Today's Veterinary Technician, January 2017 by davidpsu

BEHAVIOR PUPPY SOCIALIZATION AND NOISE ANXIETY

WELL-BEING DEPRESSION IN THE VETERINARY PROFESSION

TOXICOLOGY XYLITOL TOXICOSIS

SURGERY KEYS TO DISINFECTION AND STERILIZATION

CLINICAL PATHOLOGY UPDATE ON DIGITAL MICROSCOPY

Ferret Dentistry: NO WEASELING ABOUT IT!

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YOU’VE GOT HER BACK. VETMEDIN® HAS HER HEART.

No other canine CHF drug offers the same level of research and support as Boehringer Ingelheim Vetmedica, Inc. Industry-trusted VETMEDIN gives dogs with congestive heart failure (CHF) better days and longer lives.1 It’s backed by years of groundbreaking canine cardiology research. And only VETMEDIN offers free tools that educate your clients to recognize the signs of CHF faster—which can lead to treatment sooner. Contact your Boehringer Ingelheim Vetmedica, Inc. representative today for a heart to heart about VETMEDIN. Reference: 1. Lombard CW, Jöns O, Bussadori CM; for the VetSCOPE Study. Clinical efﬁcacy of pimobendan versus benazepril for the treatment of acquired atrioventricular valvular disease in dogs. J Am Anim Hosp Assoc. 2006;42(4):249–261.

IMPORTANT SAFETY INFORMATION: Use only in dogs with clinical evidence of heart failure. The safety of VETMEDIN has not been established in dogs with asymptomatic heart disease or in heart failure caused by etiologies other than atrioventricular valvular insufficiency or dilated cardiomyopathy. Please refer to the package insert for complete product information or visit www.vetmedin.com. VETMEDIN is a registered trademark of Boehringer Ingelheim Vetmedica GmbH, licensed to Boehringer Ingelheim Vetmedica, Inc. © 2016 Boehringer Ingelheim Vetmedica, Inc. VET0515009

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TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

JANUARY/FEBRUARY 2017

VOLUME 2, NUMBER 1

Today’s Veterinary Technician is proudly published by the NAVC

Chief Executive Ofﬁcer Thomas M. Bohn, MBA, CAE

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090340591/0 NADA 141-273, Approved by FDA

Vetmedin® (pimobendan) Chewable Tablets

Cardiac drug for oral use in dogs only Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Description: Vetmedin (pimobendan) is supplied as oblong half-scored chewable tablets containing 1.25, 2.5, 5 or 10 mg pimobendan per tablet. Pimobendan, a benzimidazole-pyridazinone derivative, is a non-sympathomimetic, non-glycoside inotropic drug with vasodilatative properties. Pimobendan exerts a stimulatory myocardial effect by a dual mechanism of action consisting of an increase in calcium sensitivity of cardiac myofilaments and inhibition of phosphodiesterase (Type III). Pimobendan exhibits vasodilating activity by inhibiting phosphodiesterase III activity. The chemical name of pimobendan is 4,5-dihydro-6-[2-(4-methoxyphenyl)-1H-benzimidazole5-yl]-5-methyl-3(2H)-pyridazinone. The structural formula of pimobendan is:

Indications: Vetmedin (pimobendan) is indicated for the management of the signs of mild, moderate, or severe (modified NYHA Class IIa, IIIb, or IVc) congestive heart failure in dogs due to atrioventricular valvular insufficiency (AVVI) or dilated cardiomyopathy (DCM). Vetmedin is indicated for use with concurrent therapy for congestive heart failure (e.g., furosemide, etc.) as appropriate on a case-by-case basis. a

A dog with modified New York Heart Association (NYHA) Class II heart failure has fatigue, shortness of breath, coughing, etc. apparent when ordinary exercise is exceeded.

A dog with modified NYHA Class III heart failure is comfortable at rest, but exercise capacity is minimal.

A dog with modified NYHA Class IV heart failure has no capacity for exercise and disabling clinical signs are present even at rest.

Dosage and Administration: Vetmedin should be administered orally at a total daily dose of 0.23 mg/lb (0.5 mg/kg) body weight, using a suitable combination of whole or half tablets. The total daily dose should be divided into 2 portions that are not necessarily equal, and the portions should be administered approximately 12 hours apart (i.e., morning and evening). The tablets are scored and the calculated dosage should be provided to the nearest half tablet increment. Contraindications: Vetmedin should not be given in cases of hypertrophic cardiomyopathy, aortic stenosis, or any other clinical condition where an augmentation of cardiac output is inappropriate for functional or anatomical reasons. Warnings: Only for use in dogs with clinical evidence of heart failure. At 3 and 5 times the recommended dosage, administered over a 6-month period of time, pimobendan caused an exaggerated hemodynamic response in the normal dog heart, which was associated with cardiac pathology (See Animal Safety). Human Warnings: Not for use in humans. Keep this and all medications out of reach of children. Consult a physician in case of accidental ingestion by humans. Precautions: The safety of Vetmedin has not been established in dogs with asymptomatic heart disease or in heart failure caused by etiologies other than AVVI or DCM. The safe use of Vetmedin has not been evaluated in dogs younger than 6 months of age, dogs with congenital heart defects, dogs with diabetes mellitus or other serious metabolic diseases, dogs used for breeding, or pregnant or lactating bitches. Adverse Reactions: Clinical findings/adverse reactions were recorded in a 56-day field study of dogs with congestive heart failure (CHF) due to AVVI (256 dogs) or DCM (99 dogs). Dogs were treated with either Vetmedin (175 dogs) or the active control enalapril maleate (180 dogs). Dogs in both treatment groups received additional background cardiac therapy (See Effectiveness for details and the difference in digoxin administration between treatment groups). The Vetmedin group had the following prevalence (percent of dogs with at least one occurrence) of common adverse reactions/new clinical findings (not present in a dog prior to beginning study treatments): poor appetite (38%), lethargy (33%), diarrhea (30%), dyspnea (29%), azotemia (14%), weakness and ataxia (13%), pleural effusion (10%), syncope (9%), cough

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of pimobendan and active metabolite and the maximum physiologic response (peak LV dP/dtmax). Blood levels of pimobendan and active metabolite began to drop before maximum contractility was seen. Repeated oral administration of pimobendan did not result in evidence of tachyphylaxis (decreased positive inotropic effect) or Adverse reactions/new clinical findings were seen in drug accumulation (increased positive inotropic effect). both treatment groups and were potentially related to CHF, the therapy of CHF, or both. The following adverse Laboratory studies indicate that the positive inotropic effect of pimobendan may be attenuated by the reactions/new clinical findings are listed according to concurrent use of a β-adrenergic blocker or a calcium body system and are not in order of prevalence: CHF channel blocker. death, sudden death, chordae tendineae rupture, left atrial tear, arrhythmias overall, tachycardia, syncope, Effectiveness: In a double-masked, multi-site, 56-day weak pulses, irregular pulses, increased pulmonary field study, 355 dogs with modified NYHA Class II, III, or edema, dyspnea, increased respiratory rate, coughing, IV CHF due to AVVI or DCM were randomly assigned gagging, pleural effusion, ascites, hepatic congestion, to either the active control (enalapril maleate) or the decreased appetite, vomiting, diarrhea, melena, weight Vetmedin (pimobendan) treatment group. Of the 355 loss, lethargy, depression, weakness, collapse, shaking, dogs, 52% were male and 48% were female; 72% were trembling, ataxia, seizures, restlessness, agitation, diagnosed with AVVI and 28% were diagnosed with pruritus, increased water consumption, increased DCM; 34% had Class II, 47% had Class III, and 19% urination, urinary accidents, azotemia, dehydration, had Class IV CHF. Dogs ranged in age and weight abnormal serum electrolyte, protein, and glucose from 1 to 17 years and 3.3 to 191 lb, respectively. The values, mild increases in serum hepatic enzyme levels, most common breeds were mixed breed, Doberman and mildly decreased platelet counts. Pinscher, Cocker Spaniel, Miniature/Toy Poodle, See Table 1 for mortality due to CHF (including Maltese, Chihuahua, Miniature Schnauzer, Dachshund, euthanasia, natural death, and sudden death) and for and Cavalier King Charles Spaniel. The 180 dogs (130 the development of new arrhythmias (not present in a AVVI, 50 DCM) in the active control group received dog prior to beginning study treatments) by treatment enalapril maleate (0.5 mg/kg once or twice daily), and group and type of heart disease (AVVI or DCM) in the all but 2 received furosemide. Per protocol, all dogs 56-day field study. with DCM in the active control group received digoxin. The 175 dogs (126 AVVI, 49 DCM) in the Vetmedin Table 1: CHF Death and New Arrhythmias group received pimobendan (0.5 mg/kg/day divided in the 56-Day Field Study into 2 portions that were not necessarily equal, and the Vetmedin® Active Control portions were administered approximately 12 hours Group Group apart), and all but 4 received furosemide. Digoxin was Dogs that 14.3% 14.4% optional for treating supraventricular tachyarrhythmia died n = 175 n = 180 in either treatment group, as was the addition of a due to CHF β-adrenergic blocker if digoxin was ineffective in 9 of 126 dogs 16 of 130 dogs controlling heart rate. After initial treatment at the clinic with AVVI with AVVI on Day 1, dog owners were to administer the assigned 16 of 49 dogs 10 of 50 dogs product and concurrent medications for up to 56±4 days. with DCM with DCM The determination of effectiveness (treatment success) Dogs that 39.4% 45.0% for each case was based on improvement in at developed n = 175 n = 180 least 2 of the 3 following primary variables: modified new 59 of 130 dogs NYHA classification, pulmonary edema score by a arrhythmiasa 45 of 126 dogs with AVVI with AVVI masked veterinary radiologist, and the investigator’s overall clinical effectiveness score (based on physical 24 of 49 dogs 22 of 50 dogs examination, radiography, electrocardiography, and with DCM with DCM clinical pathology). Attitude, pleural effusion, coughing, a New arrhythmias included supraventricular premature activity level, furosemide dosage change, cardiac beats and tachycardia, atrial fibrillation, atrioventricular size, body weight, survival, and owner observations were secondary evaluations contributing information block, sinus bradycardia, ventricular premature beats supportive to product effectiveness and safety. and tachycardia, and bundle branch block Based on protocol compliance and individual case Following the 56-day masked field study, 137 dogs integrity, 265 cases (134 Vetmedin, 131 active control) in the Vetmedin group were allowed to continue on were evaluated for treatment success on Day 29. See Vetmedin in an open-label extended-use study without Table 2 for effectiveness results. restrictions on concurrent therapy. The adverse reactions/new clinical findings in the extended-use Table 2: Effectiveness Results study were consistent with those reported in the 56-day for the 56-Day Field Study study, with the following exception: One dog in the Vetmedin® Active Control extended-use study developed acute cholestatic liver Group Group failure after 140 days on Vetmedin and furosemide. Treatment 80.7% 76.3% In foreign post-approval drug experience reporting, the Success on n=134 n=131 following additional suspected adverse reactions were Day 29 88 of 101 dogs 77 of 100 dogs reported in dogs treated with a capsule formulation with AVVI with AVVI of pimobendan: hemorrhage, petechia, anemia, hyperactivity, excited behavior, erythema, rash, 20 of 33 dogs 23 of 31 dogs drooling, constipation, and diabetes mellitus. with DCM with DCM To report suspected adverse reactions, to obtain a Treatment 71.1% 67.2% Material Safety Data Sheet, or for technical assistance Success on n=113 n=110 call 1-866-638-2226. Day 56 66 of 85 dogs 56 of 85 dogs Clinical Pharmacology: Pimobendan is oxidatively with AVVI with AVVI demethylated to a pharmacologically active metabolite 13 of 28 dogs 17 of 25 dogs which is then conjugated with sulfate or glucuronic with DCM with DCM acid and excreted mainly via feces. The mean extent of protein binding of pimobendan and the active No increase metabolite in dog plasma is >90%. Following a single in furosemide 78.3% 68.6% oral administration of 0.25 mg/kg Vetmedin tablets dose between n=130 n=126 the maximal mean (± 1 SD) plasma concentrations Day 1 and (Cmax) of pimobendan and the active metabolite were Day 29 3.09 (0.76) ng/ml and 3.66 (1.21) ng/ml, respectively. Individual dog Cmax values for pimobendan and the At the end of the 56-day study, dogs in the Vetmedin active metabolite were observed 1 to 4 hours postgroup were enrolled in an unmasked field study to dose (mean: 2 and 3 hours, respectively). The total monitor safety under extended use, without restrictions body clearance of pimobendan was approximately on concurrent medications. 90 mL/min/kg, and the terminal elimination half-lives Vetmedin was used safely in dogs concurrently of pimobendan and the active metabolite were receiving furosemide, digoxin, enalapril, atenolol, approximately 0.5 hours and 2 hours, respectively. spironolactone, nitroglycerin, hydralazine, diltiazem, Plasma levels of pimobendan and active metabolite antiparasitic products (including heartworm were below quantifiable levels by 4 and 8 hours after prevention), antibiotics (metronidazole, cephalexin, oral administration, respectively. The steady-state amoxicillin-clavulanate, fluoroquinolones), topical volume of distribution of pimobendan is 2.6 L/kg ophthalmic and otic products, famotidine, theophylline, indicating that the drug is readily distributed into levothyroxine sodium, diphenhydramine, hydrocodone, tissues. Food decreased the bioavailability of an aqueous solution of pimobendan, but the effect of food metoclopramide, and butorphanol, and in dogs on on the absorption of pimobendan from Vetmedin tablets sodium-restricted diets. is unknown. Palatability: In a laboratory study, the palatability of Vetmedin was evaluated in 20 adult female Beagle In normal dogs instrumented with left ventricular (LV) dogs offered doses twice daily for 14 days. Ninety pressure transducers, pimobendan increased LV dP/ percent (18 of 20 dogs) voluntarily consumed more dtmax (a measure of contractility of the heart) in a than 70% of the 28 tablets offered. Including two dogs dose dependent manner between 0.1 and 0.5 mg/ that consumed only 4 and 7% of the tablets offered, the kg orally. The effect was still present 8 hours after average voluntary consumption was 84.2%. dosing. There was a delay between peak blood levels

(7%), sudden death (6%), ascites (6%), and heart murmur (3%). Prevalence was similar in the active control group. The prevalence of renal failure was higher in the active control group (4%) compared to the Vetmedin group (1%).

Animal Safety: In a laboratory study, Vetmedin chewable tablets were administered to 6 healthy Beagles per treatment group at 0 (control), 1, 3, and 5 times the recommended dosage for 6 months. See Table 3 for cardiac pathology results. The cardiac pathology/histopathology noted in the 3X and 5X dose groups is typical of positive inotropic and vasodilator drug toxicity in normal dog hearts, and is associated with exaggerated hemodynamic responses to these drugs. None of the dogs developed signs of heart failure and there was no mortality. Table 3: Incidence of Cardiac Pathology/ Histopathology in the Six-month Safety Study Severe left ventricular hypertrophy with multifocal subendocardial ischemic lesions

One 3X and two 5X dogsa

Moderate to marked myxomatous thickening of the mitral valves

Three 5X dogs

Myxomatous thickening of the chordae tendineae

One 3X and two 5X dogs

Endocardial thickening of the left ventricular outflow tract

One 1X, two 3X, and two 5X dogs

Left atrial endocardial thickening (jet lesions) in 2 of the dogs that developed murmurs of mitral valve insufficiency

One 3X and one 5X dog

Granulomatous inflammatory lesion in the right atrial myocardium

One 3X dog

Most of the gross and histopathologic findings occurred in these three dogs

Murmurs of mitral valve insufficiency were detected in one 3X (Day 65) and two 5X dogs (Days 135 and 163). These murmurs (grades II-III of VI) were not associated with clinical signs. Indirect blood pressure was unaffected by Vetmedin at the label dose (1X). Mean diastolic blood pressure was decreased in the 3X group (74 mmHg) compared to the control group (82 mmHg). Mean systolic blood pressure was decreased in the 5X group (117 mmHg) compared to the control group (124 mmHg). None of the dogs had clinical signs of hypotension. On 24-hour Holter monitoring, mean heart rate was increased in the 5X group (101 beats/min) compared to the control group (94 beats/min). Not counting escape beats, the 3X and 5X groups had slightly higher numbers of isolated ventricular ectopic complexes (VEs). The maximum number of non-escape VEs recorded either at baseline or in a control group dog was 4 VEs/24 hours. At either Week 4 or Week 20, three 3X group dogs had maximums of 33, 13, and 10 VEs/24 hours, and two 5X group dogs had maximums of 22 and 9 VEs/24 hours. One 1X group dog with no VEs at baseline had 6 VEs/24 hours at Week 4 and again at Week 20. Second-degree atrioventricular heart block was recorded in one 3X group dog at Weeks 4 and 20, and in one dog from each of the 1X and 5X groups at Week 20. None of the dogs had clinical signs associated with these electrocardiogram changes. Treatment was associated with small differences in mean platelet counts (decreased in the 3X and 1X groups), potassium (increased in the 5X group), glucose (decreased in the 1X and 3X groups), and maximum blood glucose in glucose curves (increased in the 5X group). All individual values for these variables were within the normal range. Three 1X and one 5X group dogs had mild elevations of alkaline phosphatase (less than two times normal). Loose stools and vomiting were infrequent and self-limiting. Storage Information: Store at 20° to 25°C (68° to 77°F), excursions permitted between 15° and 30°C (between 59° and 86°F). How Supplied: Vetmedin® (pimobendan) Chewable Tablets: Available as 1.25, 2.5, 5 and 10 mg oblong half-scored chewable tablets - 50 tablets per bottle. NDC 0010-4480-01-1.25 mg - 50 tablets NDC 0010-4481-01-2.5 mg - 50 tablets NDC 0010-4482-01-5 mg - 50 tablets NDC 0010-4479-01-10 mg - 50 tablets Manufactured by: Boehringer Ingelheim Promeco S.A. de C.V. Mexico City, Mexico Manufactured for: Boehringer Ingelheim Vetmedica, Inc. St. Joseph, MO 64506 U.S.A. Vetmedin® is a registered trademark of Boehringer Ingelheim Vetmedica GmbH licensed to Boehringer Ingelheim Vetmedica, Inc. Copyright © 2013 Boehringer Ingelheim Vetmedica, Inc. or an affiliated company. All Rights Reserved. 448005-00 Revised 06/2013

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

JANUARYFEBRUARY2017

Volume 2, Number 1

PEER-REVIEWED CE Ferret Dentistry: No Weaseling About It! JANYCE COOPER, LVT, VTS (DENTISTRY)

As with cats and dogs, periodontal disease in ferrets may go unnoticed by owners; therefore, many ferrets end up silently suffering from oral pain. Although it may be a challenging task, all ferrets need an annual oral examination, and ferret owners need education on oral care for their pet.

Keys to Successful High-Level Disinfection and Sterilization Processes HEIDI REUSS-LAMKY, LVT, VTS (ANESTHESIA & ANALGESIA, SURGERY)

Today’s veterinary technicians are uniquely placed to make a difference in the lives of animal patients, in part by ensuring that proper protocols and procedures are in place to help prevent perioperative infections. Learn about the different types of disinfection and sterilization processes and when each is appropriate.

FEATURES When Caring Hurts: Dealing with Depression in Veterinary Medicine MELANIE CODI, LVT, CVT, VTS (NUTRITION)

Depression is one of the most common mental health disorders in the United States and is strikingly prevalent in the veterinary community. Get tips on how to differentiate depression from burnout and how to find help for yourself or your coworkers.

Puppies for the Holidays: Keeping Them Fear Freesm DEBBIE MARTIN, LVT, VTS (BEHAVIOR)

Inevitably, January brings new patients that were given as gifts for the holidays. Help your clients get their new puppies off to a good start in the family and at the clinic with advice on positive training techniques.

Digital Microscopy MARGI SIROIS, EdD, MS, RVT, CVT, LAT

Adding digital microscopy to a veterinary practice can greatly enhance recordkeeping and serve as a valuable tool for client education. This article provides an overview of the benefits of this technology and some useful resources for learning more.

TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

January/February 2017

www.todaysveterinarytechnician.com

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Contents

TODAY’S VETERINARY TECHNICIAN An Official Journal of the NAVC

COLUMNS Editor’s Letter | All in a Year

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

What Moves You? | A Calming Touch

SUMMER BROOKS, MS, RVT.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

What Moves You? | Consistent Change

KAREN ELLIS, LVT, VTS (SURGERY). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

Sidebar | NAVTA 2016 Demographic Survey Results: Compassion Fatigue HEATHER PRENDERGAST, RVT, CVPM, SPHR. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Toxicology Talk | Xylitol: A Sweetener That Is Not So Sweet CARRIE LOHMEYER-MAUZY, CVT, BS.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32 48

Case Report | Sildenafil Exposure in a Dog

BRIANNA WELLS, CVT, and SAMANTHA WRIGHT, BS, MS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Ideas Into Practice | Structuring a Course for Dogs with Fireworks Anxiety

ESTHER KLOK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 64

Final Thoughts | The Antidote to Compassion Fatigue JULIE SQUIRES, CCFS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

CLIENT HANDOUTS

ON THE COVER Ashley Anne McGaha, RVTg, a zoological medicine technician at the University of Georgia, restrains a ferret for a preliminary oral examination. Photo: Christopher B. Herron. ©2016 University of Georgia.

Dental Care. . . . . . . . . . . . . . . . . . . . . . 22 Dental Cleaning. . . . . . . . . . . . . . 24 Puppy Training.. . . . . . . . . . . . . . . . 44 Puppy Socialization. . . . . . . . 70 Careers........... .......................... 81 Advertiser Index................ 21

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 (ISSN 2472-209X; print version) is published bi-monthly (Jan/Feb, Mar/Apr, May/June, Jul/Aug, Sept/Oct, Nov/Dec; 6x per year) by NAVC, 37 Paul Lane, Glen Mills, PA 19342. Application to Mail at Periodicals Postage Prices is Pending at Glen Mills, PA 19342 and additional mailing offices. POSTMASTER: Send all UAA to CFS (See DMM 507.1.5.2); NONPOSTAL AND MILITARY FACILITIES: send address corrections to CDS/Today’s Veterinary Technician, 440 Quadrangle Drive, Ste E, Bolingbrook, IL 60440.

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Amoxicillin Trihydrate and Clavulanate Potassium Tablets ANADA 200-592, Approved by FDA CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. INDICATIONS: Amoxicillin Trihydrate and Clavulanate Potassium Tablets are indicated in the treatment of: Dogs: Skin and soft tissue infections such as wounds, abscesses, cellulitis, superficial/juvenile and deep pyoderma due to susceptible strains of the following organisms: β-lactamase-producing Staphylococcus aureus, non-β-lactamaseproducing Staphylococcus aureus, Staphylococcus spp., Streptococcus spp., and E. coli. Periodontal infections due to susceptible strains of both aerobic and anaerobic bacteria. Amoxicillin Trihydrate and Clavulanate Potassium Tablets have been shown to be clinically effective for treating cases of canine periodontal disease. Cats: Skin and soft tissue infections such as wounds, abscesses, and cellulitis/dermatitis due to susceptible strains of the following organisms: β-lactamase-producing Staphylococcus aureus, non-β-lactamase-producing Staphylococcus aureus, Staphylococcus spp., Streptococcus spp., E. coli, and Pasteurella spp. Urinary tract infections (cystitis) due to susceptible strains of E. coli. Therapy may be initiated with Amoxicillin Trihydrate and Clavulanate Potassium Tablets prior to obtaining results from bacteriological and susceptibility studies. A culture should be obtained prior to treatment to determine susceptibility of the organisms to Amoxicillin Trihydrate and Clavulanate Potassium Tablets. Following determination of susceptibility results and clinical response to medication, therapy may be reevaluated. CONTRAINDICATIONS: The use of this product is contraindicated in animals with a history of an allergic reaction to any of the penicillins or cephalosporins. WARNINGS: Safety of use in pregnant or breeding animals has not been determined. ADVERSE REACTIONS: Amoxicillin Trihydrate and Clavulanate Potassium Tablets contain a semisynthetic penicillin (amoxicillin) and have the potential for producing allergic reactions. If an allergic reaction occurs, administer epinephrine and/or steroids.

Manufactured for: Putney, Inc., a wholly owned subsidiary of Dechra Pharmaceuticals, PLC. Portland, ME 04101 USA 1-866-683-0660 Made in Austria.

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AMOXICILLIN TRIHYDRATE AND CLAVULANATE POTASSIUM TABLETS DOGS: Indicated in the treatment of periodontal and skin and soft tissue infections such as wounds, abscesses, cellulitis, and superficial/juvenile and deep pyoderma due to susceptible strains of bacteria. CATS: Indicated in the treatment of urinary tract infections (cystitis) and skin and soft tissue infections such as wounds, abscesses, and cellulitis/dermatitis due to susceptible strains of bacteria. Backed by the newly combined Veterinary Technical Services and Sales Support Teams of both Dechra and Putney. Available in 62.5 mg, 125 mg, 250 mg, and 375 mg tablets supplied in foil strip packs. Each carton holds 15 foil strip packs with 14 tablets per strip (210 tablets per carton).

PUTNEY IS NOW PART OF DECHRA VETERINARY PRODUCTS

Ask your Dechra or distributor representative for further information or visit www.dechra-us.com. As with all drugs, side effects may occur. Amoxicillin Trihydrate and Clavulanate Potassium Tablets contain a semisynthetic penicillin (amoxicillin) and have the potential for producing allergic reactions. This product should not be used in animals with a history of an allergic reaction to any of the penicillins or cephalosporins. If an allergic reaction occurs, administer epinephrine and/or steroids. Refer to the prescribing information for complete details or visit www.dechra-us.com.

To order, please contact your Dechra or distributor representative or call (866) 683-0660. 24-hour Technical Support available (866) 933-2472. Nonurgent Technical Support available via email support@dechra.com.

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Dechra Veterinary Products US and the Dechra D logo are registered trademarks of Dechra Pharmaceuticals PLC.

12/14/16 7:09 PM

Editor’s Letter All in a Year

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

nother year has come and gone. Can you believe it? 2016 has been a year of growth and change, and we have so many reasons to celebrate! A Successful 2016 First, we are excited to be celebrating the first anniversary of Today’s Veterinary Technician. Readership has grown, and the comments I receive daily on our Facebook page are overwhelmingly positive, assuring me that we are succeeding in our mission to provide peer-reviewed, state-of-the-art information, written by and for veterinary technicians and nurses and other members of the veterinary health care team, and that the information we provide can be used by every veterinary technician or nurse every day. (If you haven’t subscribed to the journal yet, check out todaysveterinarytechnician.com/subscribe/.) Second, NAVTA has made huge strides on one of its primary goals of standardizing credentialing titles across the country as well as increasing awareness of the veterinary technician profession in the pet parent community. Third, as 2016 comes to a close, the NAVC is making a huge change. We are moving the NAVC Conference to a new home: the Orange County Convention Center. This move not only provides added exhibit hall space but also increases our session space to accommodate 90% of all sessions under one roof. Coming Home in 2017 A couple issues back, I described what home meant to me personally: it is where my heart lives. Now I want to share what home means to me professionally, or where my brain lives: it is where I increase my knowledge through continuing education (CE). The NAVC Conference is my home and hub for all of my CE needs, and it can be your professional home too. The Conference offers opportunities to strengthen your practical skills, soak up knowledge, become a part of a community, and enhance the client experience.

Many exciting sessions, networking opportunities, and fun activities are set up for the 2017 Conference. Tracks specifically designed for veterinary technicians, nurses, and students offer hundreds of hours of CE. The 2017 veterinary technician tracks include VTS sessions on anesthesia, behavior, clinical pathology, critical care, dermatology, dentistry, equine medicine, and internal medicine, as well as sessions on rehabilitation and physical therapy. You can also sign up for a Masterclass or hands-on lab.

2017 is going to see the debut of NAVC Live and NAVC Discovery, two more CE events in Portland, Oregon, and Buffalo, New York, respectively. Of course, the Conference offers more than just CE. You can network with your colleagues and students at the NAVTA Annual Meeting and the Veterinary Technician Networking Reception, hang out and chat in the Today’s Veterinary Technician Lounge, go on a behind-the-scenes tour, rock out at the Darius Rucker concert, and hear what Mike Rowe and Robin Roberts have to say at the Opening Ceremony and General Session. This year, the NAVC is also hosting a Health and Wellbeing Center where you can get information from speakers and other professionals on taking care of yourself, as Melanie Codi describes in her article on page 30. Looking Ahead and Branching Out If you can’t get to the NAVC Conference this year, don’t fret—we may be coming to a city near you! 2017 is going to see the debut of NAVC Live and NAVC Discovery, two more CE events in Portland, Oregon, and Buffalo, New York, respectively. Visit navc.com for more details. And if none of those cities is convenient for you, you can always check out our online CE portal, VetFolio.com, produced in partnership with AAHA. Thanks for being part of our journey so far, and hope to see you at “home” in 2017! 

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

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Cats take enough risks on their own. Why add adjuvanted vaccines to the list? • PUREVAX® Recombinant FeLV is the only nonadjuvanted canarypox-vectored feline leukemia virus vaccine available. • The canarypox vaccine vector is able to induce both humoral and cell-mediated immune responses.1 Ask your Merial representative about our Satisfaction Guarantee.

Poulet H, Minke J, Pardo MC. Development and registration of recombinant veterinary vaccines: The example of the canarypox vector platform. Vaccine. 2007;25:5606–5612. ®PUREVAX is a registered trademark of Merial. ©2017 Merial, Inc., Duluth, GA. All rights reserved. VAC16TRADEADS8 (01/17).

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Peer-Reviewed

ARTICLE 1 CR E DIT

Ferret Dentistry: No Weaseling About It! Janyce Cooper, LVT, VTS (Dentistry)

errets are now routinely seen in most veterinary clinics. This means that veterinary technicians’ professional knowledge must be expanded to ensure that every ferret patient receives a thorough physical examination and appropriate medical treatment. As with cats and dogs, periodontal disease may go unnoticed by owners; therefore, many ferrets end up silently suffering from oral pain. Although it may be a challenging task, all ferrets need an annual oral examination, and ferret owners need education on oral care for their pet. FERRET FACTS Domesticated ferrets (Mustela putorius furo) are in the family Mustelidae, which includes weasels, polecats, and non-domesticated ferrets. Their name is derived from the Latin word furittus, meaning “little thief.”

Pet Care Veterinary Hospital Virginia Beach, Virginia

Janyce is a 2003 graduate of the veterinary technology program at Blue Ridge Community College. Her professional interest in animal dentistry began in early 2004, when she began working at Pet Care Veterinary Hospital in Virginia Beach. Her fascination with exotics mixed well with her passion to educate and improve the dental health of clients’ pets. Promoting quality dental care became her ambition, and as a result she has brought a higher standard of care to Pet Care Veterinary Hospital. In 2013, Janyce obtained her veterinary technician specialty in dentistry.

Diet Ferrets are obligate carnivores that need a high-protein diet containing fatty acids and amino acids found only in animal sources. In the wild, their natural diet is small prey; however, domestic ferrets are frequently fed high-quality cat foods. Recent research has lead to the creation of ferret-specific diets, which are now preferred. Ferret diets can also be supplemented with (or can simply consist of) small prey such as frozen pinkies, mice, and chicks.1,2 8

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Dentition Ferrets are classified as having a brachyodont dentition. A brachyodont tooth has a short crown and well-developed roots that contain a narrow pulp canal. Ferrets have 28 to 30 deciduous teeth and 34 permanent teeth. Permanent teeth erupt completely by 9 months of age.2 Dental formulas for ferrets are as follows: Deciduous teeth: 2(i3-4/3 c1/1 m3/3) = 28 to 30 Permanent teeth: 2(I 3/3; C 1/1; P 3/3; M 1/2) = 34 Like cats and dogs, ferrets have highly specialized teeth, including incisors, canines, premolars, and molars (TABLE 1). A ferret’s canine teeth have a tight dental interlock (FIGURE 1). This means that the maxillary canine rests behind the mandibular canine within the interdental space, with interdigitation (“pinking-shear” interlock) continuing to the maxillary/mandibular premolars/ molars. Ferret molars have a distinct hourglass shape to maximize grinding action.

CLIENT EDUCATION AND PREVENTIVE CARE Many new ferret owners do not expect to pay for expensive dental procedures. After all, a ferret is so small, and the owner may have paid only $20 for it, so why would veterinary care cost so much? A ferret’s first veterinary visit

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

T E C HP O I N T 

All ferrets need an annual oral examination, and ferret owners need education on oral care for their pet.

should, therefore, involve arming the client with knowledge, such as a ferret care book that details what “could” happen and sample treatment plans of periodontal therapies, to allow the client to prepare financially for future care. Creating such a book can be a great client education asset for the clinic. Pain score sheets that demonstrate how ferrets show pain can be useful in discussing oral care with owners, as ferrets with dental disease may continue to eat and behavior cues may otherwise be too subtle for owners to notice or perceive as oral pain. As with all species, preventive care is always the best measure to prevent periodontal disease. The gold standard is daily brushing with a soft-bristled toothbrush. Topical cleansing gels that can be placed on the gum lines, such as TDC and Maxi/Guard (Addison Biological Laboratory, addisonlabs.com), are also available. However, given ferrets’ mischievous behavior, water additives such as healthy mouth (Healthy Mouth, healthymouth.com) or cat dental treats may be suitable off-label options. Sealants such as OraVet (Merial, merial.com) or Sanos (Allaccem, allaccem.com) can be applied, but may be difficult to start early in life because application requires A

CE Article

Ferret Dentistry: No Weaseling About It!

TABLE 1 Function and Structure of Ferret Teeth TOOTH

FUNCTION

ROOTS

Incisor

Gathering and grasping

1 root

Canine

Puncturing

1 root

Premolar

Shredding and cutting food

2 roots 3 roots (maxillary carnassial)

Molar

Grinding and crushing

3 roots (maxillary molar) 2 roots (mandibular carnassial) May have a supernumerary root 1 root (last mandibular molar)

the ferret to be anesthetized. An oral examination, including a pain score that may be associated with periodontal disease or trauma, should be part of every annual examination. No matter how diligent an owner is about home care, such measures cannot prevent oral trauma, nor can they address disease that is already present in a newly adopted ferret. When professional dental care is needed, cost is usually the biggest factor that may prevent owners from pursuing the most appropriate option. To encourage acceptance of the recommended treatment plan, it may be helpful for the clinic to create “prepackaged” estimates based on reasonable clinic expenditures for appropriate procedures that do not compromise treatment. Then, before showing the owner the bottom line, a team member should go through each step of the proposed treatment, explaining its importance and why it is necessary. Once owners understand each step and what is involved, they should be more ready to see and accept the cost of treatment.

FIGURE 1. (A) Normal interdigitation or pinking-shear dental interlock. (B) Recessed second lower incisors. This is a common finding in ferrets. TODAY’SVETERINARYTECHNICIAN

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FIGURE 2. Calculus formation and slight extrusion of the canine.

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Peer-Reviewed

TECHPOINT 

Ferrets have 28 to 30 deciduous teeth and 34 permanent teeth.

BOX 1 Basic Oral Examination in Awake Ferrets3 1. Perform extraoral and facial examination. a. Assess the face and infraorbital region for any swellings, abrasions, or growths.

ORAL EXAMINATION On an awake ferret, an oral examination may prove to be a daunting task; however, with patience, it is possible. A basic outline of the steps involved in an oral examination of an awake ferret is provided in BOX 1. In some cases, general anesthesia may be required to obtain a full oral examination. Periodontal disease is the most typical pathology seen in the oral cavity. Using the same grading system as for cats and dogs, the varying levels of gingivitis, plaque, and calculus observed should be documented (FIGURE 2). Carious lesions and resorptive lesions are rare and typically not seen in ferrets.3 Ferrets’ mischievous behavior, such as chewing on cage bars or falling from higher altitudes, may result in trauma to the maxillary canines. In an outwardly intact tooth, trauma can be observed as the presence of intrinsic staining and brown or gray portions of the tooth (FIGURE 3). More complex trauma may cause tooth fracture. Fractures can

range from affecting only the tip of the crown (FIGURE 4) to exposure of the pulp canal or chamber. All fractures need to be evaluated by radiography to determine the treatment options: root canal or surgical extraction. The lips should also be evaluated for any signs of trauma that may be a result of extruded canine teeth. Common malpositions of the mandibular canines are mesioversion (i.e., the tooth is angled more to the midline) and distoversion (i.e., the tooth is angled away from midline), which can cause the mandibular canine to rub or even puncture the maxillary lip. Finally, the facial region should be examined for any abnormal growths. Although mast cell tumors are common and are generally benign, any abnormal growth should be surgically excised and submitted for histopathology. Although rare, squamous cell carcinomas and odontomas are sometimes found.2 A more thorough examination, as outlined in BOX 2, can be performed if the patient is anesthetized. Any abnormal findings should be documented on a dental chart (FIGURE 5). Several ferret dental charts are available, and the version used tends to be based on personal preference. The dental chart should be large enough to allow recording of examination findings and all treatments performed. Dental charts should be kept in the patient’s medical record, but copies can be given to owners to help increase the perception of monetary value of services rendered.

FIGURE 3. Intrinsic staining due to trauma.

FIGURE 4. Fractured canine crown due to trauma.

b. P alpate submandibular lymph nodes. c. Examine lips for trauma and growths.

d. E xamine eyes and nose; these should be clear and absent of discharge.

2. Note initial gingivitis, plaque, and calculus indices as outlined in BOX 2.

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CE Article

Ferret Dentistry: No Weaseling About It!

BOX 2 Oral Examination in Anesthetized Ferrets3,4 1. Perform oral examination.

a. Assess tongue, lingual frenulum, hard palate, soft palate, larynx, arytenoids, epiglottis, and tonsils for abnormalities.

i. CI 0—No observable calculus

b. Assess occlusion. Class 1 malocclusions of the mandibular incisors, canines, or both are common in ferrets.

iii. CI 2—Calculus covering between one- and two-thirds of the tooth surface with minimal subgingival deposition

b. Calculus index (CI #)

ii. CI 1—Scattered calculus covering less than one-third of the buccal tooth surface

i. Neutroclusion—Class 1 malocclusion (MAL1): one or more individual teeth are out of position

iv. CI 3—Calculus covering greater than two-thirds of the tooth surface and extending subgingivally

ii. Mandibular distoclusion—Class 2 malocclusion (MAL2): maxilla is longer than the mandible (overbite)

iii. Mandibular mesioclusion—Class 3 malocclusion (MAL3): mandible is longer than the maxilla (underbite) iv. Mandibular canine: mesioversion, distoversion v. Attrition (tooth-on-tooth contact) vi. Abrasion (tooth-on-object contact) vii. Mandibular second incisors are commonly displaced lingually 2. Measure sulcus depth (FIGURE A).

a. A feline periodontal probe can be used to safely evaluate 4 to 6 points around the tooth for periodontal pockets below the gum line.

b. Normal sulcus depth in a ferret is 0 to 0.5 mm. Anything more is a significant pocket depth and should be noted in the dental chart.

3. Assess gingivitis, plaque, and calculus.

a. Plaque index (PI #)

i. PI 0—No observable plaque ii. PI 1—Scattered plaque covering less than one-third of the buccal tooth surface iii. PI 2—Plaque covering between one- and two-thirds of the buccal tooth surface iv. PI 3—Plaque covering more than two-thirds of the buccal tooth surface

c. Gingival index

i. GI 0—Normal, healthy gingiva with sharp, noninflamed margins ii. GI 1—Marginal gingivitis with minimal inflammation at the free gingiva; no bleeding on probing iii. GI 2—Moderate gingivitis with inflammation and bleeding on probing iv. GI 3—Advanced gingivitis with inflammation clinically reaching the mucogingival junction, usually with ulceration 4. Assess tooth mobility.

a. Grade 1: Small amount of motion

b. Grade 2: Can be moved in a back-to-front or side-toside motion

c. Grade 3: Can be moved in a back-to-front and side-to-side motion

5. Assess tooth furcation. A shepherd’s hook explorer probe may be used in place of a periodontal probe, as the furcation may be too small to allow the latter to pass completely through. This can make determining between grade 2 and 3 difficult.

a. Grade 1 furcation: Probe can just barely enter the furcation

b. Grade 2 furcation: Probe can reach halfway through the furcation

c. Grade 3 furcation: Probe can be completely passed through the furcation

6. Assess tooth extrusion. A periodontal probe can be used.

a. The canines may be extruded supragingivally and cementoenamel junction may be visible (FIGURE 2)

b. The measured amount of extrusion is documented as attachment loss

c. When extrusion is present in conjunction with a periodontal pocket, the total attachment loss should be calculated: Periodontal pocket (mm) + Extrusion (mm) = Total attachment loss (mm)

7. Assess teeth for fracture/trauma, typically associated with the canine teeth.

FIGURE A. Probing pocket depths.

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a. Enamel fracture (T/FX/EF): Only the enamel has been removed

b. Uncomplicated fracture (T/FX/UCF): No pulp exposure

c. Complicated fracture (T/FX/CC): Pulp exposure

d. Intrinsic staining: Brown or gray color that is result of pulp necrosis or inflammation (FIGURE 3)

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Periodontal disease is the most typical pathology seen in the oral cavity.

PREOPERATIVE PREPARATION As with dental procedures in other species, anesthesia is the biggest concern in ferret dentistry, as many dental patients are older and may have some systemic disorder. A preoperative physical examination, complete blood chemistry panel, and complete blood count should be performed before anesthesia to ensure that the patient is a good anesthetic candidate. Ferrets have a high metabolic rate, making it crucial to monitor their blood glucose level throughout the procedure. Ferrets should be fasted for no more than about 2 hours before premedication. Owners should not be advised to fast the ferret the night before or, unless the procedure will be started within 2 hours after admission to the hospital, on the morning of surgery. Some patients, especially those with an insulinoma, may need maintenance fluids supplemented with dextrose to prevent a hypoglycemic episode. To provide maintenance fluids, a 24-gauge intravenous catheter can be placed into a cephalic vein, using sterile technique. In ferrets, the cephalic vein bifurcates closer to

Address/reference

Animal name

Type/breed

C G R P F M

Right

Age

Quadrant

Date

Sex

the carpus, which can allow for easy placement. I like to apply lidocaine gel to the site before placement and use a 22-gauge needle to make a small cut in the skin. A T-port can be attached to the intravenous catheter to make connecting and disconnecting intravenous fluids easier. Ferrets are notorious for removing intravenous catheters by deliberately pulling on them or by inadvertently applying tension while trying to nest under blankets, so catheters must be taped well, allowing plenty of slack on the administration line between the fluid pump and the stress loop. If necessary, an Elizabethan collar can be applied to prevent the patient from chewing on the catheter. Quadrant Disease Scores

Adult Ferret Dental Record Owner

Calculus Gingivitis

201

102

202

103

203

104

204

105

205

106

206

107

207

108

208

109

209

110

210

411

311

410

310

409

309

408

308

407

307

406

306

405

305

404

304

403

303

402

302

401

301

Scoring :

Jaw relationship

Normal

Canine angulation

Tooth wear

101

Normal

Periodontitis

C G R P F M

Skull type

Plaque

Weight (Kg)

TECHPOINT 

− + negligible

++ to

(0 - 3)

+++ severe

Diagnosis, treatment information and comments

Key to abbreviations -

Left

Cn = Calculus deposits

(0 - 3)

Gn = Gingivitis score

(0 - 3)

Rn = Recession depth

( mm )

Pn = Probing depth

( mm )

Fn = Furcation involved (0 - 3) Mn

- -

Normal

= Mobility score

(0 - 3)

= Negligible

(0)

= Severity + to +++ (1 - 3)

A = Abscess Ca = Cavity (caries/endo access) ONF = Oro-nasal fistula ORL = Odontoclastic resorption PE = Pulp exposed (# PE / WF

PE)

PDnnn = Persistent deciduous tooth

RCT = Root canal therapy Snnn = Supernumerary tooth ST = Sinus tract U = Ulcer WF = Wear facet = Extracted

= Tooth not present

= Tipping/positioning

= Length relationship #

= Fracture (jaw or tooth)

FIGURE 5. In this dental chart, documentation of skull type, jaw relationship, and canine angulation is incorporated into an overall assessment of the ferret’s occlusion. Subjective indices—calculus (C), gingivitis (G), resorption (R), periodontal pocket depth (P), furcation (F), and mobility (M)—can be recorded for each tooth. Overall quadrant indices for plaque, calculus, gingivitis, periodontal disease, and tooth wear are also included. Courtesy of Dr. David Crossley 12

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CE Article

PREMEDICATION, PAIN CONTROL, AND ANESTHESIA Gone are the days of masking exotic patients with inhalant agents for induction and surgical maintenance of anesthesia. Studies have been done to enable safe use of injectable premedications, allowing for a well-balanced anesthesia episode that includes many of the same opioids, benzodiazepines, alpha-2 agonists, and nonsteroidal anti-inflammatory drugs (NSAIDs) used for dogs and cats (TABLE 2). As for all species, premedication protocols for ferrets should be patient specific to create a synergistic anesthetic plan.6 A typical premedication for a healthy ferret would be an opioid, such as oxymorphone or fentanyl, in combination with midazolam or dexmedetomidine. Once the premedication has been administered, the ferret should be placed in a kennel that allows it to maintain body temperature during preoxygenation. Preoxygenation is crucial to increase oxygen reserves in advance of an apneic period. A good premedication allows for the use of less induction agent (propofol or alfaxalone) and causes the ferret to lose jaw tone quickly, enabling rapid intubation. Using an induction agent that can cause apnea, such as propofol, makes the ability to intubate quickly a necessity. All intubation supplies (FIGURE 6) should be ready to hand before induction. Intubation of a ferret is similar to that of a cat. A cotton-tipped applicator with a small amount of lidocaine

FIGURE 6. Intubation supplies, from left to right: Cotton-tipped applicator, cuffed endotracheal tube, lidocaine gel, and tie. TODAY’SVETERINARYTECHNICIAN

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Ferret Dentistry: No Weaseling About It!

TABLE 2 Drugs for Pain Management in Ferrets5 AGENT

DOSE

PURPOSE

Oxymorphone

0.05–0.2 mg/kg q8h

Analgesia

Buprenorphine

0.01–0.03 mg/kg q8–12h

Analgesia

Fentanyl

0.3 mg/kg

Analgesia

Fentanyl CRI

1.25–5 mcg/kg/h (postoperatively)

Analgesia

Dexmedetomidine

0.04–0.1 mg/kg

Sedation

Midazolam

0.25–0.3 mg/kg

Mild sedation

Propofol

1–3 mg/kg

Induction

Etomidate

1 mg/kg

Induction

Meloxicam

0.2 mg/kg

Analgesia

Gabapentin

3–5 mg/kg

Analgesia (neuropathic pain)

gel can be used to suppress the tongue and visualize the tracheal opening. A cuffed 3-0 endotracheal tube is used. A tie is needed to secure the tube; however, the tie will typically not stay behind the ferret’s ears, so an additional loop behind the arms and around the sternum is often needed. To prevent bruising and compromised respiration, it is imperative to make sure that the tie is not too tight around the neck and sternum. The endotracheal tube cuff should be inflated cautiously to avoid overinflation and leak tested to ensure that it is not underinflated, which can present a risk for aspiration. For procedures that can be expected to cause severe pain, a constant rate infusion with an opioid can be used for intraoperative pain control and continued for postoperative pain control. Continued

FIGURE 7. Scaler set to the lowest intensity.

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Peer-Reviewed

hospitalization may be needed to allow appropriate pain scoring to evaluate the need for further pain management with an opioid. SCALING AND POLISHING Before scaling, the oral cavity should be rinsed with a chlorhexidine solution to reduce aerosolization of bacteria. Ferret teeth are smaller than feline teeth; therefore, the scaler’s intensity setting should be reduced to avoid iatrogenic trauma (FIGURE 7). Scaling can be performed with an ultrasonic scaler, using a smaller version of a crosshatch technique and limiting scaling time to 5 to 7 seconds per tooth. With smaller teeth, it is tempting to use the tip of the scaler; however, the tip’s jackhammer motion can create dents in the enamel, so this practice should be avoided (FIGURE 8). Care must be taken to avoid excessive contact with the gingiva to prevent bruising and burns. Curettes can be used to perform subgingival cleaning, A

again taking care to avoid damaging the gingiva. Dental mirrors may be helpful with visualization.3 A fine prophy paste is used to remove microetches produced by the scaler (FIGURE 9). Fluoride- and flavorfree paste is preferred, to avoid residual taste that may cause salivation upon recovery. Polishing should take no more than 5 seconds per tooth. The mouth should then be rinsed with a chlorhexidine solution to remove any debris (e.g., paste, calculus) as well as to aerate the gingiva. DENTAL RADIOGRAPHY Radiography is the final step needed to complete the oral examination. Dental radiographs are needed to determine the stage of any periodontal disease present, as probing may not reveal the true depth of bone loss. Dental radiographs also help in evaluating potential treatment options (root canal versus surgical extraction) and provide necessary guidance for surgical extractions. FIGURES 10 and 11 show patient positioning for basic dental radiographic views in ferrets. Clinics that use a digital number two sensor can have difficulty with the thickness of the sensor. Thinner phosphoric plates are available in a number 1 size and offer the same high definition as digital radiography. B

FIGURE 8. (A) Incorrect scaling technique using the scaler tip! (B) Correct technique with scaler lying flat.

FIGURE 9. Use fine, unflavored, fluoride-free paste to polish. Go slowly to avoid traumatizing the tooth from too much heat. 14

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C FIGURE 10. Maxillary radiographs can be obtained with the ferret in sternal recumbency. The angle of the tube head is 45°, and the sensor/film is lying flat above the tongue. (A) Positioning for maxillary canine. (B) Positioning for maxillary premolars/molar. (C) Radiograph showing canine to molar teeth.

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CE Article

NERVE BLOCKS Nerve blocks can be intimidating even on larger patients; however, the ability to offer preemptive pain control with a local anesthetic means that the pros of nerve blocks in ferrets far outweigh the cons. The required supplies (BOX 3) are minimal in cost—$0.26 per patient—but offer the ability to further decrease the use of inhalant agents and the maintenance fluid rate, thereby preventing use of hypotensive treatments and further reducing the clinic’s overhead cost. In addition, A

Ferret Dentistry: No Weaseling About It!

preemptive pain control lasts 6 to 8 hours, so postoperatively, the patient will be more inclined to eat, rest comfortably, and take medications more readily. Practice is necessary to perfect nerve block techniques and administer local anesthesia safely. Routine practice for every nerve block should involve aspiration, followed by rotating the needle in one direction 4 times. This is extremely important to avoid injecting bupivacaine into the blood vessel. A helpful rule of thumb is to start with the numbers of the syringe facing you and the bevel of the needle facing the foramen. This will allow you to know, after turning 4 times, where you started and in what direction the bupivacaine will migrate. Infraorbital A nerve block at this site (FIGURE 12) anesthetizes the infraorbital nerve and the rostral maxillary alveolar nerves, offering analgesia from to the fourth premolar to the incisors, including surrounding soft tissues such as gingiva and alveolar bone. The infraorbital foramen, which can be palpated with a delicate touch, is typically located between the mesial and distal roots. The needle is placed close to the opening of the foramen and digital pressure is applied for 20 seconds to allow the anesthetic to infiltrate the foramen. This technique is used to prevent damage to the eye and to the nerves and vessels in the foramen.

Caudal Maxillary A block at this site (FIGURE 13) anesthetizes the branches of the maxillary nerve, offering analgesia from the molars to the incisors, including surrounding soft tissues and maxillary bone. An easy landmark is just behind the last molar, where the hard and the soft palate meet. A slight bend in the needle may enable administration in a smaller space.

BOX 3 Supplies for Performing Nerve Blocks  1 cc syringe

FIGURE 11. Mandibular radiographs can be obtained with the ferret in dorsal recumbency. The angle of the tube head is 45°, and the sensor/film can lie flat above or below the tongue. (A) Positioning for mandibular incisors. (B) Radiograph of mandibular incisors. Note the periodontal disease on first incisor. (C) Positioning for mandibular canines. (D) Radiograph of mandibular canines. (E) Positioning for mandibular premolars/ molars. (F) Radiograph of mandibular premolars/molars (incomplete view of the last molar). Note the resorption on the distal root of the first molar. TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

 27-gauge needles  0.5% bupivacaine Bupivacaine is dosed at 1 mg/kg; therefore, a ferret weighing 1000 g would receive a maximum volume of 0.2 mL at 0.05 mL per site. For ferrets weighing <800 to 900 g, bupivacaine can be diluted with saline in a 1:1 ratio to avoid overdose and enable easier administration.

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NAVC CONFERENCE 2017: NEW PRODUCT GALLERY

GET THE LEAD! BE AMONG THE FIRST TO CHECK OUT NEW, REVOLUTIONARY VETERINARY PHARMACEUTICALS, EQUIPMENT, TECHNOLOGY, PRODUCTS AND SUPPLIES.

Orlando, Florida • February 4-8, 2017 (Exhibits 5-8) Orange County Convention Center • West Concourse

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The NAVC Conference 2017 New Product Gallery will feature up to 20 of the latest innovations at a glance, in Orlando, Florida, February 4-8, 2017. Each year, veterinary companies with new offerings may reveal products first at the NAVC Conference.

LEARN MORE AT NAVC.COM AND REGISTER TODAY! /TheNAVC

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TREAT YOURSELF AND LEARN SOME NEW TRICKS

Orlando, Florida • February 4-8, 2017 (Exhibits 5-8) Orange County Convention Center • West Concourse

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GET READY FOR A BIGGER, BETTER AND MORE EXHILARATING EXPERIENCE THAN EVER BEFORE.

EXPLORE the industry’s greatest and latest products and services with more than 650 exhibitors in ONE NAVC Conference Exhibit Hall.

ENJOY a wide selection of Small Animal, Large Animal, Exotics, Technician and Practice Management programs, as well as a Health & Wellbeing Center, IGNITE! 10-minute talks, FEAR FREE sessions and Hospital Design Workshop.

RECHARGE with entertainment and events featuring Grammy Award-winning artist Darius Rucker, “Dirty Jobs” host and “Deadliest Catch” narrator, Mike Rowe, and “Good Morning America” host, Robin Roberts! Also – NEW this year – Sunday’s “Big Game” event, a 5k Fun(d) Run/Walk and Fun(d) Golf Tournament to benefit the WSAVA Foundation.

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Peer-Reviewed

Middle Mental A middle mental nerve block (FIGURE 14) anesthetizes the end of the inferior alveolar nerve, offering anesthesia from the second premolar to the incisors, including surrounding soft tissues and mandibular bone. The middle mental foramen is typically located below the second premolar. Application of this block in a dog typically requires pulling the lip and lateral frenulum down and inserting the needle in a rostral to caudal direction; however, in ferrets, the lip and the frenulum are tightly connected and not easily moved, so a caudal to rostral approach is best. Again, digital pressure is applied for 20 seconds to allow the bupivacaine to infiltrate the foramen.

soft tissues and mandibular bone. Using an extraoral approach will place the needle on the inside of the mandible. This block can anesthetize the lingual nerve, so it is critical to recover the patient in sternal recumbency to avoid chewing damage to the tongue. POSTOPERATIVE CARE Postoperative care is as important as intraoperative care, and pain control should be continued for at least 5 to 7 days postoperatively. Again, many of the medications A

Caudal Mandibular The caudal mandibular nerve block (FIGURE 15) anesthetizes the inferior alveolar nerve, offering anesthesia from the last molar to the incisors, as well as surrounding

FIGURE 12. Infraorbital foramen block. (A) The foramen lies just above the mesial roots of the upper fourth premolar. Courtesy of SkullsUnlimited.com. (B) Be very cautious with needle placement, as there is not much room from the entrance of the foramen to the eye. Insert the needle just to the foramen opening and then apply digital pressure to allow for diffusion of the agent. 18

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FIGURE 13. Caudal maxillary block. (A) The location for this block is just behind the last molar. Again, be very cautious with needle placement, as there is not much room between the entrance of the foramen and the eye. Courtesy of SkullsUnlimited.com. (B) Insert the needle directly behind the last molar, where the hard and soft palate meet, and just below the gum line, and allow diffusion to take place.

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CE Article

used for pain control are similar to those used for cats and dogs. NSAIDs are typically used. Meloxicam, as a suspension, is easily dispensed; however, in patients with renal compromise, NSAIDs should be used cautiously. Gabapentin suspension in conjunction with an NSAID offers synergistic pain control as well as sedation. The patientâ&#x20AC;&#x2122;s ability and desire to eat are also important. Depending on the procedure, a soft diet may be necessary to facilitate healing of the surgical site. Ferrets are typically imprinted on their diet by an early age, and change may cause them to become anorectic. Because of their high metabolic rate, anorexia quickly leads to hypoglycemia. To prevent a hypoglycemic episode, a highly palatable liquid diet such as Oxbow Carnivore Care (Oxbow Animal Health, oxbowanimalhealth.com) can be dispensed as a postoperative supplement. The hard food that is the A

Ferret Dentistry: No Weaseling About It!

typical ferret diet can be crushed into fine particles or moistened with warm water to encourage eating. Syringe feeding may be difficult to perform safely without traumatizing oral surgical sites. Detailed written discharge instructions should be provided to the owner to explain what to expect postoperatively as well as all the medication and diet instructions for home care. A medical progress examination at 2 weeks after surgery should be scheduled to ensure that surgical sites are healing as well as to discuss further home care options with owners. A follow-up phone call the day after surgery is important to ensure that the ferret is continuing to eat and that the owner is able to administer medication or to help the veterinary team intervene if the ferret is anorectic or needs further care. Making sure that the owner perceives the value of dental surgery should be a priority. Pre- and postprocedure photographs should be shown and thoroughly explained to the owner, along with the radiographs obtained. Images help demonstrate the full extent of disease that was treated. A

FIGURE 14. Middle mental block. (A) The foramen lies just below the mesial root of the second premolar. Courtesy of SkullsUnlimited.com. (B) Because of the tight attachment of the lateral frenulum, a caudal to rostral approach is an easier approach to access the middle mental foramen. TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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FIGURE 15. Caudal mandibular block. (A) The foramen lies on the inside of the vertical ramus. Courtesy of SkullsUnlimited.com. (B) Use the lateral acanthus of the eye to guide you to the (C) mandibular notch.

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Peer-Reviewed

CONCLUSION Oral health is no longer a conversation to avoid with ferret owners. Many veterinary clinics already have most of the equipment needed to perform a complete anesthetized periodontal examination and treatment in ferret patients. With the added research that allows us to offer appropriate pain control in these patients, veterinary technicians should feel confident in learning more about how to increase their level of dental care. 

References 1. Eroshin VV, Reiter AM, Rosenthal K, et al. Oral examination results in rescued ferrets: clinical findings. J Vet Dentistry 2011; 28(1):8-15. 2. Lewington JH. Ferret Husbandry, Medicine and Surgery. 2nd ed. Toronto: Saunders Elsevier; 2007:467-484. 3. Perrone JR, ed. Small Animal Dental Procedures for Veterinary Technicians and Nurses. Wiley Blackwell; 2013:177-184. 4. Bellows J. The oral assessment. oralatp.com. Accessed November 2016. 5. Carpenter JW. Exotic Animal Formulary. Elsevier; 2013:567-571. 6. Egger CM, Love L, Doherty T, eds. Pain Management in Veterinary Practice. Wiley Blackwell; 2014:399-405.

CE Test Ferret Dentistry: No Weaseling About It! The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com/tvt.aspx. A $5 fee applies. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval. 1. A brachydont tooth has a a. long crown with well-developed roots. b. short crown with well-developed roots that contain a narrow pulp canal. c. short crown with no true root. d. none of the above 2. An adult ferret has ______ permanent teeth. a. 28 b. 30 c. 34 d. 42 3. A normal sulcus depth for a ferret is ______ mm. a. 0–0.5 b. 0.5–1 c. 1–1.5 d. 1.5–2 4. True or false: For ferrets, the ultrasonic scaler should be set to the highest setting. 5. A ______-gauge needle can be used for nerve blocks in ferrets. a. 20 b. 22 c. 25 d. 27

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6. Teeth should be polished at a slow speed to a. reduce heat production. b. avoid iatrogenic trauma to the tooth. c. cover all surface areas. d. a and b 7. In ferrets, the ______ are frequently not in proper alignment. a. molars b. incisors c. premolars d. canines 8. True or false: Intrinsic staining is a sign of trauma. 9. Tooth extrusion should be considered as a. normal. b. a sign of trauma. c. attachment loss. d. a sign of malpositioning. 10. Preoperatively, ferrets should a. be masked for induction. b. be fasted overnight. c. undergo a physical examination. d. b and c

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Advertiser Index American College of Veterinary Internal Medicine ACVIM Forum acvimforum.org . . . . . . . . . . . . . . 57 BluePearl Veterinary Associates Employment opportunities bluepearlvet.com/careers . . . . 81 Boehringer Ingleheim Vetmedin vetmedin.com . . . . . . . . . . . Inside front cover, 2 CareCredit Financing carecredit.com . . . . . . . . . . . . . . . 69 Dechra Amoxicillin trihydrate and clavulanate potassium tablets dechra-us.com . . . . . . . . . . . . . . 4, 5 Kane Biotech StrixNB strixnb.com . . . . . . . . . . . . . . . . . . . 21

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EFFECTIVE IN HELPING REDUCE TARTAR

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CLIENT HANDOUT

Dental Care  Most dogs and cats develop periodontal (dental) disease by 3 years of age.  Periodontal disease is the most common health problem in dogs and cats.  Bad breath may be a sign of periodontal disease in your pet.  Providing routine dental care for your pet can be easy and can benefit your pet’s oral and overall health.

What You Need to Know Bad breath in pets may be a sign of periodontal disease that could lead to other health problems. Periodontal disease starts when plaque (a bacterial film) coats the tooth. Plaque hardens (calcifies) into tartar, a thick yellow or brown layer on the teeth. Tartar can irritate the gums, creating an environment where bacteria thrive. As the disease progresses, the gums become tender, red, and swollen and the bacteria continue to multiply. Eventually, the inflamed gums pull

Signs of Dental Problems  Bad breath  Sensitivity around the mouth

away from the teeth, creating pockets that trap more bacteria and food particles. The gums bleed, the roots of the teeth may become exposed, teeth may become loose, and your pet may feel pain when eating. If the bacteria enter the bloodstream, they can create problems for organs such as the heart, liver, and kidneys.

What to Do Your pet needs routine dental care from your veterinarian and you. Regular veterinary checkups are essential for

 Loss of appetite  Yellow or brown deposits on the teeth  Bleeding, inflamed, and withdrawn gums  Loose or missing teeth  Pawing at the mouth or face

shutterstock.com/David Porras

 Difficulty chewing

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Dental Care continued

Ways to Prevent Periodontal Disease in Your Pet  Take your pet to annual veterinary checkups.  Brush your pet’s teeth or use plaque-reducing products at least a few times a week.  Feed dry food.  Provide plaque-reducing foods, treats, and toys.

helping your veterinarian monitor your pet’s dental health, but don’t wait for a checkup if you suspect a problem. After an examination, your veterinarian may recommend a dental cleaning for your pet. Anesthesia and pain medication are used for dental procedures. If dental disease is severe, your veterinarian will recommend the best treatment, which may include tooth extraction. Pets are never too young to start having their teeth brushed at home; in fact, the younger they are, the better. Slowly and gently introduce your pet to toothbrushing. It should be a bonding experience that is reinforced with praise and rewards. Begin by rubbing your pet’s teeth and gums with soft gauze wrapped around your finger. Gradually switch to using a specially designed pet toothbrush or baby toothbrush with pet toothpaste (do not use toothpaste for people because it is not safe to swallow). If your pet is most at ease on

your lap, keep his or her toothbrush next to the chair where you sit together. Focus on your pet’s gum line, and work up to 30 seconds of brushing for each side of the mouth at least a few times a week. If your pet won’t tolerate brushing, your veterinarian can recommend plaque-preventive products for your pet. There’s no substitute for regular brushing, but feeding dry food can help keep your pet’s teeth and gums in good condition. In addition, special plaquereducing foods, treats, and toys can help. The Seal of Acceptance from the Veterinary Oral Health Council appears on products that meet defined standards for plaque and tartar control in dogs and cats. Ask your veterinarian for recommendations. Caring for your pet’s teeth can have several benefits. For example, a few minutes of brushing each week can help give your pet a happier, healthier life. 

© 2017 Today’s Veterinary Technician. Created by Vetstreet and peer-reviewed by Today’s Veterinary Technician. Brought to you by VetFolio. Today’s Veterinary Technician grants permission to individual veterinary clinics to copy and distribute this handout for the purposes of client education. For a downloadable PDF, please visit www.todaysveterinarytechnician.com.

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CLIENT HANDOUT

Dental Cleaning  Most pets have periodontal disease by the time they are 3 years of age.  Dental disease can result in bad breath, painful chewing, and tooth loss.  Bacteria under the gum can travel to the heart, kidneys, and liver.  A professional dental cleaning is required to remove plaque and tartar from a pet’s teeth and to assess the health of the mouth.  A thorough dental cleaning requires that the pet be under anesthesia.  Regular, at-home dental care can help improve the health of your pet’s mouth and lengthen the intervals between professional dental cleanings.

work their way under the gums and cause gingivitis—inflammation of the gums. Once under the gums, bacteria destroy the supporting tissue around the tooth, leading to tooth loss. This condition is known as periodontitis. Gingivitis and periodontitis make up the changes that are referred to as periodontal disease. The bacteria associated with periodontal disease can also travel in the bloodstream to infect the heart, kidneys, and liver.

shutterstock.com/Igor Chus

Most pets have periodontal disease by the time they are 3 years of age. Periodontal disease is a progressive disease of the supporting tissues surrounding teeth and the main cause of early tooth loss. Periodontal disease starts when bacteria combine with food particles to form plaque on the teeth. Within days, minerals in the saliva bond with the plaque to form tartar, a hard substance that adheres to the teeth. The bacteria

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SAVE THE DATE FOR AN ALL NEW EDUCATIONAL EVENT VET The FASTEST way to stop bleeding and keep it stopped.

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For details and to register for the event, visit NAVC.com/Discovery.

www.ClotItVET.com

PHOTO CREDIT: Rhea Anna

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Dental Cleaning continued

How Do I Know if My Pet Needs a Dental Cleaning? Regular inspection of your pet’s mouth is important to catch dental disease in the early stages. Tartar may appear as a brownish-gold buildup on the teeth, close to the gum line. Redness or bleeding along the gum line may indicate gingivitis. Other signs of dental disease include:  Bad breath  Drooling  Pawing at the mouth  Difficulty chewing  Loose or missing teeth

shutterstock.com/Julie Keen

If you notice any of these signs in your pet, schedule an appointment with your veterinarian.

A professional veterinary dental cleaning is the best way to remove tartar from the teeth and under the gum tissue to protect your pet’s health. With a professional dental cleaning and follow-up care, gingivitis is reversible. Periodontal disease is not reversible, but diligent at-home dental care and regular veterinary cleanings can slow down the progression of the condition.

What Are the Benefits of a Dental Cleaning? A professional dental cleaning removes not only the visible plaque and tartar on the teeth surfaces but also the bacteria under the gums. This helps to eliminate potential sources of infection to the mouth and other organs and to protect your pet from pain and tooth loss.

What Is a Dental Cleaning?

What Can I Do to Keep My Pet’s Teeth Clean?

During a dental cleaning, (1) plaque and tartar are removed from a pet’s teeth and (2) the health of the entire mouth (tongue, gums, lips, and teeth) is assessed. A thorough dental cleaning can be accomplished only while the pet is under general anesthesia. Anesthesia keeps your pet free of pain during the dental procedure and allows your veterinarian to fully inspect the teeth and remove tartar from under the gums. During anesthesia, a soft plastic tube is inserted into the trachea (the main airway in the throat) to support the patient’s breathing. A dental cleaning may include:  Removal of visible plaque and tartar from the teeth E limination of plaque and tartar from under the gum line P robing of dental sockets to assess dental disease P olishing to smooth enamel scratches that may harbor bacteria D ental radiographs (x-rays) to evaluate problems below the gum line A pplication of fluoride or a dental sealer R emoval or repair of fractured or infected teeth D ental charting so progression of dental disease can be monitored  I nspection of the lips, tongue, and entire mouth for growths, wounds, or other problems

Once a dental cleaning has been performed, you can take a number of steps at home to keep your pet’s teeth clean and lengthen the intervals between dental cleanings. Your veterinarian may recommend a plaque prevention product—a substance that you apply to your pet’s teeth and gums on a regular basis. The product adheres to the surface of the teeth to create a barrier that helps prevent plaque from forming. Just as in people, daily brushing can help remove food particles from between your pet’s teeth. You can use a child’s toothbrush or purchase a finger brush from your veterinarian. Human toothpastes should be avoided because they contain ingredients that should not be swallowed by your pet. Your dog or cat may like the taste of pet toothpaste, which is available in flavors such as chicken, seafood, and malt. Several dental diets and treats can also help keep plaque and tartar to a minimum. The diets tend to have larger kibbles to provide abrasive action against the tooth surface when chewed, or they may contain ingredients that help prevent tartar mineralization. Ask your veterinarian which diets or treats are appropriate for your pet. 

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What Moves You?

A Calming Touch

I was the world’s worst at patient restraint. Somehow, no matter how hard I tried, the patient would continue to struggle or slip out of my grasp. When the doctor would ask for assistance in the exam room and I answered her call, I often saw her shoulders slump when she saw it was me. My coworkers also tended to scold me about “not holding tight enough” or “being too emotional” when I was restraining an animal. Although I was following the techniques I had been taught on the job (the same ones my coworkers were using), I always seemed to fail. But somewhere in my soul I knew that the way the veterinary community tended to approach restraint wasn’t what was best for the animal. Yes, if we had four people holding down a struggling dog for a nail trim, we would end up “getting it done.” But what if we could approach the dog in such a way that we didn’t need to meet struggling with force? Also, how could we make a cat feel more secure so that it didn’t feel the need to scratch, bite, or flee? Although I kept trying to improve my technique, and tried to become more assertive, I was still seen as the “timid” one when it came to animal restraint. As a technician, I have always had a deep interest in behavior medicine. Dr. Sophia Yin was one of my professional heroes. I loved her blog and had attended her lectures at conferences, and I hoped to someday intern with her to learn more about applied animal behavior in the veterinary setting. On September 28, 2014, when I heard the terrible news that she died, I signed up for her Low-Stress Handling™ certification course that very day as a way to honor her memory. As I started the course, I realized…this was it! This was the guidance I needed to be more confident at patient handling! Her low-stress techniques showed me how to use calm control to reduce fear and to eliminate struggling. I became well versed in multiple towel wraps for cats and how to examine or treat fearful and aggressive cats in the carrier. I learned how to restrain dogs with a myriad of hand and body holds that help them feel safe and secure, which allows us to restrain with minimal force. I also learned how to be flexible and modify restraint techniques and diagnostic procedures to help keep the animal calm. Through this training, I was no longer the “timid” one when it came to restraint. I had new tools to help keep patients relaxed, which allowed us to complete low-stress procedures like nail trims, ear flushes, and blood draws. I was amazed at the difference…both in my ability and in the positive change I saw in our patients’ behavior.

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Summer Brooks, MS, RVT Grand Animal Hospital San Diego, California

Veterinary technicians are the heart of veterinary medicine. We are passionate and dedicated, and we each have a story to tell. Today’s Veterinary Technician wants to hear yours! What drives you? What inspires you? What moves you? Send us your story at TVTech_submissions@NAVC.com. Submissions should be approximately 500 words or less and may be posted on our website or edited for publication in the journal. Tell us your story!

“I learned to look at the veterinary experience from the patient’s point of view and how to minimize fearful triggers throughout the visit.” —Summer Brooks

continued on page 29

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What Moves You?

Consistent Change

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Karen Ellis, LVT, VTS (Surgery) Gulf Coast Veterinary Specialists Houston, Texas

“Every driving force that has affected my veterinary career has been related to change— whether I spurred the change or change happened.” —Karen Ellis

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Most every person working in the veterinary community has a similar reason for starting a career with animals. We each have a passion for helping animals. But what drives us through our career? What keeps us in it when it gets tough? What drives some people through it all? I struggled to think of what has consistently driven me through my career. So many things are different, and so many things have happened that I didn’t expect. Just when I thought things would be one way, something changed. Change. Could that be it? Does change move and drive me? As I think back, every driving force that has affected my veterinary career has been related to change—whether I spurred the change or change happened and I had to adjust paths. Either my cheese was moved or I chose to move my own cheese. Summer 2003. Graduation. I didn’t get offered the pay I thought I needed to live on my own. So I moved to Houston and took a position at a specialty practice. This put me on a completely different path than I would have been if I’d stayed at home. I left my current practice for a while because of another move when I was getting married. I was unhappy at work and was considering changing careers because of limited options where I lived. Instead, I chose to go back to work where I was happy (70 miles each way), and we moved back 6 months later. There were times when I thought I wasn’t getting recognized for my skills and I wanted to do more. I thought someone else would recognize my skills. I was a quiet person, but I had to change. I had to learn to advocate for myself. I learned how to ask for things I wanted. I heard murmurs of a specialty geared for me: surgery. Huge game changer! Nothing changes your perspective on your career more than learning more. Learning and change drive each other. The energy that this type of learning brings a technician is life altering. Things at my work started changing. Some practice owners had changed. New CEO. A new hospital was being built in another city. An opportunity to learn leadership skills in a temporary role presented itself, and my path took another turn. This single turn has lead to so many other changes. Even ones that seemed negative at first have greatly influenced my current role. Several years later, and now I am in a role—Surgery Technical Staff Supervisor—that I thought would take most of my career to achieve. My hospital is in a state of rapid change and growth due to mergers. More opportunities might become available. I just have to be ready and willing to change, learn, and grow.

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

C ONSI STENT CHA NGE 



| Consistent What MovesTYou? A C ALM ING O UC H  Change

Nothing changes your perspective on your career more than learning more. Learning and change drive each other. The energy that this type of learning brings a technician is life altering.

Knowing that I can help to make a vet visit low stress and fear free makes me excited to go to work every day. I want to shout from the rooftops how this training has changed my life.

Fall 2016. I just applied to a university to finish my bachelor’s degree. Time will only tell how that change will drive my career. Change doesn’t have mean constantly changing jobs. Change is personal. It can happen within you. It can drive you. 

What Moves Me? We have a canine patient with recurring ear infections. He has been notorious for bucking and “alligator rolling” during exams. He used to become frantic from the moment his owner brought him in and snapped on the (much needed) nylon muzzle. Now, with the use of a basket muzzle and a towel wrap, he stays calm for thorough otoscopic exams and ear flushes. No more alligator rolling! One of our new feline patients had a history of needing sedation for exams and blood work at other clinics. On her most recent visit, we ushered her into a quiet room with treats and Feliway-sprayed blankets. The doctor examined her in the carrier, which kept her calm and comfortable. When it was time to draw blood, we wrapped her in a blanket and the doctor drew from the medial saphenous vein. We completed all the diagnostics in the exam room so that we did not have to disorient her by changing to a new (and busy and loud) location. The owner was amazed that her cat did not “flip out” like it always had before! After a low-stress nail trim using gentle handling and high-value treats, it is gratifying to hear an owner say, “Bringing my dog for a nail trim used to be so stressful that I would avoid it. Now I can’t wait for next time!” It moves me to pass on these techniques to other staff members and see the ripple effect that these techniques have on patient care as well as staff morale and safety. Knowing that I can help to make a vet visit low stress and fear free makes me excited to go to work every day. I want to shout from the rooftops how this training has changed my life. Sharing my experiences here is a great place to start. 

A Calming Touch, continued from page 27

In 2016, the Fear FreeSM certification course debuted, and I knew it would be the perfect addition to my low-stress handling knowledge. Through this course, I learned to look at the veterinary experience from the patient’s point of view and how to minimize fearful triggers throughout the visit. I learned how to help owners begin the visit with stress-free transport from home, and I realized that there are many small modifications we can make in the waiting room, exam room, and treatment/hospital areas to minimize fear in our patients. I also became adept at communicating the fear-free and low-stress philosophy to clients and staff. Fear FreeSM also provided me with resources to share with the veterinarians about previsit anxiety medication and sedation protocols. Because of this training, my confidence has gone through the roof. When I first offered help, I could see that my coworkers were still dubious. But now the doctor and staff often defer to me with a challenging patient because they know I have the training and tools to help in a calm and confident manner. Now, any time a “CAUTION” animal is scheduled, I am excited to be the lead tech on the case—and help the pet, owner, doctor, and staff have a successful visit. TODAY’SVETERINARYTECHNICIAN

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An Official Journal of the NAVC

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When Caring Hurts:

Dealing with Depression in Veterinary Medicine

epression is one of the most common mental health disorders in the United States.1 Although the cause is not known, research suggests that depression develops from a combination of physiologic, genetic, environmental, and biologic factors. What makes depression so prevalent in the veterinary community? According to an AVMA study,2 1 in 6 veterinarians have considered suicide since graduation. This study did not involve support staff but surveyed more than 10,000 practicing veterinarians. The study found that 6.8% of male veterinarians and 10.9% of female veterinarians have serious psychologic distress, compared with 3.5% of adult men and 4.4% of adult women who do not work in the veterinary community. The study also showed that 24.5% of male and 36.7% of female veterinarians have experienced depressive episodes since graduation, which is approximately 1.5 times the prevalence in US adults. The study suggested that veterinarians are 3 times more likely than the US national mean to consider suicide, and that 1% to 1.5% of veterinarians have attempted suicide since graduation. The results are similar to those from mental health surveys of veterinarians in other countries, including Australia, New Zealand, and the United Kingdom, thus 30

TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

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Melanie Codi, LVT, CVT, VTS (Nutrition) Blue Pearl Veterinary Partners Paramus, New Jersey

Melanie obtained her veterinary technology degree from SUNY Ulster in 2008 and has been in specialty practices for the past 9 years, working in emergency/ critical care and with boarded veterinary nutritionists and internists. Before changing her focus to veterinary technology, she majored in psychology. In 2011, she decided to obtain her veterinary technician specialist credential in nutrition because she felt that nutrition is often overlooked in general practice, critical care, and disease management. Melanie is an active member of the American Academy of Veterinary Nutrition and the committee of the Pet Nutrition Alliance. She gives lectures for owners as well as veterinary professionals on many topics.

An Official Journal of the NAVC

suggesting that depression in the veterinary community is a global epidemic. STRESS AND DEPRESSION Veterinary technicians know that workplace stress is not limited to veterinarians. Burnout is cited in the NAVTA 2016 Demographics Survey as one of the top 6 most significant problems that credentialed veterinary technicians face.3 Those of us who work in this field are likely to become stressed and overwhelmed owing to the volume and nature of the work. It often feels like the world is on our shouldersâ&#x20AC;&#x201D;no time to rest, eat, or use the bathroom; constantly ringing phones; very ill pets; very upset and high-strung owners; and what seems like little appreciation and support from owners, coworkers, family members, and friends. We have often had to cancel plans in our personal life to take care of a sick animal, thus leading to resentment of those things we once cared for so highly: animals, their well-being, their family, and the field of veterinary medicine. The lines of workâ&#x20AC;&#x201C;life balance are often blurred, and the stress from the workday, workweek, work month, or even work year is taken home with us. Busy, stressful days can lead to bad eating and sleeping habits, thus leaving staff feeling overtired, overworked, and underappreciated.

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When Caring Hurts: Dealing with Depression in Veterinary Medicine

shutterstock.com/Syda Productions

Experts agree that the more you know about compassion fatigue, the better prepared you are to recognize and cope with its effects.

Chronic stress can lead to other conditions,1 such as depression, anxiety, other psychiatric disorders, musculoskeletal disorders, insomnia, cognitive impairment (inability to remember), substance abuse, employee absenteeism, and work errors. If we are not taking care of ourselves, how can we take care of others? If we are constantly putting our physical and emotional health on the back burner, how can we ensure that we will be around to care for our patients as deeply as we once did?

If we cannot care for ourselves, how can we be sure we are giving 100% to our patients? If we cannot take care of each other as a community, who will? Feelings of depression can easily be brushed aside as resulting from the nature of our work. “It’s just compassion fatigue,” or, “I know, I’m burnt out, too,” are statements that can make someone believe that it is normal to feel overwhelmed and empty. The “nature” of a job does not have to, and should not, make someone feel as if they are constantly empty, lost, saddened, angry, unhappy, overwhelmed, anxious, or afraid. We should not feel like we are burdened by the weight of the world sitting on our shoulders. We will have days when we are unhappy and sad or when it feels like nothing is going right, but chronicity is the important factor. Constantly taking work home (physically and emotionally) or being unable to enjoy life at home or outside of work because of experiences at work is a sign that the issue may be more serious. What is termed “compassion fatigue” or “burnout” can actually be depression (TABLE 1). Signs of depression include feelings of sadness, hopelessness, and worthlessness; low energy; inability to concentrate; irritability, anger, and hostility; loss of interest in once-loved activities; changes in appetite and sleep patterns; thoughts of harming oneself and/or others; reckless behavior (including substance abuse, promiscuity, speeding, and

TABLE 1 Know the Difference: Burnout, Compassion Fatigue, or Depression4 Definition

BURNOUT

COMPASSION FATIGUE

DEPRESSION

Emotional exhaustion

Created by trauma of helping others

A serious medical condition in which a person feels

Overloaded Exhaustion Tiredness Lack of energy Pessimism Cynical attitude toward

Intrusive, negative thoughts Hopelessness Guilt Detachment Traumatic memories Decreased empathy

Sadness Emptiness Irritability Frustration Anxiety Agitation Worthlessness Guilt

Distancing oneself

Avoiding stressful situations Isolation Decreased empathy

Angry outbursts Loss of interest in normal activities one once enjoyed Change in sleep patterns (insomnia or sleepiness) Changes in appetite (increased or decreased) Excessive worrying Inability to sit still and/or concentrate Memory loss Frequent thoughts of death or suicide

Usually can be treated

Does not change with time off from

Psychotherapy Medication (antidepressants, mood stabilizers,

associated with the work environment Not related to trauma Slower onset than compassion fatigue Associated Feelings

work and colleagues

Signs

emotionally Inability to concentrate Lacking creativity

Treatment

with a change of environment

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in distress, leading to reduced capacity for empathy Can be due to exposure on one case or a “cumulative” level of trauma More rapid onset than burnout

work, because symptoms will return Requires psychotherapy/changing field or type of work to decrease exposure to trauma

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very sad, hopeless, and unimportant and often is unable to live in a normal way A psychoneurotic or psychotic disorder marked especially by sadness, feelings of dejection, hopelessness, and sometimes suicidal tendencies5

antianxiolytics, antipsychotics)

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When Caring Hurts: Dealing with Depression in Veterinary Medicine

gambling); and feeling like a burden to others.1 Talk or plans of suicide and complete behavior changes (for instance, someone who was always a pessimist suddenly becoming a very happy optimist and vice versa) are major warning signs and should not be taken lightly or brushed aside. RECOMMENDATIONS FOR THOSE STRUGGLING Many resources are available if you think you are struggling with burnout or something of a more serious nature. Your feelings about yourself, your skills, employer, and job should not be swept aside. The job description of a veterinary technician encompasses a variety of roles that can be overwhelming. We may be veterinary technicians, laboratory technicians,

radiology technicians, pharmacy technicians, customer care representatives, grief counselors, and other support staff, but wearing many different hats throughout the day can be daunting to those who are overworked and feel unappreciated. Many technicians complain about the lack of pay for the number of skills we possess, but the truth is, with depression, $1000 an hour will not help fill the void of feeling empty, alone, and hopeless. BOX 1 lists some simple measures to help you take care of yourself, mentally and physically, but treatment of true depression often requires external help (TABLE 1). If you recognize the signs of depression in yourself, remember that professional assistance exists to help you, and don’t be afraid or embarrassed to seek it.

NAVTA 2016 Demographic Survey Reveals

Compassion Fatigue Is 2nd Largest Factor Negatively Affecting the Veterinary Technician Profession Heather Prendergast, RVT, CVPM, SPHR because of compassion fatigue, and only 3% of those received any grief counseling from the practice.1

In May of last year, the National Association of Veterinary Technicians in America (NAVTA) released its 2016 Demographics Survey results. The survey was distributed to veterinary professionals and paraprofessionals nationwide; both NAVTA members and nonmembers were asked to complete the survey, and nearly 2800 responses were submitted.

Compassion fatigue is not a new topic in veterinary medicine; it has been presented at conferences and in books and journals. What is difficult, however, is to admit when we are suffering from compassion fatigue. Experts agree that the more you know about compassion fatigue, the better prepared you are to recognize and cope with its effects. Compassion is defined as “a deep awareness of the suffering of another, coupled with the wish to relieve it.”2 Fatigue is defined as “the mental weariness resulting from exertion that is associated with attending to the emotional and physical pain of others.”2 Compassion fatigue is something all of us in the veterinary profession are susceptible to, and many of us today suffer from this condition.3

Respondents were asked to rank factors that would negatively affect their job as a veterinary paraprofessional in the next 5 years. Fifty-four percent of respondents felt low salary and benefits were a factor, 41% felt compassion fatigue was a factor, and 39% felt the economy would negatively affect their jobs. Veterinary owners and managers have the ability to positively influence compassion fatigue, salary, and benefits, whereas the economy is beyond our control. The survey also asked respondents if their practice discussed compassion fatigue with the team. Seventy percent indicated yes, the effect of compassion fatigue was discussed occasionally; however, only 23% of practices offer support for those experiencing compassion fatigue. Further, 1.8% of respondents indicated they have had a coworker commit suicide

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An Official Journal of the NAVC

What about burnout? More than 50% of technicians surveyed indicated they experienced burnout as one of their top 5 most significant problems (second only to low income), while 41% experienced compassion fatigue. Part of the difficulty of diagnosing compassion fatigue is that we tend to lump all of our negative

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When Caring Hurts: Dealing with Depression in Veterinary Medicine

RECOMMENDATIONS FOR THOSE YOU THINK MAY BE STRUGGLING People are often afraid to approach a coworker about depression or suicide out of fear of being embarrassed and creating an uncomfortable situation both short and long term. However, if you feel uncomfortable approaching someone whom you are worried about, just imagine how uncomfortable it is for the person who is suffering from depression. Approaching a coworker or friend and asking how he/ she is doing can make a significant difference because people suffering from depression often feel unrecognized. Keeping the number of a suicide hotline nearby is helpful in case someone confides that he/she is having those

types of thoughts. If they won’t make the call themselves, you can call to seek guidance. Assuring those who are suffering that things can, and will, change and making plans for the next day so they have a reason to hang on for one more day can make a world of a difference. The first step is always the hardest, but it will make the most difference and can potentially save a life. RECOMMENDATIONS FOR EMPLOYERS Because of the prevalence of depression and suicidal tendencies in veterinary medicine, it is recommended that employers offer anonymous support to their staff.7 A grief counselor, even to discuss work-related issues/losses, or an

Minimizing compassion fatigue, otherwise known as “the cost of caring,” begins with taking care of ourselves. Developing a self-care plan is not as hard as it looks, yet it also is not as easy as it sounds. We simply cannot change years, perhaps a lifetime, of giving care to others first when we wake up tomorrow morning. We need tools to make these changes, as well as an understanding of what we hope to gain. Review the signs of compassion fatigue and burnout in Melanie Codi’s article, and identify self-help tips to enable success in the future. shutterstock.com/Aspen Photo

As veterinary professionals and paraprofessionals, we must start with ourselves and encourage discussion among our team. Whole Team Wellness is an initiative being explored by many organizations, including the American Veterinary Medical Association. To better serve the professionals of the veterinary team, tools and support networks encompassing compassion fatigue should be implemented in practices immediately. feelings under “burnout.” When compared, they are quite different. Burnout results from the stresses within our workplace environment, whereas compassion fatigue results from the stresses within ourselves regarding the relationships we form with our patients and clients. You may be burned out because you are working long hours in a facility that has run out of space and has faulty equipment, but you are compassion fatigued because a favorite patient just died or a client erupted angrily when you presented a treatment plan.3

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NAVTA would like to recognize Merial for its sponsorship of the NAVTA 2016 Demographic Survey. Heather Prendergast, RVT, CVPM, SPHR, is Editor in Chief of the NAVTA Journal and co-chair of the National Credential Task Force. References 1. National Association of Veterinary Technicians in America. NAVTA 2016 demographic survey results. navta.net/?page=Demographic_Survey. Accessed September 2016. 2. Figley CR, Roop RG. Compassion Fatigue in the Animal-Care Community. Washington, DC: Humane Society Press; 2006. 3. Dobbs K. Compassion fatigue exposed. NAVTA J August/September 2016.

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When Caring Hurts: Dealing with Depression in Veterinary Medicine

employee assistance program that employees can call to make personal, confidential appointments to vent about work or their personal life, can be beneficial. General awareness materials regarding depression and other mental illnesses should be made available to all staff. It is also encouraged that the staff have fun as a team outside of work. Often, we see our coworkers when they are stressed, and it may be nice to interact in a less stressful environment, where you are unlikely to get interrupted and don’t have to deal with unruly clients and patients or ringing phones. Attend an event together, management included, outside of work, even if you are representing the hospital. Doing this may seem awkward at first, but it provides a more comfortable environment to discuss situations and feelings, promotes team-building, and helps foster trust throughout the team. The best way to create mental health awareness and ensure that employees are taking care of themselves is to not ignore the problem. Mental health issues should be talked about and discussed openly in one-on-one conversations and as a group, and resources should be provided to all employees. This may help reduce employee turnover and treatment mistakes/oversights, increase employee compliance with company rules, and

even improve client satisfaction. Making sure your staff is taken care of will increase overall happiness in the hospital. Creating an open-door policy and providing an understanding and compassionate work environment, not just for pets but also for employees, may help lessen the emotional load for some employees. Some things to consider: ÆÆ Breaks are important. Make sure employees are taking breaks as they need, and encourage employees to “step out” for a few minutes if they are overwhelmed. It may throw a wrench in the day, but it will help make future hours and days more productive. Make sure you are staffed appropriately to cover uninterrupted breaks, even if your state sets no legal guidelines regarding breaks and hours worked. Remind employees that breaks are important, and offer appropriate vacation time to reduce burnout. ÆÆ Debrief. After a stressful situation goes awry—for example, a cardiopulmonary–cerebral resuscitation fails—encourage employees to take a minute to clear their heads and sort out their thoughts and feelings. Then discuss, as a team, the strengths and weaknesses of the teamwork. Acknowledge the strengths of each employee, but refrain from singling out those who need

BOX 1 Self-Help Tips for Coping with Depression6  Reach out. There is a tendency to isolate yourself if you feel shameful and like a burden. Reaching out is not a sign of weakness. Keeping in touch with people, especially face-to-face (e.g., with friends, family, teachers, coworkers, clergy members) and engaging in activities that you used to enjoy (even though you feel you no longer enjoy them) can be helpful. Caring for a pet can get you outside and give you a sense of well-being.  Move. Exercise can fight depression. Aim for 10 to 30 minutes of exercise per day, whether it’s walking your dog, doing yoga at home, swimming, walking, dancing, or even cleaning.  Push yourself. Pick up a hobby or sport that you used to enjoy. Bingewatch a TV show you used to love or a dive back into a book series you always used to read. Write down your feelings, or turn them into poetry or music. Play, or learn to play, an instrument. Go to a baseball game or a museum.  Sleep. Get on a sleep schedule. Change the environment in which you sleep; lighten up the room during the day and darken it at night. Avoid increased stimulation (TV, computer, cellphone, etc.) for at least an hour before bedtime. shutterstock.com/Odua Images

 Get some sunlight. Take a short walk outside, enjoy your coffee on the deck, have a picnic at the park, or plant a garden that you need to water.  Relax. Relaxation can help relieve stress. Yoga, deep breathing, a hot bath, progressive muscle relaxation, or a massage can be beneficial.  Eat better. Try to avoid alcohol and caffeine. Don’t skip meals or go too long without eating. Aim for eating a snack or meal every 3 to 4 hours. Minimize sugar intake to decrease a crash in your mood and energy.

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When Caring Hurts: Dealing with Depression in Veterinary Medicine

to improve. Use these situations as an opportunity to improve the quality of care your patients receive, and offer encouraging words. Building self-confidence in your employees not only benefits them personally, but also helps them perform better in future situations. ÆÆ Encourage learning. A day-to-day routine can make employees feel bored. Offer a set time once a week or month to present a case study or discuss a disease, journal article, or new product to encourage employees to keep their brains active and keep them eager to learn and work. Being able to apply what they have learned to real-life situations will make their day interesting and boost their self-confidence, as well as increase the care your patients receive. Doing so may make employees feel like they have purpose, and it may give some employees something to look forward to. ÆÆ Make resources easily available. Hotline business cards, magnets, and brochures can allow employees to keep matters confidential and less awkward. Offer employee assistance programs and put the information on how to get in touch with the coordinator in easily accessible areas, such as the employee break room or by the time clock. ÆÆ Show that you appreciate your employees. Everyone in the veterinary community is at risk of developing burnout, compassion fatigue, and depression. It does not know any boundaries. A simple “thank you” at the end of the day or incentives will help employees feel appreciated and taken care of. Our job is stressful but should also be worth it. Employees need to feel they make a difference in order to know their worth. There is no question whether depression is on the rise in veterinary medicine. The only way to combat it is by working as a team and supporting each other. Depression knows no limits, and we should all take care of ourselves and each other. The field of veterinary medicine can only be as great as the people in it.  References 1. Depression. National Institute of Mental Health, National Institutes of Health, U.S. Department of Health and Human Services. nimh.nih.gov/health/topics/depression/ index.shtml. Accessed May 2016. 2. Larkin M. Study: 1 in 6 veterinarians have considered suicide. JAVMA 2015;246(7):707-709. 3. National Association of Veterinary Technicians in America. NAVTA 2016 demographic survey results. navta.net/?page=Demographic_Survey. Accessed September 2016. 4. Scheidegger J. Burnout, compassion fatigue, depression—what’s the difference? dvm360. May 1, 2015. dvm360.com. Accessed September 2016. 5. Depression. Def. b(2). Merriam-Webster. merriam-webster.com/dictionary/ depression. Accessed September 2016. 6. Helpguide.org; Trusted guide to mental, emotional, and social health. helpguide.org. Accessed July 2016. 7. International Employee Assistance Professionals Association. eapassn.org. Accessed September 2016.

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

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

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

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

N1 17 13 13 7 5

% (n=415) 4.1 3.1 3.1 1.7 1.2

Oral active control

N2 25 2 7 4 9

% (n=200) 12.5 1.0 3.5 2.0 4.5

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

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

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Clients want to fight fleas and ticks – not their dogs. Protect dogs with the beefflavored chew they love.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 pruritus, vomiting, dry/flaky skin, diarrhea, lethargy, and lack of appetite. The safe use of NexGard in pregnant, breeding, or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures. For more information, see full prescribing information or visit www.NexGardForDogs.com.

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Puppies for the Holidays: Keeping Them Fear Free sm

lthough animals generally do not make good gifts, every year, veterinary clinics gain new patients and clients as families bring new pets home for the holidays. While the addition of a puppy to the family is always exciting and sometimes overwhelming, obtaining a puppy during the hectic holiday season can make it even more difficult for owners to provide a consistent and predictable routine to help start their pet out on the right paw. Because early removal from the litter can predispose puppies to behavior challenges such as fear, anxiety, and aggression, pet owners should be cautioned against obtaining a puppy that is younger than 8 weeks of age if they really want to make the puppy a holiday gift. It is generally recommended that puppies remain with their litter until 8 to 10 weeks of age. Puppies are little sponges of joy and are constantly learning desirable and undesirable behaviors, even when not actively being taught. Early experiences and learning have a profound effect on a puppy’s future responses. The veterinary team can play a vital role in helping their clients teach puppies that new experiences, even mildly unpleasant ones, are positive. Visiting the veterinary hospital can be as much fun as taking a walk or a trip to the park or pet store! This article offers 4 tips for creating a strong Fear Freesm foundation for new puppies. 38

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Debbie Martin, LVT, VTS (Behavior) Veterinary Behavior Consultations, LLC, Austin, TX

Debbie has been a fulltime registered/licensed veterinary technician since 1996 and worked in private practice for 14 years. Since 2005, she has been the animal behavior technician for Veterinary Behavior Consultations, LLC. She assists Kenneth Martin, DVM, DACVB, during behavior consultations. Debbie is a co-owner of TEAM Education in Animal Behavior, LLC. She is a contributing author and coeditor of the textbook Canine and Feline Behavior for Veterinary Technicians and Nurses, as well as a coauthor of the book Puppy Start Right: Foundation Training for the Companion Dog and the Karen Pryor Academy course “Puppy Start Right for Instructors.” Debbie is honored to be representing veterinary technicians on the Fear Free executive council. sm

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1. MAKE PLEASANT ASSOCIATIONS FROM THE START Be proactive with food. Rather than waiting to see if a puppy will be “ok” with something, aim to make all experiences pleasant from the start. Dogs make associations quickly. For example, a puppy being placed on a cold, slick stainless steel table is frightened because it is unable to get good footing. Then someone lifts its tail and places a thermometer in its anus. Yikes! Being on this table is not pleasant (FIGURE 1). In contrast, a positive association with the entire process can be made by providing the puppy with things it really likes, such as tasty but small treats, throughout the process. This is known as classical conditioning, a behavioral phenomenon that involves many factors. (BOX 1 contains a list of resources that interested readers can consult for fuller definitions of many behavioral terms and concepts mentioned in this article.) For example, the following steps can be used to help making the process of obtaining a temperature reading pleasant for the puppy: ÆÆ Offer a food treat when the puppy is picked up. ÆÆ Place the puppy on the table with a nonslip mat, where there is a little bit of canned puppy food to lick.

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Puppies for the Holidays: Keeping Them Fear Freesm

Early removal from the litter can predispose puppies to behavior challenges such as fear, anxiety, and aggression. Pet owners should be cautioned against obtaining a puppy younger than 8 weeks of age. ÆÆ Have the owner distract the puppy with frequent treats

or licks of canned food while you gently place your hands on the puppy. ÆÆ Gently touch the puppy’s sides; then slide your hands down the dorsal midline, displacing the tail, and finally insert the thermometer. This same process can be used to associate equipment and procedures like nail trimmers and nail trimming with pleasant stimuli. Any veterinary technician who has known a dog that runs in the other direction when it sees the nail trimmers or ear cleaner bottle has seen an example of a pet that associates these objects with unpleasant experiences.

FIGURE 1. Puppy showing signs of fear on the examination table. Signs of fear include the puppy leaning away, the whites of the eyes showing, and the puppy refusing the treats. With the use of small, high-value food treats, most dogs can learn from the start that nail trimmers or ear cleaner bottles predict good things and will come running toward them. Timing is important to create a predictive association with stimuli. Many dogs can be distracted with food treats

BOX 1 Behavior Resources for Veterinary Staff American Veterinary Society on Animal Behavior Position Statement on Puppy Socialization Available from: avsab.org/resources/position-statements/ Books  Martin KM, Martin DA. Puppy Start Right: Foundation Training for the Companion Dog. 2nd ed. Waltham, MA: Sunshine Books; 2011.  Shaw J, Martin D, eds. Canine and Feline Behavior for Veterinary Technicians and Nurses. Ames, IA; Wiley; 2015.  Zulch H, Mills DS. Life Skills For Puppies. Dorchester, MA: Hubble & Hattie; 2012. Course information and curriculum on teaching puppy classes: Puppy Start Right Instructors course through Karen Pryor Academy. karenpryoracademy.com/puppy-start-right Course information regarding Fear Freesm Foundation for Kittens and Puppies: vetfolio.com/fear-free/kittens-and-puppies Fear Freesm Information: fearfreepets.com Information on clicker training: clickertraining.com Video on dogs and car travel: Make car rides fun for Fido. veterinaryteam.dvm360.com/make-car-rides-fun-fido

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before, during, and after a procedure (FIGURE 2). However, the most efficient method to create a strong positive emotional response to stimuli is to not only condition the response with the first experience, but also to have the novel stimulus (e.g., nail trimmers) precede the pleasant one (treat), as in the following steps: ÆÆ Nail trimmers are presented  puppy notices them  person gives the puppy a treat. ÆÆ Person touches the puppy’s foot  person gives the puppy a treat (FIGURES 3 and 4). ÆÆ Person touches the nail trimmer to a nail  person gives the puppy a treat. In this learning paradigm, the nail trimmers predict the treats. Thus, over time, the dog sees the nail trimmers and anticipates getting a treat. The same behavioral response to receiving a treat will be displayed at the sight of the nail trimmers. When the staff starts forming positive and pleasant associations with every interaction in the veterinary hospital, the puppy will be on its way to being a Fear Freesm patient for life. Continuous pleasant experiences with veterinary procedures throughout the dog’s life are necessary to maintain this conditioned positive emotional response. 2. CREATE “JUST FOR FUN” VISITS TO THE VETERINARY HOSPITAL Let’s face it, going to the doctor’s office is not always

FIGURE 2. Relaxed puppy on a nonslip surface while the technician approaches from the side and the owner distracts with treats. pleasant for humans or dogs. Both species have to be touched in sensitive areas, and sometimes mildly uncomfortable procedures (e.g., injections, venipuncture) ensue. New puppy owners should be encouraged to schedule fun visits at least monthly during the first year of the dog’s life.1 A “fun visit” is a 10- to 15-minute appointment with a veterinary technician that does not

FIGURE 3. Person briefly touches the puppy’s foot.

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FIGURE 4. The touch of the foot is immediately followed with a treat.

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Building pleasant foundation memories through fun visits, coupled with the use of gentle control and low-stress handling techniques, creates Fear Freesm associations with the veterinary hospital. entail any medical procedures but instead focuses on having fun and allowing the dog to acclimate to the veterinary setting and have a good time. Depending on the puppy’s comfort level, some training focused on desensitizing and classically conditioning the puppy to routine veterinary procedures and care can also be incorporated into select sessions. Building pleasant foundation memories through fun visits, coupled with the use of gentle control and low-stress handling techniques, creates Fear Freesm associations with the veterinary hospital. Those early foundation fun visits will remain with the dog throughout its life. Each fun visit can be thought of as being a deposit in the bank. Ideally, the clinic staff and owners will build up a substantial bank account, so when some slightly uncomfortable procedures are performed, they result in only small withdrawals.2 Using fun visits to increase the number of hospital visits for the client and the dog is a win–win for everyone. Familiarity helps to minimize fear, anxiety, and/or stress for both patients and clients. Repeated visits also allow veterinary team members to build a rapport with clients and patients, thus enhancing the hospital–client/patient bond. Increased visits are also likely to result in increased sales of retail items or services. For active clients, the clinic should consider providing these fun visits as a complimentary service. The increase in sales and client and patient allegiance will yield increased revenue in both the short and the long run. As an incentive, clients can be offered the chance to enter a monthly or quarterly raffle for each fun visit. Product distributors can be approached about possible donations they might be willing to provide for the raffle. TODAY’SVETERINARYTECHNICIAN

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Puppies for the Holidays: Keeping Them Fear Freesm

For dogs that will need routine professional grooming, “just for fun” visits to the groomer should also be encouraged to acclimate the puppy to the grooming environment and being handled in a pleasant and positive manner. 3. TEACH FEAR FREEsm POSITIVE SOLUTIONS AND TRAINING FOR TYPICAL PUPPY BEHAVIORS Fear Freesm does not just refer to what happens while at the veterinary hospital. After all, dogs spend a small percentage of their time in such settings. Ideally, all aspects of a dog’s life should be as Fear Freesm as possible, including time spent in the home and interactions with owners. Veterinary professionals need to be knowledgeable about how to counsel owners to address typical dog behavior in a nonthreatening and positive manner. Some normal puppy behaviors that owners may find problematic include play biting/mouthing, chewing, jumping, counter surfing, barking, housesoiling, and digging. Training and behavior solutions should be based on positive reinforcement and funneling typical canine behaviors to an appropriate outlet. Through environmental management, reinforcement of desired behaviors, and redirection from undesired behaviors to desired ones, puppies can be set up for success and helped to learn human-preferred behaviors. Positive reinforcement training should use strong motivators such as food and play to teach and maintain behavior. Fear Freesm solutions and training avoid the use of coercion or correction-based training, which uses such elements as verbal corrections/reprimands, pinching, choking, or electric collars. The result of correction-based training is a dog that performs behaviors to avoid unpleasant consequences. This is not a Fear Freesm environment. The fear of making the wrong choice inhibits the dog’s behavior. To create a Fear Freesm learning environment, it is necessary to create an atmosphere that facilitates a pleasant learning experience without the fear of making the “wrong” choice. For example, it would be inappropriate to advise owners to address puppy play biting and mouthing by grabbing the puppy’s muzzle, pinching its lips, or verbally reprimanding the puppy. These techniques do not funnel this innate puppy behavior to an appropriate outlet or teach the puppy how to interact with people. They only teach the puppy that people can be unpredictable and something to fear. A positive reinforcement solution would include making sure the physical, mental, and social needs of the puppy are being met, redirecting the puppy to an appropriate chew toy, and reinforcing the desired behavior (FIGURES 5 and 6).

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FIGURE 5. A puppy has decided that the owner’s shorts would make a great chew toy.

FIGURE 6. The owner redirects the puppy to a more appropriate outlet for chewing.

Along with teaching basic manners and positive behavior solutions, puppies should be conditioned to travel in the car. Because trips to the veterinary hospital begin at home and often involve travel to the hospital via an automobile, acclimating and training the puppy to be relaxed in the car helps to ensure that a calm and relaxed patient reaches the veterinary hospital, thus making our job easier! For tips on making car travel stress free, watch the video at veterinaryteam.dvm360.com/make-car-rides-fun-fido.

ÆÆ Classes are taught by individuals who are specially

4. ENCOURAGE PUPPY CLASSES Puppy socialization classes are a controlled and safe way to expose puppies to novel people, dogs, and environmental stimuli. Dogs that have not attended puppy socialization classes are more likely to display behavior problems involving fear or aggression toward strangers, unfamiliar dogs, or environmental stimuli.3–5 All puppies 12 weeks or younger should be enrolled in a good puppy socialization class. The socialization period is a great time to start foundation training. The brain and learning ability of puppies is adultlike, based on electroencephalogram studies, at 8 weeks of age.6 Attending a good puppy socialization class can help puppies reach their full potential and start them on a path to preventing fear, anxiety, and stress. Proper socialization and exposure during the sensitive socialization developmental stage is critical to creating resilient and at-ease adult dogs. Not all puppy classes are created equal. Improper socialization and exposure can create fear and anxiety. Things to look for in a good class include the following: ÆÆ Puppy age is limited to the socialization period (<16 weeks of age). ÆÆ Proof of starting a vaccination series with a veterinary examination at least 10 days before class is required for attendance. 42

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trained in animal behavior, learning theory, and canine development, as well as medical conditions. ÆÆ Classes focus on a proactive and positive exposure to novelty and routine veterinary procedures (FIGURES 7 and 8). Short, controlled off-leash play sessions with small groups of same-aged puppies allows for the development of canine communication skills with a variety of breeds of dogs. Although puppy classes should not be primarily focused on obedience training, introducing positive reinforcement training and puppy behavior solution strategies provides for a foundation based on trust and understanding. To see a video

FIGURE 7. A puppy attending puppy class learning that people in surgery attire are the bearers of good treats.

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Puppies for the Holidays: Keeping Them Fear Freesm

FIGURE 8. Practicing gentle control and handling in puppy class. Owners learn how to provide distractions and use reinforcement to make the experiences pleasant and fun. example of handling exercises in a puppy class, visit todaysveterinarytechnician.com. Offering puppy socialization classes within the veterinary hospital is an invaluable service for clients. Not only does the clinic provide fun visits for puppies, the staff will develop a relationship with the clients and dogs, thereby creating a new profit center for the hospital while having a lot of fun! On a personal note, in-hospital puppy socialization classes are where I got started in behavior and training, and I encourage veterinary technicians interested in behavior to investigate these classes. CONCLUSION Puppies are constantly learning. Taking proactive measures can help teach dogs that the veterinary hospital is a fun—not scary—place. Clinics can provide pleasant associations, schedule fun visits, and offer a good puppy socialization class. Staff can provide pet owners with appropriate resources and information about creating positive solutions and training for their puppy. After all, preventing fear is much better than treating it!  References 1. Klok E. Starting veterinary technician appointments. Today’s Vet Tech 2016;1(4):49-53. 2. Friedman SG. Back in the black. Bird Talk. September 2012. http://www. behaviorworks.org/files/articles/Back%20in%20the%20Black%20BT.pdf. Accessed November 2016. 3. Martin ST. Is there a correlation between puppy socialization classes and ownerperceived frequency of behaviour problems in dogs? Masters Thesis, University of Guelph, 2001. 4. Bain MJ, Araya TL, Robbins GC, Shaikher S. Association between early socialization and adult behaviors of dogs. Proc ACVB/AVSAB Vet Behav Symp 2014. Denver, CO: pp 11-13. 5. Blackwell EJ, Twells C, Seawright A, Casey RA. The relationship between training methods and the occurrence of behavior problems, as reported by owners, in a population of domestic dogs. J Vet Behav 2008;3(5):207–217. 6. Lindsay SR. Handbook of Applied Dog Behavior and Training. Vol 1. Ames, IA: Iowa State University Press; 2000:63.

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CLIENT HANDOUT

Puppy Training  Puppy training is an important step toward a lifetime of good behavior.  Learning is adult-like in puppies by 8 weeks of age.  Puppies respond better to positive reinforcement than punishment.  Puppies should always be supervised or should be confined when you are away.  Training should be consistent, involve positive reinforcement, and include everyone in the family.  It’s important for your puppy to be socialized around other people and other pets before he or she is fully vaccinated, but consult your veterinarian about disease risks before exposing your puppy to other dogs or areas where unfamiliar dogs have been.  Group puppy preschool socialization classes are a good way to socialize your puppy while minimizing disease risks.  Group puppy kindergarten classes are excellent for teaching puppies basic manners with exposure to other puppies and a training expert on-hand for guidance.

Why Is Puppy Training Important?

What Should I Know About Puppy Training?

Like children, puppies need to learn the appropriate behavior for living in a household and interacting with others. Puppies also seek positive reinforcement and are willing and able to learn. Learning is adult-like by just 8 weeks of age. Unfortunately, many puppies grow into dogs that are eventually surrendered to shelters because of behavior problems. In most cases, it’s not the dog’s fault. It’s simply because of a lack of early appropriate training and socialization. Proper puppy training early on will help you avoid bumps in the road and lead to a better relationship with your dog in the years ahead. Training can not only prevent some undesirable behaviors but also give you appropriate ways to address problematic behaviors. Training can provide for clear communication between you and your dog.

Several basic rules of puppy training will lead to a more rewarding experience for everyone involved:  Reward good behavior. Puppies respond best to positive reinforcement. Reward good behavior with a special treat, piece of kibble, petting, or praise.  Be consistent. When you are training the puppy, make sure a consistent cue (verbal or hand signal) is used by everyone in the family. If, for example, one family member says “here” and another says “come,” the inconsistency may confuse the puppy. Consistency will make it easier for the puppy to understand what you are asking for.  Be predictable. Have predictable interactions with your puppy. Predictable interactions foster trust and teach good manners. Before feeding, or giving a toy, ask your puppy to respond to a known cue, such as “sit.”

Kenneth Martin, DVM, DACVB, puppystartright.com.

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Puppy Training continued

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Once you receive an appropriate response, give the puppy the food or toy and praise for good behavior. A void punishment. You should never spank or yell at a puppy, yank on a puppy’s collar, or rub a puppy’s nose in urine or feces. Punishment not only can weaken a puppy’s trust in people, but also can lead to fear, anxiety, and aggression. For example, with house training, punishment just teaches the puppy not to eliminate in the presence of people rather than where it’s appropriate to eliminate. If the puppy has an accident, simply clean the soiled area without scolding. Take the puppy outside and reward elimination in the appropriate area. Consult your veterinarian if you are having problems house training your puppy.  Puppies should always be supervised. Until your puppy is trained, he or she should be supervised at all times or confined safely in a crate, kennel, or exercise pen when you are away. This will reduce accidents in the house and keep your puppy from chewing on or swallowing items that could be dangerous. K eep training sessions short. Like children, puppies have short attention spans. Initially, training sessions at home should only last for about 1 to 5 minutes. Sessions may be lengthened as the puppy matures. Exposure at group classes should be careful not to overwhelm the puppy. T each your puppy to be comfortable being handled. Whenever possible, offer food treats when handling your puppy’s paws, ears, mouth, and body. Fostering positive associations with being handled will make it easier for you to trim nails, brush teeth, clean ears, and give medications. It will also make for less stressful trips to the groomer and veterinary clinic.

 Expose your puppy to other people and pets. The earlier your puppy is introduced to other people, the more comfortable he or she will feel around them, and the less likely he or she will be to exhibit shy behavior. Puppies should be allowed to interact at their own pace rather than being forced into an interaction. Treats should be used to create pleasant memories. Exposure to other pets is important, too, but be careful of disease risks at dog parks or from interactions with unknown dogs with a questionable vaccine history. Consult your veterinarian regarding the benefits of early enrollment in a puppy socialization class. Your veterinarian can help you manage disease risks while still allowing for smart socialization experiences with environments and other dogs.  Provide your puppy with appropriate chew toys. Puppies explore the world with their mouths and enjoy chewing. Consequently, your puppy may want to chew on furniture, clothing, hands, and other inappropriate items. Simply interrupt the undesirable behavior by getting the puppy’s attention in a nonconfrontational way and redirect the puppy to something more appropriate to chew on. Avoid giving your puppy a sock or other article of clothing to chew. These items may be inadvertently swallowed, and may also give the puppy the message that it’s okay to chew on clothing. Consult your veterinarian about which chew toys are safest.

Why Should I Consider Attending Group Puppy Preschool Socialization Classes or Puppy Kindergarten Training Classes? Puppy preschool socialization classes are designed for young puppies in their socialization period (under 3 to 4 months

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Puppy Training continued

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 A controlled and safe environment for puppy play, socialization, and exploration during sensitive periods of development

of age). The focus is on education regarding normal behavior, providing positive socialization experiences, and teaching problem prevention techniques. Puppy kindergarten training classes are for puppies outside of their socialization period (older than 3 to 4 months of age). Generally, there is a greater focus on teaching basic manners in older puppies and building on previous experiences. Attending a group puppy class led by a training specialist has several advantages, including: E mpathy and understanding regarding normal behaviors E xpert guidance and answers to questions or concerns regarding undesirable behaviors  I ntroduction to positive reinforcement training K nowledge of how to implement problem-solving techniques P revention of behavioral problems related to fear, anxiety, and aggression

Group puppy classes are offered by many veterinary clinics, dog training facilities, and pet supply stores. It’s important to find a course that emphasizes pet parent education and positive, controlled socialization experiences. Classes should highlight positive reinforcement training rather than punishment. Ask your veterinarian for recommendations regarding group socialization classes and puppy training classes. Several positive puppy training resources are available. Among other things, good puppy classes should cover:  Proper socialization and environmental exposure  Play biting and mouthing  Destructive chewing  Prevention of food and resource guarding  Crate training and exercises fostering independence  Handling and restraint exercises  Housetraining tips and techniques  Basic training for good manners and loose leash walking Reputable facilities will require proof of vaccination and good physical health for all puppies attending the course. This minimizes disease risk, especially while young puppies’ (younger than 4 months) immune systems are still developing. Some vaccinations need to be given at least 7 to 10 days before the class begins to protect your puppy. Consult your veterinarian about when your puppy will be ready to attend classes. 

© 2017 Today’s Veterinary Technician. Today’s Veterinary Technician grants permission to individual veterinary clinics to copy and distribute this handout for the purposes of client education. For a downloadable PDF, please visit www.todaysveterinarytechnician.com.

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Peer-Reviewed

Toxicology Talk

Xylitol: A Sweetener That Is Not So Sweet

Carrie Lohmeyer-Mauzy, CVT, BS ASPCA Animal Poison Control Center Urbana, Illinois

Carrie has been working as a certified veterinary technician at the ASPCA Animal Poison Control Center (APCC) since 2007. She obtained her associate’s degree in veterinary technology from Parkland College in 2003 and her bachelor’s degree in natural resources and environmental science from the University of Illinois in 2006. She worked for 2.5 years at a small animal clinic while in college and has assisted with several research projects in fish and wildlife ecology.

ylitol is a sugar alcohol commonly found in sugar-free gums and mints, oral hygiene rinses, toothpaste, chewable supplements, nasal sprays, nicotine gum and lozenges, candy, chocolate, and peanut butter.1 It is also manufactured in granulated and powdered form to be used as a sugar substitute in baking. The ASPCA Animal Poison Control Center (APCC) received its first case involving xylitol in 2002.1,2 Over a 9-year period between 2002 and 2010, the ASPCA saw a significant increase in documented xylitol cases per year (FIGURE 1).1 This increase is likely related to pet owners and veterinary professionals becoming more knowledgeable about the dangers of xylitol, as well as increased use of xylitol in consumer products. For 2 consecutive years, 2011 and 2012, the total number of xylitol cases per year decreased compared with 2010.1 The reason for this decrease is unknown. In 2013, the number of xylitol cases surpassed the number seen in 2010, and incidents have steadily increased each year since, with the highest number of cases (4014) noted in 2015.1 Of those 4014 xylitol toxicity cases, more than 75% involved pets exposed to sugar-free gum.1 TOXICITY Xylitol causes significant insulin secretion in dogs, resulting in hypoglycemia.2–4 There is also evidence, both clinical and experimental, that xylitol can cause hepatic damage.3–5 The degree of xylitol toxicosis is dose dependent. Dogs are at risk for hypoglycemia at doses >100 mg/kg, while the risk for hepatic damage begins at doses >500 mg/kg.6 Serious signs are

shutterstock.com/ Anna Hoychuk

During her 9 years at the APCC, Carrie has gained a wealth of knowledge in the field of toxicology and is currently studying to become a board-certified toxicologist. She lives in a small town outside Champaign–Urbana with her husband and her two tortoiseshell cats.

XYLITOL is a sugar alcohol commonly found in sugar-free gums and mints, oral hygiene rinses, toothpaste, chewable supplements, nasal sprays, nicotine gum and lozenges, candy, chocolate, and peanut butter. 48

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T E C HP O I N T 

Toxicology Talk

Treatment for xylitol toxicosis involves management of hypoglycemia and hepatic damage through supportive and symptomatic therapies.

generally not anticipated with xylitol exposures at a dose <100 mg/kg1 (TABLE 1). Because xylitol toxicosis is dose dependent, the xylitol dose should be calculated when a suspected or known exposure has occurred. Although some products list the amount of xylitol on the package label, many companies consider this proprietary information, and the amount of xylitol may not be available to the consumer. Contacting the company directly or an animal poison control center may help in determining the amount of xylitol in certain agents.

Xylitol: A Sweetener That Is Not So Sweet

TABLE 1 Quick Reference Guide for Xylitol Toxicosis DOSE OF XYLITOL

CLINICAL EFFECTS

HOSPITALIZATION

<50 mg/kg

No serious signs expected

50-100 mg/kg

Low risk for hypoglycemia

No (unless pet is symptomatic)

>100 mg/kg

Moderate risk for hypoglycemia

Yes

>500 mg/kg

Moderate to high risk for hypoglycemia; hepatic injury is possible

Yes

CLINICAL SIGNS Hypoglycemia has been reported within 30 to 60 minutes after ingestion2–6 but may be delayed up to 12 hours, depending on the agent involved.6 Clinical signs commonly seen with xylitol toxicosis include vomiting, weakness, ataxia, collapse, and seizures.1 Hypokalemia and hypophosphatemia may also be observed on blood chemistry panels as a result of hyperinsulinemia.2 Clinical signs related to hepatic injury may include lethargy, vomiting, and coagulopathy developing 9 to 72 hours

4,500

4014 3,375

NUMBER OF CASES

3273 3041

2910

2693

2690 2565

2513

2,250 1914

1,125 711

240

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

YEAR

FIGURE 1. Number of xylitol cases per year reported by the ASPCA APCC from 2002 through 2015. TODAY’SVETERINARYTECHNICIAN

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after exposure.2,6 Elevated alanine aminotransferase (ALT), hyperbilirubinemia, prolonged prothrombin time (PT) and partial thromboplastin time (PTT), hyperphosphatemia, thrombocytopenia, hypoglycemia, and elevated alkaline phosphatase have been observed in pets that developed hepatic injury and necrosis.2 Liver enzyme elevation typically occurs within 8 to 24 hours.1 With liver-toxic doses of xylitol, some pets may not exhibit signs of hypoglycemia before developing liver failure.1,2 MANAGEMENT Treatment for xylitol toxicosis involves management of hypoglycemia and hepatic damage through supportive and symptomatic therapies. If an owner calls the clinic from home with a pet exhibiting signs of hypoglycemia, the owner should be instructed to rub honey, pancake syrup, or corn syrup on the gums and immediately bring

BOX 1 Case Example: Xylitol Toxicosis in a Husky A 4-year-old, 65-lb Siberian husky ingested an unknown amount of xylitol powder. The pet was found at home recumbent and twitching. On presentation to the clinic, the dog was hypoglycemic (blood glucose, 30 mg/dL; normal range, 74–143 mg/dL). The animal was also hypophosphatemic (serum phosphorus, 0.9 mg/dL; normal range, 2.5–6.8 mg/dL) and hypokalemic (serum potassium, 2.9 mmol/L; normal range, 3.5–5.8 mmol/L). ALT was mildly elevated (147 U/L; normal range, 10–125 U/L). The pet was started on IV fluids and given a bolus of dextrose (25% dextrose 10 mL IV slowly); dextrose was then administered as a CRI (normal saline with 2.5% dextrose at 120 mL/h IV). Liver protectants, including S-adenosylmethionine and N-acetylcysteine, were started. N-acetylcysteine was given as a loading dose of 140 mg/kg slowly IV and repeated every 6 hours at 70 mg/kg. Activated charcoal was not administered. Liver enzymes were rechecked 12 hours after presentation. ALT had increased to 450 U/L. The animal was doing well clinically at this time. Twenty-four hours after the dog presented to the clinic, ALT was at 452 U/L, IV dextrose had been discontinued, and blood glucose was normal. The pet was eating and drinking on its own. Liver protectants were continued. No further increase in ALT occurred, and the dog did not develop coagulopathy associated with acute hepatic failure. Liver values were last rechecked by the dog’s referring veterinarian 10 days after ingestion, and the ALT was still mildly elevated at 124 U/L. This mild elevation may be idiosyncratic for this patient.

TECHPOINT 

It is important to obtain the full product name, including flavors when applicable, and collect any packaging the owner may have. the pet to the hospital. Patients that ingested >100 mg/kg of xylitol should be admitted to the clinic.2 Emesis is recommended within 4 to 6 hours after xylitol ingestion, but only if the pet is asymptomatic.4 Activated charcoal is generally not recommended. Studies have suggested that charcoal has a low affinity to bind xylitol.2 Signs of hypoglycemia can be delayed up to 12 hours, so glucose values should be monitored every 2 hours for 12 to 24 hours.2 Hypoglycemia should be treated with a 1 mL/kg IV bolus of 50% dextrose diluted 1:2 with a crystalloid solution, followed by a 5% dextrose constantrate infusion (CRI) for 12 to 24 hours.2 The patient’s phosphorus and potassium levels should be monitored,2 and supplementation should be considered if phosphorus is <1 mg/dL1 or potassium is <2.5 mEq/L.6 Baseline liver enzymes should be obtained on presentation and rechecked at 24, 48, and 72 hours.2 In patients that have ingested high doses of xylitol (>500 mg/kg), IV dextrose should be considered even if the pet has a normal blood glucose level on presentation.2 Liver protectants, such as S-adenosylmethionine, silymarin, or N-acetylcysteine, should be started prophylactically in these patients.2 With severe hepatic necrosis, coagulopathy may develop. Coagulopathies should be treated with plasma transfusions and vitamin K1.1 The prognosis for dogs exposed to xylitol is generally considered good when hypoglycemia is treated quickly and only mild elevation in liver enzymes occurs (BOX 1).2 In patients that develop severe hepatic injury and coagulopathy, prognosis is guarded or poor.2 ROLE OF THE TECHNICIAN Veterinary technicians have many responsibilities in cases when there has been a suspected or confirmed exposure to xylitol. Pets admitted to the clinic for xylitol toxicosis will likely be hospitalized for a minimum of 12 hours and sometimes longer than 72 hours, depending on the continued on page 74

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P O R T L A N D ,

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AU G U ST 20-23 , 2017 T HE HILTON P O R T L A N D & EX EC U T I V E TOW E R The NAVC is extending its popular educational platform to the great Northwest with an innovative experience unlike any conference you’ve seen before. NAVC LIVE will feature professional “case theater” veterinarian/client presentations, live-streamed general sessions, short talks, Q&A for remote attendees and clinical content in a non-clinical setting, as well as engaging networking opportunities, key tours and experiences in one of the West Coast’s hottest travel destinations.

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Peer-Reviewed

Sildenafil Exposure in a Dog

Case Report

HISTORY A 1-year-old, 55 lb (24.92 kg) female golden retriever chewed open a blister pack of 100 mg Viagra (sildenafil) tablets. The dog ingested up to 3.5 tablets within a 3-hour time frame. The estimated dose of sildenafil ingested was 14.03 mg/kg. The pet arrived at the emergency clinic within 30 minutes of the latest exposure time. It is unknown if the pet was displaying any clinical signs before presentation.

ASPCA Animal Poison Control Center Urbana, Illinois

Brianna discovered her passion for veterinary medicine when she worked as an assistant in a small animal clinic while attending college. She changed her career focus to veterinary technology and transferred to Parkland College, graduating from their veterinary technology program in May 2011. She earned her certification in July 2011. She has worked for the ASPCA Animal Poison Control Center for a little over 4 years. Her special interests are toxicology and animal behavior. In her spare time, Brianna likes to research genealogy, ride motorcycles with her family, and spend time with her dog, Parker.

TODAY’SVETERINARYTECHNICIAN

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CASE MANAGEMENT Upon presentation at the clinic, the pet was tachycardic, with a heart rate of 220 bpm (normal range, 80–120 bpm), and slightly hypertensive, with a blood pressure of 161/95 mm Hg (normal range, 160/70–160/90 mm Hg). The clinic’s veterinary team induced emesis with apomorphine (unknown route) and was able to recover some of the foil blister pack. They did not observe any evidence of the tablets. The clinic contacted the ASPCA Animal Poison Control Center (APCC) for treatment recommendations approximately 20 minutes after the client presented the pet. The APCC advised intravenous fluid therapy (preferably lactated Ringer’s solution) and monitoring of the cardiovascular function (electrocardiogram, heart rate, and blood pressure). The clinic was advised to call for further case discussion if needed. The owner called the next day around 12:22 CST with an update. It was noted that the pet recovered and was discharged from the clinic approximately 4.5 hours after presentation. The dog did not require any additional medical treatment beyond monitoring and fluids. DISCUSSION Sildenafil: Pharmacokinetics and Pharmacodynamics Sildenafil is a medication that is used for erectile dysfunction in humans. It is classified as a vasodilator as well as a phosphodiesterase type V inhibitor.1 The 2 other medications that are used for erectile dysfunction (vardenafil and tadalafil) act similarly. Sildenafil affects cyclic guanosine monophosphate (cGMP), which is found in areas such as the corpus cavernosum and pulmonary vasculature. The inhibition of phosphodiesterase V leads to an increase in cGMP; this causes smooth muscle relaxation, which then leads to a decrease

An Official Journal of the NAVC | January/February 2017

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Brianna Wells, CVT

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Case Report

Sildenafil Exposure in a Dog

Case Report

in blood pressure (hypotension).1 If the patient suffers from preexisting hypotension or is taking medications that can decrease blood pressure, sildenafil can intensify the effects. Sildenafil is increasingly being used in veterinary medicine for dogs that have pulmonary hypertension. When used therapeutically, the dose can range from 0.5 to 3 mg/kg orally, every 8 to 12 hours.1,2 Sildenafil is often more cost-effective than other medications used for this purpose, making this the more ideal medication for veterinary patients.3 The onset of action for sildenafil is 30 minutes to 2 hours after the exposure. The primary risks are hypotension and tachycardia. However, lesser clinical signs can include lethargy, ataxia, and behavior changes. Diagnosis and Treatment of Sildenafil Exposure Diagnosing a sildenafil exposure can be difficult because many other health concerns or toxins can affect the heart rate and blood pressure. Diagnosis of sildenafil toxicosis is based on history of an exposure and clinical signs. Rule-outs should include other hypotensive agents or conditions, such as calcium channel blockers, angiotensin-converting enzyme inhibitors, beta blockers, cardiac disease, shock, or trauma. Diagnosis can be determined by confirming with the owner that the medication is in the home and that the pet could have had access to it. Peak plasma levels occur within 30 to 120 minutes, so identifying a time frame of possible exposure is important as well. There are no current blood tests available to determine the presence of sildenafil for the purpose of treatment. If the exposure was within 30 minutes, emesis may be induced as long as the pet is asymptomatic and no other contraindications exist. If the animal is symptomatic, decontamination with emesis is not recommended because the medication is already being absorbed into the system. With symptomatic patients, treatment depends on the clinical signs the pet is displaying. Hypotension and tachycardia generally respond well to IV fluid therapy, which helps reestablish the blood pressure. If fluids are not sufficient to support the blood pressure, vasopressors such as dopamine (1–3 mcg/kg/min constant-rate infusion1) can be included. CONCLUSION AND CLINICAL RELEVANCE Sildenafil can be used to treat erectile dysfunction in humans and pulmonary hypertension in pets and humans. Questioning the owner about medications in the home, even if they do not think there could have been an exposure, is important while obtaining the patient’s history. Most symptomatic patients have resolution of clinical signs within 24 to 48 hours after ingestion. Depending on the patient’s signalment and the time frame in which treatment is started, some patients are able to recover more quickly. No long-term effects are expected.  References 1. Bach JF, Rozanski EA, MacGregor J, et al. Retrospective evaluation of sildenafil citrate as a therapy for pulmonary hypertension in dogs. J Vet Intern Med 2006;20(5):1132-1135. 2. Plumb DC. Plumb’s Veterinary Drug Handbook. 8th ed. Ames, IA: Wiley-Blackwell; 2008:1100-1101. 3. Rozanski EA, Bach JF, Shaw SP. Advances in respiratory therapy. Vet Clin North Am Small Anim Pract 2007;37(5):965-966.

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An Official Journal of the NAVC

Samantha Wright, BS, MS ASPCA Animal Poison Control Center Urbana, Illinois

Samantha received her bachelor’s degree in animal science from the University of Illinois. She also has a master’s degree in leadership and executive coaching. She has worked for the ASPCA Animal Poison Control Center for 6.5 years and has been a manager for the center for 4.5 years. In her spare time, Samantha enjoys traveling with her husband Kevin and spending time with her 2 dogs and 4 cats.

This case report was written and reviewed by members of the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center (APCC). The ASPCA APCC includes a full staff of veterinarians, including board-certified toxicologists, certified veterinary technicians, and veterinary assistants. The mission of the APCC is to help animals exposed to potentially hazardous substances.

January/February 2017

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ARTICLE 1 CR E DIT

Keys to Successful High-Level Disinfection and Sterilization Processes Heidi Reuss-Lamky, LVT, VTS (Anesthesia & Analgesia, Surgery)

he care and maintenance of surgical instruments and equipment is generally one of the many job duties of veterinary technicians. Media reports about antibiotic-resistant infections that abound in human medicine should serve as a way to raise awareness about healthcare-associated (nosocomial) infections (HAIs) in veterinary medicine. Iatrogenic surgical site infections can prolong recovery, increase patient morbidity and mortality, and lead to unnecessary costs for clients. Today’s veterinary technicians are uniquely poised to make a difference in the lives of animal patients, in part by ensuring that proper protocols and procedures are in place to help prevent perioperative infections. Any successful infection control program must consist of a multipronged approach, which may incorporate issues such as perioperative antibiotic use, choice of antiseptics and disinfectants, atraumatic hair removal during surgical patient preparation clipping, best practices for prepping and draping, and proper housekeeping methods in addition to sterile processing.

DISINFECTION VERSUS STERILIZATION What is the difference between disinfection and sterilization? 54

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Oakland Veterinary Referral Services Bloomfield Hills, Michigan

Heidi graduated from Michigan State University’s Veterinary Technology Program in 1984. After many years in private practice, she became affiliated with Oakland Veterinary Referral Services in 2006. She earned her VTS through the Academy of Veterinary Technicians in Anesthesia and Analgesia in 2003 and served on the credentials committee from 2005 to 2009. She served in the president’s role on the Executive Board of the Michigan Association of Veterinary Technicians from 2007 to 2009. She was a founding member of the Academy of Veterinary Surgical Technicians and currently sits on the executive board. She is an accomplished author and lecturer and was presented with the 2013 NAVC Dr. Jack L. Mara Memorial Lecturer award.

An Official Journal of the NAVC

Sterilization is defined as the destruction of all microbial life, whereas disinfection involves the use of a chemical sterilant/agent to eliminate virtually all recognized pathogenic microorganisms, but not necessarily all types of microorganisms (e.g., bacterial endospores) present on inanimate objects. There are three levels of disinfection: high, intermediate, and low. The high-level disinfection (HLD) process kills all vegetative microorganisms, mycobacteria, lipid and nonlipid viruses, fungal spores, and some bacterial spores. Intermediate-level disinfection kills mycobacteria, most viruses and bacteria, and is registered by the Environmental Protection Agency (EPA) as a “tuberculocide.” Lowlevel disinfection kills some viruses and bacteria.1 Almost 40 years ago, Dr. E. H. Spaulding established a categorization system for medical devices based on the risk of infection associated with their use. This classification system has been embraced by the US Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) and is used by many professional medical organizations to choose disinfection or sterilization protocols for various medical devices. Medical devices are assigned to one of three categories1:

January/February 2017

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T E C HP O I N T 

Veterinary technicians play a key role in ensuring that medical devices are clean and functional before HLD and sterilization, and much can be learned from the mistakes made in human medicine.

CE Article

High-Level Disinfection and Sterilization Processes

Inconsistent processes and/or equipment malfunction can jeopardize the goals of sterile processing. Susan Flynn, BESc, CSPDT (Central Sterile Processing and Distribution Technician), explains that human error accounts for approximately 85% of processing-related issues, much more so than utility (e.g., poor steam quality) and equipment problems.a Therefore, each facility should strive to ensure quality outcomes by implementing an evolving plan that continually improves while eliminating or minimizing waste.2

GOALS OF STERILE PROCESSING Adequate sterile processing depends on the performance of people, processes, and equipment to achieve the highest level of sterility assurance. Therefore, the goals for individuals participating in a sterile processing program include: ÆÆ Ensuring that every item in each load is sterile ÆÆ Minimizing the risk of HAIs ÆÆ Meeting regulatory requirements by emulating human sterility practices and standards ÆÆ Maintaining personal integrity ÆÆ Undergoing periodic training, education, and process review ÆÆ Ensuring quality outcomes

QUALITY OUTCOMES MATTER! Why care? According to USA Today, at least 100 endoscoperelated infections have been reported in human patients in several major US cities, some of which were fatal.3 According to a US Senate report,4 major duodenoscope maker Olympus and the FDA failed to alert the US public that hundreds of patients were becoming infected with a so-called “superbug”—a drug-resistant bacterial strain (carbapenem-resistant Enterobacteriaceae) associated with a roughly 50% mortality rate—because of lapses in basic cleaning, disinfection, and sterilization of medical devices. On September 11, 2015, the CDC alerted healthcare providers and facilities about the public health need to properly maintain, clean, and disinfect or sterilize reusable medical devices, citing noncompliance as a critical gap in patient safety. In other words, cleaning procedures conducted against the manufacturers’ instructions for use (IFU) resulted in a lapse in infection control.5 Shortly afterward, both the FDA Safety Commission and CDC raised a number of issues regarding sterilization and HLD in human healthcare facilities,6 including: ÆÆ Are all reprocessing personnel properly trained or certified? Some states have laws that require reprocessing personnel to be certified and to complete minimum continuing education requirements (10+ units) annually. Personnel training may be provided by a full-time educator. ÆÆ Are regular audits performed to observe compliance with reprocessing steps? Details regarding regular audits, training records, and annual competency documentation (including involvement of third-party contractors) are encouraged. ÆÆ Are policies and procedures consistent with national standards? Policies and procedures should include a review of written IFU before purchasing, borrowing, or testing a new reusable medical device; require device

In short, assuming that all steps throughout the sterilization process are working simply because they are being performed correctly is just not good enough.

Susan Flynn, BESc, CSPDT, technical service specialist, 3M Health Care, Sterilization Assurance Group, St. Paul, MN, oral communication, April 2008.

ÆÆ Critical: A device that enters normally sterile tissue or

the vascular system where blood flows. These devices (e.g., surgical instruments, needles, intravenous catheters) should undergo sterilization. ÆÆ Semicritical: A device that comes into contact with intact mucous membranes and does not ordinarily penetrate sterile tissues (e.g., laryngoscopes, thermometers, flexible endoscopes). These devices should receive, minimally, HLD. ÆÆ Noncritical: A device that ordinarily does not come into contact with the patient or touches only intact skin (e.g., bedpans, blood pressure cuffs, stethoscopes). These devices should be cleaned by low-level disinfection.

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manufacturers to update users with IFU changes; and be fully enforced (especially in regard to loaner surgical instrument trays, which are reusable surgical instruments that are not owned or stored in the healthcare facility). ÆÆ Are all device manufacturers’ IFU available and accessible to reprocessing personnel? If not, users should consult the manufacturer’s website, sales representative, or onesourcedocs.com (fee charged for database access). ÆÆ What happens if there are conflicting IFU? Conflicts surrounding the resources needed to comply with all reprocessing steps should be identified, including considerations of space, supplies, equipment, water quality, training, and environmental controls. ÆÆ Is there enough time to comply with device IFU? All steps required to reprocess the item must be considered, including drying time, proper storage, and transportation to the point of use. ÆÆ Is there documentation of compliance? Human healthcare facilities are obligated to document all reprocessing activities, including maintenance records (e.g., autoclaves, automated endoscope reprocessors, medical washers and washer–disinfectors, water treatment systems), sterilization records (physical, chemical, and biological indicator results), and records verifying that liquid chemical sterilant reprocessing duties contracted to third-party vendors and HLD liquid concentrations were tested and replaced appropriately. It is also important to ensure adequate environmental A

TECHPOINT 

Regularly updating hospital policies and procedures and verifying the efficacy of cleaning and sterilization processes can play an important role in preventing HAIs during the pursuit of excellence in veterinary patient care. conditions during transportation and storage (e.g., control humidity, damage) to maintain sterility. If reprocessing duties are contracted to third-party vendors, it must be confirmed that they are approved or certified by the manufacturer to provide those services. Notably, these guidelines are currently only for human healthcare. Similar guidelines have not yet been developed for the veterinary profession, although

FIGURE 1. SonoCheck (Healthmark). (A) Sonocheck tests the efficacy of cavitation energy in ultrasonic cleaners. The color of the test solution changes from dark green to amber to indicate effective cavitation energy. (B) For best results, Sonocheck test vials should be evenly distributed throughout the ultrasonic cleaner’s basket. 56

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January/February 2017

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CE Article

American Animal Hospital Association (AAHA) certification covers some areas of sterilization. It is up to the veterinary team to voluntarily improve practices through education. CLEANING AND VERIFICATION Ensuring that all items are ”surgically clean” before HLD, liquid chemical sterilization (LCS), or other forms of sterilization (e.g., steam, ethylene oxide [EO], hydrogen peroxide gas plasma) plays a key role in ensuring quality outcomes, and its importance cannot be overemphasized. There are several ways to accomplish this goal. First and foremost is strict adherence to manufacturers’ IFU regarding device cleaning. All surgical equipment and instrumentation (devices) should be meticulously washed either by hand or mechanically immediately after use. If surgical devices cannot be cleaned immediately, they should be kept moist until they can be cleaned, preferably using products approved for this purpose7 (e.g., Spectra-Soak; IMS Animal Health, spectrumveterinaryinstruments.com). It is recommended that only detergents and enzymatic cleaners approved for surgical devices be used for washing, as per manufacturers’ IFU. Specific instrument-cleaning

Keys to Successful High-Level Disinfection and Sterilization Processes

brushes should be used to access box locks, channels, or any other area considered difficult to clean. All cannulated items (e.g., Frazier or Poole suction tips, endoscopic or arthroscopic equipment) should be cleaned using a 3-step process: flush (using copious amounts of water), brush (with an appropriate-diameter brush), and rinse. Using the correct brush size for the lumen is critical to create effective cleaning friction against the lumen walls. If the brush diameter is too large, bristles will bend backwards and will not scrub away debris. If the brush is too small, the limited friction and contact between the bristles and lumen walls prevent adequate cleaning. Ultrasonic cleaning should be included as part of a comprehensive standardized cleaning process. Although not designed to eliminate all (gross) debris, ultrasonic cleaners remove more dried serum, whole blood, microorganisms, and other fine debris from less accessible surfaces than is possible with manual scrubbing alone.8 In fact, one study demonstrated that only 3 minutes of ultrasonic cleaning time eliminated 99.9% of residual blood on contaminated instruments.8 For optimum

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performance, ultrasonic cleaning solutions should be de-gassed per the manufacturer’s IFU and changed daily (sooner if needed). After manual cleaning, items are placed in the ultrasonic cleaning basket with box locks in the open position. The basket should be two-thirds to three-quarters full; the tank should not be overfilled. To confirm that the ultrasonic cleaner is creating adequate cavitation energy, the aluminum foil test (in which indentations in a piece of foil demonstrate cavitation energy9) or a specific ultrasonic cleaner test (e.g., SonoCheck; Healthmark, hmark.com) should be performed on a regular basis (FIGURE 1). Instruments removed from the ultrasonic cleaner should be rinsed thoroughly. Distilled water may be preferred over rinsing with hard water. Surgical devices must be completely dry, as water droplets can interfere with steam sterilization or dilute liquid chemical sterilants. The drying phase can be accelerated using high-pressure canned air (nitrogen) tanks. Hot air drying is contraindicated before EO sterilization.10 Because not all contamination is visible to the naked eye, the thoroughness of cleaning can be assessed via keen visual inspection augmented by use of a magnifying glass and good light source (FIGURE 2). Surface stains can be differentiated from residual blood contamination by using commercially available peroxidase detection products such as HemoCheck-S (Healthmark; FIGURE 3), which quickly detects blood residue down to 0.1 mcg, or EndoCheck (Healthmark), designed for use with flexible endoscopes. Protein residue is common on contaminated instruments and can be a significant source of bioburden.

TECHPOINT 

Personnel should wear appropriate personal protective equipment to prevent skin and eye contact with the solutions. ProChek-II (Healthmark) detects residual amounts of protein (sensitive to 1 mcg) using clinical chemistry techniques evolved from the pyrogallol-red method. Proper cleaning and preparation of surgical devices intended for LCS/HLD is imperative. Organic matter or residual moisture from the cleaning process can dilute or inactivate the active ingredients in sterilants/disinfectants and can interfere with direct contact to the device surfaces. Substances such as soap, detergent, cork, cotton, lint, cotton wool, cellulose sponges, and minerals found in hard water can also affect the efficacy or pH of some liquid chemical sterilants. Devices must be dried properly before further processing, as per manufacturers’ IFU.7 LIQUID CHEMICAL STERILANTS AND HIGH-LEVEL DISINFECTANTS Many liquid chemical sterilants and high-level disinfectants approved by the FDA are labeled for use in both sterilization and HLD, with sterilization requiring a longer contact time than HLD (BOX 1). The label conditions required for HLD to occur are the time and temperature needed to achieve a six-log reduction of an appropriate A

FIGURE 2. Careful visual inspection using a good light source and magnification is imperative to thoroughly assess the cleanliness of surgical devices before proceeding to the next phase of sterilization. 58

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FIGURE 3. (A) Detecting microscopic levels of blood contamination on surgical instruments and equipment is simple when using a HemoCheck-S (Healthmark) test. (B) The green color change in the HemoCheck-S tube on the right demonstrates a positive result for residual blood contamination, while the clear test solution indicates blood was not the source of contamination on surgical instrument pictured left. Courtesy of Healthmark

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Mycobacterium species, when used as per manufacturers’ IFU. Most FDA-cleared LCS/HLD products that have labeled contact conditions for sterilization must pass the Association of Official Analytical Chemists Sporicidal Activity Test as a sterilant (i.e., they must pass the test perfectly).7 Devices must be completely submerged in the LCS/ HLD solution (activated, diluted, or ready-to-use) for the specified time and temperature, and the sterilant/ disinfectant must be at the correct concentration. The solution should be visually inspected before each use and discarded if precipitates are noted, even if the solution is within its usable life.7 The concentration of the active ingredient in solutions should be monitored before each use. Because biologic and chemical indicators are generally not available or labeled for use with liquid chemical sterilants/high-level disinfectants, most manufacturers provide solution test strips or chemical monitoring devices for use with their products (FIGURE 4). The test strips monitor for the concentration of active ingredients. A thermometer and timer are used for physical monitoring and documentation of manual LCS/HLD processes for each cycle. Disposable

FIGURE 4. Agent-specific test strips are used to determine if a solution has maintained effective concentration levels with prior use and storage. TODAY’SVETERINARYTECHNICIAN

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Keys to Successful High-Level Disinfection and Sterilization Processes

water temperature verification strips are also available to help assess cycle efficacy.7 Upon completion of the LCS/HLD process, the sterilized/disinfected items are manually rinsed using aseptic technique as described in the CDC or Association for the Advancement of Medical Instrumentation (AAMI) standards, or according to the manufacturer’s IFU. If the device is not rinsed in sterile water, its sterility will be compromised. Healthcare personnel must be advised of the hazards associated with the chemicals they work with, and they should be provided with education and safety procedures to ensure compliance, as per OSHA Hazard Communication Standard (29 CFR 1910.1200). In general, healthcare personnel should avoid direct contact with liquid chemical sterilants/high-level disinfectants. Personnel should wear appropriate personal protective equipment (PPE) to prevent skin and eye contact with the solutions (FIGURE 5). Furthermore, these solutions should be used in a wellventilated area and kept covered to prevent inhalation exposure to the fumes. Recommended aeration or rinsing procedures must be followed after use of these chemical sterilants, as per the manufacturer’s IFU. Finally, each facility should designate and train a liquid chemical sterilant/

FIGURE 5. It is imperative to wear appropriate personal protective equipment, as advised by the manufacturers’ instructions for use, when handling liquid chemical sterilants.

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Each facility should designate and train a liquid chemical sterilant/ high-level disinfectant spill containment response team to ensure that spills can be cleaned up safely.

high-level disinfectant spill containment response team to ensure that spills can be cleaned up safely.7 STERILIZATION INDICATORS Six classes of chemical indicators (CIs) are used to assess parameters identified as being essential or critical to the sterilization process. The variables considered critical for effective sterilization may include different parameters based on the sterilization process being used. For example, steam sterilization parameters include time, temperature, and water (as delivered by saturated steam), but those considered critical for effective EO sterilization involve time, temperature, relative humidity, and EO concentration.1,2 Some CIs use a reactive ink technology that produces a chemical reaction driven by exposure to process variables and results in a color change. “Moving front” CIs possess tablets that melt in response to steam and temperature and wick down a paper path. Class 1 (process indicators): These are used externally as an exposure control (e.g., indicator tapes) on individual units to distinguish between processed and unprocessed units. Class 1 indicators are relatively simple and are designed to react to one or more of the critical process variables. Class 1 indicator tapes are agent specific, meaning that, for example, a class 1 steam indicator tape would not work as a class 1 indicator tape for an EO unit. Class 2 (test sterilizer performance during a specific test

TECHPOINT 

procedure, such as a Bowie–Dick test): Bowie–Dick testing can detect anomalies such as air leaks, inadequate air removal, inadequate steam penetration, or the presence of noncondensable gases (air or gases from boiler additives) in vacuum-assisted sterilizers. Class 3 (single-variable indicators): These are designed to react to one of the critical variables and indicate exposure

PASS

FAIL

FIGURE 6. Class 5 (integrating) indicators are designed to react to all critical variables and are identified as the CI type providing the highest level of sterility assurance. To determine the efficacy of a steam sterilization cycle using a 3M Comply SteriGage (as shown), the black bar must wick into the ACCEPT zone. 60

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FIGURE 7. As an alternative to running and incubating biologic indicator tests on site, sterilization monitoring service is available through outside companies such as SPS Medical. (Quarterly SPS Medical report pictured with class 5 indicators.)

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to a sterilization process at a stated value (SV) of the chosen variable. Class 3 indicators may become obsolete. Class 4 (multi-variable indicators; usually paper strips): These are designed to react to 2 or more critical variables. This type of CI indicates exposure to a sterilization cycle at an SV of the chosen variables. Class 5 (integrating indicators): These are designed to react to all critical variables. The SVs for a class 5 indicator are equivalent to the performance requirements for biologic indicators (BIs).11 Their response must correlate to a BI at 3 time/temperature relationships: 250°F/121°C, 275°F/135°C, and one or more temperatures in between, such as 263°F/128°C. SVs must be listed on the product or provided on the label/IFU (FIGURE 6). Again, class 4 and 5 indicators for steam sterilization are different than class 4 and 5 indicators for EO.

Keys to Successful High-Level Disinfection and Sterilization Processes

Class 6 (emulating indicators): These are cycle verification indicators that are designed to react to all critical variables for specified sterilization cycles. The SVs are generated from the critical variables of the specified sterilization process. Class 6 indicators are cycle specific and must pass an appropriate dry heat test; their response does not correlate to a BI. BIs contain >100,000 viable spores of a highly resistant organism on a strip and therefore are considered the most reliable level of testing available. Using BIs during a sterilization cycle provides the only direct method of demonstrating lethality within that particular load.1,2,12 BIs may also be used during low-temperature sterilization methods such as EO, hydrogen peroxide gas plasma, and ozone sterilization processes. Nonetheless, it is possible to have a negative BI and still have a CI failure elsewhere in the load.2

BOX 1 Liquid Chemical Sterilants and High-Level Disinfectants Glutaraldehyde solutions. Glutaraldehyde is a major component of many LCS/HLD products. Two-percent glutaraldehyde in alkaline aqueous solution was discovered in the 1960s.7 Alkaline glutaraldehyde products are usually supplied in 2 parts and require mixing, while acid glutaraldehyde usually does not. Depending on the glutaraldehyde formulation and concentration, conditions for HLD generally range from 5–90 minutes at temperatures ranging from 20°C–35°C (68°F–95°F). The contact time for sterilization is 10 hours at temperatures ranging from 20°C–25°C (68°F–77°F) or 7 hours and 40 minutes at 35°C (95°F). However, recent evidence suggests that some types of microorganisms demonstrate resistance to the antimicrobial effects of glutaraldehyde and may not be inactivated by these solutions.7 Hydrogen peroxide solutions. These ready-to-use HLD solutions are used primarily for heat-sensitive and submersible medical devices (e.g., flexible or rigid endoscopes.) Two-percent hydrogen peroxide lists contact conditions of 8 minutes at 20°C (68°F) and has a reuse life of 21 days at or above 1.5% concentration. Labeled for an HLD contact time of 30 minutes at 20°C (68°F), 7.5% hydrogen peroxide has a sterilization contact time of 6 hours at 20°C (68°F), with a similar 21-day reuse life if solution concentration remains above 6%. Ortho-phthalaldehyde (OPA) solutions. OPA solutions are FDA approved for use as high-level disinfectants for reprocessing heat-sensitive medical devices. They are especially active against particular strains of mycobacteria, but some strains have shown a high level of resistance, as have some cyst and vegetative forms of protozoa. Products containing 0.55%–0.6% OPA have been approved for use as high-level disinfectants during manual reprocessing at 12 minutes and 20°C (68°F); the solution has a reuse life of 14 days. Use of OPA to process urologic instrumentation has been associated with anaphylactic-like reactions in humans with a history of bladder cancer.7 Peracetic acid–hydrogen peroxide solutions. Peracetic acid solutions have strong microbial effects and a broad spectrum of activity and can be used for HLD and sterilization applications. Peracetic acid solutions can vary significantly, ranging from 35% peracetic acid and 6% hydrogen peroxide to 5% peracetic acid and 26% hydrogen peroxide. Based on composition, typical HLD contact times range from 5–30 minutes, with sterilization contact times of 6 minutes to 8 hours at 20°C (68°F). Ready-to-use formulations can be reusable for up to 14 days. Sodium hypochlorite solutions. Bleach-type chemicals such as chlorine and chlorine-releasing agents (CRAs) have a long history of use for antisepsis of the skin, hands, and wounds, as well as for disinfection of hospitals, water, and sewage and textile bleaching. Sodium hypochlorite is the most commonly used CRA in healthcare facilities as a hard surface and environmental disinfectant. Sodium hypochlorite and related solutions rapidly lose effectiveness in the presence of organic matter (e.g., blood, feces, tissue). Although chlorine compounds are biocidal to a broad spectrum of microorganisms, most CRA preparations are not intended for HLD or sterilization of medical devices because of their highly corrosive effects.7 Additional resources can be found on the FDA website: FDA-Cleared Sterilants and High Level Disinfectants with General Claims for Processing Reusable Medical and Dental Devices (http://is.gd/vK7uV6).

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Healthcare facilities can either process BIs on site using test vials and an incubator or contract with a sterilization monitoring service (FIGURE 7). A process challenge device (PCD) is an item (pack/tray) designed to create a defined resistance to a sterilization process and is used to assess the performance of the sterilization process. For example, a Bowie–Dick test ensures

the sterilizer is removing air efficiently in dynamic-air-removal (i.e., vacuum-assisted) steam sterilizers and detects trapped air within the sterilizer, which can compromise sterility. A PCD containing a BI is considered a BI challenge test pack/tray, whereas a PCD containing only a class 5 integrating indicator is considered a CI challenge test pack/tray. In large facilities, PCDs are often run at the beginning of each day.1,2,12

CE Test Keys to Successful High-Level Disinfection And Sterilization Processes The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com/tvt.aspx. A $5 fee applies. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval. 1. Which of the following products has been associated with bladder neoplasia in humans? a. Sodium hypochlorite b. OPA c. Glutaraldehyde d. Chlorhexidine

6. The most common reason for failure of a sterile process is a. human error. b. poor service from third-party vendors. c. equipment malfunction. d. utility (e.g., water quality) issues.

2. The most crucial step in the reprocessing of surgical devices for HLD or sterilization is a. thorough verification of the cleaning process. b. location of a class 3 chemical indicator. c. ensuring the usable shelf life for each liquid chemical sterilant is not exceeded. d. correct placement of the biologic indicator.

7. The primary difference between an HLD process and sterilization with a liquid chemical depends on the a. concentration of the solution. b. acidity of the product used. c. contact time and temperature. d. presence or absence of residual organic matter.

3. The efficacy of each batch of liquid chemical sterilant or HLD solution is determined by a. chemical indicators. b. solution temperature. c. agent-specific test strips. d. expiration dates.

8. Which of the following can be used to verify the presence of adequate cavitation energy in ultrasonic cleaning units? a. pyrogallol-red method b. solution-specific test strip c. aluminum foil test d. a peroxidase detection product

4. When cleaning cannulated items, it is important to a. use a 3-step cleaning method: flush, flush, rinse. b. use approved pipe cleaners. c. use enzymatic cleaners. d. select a brush similar in diameter. 5. A Bowie–Dick test is an example of a a. class 1 indicator. b. process challenge device. c. cavitation energy test. d. residual protein assay.

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9. Which liquid chemical is the most commonly used chlorine-releasing agent in healthcare facilities for disinfection of hard surfaces? a. OPA b. glutaraldehyde c. peracetic acid compounds d. sodium hypochlorite 10. Reacting to all critical variables, this indicator’s performance requirements are equivalent to those of a biologic indicator: a. Class 3 b. Class 4 c. Class 5 d. Class 6

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CONCLUSION Veterinary technicians play a key role in ensuring that medical devices are clean and functional before HLD and sterilization, and much can be learned from the mistakes made in human medicine. Regularly updating hospital policies and procedures and verifying the efficacy of cleaning and sterilization processes can play a vital role in preventing HAIs during the pursuit of excellence in veterinary patient care.  Acknowledgments The author would like to thank Renee Lombardi, veterinary assistant, and Jennifer Mathieu, LVT, at Oakland Veterinary Referral Services, for their assistance with this article. Portions reprinted with permission from Reuss-Lamky H. Beating the “bugs”: sterilization is instrumental. Veterinary Technician 2011;32(11):E1-E9. References 1. Centers for Disease Control. Guidelines for Disinfection and Sterilization in Healthcare Facilities. [Online] 2008. cdc.gov/hicpac/pdf/guidelines/Disinfection_ Nov_2008.pdf, Accessed November 2016. 2. 3M Attest Sterile U Network. The Fundamentals of Sterilization Process Monitoring. St. Paul, MN: 3M Health Care; 2007. 3. Eisler P. Deadly infections from medical scopes go unreported, raising health

Keys to Successful High-Level Disinfection and Sterilization Processes

risks. USA Today January 8, 2016. Accessed November 2016. usatoday.com/ story/news/2015/08/05/duodenoscope-infections-not-reported/29988165/ 4. United States Senate Health, Education, Labor, and Pensions Committee. Preventable Tragedies: Superbugs and How Ineffective Monitoring of Medical Device Safety Fails Patients. Accessed November 2016. help.senate.gov/imo/ media/doc/Duodenoscope%20Investigation%20FINAL%20Report.pdf. 5. Health Alert Network. Immediate Need for Healthcare Facilities to Review Procedures for Cleaning, Disinfecting, and Sterilizing Reusable Medical Devices. September 11, 2015. Accessed November 2016. emergency.cdc.gov/han/ han00382.asp. 6. Food and Drug Administration. Infections associated with reprocessed flexible bronchoscopes: FDA safety communication. September 17, 2015. Accessed November 2016. http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ ucm462949.htm. 7. Association for the Advancement of Medical Instrumentation. ANSI/AAMI ST58:2013, Chemical Sterilization and High Level Disinfection in Health Care Facilities. Arlington, VA: Association for the Advancement of Medical Instrumentation; 2013:36-46, 71, 79, 83, 88, 94. 8. Muscarella LA. The benefits of ultrasonic cleaning. Accessed November 2016. infectioncontroltoday.com/articles/2001/05/the-benefits-of-ultrasonic-cleaning. aspx. 9. ProSciTech Pty Ltd. Ultrasonic cleaner aluminium foil efficiency test. December 5, 2014. Accessed November 2016. https://laboratoryresource.com. au/?navaction=getitem&id=116 10. Andersen Products. Anprolene Key Operator Study Guide. Accessed November 2016. http://www.anderseneurope.com/english/images/library/safety/AnproleneKey-Operator-Study-Guide.pdf 11. International Organization for Standardization. ISO 11138-1:2006. Sterilization of health care products -- Biological indicators -- Part 1: General requirements. 12. Association of the Advancement of Medical Instrumentation. ANSI/AAMI ST79:2006 and A1:2008, A2:2009 (Consolidated Text), Comprehensive Guide to Steam Sterilization and Sterility Assurance in Health Care Facilities. Arlington, VA: Association of the Advancement of Medical Instrumentation; 2009.

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Structuring a Course for Dogs with Fireworks Anxiety

s veterinary technicians, we are often very busy from the middle of December through the beginning of January. At my practice, we have such long lines at the front desk that it sometimes appears as though we are giving away something for free! (During this time, vet techs need a lot of chocolate to stay happy.) But there’s more to this stressful season in the Netherlands, because everyone is allowed to light fireworks in honor of the New Year. They not only do it while it’s allowed, but they love to start 2 weeks early. Sometimes it sounds like a war is going on outside, because our windows clatter and the ceiling sounds like it’s coming down! A lot of animals are so afraid of the noise that it becomes a big problem for their owners. So all the owners come in and ask for MAGIC! Specifically, they want to know if we have medicine to help their pet not be afraid. For many years, we sold acepromazine. We now know that’s not the best answer to the problem. Dogs on acepromazine react less to noise, but that’s because they can’t move as much as they want. They are just as anxious!1 Later, we started prescribing alprazolam, which is much safer for the dog, but is still not the best solution. When a dog has already been anxious for months or years, just giving it alprazolam does not do enough.2 The best solution? Helping the animals learn to cope with fireworks and noises.

Esther Klok Dierenkliniek Winsum The Netherlands Esther Klok, a veterinary technician at Dierenkliniek Winsum in the Netherlands, previously described her passion for bringing new ideas from the NAVC Conference home to her clinic in 3 articles in 2016 (available on TodaysVeterinaryTechnician. com). In this article, she outlines how her clinic designed a program that not only helps dogs with noise anxiety, but also improves the human–animal bond and has even increased community awareness of how noises affect animals.

“When you see a tear on the cheek of a happy and proud owner, then you know…we did good!” — Esther Klok FIGURE 1. The class in the horse arena. 64

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We designed a 3-month course because both dogs and owners need at least this much time to learn and change habits. A COMMON PROBLEM Fireworks are not the only sounds that can be a problem. For example, one of our patients was a 5-year-old Labrador retriever that lived 3 months of the summer on a sailboat. The owners and the dog loved it! One day, however, the dog was sleeping on the high deck, and something exploded near the boat. The dog was so shocked that he fell down on the lower deck. From that day on, he started to run whenever he heard loud noises, and that became a serious problem. On one occasion, the owner and dog were walking in the fields when a hunter shot a duck. The dog was so afraid that he ran away through the fields. The owner saw him disappear and searched for him all night, but it took 2 days to find the dog. The problem was progressively getting worse. When the dog heard the sound of a pan clatter while the owner was cooking, he was so afraid that the only thing he could do was get out of the house. Another one of our patients had a problem with both sounds and light. When the owner was taking pictures, the dog would panic and run. Even the doorbell or a loud truck on the road was a trigger to run away. Then, of course, there are all the dogs that are terrified of thunder and lightning. One dog was so afraid that the owners put him in a big kennel in the quietest place in the house. They thought he was safe. But the dog grew so panicked that he ate through the wooden back wall of the kennel, injuring himself. He came to us with his legs and mouth covered in blood. A MIDNIGHT SOLUTION Faced with all of those people in line at the front desk during the 2 weeks before New Year’s Eve, I wondered if we could do something to help those animals and their owners. Something more than giving the dogs medicine and knowing that it was not the best solution. Well, you all know what happens next. You don’t get much sleep when new ideas are popping into your head all night! The result of my brainstorming was this: TODAY’SVETERINARYTECHNICIAN

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Provide a 3-month course for dogs and owners who want to have a good New Year’s Eve experience, followed by a good rest of the year without being afraid of noises and fireworks. PLANS INTO ACTION The next morning, I told the rest of the team about my plan and was a little bit afraid of their response. They always end up with more work because of me! So I was very happy that, when I told them my idea, they were enthusiastic. But I did have to promise them that I would try to keep the amount of work as small as possible. We decided we should hire the best certified dog trainer we knew to conduct the lessons and that there should always be 2 vet techs available to help him. Lucky for us, the trainer was really enthusiastic about the idea and immediately said yes to our training schedule. We had a few meetings to talk about how we would like the lessons to be and what his ideas were. It was important that both the trainer and the veterinary staff felt comfortable with the training. There are really good trainers who can do amazing things with dogs, but sometimes they do not prioritize the emotions of the owners. When the owners do not feel good about something, they will not finish the lessons. On the other hand, a trainer has to be firm. You have to work with both the dogs and the owners to succeed. So, first things first: these classes needed a trainer who was good with dogs and with owners. The veterinary staff needed to “click” with the trainer as well, because we had designed an intensive 3-month training session that would be emotionally heavy, not only for the owners, but also for us! We designed a 3-month course because both dogs and owners need at least this much time to learn and change habits, but a longer course runs the risk of being too expensive for owners to consider. LESSON #1 The first lesson took place in our vet practice. We had 4 groups of 8 dogs each. During the first lesson, we let the owners tell the rest of the group what their pet’s problem was. Then we started to find out what each dog loved the most—a toy, food, or something else. This was very important because, to get the best results, each dog needed to keep its attention on the owner, so the owners needed to have something their pet adored. Also, when a dog is afraid, you have to try to shift it out of that mindset. When we explored in a group what the dogs liked, the owners learned from their own dogs as well as the other owners and dogs.

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When we explored in a group what the dogs liked, the owners learned from their own dogs as well as the other owners and dogs.

The homework for the owners after the first lesson was to find out what their dogs liked the most in attention, food, and toys. Toys with sounds are very important for getting a dog’s attention, so they were urged to find one. LESSON #2 The next lesson took place in an indoor horse arena, but with no horses in the building. The floor of the arena we used was covered with sand, so the dogs didn’t have to worry about sliding around (FIGURE 1). The first part of the lesson was to let the owners walk and try to keep their dog’s attention. It sounds strange, but just this first step made some owners start to cry from happiness. They didn’t even know how to begin this basic process! For me, it was very important to not judge people who didn’t understand such basic things. I started this course to help people. It’s easy to think, “Why didn’t you go to puppy training?” I had to clear my head and only be proud of every step forward the owners made. The homework for the owners after the second lesson was to keep their dog’s attention in various situations. LESSON #3 For the third lesson, we started with a noise CD we made ourselves. The trainer and owners played with the dogs in the enclosed arena with the sounds of fireworks and thunder and lightning in the background. Not too loudly at first, because we would gradually make it louder at every lesson. Owners received tips and tricks from the trainer, and the best part was seeing the trainer get the attention of the dog. In a few seconds, most of the dogs turned around and walked with him as if there was no sound. This was an eye-opener for most of the owners and a reason to work even harder to accomplish the same goal. During this lesson, it was important to have 2 vet techs present, so we could help where necessary. For example, we could hold a dog while the owner was talking with the trainer. Or when somebody was crying (emotions are sometimes really high!), we could bring a cup of coffee or a just put an understanding arm around the owner. For the homework after this third lesson, all the owners received their own noise CD and had to practice with the tips they were given by the trainer for themselves and their dog. LESSON #4 For the fourth lesson, we repeated the previous one. When it went well, we turned up the CD a little louder. Then we put a van inside the enclosed arena. Every owner 66

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TECHPOINT 

had to crawl through the car with his or her dog and make a game of it! They used a toy, and the purpose was to have fun together. Once the pairs accomplished that, we played the noise CD inside the car. Now everybody had to have fun and go through the car the same as before. And it worked! Why? Because the owners were focusing on getting through the car without being stuck, which meant they did not pay attention to the sound and neither did most of the dogs! A few dogs were affected by the noise, but the trainer stepped in and managed to get all the dogs through the car. The homework following this lesson was for the owners to use the noise CD in different places, such as in a backyard or at a dog park. LESSON #5 In this lesson, we introduced a strobe light, because sound is not always the only problem. Flashing lights can worsen the situation. We followed the same procedures as we did when we used the sound. The first task was to get the dog to focus on the owner by using, for example, a toy. The trainer brought a big bag of toys so everybody could use one that their dog liked (the favorite was a ball with a beeping noise). The homework for this lesson was to use the noise CD and a camera flashlight at home to simulate lightning and thunder as well as fireworks. LESSON #6 In this lesson, we introduced smell. We used a smoke machine so the dogs would see white smoke and be able to smell it (FIGURE 2). The machine we used could make big or small clouds of thin or dense smoke, and we learned that we could fill our enclosed arena with smoke! We had to air it out between the groups of dogs. (I recommend using thin smoke, or you will not be able to see anything for at least half an hour!)

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Ideas Into Practice

Interestingly enough, even though most of the dogs had become really relaxed with all the sounds and lights, as soon as we added the sense of smell, they fell back into their old behaviors and were afraid. But when we started the process over again, they recovered and responded faster, and at the end of the lesson, we were almost back to the same level as at the beginning. So if you take a step back, work hard to take another step forward. Don’t be disappointed if the dogs need some extra time. It’s all part of the learning process and the road to success! The homework following this lesson was to practice with sparklers. LESSON #7 Once again, we repeated the previous lesson. Once that went okay, we started popping balloons. Air pressure differences can be a problem for dogs. We started with very small balloons, which most of the dogs did not seem to mind. I was surprised, but it really showed how much we had progressed! This was another emotional moment for the owners, because they started to believe it was possible to get an amazing result out of all the work they had done. What a beautiful moment this was! The homework following this lesson was to get the whole family involved with popping balloons. The owners were supposed to ask people to hide along their dogwalking route (e.g., in the city, in a park). Those hiding were not allowed to tell the owners where they would be, so the owners would also be surprised when they jumped out and popped a balloon. The reason for this is that people react differently when they expect a bang. One of the owners told me that he asked the teenaged loiterers in his village to work with him…and they did! He said that it took 2 weeks of intense practice to achieve the

FIGURE 2. A dog approaches the smoke. TODAY’SVETERINARYTECHNICIAN

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Structuring a Course for Dogs with Fireworks Anxiety

desired results (also for his heart to get used to it). The results? An anxiety-free dog and more understanding from the youth in the village about dogs and their fear of sounds. Now the teenagers are not as likely to use fireworks around dogs. LESSON #8 In this lesson, it was finally time to use real fireworks. We had purchased some made for children. A team of helpers (the wife of the dog trainer, two colleagues, and another dog trainer) was there, and we split the attendees into 2 groups so the trainer had a good eye on all the dogs. Of course, there was also a team of vet techs and a veterinarian. The trainer let the owners do some exercises to show the dogs were paying attention to them. It was amazing to see. Everybody had worked so hard at home. The owners understood their dogs better, and the result was less stress for both the owner and the dog. Only one dog was still not doing very well with everything. We could see that he needed more time, so at this stage, we took him out of the classroom and worked with him alone so we could see what the dog and owner needed to do to progress. LESSON #9 Again, we repeated the previous lesson. We encouraged the owners to help each other out when an owner or a dog was in trouble. Then we told them to be ready for the final week. We were ready for our own firework show! THE SHOW Outside the training location a week later, there was a firework show. Loud noises, smoke, and lots of colors filled the air. And there we were! The trainer, many dogs, and many owners. And, of course, the vet team. The feeling for everyone was the same: we were so PROUD! We all did it together. Everybody worked really hard and did it because of a mutual love for the dogs. It felt super to see them, heads and tails up! When you see a tear on the cheek of a happy and proud owner, then you know…we did good! THE RESULTS In summary, training classes like this can have big benefits for your practice, including: ÆÆ Very happy owners who will tell others about the training and leave good comments on your website and on social media

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Results can include very happy owners who will tell others about the training and leave good comments on your website and on social media.

ÆÆ A stronger client–clinic relationship ÆÆ Free press when your classes are featured in

newspapers and on the radio and television (FIGURE 3) ÆÆ A great learning experience for you and your team ÆÆ Team building within your practice ÆÆ Extra revenue ÆÆ Happy dogs ÆÆ A proud team of professionals It is important to note that, after the classes, the trainer and vet talked to all the owners. In some cases, it still might be necessary to get extra help from products like Zylkene (vetoquinolusa.com), which helps dogs with lower anxiety levels, or clomipramine, for dogs who have a bigger problem. Our veterinarian talked with the dog trainer, and they decided together if a dog needed medication. Then our vet decided what kind of medication to prescribe and informed the trainer about it, with follow-up conversations about how it worked and whether a change in dose or medication was needed. During the classes, it was up to the trainer to assess each dog’s anxiety level and explain it directly to the owner as he worked with the dog. He taught the owners to observe their pet’s body language and recognize different moods. Most of this was in the very first lesson, but some dogs started showing much more anxiety when we reached the smoke machine. So the owners and the trainer got to see the dogs’ behavior change, and at that moment, the trainer would talk about it with the owner

TECHPOINT 

and the group, because it was a learning experience for all of us—owners, trainer, and vet staff. This course is perfect for a dog trainer to show owners all the signs of anxiety, fear, and happiness! We try to keep the fun high in all the lessons, for dogs and owners. Every dog is different. If a dog needs more time, we try to work with the owner individually. Some dogs and owners have taken the course more than once. DARE TO DREAM BIG I hope many of you will dream tonight about great ideas. I know we, as vet techs, already work so many hours. I know we do not make a great deal of money. I also know that firework training is not in our job description. But…I know that we, as vet techs, can make a big difference! We have a love for dogs. We have a great deal of patience. We have enough knowledge about the behavior of dogs and their owners to help them. We have a big shoulder to cry on. We have the strength to reach a goal, even when we take a few steps back. We are there to help dogs and people where and whenever they need us. That’s who we are! So go for it! 

References 1. O verall K, Seksel K. Behavior: pharmacotherapy. vetstream.com/canis/Content/Freeform/fre60065. Accessed September 2016. 2. O verall KL. Noise reactivities and phobias in dogs: implementing effective drug therapy. veterinarynews.dvm360.com/noise-reactivitiesand-phobias-dogs-implementing-effective-drugtherapy. Accessed September 2016.

FIGURE 3. Publicity for the practice and the class! 68

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93% of cardholders say financing helped with unplanned expenses so they were always prepared.*

Be ready. Accepting the CareCredit healthcare credit card can help clients move forward with care for their pets. Visit CareCredit at NAVC Booth #1117 and WVC Booth #4335 or call 800-300-3046, ext. 4519.

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CLIENT HANDOUT

Puppy Socialization  Socialization is the learning process through which puppies become accepting of interactions with various people and animals.  Localization is the learning process through which puppies become familiarized and accustomed to various novel objects and environments.  Proper socialization can help prevent or eliminate behavior problems and help create a better bond between the dog and the family.  When introducing puppies to new people, animals, or environments, provide treats proactively so the puppy associates a positive experience with each new stimulus.  It’s important for puppies to be socialized around other people and other pets at an early age (before they are fully vaccinated), but consult your veterinarian about disease risks before exposing your puppy to novel environments and other dogs with an unknown vaccine history.  Group puppy socialization classes are a good way to socialize your puppy while minimizing disease risks, and they provide access to a training expert for guidance.

What Is Puppy Socialization? Socialization is the learning process through which puppies become accepting of interactions with various people and animals. Socialization includes localization and allows puppies to become familiar with and accustomed to various novel objects and environments. Socialization is easiest during the sensitive socialization period, or the first 3 months of a puppy’s life. From 3 to 4 months of age, the socialization period wanes and puppies become progressively more fearful, especially in the absence of early positive socialization experiences. By exposing puppies to different stimuli in a positive way (using food treats) before they are fearful, puppy parents can reduce the likelihood of behavior problems in the future and can help to build a stronger human–dog bond.

shutterstock.com/Ermolaev Alexander

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Why Is Puppy Socialization Important? Unfortunately, behavior problems remain the top reason that pets are relinquished to animal shelters or worse. Likely, many behavior problems can be prevented with early and appropriate socialization. Proper socialization helps make puppies more tolerant of changes in their environment and helps prevent common behavior problems related to fear, anxiety, and/or aggression. Lack of early proper socialization experiences can be just as detrimental as negative experiences for your puppy. Early socialization optimizes the chances for a dog to be friendly and well adjusted in a multitude of environments later in life.

Why Should I Consider Attending Group Puppy Preschool Socialization Classes? Group puppy preschool socialization classes can be a safe and controlled

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Puppy Socialization continued place for socialization to other puppies and people, and they allow for the exploration of novel objects and environments. Reputable puppy classes will maintain strict health, vaccination, and disease risk management protocols, thereby minimizing health risks. Attending a group puppy preschool socialization class led by a training specialist has several advantages. Group puppy preschool socialization classes are offered by many veterinary clinics, dog training facilities, and pet supply stores. It’s important to find a course that emphasizes pet parent education and positive controlled socialization experiences and exploration. Classes should highlight appropriate management and supervision and emphasize positive reinforcement training rather than punishment or correction. Enrollment should begin during the sensitive socialization period (the puppy’s first 2 to 3 months of life). Older puppies

The benefits of attending group puppy preschool socialization classes include:  Empathy and understanding regarding normal behaviors  Expert guidance and answers to questions or concerns regarding undesirable behaviors  Introduction to positive reinforcement training  Knowledge of how to implement problemsolving techniques

outside their socialization period should be enrolled in group puppy kindergarten classes with age-appropriate activities and positive reinforcement training. Ask your veterinarian for recommendations regarding group puppy preschool socialization classes and for positive puppy training resources. Your veterinarian can help you determine when your puppy is ready for class. Among other things, good group puppy preschool socialization classes should cover:  Proper socialization and environmental exposure  Play biting and mouthing  Destructive chewing  Prevention of food and resource guarding  Crate training and exercises fostering independence  Handling and restraint exercises  Housetraining tips and techniques  Basic training for good manners

 A controlled and safe environment for puppy play, socialization, and exploration during sensitive periods of development

Kenneth Martin, DVM, DACVB, puppystartright.com.

 Prevention of behavior problems related to fear, anxiety, and aggression

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Kenneth Martin, DVM, DACVB, puppystartright.com.

Puppy Socialization continued

How Else Can I Socialize My Puppy? The goal of proper socialization is to expose your puppy to different people, animals, environments, and stimuli in a safe and positive manner, without overwhelming your puppy. Start by familiarizing your puppy with touch and handling by familiar people. Whenever possible, when handling your puppy’s paws, ears, mouth, and body, offer special food treats. This helps to foster positive associations with being handled rather than just learning to tolerate it, or worse, becoming overly sensitive to handling. Next, in a positive manner, using food treats, expose the puppy to people of different ages, sexes, heights,

and races. If your puppy is enjoying the social interaction, he or she will readily eat the treats and/or display affection with a desired interest in social interaction. It is important for your puppy to become comfortable with being handled by others at the veterinary clinic or grooming facility. Adding food to social interactions helps foster positive associations. It’s also important for your puppy to learn to be comfortable around other animals. Group puppy preschool socialization classes are a safe place to expose your puppy to other puppies because health and vaccination requirements should be mandatory for all participants. If your puppy is older, consider group puppy kindergarten classes. In general, you should avoid taking your puppy to a dog park or other hightraffic public area where unfamiliar dogs roam. These experiences should be off-limits until your puppy has been fully vaccinated. Exposing your puppy to an infectious disease, such as parvovirus, when his or her immune system is still developing can have devastating results. Puppyhood is also a great time to familiarize your puppy with all the sights and sounds of his or her world, from riding in a car to being around a vacuum cleaner. Once your puppy has been fully vaccinated, you can expand your destinations as the risk of infectious disease is greatly reduced. Each time you introduce your puppy to a new stimulus, make sure to provide positive reinforcement in the form of treats. You want your puppy to associate positive experiences with new people, animals, and environments. 

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TRUST. 1 2

Data on file at Merial. Freedom of Information: NADA140-971 (January 15, 1993).

PREVENTS HEARTWORM DISEASE

TREATS AND CONTROLS 3 SPECIES OF HOOKWORMS

TREATS AND CONTROLS 2 SPECIES OF ROUNDWORMS

OWNERS PREFER IT1 AND DOGS LOVE IT2

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

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Toxicology Talk

Xylitol: A Sweetener That Is Not So Sweet

Toxicology Talk, continued from page 50 chewables

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

Chewables Per Month

Ivermectin Content

Pyrantel Content

Color Coding 0n Foil Backing and Carton

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

1 1 1

68 mcg 136 mcg 272 mcg

57 mg 114 mg 227 mg

Blue Green Brown

HEARTGARD Plus is recommended for dogs 6 weeks of age and older. For dogs over 100 lb use the appropriate combination of these chewables. ADMINISTRATION: Remove only one chewable at a time from the foil-backed blister card. Return the card with the remaining chewables to its box to protect the product from light. Because most dogs find HEARTGARD Plus palatable, the product can be offered to the dog by hand. Alternatively, it may be added intact to a small amount of dog food. The chewable should be administered in a manner that encourages the dog to chew, rather than to swallow without chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes after administration to ensure that part of the dose is not lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended. HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors), potentially carrying infective heartworm larvae, are active. The initial dose must be given within a month (30 days) after the dog’s first exposure to mosquitoes. The final dose must be given within a month (30 days) after the dog’s last exposure to mosquitoes. When replacing another heartworm preventive product in a heartworm disease preventive program, the first dose of HEARTGARD Plus must be given within a month (30 days) of the last dose of the former medication. If the interval between doses exceeds a month (30 days), the efficacy of ivermectin can be reduced. Therefore, for optimal performance, the chewable must be given once a month on or about the same day of the month. If treatment is delayed, whether by a few days or many, immediate treatment with HEARTGARD Plus and resumption of the recommended dosing regimen will minimize the opportunity for the development of adult heartworms. Monthly treatment with HEARTGARD Plus also provides effective treatment and control of ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). Clients should be advised of measures to be taken to prevent reinfection with intestinal parasites.

degree of toxicity. Technicians are usually responsible for obtaining a thorough history surrounding the exposure. It is important to obtain the full product name, including flavors when applicable, and collect any packaging the owner may have. This information will be very important if an animal poison control center is contacted. The time of exposure, clinical signs observed at home, and treatments implemented at home should also be recorded, along with a worst-case scenario amount of the agent ingested. While the patient is in hospital, the technician typically collects blood samples and conducts lab work, administers IV fluids and medications, and monitors clinical status for signs of hypoglycemia.  References 1. ASPCA Animal Poison Control Center. Unpublished data, 2016. 2. Piscitelll CM, Dunayer EK, Aumann M. Xylitol toxicity in dogs. Compend Contin Educ Pract Vet 2010 ;32(2):E1-E4. 3. Xia Z, He Y, Yu J. Experimental acute toxicity of xylitol in dogs. J Vet Pharm Ther 2009;32:465-469. 4. Todd JM, Powell LL. Xylitol intoxication associated with fulminant hepatic failure in a dog. J Vet Emerg Crit Care 2007;17(3):286-289. 5. Dunayer EK, Gwaltney-Brand SM. Acute hepatic failure and coagulopathy associated with xylitol ingestion in eight dogs. JAVMA 2006;229(7):1113-1117. 6. Dunayer EK. New findings on the effects of xylitol ingestion in dogs. Vet Med December 2006:791-797.

EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development of the adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense).

Toxicology Talk is written and reviewed by members of the American Society for the Prevention of Cruelty

ACCEPTABILITY: In acceptability and ﬁeld trials, HEARTGARD Plus was shown to be an acceptable oral dosage form that was consumed at ﬁrst offering by the majority of dogs.

to Animals (ASPCA) Animal Poison Control Center

PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult heartworms and microﬁlariae before initiating a program with HEARTGARD Plus.

(APCC). The mission of the APCC is to help animals

While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level, HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due to dead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials with ivermectin alone after treatment of some dogs that have circulating microfilariae.

exposed to potentially hazardous substances, which it

Keep this and all drugs out of the reach of children. In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans.

treatment recommendations from specially trained

does by providing 24-hour veterinary and diagnostic veterinary toxicologists. It also protects and improves

Store between 68°F - 77°F (20°C - 25°C). Excursions between 59°F - 86°F (15°C - 30°C) are permitted. Protect product from light.

animal lives by providing clinical toxicology training to

ADVERSE REACTIONS: In clinical ﬁeld trials with HEARTGARD Plus, vomiting or diarrhea within 24 hours of dosing was rarely observed (1.1% of administered doses). The following adverse reactions have been reported following the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions and hypersalivation.

veterinary toxicology residents, consulting services, and case data review.

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

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

HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant or breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used ﬂea collars, dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with HEARTGARD Plus in a heartworm disease prevention program.

requests for help from all over the world, including South America, Europe, Asia, and the Pacific Islands.

In one trial, where some pups had parvovirus, there was a marginal reduction in efﬁcacy against intestinal nematodes, possibly due to a change in intestinal transit time. HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (See DOSAGE section) for dogs of different weights. Each strength comes in convenient cartons of 6 and 12 chewables. For customer service, please contact Merial at 1-888-637-4251.

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Peer-Reviewed

Adapted with permission from Sirois M. Laboratory Procedures for Veterinary Technicians. 6th ed. St. Louis, MO: Elsevier Mosby; 2015.

Digital Microscopy

any veterinary practices incorporate digital images of new patients when creating patient records. Veterinary practices also use digital imaging to document specific patient conditions and, increasingly, to obtain images in the radiology suite. Many practices take “before and after” images of patients undergoing dental procedures to provide visual evidence of treatment to clients. Photographs can be used to help explain concepts or disease conditions to pet owners, which may lead to increased client compliance. Digital images can also be used to share patient information during consultations with other veterinary professionals and to create an image library for teaching purposes.

REASONS TO USE DIGITAL MICROSCOPY Adding digital photomicrophotography, also known as digital microscopy, can also enhance a veterinary practice (BOX 1). Photomicrographs

BOX 1 Benefits of Digital Microscopy  Enhanced communication with consultants  Improved client education  Archiving of images for teaching  Legal documentation of a patient’s condition

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

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

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of abnormalities seen on blood films or tissue cytology preparations, parasite evaluations, urine sediment evaluations, and similar diagnostic tests can be used to document findings in a patient’s record. This can be especially beneficial when handling legal issues that arise from diagnosis or treatment of patients. Photomicrographs can be added to electronic patient records as a simple way to document diagnoses. Regardless of the type of microscope used, having it professionally serviced according to manufacturer’s recommendations is essential. Digital microscopy has become more affordable, even for small practices. Three common types of digital systems are generally used: those that incorporate a digital microscope, those that attach to the third eyepiece of a trinocular microscope (FIGURE 1), or those that replace one of the eyepieces on a standard binocular microscope. Some systems incorporate a small viewing screen in addition to interfacing with a computer screen or monitor. While it may be possible to obtain an adapter to attach a microscope eyepiece to a standard handheld digital camera for obtaining photomicrographs, some newer cameras cannot be used in this way, and the adapters may be cost prohibitive. Digital microscopy systems may include computer software that allows captured images to be categorized and archived in standard formats such as jpg, bmp,

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Peer-Reviewed

Digital microscopy can greatly enhance practice recordkeeping and can become a valuable tool for client education and staff training.

and tiff. Some of these programs can directly export images to a photo editing program. In addition to still images, most of the systems can capture video, which can be played back in real time on a monitor or computer screen. This can serve as a training tool for new staff members, allowing multiple individuals to view microscopic images as a veterinary technician performs a microscopic evaluation. Real-time streaming of images via the internet may also be possible and can greatly enhance consultations with other veterinary professionals. RESOLUTION Digital microscopy systems vary in image resolution capability. Resolution refers to the degree of clarity and visible detail in images. Resolution is measured in pixels: the greater the number of pixels, the greater the degree of detail and clarity and the more the image can be enlarged without loss of clarity. The two primary types of digital imaging methods use different types of image sensors. Charge-coupled device

TECHPOINT 

(CCD) and complementary metal-oxide semiconductor (CMOS) image sensors vary in the degree of sharpness of the images they produce. CCD cameras are recommended because they tend to provide higher-quality images than a comparable CMOS camera at the same resolution. In addition, a CMOS camera may not allow smooth real-time projection of images. The resolution of an image is limited by the resolution of the output device used, such as the computer screen or monitor used to display the image. Unless the images are to be submitted to a professional publication, the veterinary practice should choose the highest-resolution camera system within its budget. If the practice wishes to print images to give to clients, a resolution of 2 megapixels is generally sufficient for printing images up to 5 × 7 inches without loss of clarity. TYPES OF SYSTEMS Digital microscopes that incorporate a digital camera and include software to download and save images to a

FIGURE 1. A trinocular head microscope with attached digital camera. (UNICO Microscope; courtesy of VetLab Supply, Palmetto Bay, Florida) 76

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FIGURE 2. A digital eyepiece camera on a clinical microscope.

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T E C HP O I N T 

While image resolution is a significant factor, choosing a system that allows simple image acquisition, storage, and management may be more important. computer are generally compatible with both Windows and Mac operating systems. These integrated systems tend to be much more costly than purchasing a separate camera to attach to a standard binocular or trinocular clinical microscope. However, integrated systems have the advantage of always being ready to capture images, which they generally do quickly. A very busy practice laboratory may find the higher cost worthwhile. Various less expensive digital cameras are available to add to a standard clinical microscope for photomicroscopy. Digital cameras that attach to trinocular microscopes are the most efficient. The camera attachment is mounted to the third eyepiece and the system attached to a computer, most often via a universal serial bus (USB) attachment. Some systems contain an integrated media device, such as a secure digital (SD) card, that can be removed to transfer images to a computer. These systems allow veterinary technicians to obtain images quickly in a clinical setting.

FIGURE 3. Images can be captured directly on a computer using software provided by the camera manufacturer. TODAY’SVETERINARYTECHNICIAN

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Digital Microscopy

An eyepiece camera that attaches to a binocular microscope usually requires replacing one of the microscope eyepieces with the eyepiece camera to capture images directly on a computer (FIGURE 2). These systems are highly cost effective but tend to be slightly slower than the systems discussed above. With an eyepiece camera system, a veterinary technician would remove one of the microscope eyepieces, attach the camera, and capture an image directly on a computer (FIGURE 3). The technician would then remove the camera and replace the eyepiece to continue the remainder of the evaluation. Devices are also available to allow capture of digital images via a smartphone or tablet attached to a platform that is connected to the microscope eyepiece (FIGURE 4). The platform contains adjustable grips to hold the phone in proper alignment. Each different phone or tablet used requires modification of the grip adjustment. An additional eyepiece can be purchased that is left permanently attached to the platform so that the camera alignment does not have to be adjusted before each use. Many smartphones and tablets also have ports that allow the device to be connected to an external monitor or video projector. IMAGE QUALITY It is important that microscopes used for obtaining photomicrographs have high-quality optics. The overall

FIGURE 4. The miPlatform system attaches to any microscope to allow capture of photos and video using a smartphone or tablet.

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T E CHP O I N T 

CCD cameras are recommended because they tend to provide higher-quality images than a comparable CMOS camera at the same resolution. quality of digital photomicrographs is greatly influenced by the quality of a microscope’s optics. The microscope should have plan achromatic (flat field) objectives. Many older clinical microscopes use filament light sources (generally halogen or tungsten) and are configured for Köhler illumination. To obtain high-quality images, the

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BOX 3 Online Tutorial Resources  Microscopy U (Nikon Instruments) microscopyu.com/articles/digitalimaging/index.html  Microscopy Resource Center (Olympus) olympusmicro.com/primer/digitalimaging/index.html

microscope must be adjusted to proper Köhler illumination (BOX 2). Without proper illumination and adjustments, the image may appear to be unevenly illuminated, containing bright and dark areas or shadows. A tutorial for performing adjustments to obtain Köhler illumination can be found at microscopyu.com/tutorials/java/kohler/; other resources for online tutorials on obtaining high-quality digital microscope images are listed in BOX 3. Newer clinical microscopes that use light-emitting diodes (LEDs) tend to produce the highest-quality images as a result of enhanced color balance and greater stability of light output.

BOX 2 Steps for Köhler Illumination 1. Secure a slide on the microscope stage. 2. Adjust the light source to approximately half its total brightness. 3. Place the 10× ocular lens in position. 4. Verify that the eyepiece is at the correct interpupillary distance and is focused. 5. Use the coarse adjustment knob to focus on the specimen (FIGURE A).

7. If needed, adjust the condenser screws until the light is centered in the field of view (FIGURE B). 8. Open the diaphragm until the circle of light just touches the edge of the circumference of the field of view. 9. Adjust the condenser until the light is in sharp focus. If this makes the image darker, adjust the brightness to compensate. 10. Repeat this procedure for each ocular objective.

6. Close the field diaphragm and condenser until a small ring of light is visible through the specimen in the field of view.

FIGURE A.

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FIGURE B.

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AUTOMATED SYSTEMS Automated microscopy systems have long been used in human reference laboratories. These systems are now becoming available to veterinary clinics. One significant advantage of automated systems is improved consistency in preparation and evaluation of samples. Many of these systems are affordable for even smaller-volume veterinary facilities. The specific functions performed by the systems vary. One type of system is capable of preparing a variety of fluid sample types for evaluation in addition to capturing digital images (FIGURE 5). This system can be used to smear and stain specimens, to stain previously prepared samples, or to scan samples that have already been smeared and stained. The scanned image is saved as a DICOM (Digital Imaging and Communications in Medicine) image and can easily be shared with a pathologist when additional review is needed. Automated systems are also available that can scan a prepared blood smear and provide initial classification of the cell types (FIGURE 6). The veterinary technician can then view the preclassified cells and confirm or reclassify them as needed. This system also allows review and initial evaluation of red blood cell morphology and platelet estimate.

CONCLUSION Digital microscopy can greatly enhance practice recordkeeping and can become a valuable tool for client education and staff training. While image resolution is a significant factor, choosing a system that allows simple image acquisition, storage, and management may be more important. The busy practice laboratory may benefit from the use of one of the automated systems that also provides digital image capture. ď Ž

FIGURE 6. Automated system designed to capture images and classify cell types. (Photo courtesy of CellaVision NorthAmerica, Durham, NC. cellavision.com/en/)

FIGURE 5. This Microview system automates the process of smearing, staining, and viewing blood smears and other types of samples and captures a digital image of the slide. (Photo courtesy of Revo Squared. Kennesaw, GA. revosquared.com/microview.html) 80

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IOWA — Veterinary Technician, preferably registered, needed to work at progressive, mixed animal practice that is the only commercial business to provide C-section Derived, Colostrum Deprived piglets to the US biological industry. Candidates must be proficient in surgical assistance, dosage calculation, laboratory work and analysis, phlebotomy, restraint, and dental prophylaxis. Willingness to learn and work in a team as well as individually and the ability to multitask are critical. Benefits include health insurance; simple IRA w/match; paid CE, holidays, and vacation.

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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

The Antidote to Compassion Fatigue The other day, a veterinary technician said to me, “I have the best job in the world. Are you kidding me? I get to help animals get well. What could be better than that?” Not much that I can think of. But it’s not all butterflies and rainbows, is it? The clients can take a toll on us. There are no-win situations that push our ethical limits. We sometimes have feelings of not doing enough and not being enough. We can find ourselves worn out from giving and can run low on compassion. Sometimes we might question our sustainability in the field and our future. And often, there’s that omnipresent feeling of wishing that things were different than they actually are.

Julie Squires, CCFS Rekindle, LLC Julie is a compassion fatigue specialist who brings a unique perspective and approach to support the sustained energy and passion of animal workers. Her company, Rekindle LLC, offers on-site compassion fatigue training to veterinary hospitals, animal shelters, and other animal organizations.

Compassion Fatigue Compassion fatigue is the combination of emotional, physical, psychological, and spiritual exhaustion and depletion that can result when we are repeatedly exposed to another’s pain and suffering. It’s the negative aspect of veterinary medicine, and, like it or not, it is a normal consequence of working in a helping profession. You are not alone in how you feel. I can assure you of that. But there is an antidote.

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.

shutterstock.com/Monkey Business Images

Compassion Satisfaction Is Protective Compassion satisfaction is the positive aspect of veterinary medicine. It’s the puppies (and their breath!), the thankful clients, the patients that get better. It’s feeling pride in our work, educating clients, caring for

COMPASSION FATIGUE is the combination of emotional, physical, psychological, and spiritual exhaustion and depletion that can result when we are repeatedly exposed to another’s pain and suffering. TODAY’SVETERINARYTECHNICIAN

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Final Thoughts

The Antidote to Compassion Fatigue

our patients, learning new skills, working as a team, and making a difference in someone’s life, to name just a few contributing factors. The pleasure we derive from our work can help shield us from the negative effects (i.e., compassion fatigue) if we are aware of it and recognize it as such. Many times, we get caught up in the hustle and bustle of a busy practice and equally busy personal life and lose touch with the reasons why we do what we do. Many in helping professions such as veterinary medicine have wanted to do such work from a very early age and can’t imagine doing anything else. To sustain our passion and love of our work, we must experience compassion satisfaction on a regular basis. Compassion satisfaction helps balance out compassion fatigue. Together, they are the yin and the yang, the good and the bad, the pleasure and the pain, the dark and the light.

“We realize the importance of light when we see darkness.” —Malala Yousafzai, I am Malala

Celebrate the Wins When I facilitate workshops, I always pose the question, “Do we celebrate the wins as much as we fixate on the losses?” It’s a great question to ponder personally as well as within the practice where you work. Human beings instinctively seek the negative. It’s what kept our caveman ancestors alive: they had to focus on the negative or risk being killed by predators. This was essential thousands of years ago, but is no longer helpful. Still, our brains are hardwired for it. Negative experiences are sticky and get caught in the mind. Acknowledging the positive—like the patients that have a good outcome and the satisfied clients—requires some practice and steadfastness. In the practice of mindfulness, this is the concept of savoring: allowing joy, celebration, and gratitude to linger as we do with a good meal, a decadent dessert, or a day at the beach. The same applies to our work. Allow yourself to savor the hepatic lipidosis cat that finally starts eating on its own or, better yet, goes home. Or the client who brings the team cookies even though they lost their dog to renal failure. We are so quick to move away from the heart-warming and back to the heart-wrenching. By doing so, we cheat ourselves out of the rewards of our work. Being satisfied is a practice and takes some reminding, but it is worth the effort. 84

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Reflection and Writing Exercise In Trauma Stewardship, Laura van Dernoot Lipsky recommends that, before starting your workday, you take a moment to literally stop in your tracks and ask yourself, “Why am I doing what I am doing?” After you hear your answer, remind yourself, gently, that you are making a choice to do this work. Take a deep breath. Breathe in both the responsibility and the freedom in this acknowledgment. Find a quiet place and a journal and work your way through these contemplative questions to rediscover your why and intentions for being in this profession. ÆÆ Why am I doing this work? ÆÆ What drew me to veterinary medicine? ÆÆ What did and do I want to achieve by being a veterinary technician? ÆÆ Am I in touch with the positive aspects of my work? ÆÆ What keeps me going and sustains me both personally and professionally, given the challenges of veterinary medicine? ÆÆ Do I celebrate the “wins” for more than 30 seconds? ÆÆ Can I think of a situation where I know I’ve made a difference? ÆÆ Are there any specific patients or clients that have profoundly touched me in a positive way? ÆÆ If I had it to do all over again, would I make any different choices? ÆÆ Do I still love this work? Where Do You Go From Here? Your future comes down to where you put your focus and what you tell yourself. Your mind is a powerful thing, the most powerful thing you have, and left on its own, it will seek and hold onto negative experiences, situations, and feelings. But with constant redirection, you can reconnect to your passion for being a veterinary technician and helping those that can’t speak for themselves. When I find myself stuck and not able to see the good in my situation, I ask myself this simple question: How can I see this differently? I’m constantly amazed at how this question opens my heart and reminds me to choose love over fear. Viktor Frankl, neurologist, psychiatrist, and Holocaust survivor, said in his wildly popular book Man’s Search for Meaning, “Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.” It’s all about where we choose to dwell, where we choose to focus our attention. Focus your attention on that which brings you joy. 

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Texas A&M University and the North American Veterinary Community (NAVC) are proud to introduce:

If you consider yourself an innovative thinker or disruptor that welcomes change and growth, you won’t want to miss this one-of-a-kind CE opportunity. Dedicated to sparking and fostering ingenuity, The Veterinary Innovation Summit offers a combination of unique programming, a diverse attendee pool and an immersive learning environment.

APRIL 28-30 COLLEGE STATION, TEXAS Registration opens January 2017

Get fresh perspectives from veterinary and non-veterinary entrepreneurs and health professionals on the latest technologies in veterinary healthcare.

Participate in interactive “Speaker Conversations” about the future of veterinary practice and enjoy positive, creative conversations among veterinary innovation and design competition finalists.

Learn about experiences, successes and failures from business owners during “Founders Fireside Chats.”

Listen to and participate in debates on controversial issues in “Collision Panels.”

Be a part of this ground-breaking, cuttingedge veterinary education event to catapult the profession towards the next paradigm shift in veterinary medicine.

Visit VeterinaryInnovationSummit.com for more details.

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PROVEN REDUCTION IN KEY ORAL HEALTH INDICATORS1*

HALITOSIS

PLAQUE

CALCULUS

53% 42% 54%

Block plaque, calculus, and halitosis with the science of prevention OraVet® Dental Hygiene Chews work in a new way to combat plaque, calculus, and halitosis where they start—bacterial biofilms. The mechanism of action is simple but remarkably effective: Each daily chew releases delmopinol hydrochloride, a surfactant used for years in a human oral rinse, to create a barrier that prevents bacterial attachment.2,3 When bacteria can’t attach, they can’t produce plaque biofilms or the volatile sulfur compounds of halitosis. And the scrubbing action of the chew works in parallel to effectively remove plaque and calculus. For more information, contact your Merial representative or visit OraVet.com

Science You Can Believe In • Efficacy demonstrated in multiple canine trials • Delmopinol has been extensively tested in human and animal trials • Novel mechanism of action • Exceptional halitosis control1 • Highly palatable1 • Proven technology originally developed for a human oral rinse • Available through veterinarians

*Compared with dry diet alone. References: 1. Data on file, Merial, Inc. 2. Steinberg D, Beeman D, Bowen W. The effect of delmopinol on glucosyltransferase adsorbed on to saliva-coated hydroxyapatite. Archs Oral Biol. 1992;37:33-38. 3. Vassilakos N, Arnebrant T, Rundergren J. In vitro interactions of delmopinol hydrochloride with salivary films adsorbed at solid/liquid interfaces. Caries Res. 1993;27:176-182. ®ORAVET and SERIOUS ORAL CARE MADE SIMPLE are registered trademarks of Merial. ©2016 Merial, Inc. Duluth, GA. All rights reserved. OVC15TRADEAD (12/16).

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