, TODAY’SVETERINARYTECHNICIAN

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 Lens of eye: 15 rem/y  Embryo/fetus: 0.5 rem/y

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Lead aprons or wraps, whether front sided or two sided, should fit appropriately. They should shield the body from the neck to midthigh and wrap halfway around the sides of the body. PPE is expensive; therefore, it requires appropriate handling and maintenance. To prevent cracks, lead gowns should be draped over a rounded surface and not folded or wrinkled. Lead gloves should be kept on a glove rack or stored on a flat surface with round PVC pipes placed inside the liner to prevent the material from creasing in the same spot over time. PPE should be inspected routinely for damage. Since gloves sustain the most physical wear, they should be inspected at least every 6 months. Lead gowns should be inspected annually, at minimum. Inspections should include a visual and radiographic assessment. During the visual inspection, all ties, buckles, and Velcro straps should be checked to ensure they are in working condition. No part of the lead should be uncovered or showing through the protective outer layer. The radiographic inspection involves using a fluoroscopy or radiography unit to look for cracks in the lead.9 Common settings for this inspection are 80 kVp and 5 mAs; the settings can be adjusted based on the desired density of the material.2 Although there are no

BOX 2 Basic Positioning Aids

 V trough  Sandbags

 Radiolucent blocks and paddles

 Cotton

 Foam wedges

 Tape

TECHPOINT 

Taking at least two orthogonal views is of critical importance when trying to get diagnosticquality images. federal guidelines for determining when to replace PPE, a general rule is to take equipment out of service if cracks are found over any pertinent organs, including reproductive and endocrine organs, or if the area of the crack is larger than 5.4 cm.10 Lead should be properly disposed of according to guidelines regulated by each state. GENERAL GUIDELINES FOR DIAGNOSTIC RADIOGRAPHY One of the standards we follow at Purdue is to perform a complete radiographic series, no matter what is being imaged. Providing the most information we can to obtain the best possible diagnosis or outcome for the patient is our primary goal! Although certain circumstances (e.g., patient stability) may allow only one radiographic image to be obtained, it is possible to miss metastasis, disease processes, or even fractures based on a single radiograph. Therefore, taking at least two orthogonal views is of critical importance when trying to get diagnostic-quality images.11 Orthogonal views are images that are taken at 90° to each other. The following tutorial includes positioning instructions to obtain two orthogonal views for the skull, shoulders, and elbows. Depending on the part of the body being imaged, this may include a mediolateral or lateromedial view, a caudocranial or craniocaudal view, a dorsoventral or ventrodorsal view, and even some oblique views. Basic positioning aids are listed in BOX 2; these will be described in more detail in Part 2.

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Radiographic Positioning: Head, Shoulders, Knees, and Toes, Part 1

The terms used to describe radiographic positioning can be confusing and depend on the area being imaged. When describing the way the beam enters and exits the body or head, it is appropriate to use ventrodorsal or dorsoventral. The terms caudocranial and craniocaudal are used to describe the way the beam enters and exits a forelimb or hindlimb. Markers should always be placed to indicate patient position and/or beam direction. To reduce the amount of equipment in the images, most of the photographs in this article feature cadavers or welltrained healthy dogs that could be taped and positioned without sedation. Sedated patients should always be appropriately maintained with oxygen and monitoring.

region around C1–C3 to help extend the spine and straighten the head if needed (FIGURE 4). If needed, tape can be applied across the rostral portion of the mandible or behind the canine teeth on the maxilla to position the nose parallel to the table. If the patient has a prominent occipital protuberance, it can be difficult to balance the head symmetrically. In these cases, place a small piece of cotton under the head to keep it from tipping to the side. The view must include the entire head from the base of the skull to the tip of the nose (FIGURE 5). The marker should be placed on one side of the patient to indicate right or left. Rostral Caudal Open Mouth Tympanic Bullae View The patient is positioned in dorsal recumbency. The forelimbs should be extended caudally and secured with tape. The patient’s nose should be pointing upward. Tape is applied behind the maxillary canine teeth to pull the nose 10° to 15° cranially (FIGURE 6). Tape is also applied around the mandibular canines and pulled caudally to open the mouth wide; how wide the mouth needs to be open depends on the species or breed of animal. It should be possible to visualize the bullae without the mandible or maxilla superimposed over them. The field of view includes the entire nasopharyngeal region (FIGURE 7). The marker should be placed on one side of the patient to indicate right or left.

POSITIONING THE PATIENT: STEP BY STEP Head Lateral View The patient is positioned in lateral recumbency. The forelimbs should be pulled caudally to aid in positioning the skull, and the affected side of the skull is placed closest to the plate or cassette. The goal of this view is to superimpose the mandibular rami, so it is essential to place some cotton padding or a radiolucent wedge under the mandible. The nose should be parallel to the table, so padding also needs to be applied under the nose (FIGURE 1). The view must include the entire head from the base of the skull to the tip of the nose (FIGURE 2). The marker should indicate the patient’s recumbency.

Rostral Caudal Frontal Sinus View The patient is positioned in dorsal recumbency. The forelimbs should be extended caudally and secured with tape. For this view, the patient’s nose should be perpendicular to the plate or cassette, so the nose should be pointing up at a 90° angle from the table and wrapped with tape to secure it in this position (FIGURE 8). This view needs to be collimated down to just include the top of the head (FIGURE 9). Center the beam between the eyes just under the frontal sinus. The marker should be placed on one side of the patient to indicate right or left (FIGURE 10).

Ventrodorsal View The patient is positioned in dorsal recumbency. The forelimbs should be pulled caudally to aid in getting the patient’s head straight. A positioning aid such as a V trough can be used to get the patient as straight as possible (FIGURE 3). If a V trough is not available, sandbags or lead blocks can be placed near the shoulders to prop up the patient. Cotton or radiolucent material can be placed under the cervical

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Rostral Caudal Occipital View Positioning for this view is very similar to the frontal sinus view. The patient is positioned in dorsal recumbency. The forelimbs should be extended caudally and secured with tape. The patient’s nose should still be perpendicular to the plate or cassette; however, instead of securing the tape around the muzzle to make a 90° angle with the table, pull a little more caudally and secure the tape. The nose is now between 100° and 105° when the patient is viewed from the side (FIGURES 11 and 12). In patients with an endotracheal tube in place, be sure not to bend the tube. Center the beam on the top of the cranium and collimate to include only the entire cranium (FIGURE 13). The marker should be placed on one side of the patient to indicate right or left. Rostral Caudal Open Mouth Maxilla View As with the previous views, the patient is placed in dorsal recumbency and the forelimbs are extended caudally and secured with tape. This view requires the maxilla to be parallel to the table, so it is best to secure the maxilla with tape across the hard palate. Place tape around the mandible behind the canine teeth and pull caudally to open the mouth wide (FIGURE 14). If the patient is under general anesthesia, be sure to either tie the tube to the mandible or remove the tube briefly for the exposure to prevent the tube from being superimposed over the maxilla. The tube head will need to be angled about 20° to direct the beam inside the mouth (FIGURE 15). The maxilla should be centered on the plate or cassette, and the field

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of view should include the rostral maxilla to the pharynx region or to C2 (FIGURE 16). The marker should be placed on one side of the patient to indicate right or left. Maxillary Obliques The position of the patient for these views depends on the level of sedation being used. If the patient is under heavy sedation or general anesthesia, it may be placed in lateral recumbency with the affected dental arcade closest to the plate or cassette. The head is rotated ventrally at a 45° angle, using a radiolucent wedge or foam padding to lift the mandible off the table (FIGURE 17). This position helps to isolate one side of the maxilla by avoiding superimposition of the opposite dental arcade. The mouth is propped open with a radiolucent object such as a syringe casing or a tongue depressor. The tube head is not angled for this view but is aimed ventrodorsally. The field of view can be collimated to include only the maxilla from the tip of the nose to the ear or to include the entire skull, depending on the clinician’s preference (FIGURE 18). Two markers are placed in this view, one indicating the recumbency of the patient and the other the beam direction. For example, VDLR means the beam is traveling ventrodorsally from the left side of the patient to the right side (FIGURE 19). To isolate the opposite arcade (the left maxilla), a VDRL view would be needed. Mandibular Obliques The position of the patient for these views may depend on anesthetic depth. The patient can be placed in sternal

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Radiographic Positioning: Head, Shoulders, Knees, and Toes, Part 1

in place (FIGURE 22). Extend the head back as far as it can go to prevent the trachea from being superimposed over the joint space on the radiograph. Center the beam over the thoracic inlet (FIGURE 23) and collimate down to include the scapulohumeral joint, the distal scapula, and the proximal humerus (FIGURE 24). The marker should be placed cranial to the joint indicating which leg is being imaged.

or lateral recumbency. Depending on the patient position, the head is rotated in an oblique position as close to 45° as possible, with the affected mandibular arcade closest to the table (FIGURE 20). This position helps to isolate one side of the mandible by avoiding superimposition of the opposite dental arcade. The mouth is propped open with a radiolucent object such as a syringe casing or a tongue depressor. The tube head is angled for this view but is aimed dorsoventrally. The field of view can be collimated to include only the mandible from the tip of the jaw to the ear or to include the entire skull, depending on the clinician’s preference (FIGURE 21). Two markers are placed in this view, one indicating the recumbency of the patient and the other the beam direction. For example, DVLR means the beam is traveling dorsoventrally from the left side of the patient to the right side. To isolate the opposite arcade (the right mandible), a DVRL view would be needed.

Supinated Shoulder View This view is used in patients being evaluated for osteochondritis dissecans (OCD). The positioning is identical to that for the mediolateral view, with one addition: a radiolucent material such as cotton or a foam wedge is placed under the elbow to elevate it and rotate the shoulder into a supinated position (FIGURE 25). The marker should be placed cranial to the joint indicating which leg is being imaged (FIGURE 26). Caudocranial Shoulder View The patient is positioned in dorsal recumbency. A V trough or other positioning device should be used to ensure the patient is as straight as possible (FIGURE 27). Use tape around the carpi and fully extend the limb of interest or both forelimbs cranially so that each humerus appears parallel to the cassette or plate. Secure the tape. Place tape around one or both forelimbs at the level of the proximal antebrachium to ensure that the elbows are pointing upward. If the elbows are rotated, tape around them and pull in either direction to ensure that they point straight up.

Shoulders Mediolateral View The patient should be positioned in lateral recumbency with the affected forelimb on the table closest to the plate or cassette. Position the opposite limb out of the way by taping around the carpus and pulling it across the body in a caudodorsal direction, and attach the tape to the edge of the table. Pull the affected limb cranially and position it in a normal walking motion, using tape or a sandbag to secure it

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Center the beam over the axillary joint space of the leg of interest (FIGURE 28). Collimate to include about half of the scapula and about half of the humerus (FIGURE 29). The marker should be placed lateral to the joint indicating which leg is being imaged. Lateromedial Scapula View There are two ways to position for this view12: 1. The patient is positioned in lateral recumbency with the affected limb up. This is very different from lateral positioning for other joints or bones. The down limb is pulled perpendicular to the body, while the limb of interest is extended cranially in full extension and secured to the table (FIGURE 30). This displaces the scapula dorsally above the dorsal spinous processes of the thoracic vertebrae. Padding may need to be added under the elbow to position the scapula in true lateral (FIGURE 31). Center the beam over the scapula and collimate to include the entire bone (FIGURE 32). The marker is placed on the dorsal aspect of the patient indicating recumbency. This view helps to visualize the spine of the scapula and the proximal border. 2. The patient is positioned in lateral recumbency with the affected limb down on the table and pulled caudally. The opposing limb should be pulled cranially out of the view (FIGURE 33). The sternum of the patient can be rotated up from the table to better visualize the entire scapula. This view superimposes the scapula over the cranial portion of the thorax and helps to better visualize the distal scapula. (FIGURE 34).

FIGURE 28

FIGURE 29

Elbows Mediolateral Elbow View The patient is positioned in lateral recumbency with the affected leg closest to the cassette or plate. Similar to the mediolateral shoulder view, tape around the unaffected carpus, pull the leg across the body caudodorsally, and secure the tape to the table (FIGURE 37). Extend the head and neck slightly dorsal so that they are out of the view. Place tape around the carpus of the affected limb and pull the limb forward in a natural position. Cotton or a foam wedge may be used under the carpus or elbow to enable a true lateral position through the radiohumeral joint space. Center the beam over the elbow (FIGURE 38) and collimate to include half of the humerus and half of the radius and ulna (FIGURE 39). The marker should be placed cranial to the joint indicating which leg is being imaged. Craniocaudal Elbow View The patient is placed in sternal recumbency. A foam pad may be placed under the hips to make this position more comfortable. Pull the affected limb cranially, extending the

FIGURE 30

FIGURE 32

FIGURE 33

Caudocranial Scapula View The positioning for this view is identical to the caudocranial view of the shoulder. Center the primary beam over the scapula (FIGURE 35) and collimate to include the entire bone and approximately one-third of the proximal humerus (FIGURE 36). The marker should be placed lateral to the joint indicating which leg is being imaged.

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elbow, and secure it with tape (FIGURE 40). If the patient is not heavily sedated, a staff member wearing the required PPE may be needed to restrain the patient’s head. For sedated patients, a large foam pad can be used to elevate and rest the head and extend it away from the forelimb of interest. When pulling the head to one side, be careful not to rotate the elbow too far medially or laterally. Palpate the elbow. The olecranon should remain centered between the medial and lateral epicondyles of the humerus. Center the beam over the elbow and collimate to include half of the humerus and half of the radius and ulna (FIGURE 41). The marker should be placed lateral to the joint indicating which leg is being imaged.

around the affected carpus, pull the carpus cranially under the head, and secure the tape to the table (FIGURE 42). Be sure the keep the elbow in a true lateral position through the joint. Center over the elbow and collimate to include half of the humerus and half of the radius and ulna (FIGURE 43). If possible, the marker should be placed cranial to the joint indicating which leg is being imaged. CONCLUSION There are many important things to keep in mind when taking radiographs, but first and foremost, it should be the duty of the veterinary technician to do what is best for the patient. We will continue this discussion in part 2. 

Hyperflexed Elbow View The patient is positioned as for the mediolateral elbow view, with the affected leg down and the opposite limb taped across the body. A heavy positioning aid can be placed under the carpus of the affected limb to push it up toward the head and hyperflex the elbow. If such an aid is not available, tape

Recommended Reading Lavin LM. Radiography in Veterinary Technology. 5th ed. Philadelphia, PA: Elsevier Saunders; 2014.

References 1. ORAU. Shoe-fitting fluoroscope (ca. 1930-1940). Accessed September 2016. orau.org/ ptp/collection/shoefittingfluor/shoe.htm. 2. Han CM, Hurd CD. Practical Diagnostic Imaging for the Veterinary Technician. 3rd ed. St. Louis, MO: Elsevier Mosby; 2005:38-103. 3. Ayers S. Small Animal Radiographic Techniques and Positioning. West Sussex, UK: Wiley Blackwell; 2012:60-65. 4. US Nuclear Regulatory Commission. Occupational dose limits for adults. 56 Federal Register 23396 (May 21, 1991). Accessed September 2016. nrc.gov/reading-rm/doccollections/cfr/part020/part020-1201.html. 5. US Nuclear Regulatory Commission. NRC occupational dose limits. Accessed September 2016. nrc.gov/images/about-nrc/radiation/dose-limits.jpg. 6. Association of Surgical Technologists. AST Standards of Practice for Ionizing Radiation Exposure in the Perioperative Setting. Available from: ast.org/AboutUs/

FIGURE 36

Surgical_Technologists_Responsibilities/. Accessed September 2016. 7. NC Department of Health and Human Services. The use and care of lead protective equipment. July 2009. Accessed September 2016. ncradiation.net/xray/documents/ leadapronsgud.pdf. 8. Indiana State Department of Health. 410 IAC 5-6.1: X-rays in the healing arts. in.gov/ isdh/24361.htm. Accessed September 2016. 9. Cone Instruments. X-ray aprons—inspect to protect! Accessed September 2016. coneinstruments.com/buying-guides/a/lead-apron-inspection/. 10. Pillay M, Stam W. Inspection of lead aprons: a practical rejection model. Health Phys 2008;95(suppl 2):S133-S136. 11. Thrall D. Textbook of Veterinary Diagnostic Radiology. 6th ed. St Louis, MO: Elsevier Saunders; 2013:287. 12. Lavin LM. Radiography in Veterinary Technology. 5th ed. Philadelphia, PA: Elsevier Saunders; 2014:307-326.

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The Case for Veterinary Midlevel Professionals Kenichiro Yagi, BS, RVT, VTS (ECC, SAIM) Ken practices at Adobe Animal Hospital as an ICU and Blood Bank Manager. He is an active educator, lecturing internationally, providing practical instruction, and authoring texts, chapters, and articles on transfusion medicine, respiratory care, and critical care nursing. He serves on the boards of the Veterinary Emergency and Critical Care Society and the Academy of Veterinary Emergency and Critical Care Technicians, on the Veterinary Innovation Council, and as the NAVTA State Representative Chairperson. He is a graduate student in veterinary medicine and surgery through the University of Missouri. Ken invites all veterinary technicians to ask “Why?” to understand the “What” and “How” of our field and to constantly pursue new goals as veterinary professionals.

Kenichiro Yagi, BS, RVT, VTS (ECC, SAIM) Adobe Animal Hospital Los Altos, California

Mandy Fults, BS, LVT, CVPP, VTS (Clinical Practice — Canine/Feline) Comanche Trail Veterinary Center Liberty Hill, Texas

n 2009, Kogan and Stewart initiated a discussion within the veterinary medical community bringing forth the concept of veterinary professional associates, midtier professionals similar to physician’s assistants (PAs).1 The article evaluated the need for such a role through discussion of societal needs for more veterinarians and described the motivations, developmental history, intended role, 52

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Mandy Fults, BS, LVT, CVPP, VTS (Clinical Practice — Canine/Feline) Mandy is a veterinary technician with more than 15 years of experience. She is currently employed with Comanche Trail Veterinary Center in Liberty Hill, Texas, as the clinical care coordinator. She earned her veterinary technology degree in 2001 and her bachelor of science degree in agriculture economics from Texas A&M University. Currently, she is pursuing a master’s degree in veterinary biomedical science with small animal endocrinology as her primary interest through the University of Missouri.

responsibilities, limitations, benefits, and certification process of PAs. In the recent years, the veterinary technician (VT) profession has reached a new height, with 13 veterinary technician specialist (VTS) academies officially recognized by the National Association of Veterinary Technicians in America (NAVTA) and the entire field working toward a unified credentialing title. More than 850 credentialed

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The Case for Veterinary Midlevel Professionals

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More than 850 credentialed veterinary technician specialists have become certified through a rigorous application and examination process.

VTSs have become certified through a rigorous application and examination process, with the majority practicing within the United States. Additionally, programs such as the biomedical sciences master’s program in veterinary medicine and surgery at the University of Missouri, which is offered to veterinarians, veterinary technologists, and VTSs, have emerged. The University of Missouri program is the first of its kind to target credentialed technicians and provide an advanced educational pathway geared toward career advancement opportunities. In 2016, 6667 highly competitive candidates applied for admission to US and international Association of American Veterinary Medical Colleges member institutions, with only 4227 accepted as first-year veterinary students.2 If this trend continues, more than 2000 highly qualified candidates will be denied a path to a doctorate degree in veterinary medicine each year. While many might reapply the subsequent year, establishment of a midlevel veterinary professional (MLVP) position would provide an alternate career path in veterinary medicine, leading to the entry of bright minds into the field in a different form. Could these individuals be MLVP candidates, and should this role exist? If so, how might it be established? TODAY’SVETERINARYTECHNICIAN

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THE MIDLEVEL PROFESSIONAL Two professions are established in the human medicine system as midlevel professions: the physician’s assistant (PA) and the nurse practitioner (NP). These roles have an established education and certification system that allows for the legal practice of medicine on a limited scale. Both roles help fill a societal need brought on by increasing demands for medical care unable to be met by the number of physicians entering the field. The potential supply of medical professionals to meet this demand was seen during World War II, when Dr. Eugene Stead realized that an intermediate role might be possible through employment of soldiers who had gone through a 2-year medical training program to become medics in combat.1 By the end of the Vietnam War, a large number of medical corpsmen had returned to the United States, providing a large pool of medically inclined, highly trained individuals without the ability to practice as physicians. This supply, along with an ever-increasing demand for doctors, served as a trigger for the establishment of the PA role.1 The NPs followed a similar path of providing healthcare professionals to meet the public’s demands for primary |

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care providers in the 1960s. Loretta Ford and Henry Silver established the first NP training program in 1965, which then led to the emergence of similar programs nationwide.3 While there was strong opposition to the establishment of the profession from both nursing and physician communities, NPs were able to document increased availability of primary care, satisfaction of both nurses and physicians in collaborating, and equal competency and patient outcomes when compared with physicians through a series of published articles and studies. Overall, the NP profession was able to provide cost-effective and more widely available healthcare while functioning in an autonomous manner.3 Ensuring Quality of Knowledge While initial efforts in establishing the PA and NP professions involved voluntary certifications and titles that led to various credentials and scopes of practice, minimum requirements of education were eventually standardized. Ensuring the quality of knowledge through proper curriculum development, accreditation standards, continuing medical education (CME) requirements, and national certification through standardized examination played a large role in acceptance of the professions. For example, the PA role requires formal education through a program accredited by the Accreditation Review Commission on Education for the Physician Assistant, passing of the PANCE exam administered by the National Commission on Certification of Physician Assistants,

TECHPOINT 

NPs are allowed to practice autonomously in most states, while PAs practice under the physician’s license. 100 hours of CME every 2 years, and recertification through a written examination every 6 years. The PA role was established through involvement of professional groups and stakeholders who would potentially be affected by the role in the planning process, to allow for defining of boundaries of authorized function. The establishment of MLVPs would likewise require strict regulation and quality control. This would need to be a collaborative effort throughout the profession to outline a strategic plan of action. Nurse Practitioner and Physician’s Assistant Roles Eventually, both the PA and NP roles were established as healthcare professionals licensed to practice medicine, with the ability to perform physical examinations, diagnose and treat illnesses, order and interpret tests, counsel on preventive healthcare, assist in surgery, and write prescriptions (in almost all states). Autonomy is

Timeline of Veterinary Technicians in Comparison to Human Mi Veterinary Technician NAVTA formed (1981) Animal technicians established (1960)

1950

First journal published: The Journal for Animal Health Technicians (1976)

1960

1970

1980 First NP continuing education symposium held (1975)

First PA program established (1965)

First PA journal published: Physician’s Associate (1971)

First NP program established (1965)

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T E CHP O I N T 

The Case for Veterinary Midlevel Professionals

PAs are largely seen as generalists that perform primary care, whereas NPs are certified in a specific population focus, such as acute care, gerontology, pediatrics, and others.

Benefits of the Midlevel Profession Regardless of the role, the establishment of an intermediate role has shown many benefits in human medicine, including greater efficiency and overall accessibility to healthcare. From a financial standpoint, physicians were able to work 1 week less a year, yet the number of available office visits grew and net income increased by 18%.1 PAs, for example, cost $0.28 for each $1 brought into the practice.1 Patient satisfaction is improved because of reduced waiting times and even a preference to see PAs over physicians in various settings. In a study, incorporation of NPs to inpatient care teams was observed to increase revenue, reduce length of hospital stays, and standardize quality of care,4 while another study observed the employment of one NP per two physicians to decrease patient costs without compromising quality of care.5 Although creating an efficient PA or NP and physician team takes commitment, the benefits easily outweigh the costs, allowing for clear division of labor and leading to an efficient and effective team.

given in medical decision making, and both professions include roles in education, research, and administrative services in addition to primary care. The types of duties vary based on needs of the physician, abilities of the PA or NP, and the work setting. Although both PAs and NPs can diagnose, treat, and prescribe, there are some significant differences between the two professions. PAs are largely seen as generalists that perform primary care, whereas NPs are certified in a specific population focus, such as acute care, gerontology, pediatrics, and others. NPs are allowed to practice autonomously in most states, while PAs practice under the physician’s license.

Implications for Veterinary Medicine So where does this leave us in veterinary medicine? Incorporating MLVPs into practice could bring the same benefits PAs and NPs have brought to human medicine by providing better access to veterinary care without compromising client satisfaction and patient care. The potential for financial benefits by increasing a practice’s net income and alleviating the veterinarian’s workload are also critical factors in the longevity of the field of veterinary

an Midlevel Professionals AVMA approves the term “veterinary technician” (1989)

13th VTS academy recognized: Ophthalmology (2016)

NAVTA forms Committee on Veterinary Technician Specialties (1994) More than 850 VTSs (2016)

First VTS academy recognized: Emergency and Critical Care (1996)

1990

2000

2010

tion

2020

92,049 PAs certified (2010) 135,000 NPs (2010)

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Incorporating MLVPs into practice could bring the same benefits PAs and NPs have brought to human medicine by providing better access to veterinary care without compromising client satisfaction and patient care.

medicine. Nevertheless, the mention of a MLVP sparks debate both in support for and opposition to the concept. NEEDS ASSESSMENT The first element of successful establishment of an MLVP is demand. Is there a demand in veterinary medicine? In 2009, when the Kogan and Stewart article was originally published, the National Veterinary Medical Service Act of 2003 and the Veterinary Workforce Expansion Act of 2007 had been implemented to attempt to fill a shortage of veterinarians. Along with the perceived shortage, veterinary medicine was the 9th fastest growing field, expected to show 35% growth over the next few years. However, in 2013, the AVMA Workforce Advisory Group produced a report indicating a 12.5% excess, instead of a shortage, of veterinarians, and the excess was expected to remain between 11% and 14% through 2025. Interestingly, despite the excess of veterinarians, the average veterinarian was found to be working more than 40 hours a week. The discrepancy was largely attributed to the trend in increased practice hours and the inability for practices to staff more veterinarians to better distribute hours because of their size. Of the employed veterinarians surveyed, 38% indicated their practices were operating at full capacity, with their entire workday being occupied with work.6 In other words, the supply of veterinarians has increased, but demands on each individual have risen. Maldistribution Despite a general oversupply of veterinarians, maldistribution of veterinarians regionally and in certain sectors is a continuing issue in veterinary medicine, with 198 areas designated as “shortage areas” within the United States.6 In 2008, it was reported that approximately 500 rural US counties, with more than 5,000 head of cattle, lacked a veterinarian. A survey of large animal breeders in a specific county revealed that 84% performed their own veterinary work on a routine basis because of a lack of available large animal veterinarians in the area. Efforts to help offset the shortage of rural area veterinarians have been implemented and include multiple incentives, such as tuition relief for veterinary students, state support for providing treatment vans, scholarships to students who express an interest in large animal medicine, and even modifying laws to allow VTs to function in a greater capacity. Livestock owners and local farmers have set forward some proposals, one of which suggests a future program “for legislative consideration to increase the legal activities and capabilities of veterinary technicians similar to those used by Nurse Practitioners and Physician Associates.”7 56

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TECHPOINT 

The establishment of MLVPs in the area of production and large animal medicine is a possible solution to alleviate some of the demand within rural communities. The Academy of Veterinary Technicians in Clinical Practice, established in 2013, has 4 recognized VTSs in production medicine, and the Academy of Internal Medicine for Veterinary Technicians, established in 2006, has 7 recognized VTSs in large animal medicine. Future VTSs in this field of study are an invaluable asset in large animal medicine, some of which may consider roles as MLVPs. Veterinarian Burnout The overtime hours veterinarians work could be alleviated through the existence of MLVPs, as their employment would be more affordable and realistic for smaller practices than hiring more veterinarians to lessen the load. Current trends in establishing an effective work–life balance to prevent career burnout is of value to most millennial veterinarians.8 With the continued growth of veterinary medicine, including extended hours of daily operation, a business model formulated with an MLVP to provide professional support can reduce attending veterinarians’ workload, allowing more time for case management and reducing overall weekly work hours. Another benefit in lifestyle enhancement is minimizing or even eliminating the challenge of having to find a relief veterinarian in the case of unexpected or planned events, such as family emergencies or a day off for a local event with the family. Otherwise, the absence of the

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T E C HP O I N T 

The Case for Veterinary Midlevel Professionals

The establishment of MLVPs in the area of production and large animal medicine is a possible solution to alleviate some of the demand within rural communities.

(i.e., those with a higher degree of education and training) resulted in an increase in annual revenue by $93,311 per credentialed VT compared with practices employing non-credentialed equivalents.10 A second layer of tasks delegated by the veterinarian to qualified individuals can be added through establishment of MLVPs. Real examples of practices unable to meet demands despite employing VTs exist. Dr. Brian Stuckey, a practice owner in Texas, states there are needs unmet by VTs even though he uses his credentialed VTs to the maximum allowable by law. He sees an immediate need for individuals who can perform wellness care in his hospital to enable the veterinarians to concentrate on more complex cases.a In such practices, the shortage can be met by another veterinarian, though that increases operation cost compared with MLVPs, and this cost will be passed on to pet owners. In addition, veterinarians who are providing services that could be performed by an MLVP are reducing their potential and preventing full realization of their education and training.

veterinarian can result in rescheduling of appointments or lead to closing the doors for the day(s), depending on practice size and available associates to cover the additional workload. With suicide rates being higher among veterinarians compared with other professionals, along with contributing factors such as work-related stressors (e.g., long hours worked, work overload),9 MLVPs should be a tremendous benefit. MLVPs could also give veterinarians the flexibility of spending their time and focus on aspects of their work that is important to them. Fulfillment in the job is another factor in career longevity.

Veterinary Technician Scope of Practice From the perspective of VTs, the one misconception to dispel is that VTs are already performing the roles of MLVPs—this would be in violation of legislation. For example, performing a skin scraping and determining the patient to have demodicosis would constitute making a diagnosis, as would determining an abnormality in blood work and relating it to specific organ dysfunction. Lancing a cat’s abscess or creating an incision for esophagostomy tube placement with a surgical blade can be considered surgery. Obtaining a medical history and recommending blood work is prescribing. Emergency examination of a puppy that had a seizure and measuring blood glucose is prescribing a diagnostic. Many simple tasks that veterinarians trust VTs to perform could be interpreted as practicing without a license. The goal of establishing MLVPs is to help streamline daily operations by focusing on basic-level veterinary medicine. This establishment would be of benefit to VTs and veterinary assistants, where many routine questions and modifications to therapy could be approved without the need to consult the veterinarian. For example, prescribing parasiticides after fecal examinations, authorizing refills of potentially nephrotoxic medications after confirming no signs of renal dysfunction, or ordering adjustments in analgesics for an inpatient might all be performed without the need for the veterinarian’s intervention, providing swifter turnaround and relief for patients and clients. This would be a major advantage for practices in which veterinarians are

Economic Growth Further economic growth in veterinary medicine is necessary to alleviate crippling issues, including repayment of rising student debt for both veterinarians and VTs, that deter qualified individuals from entering or staying in a career in veterinary medicine. Employment of MLVPs can reduce the cost of veterinary care by allowing individuals earning a lower salary to increase the volume of cases seen through delegation. Financial gain for the practice can allow options to better compensate the entire team. The addition of an MLVP to the staff is thought to increase practice revenue by improving the efficiency of veterinarians by freeing them from tasks that can be performed by MLVPs. One example of this advantage would be MLVPs performing wellness examinations while the veterinarian performs surgeries, reducing the revenue lost by blocking off examination time. The concept is similar to VTs bringing value to a practice by freeing veterinarians from tasks they would have to perform should VTs be absent. The AVMA Biennial Economic Survey of 2008 indicated that employing credentialed VTs TODAY’SVETERINARYTECHNICIAN

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high in demand for minute-to-minute decision making, alleviating some workload. Another strong potential for the usefulness of MLVPs in practice is in the area of anesthesia. Often, the model of veterinary surgery consists of a VT administering anesthesia and monitoring the patient while the veterinarian performs the surgery. In the event that complications arise, the VT requires the veterinarian’s approval for interventions to stabilize the patient. Veterinarians are required to split their attention between the patient’s status regarding anesthesia and completing the surgical procedure safely. While this is achievable without obvious consequences most of the time, an educated, trained, and experienced veterinary professional dedicated to the maintenance of life and anesthesia would prove invaluable in critical cases. This role can currently be accomplished by another veterinarian, although an MLVP focusing in the field of anesthesia is likely more cost-effective in smaller operations. A collaborative veterinarian–MLVP approach would increase accessibility to veterinary care, alleviate veterinarian burnout, promote growth in the veterinary economy, and create professionals that are trained and approved for higher-level care than VTs currently are.

TECHPOINT 

Despite the excess of veterinarians, the average veterinarian was found to be working more than 40 hours a week.

WHERE DO WE GO FROM HERE? Establishment of a midlevel profession in veterinary medicine is a topic of ongoing discussion in the field. The potential benefits to veterinarians, VTs, veterinary assistants, patients, and pet owners are many. However, questions still remain: is the demand high enough, is the benefit to the public is great enough, and is the present day the right time to encourage the change? Similar to the processes NPs and PAs went through to become established, related concerns and opposition are likely to surface. However, continued discussion among allied veterinary professional groups to understand the role and scope of MLVPs, collection of more data on the potential benefits of MLVPs, and documented support from intended beneficiaries are anticipated to ease any initial opposition.

Some fears include the possibility for MLVPs to fill positions normally available to veterinarians when there already is a surplus of veterinarians. This is a reasonable concern, and we should monitor the effect as initial MLVPs enter the field. Those who do not believe this to be a valid concern feel that the financial gain of the practice will allow for practice growth; also, by providing an alternative revenue source for universities, establishment of MLVP programs can help reduce the overproduction of veterinarians due to financial pressure of the institution. If the role is to be implemented, careful consideration of standards for an academic curriculum and licensing examination to ensure high-quality education will be needed. The regulatory structure and scope of practice of the profession will also need to be determined to provide quality assurance for individuals in practice as an MLVP. With the growing number of VTs and VTSs with bachelor’s and master’s degrees, as well as the demand by the public for affordable and accessible veterinary care, MLVPs are a potential solution for cost-effective means of delivering primary veterinary care and reducing job-related stress on veterinarians. As the national credentialing initiative put forth by NAVTA to standardize credentialing requirements and uniting veterinary technicians under one title progresses, the path in which veterinary technicians become more effective in driving better patient care, veterinary team function, and protection of the veterinary care consumer should be considered, with MLVPs a worthy concept to explore. 

References 1. Kogan LR, Stewart SM. Veterinary professional associates: does the profession’s foresight include a mid-tier professional similar to physician assistants? J Vet Med Educ 2009;36:220-225. 2. Annual Data Report 2015-2016 [Internet]. Washington, DC. Association of American Veterinary Medical Colleges; 2016 February:1-27. Available from: http://www.aavmc. org/About-AAVMC/Public-Data.aspx. Accessed June 16, 2016. 3. O’Brien JM. How nurse practitioners obtained provider status: lessons for pharmacists. Am J Health Syst Pharm 2003;60:2301-2307. 4. Kapu AN, Kleinpell R, Pilon B. Quality and financial impact of adding nurse practitioners to inpatient care teams. J Nurs Adm 2014;44(2):87-96. 5. Kralewski J, Dowd B, Curoe A, et al. The role of nurse practitioners in primary healthcare. Am J Manag Care 2015;21(6):e366-371.

6. AVMA Workforce Advisory Group. Implications of the 2013 US Veterinary Workforce Study and Recommendations for Future Actions. 2013. https://www.avma.org/KB/ Resources/Reports/Documents/WAG-report_Workforce-Implicatn-Recommend_2013. pdf. Accessed June 16, 2016. 7. Moran DD. Production-animal veterinarian shortage: a rural case study of West Virginia. Online J Rural Res Policy 2010;5(7). 8. Boston S. The end of “suck it up”? drandyroark.com/the-end-of-suck-it-up. Accessed June 2016. 9. Bartram DJ, Baldwin DS. Veterinary surgeons and suicide: a structured review of possible influences on increased risk. Vet Rec 2010;166:388-397. 10. American Veterinary Medicine Association. Contribution of veterinary technicians to veterinary business revenue, 2007. JAVMA 2010;236(8):846.

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The Case for Veterinary Midlevel Professionals

NAVTA National Credentialing and Veterinary Nurse Update Heather Prendergast, RVT, CVPM Kenichiro Yagi, BS, RVT, VTS (ECC, SAIM)

The National Association of Veterinary Technicians in America (NAVTA) has spent the year researching options and opportunities that will help drive the professional standards for credentialed veterinary technicians. Currently, credentialed veterinary technicians may be referred to as RVT, CVT, LVT, or LVMT, depending on the state in which they practice. This causes great confusion among veterinary consumers and even within the veterinary profession. NAVTA’s goal is to create one standard title for credentialed veterinary technicians, a uniform credentialing process (for entry and maintenance), and title protection in every state. At present, a majority of survey respondents favor the term veterinary nurse (for full survey results, visit navta.net and click “2016 Demographic Survey Results”). Those who favor the term veterinary technician have identified two objections:

1. “We do more than nurses.” 2. “The nurses will never allow us.”

“We Do More Than Nurses.” At first glance, this can appear to be true. Veterinary technicians administer anesthesia, monitor surgical recovery, provide nursing care to patients, perform dental prophylaxis, and more; however, when the the specialized functions nurses serve are taken into account, the similarities of the two professions outweigh the differences. Look at veterinary medicine moving forward, and how many areas are becoming specialized in veterinary medicine. One could also place the educational requirements of veterinary technicians and nurses next to each other and find more similarities than not. Ask yourself: What do your veterinary clients understand about your position as a veterinary technician? How do you explain your role in their pets’ care to them?

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What do your clients understand about your position as a veterinary technician? How do you explain your role in their pets’ care?

“The Nurses Will Never Allow Us.” This used to be the presumed answer; however, preliminary results and discussions show that reality is much different than we might have thought. Nurse title protection exists in a majority of US states, but the status of these protections causes no conflict in 14 of those states; an additional 12 states have no title protection. NAVTA has learned that many professionals in the human medical profession do not know/understand the role of the credentialed veterinary technician/ nurse, nor are they aware of the educational requirements and board examinations needed to earn and use the title. Providing information on the educational and credentialing process has gained the support of nursing professionals. What Does This Process Look Like? NAVTA will spend the remainder of 2016 working through processes with the American Veterinary Medical Association (AVMA), AVMA Committee on Veterinary Technician Education and Activities (CVTEA), American Association of Veterinary State Boards (AAVSB), and Association of Veterinary Technician Educators (AVTE), along with other veterinary stakeholders; they will also continue building relationships with nursing associations. Recommending that the same title be used in every state with uniform requirements affects many entities, and all processes and procedures must be considered, allowing the right strategy to be developed and implemented. Currently, informational webinars are being developed for state veterinary technician associations to answer questions and guide the processes on a state-by-state basis. For the most current information, FAQs, and an e-mail address to submit your questions, please visit navta.net/?page=VeterinaryNurse.

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Careers Career Opportunities for Veterinary Technicians NATIONWIDE

Veterinary Technician Positions Available

Join Our Family! At BluePearl Veterinary Partners, we’re always looking for passionate veterinary assistants and technicians to join our national network of specialty and emergency hospitals. Learn more at bluepearlvet.com/careers and apply today! Please follow us on FaceBook at: facebook.com/BluePearlJobs

General, Specialty, & Emergency/Critical Care Practice We are accepting applications from enthusiastic, motivated, compassionate, dedicated, CVTs, LVTs, RVTs, & experienced technicians. Both night and daytime shifts are available. Salary is commensurate with experience. Generous benefits package that includes subsidized health insurance, paid sick or personal days, paid holidays, CE and uniform allowance, retirement plan, bonuses, and discounted pet care.

AAHA “National Referral/Specialty Practice of the Year 2015”

Please send resume to:

E-mail: mycareer@coralspringsanimalhosp.com

IOWA

SOUTH CAROLINA — Licensed Veterinary Technician needed for full/part-time position at AAHA accredited hospital to assist 5-doctor practice. Emphasis on technical skills in surgery/anesthesia, client/patient care, education, and creating positive relationships with clients and co-workers. Benefits include health insurance, 401K, continuing education, vacations, uniforms, pet care discount. Seeking employees who strive for excellence and demonstrate reliability, flexibility, strong communication and organizational skills. Some weekends required. Non-smoking and drug-free workplace.

Looking for big city capabilities with small town hospitality? Veterinary Associates of Manning, Iowa, is seeking a Veterinary Technician (preferably Registered) to work at their progressive, mixed animal practice. Veterinary Associates offers in-house blood work as well as surgery and therapy lasers, digital radiography, stem cell regenerative therapy, ultrasonic dental capability and a full pharmacy. For this reason, the applicant must be proficient in restraint, phlebotomy, laboratory work and analysis as well as surgical assistance, dental prophylaxis and the ability to figure medication dosages.

Email resumes to Angela at blufftonvet@gmail.com.

The willingness to learn, work as a team as well as individually, and to multi-task is a must.

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HURRY! Space in the new Careers section won’t last forever!

Veterinary Associates is nestled in a small town of 1,500 people and services clients from 4 county seat towns of 10,000+ within a 30 minute radius. Manning is a progressive and forward-thinking town with many conveniences. If you’re looking for a place to feel like part of the community & actually know your neighbors, Manning is the place for you! Please submit resume and brief biography to: Veterinary Associates of Manning 1603 Enterprise Street Manning, IA 51455 or email to manningvets@gmail.com

Advertise in the new Careers section of Today’s Veterinary Technician. Call Renee Luttrell today 610-558-1819 or email RLuttrell@NAVC.com to find out how.

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Final Thoughts

Technician, Heal Thyself First and foremost, I don’t think you are broken and in need of fixing. But I am concerned about something: you and your sustainability as a veterinary technician. Over the past few weeks, I’ve been asking my compassion fatigue seminar and workshop participants the question, “How many of you consider yourself a healer?” Less than 10% of my audiences do, and I’ve noticed that most who do are veterinarians. This got me thinking…a lot.

Julie Squires Rekindle, LLC

Merriam-Webster defines healer as one who heals. So I dug a little deeper. What is the definition of heal? “To become healthy or well again; to make (someone or something) healthy or well again.” Stop me if I’m wrong, but is that not what veterinary medicine is all about? I wondered what I was missing and why veterinary professionals aren’t identifying with their work in this way, especially veterinary technicians and nurses.

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.

Healer or Not This idea of healer goes back to the keynote speech given in August by Dr. Dan Siegel, neuropsychiatrist, at the American Veterinary Medical Association conference in San Antonio, Texas. Dr. Siegel spoke very candidly about the suicide rate plaguing veterinary medicine and said something I’m still thinking about. He said, “The problem is, we have a community of healers that haven’t been taught to heal themselves.”

shutterstock.com/Tyler Olson

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.

AS A VETERINARY TECHNICIAN, you’ve been given the rare gift of being able to aid in the healing of others, animals, and people. You’ve made a difference in more lives than you will ever know. 62

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Final Thoughts

Is he on to something? I sure thought so. What I wasn’t prepared for is that so many people in veterinary medicine don’t consider themselves healers. While it may not be necessary to claim “healer” status, what is necessary is to recognize that to provide care to another being in a sustainable way, we have to take care of ourselves first. This is not intuitive to anyone in a caregiving role. When we put ourselves last on the list, why are we surprised when we feel stressed, anxious, depressed, depleted, or exhausted? It is our job to meet our needs, no one else’s. We can’t wait for others in our life to tell us to take a day for ourselves or go for a walk. That responsibility falls in our hands. We need to ask for what we need, unapologetically. What You Need Based on psychologist Abraham Maslow’s “hierarchy of needs,” all human beings need the following: ÆÆ Sustenance/Health ÆÆ Safety/Security ÆÆ Rest ÆÆ Autonomy/Authenticity ÆÆ Creativity/Play ÆÆ Meaning/Contribution ÆÆ Love/Caring ÆÆ Empathy/Understanding ÆÆ Community/Belonging Can you identify needs that are not being met in your life? Most of us can, and that is okay. The question is, what can you do to fulfill those needs? We need to realize that the extent to which our work is traumatizing is the same extent to which we need to balance it with self-initiated action aimed at meeting our needs. This is not something we can ignore or hope will go away. I recently met an LVT who has been a veterinary technician for 30 years. She told me that asking for what she needs from her family is much of what has sustained her in her career. She asks for “alone time” routinely and time to transition when she comes home from work. Her family knows that she needs 20 minutes or so to decompress after work. This is how she meets her need for rest. If you live with others, what do you need to ask for to take care of yourself? If you live alone, what is one thing you can start doing daily for yourself? It doesn’t have to be very time consuming. Finding 10 to 20 minutes a day to gift yourself is often enough. What Gets in the Way The most common reason I hear for not attending to ourselves TODAY’SVETERINARYTECHNICIAN

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Technician, Heal Thyself

is that it is selfish. Au contraire, mon frère. Being selfish is when we care only for and about ourselves. That is not at all what I’m suggesting, and if you are reading this, I am absolutely certain that you are incapable of it. As a veterinary technician, you are called to serve others. It’s part of who you are. That is beyond commendable, and I am grateful that you are in this world, serving animals in the way that you do. But. It is unreasonable and unrealistic to think that we can serve others, give the best of ourselves and our hearts, and not have to do anything to maintain that beautiful well within. How long will your car run if you never refill the tank? What are you telling yourself about why your needs don’t matter? Remember, our thoughts determine our feelings.a Our feelings dictate our actions, and our actions determine our results. Said another way, what you choose to think determines your outcome in life. So if your thoughts are along the lines of, I don’t deserve to take time for myself, why is that what you are choosing to think? Could you consider a thought like, I’m good at what I do, I care deeply for my patients/animals, and I know I’m better when I take time for me. How You Start Your Day Matters I study under many of the personal development thought leaders of our time, and I’ve found that they all follow their own very intentional morning routine to set their day up for success. I do too. My routine involves excellent coffee, real food, meditation, and exercise. Sometimes my exercise becomes my meditation, but the routine is non-negotiable. I. Do. It. Every. Morning. Sustenance and health are enormous needs of mine that I honor every day. Sometimes this means I have to get up earlier depending on my travel schedule or the day’s activities. I do it anyway, because I know that following my routine will dramatically improve the quality of my mind, body, and soul for that day. I’ll be better able to serve those I care for and feel better about myself. When the start of your day is consistently filled with chaos, and then you go to work in the often unpredictable world of veterinary medicine, it is too easy to set yourself up for failure in your well-being and emotional state. Be a Rebel I’m asking you to break out of the traditional box of caregivers and practice giving to yourself. Be rebellious and stare down martyrdom. Don’t be surprised when your mind chatters back, because it inevitably will. There will always be something else you should be doing other than gifting to yourself. Do it anyway. November/December 2016

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Final Thoughts

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

1. Anticipate it Expect that your mind will try to derail you from your self-care efforts. Prepare for it. Think about what you will tell yourself when your mind tries to talk you out of going for that walk, doing yoga, enjoying a cup of tea outside, or reading a book for pleasure. 2. Acknowledge it I literally say, Oh I see you, or Oh you again, to my mind chatter. I know I am not my mind,a so when I recognize my mind trying to talk me out of what is in my best interest, I just smile and acknowledge it. I don’t dwell on it or believe it, but I let it know I see it.

% (n=200) 12.5 1.0 3.5 2.0 4.5

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

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

3. Answer it in a way that best serves you This is where we can decide to think differently. Many people believe their mind chatter and never dream of answering it from their heart, No. I need to and deserve to have some time to myself. This will become much easier the more you do it, so don’t give in to your old way of thinking. As a veterinary technician, you’ve been given the rare gift of being able to aid in the healing of others— animals—and people. You’ve made a difference in more lives than you will ever know. If you also believe you have this gift, then please honor, cherish, nurture, and feed it. The only thing holding you back from being the best version of yourself is your own thoughts. Thankfully, you can choose different thoughts any time you want. Why not start now?  For more tips on how to learn to recognize and change negative thought patterns, read “The Golden Ticket to Feeling Better” on todaysveterinarytechnician.com.

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Technician, Heal Thyself

A workshop participant recently told me that she had started honoring her need for creativity/play by taking a weekly painting class, something that she once really enjoyed and had decided to give to herself again. She told me how she fights with herself every week about it. Her mind will say things like, You shouldn’t go, you have so much laundry to do. But instead of giving in to this subtle, “practical” sabotage, she pushes back and decides, No, this is something I’m doing for myself. I really enjoy it, and it makes me feel good when I do it. The laundry isn’t going anywhere. We all have this mind chatter. The best thing you can do with it is:

Oral active control

N2 25 2 7 4 9

TODAY’SVETERINARYTECHNICIAN

November/December 2016

10/7/16 7:41 PM

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

Dogs love it! 1

Data on file at Merial.

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IMPORTANT SAFETY INFORMATION: NexGard is for use in dogs only. The most frequently reported adverse reactions included vomiting, dry/flaky skin, diarrhea, lethargy, and lack of appetite. The safe use of NexGard in pregnant, breeding, or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures. For more information, see full prescribing information or visit www.NexGardForDogs.com. 10/7/16 8:44 PM