Today's Veterinary Technician, March 2017 by davidpsu

DERMATOLOGY CANINE DEMODICOSIS

RADIOGRAPHIC POSITIONING KNEES, PELVIS, AND TOES

INTERNAL MEDICINE BODY CAVITY CENTESIS

TOXICOLOGY CANTHARIDIN TOXICOSIS

PAIN MANAGEMENT BECOMING A PATIENT ADVOCATE

Pediatric Emergencies: CARING FOR THE VERY YOUNG

FRIENDS

LIFE

6-in-1 parasite protection is the key to a lasting relationship.

Prevention. Protection.

The coverage and convenience you need with the compliance you want.1 Broad-spectrum protection—fleas*, heartworm, whipworm, roundworm, hookworm,† and tapeworm. 99% acceptance rate2 —Available in a tasty, beef and bacon flavored chew dogs love. Powerful flea prevention—Uses lufenuron, a unique ingredient that prevents flea infestations. Easy year-round coverage—Prevent and control parasites with just 1 chew, every 30 days. Built for compliance1 —Enhanced compliance compared to combination flea/tick and heartworm prevention regimens.1‡ To order, contact your distributor or call your Virbac representative at 1-844-4-VIRBAC (1-844-484-7222). Dogs should be tested for heartworm prior to use. Mild hypersensitivity reactions have been noted in some dogs carrying a high number of circulating microfilariae. Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention. Please see full product label for more information, or visit www.virbacvet.com. References: 1. Data on file, Vetstreet Data Analytics. Virbac Corporation. 2. SENTINEL® SPECTRUM® (milbemycin oxime/ lufenuron/praziquantel) [Freedom of Information Summary]. Greensboro, NC: Novartis Animal Health; 2011. * Prevents flea eggs and maggot-like larvae from developing; does not treat adult fleas. † A. caninum. ‡ SENTINEL® Brand Products.

TODAY’SVETERINARYTECHNICIAN todaysveterinarytechnician.com

MARCH/APRIL 2017

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

Editorial Advisory Board Brenda K. Feller, LVT, CVT, VTS (Anesthesia) Animal Specialty Hospital of Florida, Naples, Florida Rosemary Lombardi, CVT, VTS (Emergency and Critical Care) Director of Nursing, University of Pennsylvania Matthew J. Ryan Veterinary Hospital Jeanne R. Perrone, CVT, VTS (Dentistry) VT Dental Training, Plant City, Florida Heidi Reuss-Lamky, LVT, VTS (Anesthesia and Analgesia, Surgery) Oakland Veterinary Referral Services, Bloomfield Hills, Michigan Kathi L. Smith, RVT, VTS (Oncology) Portland Veterinary Specialists Portland, Maine Deborah A. Stone, MBA, PhD, CVPM StoneVPM Austin, Texas Daniel J. Walsh, MPS, RVT, LVT, VTS (Clinical Pathology) Purdue University (Retired)

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

An Official Journal of the NAVC

VOLUME 2, NUMBER 2

Chief Executive Ofﬁcer Thomas M. Bohn, MBA, CAE

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TODAY’SVETERINARYTECHNICIAN

March/April 2017

CONTENTS

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

todaysveterinarytechnician.com

MARCHAPRIL2017

Volume 2, Number 2

PEER-REVIEWED CE Pediatric Emergencies LOUISE O’DWYER, MBA, BSC (HONS), VTS (ANESTHESIA, ECC), DIP.AVN (MEDICAL & SURGICAL), RVN and

TRISH FARRY, CVN, VTS (ECC, ANESTHESIA/ANALGESIA), CERT.TAA, GCHED

Neonatal and pediatric patients differ significantly from their adult counterparts. Veterinary nurses and technicians must understand these patients’ unique physiologic differences and how they affect diagnosis and treatment of emergencies. To see the CE test for this article, please visit todaysveterinarytechnician.com.

Body Cavity Centesis: Techniques for the Pleural, Abdominal, and Pericardial Cavities H. EDWARD DURHAM, JR, CVT, RVT, LATG, VTS (CARDIOLOGY)

Body cavity centesis is a valuable and effective treatment for removal of large effusions. Although veterinarians generally perform centesis, it is important for veterinary technicians to be knowledgeable about the techniques used to properly prepare, assist with, and monitor these patients. To see the CE test for this article, please visit todaysveterinarytechnician.com.

FEATURES A Technician’s Role in the Treatment of Demodex Patients MISSY STREICHER, AAS, CVT

Diagnosis of demodicosis depends on identifying Demodex mites in dermal samples. Read this article for tips on how to obtain and analyze diagnostic samples.

Pain Management and Becoming a Patient Advocate JODY NUGENT-DEAL, RVT, VTS (ANESTHESIA/ANALGESIA, CLINICAL PRACTICE – EXOTIC COMPANION ANIMAL)

Information on pain management and assessment in veterinary patients has grown tremendously. This article provides an overview of common pharmaceuticals as well as advanced multimodal techniques to help veterinary technicians realize their role as patient advocates in minimizing pain.

Radiographic Positioning: Head, Shoulders, Knees, and Toes, Part 2 LIANE K. SHAW, BS, RVT, and JEANNINE E. HENRY, BA, RVT

This second of two articles on radiographic positioning provides an overview of proper patient restraint as well as techniques to obtain good-quality radiographs of the stifles, pelvis, and phalanges.

TODAY’SVETERINARYTECHNICIAN

March/April 2017

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

17136

TODAY’S VETERINARY TECHNICIAN

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

An Official Journal of the NAVC

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

MARCHAPRIL2017 COLUMNS

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

Editor’s Letter | If You Missed It…

LYNNE JOHNSON-HARRIS, LVT, RVT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Dosage Schedule Lufenuron per chewable

2 to 8 lbs.

2.3 mg

46 mg

22.8 mg

One

8.1 to 25 lbs.

5.75 mg

115 mg

57 mg

One

25.1 to 50 lbs.

11.5 mg

230 mg

114 mg

One

50.1 to 100 lbs.

23.0 mg

460 mg

228 mg

One

Over 100 lbs.

What Moves You? | Gratitude and Giving Back

Praziquantel per Number of chewable chewables

Milbemycin Oxime per chewable

Body Weight

ELIZABETH EXLINE, LVT.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46

Toxicology Talk | Cantharidin Toxicosis from Blister Beetles in Horses

MARYELLEN MALYSIAK, BS, CVT.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

CLINIC RESOURCES

Administer the appropriate combination of chewables

Colorado State University Feline Pain Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

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

Colorado State University Canine Pain Scale. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

SENTINEL SPECTRUM may be offered to the dog by hand or added to a small amount of dog food. The chewables should be administered in a manner that encourages the dog to chew, rather than to swallow without chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole. Care should be taken that the dog consumes the complete dose, and treated animals should be observed a few minutes after administration to ensure that no part of the dose is lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended.

Advertiser Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Careers | Employment Opportunities.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Contraindications There are no known contraindications to the use of SENTINEL SPECTRUM. Warnings Not for use in humans. Keep this and all drugs out of the reach of children. Precautions Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention.

LOGY DERMATO CANINE DEMODICOSIS

RADIOGRAPHIC POSITIONING TOES AND KNEES, PELVIS,

MEDICINE INTERNAL BODY CAVITY CENTESIS

MENT PAIN MANAGEG A BECOMIN TE PATIENT ADVOCA

TOXICOLOGY CANTHARIDIN TOXICOSIS

CHNICIAN TERINARYTE TODAY’SVE r2

Prior to administration of SENTINEL SPECTRUM, dogs should be tested for existing heartworm infections. At the discretion of the veterinarian, infected dogs should be treated to remove adult heartworms. SENTINEL SPECTRUM is not effective against adult D. immitis.

| An Official Journal

of the NAVC

| todaysveterinar

Pediatric ies: Emergenc THE CARING FOR NG VERY YOU

Mild, transient hypersensitivity reactions, such as labored breathing, vomiting, hypersalivation, and lethargy, have been noted in some dogs treated with milbemycin oxime carrying a high number of circulating microfilariae. These reactions are presumably caused by release of protein from dead or dying microfilariae. Do not use in puppies less than six weeks of age. Do not use in dogs or puppies less than two pounds of body weight. The safety of SENTINEL SPECTRUM has not been evaluated in dogs used for breeding or in lactating females. Studies have been performed with milbemycin oxime and lufenuron alone.

ytechnician.com

| Volume 2, Numbe

2017 | March/April

ON THE COVER Neonatal and pediatric patients differ significantly from their adult counterparts. Veterinary nurses and technicians must understand these unique physiologic differences and how they affect diagnosis and treatment. Photo: Shutterstock/ Nastivan

Adverse Reactions The following adverse reactions have been reported in dogs after administration of milbemycin oxime, lufenuron, or praziquantel: vomiting, depression/lethargy, pruritus, urticaria, diarrhea, anorexia, skin congestion, ataxia, convulsions, salivation, and weakness.

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.

To report suspected adverse drug events, contact Virbac at 1-800-338-3659 or the FDA at 1-888-FDA-VETS. Information for Owner or Person Treating Animal Echinococcus multilocularis and Echinococcus granulosus are tapeworms found in wild canids and domestic dogs. E. multilocularis and E. granulosus can infect humans and cause serious disease (alveolar hydatid disease and hydatid disease, respectively). Owners of dogs living in areas where E. multilocularis or E. granulosus are endemic should be instructed on how to minimize their risk of exposure to these parasites, as well as their dog’s risk of exposure. Although SENTINEL SPECTRUM was 100% effective in laboratory studies in dogs against E. multilocularis and E. granulosus, no studies have been conducted to show that the use of this product will decrease the incidence of alveolar hydatid disease or hydatid disease in humans. Because the prepatent period for E. multilocularis may be as short as 26 days, dogs treated at the labeled monthly intervals may become reinfected and shed eggs between treatments. Manufactured for: Virbac AH, Inc. P.O. Box 162059, Ft. Worth, TX 76161 NADA #141-333, Approved by FDA © 2015 Virbac Corporation. All Rights Reserved. SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation. 02/15

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

PUT RELIEF IN MOTION

Important Safety Information As a class, cyclooxygenase inhibitory NSAIDs may be associated with gastrointestinal, kidney or liver side effects. These are usually mild, but may be serious. Pet owners should discontinue therapy and contact their veterinarian immediately if side effects occur. Evaluation for pre-existing conditions and regular monitoring are recommended for pets on any medication, including PREVICOX. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided. Refer to the Prescribing Information for complete details. Merial is now part of Boehringer Ingelheim. REFERENCES: 1. Pollmeier M, Toulemonde C, Fleishman C, Hanson PD. Clinical evaluation of firocoxib and carprofen for the treatment of dogs with osteoarthritis. Vet Rec. 2006;159(17):547-551. 2. Data on file at Merial. ®PREVICOX is a registered trademark of Merial. ©2017 Merial, Inc. Duluth, GA. All rights reserved. PVX15TRADEADA-R (02/17).

CHEWABLE TABLETS Brief Summary: Before using PREVICOX, please consult the product insert, a summary of which follows: Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Indications: PREVICOX (firocoxib) Chewable Tablets are indicated for the control of pain and inflammation associated with osteoarthritis and for the control of postoperative pain and inflammation associated with soft-tissue and orthopedic surgery in dogs. Contraindications: Dogs with known hypersensitivity to firocoxib should not receive PREVICOX. Warnings: Not for use in humans. Keep this and all medications out of the reach of children. Consult a physician in case of accidental ingestion by humans. For oral use in dogs only. Use of this product at doses above the recommended 2.27 mg/lb (5.0 mg/kg) in puppies less than seven months of age has been associated with serious adverse reactions, including death (see Animal Safety). Due to tablet sizes and scoring, dogs weighing less than 12.5 lb (5.7 kg) cannot be accurately dosed. All dogs should undergo a thorough history and physical examination before the initiation of NSAID therapy. Appropriate laboratory testing to establish hematological and serum baseline data is recommended prior to and periodically during administration of any NSAID. Owners should be advised to observe for signs of potential drug toxicity (see Adverse Reactions and Animal Safety) and be given a Client Information Sheet about PREVICOX Chewable Tablets. For technical assistance or to report suspected adverse events, call 1-877-217-3543. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDAVETS or http://www.fda.gov/ AnimalVeterinary/SafetyHealth Precautions: This product cannot be accurately dosed in dogs less than 12.5 pounds in body weight. Consider appropriate washout times when switching from one NSAID to another or when switching from corticosteroid use to NSAID use. As a class, cyclooxygenase inhibitory NSAIDs may be associated with renal, gastrointestinal and hepatic toxicity. Sensitivity to drug-associated adverse events varies with the individual patient. Dogs that have experienced adverse reactions from one NSAID may experience adverse reactions from another NSAID. Patients at greatest risk for adverse events are those that are dehydrated, on concomitant diuretic therapy, or those with existing renal, cardiovascular, and/ or hepatic dysfunction. Concurrent administration of potentially nephrotoxic drugs should be carefully approached and monitored. NSAIDs may inhibit the prostaglandins that maintain normal homeostatic function. Such anti-prostaglandin effects may result in clinically significant disease in patients with underlying or pre-existing disease that has not been previously diagnosed. Since NSAIDs possess the potential to produce gastrointestinal ulceration and/or gastrointestinal perforation, concomitant use of PREVICOX Chewable Tablets with other anti-inflammatory drugs, such as NSAIDs or corticosteroids, should be avoided. The concomitant use of protein-bound drugs with PREVICOX Chewable Tablets has not been studied in dogs. Commonly used protein-bound drugs include cardiac, anticonvulsant, and behavioral medications. The influence of concomitant drugs that may inhibit the metabolism of PREVICOX Chewable Tablets has not been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy. If additional pain medication is needed after the daily dose of PREVICOX, a non-NSAID class of analgesic may be necessary. Appropriate monitoring procedures should be employed during all surgical procedures. Anesthetic drugs may affect renal perfusion, approach concomitant use of anesthetics and NSAIDs cautiously. The use of parenteral fluids during surgery should be considered to decrease potential renal complications when using NSAIDs perioperatively. The safe use of PREVICOX Chewable Tablets in pregnant, lactating or breeding dogs has not been evaluated. Adverse Reactions: Osteoarthritis: In controlled field studies, 128 dogs (ages 11 months to 15 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27mg/lb (5.0 mg/kg) orally once daily for 30 days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed adverse reactions during the study. Adverse Reactions Seen in U. S. Field Studies Adverse Reactions Vomiting Diarrhea Decreased Appetite or Anorexia Lethargy Pain Somnolence Hyperactivity

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

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

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

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

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

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

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

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

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

Post-Approval Experience (Rev. 2009): The following adverse reactions are based on post-approval adverse drug event reporting. The categories are listed in decreasing order of frequency by body system: Gastrointestinal: Vomiting, anorexia, diarrhea, melena, gastrointestinal perforation, hematemesis, hematachezia, weight loss, gastrointestinal ulceration, peritonitis, abdominal pain, hypersalivation, nausea Urinary: Elevated BUN, elevated creatinine, polydypsia, polyuria, hematuria, urinary incontinence, proteinuria, kidney failure, azotemia, urinary tract infection Neurological/Behavioral/Special Sense: Depression/lethargy, ataxia, seizures, nervousness, confusion, weakness, hyperactivity, tremor, paresis, head tilt, nystagmus, mydriasis, aggression, uveitis Hepatic: Elevated ALP, elevated ALT, elevated bilirubin, decreased albumin, elevated AST, icterus, decreased or increased total protein and globulin, pancreatitis, ascites, liver failure, decreased BUN Hematological: Anemia, neutrophilia, thrombocytopenia, neutropenia Cardiovascular/Respiratory: Tachypnea, dyspnea, tachycardia Dermatologic/Immunologic: Pruritis, fever, alopecia, moist dermatitis, autoimmune hemolytic anemia, facial/muzzle edema, urticaria In some situations, death has been reported as an outcome of the adverse events listed above. For a complete listing of adverse reactions for firocoxib reported to the CVM see: http://www.fda.gov/downloads/ AnimalVeterinary/SafetyHealth/ProductSafetyInformation/UCM055407.pdf Information For Dog Owners: PREVICOX, like other drugs of its class, is not free from adverse reactions. Owners should be advised of the potential for adverse reactions and be informed of the clinical signs associated with drug intolerance. Adverse reactions may include vomiting, diarrhea, decreased appetite, dark or tarry stools, increased water consumption, increased urination, pale gums due to anemia, yellowing of gums, skin or white of the eye due to jaundice, lethargy, incoordination, seizure, or behavioral changes. Serious adverse reactions associated with this drug class can occur without warning and in rare situations result in death (see Adverse Reactions). Owners should be advised to discontinue PREVICOX therapy and contact their veterinarian immediately if signs of intolerance are observed. The vast majority of patients with drug-related adverse reactions have recovered when the signs are recognized, the drug is withdrawn, and veterinary care, if appropriate, is initiated. Owners should be advised of the importance of periodic follow up for all dogs during administration of any NSAID. Effectiveness: Two hundred and forty-nine dogs of various breeds, ranging in age from 11 months to 20 years, and weighing 13 to 175 lbs, were randomly administered PREVICOX or an active control drug in two field studies. Dogs were assessed for lameness, pain on manipulation, range of motion, joint swelling, and overall improvement in a non-inferiority evaluation of PREVICOX compared with the active control. At the study’s end, 87% of the owners rated PREVICOX-treated dogs as improved. Eighty-eight percent of dogs treated with PREVICOX were also judged improved by the veterinarians. Dogs treated with PREVICOX showed a level of improvement in veterinarian-assessed lameness, pain on palpation, range of motion, and owner-assessed improvement that was comparable to the active control. The level of improvement in PREVICOX-treated dogs in limb weight bearing on the force plate gait analysis assessment was comparable to the active control. In a separate field study, two hundred fifty-eight client-owned dogs of various breeds, ranging in age from 10.5 weeks to 16 years and weighing from 7 to 168 lbs, were randomly administered PREVICOX or a control (sham-dosed-pilled) for the control of postoperative pain and inflammation associated with soft-tissue surgical procedures such as abdominal surgery (e.g., ovariohysterectomy, abdominal cryptorchidectomy, splenectomy, cystotomy) or major external surgeries (e.g., mastectomy, skin tumor removal ≤8 cm). The study demonstrated that PREVICOXtreated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with soft-surgery. A multi-center field study with 226 client-owned dogs of various breeds, and ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group was conducted. Dogs were randomly assigned to either the PREVICOX or the control (sham-dosedpilled) group for the control of postoperative pain and inflammation associated with orthopedic surgery. Surgery to repair a ruptured cruciate ligament included the following stabilization procedures: fabellar suture and/or imbrication, fibular head transposition, tibial plateau leveling osteotomy (TPLO), and ‘over the top’ technique. The study (n = 220 for effectiveness) demonstrated that PREVICOX-treated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with orthopedic surgery. Animal Safety: In a targeted animal safety study, firocoxib was administered orally to healthy adult Beagle dogs (eight dogs per group) at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated dose of 5 mg/kg, there were no treatment-related adverse events. Decreased appetite, vomiting, and diarrhea were seen in dogs in all dose groups, including unmedicated controls, although vomiting and diarrhea were seen more often in dogs in the 5X dose group. One dog in the 3X dose group was diagnosed with juvenile polyarteritis of unknown etiology after exhibiting recurrent episodes of vomiting and diarrhea, lethargy, pain, anorexia, ataxia, proprioceptive deficits, decreased albumin levels, decreased and then elevated platelet counts, increased bleeding times, and elevated liver enzymes. On histopathologic examination, a mild ileal ulcer was found in one 5X dog. This dog also had a decreased serum albumin which returned to normal by study completion. One control and three 5X dogs had focal areas of inflammation in the pylorus or small intestine. Vacuolization without inflammatory cell infiltrates was noted in the thalamic region of the brain in three control, one 3X, and three 5X dogs. Mean ALP was within the normal range for all groups but was greater in the 3X and 5X dose groups than in the control group. Transient decreases in serum albumin were seen in multiple animals in the 3X and 5X dose groups, and in one control animal. In a separate safety study, firocoxib was administered orally to healthy juvenile (10-13 weeks of age) Beagle dogs at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated (1X) dose of 5 mg/kg, on histopathologic examination, three out of six dogs had minimal periportal hepatic fatty change. On histopathologic examination, one control, one 1X, and two 5X dogs had diffuse slight hepatic fatty change. These animals showed no clinical signs and had no liver enzyme elevations. In the 3X dose group, one dog was euthanized because of poor clinical condition (Day 63). This dog also had a mildly decreased serum albumin. At study completion, out of five surviving and clinically normal 3X dogs, three had minimal periportal hepatic fatty change. Of twelve dogs in the 5X dose group, one died (Day 82) and three moribund dogs were euthanized (Days 38, 78, and 79) because of anorexia, poor weight gain, depression, and in one dog, vomiting. One of the euthanized dogs had ingested a rope toy. Two of these 5X dogs had mildly elevated liver enzymes. At necropsy all five of the dogs that died or were euthanized had moderate periportal or severe panzonal hepatic fatty change; two had duodenal ulceration; and two had pancreatic edema. Of two other clinically normal 5X dogs (out of four euthanized as comparators to the clinically affected dogs), one had slight and one had moderate periportal hepatic fatty change. Drug treatment was discontinued for four dogs in the 5X group. These dogs survived the remaining 14 weeks of the study. On average, the dogs in the 3X and 5X dose groups did not gain as much weight as control dogs. Rate of weight gain was measured (instead of weight loss) because these were young growing dogs. Thalamic vacuolation was seen in three of six dogs in the 3X dose group, five of twelve dogs in the 5X dose group, and to a lesser degree in two unmedicated controls. Diarrhea was seen in all dose groups, including unmedicated controls. In a separate dose tolerance safety study involving a total of six dogs (two control dogs and four treated dogs), firocoxib was administered to four healthy adult Beagle dogs at 50 mg/kg (ten times the recommended daily dose) for twenty-two days. All dogs survived to the end of the study. Three of the four treated dogs developed small intestinal erosion or ulceration. Treated dogs that developed small intestinal erosion or ulceration had a higher incidence of vomiting, diarrhea, and decreased food consumption than control dogs. One of these dogs had severe duodenal ulceration, with hepatic fatty change and associated vomiting, diarrhea, anorexia, weight loss, ketonuria, and mild elevations in AST and ALT. All four treated dogs exhibited progressively decreasing serum albumin that, with the exception of one dog that developed hypoalbuminemia, remained within normal range. Mild weight loss also occurred in the treated group. One of the two control dogs and three of the four treated dogs exhibited transient increases in ALP that remained within normal range. Made in France Marketed by: Merial, Inc., Duluth, GA 30096-4640, U.S.A. 1-877-217-3543 NADA 141-230, Approved by FDA Rev. 09-2015 ®PREVICOX is a registered trademark of Merial. ©2016 Merial, Inc., Duluth, GA. All rights reserved.

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EDITOR’S LETTER

If You Missed It… Lynne Johnson-Harris, LVT, RVT | Editor in Chief

I have had the pleasure of being involved with NAVC for more than 27 years as a speaker, moderator, member of the Board of Directors, and President. But after last week, all I can say is…wow! NAVC just completed its 2017 Conference—the last one with that name—in its new home, the Orange County Convention Center (OCCC). Of all the NAVC Conferences I have attended, this one was the most amazing. Some of the highlights: ÆÆ We unveiled a new name for the conference: the NAVC Veterinary Meeting and Expo, or VMX. The new name reflects the fact that NAVC is no longer just a conference, but a whole community that includes VetFolio, Institute, publications like Today’s Veterinary Technician, and much more. ÆÆ It was another record year for attendance. The conference hosted more than 17,000 veterinary healthcare professionals and offered more than 1200 CE hours. Veterinary technician tracks alone accounted for 77 hours of CE. ÆÆ The Exhibit Hall was one huge—and busy— place! More than 700 exhibitors representing all areas of veterinary healthcare were present. It was a mile from end to end, I’m sure (I walked it several times a day). ÆÆ Congratulations go to Kara Burns, MS, Med, LVT, VTS (Nutrition), and Kenichiro Yagi, BS, RVT, VTS (ECC, SAIM). Kara received the

EDITOR’S LETTER

NAVC Veterinary Technician 2016 Speaker of the Year Award; she was also honored with this award in 2013. Ken received the NAVTA Veterinary Technician of the Year Award. ÆÆ The entertainment was outstanding. We were inspired by Robin Roberts, co-host of Good Morning America, who launched the conference at its General Session. Mike Rowe shared his “dirty jobs” with us at the Opening Ceremony, and Darius Rucker rocked the house as part of our annual Concert Series. Football fans watched the “Big Game” on the big screen at a party that featured food, fun, and adoptable puppies! ÆÆ Veterinary technicians, veterinary technician students, and practice managers had the chance to recharge and network in their own space—the Veterinary Technicians’ Lounge— and then stepped into “Wonderland” at a sponsored reception. ÆÆ Finally, on the last night, we stepped back into the ‘60s and ‘70s, with people dressed in go-go boots, miniskirts, leisure suits, and all, at the RECHARGING in the Veterinary Technicians’ Lounge. Studio 54 Finale Party. I’ll admit, it wasn’t a perfect transition. Change is always hard, and it takes a lot of hard work. But I know the NAVC folks—myself included— are already on the job for a great 2018. So if you missed the last NAVC Conference, I invite you to join us at the first VMX at the OCCC South Concourse, February 3 through 7, 2018. It will be awesome! 

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

TODAY’SVETERINARYTECHNICIAN

March/April 2017

1 Credit Continuing Education | Peer Reviewed CONTINUING EDUCATION CONTINUING EDUCATION

M E E T T H E AU T H O R S

Louise Oâ&#x20AC;&#x2122;Dwyer, MBA, BSc (Hons), VTS (Anesthesia, ECC), DipAVN (Medical & Surgical), RVN Vets Now United Kingdom

shutterstock.com/Anurak Pongpatimet

Pediatric Emergencies The neonatal stage is a major risk period in dogs, as around 20% of live-born puppies die before they are 21 days old, with 70% of those deaths being in the first week postpartum.1,2 A similar mortality rate is expected in kittens.1,2 The Apgar scoring system is used to evaluate newborn humans but is not commonly used for newborn puppies and kittens. Other methods are used in veterinary medicine , including the neonatal resuscitation form used at the University of Pennsylvania Ryan Veterinary Hospital. Parameters measured using this scoring system include respiratory effort, heart rate, muscle tone, response to stimulation, and mucous membrane color (BOX 1). The terms neonate and pediatric tend to be used interchangeably, but cats and dogs are normally defined as being neonates for the first 7 to 14 days of life. Neonates have poor neurologic function and are completely dependent on the dam or queen, as their auditory and visual senses, along with spinal reflexes, are continuing to develop. The term pediatric is used to describe animals between 2 and 6 weeks of age,4 although some texts describe pediatric patients as being between 2 weeks and 6 months of age.

Louise has contributed to more than 35 books, journal articles, and book chapters, and lectures worldwide on all aspects of anesthesia, emergency and critical care, surgery, and infection control. After 15 years working at PetMedics in Manchester, England, as Head Nurse and then Clinical Director, in October 2015, she moved to Vets Now to take up the position of Clinical Support Manager. continued on page 65

Trish Farry, CVN, VTS (ECC, Anesthesia/Analgesia), CertTAA, GCHEd University of Queensland Queensland, Australia Trish Farry is an Australian certified nurse with specialist qualifications in emergency/ critical care and anesthesia/ analgesia. She is an associate lecturer and clinical instructor in anesthesia at the School of Veterinary Science at The University of Queensland, where she also co-coordinates the final year of the Bachelor of Veterinary Technology program. Her areas of teaching include emergency medicine, continued on page 65

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

TODAYâ&#x20AC;&#x2122;SVETERINARYTECHNICIAN

March/April 2017

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

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 a 45 of 126 dogs 59 of 130 dogs NYHA classification, pulmonary edema score by a arrhythmias 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

Peer Reviewed

PHYSIOLOGIC CHARACTERISTICS OF PEDIATRIC PATIENTS Neonatal and pediatric patients differ significantly from their adult counterparts. Veterinary nurses and technicians must understand these unique physiologic differences and how they affect diagnosis and treatment (TABLE 1). Thermoregulatory Mechanisms Normal body temperature in neonates is 96°F to 97°F at birth, rising to 100°F by 4 weeks of age. By the time of weaning, rectal temperature approaches that of adults. Thermoregulation in neonates is difficult because they are unable to shiver and show poor peripheral vasoconstriction in response to hypothermia. They also lack fully developed organs (liver) that contribute to cellular metabolism

TABLE 1 Common Pediatric Emergencies CONDITION

THERAPY

Anorectic

Nutritional supplementation

Hypoglycemia

IV glucose or dextrose boluses (0.5–1.5 mL/kg IV of 50% concentration diluted 1:1–1:2, or 2–4 mL/kg of a 10% solution If IV access is not available, oral glucose can be administered Isotonic fluids supplemented with 2.5%–5% glucose as a constant-rate infusion can also be used

Hypoxia

Oxygen supplementation Reversal of any agents likely to cause respiratory depression: for opioids, naloxone; for benzodiazepines, flumazenil; consider administration of doxapram

Hypothermia

Slow warming over 1–3 hours Check temperature before feeding (hypothermia can cause ileus) and do not feed if temperature is <93.9°F and/or no bowel sounds are heard on abdominal auscultation Consider supplemental oxygen, but avoid neonate becoming cold

Dehydration

Fluid therapy: 120–180 mL/kg/day in neonates; 80–120 mL/kg/day in pediatrics

Hypovolemia

Administer shock rate bolus of crystalloids: 30–45 mL/kg, dogs; 20-30 mL/kg, cats

CONTINUING EDUCATION

and produce heat. Neonates also have little body fat and poor blood flow to the periphery and lack the ability to pant, additional factors that make them unable to respond properly to hyperthermia. Cardiorespiratory System In the fetal circulatory system, blood is shunted past nonfunctioning lungs via the ductus arteriosus, which is located between the left pulmonary artery and ascending aorta. During intrauterine life, fetal respiration is through a blood–gas exchange process across the placenta. In the last days before birth, production of surfactant in the lungs is stimulated. When the umbilical cord is separated at birth, the respiratory and cardiovascular systems undergo numerous changes. Umbilical circulation stops, resulting in severe hypoxia. At the same time, peripheral resistance in the

BOX 1 Viability Scoring Systems In human pediatric medicine, the Apgar scoring system is used to objectively measure neonatal viability during the first few minutes of life. This is not commonly used in veterinary medicine, but other systems have been developed. Apgar evaluates such parameters as muscle tone, respiratory effort, heart rate, response to stimulation, and mucous membrane color. This system gives clinicians information about the general condition of the neonate, and the scores allocated to an animal correspond with the chance of survival and viability. Studies have demonstrated that a decreased rooting reflex and suckling and swallowing response are related to reduced Apgar scores.3 The University of Pennsylvania Ryan Veterinary Hospital has a canine neonatal status and treatment form that features a version of the Apgar score for veterinary patients; it allocates scores based on heart rate, respiratory effort, mucous membrane color, spontaneous activity and muscle tone, suckle reflex, and lumbosacral stimulation. Neonates are allocated a score from 0 to 2 for each parameter, with a potential maximum score of 12. The evaluation also considers interventions that have been carried out, including oxygen therapy, ventilator assistance, acupuncture, chest compressions, use of doxapram, and administration of dextrose and fluids.

TODAY’SVETERINARYTECHNICIAN

March/April 2017

Pediatric Emergencies PEER REVIEWED

peripheral vessels increases. The sense of dyspnea prompts the first chest contraction and the creation of negative pressure within the lungs, which allows air to enter the lungs. The increase in oxygen tension allows the ductus arteriosus to narrow and the pulmonary vessels to dilate. The ductus usually closes 2 to 5 days after birth. Normal heart rate for neonates is usually around 200 to 220 beats/min in the first week of life.5 Compared with adults, newborns have decreased stroke volume and peripheral vascular resistance and lower blood pressure. They maintain perfusion by having a much higher heart rate, cardiac output, plasma volume, and central venous pressure.5 The baroreflex control of their circulation is not fully developed because of incomplete autonomous innervations of heart and vessels; myocardial contractility is also limited. Heart rhythm is usually a normal sinus, as the vagal reflex develops around 8 weeks of age. It is important to remember that in the first 4 to 5 days of life, neonates respond to hypoxemia with bradycardia and hypotension; thus a heart rate around 150 beats/min in a neonate should suggest a serious underlying disease. Normal respiratory rate in neonates is approximately 15 to 35 breaths/min; it becomes similar to that of adults at 4 weeks of age. Neonates are susceptible to relative hypoxemia because of their large metabolic oxygen requirement and the immaturity of carotid body chemoreceptors. Lung expansion in newborns is essential to release both surfactant and prostacyclin, which increases pulmonary blood flow and pulmonary vasodilation. Nitric oxide synthesis is probably induced by fetal oxygenation and may also contribute to pulmonary vasodilation, therefore resulting in less pulmonary vascular resistance at birth and subsequent closure of the ductus arteriosus.6 Furthermore, because of a higher compliance of the thoracic wall, neonates must work much harder at breathing to maintain a normal tidal volume compared with adults. This factor is important to remember as any respiratory disorder that shortens inspiratory duration has the potential to negatively affect gas exchange.

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Neurologic System Normal neonate puppies or kittens spend most of their day sleeping; when awake, they should be able to respond to odor, touch, and pain. They should show strong suckle, rooting, and righting reflexes. The withdrawal reflex should be present, although it is often slower than in adults. The menace reflex normally is not fully developed until 16 weeks of age but can be present as early as 2 weeks in some animals. Pupillary light reaction should be present around 10 to 20 days of age, and vision is normal by 30 days. Pediatric puppies and kittens have a more developed neurologic system, and a neurologic examination can be performed around 6 to 8 weeks of age, when the postural reaction should be present. Gastrointestinal System At birth, the gastrointestinal (GI) tract is sterile and characterized by a neutral gastric pH and timedependent increased permeability of the intestinal mucosa, which decreases dramatically after 10 hours. The motility of the GI tract is affected by the presence of food and especially body temperature; temperature <94Â°F is associated with GI stasis and paralytic ileus, so checking body temperature in neonates before they feed is useful in the detection and prevention of ileus. Kidney function and development are incomplete in neonates, with nephrogenesis continuing for at least 2 weeks after birth. Because of this, neonates are unable to concentrate their urine. Glomerular filtration rate is decreased, as is rate of tubular secretion, reaching adult level at 8 weeks of age. Autoregulation of renal blood flow and glomerular filtration rate in neonatal puppies appear to be relatively inefficient in response to rapid changes in systemic arterial blood pressure.7 In adult dogs, the reninâ&#x20AC;&#x201C; angiotensin system is an important regulatory mechanism; however, in neonates, renal blood flow is directly correlated with arterial pressure and does not seem to be altered by inhibition of angiotensin until approximately 6 weeks of age. Caution must be exercised when administering renally excreted or metabolized antimicrobials (penicillin, ampicillin, cephalosporins,

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fluoroquinolones, and aminoglycosides) to neonates and pediatric patients. Neonates have immature liver function and limited glycogen stores, and gluconeogenesis impaired. Hepatic glucose stores will be depleted after 24 hours and hypoglycemia will ensue. In addition, neonates have poorly developed microsomal and P450 enzyme activity until 4 to 5 months of age, so caution must be exercised when using medications that require hepatic metabolism or excretion.7 Immunologic Immunity The ingestion of colostrum is essential during the first 12 to 24 hours of life, as only 5% of maternal antibodies are acquired transplacentally. Pediatric patients are unlikely to have fully developed immune systems until around 3 to 4 months of age.8 Puppy survival within the early weeks is highly dependent on colostrum, a specific secretion of the mammary gland produced during the first 2 days postpartum. Colostrum is the first mammary secretion produced after delivery (and is occasionally present before parturition), with the transition to milk occurring between day 2 and 3 of lactation; it is both a source of nutrients, including high amounts of protein and lipid, and a source of immunoglobulins (IgG), as puppies are almost agammaglobulinemic at birth.8 This means the risk of neonatal mortality depends on two factors: the quality of the transfer of passive immunity (evaluated by circulating IgG levels at 2 days of age) and the growth of the puppy during its first 2 days.9 Despite this essential requirement of colostrum for immunity and calorie energy, there are no guarantees that all puppies or kittens in a litter will consume sufficient amounts of colostrum. Colostrum also contains a number of cells, including macrophages, neutrophils, and lymphocytes, that must be consumed by the puppy before the intestinal barrier closes; these cells also play an essential role in cellular, humoral, and local digestive immunity.10,11 For passive immunity to be acquired, puppies must receive colostrum within the first 8 hours of life. This timeframe is critical for two reasons: colostral

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IgG decreases rapidly in the first few hours postpartum, and the intestinal barrier closes rapidly (within 24 hours in puppies and 16 hours in kittens), meaning that macromolecules (including IgG) can no longer cross the intestinal wall to enter the bloodstream. Thus, while puppies absorb around 40% of ingested colostral IgG at birth, only 20% is absorbed 4 hours after delivery and 9% at 12 hours.8 Nutritional Requirements Because of their limited glycogen stores, it is essential that neonates suckle every 1 to 2 hours, spending the remainder of their time sleeping. Provided the dam is in good health, her milk will be sufficient to maintain a litterâ&#x20AC;&#x2122;s health for the first 3 to 4 weeks. In situations in which milk production is nonexistent (e.g., death of the dam or queen, agalactia [lack of milk]) or insufficient (e.g., mastitis, an exceptionally large litter), milk substitutes will be required; they can also be used if neonates have low body weight at birth (e.g., 25% less than the expected average for the breed), lose >10% of their initial weight in the first 24 hours of life, or do not double their birth weight in the first 2 weeks of life8 (FIGURE 1). Milk produced by dams and queens has a high lipid content because neonates use fat, not lactose, as an energy source. Thus any milk substitute needs to replicate this. Cowâ&#x20AC;&#x2122;s milk, which is rich in lactose but low in fat and protein, is completely unsuitable. Neonates have a daily energy requirement of

FIGURE 1. Neonates should be weighed regularly.

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Pediatric Emergencies



PEER REVIEWED

around 20 to 26 kcal/100 g body weight, but most commercial milk replacements generally have only 1 kcal/100 g. Most neonates have a stomach capacity of about 4 mL/kg; therefore, it is possible to estimate an individual’s nutritional requirements and the frequency of feeding needed to meet them.8 When feeding neonates, a bottle, syringe (FIGURE 2), or orogastric tube can be used as appropriate, and a suckling reflex should be present before feeding is attempted. A feeding bottle, or sometimes a sponge, is ideal, as this initiates the suckling reflex, therefore reducing the risk of aspiration. During feeding, a neonate should be held in a normal feeding position (horizontally without an overly stretched neck; FIGURE 3). Ideally, body temperature should be assessed before feeding. If it is low, gut motility is reduced, and ileus can occur, the abdomen will become distended, and regurgitation may occur, potentially resulting in aspiration pneumonia. Body temperature should be at least 86°F and/or intestinal sounds auscultated before commencing supplemental feeding. If intestinal sounds are present at a lower body temperature, feeding can be initiated, as this suggests sufficient GI motility.

FIGURE 2. Puppy feeding from a syringe with a teat added.

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TECHPOINT 

Pediatric patients have glucose requirements 2 to 4 times those of adults. Neonates should be observed for signs of overfeeding while being fed. These signs include milk at the nostrils, regurgitation, abdominal distention or discomfort, and diarrhea.8 COMMON EMERGENCIES IN PEDIATRIC PATIENTS Hypoglycemia Pediatric patients have glucose requirements 2 to 4 times those of adults. Hypoglycemia may be a sequela of vomiting, diarrhea, anorexia, dehydration, and/or infection, or it may be a result of decreased hepatic glycogen stores, inefficient hepatic gluconeogenesis, or loss of glucose in the urine. Urinary glucose reabsorption normalizes at approximately 3 weeks of age in puppies. Liver glycogen stores are rapidly depleted in neonatal patients, providing glucose for only a limited time in fasting neonates. The neonatal myocardium uses glucose for energy, whereas adults rely on long-chain fatty acids as a substrate to the myocardium.4

FIGURE 3. Feeding should be performed with the neonate in a normal feeding position.

Clients want to fight fleas and ticks – not their dogs. Protect dogs with the beefflavored chew they love.1

Data on file at Merial.

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.

Pediatric Emergencies PEER REVIEWED

The neonatal brain requires glucose and carbohydrates as its main energy sources, and prolonged hypoglycemia in pediatric patients may result in permanent brain damage. In adults, glucagon, cortisol, epinephrine, and growth hormone are released in response to hypoglycemia to help facilitate euglycemia by increasing gluconeogenesis and antagonizing insulin. These hormones are not released in neonates as these patients have inefficient counterregulatory hormone release during a hypoglycemic event.3 Pediatric patients with hypoglycemia may present with many clinical signs, including hypothermia, weakness, seizures, lethargy, and anorexia; they should be treated immediately. Hypoglycemia is considered significant when blood glucose is <40 mg/dL. Intravenous (IV) dextrose boluses (1 mL/kg of 12.5% dextrose [dilute 50% dextrose 1:4 with sterile water]) should be administered. To decrease the risk of rebound hypoglycemia, the bolus should be followed by an infusion of isotonic fluids supplemented with 2.5% to 5% dextrose. Hypoglycemia can become refractory, and patients may require hourly dextrose boluses in addition to a dextrose-containing infusion. Blood glucose should be monitored regularly until hypoglycemia is stabilized. Care must be taken to prevent oversupplementation, as prolonged hyperglycemia may lead to osmotic diuresis, thereby worsening dehydration.6

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

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

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

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

N1 17 13 13 7 5

% (n=415) 4.1 3.1 3.1 1.7 1.2

Oral active control

N2 25 2 7 4 9

% (n=200) 12.5 1.0 3.5 2.0 4.5

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

Hypoxia Any neonate or pediatric patient that demonstrates clinical signs of hypoxemia, including dyspnea, cyanosis, orthopnea, tachypnea, and abnormal lung sounds on auscultation, requires immediate oxygen supplementation. Bradycardia and hypotension are also found in hypoxic neonates.5 Because of the lower packed cell volume in neonates, cyanosis can be much more difficult to observe, as visual detection of cyanosis is dependent on hemoglobin concentration.6 Clinical signs of hypoxia are not common in newly born puppies and kittens as neonates

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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T E C HP O I N T 

Veterinary technicians must be aware that normal methods for assessing hydration may be unreliable in sick neonates. tend not to hyperventilate until they are several days old, and most newborn animals, including those born via cesarean section, tend to recover within 45 minutes.5 Numerous factors can result in respiratory distress, including decreased surfactant in the lungs, aspiration of meconium, pneumonia, and congenital defects that can result in hypertension. Respiratory distress may also be caused by drugs used during anesthesia of the dam or queen for cesarean section (e.g., sedatives, anesthetic agents); if this is a consideration, reversal agents (e.g., naloxone, flumazenil) should be administered. If hypoxia is detected, it should be treated appropriately as it may lead to complications including respiratory depression, bacterial translocation, and chilling, which in turn can reduce resistance against bacterial infections.5 Therapy should comprise oxygen supplementation via an appropriate route, which may include flow-by (FIGURE 4), incubator, or endotracheal tube. When choosing an oxygen supplementation technique, it should be remembered that the fraction of inspired oxygen (FiO2) should not exceed 40% to 60%. The FiO2 is the concentration of oxygen a patient is inhaling. For example, a patient breathing room air will have a FiO2 of 21%. Oxygen toxicosis can manifest as acute respiratory distress syndrome or retrolental fibroplasia (which can result in blindness) as a result of prolonged exposure to a high FiO2. Care also needs to be taken to prevent high concentrations of oxygen from coming

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CONTINUING EDUCATION

into direct contact with the eyes, as this can result in retinal detachment.12 If patients do require high levels of oxygen to relieve the signs of respiratory distress, the use of positive-pressure ventilation should be considered; in reality, however, this can be difficult to provide in these small patients.6 Hypothermia Neonates are unable to thermoregulate and depend on environmental heat sources to maintain their body temperature (poikilothermic) up to 4 weeks of age. They have well-developed behavioral heat-seeking responses that enable them to maintain body temperature if heat sources are available. Neonates are prone to hypothermia because of their greater surface area:body weight ratio, immature metabolism, and impaired shivering and vasoconstrictive mechanisms.7,13

FIGURE 4. Flow-by oxygen being administered to a newly born neonate.

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Pediatric Emergencies PEER REVIEWED

Knowledge of the average body temperatures of pediatric patients is vitally important when nursing these patients. In the first week after birth, normal body temperatures in puppies should be between 96°F and 97°F, increasing to 100°F by 4 weeks of age. At birth, body temperature in kittens should be 98°F, increasing to 100°F by 4 weeks of age. Physiologic responses to hypothermia (<86°F) may include cardiopulmonary depression and bradycardia, which in time may lead to hypoxia. Normal heart rate is 200 to 220 beats/min during the first 2 weeks. Vagal tone is achieved in neonatal patients at approximately 2 weeks of age, after which time the heart rate should decrease to a normal range of 100 to 140 beats/min.3 Hypothermic patients should be warmed slowly before being fed, as hypothermia may result in GI ileus and inability to absorb orally consumed nutrients. Neonates should be warmed slowly over 1 to 3 hours to prevent overheating. Rapid warming or overheating may cause peripheral vasodilation, which can result in core body temperature shock due to decreased circulating volume to the core.6 Many heat sources can be valuable in warming hypothermic neonates, including heat mats, heat lamps, hot water bottles, and warm towels/blankets. To prevent overheating, neonates should be given space to crawl away from any heat source. Human neonatal incubators are a good option for these patients as the temperature and humidity can be controlled and oxygen supplementation can also be added if necessary.

mucous membranes, prolonged capillary refill time, cold extremities, lethargy, decreased urine output, and reluctance to suckle. Dehydration and hypovolemia most commonly occur as a result of diarrhea, vomiting, or decreased fluid intake.14 Veterinary technicians must be aware that normal methods for assessing hydration may be unreliable in sick neonates. Skin turgor, commonly used in adult cats and dogs, is less reliable in neonates owing to their increased water content and decreased subcutaneous fat. Tachycardia and concentrated urine, responses seen to dehydration in adult patients, do not occur in neonates because their heart rate is already rapid and they are unable to concentrate urine. In neonatal patients, mucous membranes often remain moist until dehydration is severe. Newborns up to 1 week in age have hyperemic mucous membranes. After this time, mucous membrane color and capillary refill time can be used as an indicator of dehydration and shock. Clinical pathology may also be difficult to interpret as neonates have lower packed cell volume, albumin, and total solids values. Neonates that are unable to suckle for the first 24 hours are at high risk for developing infections (because of the deprivation of colostrum), and care must be taken, as with all patients, to adhere to strict asepsis when administering fluid therapy.14 Routes of administration for fluid therapy include subcutaneous (SC), intraosseous (IO; FIGURE 5), IV, and intraperitoneal (IP). IV or IO fluid therapy is indicated in severely dehydrated patients or those with perfusion deficits. These routes are best for aggressive fluid resuscitation. IV fluid administration is ideal

Dehydration Pediatric patients (particularly neonates) have higher fluid requirements than adults because of their increased extracellular fluid requirements. Decreased body fat, higher metabolic rate, decreased renal concentrating ability, greater surface area:body weight ratio, and increased respiratory rate lead to greater insensible fluid losses. As a result of these factors, dehydration can occur much more acutely and rapidly in pediatric patients. Signs a neonate is dehydrated may include pale

FIGURE 5. Intraosseous catheter in situ.

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2018

SAVE THE DATES

February 3-7, 2018 (Exhibits 4-7) • Orlando, Florida Orange County Convention Center • South Concourse

For more information visit NAVC.com/VMX

Pediatric Emergencies PEER REVIEWED

but sometimes may not be possible in severely dehydrated or small patients. If IV access is not possible, IO administration is the preferred route for fluid therapy. This can be achieved by using an 18- to 22-gauge spinal or hypodermic needle placed in the proximal femur, proximal humerus, head of the tibial crest, or wing of the ileum. As with IV catheterization, strict asepsis must be followed during IO catheterization. IO catheters can be problematic to secure; once vascular volume has been restored, it may be of benefit to place an IV catheter. Because of the small size of these patients, the jugular vein is commonly used for IV catheterization. Cephalic catheterization may also be achievable using an appropriate-size catheter. In severely dehydrated or hypovolemic patients, fluid rates administered via the IO or IV route should include an initial shock dose of a balanced crystalloid (20–40 mL/kg in puppies; 20–30 mL/kg in kittens). After stabilization, maintenance rates should be administered depending on the age of the patient (80–180 mL/kg/day). As with all fluid therapy, ongoing losses should be taken into account when instigating a fluid plan. Blood glucose should be monitored frequently and supplementation implemented promptly in hypoglycemic patients (see HYPOGLYCEMIA). If IV or IO access is not achievable, fluids may be given into the intraperitoneal space. Fluids than can be administered via the IP route include colostrum, whole blood, and crystalloid solutions. Hypertonic dextrose solutions should be avoided: they will pull fluid from the intravascular space and interstitium into the abdominal cavity. The absorption of blood administered IP is slow (48–72 hours); therefore, this route of blood administration is not appropriate for treating patients with severe anemia.14 SC fluids may be administered to neonates with mild to moderate dehydration. Maintenance fluid rates for pediatric patients (120–180 mL/kg/day) are significantly higher than for adults.15 Once calculated, the appropriate amount of fluid can be administered as several boluses or as an infusion. The volume of fluid is calculated at maintenance plus the dehydration deficit (% dehydration x body weight in kg). The best

TODAY’SVETERINARYTECHNICIAN

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fluid to correct mild to moderate dehydration is a balanced electrolyte solution such as Normosol-R or lactated Ringer’s solution. Ongoing monitoring of dehydrated patients should include weighing the patient every 8 hours as well as measuring electrolyte and glucose status. When urine specific gravity (USG) reaches 1.020, dehydration is likely; USG can also be regularly monitored as an indicator of rehydration.16 In patients younger than 8 weeks, normal USG is 1.006 to 1.017. All fluids administered should be warmed to body temperature before being administered to aid in the prevention of hypothermia. CONCLUSION Understanding the unique differences between pediatric and adult patients will assist veterinary nurses and technicians in the care of these patients. Recognizing how these differences can affect diagnosis and treatment can be challenging and intimidating but also extremely rewarding and educational.  References 1. Mila H, Grellet A, Chastant-Maillard S. Prognostic value of birth weight and early weight gain on neonatal and pediatric mortality: a longitudinal study on 870 puppies. Program and Abstracts, 7th ISCFR Symposium 2012:163164. 2. Gill MA. Perinatal and late neonatal mortality in the dog. University of Sydney 2001. PhD thesis; available at http:// hdl.handle.net/2123/4137. Accessed September 2015. 3. Lopate C The critical neonate: under 4 weeks of age. NAVC Clin Brief November 2009;9-13. 4. McMicheal M. Pediatric emergencies. Vet Clin North Amer Small Anim Pract 2005;35(2):421–434. 5. Casal M. Management and critical care of the neonate. In: England G, von Heimendahl A, eds. BSAVA Manual of Canine and Feline Reproduction and Neonatology. 2nd ed. Gloucester, UK: British Small Animal Veterinary Association; 2013:135–146. 6. Lee J, Cohn JA. Pediatric critical care: part 2—monitoring and treatment. Clin Brief February 2015:39–44. 7. Valtolina C. Physiological differences and general approach to pediatric patients. Proc European Vet Emerg Crit Care Soc Pre-Congr Prague, Czech Republic; 2014:6-8. 8. Chastant-Maillard S, Mila H. Canine colostrum. Vet Focus 2016;(26)1:32-38. 9. Mila H, Grellet A, Feugier A, et al. Differential impact of birth weight and early growth rate on neonatal mortality in puppies. J Anim Sci 2015;93(9):4436-4442. 10. Wheeler TT, Hodgkinson AJ, Prosser CG, et al. Immune components of colostrum and milk—a historical perspective. J Mam Gland Biol Neoplasia 2007;12(4): 237-247. continued on page 65

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A Technician’s Role in the Treatment of Demodex Patients

M E E T T H E AU T H O R

Missy Streicher, AAS, CVT Auburn University College of Veterinary Medicine

First described in 1842 by Gustav Simon, a French dermatologist, Demodex mites are normal skin inhabitants of many mammals, and >140 species of Demodex have been identified (2 in humans, 3 in dogs).1 The mites live in hair follicles as well as the sebaceous glands and ducts and feed off of sebum, cells, and debris from the epidermis.2,3 In dogs, the mites are passed from the bitch to her puppies through close contact while nursing. Transfer of mites is noted on the pups as early as 16 hours4 but usually takes place within the first 2 to 3 days after birth.2,3 Puppies born via cesarian section that have no contact with their mother to nurse will not have Demodex mites.2,4 Although Demodex are considered normal fauna of the skin, collecting samples to assess their presence does not usually yield any mites. Thus, when mites are noted on diagnostic samples, the patient is considered to have a degree of demodicosis.2,4

Missy graduated from the Veterinary Technology program at Portland Community College in Portland, Oregon, and worked in small animal general practice until finding a fulfilling career working at a private dermatology practice in 2000. Since 2006, she has been the dermatology technician at the Auburn University College of Veterinary Medicine. Missy is one of 8 technicians recognized as an Organizing Committee Member of the Academy of Dermatology Veterinary Technicians, which was recognized by NAVTA in 2015.

DEMODEX MITES The Demodex life cycle has 4 stages: (1) egg (fusiform or lemon shaped), (2) larva (3 pairs of legs), (3) nymph (4 pairs of legs), and (4) adult (4 pairs of legs and breastplates)2 (FIGURES 1 and 2).

FIGURE 1. Demodex canis: egg, (blue box), adult (red box), and nymph (yellow box) at 10× magnification.

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From egg to adult, the Demodex life cycle takes 20 to 35 days.2 Mites have three body sections: (1) the gnathosoma (jaws or cranial portion), (2) the podosoma (legs or middle portion), and (3) the opisthosoma (tail or caudal portion).4 The penis and vulva are hidden within the legs. Three species of Demodex mites have been identified in dogs. Demodex canis is the most common. In the 1990s, a mite later named Demodex injai (FIGURE 3) was noted to have a longer tail than D. canis. D. injai is commonly found in terrier breeds, but usually in low numbers. The mites cause a greasy dermatitis (seborrhea oleosa) along the dorsum over the spine2 and have also been associated with intense facial pruritus (itch).4 Because it is caused by relatively few mites, folliculitis secondary to D. injai

demodicosis may be subtle in presentation, making a diagnosis based on clinical observation more difficult. A third mite, unofficially named Demodex cornei, was first described in dogs in the 1980s and seems to be a morphologic variant of D. canis. D. cornei has a shorter tail than D. canis; it is approximately one-half to one-third the length of the opisthosoma section.2 Additionally, this mite favors living in the more superficial structures of the stratum corneum of the skin. Different species may be found on the same patient concurrently2–4 (FIGURE 4).

FIGURE 2. Demodex canis: larva (yellow box) and adult (red box) at 10× magnification.

FIGURE 4. Demodex canis and Demodex cornei (blue box) at 10× magnification.

FIGURE 3. Demodex injai (10× magnification). Note the elongated opisthosoma.

FIGURE 5. English bulldogs may exhibit a breed predisposition for demodicosis.

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SIGNALMENT Some breed predilections exist for demodicosis. Short-coated breeds such as English bulldogs (FIGURE 5), Staffordshire terriers, and Boston

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terriers, along with longer-coated breeds such as shih tzus, West Highland White terriers, and Scottish terriers, seem to be predisposed.2,4 In Chinese Shar-Peis, skin thickness may make finding the mites on a deep skin scraping difficult, and diagnosis may require obtaining skin biopsy samples for histopathology (see DIAGNOSIS).2,4,5 Additional predisposing factors are listed in BOX 1. Iatrogenic administration of glucocorticoids and subsequent suppression of the immune system has great potential as an influencing factor in demodicosis. Demodex infections in dogs are classified as either juvenile onset (dogs younger than 18 months) or adult onset (dogs older than 4 years)2 and are further categorized as localized or generalized. For patients between 18 months and 4 years old, BOX 1 Selected a thorough dermatologic history is Predisposing necessary to determine which category Factors for of demodicosis is more likely in this age Demodicosis2,3 range. While dogs that recover fully from juvenile demodicosis may live healthy lives with no recurrence of infection, it is  Estrus possible that such dogs have a chronic  Pregnancy predisposition to demodicosis even into  Stress adulthood. The reason for this is not fully understood, but abnormalities in  Poor diet cell-mediated immunity are postulated.1  Hyperadrenocorticism Gathering a detailed history is also (Cushing’s disease) important for categorizing the type of  Hypothyroidism demodicosis (i.e., juvenile versus adult  Diabetes onset). To date, D. injai have been noted only in adult-onset disease.3

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PRESENTATION Categorizing demodicosis as localized versus generalized depends on the number and/or location of body sites affected. Localized demodicosis is defined as 1 to 5 sites affected that usually include the face (particularly the periorbital region and lip/muzzle), forelimbs, or ears (otitis externa); however, any site on the animal can be affected. Localized demodicosis commonly develops between 3 and 6 months of age and generally resolves without treatment in 6 to 8 weeks.2,4 Dogs with a history of localized demodicosis may be predisposed to develop demodicosis later in life, particularly immunocompromised animals.3 Generalized demodicosis may begin as many small, localized lesions that progress to cover a large body area. When evidence of Demodex is detected in 6 or more focal lesions,

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completely involves 2 or more paws, or involves an entire body region (such as the face), the infection is categorized as generalized.2 Other presentations of demodicosis include lesions solely affecting the paws (pododemodicosis). Pododemodicosis may be part of generalized demodicosis or be the only lesions present. When it is part of generalized demodicosis, pododemodicosis may persist despite appropriate therapy, even if resolution of other affected areas is noted. Commonly, nodules and furuncles (swollen and ruptured hair follicles) are formed with pododemodicosis (FIGURE 6), particularly in English bulldogs.2 As mentioned earlier, D. canis or D. injai mites can be found in the external ear canals. Ceruminous (waxy) exudate is usually present and may also induce pruritus for the pet. This presentation may occur by itself or as part of generalized demodicosis.5 DIAGNOSIS Demodicosis is one of 3 differentials to consider when areas of folliculitis (inflammation of the hair follicle) are observed on the skin; the others are bacterial and dermatophyte infections. Lesions associated with folliculitis are listed in BOX 2. After obtaining a thorough dermatologic and medical history, including exposure to immunosuppressive medications, particularly steroids, a dermatologic database of cytology, deep skin scraping (or alternative collection method), and dermatophyte culture should be completed to rule in/out folliculitis differentials. These diagnostic tests can be performed in the

FIGURE 6. Nodular pododemodicosis.

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Demodex infection is usually accompanied by pyoderma, making cytology and deep skin scraping necessary in most patients. veterinary clinic setting—often by veterinary technicians under the direction of a veterinarian. Demodex infection, particularly adult-onset demodicosis, is usually accompanied by pyoderma, making cytology and deep skin scraping necessary in most patients. It is important to remember that dermatophyte exposure is common in young animals because of their living situations (e.g., puppy mill, pet store, shelter) and in immunocompromised adult dogs. This reinforces the importance of always considering the possibility of the triad of folliculitis infections (bacteria, Demodex, dermatophyte) in some at-risk patients (FIGURE 7). Skin Scraping When determining whether Demodex mites are present, a deep skin scraping is typically performed. Several areas (4 to 6 sites) should be sampled in patients with generalized demodicosis; in patients with localized demodicosis, samples should be collected from each lesion. These

FIGURE 7. Patient with hyperadrenocorticism and secondary pododemodicosis.

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areas should be re-scraped at subsequent visits to assess response to therapy. Details about the sampled areas need to be documented (clearly identified and quantified) in the medical record. To avoid transfer of bloodborne disease or pathogens between patients, a new or autoclaved #10 scalpel blade should be used to perform skin scraping in each patient. The blade may be dulled before scraping the animal by running the cutting edge across a metal surface such as a stainless steel examination table. Alternatively, a skin scraping spatula may be used. The advantage to using a spatula is that, when performing a deep scraping, it is not so sharp that it will potentially cut the patient.6 A glass microscope slide is prepared by applying a heavy drop of mineral oil, and the blade or spatula is dipped in the oil before scraping the patient. This eases the friction between the blade and skin during the sampling process and promotes collecting and trapping the material to be evaluated. Skin scraping is then performed in the following steps: 1. Using the thumb and index or middle finger, pinch the selected area of skin to be sampled

BOX 2 Examples of Folliculitis Lesions4 Primary Lesions  Macules

and then release it. The purpose of this action is to facilitate extrusion of the mites from the hair follicles, thereby enhancing the quality of the collected sample. Keeping the skin pinched during scraping is not recommended because it (1) may result in further discomfort to the patient, (2) promotes scraping more deeply than intended, and (3) places one’s fingers in proximity to a very sharp tool. 2. Using the nondominant hand, spread the skin taut (FIGURE 8). 3. Position the edge of the blade perpendicular to the skin or slightly angled away from the direction of scraping. Use light, steady pressure while scraping against the skin in the direction of hair growth. Only scrape a small area to minimize patient discomfort and to decrease the amount of skin damage after sample collection. The skin may bruise during the procedure; however, continue scraping until blood is visible on the blade. Premature cessation of scraping before a small amount of blood is observed on the blade may lead to a false-negative result. 4. After blood is detected, pinch the scraped area again to enhance capillary oozing. 5. Use the scalpel blade for one final sweeping scrape to collect a generous amount of mineral oil, skin debris, and blood for the diagnostic sample. 6. Transfer as much of the collected sample as possible to the prepared slide. The most effective method is to pick up the glass slide with one hand and use the other to swirl the

 Papules  Pustules  Nodules Secondary Lesions  Epidermal collarettes  Crusts  Comedones (blackheads)  Hyperpigmentation  Alopecia FIGURE 8. Deep scrape being performed on a patient with a #10 scalpel blade.

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blade in the oil and rub the blade’s edge on the side of the slide. Placing a coverslip on top of the sample is recommended to ensure the entire area within the borders of the coverslip is assessed. Trichogram A trichogram can be used to evaluate regions that may be too painful or too risky to scrape without chemical restraint. This includes areas near the eye (FIGURE 9), the mouth, the feet of small breeds, and over the thin skin of the axilla and abdomen.2,4,5 Samples are collected by grasping the hair with hemostats and quickly plucking the hair in the direction of hair growth. They are then placed in mineral oil on a glass slide and a cover slip applied. This method may not be as sensitive as a deep skin scraping but is still informative and can confirm a diagnosis.

tape is firmly applied to the selected area of skin to be sampled. The skin under the tape is then pinched or squeezed (using fingers) to extrude the mites from the hair follicles; the mites will stick to the tape. The tape is then placed on a glass microscope slide to be evaluated by microscopy.6,7 Ear Swab For a pet with localized demodicosis of the ear, the mites may be seen when an ear swab is rolled in mineral oil on the slide and the collected material covered with a cover slip, just as is seen with Otodectes cytology preps. Secondary otitis externa complicated with Malassezia and/or bacteria is common, and a separate stained slide should be prepared.

Acetate Tape and Squeeze This technique involves using a piece of clear acetate tape that is slightly shorter in length than a glass microscope slide. The

FIGURE 9. The periocular region may be an area where a trichogram or the acetate tape/squeeze technique is preferable to a skin scrape because of its proximity to the eye.

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FIGURE 10. (A and B) Dead Demodex mites (red boxes; 10× magnification) may be more difficult to find during microscopy because they lose contrast with intense light and do not refract. Lower the microscope condenser to minimize overlooking the skeletons.

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Veterinary technicians may need to remind owners about the importance of continuing therapy to prevent a relapse, even if their dog appears “cured.” Microscopy Demodex mites are readily visualized under the microscope using the 4× objective lens; however, the 10× lens is recommended to enhance ease of detection of both mites and eggs. As when reading a fecal sample, the light condenser should be lowered and the light intensity reduced to enhance contrast between mites and skin debris. Skeletons of dead mites do not refract intense light as well as live mites (FIGURE 10), and this can lead to a false-negative interpretation that may result in premature cessation of treatment and recurrence of disease.2,4 When Demodex mites are observed, the quantity of each life stage should be documented. For example, results of a skin scraping may be reported to the veterinarian as 8 dead adults, 4 live adults, 2 nymphs, 1 larva, and 1 egg. This is necessary to assess response to the chosen treatment, which is continued over several weeks to months before the dog is deemed cured. If juvenile stages of the Demodex mite are recognized after previous scrapings had revealed only dead adults, a further exploration of the patient’s history is needed. Perhaps a young dog has outgrown the therapeutic dosing range of the chosen treatment, an owner has discontinued the medication because of the improvement noted, or a concurrent disease

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process is allowing the relapse. It is important to remember that a clinical cure (how the dog’s skin appears) is noted before the actual or microscopic cure.2 Veterinary technicians may need to remind owners about the importance of continuing therapy to prevent a relapse, even if their dog appears “cured.” In some cases, skin inflammation is severe enough to impede diagnosis via deep skin scraping techniques. These patients include dogs with nodular pododemodicosis and Shar-Peis with excessive mucin within the dermis. For these animals, diagnosis via biopsy and histopathology is required. A 6or 8-mm punch biopsy tool is used to collect multiple samples of affected skin. Mites are readily identified within the hair follicles on histopathologic evaluation2–4 (FIGURE 11). TREATMENT Several treatment options are available for demodicosis. Young puppies with localized disease may receive no treatment at all, as these infections are expected to spontaneously resolve as the puppy grows and its immune system matures. Most cases, however, do require treatment, and many medications are available to kill the mites. Miticidal therapy is continued 4 weeks beyond obtaining negative results of at least 2 scrapings performed 3 to

FIGURE 11. Histopathology sample in a patient with Demodex canis infection (10× magnification).

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4 weeks apart.3,8 Demodicosis may relapse for several reasons, including exposure to immunosuppressive medications, estrus/ parturition, or concurrent diseases. If folliculitis lesions recur, the first step is to repeat a deep skin scrape. A patient is declared cured from the current infection if there is no relapse of demodicosis for more than 12 months after miticidal therapy is discontinued.2 ROLES OF THE VETERINARY TECHNICIAN Veterinary technicians play several essential roles in diagnosing demodicosis: ÆÆ Collecting and assessing samples. Veterinary technicians are most likely to perform these procedures, and being proficient in them not only illustrates practicing quality medicine but also financially benefits the veterinary practice. ÆÆ Documentation and consistency. To ensure the medical record is complete and thorough, sample sites must be documented, as those same areas will be resampled at each recheck visit. As the dog clinically improves and the hair grows back, scrapings may be more difficult to collect. In these cases, it may be necessary to shave a small window over the previously sampled sites to obtain an acceptable sample. The numbers of eggs, larvae, nymphs, and adults identified on each sample must be recorded, and adult mites should further be classified as live or dead. ÆÆ Monitoring. It is important to weigh the pet at each visit, especially young, growing dogs that may outgrow the therapeutic range of the prescribed miticide. ÆÆ Client communication. Having open and direct communication with owners helps ensure that they are correctly continuing the directed treatment protocol and improves the likelihood for successful outcomes. Such discussions may reveal that owners have discontinued medications because their pet appears clinically improved or dislikes taking the medication. Two critical aspects of the job of veterinary technicians are to reinforce the veterinarian’s recommendations and

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To ensure the medical record is complete and thorough, sample sites must be documented, as those same areas will be resampled at each recheck visit.

to confirm that owners clearly understand the treatment protocol. Important topics to address include client understanding of the medication’s purposes, doses, and side effects, as well as treatment duration and financial expectations. Our ability to convey a deep understanding of the disease process, treatment protocol, and prognosis greatly enhances clients’ experiences and positive outcomes for each case. 

References 1. Ferrer L, Ravera I, Silbermayr K. Immunology and pathogenesis of canine demodicosis. Vet Dermatol 2014;25(5):427-e65. doi: 10.1111/vde.12136. 2. Miller WH, Griffin CE, Campbell KL. Muller & Kirk’s Small Animal Dermatology. 7th ed. St. Louis, MO: Elsevier; 2012:304-313. 3. Hnilica KA. Small Animal Dermatology: A Color Atlas and Therapeutic Guide. 3rd ed. St. Louis, MO: Elsevier; 2011:123-131. 4. Jackson HA, Marsella R (eds). BSAVA Manual of Canine and Feline Dermatology, 3rd ed. Quedgeley, Gloucester, England: British Small Animal Veterinary Association; 2012:164-172. 5. Tater K, Shell L. Demodectic Mange. Veterinary Information Network, Inc. (VIN) updated 2/2013 by Tater K (2008—Snell original author), Davis, CA. vin.com/ Members/Associate/Associate. plx?from=GetDzInfo&DiseaseId=272. 6. Deboer D. Skin scraping for external parasites. Clinicians Brief April 2016:43-47. 7. Pereira AV, Pereira SA, Gremião ID, et al. Comparison of acetate tape impression with squeezing versus skin scraping for the diagnosis of canine demodicosis. Aust Vet J 2012;90(11):448-450. 8. Ferrer L. Demodicosis: treatment of difficult and desperate cases. Proc 8th World Cong Vet Dermatol 2016:108-111.

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Pain Management and Becoming a Patient Advocate Veterinary technicians are the backbone of the veterinary practice. Technicians fill many roles, such as phlebotomist; animal restrainer; customer service specialist; radiology, laboratory, pharmacy, and surgery technician; anesthetist; and, most important, patient care advocate. The veterinary technician often spends more time with patients than does the attending veterinarian. While veterinarians are seeing appointments or performing medical and surgical procedures, technicians provide moment-to-moment care for hospitalized patients. This is a vital role because technicians must be able to properly assess individual patients, be aware of changes in a patient’s medical status, and discuss any concerns with the veterinarian. Because technicians play such an integral role in patient care, they must feel comfortable having open discussions about potential changes or additions in management strategies. The veterinary technician and veterinarian should be able to work together to achieve the best care possible for the patient. To help accomplish this task, technicians must be able to have thoughtful and intelligent discussions with the veterinarian and feel comfortable making suggestions for patient care when needed.

Jody Nugent-Deal, RVT, VTS (Anesthesia/Analgesia, Clinical Practice – Exotic Companion Animal) University of California, Davis Veterinary Medical Teaching Hospital Jody has worked at the University of California, Davis Veterinary Medical Teaching Hospital since 1999. Currently, she is the supervisor of the Small Animal Anesthesia Department. She is also the executive secretary, appeals committee chair, and a founding member of the Academy of Veterinary Technicians in Clinical Practice as well as a Member at Large for the Academy of Veterinary Technicians in Anesthesia and Analgesia. Jody has lectured throughout North America on anesthesia and exotic animal topics and has published numerous articles and book chapters. She is an instructor for VSPN and VetMedTeam and an adjunct professor for the Penn Foster Veterinary Technician Program. Her special interests are anesthesia, analgesia, pain management, and critical care in exotics, dogs, and cats.

VETERINARY TECHNICIANS play an integral role in the assessment and management of pain. Advocating for the patient will in turn improve overall patient care.

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I find that technicians often feel intimidated or worried about discussing potential treatment plans. They feel that their ideas may be dismissed as uninformed. Knowledge is power. By having a solid understanding of common techniques and drugs, how they work, and why they are used, technicians can participate in effective discussions. Although veterinary technicians cannot prescribe drugs for pain management, they can accurately assess pain and work with the veterinarian to come up with a protocol. Information on pain management and assessment in veterinary patients has grown tremendously over the past few decades. As our understanding grows, so should the techniques used to combat pain. Common pharmaceuticals range from opioids and nonsteroidal anti-inflammatory drugs (NSAIDs) to α2-agonists, gabapentin, amantadine, ketamine, and local anesthetics. A list of common drugs and dosages used at the UC Davis Veterinary Medical Teaching Hospital is available at todaysveterinarytechnician.com. More advanced multimodal techniques should also be considered when appropriate; these include epidural injections and catheters, local blockades, and constant-rate infusions (CRIs). Although beyond the scope of this article, other methods of pain management include weight management, acupuncture, laser therapy, nutraceuticals, corticosteroids, thermal therapy, and physical therapy techniques. NOCICEPTION Nociception can be described as the detection of potential or actual trauma to the tissue by the nervous system. Nociceptors detect noxious stimuli caused by mechanical, chemical, or thermal mechanisms. Recognition is generally rapid. For example, a dog running to catch a ball steps on a nail. The peripheral nociceptors sense the trauma of the nail penetrating the skin and send a signal to the peripheral nerves. This pain sensation is sent through the dorsal root ganglion to the dorsal horn of the spinal cord and up to the brain. The body recognizes the sensation of pain and reacts: the dog pulls the foot away from the painful stimulus.

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Being able to recognize and interpret signs of pain is crucial in patient care. Many different terms are used to classify types of pain: acute, chronic, visceral, somatic, idiopathic, neuropathic, inflammatory, maladaptive, adaptive, and physiologic. Animals can experience more than one type of pain at a time, and some pain can morph from one type to another. Understanding what each term means is important in being proactive in pain assessment and improving overall nursing care. PAIN SCALES AND ASSESSMENT Pain should be assessed in all patients, ideally when they come into the hospital for an appointment and before and after any procedures (this helps to develop a baseline for that individual patient). Patients being maintained on analgesics should also be assessed regularly to help ensure pain medications are administered at proper intervals. Signs of pain can vary by species; therefore, it is important to understand the differences among animals commonly seen in the practice. Common signs of pain can include hunching or tucking up of the abdomen, vocalization, increased heart rate, increased respiratory rate, increased temperature, inability to find a comfortable position, restlessness, guarding the painful area, aggression, shaking, inappetence, anorexia, bruxism, and chewing and/or licking at the site of pain. Being able to recognize and interpret signs of pain is crucial in patient care. Several pain scales are available for use, such as the visual analog scale, the grimace scale (rats, rabbits, and mice), Colorado State Canine Acute Pain Scale, Colorado State Feline Acute Pain Scale, numeric pain scale, and Glasgow Composite Pain Scale. I prefer the Colorado State scales for canine and

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feline patients (see pages 44 and 45) because they contain both images and descriptions.

Dexmedetomidine Dexmedetomidine is the α2-agonist most commonly used in small animal medicine. α2-Agonists are not controlled, provide some analgesia, and are reversible. They are potent sedatives that can be used alone or with other drugs, such as opioids or tranquilizers. When they are combined with opioids or tranquillizers, they have a synergistic or additive effect. Dexmedetomidine is effective when given at IV microdoses for patients experiencing a rough recovery from anesthesia. α2-Agonists can have substantial cardiovascular side effects. These drugs should be given only to healthy patients and are generally avoided in geriatric, diabetic, pregnant, pediatric, or sick animals. Common adverse effects include profound hypertension, bradycardia, and a reduction in cardiac output. Administration of an anticholinergic to treat bradycardia is generally contraindicated. Anticholinergics are not always effective and can increase the workload of the heart and exacerbate hypertension. It is often better to reverse the drug than to treat the bradycardia. Dexmedetomidine is usually reversed with atipamezole. Dexmedetomidine can be also be used as a CRI or can be administered in an epidural or as part of a local blockade.

A complete discussion of opioid types and uses is not within the scope of this article, but current anesthesia and analgesia textbooks often have chapters dedicated to opioids. I recommend the BSAVA Manual of Canine and Feline Anaesthesia and Analgesia, 3rd edition, as a valuable source of more detailed information about the drugs mentioned below. Common full mu opioids include hydromorphone, morphine, oxymorphone, fentanyl, remifentanil, and methadone. These drugs can be used for mild, moderate, or severe pain. Fentanyl and remifentanil are most commonly used for anesthetic induction and CRI infusions. Morphine can cause a histamine release when administered via the IV route; therefore, if given this way, it should be administered slowly. Morphine has a long onset of action compared with the other full mu opioids and can take about 30 to 40 minutes to become fully effective after SC or IM injection. Morphine should not be used in patients where vomiting is contraindicated because this drug is most likely to cause emesis. Among the full mu opioids, morphine will also likely cause the most sedation, which can be beneficial in rambunctious patients. Oxymorphone and hydromorphone have similar sedative properties and times to effect. Both may cause emesis and may be contraindicated in patients for which vomiting is not ideal. Methadone is the only full mu opioid with which emesis is extremely unlikely. Sedation is

Opioids Opioids are commonly used as part of a balanced premedication protocol. These drugs can be administered as a premedication, intraoperatively as a bolus, postoperatively to help manage pain, as a CRI, or as part of an epidural or local blockade (FIGURE 1). Different intensities of analgesia are obtained according to the type of opioid chosen. Few negative effects are associated with administration of opioids, and they are generally considered safe in pediatric, geriatric, and sick or critical patients. Respiratory depression and bradycardia can occur and are most severe with higher doses of opioids.

FIGURE 1. Feline patients generally have mydriasis after opioid administration.

COMMON ANALGESIC DRUGS

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often mild to moderate with this drug. Because it has activity on the N-methyl-d-aspartate (NMDA) receptor, it may be beneficial for patients experiencing neuropathic or “wind-up” pain. Buprenorphine is a partial mu agonist opioid and is suggested for use in mild to moderate pain control. Traditional buprenorphine has a long onset of action; it takes about 15 minutes to become effective when given via the IV route and about 40 minutes when given via the IM route. Traditional buprenorphine can also be given via a transmucosal route in cats. This may provide a good option for owners who find it hard to give injections to their pets. Buprenorphine can also be administered in an epidural or as part of a local blockade. Long-acting buprenorphine, such as Simbadol (zoetisus.com), is similar to traditional buprenorphine but is administered via the SC route at a much higher dose. This formulation is suggested for use in cats only and can be given once daily for up to 3 days. It should be used for mild to moderate pain management and is useful for feline patients that are difficult to medicate. Butorphanol is a kappa agonist, mu antagonist opioid best used for sedation or mildly painful procedures in canine and feline patients. In avian patients that are known to have more kappa receptors than mu receptors, butorphanol is considered more effective for moderate to severe pain. Butorphanol is very short acting in most species but can be used as a CRI in some avian species if longer periods of pain relief are needed. Tramadol, a centrally acting opioid analgesic, is generally well tolerated in most patients. It acts on the mu receptor and inhibits serotonin and noradrenaline uptake, which, in turn, may contribute to a reduction in nociceptive transmission within the spinal cord. There have been recent discussions on the actual efficacy of analgesia provided to some species, but more research is needed in this arena. NMDA Antagonists Ketamine can be used as both a premedication and an induction agent (often used in combination with a benzodiazepine). Ketamine produces a trancelike anesthesia often termed

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Buprenorphine may provide a good option for owners who find it hard to give injections to their pets. dissociative anesthesia or catalepsy. Common responses after administration include strong palpebral reflexes, increased muscle and jaw tone, central eye position, and an apneustic breathing pattern (patient holding breath for several seconds between a short and quick breath). Unlike most anesthetic drugs, ketamine does not decrease heart rate or depress myocardial function. Most animals exhibit tachycardia and vasoconstriction, which increase blood pressure. Ketamine should be used with caution in patients with cardiac arrhythmias, hyperthyroidism, or cardiomyopathy. Until recently, ketamine was mostly avoided in patients with brain trauma or space-occupying masses because it can contribute to increased intracranial pressure. Some argue that ketamine may benefit this patient population because it can increase cerebral perfusion, but I generally avoid ketamine in these patients. If ketamine is necessary, small doses are chosen and titrated to effect. Ketamine also increases intraocular pressure and is often considered contraindicated in patients with glaucoma or in procedures that may affect intraocular pressure. I generally avoid ketamine in these patients as well. Ketamine provides good analgesia for skin and limb pain but is a poor analgesic for visceral pain. Ketamine helps combat neuropathic or “wind-up” pain and should be considered for use as a CRI when appropriate. Amantadine is an NMDA antagonist originally developed for use as an antiviral. It is generally used as an adjunct with other drugs, such as NSAIDs, tramadol, or opioids, for both acute and longer-term, chronic pain.

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Gabapentin Gabapentin was developed as an anticonvulsant drug but is often used for its analgesic properties. It is effective for management of neuropathic pain and can be used in both cats and dogs. The most common side effect is sedation. NSAIDs Many NSAIDS are available in oral and injectable formulations. Most current NSAIDs preferentially inhibit cyclo-oxygenase (COX)-2 or are COX-1 sparing to varying degrees. COX-2 generates prostaglandins involved with inflammation, and COX-1 synthesizes prostaglandins needed for gastrointestinal and renal function. NSAIDs are commonly used to treat acute pain after trauma, postoperative pain, and chronic pain (eg, from osteoarthritis). These drugs can be used with other analgesic drugs and are not suggested for use in patients with moderate to severe kidney and/or liver disease. They should also be avoided in patients being administered corticosteroids. NSAIDs commonly used in veterinary medicine include carprofen, deracoxib, meloxicam, robenacoxib, and firocoxib. Lidocaine Lidocaine has many uses, including free radical scavenging, systemic analgesia when administered as a CRI, regional anesthesia when administered as a local block, reducing neuropathic pain, providing minimum alveolar concentration (MAC) reduction (ability to reduce vaporizer settings), antiinflammatory properties, promoting gastrointestinal motility as a prokinetic, and working as an antiarrhythmic. Lidocaine is safe when given at appropriate doses but is generally considered contraindicated for IV use in cats because of the potential for severe cardiac depression. ADVANCED ANESTHETIC TECHNIQUES Epidural anesthesia/analgesia, local blockades, and CRI of analgesic drugs are extremely effective for managing pain in several different types of medical and surgical procedures as well as after surgery. The species, type of procedure, and status of the patient must be considered before administration of any drug or drug combination.

Epidural Anesthesia and Analgesia An epidural should be considered for patients requiring painful procedures of the hindlimbs, abdomen, thorax, and potentially even forelimbs. Epidural placement can be performed in as little as 5 minutes, thereby adding little time to the total time under anesthesia. Drugs commonly used for epidural administration include preservative-free morphine, lidocaine, bupivacaine, buprenorphine, and dexmedetomidine. Epidural anesthesia/ analgesia should not be administered if the patient is septic or has signs of pyoderma or a skin infection around the epidural site. Standard Epidural Procedure A 25- or 22-gauge spinal needle is generally used for this procedure, with a length ranging from 1 inch to 3 inches depending on patient size. While a hypodermic needle can be used, a spinal needle is usually preferred because it contains a stylet. The stylet helps prevent tissue from clogging the lumen of the needle. ÆÆ Position the patient in sternal recumbency. (Lateral recumbency is an option.) ÆÆ Palpate the wings of the ilium. The lumbosacral space can be palpated between vertebral bodies L7 and S1. ÆÆ Shave and aseptically prepare the area as for a sterile surgical procedure. Wear sterile gloves when administering the epidural injection (FIGURE 2).

FIGURE 2. Epidural placement.

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ÆÆ Place the needle on the midline and slowly

insert it through the skin and into the epidural space. A “pop” will be felt as the needle passes through the ligamentum flavum and enters the epidural space. If the needle touches bone, you have gone too far and need to back the needle out slightly. ÆÆ Determine correct placement with the loss-ofresistance or hanging drop technique. For the former, place a sterile glass syringe containing a small amount of air (1 to 2 mL) on the spinal needle and inject it into the space. If the air injects easily, you are in the correct spot. If there is a vacuum on the syringe, you are not in the correct space and need to reposition.1 For the hanging drop technique, place a drop of saline onto the opening of the spinal needle. If the drop is sucked into the hub of the spinal needle, you are in the correct space. If the drop of saline is not sucked into the spinal needle, you may or may not be in the correct spot. The hanging drop technique works much better in larger animals than in smaller patients. ÆÆ Once you are in the correct space, place the syringe containing the drugs onto the spinal needle. It is important to aspirate the syringe to ensure no blood or spinal fluid is present. If blood is aspirated, remove the needle and start over. If spinal fluid is aspirated, you should deliver only about one-fourth of the initial calculated dose. Coccygeal Epidural Procedure Coccygeal epidural injections can be used to provide analgesia and/or anesthesia for surgery or medical procedures involving the more caudal portions of the body (eg, pelvis, tail, genitals, perineal area). I find this block especially useful for providing local anesthesia to blocked cats. These patients are often in very critical condition and general anesthesia may be contraindicated. When the coccygeal epidural injection is done correctly, a urinary catheter can be passed without the need for inhalant anesthetics. ÆÆ Aseptically prepare the injection site. Palpate the sacrococcygeal space, which is found just cranial to the first coccygeal vertebrae. Wear sterile gloves during this procedure.

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

TECHPOINT 

Although veterinary technicians cannot prescribe drugs for pain management, they can accurately assess pain and work with the veterinarian to come up with a protocol. ÆÆ Slowly insert a 25-gauge spinal needle or

hypodermic needle at approximately a 30° to 45° angle into the injection site along the midline of the back. A “pop” will be felt as the needle passes through the ligamentum flavum. In my opinion, the hanging drop technique does not work well at this site, especially in smaller patients. Therefore, the loss-of-resistance technique is used to ensure correct placement into the epidural space. After confirming proper needle placement, attach the drug syringe to the hub of the needle and aspirate it. If blood or cerebral spinal fluid enters the syringe, remove the needle and insert a new needle into the epidural space. Relaxation of the rectum and the tail indicates proper epidural placement. CONTINUOUS-RATE INFUSION Delivering a CRI before, during, or after general anesthesia is an excellent way to provide additional analgesia. BOX 1 provides examples of CRI calculations for administration via syringe pump and fluids. Common drugs used for analgesic CRIs include ketamine, dexmedetomidine, lidocaine, hydromorphone, morphine, and fentanyl. Using one or a combination of these drugs not only helps provide additional analgesia, but, depending on the species, may also help reduce the percentage of gas anesthesia (MAC reduction) needed. Reducing the amount of gas anesthesia has many benefits, including helping

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reduce the hypotension commonly experienced with inhalants (e.g., isoflurane, sevoflurane). If an opioid is used as a CRI at higher “anesthetic” doses, the patient should be intubated and placed on intermittent positive-pressure ventilation (manual or mechanical) because full mu opioids can cause moderate to severe respiratory depression. In many instances, analgesic CRIs require a loading dose given at the onset of CRI delivery. A loading dose will quickly increase the drug plasma concentration levels, enabling the low-dose CRI to become effective quickly.2 LOCAL ANESTHETIC TECHNIQUES Local and regional anesthetic techniques are the only way to provide a complete blockade

of peripheral nociceptive input; therefore, they are the most effective method of preventing sensitization of the central nervous system and development of pathologic pain. The onset and duration of local anesthetics vary based on the drug chosen. However, the preoperative use of local anesthetics reduces inhalant anesthetic requirements and often helps patients have a smoother and less painful recovery. Lidocaine has a quick onset but a short duration of action, whereas bupivacaine has a longer onset and longer duration of action. Lidocaine will become effective in as little as 1 to 2 minutes and will last about 1 to 2 hours or more. Bupivacaine will become effective in about 10 to 20 minutes and last about 4 to 6 hours or more.

BOX 1 Calculating a Constant-Rate Infusion Administration via Syringe Pump Administration via Syringe Pump [(Patient weight in kg) × (Dosage of the drug) × (*Time factor)] / Concentration of the drug *The time factor for this equation is 60 minutes/hour. Example: A 0.7 mcg/kg/min constant-rate infusion (CRI) of fentanyl has been prescribed for a 10-kg patient. The concentration of fentanyl is 50 mcg/mL. What is the CRI in mL/hr? [(10 kg) × (0.7 mcg/kg/min) × (60 min/hr)] / 50 mcg/mL = 8.4 mL/hr This standard equation can be used for any CRI that is administered via a syringe pump. Administration in a Bag of Fluids X (amount of drug to add in mL) =

CRI rate (mg/kg/min) or (mcg/kg/min) × total volume in bag (mL) Fluid rate (mL/kg/hr)

Example: A 0.2 mg/kg/hr CRI of morphine has been prescribed for a small dog. A 250 mL bag of fluids was chosen for the dilution. How much morphine must be added to the bag? X=

0.2 mg/kg/hr × 250 mL 5 mL/kg/hr X = 0.04 × 250 mL

X = 10 mg of morphine To convert mg to mL, divide by the concentration of the drug. X=

10 mg of morphine 15 mg/mL

= 0.67 mL

You must add 0.67 mL of 15 mg/mL morphine to 250 mL of crystalloid fluids to administer a 0.2 mg/kg/hr CRI at a fluid rate of 5 mL/kg/hr. This same equation is used when other drugs (e.g., ketamine, lidocaine) are incorporated into the CRI.

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Some people advocate mixing local anesthetics, such as lidocaine and bupivacaine, to achieve the quicker onset of action provided by lidocaine and the longer duration of action provided by bupivacaine. Generally, mixing these two drugs shortens their duration of action compared to using bupivacaine alone. Studies have shown that the onset of action stays the same or actually is delayed when these two drugs are mixed.3 Topical Anesthetics Topical anesthetics, such as 2.5% lidocaine and 2.5% prilocaine, can be applied to skin for minor procedures, such as IV and arterial catheter placement. It is advisable to shave the area of interest, spread a thin layer of cream, and place an occlusive dressing over the area of application for at least 10 minutes. I especially like this technique for placing arterial catheters in the auricular arteries of rabbit’s ears. Splash Blocks Local anesthetics can be administered into existing wounds or open surgical sites. This is usually accomplished by “splashing” the local anesthetic into the open wound before surgical closure.4 Infiltration of Local Anesthetics Local anesthetics are commonly used to provide additional anesthesia and analgesia for such procedures as minor laceration repair, skin biopsies, and removal of small tumors located

FIGURE 3. An incisional block or line block can be performed either before surgery is performed or just before recovery. Administering a local anesthetic for this block can also help reduce vaporizer settings.

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March/April 2017

just under the skin. Local anesthetics, such as lidocaine and bupivacaine, can be injected into the tissue, preferably around the nerve of interest. Procedure Infiltration of local anesthetics is generally easy and relatively quick. Shave and aseptically prepare the area before administering any drugs. Aseptic technique helps prevent contamination of the tissues with skin bacteria when the local anesthetic is injected. In most cases, use a small, 25- to 27-gauge needle attached to a 1-mL or 6-mL syringe to prevent tissue damage and allow for more precise administration of the drug (FIGURE 3). The volume of drug to be administered varies according to the area of interest and size of patient. If the patient is very small and the volume to be delivered is tiny, it may be necessary to dilute the local anesthetic before administration. Sodium chloride 0.9% is the most common fluid used for dilution. Always remember to aspirate the syringe before giving the injection. If blood is aspirated, reposition and start over (this is true for any injection of a local anesthetic). Dental Nerve Blocks Common dental nerve blocks include the maxillary, infraorbital, inferior alveolar, and mental blocks. Blocking these nerves provides excellent anesthesia for extractions and facial surgery. The maxillary nerve block provides anesthesia for the caudal portion of the maxilla. The infraorbital nerve block provides anesthesia for the rostral portion of the maxilla. The inferior alveolar nerve block provides anesthesia to the caudal portion of the mandible, while the mental nerve block provides anesthesia to the rostral portion of the mandible. It is ideal to use an insulin syringe with attached needle for very small patients. A 1- to 3-mL syringe with a 25- to 22-gauge needle attached can be used for larger dogs. Brachial Plexus, Intercostal, Testicular, and Limb Blocks Blockade of the brachial plexus is generally used to manage perioperative pain of the forelimb. The best technique is to block the nerves of the brachial plexus at C6 to T1. It is ideal to block the

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nerves close to the intervertebral foramina rather than the axillary space. This procedure is not benign. The phrenic nerve can become blocked, anesthetizing a portion of the diaphragm; thus, a brachial plexus block should be performed only unilaterally. Other complications include pneumothorax and IV and intrathecal injection. A nerve stimulator and insulated needle should be used to increase the success rate of this block. Intercostal nerve blocks can be used for patients with fractured ribs or those undergoing a lateral thoracotomy. To provide complete blockade of the affected area, inject the local anesthetic not only at the caudal border of the rib at the fracture or incision site but also at the 2 to 3 ribs on either side of the fracture or incision site. Testicular blocks are a cost-effective and easy way to provide MAC reduction and additional pain relief during and after castration. Blocks can be done in most species. Before injection, aseptically prepare the testicle. This block is generally performed in two

steps. First, insert the needle into the caudal pole of each testicle, cranially toward the spermatic cord. Second, perform an incisional block at the anticipated surgical site.

FIGURE 4. A ring block can be performed for procedures such as dewclaw removal, declawing or toe amputation, and tail amputation procedures. A needle attached to a 1 or 3 mL syringe is inserted just under the skin and aspirated before injection. The needle is inserted into multiple sites circumferentially around the digit or tail until the tissue has been infused.

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Distal limb blocks are effective for procedures involving the lower extremity and digits. Examples include dewclaw removal, cat declawing, and mass removal (FIGURE 4). The local anesthetic is injected around the nerve via the SC route and caudal to the surgical site. Common sites include the radial, ulnar, and median nerves. Soaker Catheters Soaker catheters are used for such procedures as large wound repairs, mass removals, and limb amputations. These catheters are aseptically placed by the surgeon just before closure of the surgical site. Soaker catheters are available commercially but can also be easily made by using a rubber feeding tube. To make a soaker catheter, set up a sterile barrier drape and remove the feeding tube from the package using aseptic technique. Use a sterile large-bore needle or scalpel blade to make several holes along the length of the tube. Inject sterile saline through the tube to ensure the holes are patent before handing the soaker catheter to the surgeon. Once the catheter has been sutured in place, a bolus of local anesthetic can be administered. In some cases, a CRI may be used to infuse small volumes of drug over a specific time frame. In general, soaker catheters are used for 24 to 48 hours after surgery (FIGURES 5 and 6). Chest Tubes Local anesthetics can also be infused into chest tubes to relieve postoperative pain. In general, inject a bolus of bupivacaine into the chest tube just before anesthetic recovery and incrementally as needed during the recovery period (usually every 6 hours if the patientâ&#x20AC;&#x2122;s actions indicate pain). Local anesthetic can cause pain on injection; therefore, sodium bicarbonate is often added to the bupivacaine just before injection into the chest tube. The sodium bicarbonate acts as a buffer, making the injection more tolerable for the patient. To prevent aspiration and removal of the drugs, first aspirate the chest tube to remove any fluid or air. After achieving negative pressure, insert the drugs through the tube.

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SUMMARY Veterinary technicians play an integral role in pain assessment and management. Do not be afraid to make suggestions and ask questions. It is important that technicians feel comfortable alerting veterinarians to changes in patient status and are able to offer suggestions to the treatment plan when warranted. The entire veterinary team can work more harmoniously together when the technician is armed with the knowledge of how drugs work, when drugs are most appropriately used, how various combinations of drugs work together, and when advanced techniques could be added to a procedure. Advocating for the patient will in turn improve overall patient care. ď Ž

FIGURES 5 and 6. Soaker catheters are aseptically placed by the surgeon just before closure of the surgical site. These catheters allow for intermittent injections of local anesthetics or the delivery of a CRI into the surgical site to help provide postoperative pain relief.

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References 1. Duke-Novakovski T, de Vries M, Seymour C. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2016:154. 2. Duke-Novakovski T, de Vries M, Seymour C. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2016:201-205.

3. Duke-Novakovski T, de Vries M, Seymour C. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2016:145. 4. Duke-Novakovski T, de Vries M, Seymour C. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2016:147.

Suggested Reading  Bryant S. Anesthesia for Veterinary Technicians. Ames, IA: Wiley & Sons; 2010.  Duke-Novakovski T, de Vries M, Seymour C. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Gloucester, UK: British Small Animal Veterinary Association; 2016.  Epstein ME, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain management guidelines for dogs and cats. J Feline Med Surg 2015;17(3):251-272.  Greene S. Veterinary Anesthesia and Pain Management Secrets. Philadelphia, PA: Hanley & Belfus; 2002.  Steagall PV, Monteiro-Steagall BP, Taylor PM. A review of the studies using buprenorphine in cats. J Vet Intern Med 2014;28:762-777.  Thomas J, Lerche P. Anesthesia and Analgesia for Veterinary Technicians. 5th ed. St. Louis, MO: Elsevier; 2017.  WSAVA Global Veterinary Community. Guidelines for Recognition, Assessment, and Treatment of Pain. 2014. Available at: wsava.org/sites/default/files/jsap_0.pdf.

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Date Date

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Time Time

Colorado State University Veterinary Medical Center

Feline Acute Pain Scale Canine Rescore Rescorewhen whenawake awake

Pain PainScore Score

Animal Animalis issleeping, sleeping,but butcan canbe bearoused aroused--Not Notevaluated evaluatedfor forpain pain Animal Animalcan’t can’tbe bearoused, aroused,check checkvital vitalsigns, signs,assess assesstherapy therapy

Example Example

Psychological Psychological&&Behavioral Behavioral

Response to Palpation

Comfortable Content andwhen quietresting when unattended Happy, content Comfortable when resting Not bothering wound or surgery site Interested in or curious about surroundings Interested in or curious about surroundings Signs are often subtle and not easily detected in the hospital setting; more likely to be detected by the owner(s) at home Earliest signs at home may be withdrawal from Content to slightly unsettled or restless surroundings or change in normal routine Distracted easily bybe surroundings In the hospital, may content or slightly unsettled Less interested in surroundings but will look around to see what is going on

Decreased responsiveness, seeks solitude Looks when resting Quiet,uncomfortable loss of brightness in eyes May or or crysits andtucked may lick rub Layswhimper curled up upor(all four feet wound or surgery site when unattended under body, shoulders hunched, head held Droopy facial expression slightly ears, lowerworried than shoulders, tail curled tightly (arched brows, darting eyes) or mostly closed around eye body) with eyes partially Reluctant respond when Hair coat to appears rough orbeckoned fluffed up Not to interact people orissurroundings Mayeager intensively groomwith an area that painful or but will look around to see what is going on irritating

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

Reacts palpation May or to may not reactoftowound, palpation surgery site, other site body part of wound or or surgery by looking around, flinching, or whimpering

Body BodyTension Tension

Minimal Minimal

Mild Mild

Responds aggressively or tries to escape if painful area is palpated Flinches, whimpers cries, or or approached guards/pulls away may even perk Tolerates attention, up when petted as long as painful area is avoided

Mild MildtotoModerate Moderate Reassess Reassess analgesic analgesicplan plan

May be subtle (shifting eyes or Growls or hisses at non-painful increased rate) if dog palpationrespiratory (may be experiencing isallodynia, too painful to move is stoic wind-up, oror fearful that May dramatic, such as a painbe could be made worse) sharp cry, growl, bite or bite Reacts aggressively to palpation, threat, and/orpulls pulling away adamantly away to avoid

Moderate Moderate Reassess analgesic plan Reassess analgesic plan

Decreased appetite, not interested in food

Unsettled, crying, groaning, biting or chewing wound when unattended Constantly yowling,wound growling, or hissing when Guards or protects or surgery site by unattended altering weight distribution (i.e., limping, May bite or chew at wound, but unlikely to move shifting body position) if leftbe alone May unwilling to move all or part of body

any contact

Constantly groaning or screaming when Prostrate unattended Potentially unresponsive or unlikely unawaretoof May bite or chew at wound,tobut surroundings, difficult to distract from pain move Receptive to care (even aggressive or feral Potentially unresponsive to surroundings cats will to bedistract more tolerant of contact) Difficult from pain

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

Moderate Moderatetoto Severe Severe May Maybe berigid rigidtoto avoid avoidpainful painful movement movement Reassess Reassess analgesic analgesicplan plan

Tender Tenderto topalpation palpation Warm Warm Tense Tense

RIGHT RIGHT

LEFT LEFT

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Date Time Colorado State University Veterinary Medical Center

Canine Acute Pain Scale Rescore when awake

Pain Score

Animal is sleeping, but can be aroused - Not evaluated for pain Animal can’t be aroused, check vital signs, assess therapy

Example

Psychological & Behavioral

Response to Palpation

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

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

Content to slightly unsettled or restless Distracted easily by surroundings

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

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

Flinches, whimpers cries, or guards/pulls away

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

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

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

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

Body Tension

Minimal

Mild

Mild to Moderate Reassess analgesic plan

Moderate Reassess analgesic plan

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

Tender to palpation Warm Tense RIGHT

LEFT

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todaysveterinarytechnician.com WHAT MOVES YOU

WHAT MOVES YOU? 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?

Gratitude and Giving Back

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!

“Motivation can take you far in life when you apply it to something you love.” —Elizabeth Exline

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When I was a little girl and our beloved retriever, Runner, was sick, my mom would load him into the back seat of our little Honda hatchback and off to the veterinarian we would go. Windows rolled down, wind whipping through the car, and a view of a big wet dog nose in the side mirror. I was too young to understand how vet teams worked then, and Elizabeth Exline, LVT yet I appreciated them so much because they seemed to work magic on my muchloved dog, making all right with the world again. Fast forward more than 30 years: Every morning I load Carlee Mae—my retriever—into the back seat of my little Hyundai hatchback and off to the veterinarian’s office we go. Windows rolled down, wind whipping through the car, and a view of a big wet dog nose in the side mirror. But today, all is right with the world already. The office is the veterinary clinic where Carlee Mae and I spend our days— she as the “clinic dog,” and I as part of the team that helps other people’s pets go home feeling better.

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Gratitude and Giving Back WHAT MOVES YOU

Artful Paws Photography

“The experience of earning a degree in veterinary technology from Penn Foster College changed my life. It taught me a great deal about self-esteem, self-trust, self-pride, self-patience, selfdiscipline, and maybe even a lesson or two in self-humbling.” —Elizabeth Exline

ELIZABETH EXLINE with her Labrador retriever, Carlee Mae.

Somewhere between being that little girl and today, I decided I wanted to be a part of the magic. Everything I know about this field I originally learned through “on the job” training at the vet’s office where I volunteered starting in my late teens. It wasn’t until my late 20s that I decided I wanted to get a degree in this field. But it was an intimidating decision. Was I too old to learn new tricks? Would there be enough hours left in the day to study adequately after working a 10-hour-plus shift? The experience of earning a degree in veterinary technology from Penn Foster College changed my life. Aside from the obvious benefits—that education makes us better equipped to do the best work we can each day—it also taught me a great deal about self-esteem, self-trust, self-pride, self-patience, self-discipline, and maybe even a lesson or two in self-humbling. I can honestly say that graduating, and then being honored as the 2016 Distance Education Accrediting Council (DEAC) Outstanding Graduate of the Year, is the achievement I am most proud of in my life. I’m sometimes amazed that I went to school and graduated later in

life—summa cum laude—while working more than full-time as a practice manager. For me, this is proof that we can teach old dogs new tricks and that motivation can take you far in life when you apply it to something you love. My education is furthering my career in ways I can only begin to dream of. I am so excited for the road ahead, for all the possibilities within the veterinary field, and for the endless opportunities that have come my way. This is a field for lifelong learning, and I am up for the challenge. I carry with me the knowledge that there will always be concerned little girls and their parents bringing their best pet friends into our clinic. My goal is to become the best technician possible for these patients so these little girls return home feeling that, with the magic that happened at the vet’s clinic, all is right with the world again. Whatever my future holds, it will always bring me back to the road I’ve traveled to become a licensed veterinary technician. Because when you love what you do, and you are educated to do it to the best of your ability, all will be right in the “adult” world, too. 

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Peer Reviewed | todaysveterinarytechnician.com TOXICOLOGY TALK

TOXICOLOGY TALK MEET THE AU TH O R

MaryEllen Malysiak, BS, CVT ASPCA Animal Poison Control Center Urbana, Illinois MaryEllen earned her bachelor’s degree in science at the University of Illinois in Animal Sciences. She then went back to school at Parkland College and became a certified veterinary technician. She has been an active member of the ASPCA Animal Poison Control Center since May of 2011. Outside of work, MaryEllen enjoys spending time with her off-the-track thoroughbred horse, Parker, and volunteering with her Pet Partners–registered dog, Ruby.

Cantharidin Toxicosis from Blister Beetles in Horses Blister beetles, also known as the Spanish fly or Cantharis vesicatoria, are commonly associated with toxicosis in horses. More than 200 species are found throughout the continental United States. They are generally seen in mid to late summer in the eastern and central states; however, various species can be found from southern Canada to Mexico and from the Atlantic coast to New Mexico. The beetles can appear in great swarms and tend to damage vegetables and some flowering forage crops. Blister beetles contain a toxic oily substance called cantharidin, a noxious defense mechanism that offers protection from predators. Cantharidin can severely injure or kill horses when even a small amount is ingested. Horses come into contact with cantharidin by ingesting alfalfa hay that has been infested by the beetles. The oily substance can contaminate the hay even if the beetles were crushed into the feedstuff. The amount of toxin each beetle produces varies between species and by sex within each species. The toxin is commonly in the male sex organs but is transferred to females during mating season. Cantharidin is very stable. Crushing or chemically killing the beetles does not diminish the toxin’s potency. Toxicity can actually be more serious when crushed beetles have been removed from affected hay because the toxin is more bioavailable and the presence of the beetles cannot be detected. CLINICAL SIGNS Cantharidin toxicity is dose dependent, with lethal doses as low as 1 mg/kg.1 If beetles contain an average of 1 mg cantharidin per beetle, as little as 4 to 6 g of dried beetles may be fatal to

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Cantharidin Toxicosis from Blister Beetles in Horses TOXICOLOGY TALK

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Horses come into contact with cantharidin by ingesting alfalfa hay that has been infested by blister beetles.

the average-sized horse. Onset and duration of toxicosis can vary from hours to days. Cantharidin can cause inflammation and ulceration of the urinary and gastrointestinal (GI) tracts. It is excreted through the urine and can cause significant bladder irritation. Calcium and magnesium levels in horses may decrease, and heart muscle tissue can deteriorate. Classic clinical signs are dark, congested mucous membranes and frequently drinking small amounts of water or submerging the whole muzzle in water and “water playing.” Other progressive signs include colic, depression, anorexia, ulceration of oral mucosa, diarrhea and polyuria leading to dysuria, sweating, delayed capillary refill time, tachycardia, tachypnea, muscle rigidity, collapse, dehydration, and synchronous diaphragmatic flutter. Horses that ingest a massive amount of toxin may show signs of severe shock and die within hours. Sudden death with no outward clinical signs has been reported.2 TREATMENT There is no specific antidote for cantharidin. If exposure is caught early, mineral oil can be administered via a nasogastric tube to move the toxin through the GI tract. Activated charcoal is

contraindicated because it can slow the healing of GI ulcers; also, it is unknown whether activated charcoal can fully bind cantharidin, making it an ineffective form of decontamination. Early symptomatic care is necessary for successful recovery and a good prognosis. Care can vary depending on clinical signs. Treatment includes fluids, pain management, nutritional supplementation, GI protectants, and serum electrolyte monitoring. Because cantharidin can lower calcium and magnesium levels, prolonged calcium and magnesium supplementation may be indicated. If the animal develops significant ulcers, antibiotics may also be necessary. Prognosis depends not only on the amount of cantharidin ingested and progression of clinical signs, but also the types of treatments available and the speed at which therapy is initiated. Prognosis improves daily if complications do not develop. If tachycardia and tachypnea are unresponsive to treatment and creatine kinase activity increases over the first 48 hours, prognosis is poor as patients develop shock. DIAGNOSIS Testing for cantharidin in the urine and/or GI contents is the main way to diagnose toxicosis. TODAY’SVETERINARYTECHNICIAN

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Insect parts can sometimes be identified in the GI contents or feces. In cases of colic from blister beetle toxicosis, hypocalcemia and hypomagnesemia are common. Other abnormal laboratory findings include hypoproteinemia, azotemia, increased creatine kinase activity, hyposthenuria, and hematuria.3 Necropsy results may include mucosal hyperemia, hemorrhage, edema, vesication, and ulceration anywhere within the GI or urinary tract.

BLISTER BEETLES are generally pollen feeders and can be found on alfalfa blossoms.

PREVENTION Although blister beetle exposures can be serious and sometimes fatal, horse owners can take preventive measures to make sure their animals do not eat contaminated hay. For example, owners can shake each hay flake to look for evidence of beetles before feeding. Contaminated hay should not be fed even after beetle removal because the body

Toxicology Talk is written and reviewed by members of the American Society for the Prevention of Cruelty to Animals (ASPCA) Animal Poison Control Center (APCC). The mission of the APCC is to help animals exposed to potentially hazardous substances, which it does by providing 24-hour veterinary and diagnostic treatment recommendations from specially trained veterinary toxicologists. It also protects and improves animal lives by providing clinical toxicology training to veterinary toxicology residents, consulting services, and case data review. The ASPCA APCC includes a full staff of veterinarians, including board-certified toxicologists, certified veterinary technicians, and veterinary assistants, and its state-of-the-art emergency call center routinely fields requests for help from all over the world, including South America, Europe, Asia, and the Pacific Islands.

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fluids remaining on the hay contain cantharidin and can still cause toxicosis. Hay farmers can prevent blister beetle poisoning. Blister beetles are generally pollen feeders and can be found on alfalfa blossoms. Cutting the hay before it blossoms is a great way to prevent beetle infestations. Ideally, alfalfa hay should be harvested before it reaches full bloom, when blister beetles are most attracted to it. If the alfalfa has blossomed, the hay can be left in the field to dry after cutting to allow the beetles to either fly away or settle out of the hay during the raking process. The main source of contamination is when farmers simultaneously cut and crimp or bale hay. Although this process saves time, it does not allow the potentially toxic beetles to get out of the hay before it is baled. When hay is crimped right away, the beetles in it are crushed and their body fluids contaminate the hay. Thus even if hay purchasers shake out the beetles after opening a bale, cantharidin is still present in the feedstuff. Weed prevention can also be helpful because the beetles can be attracted to blooming weeds. Farmers can also walk the fields; if any areas of the field contain swarms, avoiding infested areas for a few days will allow most insects to leave. Furthermore, using equipment without hay conditioners, or leaving the hay conditioner open, may help reduce beetle mortality and allow beetles to disperse before hay is baled. First cut hay is generally harvested before the beetle mating season, which is when swarming is common. Owners should ask hay providers when hay was baled and if it was left to dry in the field before baling. If blister beetles are found in hay that has been fed to horses, the hay should be removed from the stall and a veterinarian or the ASPCA Animal Poison Control Center should be contacted for further treatment information. ď Ž References 1. Plumlee KH. Cantharidin toxicosis from blister beetles. Vet Med 1999;94(10):850-854. 2. Helman RG, Edwards WC. Clinical features of blister beetle poisoning in equids: 70 cases (1983-1996). JAVMA 1997;21(8):1018-1021. 3. Guglick M, MacAllister CG, Panciera R. Equine cantharidiasis. Compend Contin Educ Pract Vet 1996;1:77-80.

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Radiographic Positioning: Head, Shoulders, Knees, and Toes PART 2 Part 1 of this article, published in the November/December 2016 issue of Today’s Veterinary Technician, described radiation safety policies, personal protective equipment, and guidelines for positioning orthopedic radiography patients to obtain diagnostic-quality images of the skull, shoulders, and elbows. Part 2 gives a brief overview of the 3 forms of restraint commonly used when taking orthopedic radiographs and examines some positioning techniques for radiographic views of the stifles, pelvis, and lower extremities. RESTRAINT TECHNIQUES Milan Kundera said, “Humanity’s true moral test…consists of its attitude towards those who are at its mercy: animals.”1 The oath for veterinary technicians states, “I solemnly dedicate myself to aiding animals and society by providing excellent care and services for animals, by alleviating animal suffering…” Once in practice, it is important to remember this oath. As veterinary technicians, we choose our profession because of our love and compassion for animals. Sometimes, however, we can get caught between doing what is best for the patient and working with limited monetary resources and time constraints. When positioning patients for radiographic studies, patient comfort should always be a priority, and injured or suffering patients should be made as comfortable as possible with analgesics or sedation.

M E E T T H E AU T H O R S

Liane K. Shaw, BS, RVT Purdue University Liane grew up in Valparaiso, Indiana, on a small hobby farm with horses, goats, pigs, chickens, geese, cats, a dog, and one duck named Daffy. A 10-year member of 4-H, she followed her continued on page 64

Jeannine E. Henry, BA, RVT Purdue University Jeannine was born and raised in Logansport, Indiana, where she welcomed any opportunity to spend time with animals. In 2005, she earned a bachelor’s degree in English, in pursuit of her passion for reading and writing, but soon realized continued on page 64

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Radiographs themselves are painless and noninvasive, but unsedated restraint can make the patient anxious, scared, and sometimes aggressive.2 This not only harms the patient, but also makes it more difficult to obtain diagnostic results in an efficient manner and can endanger team members. Chemical “Chemical restraint has contributed greatly to the progress made in radiology by allowing positioning that would otherwise be impossible to achieve.”2 Several types of sedation protocols can be used for patients, depending on the case (e.g., trauma, pediatric, geriatric). More information about sedation protocols can be found in the resources listed in BOX 1. The following advantages of adequate sedation help the veterinary team achieve diagnostic-quality radiographs with minimal to no harm to the patient, greatly reducing the possibility of an inaccurate or inconclusive diagnosis: ÆÆ Chemical restraint reduces patient pain and anxiety. Imagine being in excruciating pain, scared, nervous, stressed, surrounded by strangers, and unable to communicate with

BOX 1 Recommended Reading G reene SA. Veterinary Anesthesia and Pain Management Secrets. Philadephia, PA: Hanley & Belfus; 2002.  L eppanen MK, McKusick BC, Granholm MM, et al. Clinical efficacy and safety of dexmedetomidine and buprenorphine, butorphanol or diazepam for canine hip radiography. J Small Anim Pract 2006;47(11):663-669. M uir WW, Bednarski RM, Hubbell JAE, Lerche P. Handbook of Veterinary Anesthesia. 5th ed. St. Louis, MO: Elsevier Mosby; 2013. T homas JA, Lerche P. Anesthesia and Analgesia for Veterinary Technicians. 5th ed. St. Louis, MO: Elsevier; 2017:68.

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When positioning patients for radiographic studies, patient comfort should always be a priority, and injured or suffering patients should be made as comfortable as possible with analgesics or sedation.

anyone, all while being stretched out on a table in awkward and painful positions. Without sedation, this is the situation that many veterinary patients face. ÆÆ Sedated patients remain still during radiographic exposures, allowing fewer retakes of the same area of interest and therefore lowering radiation doses. ÆÆ Chemical restraint can increase efficiency in the workplace. A radiographic study can be done much more quickly when the patient does not struggle while being placed into multiple positions, allowing for more cases to be seen in a timely manner.3 ÆÆ Patient sedation can also help keep veterinary technicians healthy. A survey of more than 1200 NAVTA members found that sedation reduced the risk of on-the-job injuries, with 83% of respondents reported being injured while physically restraining a cat or dog, while only 9% reported being injured by a sedated animal.4 Even though the main focus of our profession is typically the patient, veterinary technicians should be cognizant of the care and attention we and our colleagues also need.

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Manual Although chemical restraint is the preferred option for orthopedic radiography, not all patients are medically stable enough to undergo heavy sedation. When manual restraint is needed, the minimum number of people needed to position and restrain the patient without compromising the safety of patient and other personnel should be in the room. To prevent injury resulting from the patient jumping off the table, the minimum number of people performing restraint is usually two: one person to restrain the head and forelimbs, and one person to restrain the hind portion. If the patient is large and very anxious, up to 3 people might be needed to ensure the safety of all involved. In these cases, one technician, assistant, or other trained associate should be in charge of restraining the head and forelimbs, while another trained associate should be in charge of restraining the hindlimbs. The third trained associate should be focused on positioning the patient. As discussed in part 1 of this article, it is imperative that anyone remaining in the room during an exposure be dressed in appropriate personal protective equipment (PPE), including lead gloves, a thyroid shield, a lead gown, and a dosimeter badge. To keep the radiation dose to a minimum for all involved, it is a good idea to keep a log of the number of times each person remains in the room during an exposure. The practice should always abide by the ALARA (as low as reasonably achievable) principle. Some states have laws against anyone being in the room during an exposure. It is the responsibility of the practice and the team members to be aware of and follow state regulations on physical and manual restraint. It is essential to keep in mind that patients undergoing orthopedic radiography are more likely to be in pain due to a recent traumatic event or chronic condition. This discomfort requires the team to work slowly and cautiously while positioning.

Mechanical Mechanical restraint, or the use of positioning aids and devices, can be used in conjunction with chemical and/or manual restraint. Several commercially available devices can be used to aid in positioning, such as V troughs, sandbags, cotton, tape, radiolucent blocks and wedges made of foam, and immobilization blocks5 (BOX 2). However, many other items, such as compression bands, rope, and wooden spoons and cutting boards, can also be used.6 Some items are more cost-effective than others and can work just as well as more expensive options. Some companies may allow practices to test products for a short time to determine whether they are worth purchasing. Some materials are radiolucent and some are radiopaque. Radiolucent substances absorb fewer x-rays than soft tissues and bone and appear black on radiographs. Radiopaque substances (e.g., metals) absorb more x-rays than tissue or bone and appear white on radiographs.6 At Purdue, we often use both radiolucent and radiopaque positioning aids. For example, when imaging a stifle, as described below, we use a radiopaque board under the pelvis, radiolucent cotton under the tarsus, and radiolucent tape around the opposing limb. Mechanical restraint is very helpful and, when paired with chemical restraint, eliminates the need for a technician, assistant, or trained

BOX 2 Basic Positioning Aids

 V trough  Sandbags

 Radiolucent blocks and paddles

 Cotton

 Foam wedges

 Tape

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associate to be in the room during a radiographic exposure. This should be the ultimate goal in obtaining diagnostic-quality radiographs. GENERAL GUIDELINES FOR DIAGNOSTIC RADIOGRAPHY One of the standards we follow at Purdue is to perform a complete radiographic series, no matter what is being imaged. Providing the most information we can to obtain the best possible diagnosis or outcome for the patient is our primary goal! Although certain circumstances (e.g., patient stability) may allow only one radiographic image to be obtained, it is possible to miss metastasis, disease processes, or even fractures based on a single radiograph. Therefore, taking at least two orthogonal views is of critical importance when trying to get diagnosticquality images.7 Orthogonal views are images that are taken at 90° to each other. The below tutorial includes positioning instructions to obtain two orthogonal views for the stifles, pelvis, and lower extremities. The terms used to describe radiographic positioning can be confusing and depend on the area being imaged. When describing the way the beam enters and exits the

FIGURE 1. Many types of calibration markers exist. This model, used in the following images, is from Xemarc (xemarc.com).

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Radiographs themselves are painless and noninvasive, but unsedated restraint can make the patient anxious, scared, and sometimes aggressive.

limb distal to the carpus and tarsus, it is appropriate to use the terms dorsopalmar and palmarodorsal for forelimbs or dorsoplantar and plantarodorsal for hindlimbs. The terms caudocranial and craniocaudal are used to describe the way the beam enters and exits a forelimb or hindlimb above the carpus and tarsus. Markers should always be placed to indicate patient position and/or beam direction. Many of the images in this article contain a magnification or calibration marker (FIGURE 1). These markers are primarily used in orthopedic views and are designed for use with digital hardware templates to allow surgeons to determine the exact size of the patient’s bone. In any radiographic study, especially digital studies, magnification resulting from patient size and exposure technique can be an issue. Using this marker allows the veterinary team to adjust for magnification by calibrating the radiograph with a known value: the size of the metal ball at the end of the flexible arm. For example, the ball in the marker shown in FIGURE 1 is 25 mm in diameter. The ball should be positioned next to the bone or joint being imaged and appears in the resulting radiograph as a radiopaque or bright circle. To reduce the amount of equipment in the images, most of the following photographs feature cadavers or well-trained

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healthy dogs that could be taped and positioned without sedation. Sedated patients should always be appropriately maintained with oxygen and monitoring. POSITIONING THE PATIENT: STEP BY STEP Stifles (Knees) Mediolateral View The patient is positioned in lateral recumbency with the affected limb closest to the plate or cassette. For example, if the left stifle is affected, position the patient in left lateral recumbency. The goal of this view is to superimpose the condyles of the femur. Therefore, start by placing 1 to 2 inches of padding under the patientâ&#x20AC;&#x2122;s pelvis to aid in rolling the stifle down toward the table to be parallel with the table (FIGURE 2). If the patient weighs <20 kg, only 0.5 to 1 inch of padding will likely be needed. At Purdue, we typically use a plastic cutting board under the pelvis, but when using a device like this, ensure that it does not show up in the collimated view. Abduct the opposing limb and secure it with tape to the table. If needed, place some

FIGURE 2

FIGURE 3

FIGURE 5

cotton padding under the tarsus to lift it and aid in superimposing the femoral condyles (FIGURE 3). In some cases, if the condyles are not superimposed, the cotton under the tarsus can be removed and placed under the stifle. (FIGURE 4) Similarly, the thickness of the padding under the pelvis may need to be increased or decreased to superimpose the condyles. Center the primary beam over the stifle and collimate to include approximately one-third of the femur and one-third of the tibia. The marker should be placed on the cranial aspect of the stifle (FIGURE 5). Caudocranial View The patient is positioned in sternal recumbency. Sedation is very helpful for this view, which can be painful and awkward for a nonsedated patient. Place a triangular wedge under the caudal abdomen, close to the pelvis. Tape around the metatarsus of the affected limb and completely extend the leg and tape it to the table (FIGURES 6 and 7). Use foam padding or cotton to lift the unaffected limb and roll the affected limb medially or laterally based on the position of the patella. The primary goal is to center the patella. The fabellae may or may not

FIGURE 4

FIGURE 7

FIGURE 6

FIGURE 8

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FIGURE 9

appear symmetric; however, the diagnostic view should show fabellae that are bisected symmetrically by the epicondyles of the femur. You may have to palpate the patella to find the center. Center the primary beam over the stifle. Collimate to include approximately one-third of the femur and one-third of the tibia (FIGURE 8). The marker should be placed on the lateral aspect of the stifle. Tibial Plateau Leveling Osteotomy Views Radiographic studies to assess the cranial cruciate ligament and aid in planning for tibial plateau leveling osteotomy (TPLO) are common in orthopedics. The series consists of 2 views: mediolateral and caudocranial.

Mediolateral view. For this view, it is necessary to include the entire tibia, from the stifle to the tarsus, to calculate the slope of the tibial plateau. The reference line for this calculation is the mechanical axis of the tibia, which is defined by drawing a line through the talus and the intercondylar spines, then identifying the cranial and caudal edges of the medial part of the tibial plateau. The difference between that angle and a perpendicular line to the mechanical axis is the tibial slope (FIGURE 9).a The patient is positioned in lateral recumbency with the limb of interest closest to the plate or cassette. Place some padding under the pelvis with the goal of superimposing the condyles of the stifle (FIGURE 2). Abduct the nonaffected limb out of the view by taping it to the table. Angle the affected tibia so that the femorotibial (stifle) joint and the tibiotarsal (tarsus) joints are at 90° angles (FIGURE 10). If needed, tape can be applied around the tarsus to pull the femur down to get the femorotibial joint at a 90° Mark Rochat, DVM, MS, DACVS, Clinical Professor and Chief of Small Animal Surgery. Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, personal communication.

FIGURE 11

FIGURE 10

FIGURE 12 FIGURE 13

FIGURE 14

FIGURE 15

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Orthogonal views are images that are taken at 90° to each other.

angle. Use some cotton or a radiolucent wedge under the tarsus to aid in superimposing the femoral condyles. Center the primary beam over the tibia and collimate to include the stifle and the tarsus (FIGURE 11). The marker should be placed on the cranial aspect of the tibia (FIGURE 12). Again, in some cases, if the condyles are not superimposed, the cotton from the tarsus can be removed and applied under the stifle. Similarly, the padding under the pelvis may need to be increased or decreased to superimpose the condyles. Caudocranial view. The patient is positioned in sternal recumbency with a triangular wedge under the abdomen and pelvis. Tape around the tarsus of the limb of interest, extend the limb completely, and secure it to the table. Lift the unaffected limb to roll the patella of the affected limb medially to center it (FIGURE 13). Secure this limb with

FIGURE 16

tape or another positioning device. Again, the fabellae may or may not appear symmetric; however, the diagnostic view should show fabellae that are bisected symmetrically by the epicondyles of the femur. Center the primary beam in the middle of the tibia (FIGURE 14) and collimate to include the stifle and the tarsus. The marker should be placed on the lateral aspect of the tibia (FIGURE 15). Tibial Tuberosity Advancement Views Radiographic studies to assess the cranial cruciate ligament and aid in planning for tibial tuberosity advancement (TTA) are also common in orthopedics. Again, the series consists of 2 views: mediolateral and caudocranial. Mediolateral view. The patient is positioned in lateral recumbency with the affected limb closest to the plate or cassette. If needed, place some padding under the pelvis to rotate the affected stifle down toward the table to be parallel to the table (FIGURE 2). Abduct the nonaffected limb out of the view and tape it to the table (FIGURE 16). For this view, position the affected tibia to be at a 135° angle with the stifle. This angle can be measured by using an instrument called a goniometer; however, if a goniometer is not available, the

FIGURE 17

FIGURE 18 FIGURE 19

FIGURE 20

FIGURE 21

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limb can be positioned at a normal walking angle, which is typically close to 135°. There is no specific angle for the tarsus. Use some cotton or a radiolucent wedge under the tarsus to aid in superimposing the femoral condyles (FIGURE 17). Center the primary beam over the tibia and collimate to include the stifle and the tarsus (FIGURE 18). The marker should be placed on the cranial aspect of the tibia. If the condyles are not superimposed, alter the padding under the tarsus, stifle, or pelvis as needed to superimpose them. FIGURE 19 shows the reference lines and angles used to measure when planning TTA, similar to those used in TPLO. Caudocranial view. The patient is positioned in sternal recumbency with a triangular wedge under the abdomen and pelvis. Tape around the tarsus of the limb of interest, extend the limb completely, and secure it to the table. Lift the unaffected limb to roll the patella of the affected limb medially to center it (FIGURE 13). Secure this limb with tape or another positioning device. Center the primary beam in the middle of the tibia (FIGURE 14) and collimate to include the stifle and the tarsus. The marker should be placed on the lateral aspect of the tibia (FIGURE 15).

FIGURE 22

FIGURE 23

FIGURE 26

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Sedated patients remain still during radiographic exposures, allowing fewer retakes of the same area of interest and therefore lowering radiation doses. Pelvis Lateral View The patient is positioned in right lateral recumbency. The goal of this view is to superimpose the wings of the ilium and hemipelvis. Place a foam wedge between the hindlimbs and use the wedge to push the right hindlimb cranially (FIGURE 20). Positioning the patient this way ensures that the left hindlimb is “left behind” to delineate which femur is which on the radiograph.

FIGURE 24

FIGURE 27

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FIGURE 25

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Center the primary beam over the pelvis and palpate the wings of the ilium as the cranial landmark and the caudal border of the ischium as the caudal landmark. Collimate over just the pelvis (FIGURE 21). The marker should be placed dorsal to the pelvis. Extended View This view of the pelvis is considered the most diagnostic view. The patient is positioned in dorsal recumbency with the help of a V trough or other positioning device to get the pelvis straight. Tape around the tarsus of each leg, extend the hindlimbs completely, and secure the tape to the table (FIGURE 22). Go under the hindlimbs, just above the stifles, with tape, then bring the tape up and crisscross it above the stifles to rotate the hindlimbs medially so that the femurs are parallel to each other. A diagnostic view of the extended pelvis shows the patellas centered, the femurs parallel to each other, the tuber ischia equally overlapped by the femurs, a symmetric obturator foramen, and the tail between the femurs (FIGURE 23). Center the primary beam just cranial to the ischium (FIGURE 24). Collimate to include the wings of the ilium and a small portion of the proximal tibias, just

caudal to the femorotibial joints (FIGURE 25). A marker should be placed on one side of the patient to denote the right or the left side. For patients that are not medically stable enough for this view, such as those with a fracture or unsedated patients, a frog-leg ventrodorsal view can be taken by letting the hindlimbs rest naturally. Collimate over the pelvis to include the wings of the ilium and the ischium. Phalanges (Toes) Front Foot Views Mediolateral view. The patient is positioned in lateral recumbency with the affected limb closest to the plate or cassette. Tape around the foot, extend the forelimb cranially, and secure it to the table (FIGURE 26). Cotton padding may be needed under the carpus or foot to get the limb in a true lateral position. Center the primary beam over the metacarpal bones and collimate to include the carpus and all of the phalanges (FIGURE 27). The marker should be placed on the cranial aspect of the foot. Dorsopalmar view. The patient is positioned in sternal recumbency. Tape around

FIGURE 28

FIGURE 29

FIGURE 30

FIGURE 31

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the foot, extend the forelimb cranially, and secure it to the table (FIGURE 28). To get the forelimb in a straight craniocaudal position, the patient’s head and body may need to be rotated left to right (FIGURE 29). This can be achieved by using a positioning device to prop the patient’s head to the lateral side or, if needed, having a team member in PPE hold the head out of the primary beam. Center the primary beam over the metacarpal bones and collimate to include the carpus and all of the phalanges (FIGURE 30). The marker should be placed on the lateral aspect of the foot. Mediolateral view (splay toe). The patient is positioned in lateral recumbency with the affected limb closest to the plate or cassette. To separate the phalanges, take a 0.5-inch wide piece of tape, wrap it around P2, and pull the toe cranially. Take another 0.5-inch wide piece of tape, wrap it around P5, and pull caudally (FIGURE 31). This should separate the toes enough to visualize each toe. Center the primary beam over the metacarpal bones and collimate to include the carpus and all of the phalanges (FIGURE 32). The marker should be placed on the cranial aspect of the foot. Dorsopalmar view (splay toe). The patient is positioned in sternal recumbency. Tape around

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TECHPOINT 

Chemical restraint has contributed greatly to the progress made in radiology by allowing positioning that would otherwise be impossible to achieve.

the foot, extend the forelimb cranially, and secure it to the table. As with the regular craniocaudal view, the head and body of the patient may need to be rotated left to right to get the forelimb in a straight craniocaudal position, using a positioning device or a team member wearing PPE. To separate the phalanges, place some cotton between each toe (FIGURE 33). This will help to visualize the toes individually on the radiograph. Center the primary beam over the metacarpals and collimate to include the carpus and all of the phalanges (FIGURE 34). The marker should be placed on the lateral aspect of the foot.

FIGURE 32

FIGURE 33

FIGURE 34

FIGURE 35

FIGURE 36

FIGURE 37

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Carpus Views Medial stress view. The patient is positioned in sternal recumbency. Tape around the proximal phalanges, extend the forelimb cranially, and secure it with tape to the table. Place another piece of tape around the metacarpus, above the first piece, distal to the carpus. Pull it laterally and secure it to the table. Press the edge of a wooden spoon or similar radiolucent device on the lateral aspect of the carpus, near the middle carpal joint. Hold the elbow of the patient in place with a lead-gloved hand, and gently press the spoon medially to stress the medial joint of the carpus (FIGURE 35). Collimate to include approximately one-third of the radius and ulna and, at minimum, onethird of the metacarpus (FIGURE 36). If the clinician prefers, all the phalanges can be included in this view. The marker should be placed on the lateral aspect of the carpus. Lateral stress view. The patient is positioned in sternal recumbency. Tape around the proximal phalanges and extend the forelimb cranially. Secure it with tape to the table. Place another piece of tape around the metacarpus, just above the first piece, pull it medially, and secure it to the table. Press the edge of a wooden spoon or similar radiolucent

device on the medial aspect of the carpus, near the middle carpal joint. Hold the patientâ&#x20AC;&#x2122;s elbow in place with a lead-gloved hand and gently press the spoon laterally to stress the lateral joint of the carpus (FIGURE 37). Collimate to include approximately one-third of the radius and ulna and, at minimum, onethird of the metacarpus (FIGURE 38). If the clinician prefers, all the phalanges can be included in this view. The marker should be placed on the lateral aspect of the carpus. Hyperflexion. The patient is positioned in lateral recumbency with the affected limb closest to the plate or cassette. Flex the carpus so that the phalanges almost touch the distal aspect of the radius and ulna. Secure the foot either by taping in a figure 8 pattern proximal and distal to the carpus (FIGURE 39) or by using a heavy positioning aid against the distal portion of the foot to force the foot against the radius and ulna. Center the primary beam over the flexed carpus and collimate to include approximately one-third of the radius and ulna and one-third of the metacarpus (FIGURE 40). The marker should be placed on the cranial aspect of the foot. Hyperextension. The patient is positioned in lateral recumbency with the affected limb

FIGURE 38

FIGURE 39

FIGURE 41

FIGURE 42

FIGURE 40

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closest to the plate or cassette. Extend the carpus by placing a heavy positioning aid against the foot and pushing against the carpus (FIGURE 41). If this does not work, place a piece of tape around the metacarpus, pull cranially, and secure it to the table. Place another piece of tape around the middle of the carpus, pull caudally to extend the carpus, and secure it to the table. Center the primary beam over the extended carpus and collimate to include approximately one-third of the radius and ulna and one-third of the metacarpus (FIGURE 42). The marker should be placed on the cranial aspect of the foot. CONCLUSION Anthony Douglas Williams, spiritual author, once said, “When I look into the eyes of an animal, I do not see an animal. I see a living being. I see a friend. I feel a soul.” Many veterinary technicians can relate to this quote and see the truth behind it. We entered into this profession with a passion for animals and have gained an immense knowledge of veterinary medicine, but it is our responsibility to learn more. This 2-part article has given an overview of radiation safety, types of restraint for orthopedic radiography, and positioning techniques to obtain diagnostic radiographs of the skull, shoulder, elbow, stifle, pelvis, and feet. It is imperative to remember that obtaining a diagnostic-quality image aids in achieving the appropriate diagnosis for the patient.  References 1. Kundera M. The Unbearable Lightness of Being. New York, NY: HarperPerennial; 1989. 2. McCurnin DM, Bassert JM. Clinical Textbook for Veterinary Technicians. 7th ed. St. Louis, MO: Elsevier Saunders; 2010:574-575. 3. Thomas JA, Lerche P. Anesthesia and Analgesia for Veterinary Technicians. 5th ed. St. Louis, MO: Elsevier; 2017:68. 4. NAVTA members speak out: benefits of sedation vs. manual restraint. NAVTA J Oct/Nov 2015:16-17. navta. net/?page=ZoetisSurvey. Accessed November 2016. 5. Han CM, Hurd CD. Practical Diagnostic Imaging for the Veterinary Technician. 3rd ed. St. Louis, MO: Elsevier Mosby; 2005:57-103. 6. Lavin LM. Radiography in Veterinary Technology. 5th ed. Philadelphia, PA: Elsevier Saunders; 2014:307-326. 7. Thrall D. Textbook of Veterinary Diagnostic Radiology. 6th ed. St Louis, MO: Elsevier Saunders; 2013:287.

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Liane K. Shaw, BS, RVT passion for animals by applying to the veterinary technology program at Purdue University, where she earned not only an associate’s degree, but also a bachelor’s in applied science, with a minor in organizational leadership and supervision. After working as a supervisor in private practice for 6 years, Liane returned to Purdue to pursue her love of teaching. In the past 9 years as Purdue’s Diagnostic Imaging Instructional Technologist, she has completely remodeled the diagnostic imaging curriculum to include many labs for a more hands-on approach. In 2011, she received a Teaching Excellence award from Purdue University and Elanco Animal Health. In 2013, she spoke at Purdue’s fall conference on the topic of dental radiography. Liane stays busy by spending the evenings outside with her husband and two sons on their 22-acre farm in Attica, Indiana, which is home to horses, dogs, cats, and a donkey!

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

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Advertiser Index Pediatric Emergencies, continued from page 20

American College of Veterinary Internal Medicine ACVIM Forum acvim.org . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Animal Medical Center Recruitment amcny.org . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Bayer Seresto animalhealth.bayer.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Boehringer Ingelheim Vetmedin boehringer-ingelheim.com . . . . . . . . . . . . . . . . . . . . . . . 3, 10 Merial Frontline Gold frontline.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51 Heartgard heartgard.com . . . . . . . . . . . . . . . . . . . . . . . . . 76, back cover NexGard nexgardfordogs.com . . . . . . . . . . . . . . . . . . . 15, 16, insert Previcox previcox.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5, 6 NAVC VMX 2018 navc.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Nestle Purina NeuroCare diet purina.com . . . . . . . . . . . . . . . . . . . . . . . . . . inside back cover Ocala Equine Hospital Recruitment ocalaequinehospital.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Protege Biomedical Clotting protegebiomedical.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 Tuttnauer EZPlus Sterilizers tuttnauer.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Vetoquinol Flexadin vetoquinolusa.com . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Virbac Sentinel Spectrum virbacpets.com . . . . . . . . . . . . . . . . . inside front cover, 4

11. Mila H, Feugier A, Grellet A, et al. Inadequate passive immune transfer in puppies: definition, risk factors and prevention in a large multi-breed kennel. Prev Vet Med 2014;116(1-2):209-213. 12. Casal M. Clinical approach to neonatal conditions. In: England G, von Heimendahl A, eds. BSAVA Manual of Canine and Feline Reproduction and Neonatology. 2nd ed. Gloucester, UK: British Small Animal Veterinary Association; 2013:147-154. 13. Grundy S: Clinically relevant physiology of the neonate. Vet Clin North Amer Small Anim Pract 2006;36(3):432-459. 14. Macintire DK. Pediatric fluid therapy. Vet Clin North Amer Small Anim Pract 2008;38:621-627. 15. Poffenbarger EM, Olson PN, Chandler ML, et al. Canine neonatology: part 2. Disorders of the neonate. Compend Contin Educ Pract Vet 1991;13:25-37. 16. Macintire DK. Pediatric intensive care. Vet Clin North Amer Small Anim Pract 1999;(29):837-852.

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Louise O’Dwyer, MBA, BSc (Hons), VTS (Anesthesia, ECC), DipAVN (Medical & Surgical), RVN Louise’s interests include all aspects of emergency care, particularly trauma, as well as anesthesia, surgical nursing, infection control, and wound management. In 2016, Louise was delighted to receive the prestigious Bruce Vivash Jones Veterinary Nurse Award, which recognizes outstanding contributions to the advancement of small animal veterinary nursing, as well as the Royal College of Veterinary Surgeons Golden Jubilee Award for exceptional contribution to veterinary nursing. Louise is the PresidentElect for the Academy of Veterinary Emergency and Critical Care Technicians.

Trish Farry, CVN, VTS (ECC, Anesthesia/Analgesia), CertTAA, GCHEd anesthesia, analgesia, and clinical practices for undergraduate veterinary and veterinary technology students. She has been President of the Academy of Emergency and Critical Care Technicians as well as a board member of the Academy of Veterinary Technician Anesthetists and the International Veterinary Academy of Pain Management.

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Body Cavity Centesis:

M E E T T H E AU T H O R

Techniques for the Pleural, Abdominal, and Pericardial Cavities Body cavity centesis is a valuable and effective treatment for removal of large effusions. Although centesis is generally performed by veterinarians, it is important for veterinary technicians to be knowledgeable about the techniques used to properly prepare, assist with, and monitor these patients. Many methods of performing centesis exist, and the equipment used may vary, but the fundamental concepts remain the same. This article presents those fundamental concepts, examples of equipment, and important details for avoiding complications. Although specific examples are given, other, equally valid methods may be used. All body cavity centesis procedures should be performed using aseptic technique, including proper hair removal and disinfection of the skin with chlorhexidine or povidone–iodine scrub before entering the body cavity. Failure to do so can lead to serious infections. Samples of all fluid removed from body cavities should be submitted for fluid analysis and histopathologic examination to determine the cause of the effusion. To view the CE test for this article, please visit todaysveterinarytechnician.com.

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H. Edward Durham, Jr, CVT, RVT, LATG, VTS (Cardiology) Ross University School of Veterinary Medicine St. Christopher and Nevis, West Indies Ed is currently a senior veterinary technician in the anesthesia section of the Ross School of Veterinary Medicine. Before moving to Ross University, he was the senior veterinary technician for the cardiology service at the University of Missouri Veterinary Health Center. He is a speaker at national and international conferences, has published several peer review articles in cardiology, and is the editor of the soon-to-be published Cardiology for Veterinary Technicians and Nurses. He is also a charter member of the Academy of Internal Medicine for Veterinary Technicians (AIMVT) and serves as the Director at Large–Cardiology on the AIMVT Executive Board.

DEMONSTRATION of the proper way to hold the catheter for abdominocentesis.

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THORACENTESIS Indications for thoracentesis, also called thoracocentesis, include pleural effusion (chylothorax, hemothorax, pyothorax) and pneumothorax. Both pleural effusion and pneumothorax impair respiration, and dyspnea is the primary clinical sign. Pleural effusion impairs respiration as fluid builds up in the pleural space, limiting expansion of the lungs. In the case of pneumothorax, air trapped in the pleural space obliterates the normal negative pressure of the thorax, again making it difficult to expand the lungs. Thoracentesis either restores the pleural space by removing the fluid or recreates negative pressure by evacuating the trapped air from the thorax. In both cases, full expansion of the lungs can be restored, and breathing becomes easier for the patient. Equipment typically used for thoracentesis is listed in BOX 1.

of the chest. Thoracentesis is generally performed with the patient in sternal recumbency. Two operators are required to safely perform thoracentesis: one to restrain the patient and another to perform the procedure. Having a third person present to assist with the procedure is ideal. 1. Clip both sides of the chest from the 5th to the 11th intercostal space and from at least the costochondral junction to about 65% of the way up the chest wall. If a pneumothorax is suspected, clip the thorax dorsally to the spine. If the patient is in sternal recumbency, fluid will be ventral in the thoracic cavity, but air will be dorsal. 2. After the thoracic wall is properly prepped, palpate the 7th to 9th intercostal space while wearing sterile gloves. Lidocaine may be used for a local anesthetic at the puncture site. If available, ultrasonography may be used to identify the optimal location for

Procedure Compartmentalization or a complete mediastinum may prevent complete removal of the effusion from just one side; therefore, thoracentesis is often needed on both sides

BOX 1 Equipment for Thoracentesis 1. Sterile gloves suitably sized for the sterile operator 2. ~1.5 mL 2% lidocaine for skin block as needed 3. Needle or catheter of suitable length to penetrate the chest wall 4. 3- or 4-way stopcock 5. IV extension tubing 6. 10â&#x20AC;&#x201C;60 mL syringe, depending on the size of the patient and volume of effusion expected 7. EDTA tube and plain red top tube for sample collection 8. Basin to hold evacuated effusion 9. Sterile probe cover/sterile gel/elastic band as needed for ultrasonography

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FIGURE 1. Example of how to connect the syringe, stopcock, extension set, and catheter to prepare for any type of body centesis. The assembly is made using aseptic technique. Once completely assembled, the syringe can be handed to a nonsterile assistant who can operate the stopcock during the centesis. This basic configuration can be used for all procedures described in the text and can be easily modified depending on operator preference and available supplies.

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T ECHP O I N T 

In veterinary medicine, patients often jump not when the needle enters the skin, but when it passes into the pleural space. Therefore, it is good practice to provide some pain control for thoracentesis. needle insertion. The ultrasound probe should be covered with a sterile probe cover. 3. Attach the needle or catheter to the extension tubing, the extension tubing to the stopcock, and the stopcock to the syringe (FIGURE 1). Sterility should be maintained throughout this procedure. Once everything is connected, the syringe can be handed to a second operator, who does not need to be sterile. This person applies gentle negative pressure to the syringe while the first (sterile) operator advances the needle through the thoracic wall. 4. The first operator can now position the needle in the chosen site (7th to 8th or 8th to 9th intercostal space). Advance the needle through the chest on the cranial aspect of the rib to avoid puncturing the intercostal vessels. If effusion is suspected, the needle is positioned ventrally; if pneumothorax is suspected, the needle is placed dorsally. As the needle is advanced into the chest, the second operator keeps a small amount of suction in the system to allow immediate aspiration of any effusion and help avoid inducing a pneumothorax during the procedure. 5. Once fluid (or air, in the event of a pneumothorax) begins flowing into the extension tubing, the first operator must

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manually secure the needle while the second operator gently aspirates the effusion into the syringe. Samples for histopathology can be collected by turning the stopcock “off” to the patient and expressing a sample into the collection tube. Excess fluid can be emptied into the basin for disposal as needed by turning the stopcock “off” to the patient. Turning the stopcock back to “off” toward the outside will allow resumption of aspiration. 6. The second operator continues aspiration until fluid stops flowing and negative pressure is felt. If the thoracentesis is for pneumothorax, evacuation continues until negative pressure is once again achieved. During aspiration, the second operator should never apply more than 5 mL of negative pressure. Excessive suction may induce a pneumothorax by “pulling” air through the lung tissue. 7. Once the second operator feels only negative pressure, the first operator may try repositioning the needle by changing the angle to determine if any further fluid can be removed at that site. If the first operator is satisfied that no more fluid is available, they may begin withdrawing the needle. Again, the second operator should maintain slight negative pressure during withdrawal. 8. Repeat the above procedure on the other hemithorax, using new supplies. Ultrasonography is a very useful way of assessing the amount of remaining fluid; thoracic radiographs can also be used to assess the results. In some cases, thoracentesis may need to be repeated every few weeks as part of a therapeutic plan. In such instances, mild sedation may be considered as a gentler approach than simple physical restraint. The pleural lining does have sensory nerve supply, and in human medicine, patients report that thoracentesis is quite painful. In veterinary medicine, patients often jump when the needle is inserted into the thorax. Therefore, it is good practice to provide some pain control for thoracentesis.

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Complications After thoracentesis, the patient should be monitored for dyspnea. Inadvertent puncture of a thoracic or intercostal blood vessel may lead to hemothorax. It is also possible that during the thoracentesis, air may enter the thoracic cavity and induce pneumothorax. Until the cause of the effusion is corrected, a return of the effusion is possible. Signs of hemothorax, pneumothorax, and, in the longer term, infection should be monitored. Provided that aseptic technique was maintained, postprocedural antibiotics are not necessary. ABDOMINOCENTESIS Abdominocentesis may be indicated when abdominal distention caused by an effusive fluid, or ascites, is present. Importantly, not all patients with large abdomens have effusion. The “5Fs” of abdominal distention are a useful memory device for common causes of enlarged abdomen: fluid, flatulence, fat, fetus, and feces. Ascites of sufficient quantity to cause difficulty breathing and results of diagnostic sample analysis are the primary indications for abdominocentesis. Generally, unless the ascites is significant enough to cause dyspnea, treating the cause (e.g., uroabdomen, hemoabdomen) often resolves the problem, and therapeutic abdominocentesis is not necessary. Collection and analysis of diagnostic samples of ascites enable determination of the source of the fluid.

To collect a diagnostic sample, a 21- or 20gauge needle and a 3- to 5-mL syringe are all that is necessary. After prepping the abdomen, simply pass the needle into the abdomen approximately 1 to 2 cm caudal to the umbilicus on midline and aspirate. The collected sample is sterile and immediately available for analysis. For therapeutic abdominocentesis, more supplies are required (BOX 2). Procedure Several methods for performing abdominocentesis exist. In my experience, the one described below is the most effective. 1. Position the patient in either right or left lateral recumbency. Shave and aseptically prepare the ventral abdomen. If ultrasonography is available, the probe may be covered with a sterile cover and used to locate the largest pocket of fluid. Alternatively, the section of abdomen 1 to 2 cm caudal to the umbilicus is typically a good location. Inserting the catheter directly into the

BOX 2 Equipment for Abdominocentesis 1. Sterile gloves suitably sized for the operator 2. ~1.5 mL 2% lidocaine for skin block as needed 3. 18- to 14-gauge over-the-needle catheter (fenestrated or unfenestrated according to operator preference) 4. 3- or 4-way stopcock 5. Extension set 6. Basin to collect the ascites 7. Sterile probe cover/sterile gel/elastic band as needed for ultrasonography

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FIGURE 2. Demonstration of the proper way to hold the catheter for abdominocentesis. The right hand is used to drive the catheter forward while the left hand provides a “stop” to prevent overpenetration. Note that the catheter is placed directly on the midline of the abdomen and will be passed through the linea alba. No cap is placed on the catheter, allowing the free flow of ascites once the needle and catheter have penetrated the abdominal wall. Once a flash of ascites is seen, the catheter will be advanced over the needle into the abdomen, the needle discarded, and an IV extension set attached to begin the fluid removal process.

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The “5Fs” of abdominal distention are a useful memory device for common causes of enlarged abdomen: fluid, flatulence, fat, fetus, and feces. linea alba in this location seems to provide for the least leakage of fluid after the procedure and avoiding soft abdominal organs. Lidocaine may be used for a local block at the puncture site. 2. Insert the catheter and needle assembly until fluid (“flash”) appears in the needle hub (FIGURE 2). Advance the catheter off the needle into the abdomen and discard the needle. Attach the extension tubing to the catheter and place the distal end in the basin. Position the basin lower than the patient. The positive pressure of the abdomen and gravity will allow the fluid to flow from the abdomen through the extension set to the basin. Systems using suction, such as syringes or suction pumps, may be employed; however, in my experience, these methods are more likely to aspirate omentum or organs to the tip of the catheter, thereby necessitating chronic manipulation and potentially increasing the chance of infection, catheter dislodgment, or kinking of the catheter. 3. Allow the fluid to flow passively out of the abdomen until it ceases. Gentle pressure on the abdomen may evacuate more fluid. In patients with transudative ascites from congestive heart failure, removing as much fluid as possible is acceptable. Removal of large volumes of protein-rich effusion may result in hypoproteinemia.1 Because the goal of abdominocentesis is to improve respiration by relieving pressure on the diaphragm,

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it is not necessary to remove all the fluid. Once respiration is improved, the cause of the ascites should be addressed directly. 4. Once the fluid is removed, withdraw the catheter and hold dry gauze over the puncture site for 3 to 5 minutes. A small amount of leakage is possible after the gauze is removed. One advantage of entering the abdominal cavity on the linea alba is that postprocedural leakage will exit the patient completely, rather than pooling in the ventral subcutaneous tissue. A light belly wrap may be placed for 30 to 45 minutes to absorb any extra abdominal fluid. If abdominal distention is due to hemoabdomen from trauma or hemorrhage of a soft tissue tumor, abdominocentesis is not always the best treatment. Emergency surgery is indicated in these cases to stop the source of the hemorrhage, and hemoabdomen may in fact slow the bleeding until surgery is performed by creating increased abdominal pressure.2 Complications Complications of abdominocentesis include infection from breaks in aseptic technique, hemorrhage from organ puncture with the catheter needle, and insufficient removal of fluid. Insufficient fluid removal may be the result of the omentum occluding the catheter tip, compartmentalization of fluid, or incompletely passing the needle through the abdominal wall. Because the needle tip extends beyond the catheter tip, a flash may be seen from the needle tip while the catheter tip is still in the tissue of the abdominal wall. In this situation, the catheter tip may track between the layers of the abdominal wall and not pass into the abdominal cavity. This complication can be avoided by linea alba placement and by advancing the catheter and needle together another 1 to 2 mm after the flash is seen. Organ puncture is a common complication. Long-term consequences are rare, but the patient must be monitored closely for onset of anemia. Overadvancing the catheter/needle can be avoided by “choking up” on the needle,

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leaving only 2 to 3 cm of needle exposed in front of the fingers. Because the abdominal wall is fibrous and tough, a significant amount of pressure is required to pass the needle into the abdominal cavity. Without gripping the catheter and needle near the tip, the operator can easily advance the entire needle length into the patient suddenly when the wall yields. PERICARDIOCENTESIS Any abnormal effusion in the pericardium that is significant enough to cause cardiac tamponade warrants pericardiocentesis. Cardiac tamponade describes a condition in which the pericardial effusion creates pressure in the pericardium greater than that of the right atrium (RA). The increased pressure causes the RA wall to collapse during diastole, limiting filling of the RA and reducing the amount of blood delivered to the right ventricle and, thus, to the lungs and left heart. This leads to a decrease in cardiac output to the whole body. An echocardiogram is needed to diagnose cardiac tamponade (FIGURES 3 and 4).

FIGURE 3. Long-axis view of the heart on an echocardiogram. The apex of the heart is to the left of the image, and the atria are toward the right. The left ventricle (LV) and left atrium (LA) are toward the bottom of the image. The pericardial effusion (PCE) can be seen as a large, fluid-filled space around the heart. The bright white line outside the fluid is the pericardium. The right atrium (arrow) is noticeably smaller than the LA, indicating decreased filling due to the pressure of the PCE.

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If cardiac tamponade is not present and cardiac output is not compromised, pericardiocentesis may not be indicated. Clinical signs such as collapse, muffled heart sounds, ascites, and/or tachycardia should raise suspicion of acute pericardial effusion. An electrocardiogram may show diminished QRS amplitude, electrical alternans, and possibly ventricular premature complexes. Paroxysmal ventricular tachycardia may also be noted. Emergency treatment of pericardial effusion includes intravenous fluid therapy. It should be noted that furosemide is contraindicated in cases of pericardial effusion. Diuretics remove volume from the circulatory system, thereby decreasing cardiac output even more and worsening systemic hypotension.3 Intravenous fluids are administered to expand blood volume and increase cardiac output. Some patients with pericardial effusion have ascites, and the temptation to use furosemide can be great, but until the pericardial effusion is removed it does more harm than good.

FIGURE 4. Short-axis view of the heart on an echocardiogram. In this plane the heart is transected across the body of the left ventricle (LV), similar to a pineapple slice. The LV is in the center, with the right ventricle (RV) seen as a sliver above it. The pericardial effusion (PCE) is noted around the entire heart. The pericardium is seen as the bright white line outside the PCE.

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T ECHP O I N T 

Pericardiocentesis is perhaps the most challenging centesis procedure because of the proximity to the heart. Equipment typically used for thoracentesis is listed in BOX 3. Procedure Placement of a peripheral indwelling catheter is highly recommended. As stated, cardiovascular support is necessary. Venous access allows for rapid intravenous infusion of lidocaine in the event of significant ventricular arrhythmias. It is a good plan to have one dose of 2 mg/ kg lidocaine ready in the event of ventricular tachycardia. Continuous electrocardiography monitoring is recommended to watch for ventricular arrhythmias during the procedure. As for thoracentesis, 2 operators are required to perform a pericardiocentesis; 3 is ideal. Pericardiocentesis is performed from the right hemithorax to avoid the coronary arteries, which course around the left ventricle. 1. Place the patient in left lateral recumbency, using sedation as necessary to ensure it does not move during the pericardiocentesis. 2. Wearing sterile gloves, and after proper aseptic scrub, the first operator locates the optimal location for the procedure. If available, ultrasonography is useful for this determination, using a sterile probe cover over the probe. Typically, the puncture site is in the 3rd to 5th intercostal space, approximately 1 to 2 cm dorsal to the costochondral junction. Lidocaine is administered at the insertion site and injected into the skin, intercostal muscles, and to the pleura. 3. After final aseptic scrub prep, the patient is draped and a small stab incision is made

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with the #11 blade. This incision is only about 5 mm long and penetrates the full thickness of the skin to prevent the catheter from becoming burred when passing through the skin. The second operator can attach the stopcock and extension set to the syringe; these connections need not be sterile. The distal end of the extension tube must be kept sterile so that the first operator can handle it without contaminating the field. 4. Using the 14-gauge catheter, the first operator advances the catheter–needle assembly at a 90° angle to the skin into the thoracic wall on the cranial edge of the rib,

BOX 3 Equipment for Pericardiocentesis 1. #11 surgical blade 2. 3- or 4-way stopcock 3. Sterile probe cover/sterile gel/elastic band as needed for ultrasonography 4. Sample tubes a. EDTA tube b. Plain tube c. Activated clotting time tube (gray top) warmed to body temperature 5. 14-gauge × 3.25" catheter or 14-gauge × 2" over-the-needle catheter (length suitable for patient; fenestrated or unfenestrated according to operator preference)a 6. 30- or 60-mL syringe 7. Sterile gloves suitably sized for the sterile operator 8. 30" IV extension set 9. Sterile 24 × 24" fenestrated drape 10. Sterile lube packets 11. ~1.5 mL 2% lidocaine for skin block 12. Basin to collect the effusion Many types of catheters are available for pericardiocentesis. The method described in this article is effective and reasonably priced. Special pericardiocentesis catheters are available with a pigtail configuration to help maintain placement in the pericardium.

TODAY’SVETERINARYTECHNICIAN

March/April 2017

Body Cavity Centesis: Techniques for the Pleural, Abdominal, and Pericardial Cavities PEER REVIEWED

and through the pleura to the pericardium (FIGURE 5). Pericardial effusion is identical in appearance to blood and will flow freely from the catheter–needle assembly. 5. Once the effusion has begun to flow from the catheter–needle assembly, the catheter is advanced over the needle into the pericardium and the extension set attached. The second operator begins aspirating while the first operator maintains the catheter position. 6. Because pericardial effusion has the same appearance as blood (FIGURE 5), it is not possible to tell by observation if the catheter–needle assembly has penetrated a chamber of the heart. Removing more volume from the circulatory system could be catastrophic, so before aspiration continues, correct placement of the catheter tip is confirmed by collecting a sample to perform a coagulation survey (BOX 4). Pericardial effusion is devoid of clotting factors because it is defibrinated (the fibrin has been broken down by the body); therefore, it does not

clot. If the collected sample clots within a predetermined period, the right ventricle has been catheterized and the catheter must be removed and the procedure restarted. 7. Samples for histopathology can be collected by turning the stopcock “off” to the patient and expressing a sample into the collection tube. Excess fluid can be emptied into the basin for disposal as needed by turning the stopcock “off” to the patient. Turning the stopcock back to “off” toward the outside will allow aspiration to resume. 8. The second operator continues aspiration until fluid stops flowing and negative pressure is felt. It is common during the procedure for the first operator to feel the heart beating against the catheter and for premature ventricular contractions to occur as the volume in the pericardium diminishes. Once all available effusion has been removed, the first operator slowly withdraws the catheter while the second operator maintains gentle negative pressure. A follow-up echocardiogram will confirm removal of the effusion. As the cardiac tamponade is released, the cardiac output increases, and the heart rate generally slows to a more normal rate.

FIGURE 5. Proper placement of the catheter for pericardiocentesis. The catheter is perpendicular to the chest wall. The effusion can be seen in the tubing attached to the back of the catheter. Note that it has the appearance of fresh blood. From this position the catheter is advanced over the needle, the needle discarded, and the drainage line quickly attached to the catheter for effusion evacuation.

TODAY’SVETERINARYTECHNICIAN

March/April 2017

FIGURE 6. An example of the supplies needed for pericardiocentesis prepackaged by a veterinary technician for quick access by the veterinarian. The contents of the package are sterile in their original packaging, but the outer package, which is simply to hold all the items together, has not been sterilized. A less-expensive alternative, such as a Ziploc bag, could also be used.



T ECHP O I N T 

It is a good plan to have one dose of 2 mg/kg lidocaine ready in the event of ventricular tachycardia. Complications During pericardiocentesis, ventricular arrhythmias may be life threatening. If they occur, the catheter should be removed and/or lidocaine administered. Catheter dislodgment during the procedure may necessitate a second puncture, or the pericardial fluid may leak out into pleural space, relieving the clinical signs. In these cases, the pericardial effusion is usually of insufficient quantity to require thoracentesis, but thoracentesis may be performed as needed. Overadvancement of the catheter into the heart can be a serious complication. Ventricular arrhythmias, palpation of a “bouncing” catheter, and coagulation of the aspirate are all signs of a catheter placed in the heart. Passing the needle into the heart usually causes ventricular premature complexes, but not always. If the heart is punctured, the only course is to remove the needle and start over. Typically, the heart can adapt to a single puncture without complication. After the procedure, signs of hemothorax, pneumothorax, and, in the longer term, infection should be monitored. Provided that aseptic

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technique was maintained, postprocedural antibiotics are not necessary. Pericardial effusion may recur within 24 hours, and a second procedure may be necessary. Chronic effusion should be treated with surgical removal of the pericardium to prevent constrictive pericarditis resulting from frequent pericardiocentesis. CONCLUSION Veterinary technicians need to be proficient in understanding centesis procedures. Time is often an important factor in the overall outcome of these patients. By anticipating the needs of the veterinarian performing the procedure, the veterinary technician can save valuable time for the patient and improve outcomes. Some small steps the veterinary technician can take to aid the process are having the equipment necessary for the specific procedure collected and prepackaged together to save time (FIGURE 6), understanding the indications and clinical signs for conditions that would benefit from a centesis, and being able to monitor the patient after the procedure. Although veterinary technicians do not usually perform these procedures, they are a critical part of their success.  References 1. Watson PJ, Bunch SE. Treatment of complications of hepatic disease and failure. In: Nelson RW, Couto CG, eds. Small Animal Internal Medicine. 4th ed. St. Louis, MO: Mosby/Elsevier; 2009:575. 2. Silverstein DC, Hopper K. Small Animal Critical Care Medicine. St. Louis, MO: Saunders-Elsevier; 2009:669. 3. Ware WA. Pericardial diseases and cardiac tumors. In: Cardiovascular Diseases in Small Animal Medicine. London, UK: Manson; 2011:326.

BOX 4 Coagulation Survey During Pericardiocentesis  Warm an activated clotting time (ACT) tube (gray top) to body temperature. This can be accomplished using a warming block or water bath or by having one of the operators put the tube next to their skin under an elastic band.  Collect a sample from the catheter–needle assembly into the tube, mix, and keep the tube at body temperature.  If the collected sample is from the right ventricle, it will clot within 2 minutes. If a clot has not formed after 2 minutes, aspiration is safe and can resume until all available effusion has been removed. Note: ACT tubes allow rapid assessment of clotting (<2 minutes). However, if an ACT tube is not available, it is possible to create one by adding 30 mg of diatomaceous earth (available at pool supply stores) to a 10-mL red top tube. The resulting tube can be used as described above. If a plain red top tube is used, clotting may take 4 to 5 minutes.

TODAY’SVETERINARYTECHNICIAN

March/April 2017

PEER REVIEWED

CAREERS chewables

CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian.

The Animal Medical Center, a full service veterinary hospital on Manhattan’s Upper East Side, is now accepting applications for Licensed Veterinary Technicians and Veterinary Assistants. AMC is committed to providing the highest quality veterinary care for its patients, and we are looking for candidates who share the same passion. Visit www.amcny.org/employment

1/2017 The Elmer and Mamdouha Bobst Hospital Caspary Research Institute The Institute for Postgraduate Education

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.

OCALA EQUINE HOSPITAL

SURGERY TECHNICIAN Basic medical training and understanding of sterile technique, horse experience and a B.S. Degree or a degree from a veterinary technical program are essential. Office hours are 8 am to 5 pm, Monday - Friday. Please contact Vicki Ferguson at 352-368-1616 with questions or fax or email your resume to: fax 352-368-1609, vickifoeh@gmail.com. Located in Ocala, FL. Website: www.ocalaequinehospital.com

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. EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development of the adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). ACCEPTABILITY: In acceptability and field trials, HEARTGARD Plus was shown to be an acceptable oral dosage form that was consumed at first offering by the majority of dogs. PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult heartworms and microfilariae before initiating a program with HEARTGARD Plus. While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level, HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due to dead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials with ivermectin alone after treatment of some dogs that have circulating microfilariae. Keep this and all drugs out of the reach of children. In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans. Store between 68°F - 77°F (20°C - 25°C). Excursions between 59°F - 86°F (15°C - 30°C) are permitted. Protect product from light.

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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. SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability of ivermectin. The dose regimens of HEARTGARD Plus and HEARTGARD are the same with regard to ivermectin (6 mcg/kg). Studies with ivermectin indicate that certain dogs of the Collie breed are more sensitive to the effects of ivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds. At elevated doses, sensitive dogs showed adverse reactions which included mydriasis, depression, ataxia, tremors, drooling, paresis, recumbency, excitability, stupor, coma and death. HEARTGARD demonstrated no signs of toxicity at 10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies, support the safety of HEARTGARD products in dogs, including Collies, when used as recommended. HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant or breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea collars, dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with HEARTGARD Plus in a heartworm disease prevention program. In one trial, where some pups had parvovirus, there was a marginal reduction in efficacy against intestinal nematodes, possibly due to a change in intestinal transit time. HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (See DOSAGE section) for dogs of different weights. Each strength comes in convenient cartons of 6 and 12 chewables. For customer service, please contact Merial at 1-888-637-4251.

today 610-558-1819 or email RLuttrell@NAVC.com to find out how.

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TODAY’SVETERINARYTECHNICIAN

March/April 2017

REDUCES SEIZURES IN EPILEPTIC DOGS

WHEN FED AS AN ADJUNCT TO VETERINARY THERAPY

Epilepsy can make your clients feel powerless – but now, you can offer them an additional way to help their dogs. Purina® Pro Plan® Veterinary Diets NeuroCare is formulated with medium chain triglyceride oil to help nutritionally manage dogs with epilepsy along with their current medication. Give your clients the power of nutrition to help their dogs in a new way, every day.

ET Y DI E ONLLLY MA*NAG & T A FIRS ITION PSY UTR PILE TO N WITH E S G O D

TO L E A R N M O R E A B O U T N E U RO CA R E , V I S I T PURINAPROPLANVETS.COM. Law TH, Davies ES, Pan Y, et al. A randomised trial of a medium-chain TAG diet as treatment for dogs with idiopathic epilepsy. Br J Nutr. 2015 Nov 14;114(9):1438-47 Purina trademarks are owned by Société des Produits Nestlé S.A. Printed in USA.

*as an adjunct to veterinary therapy

TRUST. 1 2

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

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.

PREVENTS HEARTWORM DISEASE

TREATS AND CONTROLS 3 SPECIES OF HOOKWORMS

TREATS AND CONTROLS 2 SPECIES OF ROUNDWORMS

OWNERS PREFER IT1 AND DOGS LOVE IT2