Today's Veterinary Technician, September 2017 by davidpsu

ONCOLOGY CANINE LYMPHOMA

ANESTHESIA PEDIATRIC ANESTHESIA

IDEAS INTO PRACTICE PUBLIC RELATIONS

TOXICOLOGY DECONTAMINATION: SKIN, EYES, AND AIRWAYS

CLINICAL PATHOLOGY MDR1 MUTATION: WHAT TO KNOW

BEHAVIOR SERVICES:

How You Can Expand Your Practice and Help Your Patients

1 DOSE. 12 WEEKS.* COMPLIANCE WITH LESS STRESS. INTRODUCING THE DIFFERENCE OF 12-WEEK* FLEA AND TICK PROTECTION FOR CATS Whether cats stay inside or go outside, there’s no hiding from fleas and ticks. Only Bravecto® takes care of protecting cats for 12 weeks* with just one topical dose.1 More convenient dosing – User-friendly Twist’N’Use™ design makes application simple Fewer potential gaps in protection1 – nearly 3X longer compliance per dose than monthly treatments Less hassle – Fewer treatments per year means less stress for pet owners and their cats Discover the difference at BravectoVets.com

START RECOMMENDING PRESCRIPTION-ONLY BRAVECTO TO PET OWNERS AT YOUR HOSPITAL * Bravecto kills fleas and prevents flea infestations, and kills ticks (black-legged tick) for 12 weeks. Bravecto also kills American dog ticks for 8 weeks. IMPORTANT SAFETY INFORMATION: The most common adverse reactions recorded in clinical trials were vomiting, itching, diarrhea, hair loss, decreased appetite, lethargy, and scabs/ulcerated lesions. Bravecto has not been shown to be effective for 12-weeks’ duration in kittens less than 6 months of age. Bravecto is not effective against American dog ticks beyond 8 weeks of dosing. For topical use only. Avoid oral ingestion. The safety of Bravecto has not been established in breeding, pregnant and lactating cats. Use with caution in cats with a history of neurologic abnormalities. Neurologic abnormalities have been reported in cats receiving Bravecto, even in cats without a history of neurologic abnormalities. PLEASE SEE BRIEF SUMMARY FOR MORE INFO. REFERENCE: 1. Bravecto Topical Solution for Cats [prescribing information]. Madison, NJ: Merck Animal Health; 2016. Copyright © 2017 Intervet Inc., d/b/a Merck Animal Health, a subsidiary of Merck & Co. Inc. All rights reserved.

TODAY’SVETERINARYTECHNICIAN todaysveterinarytechnician.com

SEPTEMBER/OCTOBER 2017

Editor in Chief Lynne Johnson-Harris, 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

An Official Journal of the NAVC

VOLUME 2, NUMBER 5

Chief Executive Ofﬁcer Thomas M. Bohn, MBA, CAE Senior Vice President of Sales and Publishing Laura C.S. Walker LWalker@NAVC.com

Vice President of Sales and Marketing, NAVC Publishing Rick Boggess RBoggess@NAVC.com Director of Operations and Finance, NAVC Publishing Nick Paolo, MS, MBA NPaolo@NAVC.com Executive Editor Robin Henry RHenry@NAVC.com Managing Editor Jackie D’Antonio JDantonio@NAVC.com Director of Sales Renee Luttrell 610.558.1819 | RLuttrell@NAVC.com Account Executive Paige Ellington 404.550.6649 | PEllington@NAVC.com Director of Audience Development Sondra Reynolds SReynolds@NAVC.com Senior Art Director Michelle Taylor Art Director David Beagin Staff Editors Cheryl Hobbs; Suzanne B. Meyers; Lisa Wirth, VMD

Deborah A. Stone, MBA, PhD, CVPM StoneVPM Austin, Texas

President Gail Gibson, VMD Immediate Past President Melinda D. Merck, DVM President-Elect K. Leann Kuebelbeck, DVM, DACVS Vice President Cheryl Good, DVM Treasurer Laurel Kaddatz, DVM Directors Paige Allen, MS, RVT Harold Davis, Jr, BA, RVT, VTS (Emergency and Critical Care, Anesthesia and Analgesia) Sally Haddock, DVM Bob Lester, DVM

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

Today’s Veterinary Technician is proudly published by the NAVC

Group Publisher Chris Kelly CKelly@NAVC.com

Kathi L. Smith, RVT, VTS (Oncology) Portland Veterinary Specialists Portland, Maine

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

NAVC Board of Directors

Subscriptions (only): 630.739.0900 CDS/Today’s Veterinary Technician 440 Quadrangle Drive, Suite E Bolingbrook, IL 60440 Email subscription form to subscriptions@CDS1976.com or fax to 630.739.9700 For a new subscription, confirmation, or renewal, please visit TodaysVeterinaryTechnician.com to fill out an online form. For updates, please include your subscription ID from the mailing label. Change Name/Address or Cancel Please use online form at TodaysVeterinaryTechnician.com or contact us by phone or fax or by e-mail at subscriptions@CDS1976.com. Please provide the ID number (directly above your name on label) for positive identification. If the ID number is not available or legible, provide name and address as they appear on the label to allow identification of the subscription. *Qualifying Subscribers: veterinary technicians, veterinary assistants, veterinary technician students and other members of the veterinary healthcare team in the United States. Eastern States Veterinary Association, Inc (NAVC) reserves the right to determine eligibility for a free subscription.

WARRANTIES, LIMITATIONS. Except as expressly set forth herein, Eastern States Veterinary Association, Inc (NAVC) makes no warranties whatsoever, express, implied, or statutory. NAVC specifically disclaims any implied warranty of merchantability or fitness for a particular purpose. In no event will NAVC be liable to you or any third party for any indirect, punitive, special, incidental, or consequential damages (including loss of profits, use, data, or other economic advantage), however it arises, even if NAVC has previously been advised of the possibility of such damage. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. Entire contents ©2017 Eastern States Veterinary Association, Inc (NAVC).

TODAY’SVETERINARYTECHNICIAN

September/October 2017

NADA 141-459, Approved by FDA

(fluralaner topical solution) for Cats BRIEF SUMMARY (For full Prescribing Information, see package insert) Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Indications: Bravecto kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis) and the treatment and control of Ixodes scapularis (black-legged tick) infestations for 12 weeks in cats and kittens 6 months of age and older, and weighing 2.6 pounds or greater. Bravecto is also indicated for the treatment and control of Dermacentor variabilis (American dog tick) infestations for 8 weeks in cats and kittens 6 months of age and older and weighing 2.6 pounds or greater. Contraindications: There are no known contraindications for the use of the product. WARNINGS Human Warnings: Not for human use. Keep this and all drugs out of the reach of children. Do not contact or allow children to contact the application site until dry. Keep the product in the original packaging until use in order to prevent children from getting direct access to the product. Do not eat, drink or smoke while handling the product. Avoid contact with skin and eyes. If contact with eyes occurs, then flush eyes slowly and gently with water. Wash hands and contacted skin thoroughly with soap and water immediately after use of the product. The product is highly flammable. Keep away from heat, sparks, open flame or other sources of ignition. Precautions: For topical use only. Avoid oral ingestion. Use with caution in cats with a history of neurologic abnormalities. Neurologic abnormalities have been reported in cats receiving Bravecto, even in cats without a history of neurologic abnormalities. Bravecto has not been shown to be effective for 12-weeks duration in kittens less than 6 months of age. Bravecto is not effective against Dermacentor variabilis ticks beyond 8 weeks after dosing. The safety of Bravecto has not been established in breeding, pregnant and lactating cats. Adverse Reactions: In a well-controlled U.S. field study, which included a total of 161 households and 311 treated cats (224 with fluralaner and 87 with a topical active control), there were no serious adverse reactions. Percentage of Cats with Adverse Reactions (AR) in the Field Study Adverse Reaction (AR)

Bravecto Group: Percent of Cats with the AR During the 105-Day Study (n=224 cats)

Control Group: Percent of Cats with the AR During the 84-Day Study (n=87 cats)

Vomiting

7.6%

6.9%

Pruritus

5.4%

11.5%

Diarrhea

4.9%

1.1%

Alopecia

4.9%

4.6%

Decreased Appetite

3.6%

0.0%

Lethargy

3.1%

2.3%

Scabs/Ulcerated Lesions

2.2%

3.4%

In the field study, two cats treated with fluralaner topical solution experienced ataxia. One cat became ataxic with a right head tilt 34 days after the first dose. The cat improved within one week of starting antibiotics. The ataxia and right head tilt, along with lateral recumbency, reoccurred 82 days after administration of the first dose. The cat recovered with antibiotics and was redosed with fluralaner topical solution 92 days after administration of the first dose, with no further abnormalities during the study. A second cat became ataxic 15 days after receiving its first dose and recovered the next day. The cat was redosed with fluralaner topical solution 82 days after administration of the first dose, with no further abnormalities during the study. In a European field study, two cats from the same household experienced tremors, lethargy, and anorexia within one day of administration. The signs resolved in both cats within 48-72 hours. In a European field study, there were three reports of facial dermatitis in humans after close contact with the application site which occurred within 4 days of application. For technical assistance or to report a suspected adverse drug reaction, or to obtain a copy of the Safety Data Sheet (SDS), contact Merck Animal Health at 1-800-224-5318. Additional information can be found at www.bravecto.com. 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. How Supplied: Bravecto is available in three strengths for use in cats (112.5, 250, and 500 mg fluralaner per tube). Each tube is packaged individually in a pouch. Product may be supplied in 1 or 2 tubes per carton. Distributed by: Intervet Inc (d/b/a Merck Animal Health) Madison, NJ 07940 Made in the USA. Copyright ÂŠ 2016 Intervet Inc, a subsidiary of Merck & Company Inc. All rights reserved 155373 R8

CONTENTS

TODAY’SVETERINARYTECHNICIAN An Official Journal of the NAVC

todaysveterinarytechnician.com

SEPTEMBEROCTOBER2017

Volume 2, Number 5

PEER-REVIEWED CE Anesthesia for Pediatric Patients TRISH FARRY, CVN, AVN, VTS (ECC, ANESTHESIA & ANALGESIA), TAA GCHED, and WENDY GOODWIN, BVSC, PHD, FANZCVS (VETERINARY ANAESTHESIA, CRITICAL CARE)

With adequate preparation and understanding of the unique physiologic and anatomic differences involved, anesthetists can provide excellent care for pediatric patients. This article highlights these aspects of anesthesia in pediatric patients. To see the CE test for this article, please visit todaysveterinarytechnician.com.

Canine Multicentric Lymphoma: An Overview KRISTE SEARS-SEIN, RVT, VTS (ONCOLOGY)

This article provides an overview of canine high-grade multicentric lymphoma and its classification, diagnosis, and treatment. To see the CE test for this article, please visit todaysveterinarytechnician.com.

FEATURES Technician-Driven Preventive Behavior Services DEBBIE MARTIN, LVT, VTS (BEHAVIOR)

Behavior concerns are the number-one cause for pet relinquishment. Through preventive behavior services, veterinary technicians can help preserve the human–animal bond.

MDR1 Genetic Testing: What You Need to Know REBECCA CONNORS, LVT

Hidden in the genetic code of many herding-breed dogs is a mutation that increases their susceptibility to drug toxicosis. It is important for veterinary technicians to recognize which dogs are at risk and which drugs to avoid or administer with a reduced dose.

ON THE COVER Debbie Martin, LVT, VTS (Behavior), shows a kitten that veterinary visits can be fun at Southwest Vet in Austin, Texas. Positive interactions help decrease patient fear, anxiety, and stress. Photo by Rachel Boettcher/Lifesketch Photography.

TODAY’SVETERINARYTECHNICIAN

September/October 2017

CONTENTS chewables

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

Chewables Per Month

Ivermectin Content

Pyrantel Content

Color Coding 0n Foil Backing and Carton

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

1 1 1

68 mcg 136 mcg 272 mcg

57 mg 114 mg 227 mg

Blue Green Brown

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

COLUMNS Editor’s Letter What’s Your Happy Place?

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

What Moves You? Education!

ANN WORTINGER, BIS, LVT, VTS (ECC, SAIM, NUTRITION). . . . . . . . . . . . . 10

Ideas Into Practice Show What You’ve Got! Lessons in Public Relations

ESTHER KLOK. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

VET Report Vitals How Can We Address Antimicrobial Resistance Head On?

RACHEL BECK, CVT, PMP.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Toxicology Talk Dermal, Ocular, and Inhalation Decontamination in Dogs and Cats

ERIN FREED, CVT, BAS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24

Final Thoughts A Personal Journey to Mindfulness

KIM POPE-ROBINSON, DVM, CCFP.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63

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.

Letter to the Editor. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

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.

Advertiser Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

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’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, 622 East Washington St, Ste 300, Orlando, FL 32801. POSTMASTER: Send all UAA to CFS (See DMM 507.1.5.2); NON-POSTAL AND MILITARY FACILITIES: send address corrections to CDS/Today’s Veterinary Technician, 440 Quadrangle Drive, Ste E, Bolingbrook, IL 60440.

TODAY’SVETERINARYTECHNICIAN

Sept/Oct 2017

TRUST. 1 2

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

PREVENTS HEARTWORM DISEASE

TREATS AND CONTROLS 3 SPECIES OF HOOKWORMS

TREATS AND CONTROLS 2 SPECIES OF ROUNDWORMS

OWNERS PREFER IT1 AND DOGS LOVE IT2

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

September/October 2017

What’s Your Happy Place?

EDITOR’S LETTER

What’s Your Happy Place?

EDITOR’S LETTER

Lynne Johnson-Harris, RVT | Editor in Chief

“Find your happy place.” I’m sure you’ve heard it somewhere, whether in a TV show, a movie, or just casual conversation. Have you ever taken it seriously? Do you have a happy place— somewhere you can go to “get your groove back on”? It’s not a trite saying. Everyone needs a happy place. Happy places are where you feel at ease, aware of and at peace with yourself. They can in be your mind or a physical place. Mindfulness helps us find our way to our happy place. Are you mindful? According to mindful.org, the definition of mindfulness is “the basic human ability to be fully present, aware of where we are and what we’re doing, and not overly reactive or overwhelmed by what’s going on around us.” My happy place is Middle Range Pond in Poland Spring, Maine. It takes 13 hours to get there from my house in Ohio by car; however, once I cross the river into Maine, I take a deep breath and say, “I’m home.” After a long, overnight drive, I pull up to my retreat

and my stress eases. I become totally aware of where I am and what I need to do for myself to be mindful. We all have stress in our days, and we all handle stress differently. Without having a “place” to go, those stressful days become more challenging. We are also all aware of the increase in mental health issues and suicide in our profession. Even if you do have a happy place, where can you go if you are facing depression or know of a colleague that might be struggling? The NAVC and its partners are very involved in helping all veterinary healthcare team members handle the stressful parts of their lives that they find challenging. One free resource center for veterinary team members is on the NAVC–AAHA site, VetFolio.com (vetfolio.com/wellbeing). In addition, the NAVC will have programming at the 2018 VMX that addresses how to identify and manage stress. Become aware, talk about it, become mindful. Resources and professionals exist to help you or someone you know with challenges that might feel overwhelming. Join us at the 2018 NAVC VMX and attend our Health and Wellbeing sessions. Check out the VetFolio content. Find your happy place. 

We all have stress in our days, and we all handle stress differently. Without having a “place” to go,

shutterstock.com/OtmarW

those stressful days become more challenging.

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

TODAY’SVETERINARYTECHNICIAN

September/October 2017

FELINE HEARTWORM-FELINE LEUKEMIA VIRUS ANTIGENFELINE IMMUNODEFICIENCY VIRUS ANTIBODY TEST KIT

TRIPLE THREAT

DETECT THREE CRITICAL DISEASES WITH ONE SIMPLE, CONVENIENT, AND COST-EFFECTIVE TEST

WITNESS® FFH is a triple test kit that detects antigens to feline leukemia (FeLV) and feline heartworm and antibodies to feline immunodeficiency virus (FIV). RELIABLE PERFORMANCE • FeLV: 97.7% sensitivity* and 100% specificity1† • FIV: 95.2% sensitivity and 98.2% specificity2 • Heartworm: 96.3% sensitivity and 100% specificity3

GET MORE VALUE IN A TRIPLE TEST WITNESS FFH is the affordable and easy-to-use alternative to other dual FeLV-FIV test brands on the market with the added benefit of offering heartworm testing. WITNESS SIMPLICITY WITNESS FFH uses only a single buffer, so there is no confusion with which buffer to use. And you can test for three—not just two—important feline diseases.

For more information on WITNESS FFH or other WITNESS products, visit www.simplysmarterchoice.com. To order, call Zoetis customer service at 1-888-ZOETIS-1 (963-8471) or visit shop.zoetisus.com. *Sensitivity represents the ability to correctly identify positive samples. †Specificity represents the ability to correctly identify negative samples. References: 1. Data on file, Study Report No. D886R-US-17-038, Zoetis Inc. 2. Data on file, Study Report No. D886R-US-16-033, Zoetis Inc. 3. Data on file, Study Report No. D886R-US-16-032, Zoetis Inc. All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted. ©2017 Zoetis Services LLC. All rights reserved. WIT-00263

DETECT. PREVENT. TREAT.

Feline Heartworm Disease: Fact or Fiction

LETTER TO THE EDITOR

Feline Heartworm Disease: Fact or Fiction

LETTER TO THE EDITOR

Matthew Krecic, DVM, MS, MBA, DACVIM (SAIM) Adrienne Abel, CVT

In the May/June 2017 issue of Today’s Veterinary Technician, we were pleased to come across the article “Feline Heartworm Disease: Fact or Fiction” by Ms. Ann Wortinger and agree that feline heartworm disease is indeed fact.1–3 We likewise agree that confirming heartworm disease in cats is complex, and the author discusses the advantages and limitations of several modalities, including ELISA antibody testing.4 However, the author did not mention another antibody detection method called immunochromatography. An in-clinic test using immunochromatography is available for detection of heartworm antibody within the serum, plasma, or anticoagulated whole blood of cats (Solo Step FH® Heartworm Test, Heska). Although veterinarians and veterinary parasitologists may debate the accuracy of each antibody test method, we believe informing your readers that such an in-clinic test exists is important. Similarly, a variety of ELISA and immunochromatography tests are available for in-clinic use to detect feline heartworm antigen. These may be the same standalone heartworm antigen tests used for dogs. Often, a combination of antigen and antibody testing is necessary in an attempt to detect an infection in cats.1–3 The author also commented that “most cats with heartworm disease are antigen negative because of low titers.”4 We believe the use of the word “titers” here is inaccurate. A titer refers to the highest dilution of serum at which a test is able to identify antigen (or antibody) within that serum.5 Yet, to our knowledge, such serum dilution studies have not been performed with these heartworm antigen tests. Instead, studies have been published regarding the relative sensitivities—or rather, insensitivities—of the in-clinic heartworm antigen tests at identifying infected dogs with low adult heartworm burdens.6,7 Infected cats will have zero or low numbers of adult heartworms.1,2 Accompanying the article is the well-written client handout “Heartworm Disease in Cats” that Vetstreet personnel authored and editors of Today’s Veterinary Technician reviewed.8 We wanted to also inform your

readers that, in addition to the mentioned SNAP® test (IDEXX) for feline heartworm antigen testing, other in-clinic heartworm antigen tests, including one from Zoetis, are available. Specifying only one test may erroneously lead cat owners and your readers to believe that such test is the only available in-clinic heartworm antigen test for use with cats. With respect to the information in the handout, we also wish to note that many veterinarians likely do not begin evaluating cats with clinical signs compatible with heartworm disease with any in-clinic antigen test because of the relative insensitivity for antigen detection in any infected cat.1–3 In an effort to increase the success of confirming a suspected infection, veterinarians may instead choose to send samples to a reference laboratory for both antigen and antibody testing, because an in-clinic combination antigen and antibody test for identifying heartworm-infected cats is not currently available. Alternatively, veterinarians may not proactively test any cat—healthy or ill—specifically for heartworm disease, because, among other reasons, they may believe asthma or bronchitis is instead the cause of clinical signs (which heartworm disease often mimics) or because no specific treatment is available for heartworminfected cats (even if heartworm disease is confirmed).3 They may instead administer and prescribe empirical therapies to prevent, lessen, or resolve any clinical signs.

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

TODAY’SVETERINARYTECHNICIAN

September/October 2017

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LETTER TO THE EDITOR

We hope that the above is not dissuasive for heartworm testing of cats. We strongly believe testing remains important for several reasons: (1) client peace of mind for having a diagnosis; (2) impetus for monthly heartworm prevention for both asymptomatic and symptomatic, infected cats in order to prevent maturation of any susceptible tissue-stage larvae; and (3) impetus to ask about any other pets within the household that should be tested and/or receive preventive. For example, an infected dog within the household may be the source of heartworm and therefore should be tested for heartworm antigen and microfilariae. Also, other cats within the household may also benefit from monthly heartworm preventive, given that they are subject to the same environment as the infected cat. We are glad that the editors of Today’s Veterinary Technician published this article and the accompanying client handout on a difficultto-diagnose condition that likely affects more cats than veterinarians have been able to confirm.1–3 Veterinary technicians can be positive influences to the veterinarians with whom they work and can feel that they are empowered to encourage their veterinarians to consider heartworm disease and test their feline patients after reading both the article and the client handout. 

Come Browse Our Shelves NAVC.com/Bookstore A convenient online shopping experience for all of your veterinary reference and educational needs. Come explore the offerings that will help you learn, experience and grow as a veterinary professional.

Disclosure: Both authors are employees of Zoetis, manufacturer of heartworm preventives and heartworm tests for both dogs and cats. References 1. Snyder PS, Levy JK, Salute ME, et al. Performance of serologic tests used to detect heartworm infection in cats. J Am Vet Med Assoc 2000;216:693-700. 2. Gruntmeir JM, Adolph CB, Thomas JE, et al. Increased detection of Dirofilaria immitis antigen in cats after heat pretreatment of samples. J Feline Med Surg 2016. doi: 10.1177/1098612X16670562. 3. Lin CH, Lo PY, Tsai HJ, et al. Dirofilaria immitis exposure status in client-owned cats with or without lower airway/lung-associated signs: case-control study in a canine heartworm-endemic area. J Feline Med Surg 2017;19(2):153-157. 4. Wortinger A. Feline heartworm disease: fact or fiction? Today’s Vet Tech 2017;2(3):37-45. 5. Titer. https://en.wikipedia.org/wiki/Titer. Accessed May 2017. 6. Courtney CH, Zeng QY. Comparison of heartworm antigen test kit performance in dogs having low heartworm burdens. Vet Parasitol 2001;96:317-322. 7. Atkins CE. Comparison of results of three commercial heartworm antigen test kits in dogs with low heartworm burdens. J Am Vet Med Assoc 2003;222:1221-1223. 8. Heartworm disease in cats. http://todaysveterinarytechnician.com/ wp-content/uploads/2017/04/TVET-2017-0506_Handout_ Heartworm-Cats.pdf. Accessed May 2017.

TODAY’SVETERINARYTECHNICIAN

September/October 2017

Education! WHAT MOVES YOU

Education! WHAT MOVES YOU?

It is obvious from my string of initials that I love to learn. For each of my specialty certifications, I am required to do 60 hours of continuing education (CE) every 5 years or, on average, 12 hours every year. That is 36 hours per year just for my specialty certifications. In 2019, that number will go up when I renew my license under Michigan’s new CE requirements. While that may seem daunting, I love it, and I love seeing how many different ways I can earn my credits. Some of the hours will obviously from Ann Wortinger, BIS, on-site lectures at conferences, while LVT, VTS (ECC, others will be from online instruction SAIM, Nutrition) or RACE-approved articles in journals like this one. The most enjoyable way for me is mentoring new VTS candidates. I mentor for all 3 specialties and am proud to say that I have successfully mentored over 18 fellow VTSs to their specialty certification. I also love to teach! Our education as veterinary technicians usually begins in college in our veterinary technology programs, but please do not let it end there. Believe me, the sum total of all knowledge is not conferred on you when you pass the VTNE! When I think of how much veterinary medicine and veterinary nursing have changed since I graduated 34 years ago, it is astounding. For me, the best way to stay engaged in the field has been through learning. When I was in college, organic chemistry blew me out of the water. If not for my lab partners, I would never have passed. But when I started getting interested in nutrition, it all began to make sense. I’m sure many of you have found that if you can see the practical application of a piece of knowledge, it helps to put all the pieces in the right places. For example, do you know what the difference is between omega 3 and omega 6 fatty acids, and why they are both essential fatty acids, but omega 9 is not? I do, and it isn’t easy, but it is fascinating. Nutrition is all about organic chemistry, from provision of nutrients to the body for essential functions to maintenance of acid-base balance, growth, and reproduction. It’s all chemistry! To help stay engaged in the field, look around you. What excites you, what makes you happy, what keeps you going? When you look at the 15 NAVTA-approved specialties, none of them are covered to any extent in veterinary technology programs. Every one of the veterinary technicians who had the vision to form an organizing committee, submit an application, or sit for an examination did it on their own. They determined what they needed to learn and devised ways to learn and to perfect their skills. There were no semester tests, no GPA to maintain, and no diploma at the end, although you do get an awesome certificate when you pass your specialty exam! (And a pin that you should wear with pride.) Many of us are lucky enough to work with veterinarians who push us to learn and who encourage us to reach beyond our comfort level. Sometimes, we are the ones who are pushing and encouraging others. If you are bored or unhappy with your job, you are the only one who can change it. Find your passion, enjoy the ride to learning, and teach what you know! 

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

“ Find your passion, enjoy the ride to learning, and teach what you know!” — Ann Wortinger

TODAY’SVETERINARYTECHNICIAN

September/October 2017

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This product has not been approved by the FDA nor is it intended to diagnose, treat, cure, or prevent any disease. Should only be used through consultation of a veterinarian and in conjunction with an overall wellness program. Microlactin is a registered trademark of Stolle Milk Biologics, Inc. Duralactin is a registered trademark of PRN Pharmacal, Inc. ©2017 PRN Pharmacal, Inc. All rights reserved.

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Show What You’ve Got! Lessons in Public Relations IDEAS INTO PRACTICE

IDEAS INTO PRACTICE MEET THE AU TH O R

Esther Klok Dierenkliniek Winsum The Netherlands

Esther Klok has 24 years of experience as a veterinary technician. She works in a mixed practice that handles both small animals and horses. Most of the time she can be found working in the back, but she also enjoys the front desk and has convinced her boss she really needs to be there one day a week. She has also just started her own company, Improve on the Move. She loves giving lectures, teaching, organizing conventions, and writing and providing photos for magazines. And, because she obviously needs to do something with any leftover time, Esther and her boyfriend travel throughout Europe to compete for the Dutch team in single horse carriage driving.

Show What You’ve Got! Lessons in Public Relations In the 25 years that I have been a veterinary technician, I have seen many things about the veterinary practice change—and fast. One thing is that we have to be much more active in getting clients into the practice. During the first few years of my career, our practice did not worry much about attracting clients. People just went to the veterinarian in their neighborhood. Back then, we had never heard the phrase: “You must think about your public relations and marketing.” Now it’s a different story. Of course, maybe not everyone at your practice feels the need to get more clients in the door, but I think many of us do. Then it’s a question of how. There are so many ways to deal with public relations and marketing. Luckily, there are also many great courses you can take or professionals you can hire for the job. But don’t forget: the practice already has some perfect tools: Us! Veterinary technicians! I believe we can do a super job of public relations, and I’ll tell you why. ONCE UPON A DOG SHOW About 15 years ago, I attended one of the biggest dog shows in Holland, which was in a city near our practice. While I was walking around there among so many dogs, I saw a few of our clients showing. And they loved that I was standing on the side and watching their performance. After the show, these clients introduced me to their friends and breeders. We started to talk, and I had the opportunity to tell them about our practice and all the things we do. A New Idea The next day at work, I told my boss I wanted to go to another dog show. He said, “You are crazy!” I explained that I had the opportunity to talk to many interesting people who might also be potential clients. In addition, I talked to people who lived near our clinic and were driving 1 hour to another clinic because they wanted a veterinarian who could give them “the whole package,” including

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todaysveterinarytechnician.com IDEAS INTO PRACTICE

FIGURE 1. Where the idea began…a large dog show.

progesterone testing and everything else associated with breeding and birth. So I told these folks— potential clients!—that we offered these services and we were really good at them. They asked, “Can you really do this at your local clinic?” They wondered this because my practice is in a small country town, and they did not expect us to have those facilities. And because they did not expect us to have them, no one had checked our website to find out. After I shared this story, my boss said it wasn’t normal for veterinary clinics to visit dog shows. But he also said, “Okay, give it a try, but it’s not a thing for me.”

BOX 1 Booth Checklist  A long table (if not provided at the event)  1 or 2 tall tables (for monitors, brochures, etc; FIGURE 2B)  Tablecloth(s) in your practice colors  Banners  Chairs for casual conversations  Big picture frames with action shots of your practice  A TV and a DVD player to show video clips of what your practice does  A computer with access to the practice management system (if wi-fi is available)  Electrical cables for your equipment

The Value of Being a Showoff When you can demonstrate your skills, then you have the opportunity to talk about a better salary. You shouldn’t just complain that you don’t earn enough money. In any profession, it’s all about what you deliver, and veterinary technicians can deliver so much. So, the way to earn more is to show your employer that you add value to the practice. Besides, I love a new challenge, don’t you?

 Practice brochures with a description of services  A fee schedule of the top 20 common services, like vaccination, heartworm and fecal tests, and common lab work (avoid procedures that require estimates)  Paper and pen to write down questions, email addresses, and phone numbers (or an electronic means to do so)  Something fun for kids to do (FIGURES 4 and 5)  Something free (eg, food samples)  A handy box with items like nails, adhesive tape, rope, etc, to build your booth  A credentialed veterinary technician who loves to talk  A veterinarian available who you can call for questions

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Show What You’ve Got! Lessons in Public Relations IDEAS INTO PRACTICE

Now you may think, when your boss isn’t into something, why should you try it? However, I think that in every clinic, each team member has a special gift that should be utilized. And because I love to talk, promotion is really my thing, and I love to show how great we vet technicians are.

FIGURE 2. Our booth setup at a local dog show.

FIGURE 3. A professional banner is a nice, eye-catching touch to a booth.

FIGURE 4. It’s always good to provide some activity for kids, because they are often less shy than adults. Here, we placed a barrier where they had to reach through and guess what the object behind it was.

TODAY’SVETERINARYTECHNICIAN

| September/October 2017

SHOWTIME In my pursuit of this new plan, I recruited a colleague. We prepared to set up a nice booth at the next dog show. We knew it needed to be cost effective to keep the boss happy (you know how they are!). So we went to IKEA to get some cheap photo frames, and we printed up pictures of all the things we do in our practice. We also ordered two professional banners and set up a booth, which included the television from our waiting room so we could show a video of laparoscopic sterilization done at our practice (which we already had). We also took a box that we use to train farmers to birth lambs. On one side of our display, we put an instrument or item commonly used in practice, such as an otoscope, thermometer, bandage, or stethoscope. Then we played a game with the kids attending: if they could reach through and guess what the item was, they won a prize. We had a great time! And, oh, how proud we were to highlight our practice and all we do. Every day, vet technicians work like crazy and do so many amazing things. So for my colleague and me, it was really rewarding to finally show a big group of people what we could do for their pets. People Just Don’t Know! How did it go? Well, we were exhausted after 2 days. We talked to so many people and discovered that most of them didn’t know what veterinary technicians—or our practice—could really do. Without that knowledge, many of them had never thought to ask their veterinary team about extra care for their pets beyond routine wellness procedures, like vaccinations.

FIGURE 5. The backside of the barrier in Figure 4.

todaysveterinarytechnician.com IDEAS INTO PRACTICE

We went to teach, but we learned a lot. One key point we learned was that pet owners may not have all the information they need to keep their pets healthy, but they want to learn. It is our job as pet advocates to give them that information. So when we had the chance to speak with them, we shared things like: ÆÆ Dental disease can be painful, so yes, you can have your pet’s teeth cleaned, much like what your dentist does to keep your mouth healthy. Yes, we can clean dogs’ and cats’ teeth! Pets are happier when they are not in pain. ÆÆ We can take x-rays quickly and in many cases have the results while you wait (especially if you think your pet has eaten your daughter’s doll). ÆÆ We can do laparoscopic surgeries, including sterilization, so don’t be afraid to have your pet spayed or neutered because you think a big incision is needed. ÆÆ We have a rehab program, and we’re happy to work with our patients’ physiotherapists, even if they live far away. Finally, we invited pet owners to visit our practice, take a tour, and discuss the other services we offer. If they had questions we couldn’t answer, we wrote the questions down with their phone number so that our vets could call them back later. Reaping the Results Two days after this first show experience, a breeder called us to ask if they could come in for a tour and meet our boss. They really loved the way we dealt with people and their questions at the show. Now, many years later, they remain a loyal client. They love their dogs and really do the best they can when it comes to veterinary health care. They also recommend our practice to the new owners of their puppies as the place to go for superior care. At the show, we played a video of our way of taking radiographs, and many pet owners had asked about it. As a result, we have dog breeding clubs who visit us on Saturdays to have coffee and cookies and talk with one another while we take the radiographs needed for their dog breeding plans. Finally, by showing all the things we could do with dental health, owners realized it’s similar to their own oral health. When owners understand that the issues can be the same, they are more willing to do accept our recommendations. Many people did not expect us to have such a modern dental unit in our small countryside clinic. Now, only a few years later, we are well known for our excellent dental care programs. Needless to say, all this has brought more money into the practice. And that makes everyone happy!

GETTING STARTED Local Opportunities Of course, you do not have to start with a big dog show. In your own community, there are plenty of opportunities. In our town, a street market is held every year. We always attend with our booth. People like to see that you are involved with the community. We always bring our “front desk superstar” to this event because she knows so many of our clients and their pets by name! Owners love it when you know who they are and what procedures you have performed for their pet. And of course, at an event like this, they always have questions. That’s when you realize there is a limit to the recommendations you can provide, and you might suggest they make an appointment to come into your practice to speak with the veterinarian. However, when we are at our community event, owners often decide on the spot that they should bring their pet in for an examination. We make sure we have internet access to our practice management system and schedule the appointment right there. We love the instant gratification of knowing that we are improving care for pets. Dog “Events” So many people love to “sport” with their dogs. They anticipate an event for weeks, and on the big day, they often feel the way they did when they were young and headed out on a school field trip— enthusiastic, a little nervous, and very excited. What is better than experiencing that feeling with potential clients? You can be there with a booth and be a first-aid person for the dogs. You are building a bond with the owners, all while having fun! If you think about it, I bet you can come up with several opportunities. These might include breeder action days, club meetings, and even competitions. What does your community have that you can use to your advantage? In many cities in Holland, you are allowed to swim with your dog in the local swimming pool on the last day of the season. Most of the pools have safe water conditions for the dogs, so

FIGURE 6. A “dog day” at the swimming pool. Another great outreach opportunity.

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Show What You’ve Got! Lessons in Public Relations IDEAS INTO PRACTICE

you can have a lot of fun at the pool together. If my clinic brings presents for all the dogs, like a healthy snack, we end up having plenty of “fans” that day. Giving Back Everywhere in the world, people want to help others in need, whether people or animals. In Holland, before Christmas, we have “the glass house,” where 3 disc jockeys from one of the biggest radio stations are locked up for 1 week in a house of glass. They broadcast the radio program from there with lots of guests. It’s on all the TV stations, and many people visit the house and enjoy the concerts they provide 24 hours a day. The goal every year is to earn money for a different charity. The disc jockeys ask all the Dutch people to join them in action. And all of Holland does! People wash cars, give dancing classes on the street, sell hot chocolate, and bake cookies, and all the money goes into the glass house, where they count it every day. For the practice where I work, it’s a great opportunity to join the community in a common goal. One year, we brought a truck where we could microchip animals, and all the money went to the glass house project. Our practice participation was recognized in the newspaper and on the local TV stations. Now that’s a win-win!

Horse Shows Sometimes you have to think of opportunities a little bit outside the box. Even if you are not an equine vet tech, it still can be really interesting to go to a horse competition. In the winter here in Holland, we have big indoor competitions with lots of booths. Now, probably you’re thinking, “But our practice doesn’t see horses.” Maybe not, but most horse owners and show competitors also own dogs and cats! And they are really interested in what you offer, because most horse owners are accustomed to special medical treatments, dentals, rehab, and all the things veterinary practices do. At one of these local horse shows, we set up a big booth with lots of pictures and, of course, our television showing who we are and what we do in our practice. We ended up being very busy with owners who had questions. Our booth was crowded with people for most of the day. So try it! Take off your “blinders” and think outside the box! CONCLUSION Don’t think of outreach as something that’s difficult! As veterinary technicians, we are proud of what we do, so every opportunity you get to deliver a message about pet health, take it! Also, I personally feel that it’s really important to give something back to your community. Taking your show on the road can be a great way to do that—and have fun at the same time. 

FIGURE 7. The microchipping truck for a community event. The money from the microchipping benefited the charity, but the public relations benefited the practice!

FIGURE 9. Horse shows are another great opportunity for reaching dog and cat owners.

FIGURE 8. The practice’s microchipping truck.

FIGURE 10. Team gear and team spirit go hand-in-hand for great public outreach!

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FINAL THOUGHTS

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September/October 2017

How Can We Address Antimicrobial Resistance Head On? VET REPORT VITALS

VET REPORT VITALS MEET THE AU TH O R

How Can We Address Antimicrobial Resistance Head On?

Rachel Beck, CVT, PMP Banfield Pet Hospital Portland, Oregon

THE MODEL FOR IMPROVEMENT Addressing AMR in a veterinary clinic is a quality improvement challenge that can be approached by using structured methods for success. Quality improvement developed as a science in the 1950s. It began as a tool in the manufacturing industry, and its applicability to a variety of other situations, including healthcare, was quickly recognized. The Model for Improvement, developed by Associates in Process Improvement, guides application of key concepts of quality improvement to business challenges of many types. In alignment with the Model for Improvement, a journey of quality improvement begins by asking 3 crucial questions:1 1. AIM: What are we trying to accomplish? To define the aim, the user must explicitly define what is to be accomplished and the timeframe in which it is to be achieved: for

Rachel Beck is a certified veterinary technician and credentialed project manager on the Veterinary Medical Programs team at Banfield Pet Hospital. She currently leads a team of project managers who specialize in implementation. Having been in the veterinary field for over 15 years, she has served roles both in hospitals and at Banfield’s central office. She is passionate about engaging the whole veterinary team in proactive health and wellness as well as about career pathing for paraprofessionals in the industry. She resides in Portland, Oregon, with her significant other and 2 cats.

Welcome to VET Report Vitals, a column focused on the results of the groundbreaking Banfield Veterinary Emerging Topics (VET) Report, “Are We Doing Our Part to Prevent Superbugs? Antimicrobial Usage Patterns Among Companion Animal Veterinarians.” This report, a collaboration between the NAVC and Banfield Pet Hospital, focuses on a critical topic: antimicrobial resistance (AMR). It promotes prudent antimicrobial use among companion animal practitioners by contributing a baseline of antimicrobial usage data to the discussion on how to improve concordance with published guidelines. This article examines the issue of AMR within the larger One Health context and proposes a method by which to change behavior among hospital teams and drive quality improvement within the veterinary profession.

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todaysveterinarytechnician.com VET REPORT VITALS

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Through the combined efforts and brainpower of all members of the veterinary team, a clinic can address nearly any problem.

example, “Improve concordance with first-line drug recommendations for urinary tract infections [UTIs] by 50% over a 6-month period.” 2. MEASURE: How will we know that a change is an improvement? Objective measures are used to determine the point at which the goal has been reached. This requires data for baseline measurement and results to compare against. Many data sources can be used to measure antimicrobial guideline concordance, but all must be assessed for validity and accuracy to ensure appropriate interpretation. Examples include medical record reviews, logs of antimicrobial dispensing practices, case response logs, doctor surveys, or a combination of data. A sample objective measure is “Track UTI diagnoses and resulting prescriptions on a clipboard in the pharmacy. Assess percentage of cases that received recommended first-line antimicrobial.” 3. CHANGE: What changes can we make that will result in improvement? Finally, a plan is created by identifying barriers to achieving the desired goal and determining potential strategies to address them. Brainstorming applicable goals, barriers, and strategies should involve all members of the veterinary team and might also include clients, pharmaceutical representatives, and local professional organizations, among other stakeholders. An example is “Relocate first-line antimicrobials in the pharmacy so that they are easier to find. Ensure that pricing of antimicrobial drugs supports use of recommended first-line drugs.”

HUMAN FACTOR ENGINEERING AND NORMALIZATION OF DEVIANCE Not all changes to a system have equal likelihood of driving improvement. Experts in human factors engineering—a discipline that combines engineering and human psychology—have demonstrated that people make mistakes for many reasons: lack of knowledge or experience, misinterpretation or misuse of rules and processes, and lack of necessary skills to accomplish a task.2 Human factors engineering involves identifying and accounting for factors that influence the human ability to perform a function, including environmental conditions (eg, temperature, light level, noise), stress levels, leadership, culture, interruptions, and the need to cut corners or multitask to keep pace with expectations. Also important to consider is normalization of deviance: the gradual acceptance of actions that deviate from standards of practice until such actions become the norm.3 For antimicrobial use, this may include straying from the guidelines, ignoring risk factors, or not educating clients about preventive strategies. Any healthcare practitioner can deviate from the norm. In the case of inexperienced practitioners, it may be due to a lack of knowledge or understanding of why a rule is in place. For experienced practitioners, it may stem from a belief that personal experience is more trustworthy than the standard. Addressing normalization of deviance requires a culture that supports appropriate behaviors and accountability and ensures that communication about standards of practice is consistent and effective.

TODAY’SVETERINARYTECHNICIAN

September/October 2017

When identifying potential changes for improvement, different strategies have different reliability levels:2 ÆÆ Most reliable:  Functions or physical stops that prevent incorrect actions  Computerized automation  Human/machine redundancy ÆÆ Somewhat reliable:  Checklists  Pauses in a process to recheck details and steps  Reminders  Standardization of equipment and supplies  Self-check or double-check ÆÆ Least reliable:  Education and training  Rules, policies, and procedures Fundamental changes that have a higher likelihood of success include those that affect how work is done, produce observable positive differences, and have a lasting impact. Such changes result from design/redesign of a process or system or those that fundamentally change how a system works and what is done to drive it forward. Examples include applying standardization, streamlining choices, and changing the order of tasks; implementing cross-training; and soliciting feedback from customers or employees.1 Any change intended to influence medical prescribing practices requires buy-in from clinicians and team members. As such, large-scale, abrupt changes may not be readily accepted or adopted and are often operationally unfeasible or risky. Small, incremental changes can be more acceptable and allow for better assessment of their true effects in the complex environment of a healthcare facility. The implementation of incremental changes is supported by the “plan, do, study, act” (PDSA) cycle, a tool of the Model for Improvement. The PDSA cycle is a recognized method for quality improvement projects that requires thoughtful planning and implementation (“do”) of a step intended to move toward a goal; study of results; and actions to ensure continual progress toward the improvement desired. PUTTING THE MODEL INTO ACTION Once a clear goal and a model to achieve it are identified, the next step is to identify changes that are believed to lead to meaningful progress. Our goal is to achieve voluntary adjustment of usage patterns among veterinarians to improve concordance with existing guidelines. To begin this process, we must understand the perceived barriers to appropriate antimicrobial use. An American Veterinary Medical Association survey revealed that barriers to antimicrobial use

TODAY’SVETERINARYTECHNICIAN

September/October 2017



TECHPOINT 

Brainstorming applicable goals, barriers, and strategies should involve all members of the veterinary team and might also include clients, pharmaceutical representatives, and local professional organizations, among other stakeholders. in concordance with guidelines included lack of awareness of guidelines.4 Other surveys indicate that pressure to dispense antimicrobials to satisfy client expectations influences antimicrobial use, as does the cost of culture and susceptibility testing.4,5 Finally, intrinsic factors, such as personal preference, and extrinsic factors, such as perceived compliance by client and willingness/ ability of the client to pay, may influence decisionmaking about antimicrobial use.5 Additional barriers to alignment that might be considered include availability of first-line antimicrobials, dosing regimens, and owner compliance. One proposed change might be to improve visibility to prescriptions and outcomes in a clinic. “Plan” could entail tracking of antimicrobial prescriptions and outcomes across cases. Implementation (the “do” step) might include a checklist where the drug and outcome are recorded and reviewed weekly. After an appropriate amount of time, results would be evaluated (the “study” step)

shutterstock.com/KTW 2016

How Can We Address Antimicrobial Resistance Head On? VET REPORT VITALS

A PLAN could entail tracking of antimicrobial prescriptions and outcomes across cases. Implementation might include a checklist where the drug and outcome are recorded and reviewed weekly. After an appropriate amount of time, results would be evaluated and potential adjustments to make the process more effective would be assessed.

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 (07/17).

How Can We Address Antimicrobial Resistance Head On? VET REPORT VITALS

and potential adjustments to make the process more effective would be assessed. On the basis of that assessment, the “act” step would involve refinement of the goal and planning for subsequent cycles. Another cycle would be started with adjustments for improvement, allowing each subsequent assessment to guide the types of improvements needed to improve guideline concordance. Once potential areas for improvement are identified, it is time to implement a PDSA cycle (BOX 1). This method of incremental change allows for operational and behavioral acceptance by minimizing major disruption, while measurement and assessment ensure that the right changes are being made. From a healthcare perspective, these safeguards help ensure patient safety and quality of

BOX 1 Sample “Plan, Do, Study, Act” Cycle PLAN: Consider the goal, what you need to do to get there, and what to measure to ensure it is met.  “Achieve 80% compliance with first-line antibiotic recommendations for UTIs within 6 months of implementing changes by daily tracking of prescriptions and outcome for each UTI case seen.” DO: Implement the plan. Focus on small, incremental alterations rather than widespread change.

References 1. Langley GJ, Moen R, Nolan KM, et al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. San Francisco: John Wiley & Sons; 2009. 2. The Joint Commission. Human factors analysis in patient safety systems. The Source 2015;13:1-10. 3. Banja J. The normalization of deviance in healthcare delivery. Bus Horiz 2010;53:139. 4. American Veterinary Medical Association Task Force for Antimicrobial Stewardship in Companion Animal Practice. Understanding companion animal practitioners’ attitudes toward antimicrobial stewardship. JAVMA 2015;247(8):883-884. 5. Mateus AL, Brodbelt DC, Barber N, et al. Qualitative study of factors associated with antimicrobial usage in seven small animal veterinary practices in the UK. Prev Vet Med 2014;117(1):68-78.

Banfield has always been dedicated to using its extensive data to provide insights to the

STUDY: Work to understand the outcomes of the change. Sometimes unintended results have a larger impact than intended results. By understanding the consequences, you may adjust the plan to better achieve your stated goals.

collaborative educational efforts of the NAVC,

ACT: Finally, make adjustments that were indicated in the “study” phase, and then repeat the cycle. Regularly analyze the results of each new cycle to inform the next step and ensure continual progress toward the goal.1  “Based on staff input, outcomes will be recorded after 2 weeks following call back with client and discussing with doctor. Switch from notes to checklist to improve efficiency.”  “Ensure that first-line antimicrobials are always stocked in the hospital by adding them as a standing item to the weekly order list.”

CLINICAL BOTTOM LINE Addressing an issue such as AMR may seem daunting, but progress can be made if the solution is broken into small, manageable goals to improve medical quality. The science of quality improvement, specifically the Model for Improvement, provides simple yet effective processes and tools for achieving this progress. Through the combined efforts and brainpower of all members of the veterinary team, a clinic can address nearly any problem by following the steps outlined in this article. 

 “Add clipboard to pharmacy and have staff track all UTI diagnoses and associated prescriptions, including client, pet, drug, duration, dose, frequency, and outcome. Review list in weekly team meeting.”

 “Assess process with staff after 3 months for feasibility and efficacy. Assess outcomes after 6 months and review with veterinarians to determine next steps.”

care by confirming that a change has the intended effect before widespread implementation.

TODAY’SVETERINARYTECHNICIAN

September/October 2017

profession on topics that can improve veterinary care for pets. The first annual Banfield Veterinary Emerging Topics (VET) Report, supported by the focuses on a critical topic: antimicrobial resistance. It is titled “Are We Doing Our Part to Prevent Superbugs? Antimicrobial Usage Patterns Among Companion Animal Veterinarians.” “We are proud to team up with the NAVC on the 2017 VET Report to raise awareness about the critical topic of antimicrobial resistance in companion animal practice and how veterinarians can address it in their own practices,” said Dr. Karen Faunt, Vice President of Medical Quality Advancement at Banfield Pet Hospital. The full report is available at Banfield.com/ VETReport or VetFolio.com/VETReport.

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.

Dermal, Ocular, and Inhalation Decontamination in Dogs and Cats TOXICOLOGY TALK

Dermal, Ocular, and Inhalation Decontamination in Dogs and Cats

TOXICOLOGY TALK MEET THE AU TH O R

Prevention is the best way to decrease the incidence of pet poisonings, but even with precautions in place, accidental poisonings happen every day. The management of poisoning cases generally consists of decontamination and symptomatic and supportive care because very few antidotes are available, and those that are available can be cost prohibitive or difficult to obtain.1 Therefore, it is important to consider methods to decontaminate a poisoned pet when indicated.1 Decontamination is the process of removing a toxicant to reduce its absorption or enhance its elimination, thus minimizing clinical signs or even preventing them from developing.2,3 The most common methods of decontamination in pets are oral, dermal, ocular, and inhalation.1–3 This article specifically addresses dermal, ocular, and inhalation decontamination in dogs and cats, including potential contraindications and precautions. For information on oral decontamination, please refer to “Oral Decontamination in Dogs and Cats” in the November/December 2016 issue. BOX 1 lists the key points to remember when managing poisoned pets.1–7

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

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

TODAY’SVETERINARYTECHNICIAN

DERMAL DECONTAMINATION Dermal exposures can involve a variety of agents, including greasy and oily substances, sticky materials, irritating or corrosive products, dry substances, and skunk spray.1,2,4 Dermal exposures can also happen when an owner applies drops, sprays, ointments, or other substances directly to the pet.2 The goals of dermal decontamination are to prevent transdermal absorption and oral reexposure from the pet grooming itself.3,6,7 Dermal decontamination involves removing a substance from the fur and skin without using any harsh chemicals or solvents, which can further irritate and damage the skin.2–5 Bathing is generally the best technique for removing substances from the fur and skin, but a dermal decontamination plan should be designed based on the nature and amount of the substance, duration of exposure, the number of substances involved, and the pet’s condition, signalment, and species.2,5 Veterinary staff should be aware of the public health risks associated with certain toxicants.6 Dermal decontamination should take place in a well-ventilated area, and personal protective equipment (PPE), such as protective clothing (eg, impermeable gloves and apron), protective eyewear (eg, goggles, face shield), and respiratory protection (eg, surgical mask), should be worn to avoid human exposure.1–7 Although the PPE needed will

September/October 2017

Peer Reviewed TOXICOLOGY TALK

shutterstock.com/Boryana Manzurova

To remove a greasy or oily substance, bathe the pet with a liquid dishwashing soap used for hand-washing dishes. Towel-dry the pet and keep it in a warm environment.

depend on the substances involved, it is important to remember that certain agents, such as pepper spray, organophosphate insecticides, zinc/aluminum phosphide rodenticides, and irritating/corrosive substances, can pose a risk to veterinary staff.2,3,5,6 Be sure to remove contaminated items from the animal as well as items used in transport (eg, collar, towels, blankets).4 Pets should not ingest substances used in dermal decontamination (eg, soap, oils, skunk-off mixture) because they can cause gastrointestinal upset.2–4,8

BOX 1 Key Points in Managing Toxic Exposures  Any substance has the potential to be toxic.  Treat the pet and not the poison.1  If the pet is stressed or symptomatic, stabilization and examination should be performed before decontamination.1,4,5  The decontamination plan should be designed based on the nature and amount of the substance, number of substances involved, time and route of exposure, and the pet’s condition, signalment, and species.2,5  Wear impermeable PPE.1–4,6,7  Proper client education is crucial to poison prevention.1

Greasy and Oily Substances Greasy and oily substances include herbicides, topical spot-on insecticides, glow sticks, and essential oils.1,6 To remove a greasy or oily substance, bathe the pet with a liquid dishwashing soap used for hand-washing dishes (eg, Dawn, Joy).1–3,5,6 Wet the animal thoroughly with warm water, apply the soap, lather, and rinse thoroughly.1,5 The bath can be repeated until the product’s residue/odor has been significantly decreased or eliminated.1,4,5,9 Towel-dry the pet and keep it in a warm environment or wrap the pet in a blanket to prevent chilling.1,2,5 The pet’s body temperature should be monitored closely because the bathing process can have a cooling effect and the animal may become hypothermic.3,4,7 Clinical signs, such as tremors, may worsen if the animal shivers from being cold, so provide thermoregulation and heat support if needed.2,3,6,9 Cautions and Contraindications. Do not use dishwashing detergents used in electric dishwashers to bathe pets because these are too harsh for the skin; also avoid shampoos containing insecticides, antifungals, antibiotics, and coal tar.2–4 Avoid pet shampoos because they are typically insufficient to remove oil-based products and clinical signs may persist from continued absorption, despite medical treatment.3 Sticky Substances Sticky substances can include tar, asphalt, sap, oilbased paint, glue, wax, and insect glue traps.1,2,4,5 To remove a sticky substance from the fur, the sticky bond must be softened. Oils such as butter/margarine,

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September/October 2017

Dermal, Ocular, and Inhalation Decontamination in Dogs and Cats PEER REVIEWED

vegetable/olive oil, peanut butter, or mineral oil can be applied and worked into the fur.1,2,4,5 The sticky substance generally dissolves into pliable, gummy balls that can be combed or picked out using your fingers.1,4 Some substances may require the oil to sit on the fur for 5 minutes.5 Once the sticky substance is removed, the oil can be washed off using liquid dishwashing soap.1,2,4,5 Insect and rodent glue traps can be removed using the same method, but also apply baby powder, cornstarch, or paper towels to any remaining sticky areas on the traps to prevent further attachment to the fur or skin.4 Substances such as super glue or paint may not come off with appropriate dermal decontamination. Once dry, these substances pose a low risk for toxicosis and can be allowed to wear off naturally.4 Leaving the substance on the fur may concern some owners, in which cases the fur may be clipped or shaved.4 Clipping and shaving may also be necessary for long-haired pets or pets that cannot be bathed.1–3,5,7 Cautions and Contraindications. Do not use harsh chemicals or solvents (eg, paint thinner, acetone) to remove sticky substances from the fur because these products can be irritating and damaging to the skin.4 Irritating or Corrosive Substances Irritating or corrosive substances can include fabric softener from unused sheets, liquid potpourri, electric dishwashing detergents, drain and oven cleaners, mineral spirits, and gasoline.1,2,6 To remove such substances, gently flush the pet’s fur and skin with copious amounts of water for 15 to 20 minutes.3,6,7 Cautions and Contraindications. Avoid any abrasive scrubbing or high-pressure sprays that may further traumatize the skin.3,6,7 Do not use neutralizing agents on the skin (eg, applying an acid on an alkaline substance) as doing so may result in a chemical reaction that further damages the skin.3,6 Dry Substances Dry substances can include powders, dust, and granules.2 To remove these, the fur can be brushed or vacuumed before bathing with a mild liquid dishwashing soap.2,5 Vacuuming should take place in a well-ventilated area or outdoors.4 Some dry products may become clumped or sticky when water is added.2 Skunk Spray Skunk spray contains thiols that are responsible for the foul odor.10 Thiols are not water soluble and are difficult to remove, even with soap.10 To decrease the odor, the thiols must be converted into compounds that have little to no odor using a skunk-off mixture of 1 quart 3% hydrogen peroxide, ¼ cup baking soda, and 1 to 2 teaspoons liquid dishwashing soap.4,8,10 The baking soda catalyzes

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the oxidative ability of the peroxide, which then oxidizes the thiols into highly water-soluble sulfonates (sulfonic acid).10 For large dogs, 1 quart of water can be added to the skunk-off mixture to ensure complete coverage.10 Wet the pet thoroughly, apply the mixture, and work it into the fur.4,8 Allow the skunk-off mixture to sit on the fur for 5 minutes and then rinse thoroughly.4,8 This procedure can be repeated as needed. A bleaching effect may be noted on clothes, carpets, towels, and the pet’s fur.4,10 Because the skunk-off mixture produces oxygen gas, bathe the pet in a well-ventilated area away from heat sources and open flames.4,8,10 Discard all unused mixture and do not store it in a closed container.10 OCULAR DECONTAMINATION The goals of ocular decontamination are to remove substances from the eyes and reduce ocular tissue damage.5 Ocular exposures can occur with solids, liquids, or gases.2 Substances can enter the eyes accidentally or intentionally through splashes, immersions, or instillations.2 Any substance not specifically formulated for the eyes can cause irritation, corneal abrasions or ulcerations, and blindness.1–3,5 To remove a substance, the eyes should be flushed for at least 20 to 30 minutes using sterile saline or tepid water.1–3,6–8 Eye flushing can be done using a bottle of sterile saline, a clean syringe without the needle, or an eye dropper.1,2,5,9 If these items are unavailable, use a clean washcloth or cotton ball to soak up and squeeze the flushing solution into the eyes. A small paper/ plastic cup or a water bottle can also be used to rinse the eyes.1,5 Hold the item (eg, dropper, cotton ball, cup) as close to the eye as possible, without touching the surface, and allow the saline or water to flow across the eye in a slow, steady stream.1 Flushing can be repeated with periods of rest for the pet and owner between flushings.1,5,9 Any time an ocular exposure happens, it is best to follow up with an examination and fluorescein dye test to check for corneal damage.1,2,5 Cautions and Contraindications. High-pressure spray devices (eg, detachable sink rinse or shower head) should not be used because the pressure is too high and may cause additional irritation or pain. Neutralizing agents, decongestant allergy eye drops, or redness relief eye drops (eg, Visine) should not be used to rinse a pet’s eyes.8,9 Ocular chemical burns are generally treated with lubricated ointments, but corticosteroid ointments should be used only if the corneal epithelium is intact.8 To prevent further injury to the eyes, do not allow the pet to rub or scratch the eyes.3 INHALATION DECONTAMINATION The goal of inhalation decontamination is to remove the pet from the substance and reduce further exposure. Substances likely to be inhaled include gases, smoke,

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Dermal, Ocular, and Inhalation Decontamination in Dogs and Cats PEER REVIEWED

toxic fumes, dusts, powders, and granules.2,11 Some substances can cause pulmonary damage when ingested orally (eg, paraquat, minoxidil).1,11 Pulmonary injury depends on the mechanism of action of the substance.11 Substances may cause respiratory irritation (eg, ammonia, chlorine), asphyxiation (eg, carbon dioxide, carbon monoxide, methane, cyanide), increased bronchial secretions (eg, anticholinesterase insecticides), aspiration pneumonia (eg, hydrocarbons, activated charcoal), pulmonary edema (eg, sulfuryl fluoride, pine oil), or pulmonary fibrosis (eg, paraquat).2,11 Removing the pet from the source of exposure and providing adequate ventilation are generally sufficient methods of inhalation decontamination.2,3,6,11 Pets should be evaluated for respiratory changes, audible sounds, hypoxia, damage to the lining of the respiratory tract, and physical pulmonary injury.2,3,6 Oxygen support should be provided for pets in respiratory distress.2,3,6 Cautions and Contraindications. Certain agents, such as pepper spray or zinc/aluminum phosphine gas (ie, toxic gas produced in a pet’s stomach after eating mole/gopher bait), can pose a hazard for veterinary staff if inhaled.2,3,6 In these cases, decontamination should take place in a well-ventilated area or outside.6 DECONTAMINATING SYMPTOMATIC OR DIFFICULT PETS Decontaminating symptomatic or difficult pets can be challenging and must not cause additional stress or worsen the pet’s clinical signs (BOX 2). Some owners

BOX 2 Case Example: Decontaminating a Symptomatic Pet Sarge, a 4-year-old, 75-pound rottweiler mix, was sprayed directly in the face by a skunk. He presented to the clinic with difficulty breathing, blinking, drooling, and reeking of skunk spray. As a veterinary technician, what decontamination steps should you consider and in what order? Stabilization and inhalation decontamination are the first steps that should be implemented. Sarge has been removed from the source of the toxin but needs oxygen support and respiratory evaluation. Once Sarge has been stabilized and examined, the second step is ocular decontamination with flushing, followed by a fluorescein eye test. The third step is dermal decontamination with the skunk-off mixture. Oral rinsing and dilution can also be considered in this case. Although Sarge’s case is uncommon, veterinary technicians should be prepared and always consider the guidelines before proceeding with decontamination.

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are unable to restrain animals for adequate bathing and ocular flushing, so veterinary attention is often required.6,8 In some cases, dermal and ocular decontamination may be less stressful for the pet and safer for the handler if the pet is sedated.1 Sedatives should be used only if the pet’s health allows.1,5 If sedatives are not used, the animal should be allowed to rest at regular intervals to minimize stress.1,5 Severely depressed or otherwise compromised pets should be monitored closely to avoid hypothermia, extreme stress, or aspiration.5  References 1. DeClementi C. Prevention and treatment of poisoning. In: Gupta RC, ed. Veterinary Toxicology: Basic and Clinical Principles, 2nd ed. Waltham, MA: Academic Press; 2012:1361-1368. 2. Murphy L. Decontamination procedures. In: Poppenga RH, Gwaltney-Brant SM, eds. Small Animal Toxicology Essentials. Ames, IA: Wiley-Blackwell; 2011:51-53. 3. Lee JA. Decontamination and detoxification of the poisoned patient. In: Osweiler GD, Hovda LR, Brutlag AG, Lee JA, eds. Blackwell’s Five-Minute Veterinary Consult: Small Animal Toxicology. Ames, IA: John Wiley and Sons; 2010:5-19. 4. Bough M. Dermal decontamination: Dealing with sticky situations. Vet Tech August 2003:538-540. 5. Heller JB. Decontamination of the poisoned pet. NAVC Clinician’s Brief November 2004:65-69. 6. Lee JA. Decontaminating the poisoned patient. Clinician’s Brief March 2013:13-15. 7. Peterson ME. Toxicologic decontamination. In: Peterson ME, Peterson PA, Talcott PA, eds. Small Animal Toxicology, 3rd ed. St. Louis: Elsevier; 2013:73-83. 8. Beasley VA. Diagnosis and management of toxicoses. In: A Systems Affected Approach to Veterinary Toxicology. Urbana, IL: University of Illinois; 1999:27-69. 9. Dunayer EK. Small mammal toxicology. In: Peterson ME, Peterson PA, Talcott PA, eds. Small Animal Toxicology, 3rd ed. St. Louis: Elsevier; 2013:251-257. 10. Means C. Skunk spray toxicosis: An odiferous tale. DVM360 April 2013:1-3. 11. Pickrell JA, Dhakal K, Gwaltney-Brant S. Pulmonary system. In: Poppenga RH, Gwaltney-Brant SM, eds. Small Animal Toxicology Essentials. Ames, IA: Wiley-Blackwell; 2011:95-97.

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-theart emergency call center routinely fields requests for help from all over the world, including South America, Europe, Asia, and the Pacific Islands.

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Technician-Driven Preventive Behavior Services

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Undesirable behavior in pets results in a weakened human–animal bond and can lead to relinquishment. Behavior concerns are the number-one cause for pet relinquishment; in one study, 40% of pets were relinquished to shelters for behavior issues.1 In another study, the number-one behavior reason for relinquishment of both dogs and cats was house soiling.2 Through preventive behavior services, veterinary technicians can educate clients on proper techniques for addressing normal behavior challenges in their pets and thus help preserve the human–animal bond. Preventive services that can be offered in the hospital and implemented by or with the assistance of a veterinary technician or other trained professional include: ÆÆ Preventive care visits ÆÆ Pet selection counseling ÆÆ Puppy socialization classes ÆÆ Kitten classes ÆÆ Fun visits ÆÆ Victory visits ÆÆ Veterinary visit preparation classes ÆÆ Private training or behavior modification sessions

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

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

BEST BEHAVIOR Through preventive behavior services, veterinary technicians can educate clients on proper techniques for addressing normal behavior challenges in their pets and thus help preserve the human–animal bond.

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Technician-Driven Preventive Behavior Services PEER REVIEWED

PREVENTIVE CARE VISITS If you are in general practice, you are already doing preventive care visits! Incorporating behavior questions into the history taking is a simple, but imperative, step. Clients are not always forthcoming with behavioral concerns. They may be embarrassed that their cat is peeing on the carpet or that their 1-year-old dog is chewing the couch when home alone. By screening for common behavior concerns, veterinary technicians can identify situations before the human–animal bond is irreparably damaged. Consider adding a specific preventive care visit for dogs and cats that are between 8 and 12 months old to address behavior concerns that have developed since the routine puppy and kitten examination series. Most pets relinquished to shelters are between 5 months and 3 years of age (47.4% of dogs and 40.3% of cats) and have been owned between 7 months and 1 year (37.1% of dogs and 30.2% of cats).3 This is a period in which many are not brought to a veterinary hospital. By reaching out and suggesting a behavioral checkup during this time, veterinary technicians can provide early intervention. If behavior concerns are detected, appropriate services based on the behavioral challenges can be recommended, such as private training, group classes, or referral to a veterinary behaviorist. PET SELECTION COUNSELING Pet selection counseling is the first defense against preventing behavior problems and the first offense in influencing a strong human–animal bond. Educating and preparing the prospective pet owner are the primary goals of this service. Misconceptions regarding expectations, preventive care, and training can be discovered and addressed. The new pet owner not only will be better prepared but also can set their new companion up for success. This service can be offered as a private or group session for prospective pet owners. PUPPY SOCIALIZATION CLASSES A true puppy socialization class restricts the age of participants to the socialization period (up to 12 to 16 weeks of age). Because the socialization period wanes between 3 and 4 months of age, puppies should complete the class by age 14 to 16 weeks. Because the puppies will not be fully vaccinated, this includes adhering to strict guidelines and having vaccination and health status protocols as well as facility cleaning protocols in place to minimize disease risks. A study found that puppies aged ≤16 weeks that attended socialization classes were at no greater risk of parvovirus than those that did not attend classes.4

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Arguably, early proper socialization and attendance in puppy socialization classes can decrease relinquishment by preventing behavior problems. The main focus at this age is not on manners training but on creating positive experiences for the puppy and teaching puppy owners appropriate and humane techniques for addressing normal puppy behavior. A reputable puppy socialization class provides a safe environment for exploration and exposure to a variety of stimuli in a controlled and positive manner. The benefits of puppy socialization classes include: ÆÆ Preventing behavior problems ÆÆ Decreasing pet relinquishment ÆÆ Bonding the client to the puppy and your facility ÆÆ Educating puppy parents on normal canine development and humane training techniques ÆÆ Acclimating puppies to handling and routine veterinary procedures ÆÆ Allowing early intervention for high-risk puppies (ie, puppies removed from the litter before 8 weeks of age; that have increased fear, anxiety, and/ or hyperexcitability; that have shown aggression over resources or with handling; or that have had a serious illness before 4 months of age) ÆÆ Helping all puppies reach their full potential A good resource regarding the importance of offering puppy classes is available at avsabonline.org, under Position Statements. Other resources are listed in BOX 1.

BOX 1 Resources for Behavior Services Online  Fear Freesm Foundations for Kittens and Puppies course: fearfreepets.com  Kitten classes: drsophiayin.com/blog/entry/ kitty-kindergarten-learn-how-to-teach-earlykitten-socialization-classes-wi/  Puppy socialization classes: puppystartright.com  Victory visits: veterinaryteam.dvm360.com/ what-heck-victory-visit Print M artin KM, Martin DA. Puppy Start Right: Foundation Training for the Companion Dog. 2nd ed. Waltham, MA: Sunshine Books; 2011. S haw J, Martin D, eds. Canine and Feline Behavior for Veterinary Technicians and Nurses. Ames, IA: Wiley; 2015.

T ECHP O I N T 

Pet selection counseling is the first defense against preventing behavior problems and the first offense in influencing a strong human–animal bond. KITTEN CLASSES Kittens attending a class should be less than 14 weeks old; kittens older than 14 weeks are more likely to fight than play with each other. As with puppy classes, health and cleaning protocols must be in place to minimize disease risks. The benefits of offering kitten classes in your hospital include: ÆÆ Creating a strong bond between the owner and the kitten, as well as your hospital ÆÆ Educating owners regarding normal feline development and behavior ÆÆ Coaching owners on responsible cat ownership and management ÆÆ Providing a safe and controlled environment for exposure and desensitization to veterinary procedures ÆÆ Identifying and preventing behavior problems FUN VISITS A “fun visit” refers to the pet visiting the hospital just for fun. No medical procedures are performed. If you are offering kitten and puppy classes in your hospital, attendees are having a fun visit when they come to class. Once the participants have graduated, it is important that they continue to return to the hospital for good experiences. Continued fun visits help build a positive emotional response and memories with your facility. Because fun visits are informal, they do not necessarily need to be scheduled. However, it may be helpful to post suggested times for fun visits that correspond with less traffic in the lobby or reception area. Because fun visits are a preventive behavior service, they are appropriate and should be encouraged for all pets that do not already have an established fear associated with the veterinary hospital. During a fun visit, owners should focus on creating a positive association with the hospital by incorporating things the dog or cat enjoys, such as special treats, a special meal, toys/play, or even

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grooming (for pets that enjoy being brushed). For example, a dog might get some special treats for being in the waiting room, getting on the scale, and going into an examination room. In the examination room, the owner might pull out the dog’s favorite toy and play with him. For cats, the owner can let the cat explore an examination room and provide a special meal, play with the cat with a favorite toy, and/or brush the cat. Fun visits implemented in this manner generally do not require direct team member assistance. Clients complete the visit on their own, and it is usually a complimentary service. VICTORY VISITS In contrast to fun visits, a victory visit is a scheduled session that involves a qualified team member. These visits may be set up as short (15- to 30-minute) private sessions. To maximize efficiency, it may help to schedule them during a block of time each week—for example, every Tuesday between 12:00 to 2:00 pm. The focus of victory visits is not just on making the veterinary hospital a fun place but also acclimating the pet to gentle control/restraint and veterinary equipment. Victory visits can be a preventive service to work on conditioning to veterinary procedures and manipulations or an intervention service for

Rachel Boettcher/Lifesketch Photography

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FUN VISITS help build a positive emotional response and memories with your facility.

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Technician-Driven Preventive Behavior Services

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Veterinary visit preparation classes not only set pets and owners up for success, but also make the work of the veterinary team easier and more enjoyable.

a pet that has established fear, anxiety, and stress associated with the veterinary hospital. If the pet has an established fear of the hospital or handling, there has been a previous negative experience that the pet needs to overcome. Trust and positive associations can take several visits to establish. Because victory visits require a trained and skilled team member to implement the techniques effectively, the client should be charged appropriately for the service. Many clients will be willing to pay for this service to make their pet more comfortable coming to your hospital and to learn how to provide care at home. VETERINARY VISIT PREPARATION CLASSES Offering a group class centered on making the veterinary visit and at-home pet care more enjoyable for the pet is another sensible option. These classes are an extension of puppy and kitten classes, but with complete focus on training operant behaviors for voluntary cooperative care. Such classes teach pets to perform cued behaviors such as sit, stand, and lie on their side to aid in positioning for procedures, going to a mat or station to be able to get an accurate weight, or even performing a “chin rest” to keep their head still during a blood draw or ear cleaning. Veterinary visit preparation classes not only set pets and owners up for success, but also make the work of the veterinary team easier and more enjoyable.

PRIVATE TRAINING AND BEHAVIOR MODIFICATION SESSIONS Private training and behavior modification sessions are scheduled appointments with a qualified team member to address manners and preventive training. Generally, behavior modification implies the treatment of an existing fear or anxiety. Depending on the situation, a veterinary behavioral diagnosis and treatment plan may be needed before behavior modification sessions can be considered. However, for a mild apprehension, such as avoidance of nail trimmers, a behavior modification session to coach owners on how to appropriately condition a dog or cat to a situation (eg, nail trimming) would be considered preventive. Private training sessions could also be scheduled for activities like teaching owners how to acclimate their cat to wearing a harness or their dog to wearing a headcollar.

Rachel Boettcher/Lifesketch Photography

PRIVATE TRAINING AND BEHAVIOR MODIFICATION SESSIONS are scheduled appointments with a qualified team member to address manners and preventive training.

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TECHPOINT 

CONCLUSION Veterinary technicians can take on the role of the preventive behavior services coordinator and disseminate crucial information regarding animal behavior and training to clients and team members. By providing behavior services, you can help keep pets in their homes, improve pet welfare, save pets’ lives, retain pets at your hospital, provide a new profit center for the hospital, and enhance your career and job satisfaction.  References 1. Patronek GJ, Glickman LT, Beck AM, et al. Risk factors for relinquishment of dogs to an animal shelter. JAVMA 1996;209(3): 572-581. 2. Salman MD, Hutchison J, Ruch-Gallie R, et al. Behavioral reasons for relinquishment of dogs and cats to 12 shelters. J Appl Anim Welfare Sci 2000;3(2):93-106. doi:10.1207/s15327604jaws0302_2. 3. Salman MD, New JG Jr, Scarlett JM, et al. Human and animal factors related to relinquishment of dogs and cats in 12 selected animal shelters in the United States. J Appl Anim Welfare Sci 1998;1(3):207-226. doi:10.1207/s15327604jaws0103_2. 4. Stepida ME, Bain MJ, Kass PH. Frequency of CPV infection in vaccinated puppies that attended puppy socialization classes. J Am Anim Hosp Assoc 2013;49(2):95-100.

Dogs take enough risks on their own. Why add unnecessary proteins to the list? Give dogs all the Lyme protection they need and none of the antigens they don’t. It only takes a single protein, OspA, to block the transmission of Borrelia burgdorferi in the United States.1,2,3

RECOMBITEK® Lyme - the only vaccine with OspA in a nonadjuvanted formula Merial is now part of Boehringer Ingelheim. ®RECOMBITEK is a registered trademark of Merial. ©2017 Merial, Inc., Duluth, GA. All rights reserved. REC16NALYMEAD2 (09/17).

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Straubinger RK, Chang YF, Jacobson RH, Appel MJ. Sera from OspA-vaccinated dogs, but not those from tick-infected dogs, inhibit in vitro growth of Borrelia burgdorferi. J Clin Microbiol. 1995;33(10):2745-2751.

Rice Conlon JA, Mather TN, Tanner P, Gallo G, Jacobson RH. Efficacy of a nonadjuvanted, outer surface protein A, recombinant vaccine in dogs after challenge by ticks naturally infected with Borrelia burgdorferi. Vet Ther. 2000;1(2):96-107.

Probert WS, Crawford M, Cadiz RB, LeFebvre RB. Immunization with outer surface protein (Osp) A, but not OspC, provides cross-protection of mice challenged with North American isolates of Borrelia burgdorferi. J Infect Dis. 1997;175(2):400-405.

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1 Credit Continuing Education | Peer Reviewed

This article has been updated, edited, and reprinted with permission of John Wiley & Sons, Inc. From: Anesthesia for Veterinary Technicians, Ed. Bryant 2010©

CONTINUING EDUCATION

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

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Trish Farry, CVN, AVN, VTS (ECC, Anesthesia & Analgesia), TAA GCHEd School of Veterinary Science at The University of Queensland, Australia

Anesthesia for Pediatric Patients Veterinary neonatal and pediatric patients pose a unique set of perianesthetic management challenges for the veterinary anesthetist. Challenges range from the patients’ immature physiologic system and altered handling of anesthetic and analgesic drugs to their small size, which makes IV catheter placement and endotracheal (ET) intubation potentially difficult. Even agreement on the veterinary definitions of neonatal and pediatric has been challenging. According to the American Animal Hospital Association (AAHA) life stage guidelines for dogs and cats, the neonatal stage extends from birth to weaning (~4 weeks of age) and the pediatric stage is generally from weaning until sexual maturity (~6 months of age, depending on breed and species).1,2 The clinical and therapeutic challenges presented by this subset of patients make it important that veterinary technicians understand the unique anatomic, physiologic, and pharmacologic differences in these patients to help formulate and provide the most appropriate anesthetic regimen.

Shutterstock.com/Forewer

PHYSIOLOGY Neonatal and pediatric anesthetic patients have a limited reserve capacity in most physiologic systems. The cardiopulmonary system undergoes rapid and dramatic changes at the time of birth to support life during the transition from intrauterine physiology to adult physiology.3 Neonatal and

Trish Farry is an Australian certified nurse with specialist qualifications in emergency and critical care and anesthesia. She is an associate lecturer and clinical instructor in anesthesia within the School of Veterinary Science at The University of Queensland in Australia and co-coordinates the final year of BAppSci (Veterinary Technology) program. Her areas of teaching include emergency medicine, anesthesia, analgesia, and clinical practices for undergraduate veterinary and veterinary technology students.

Wendy Goodwin, BVSc, PhD, FANZCVS (Veterinary Anaesthesia, Critical Care) School of Veterinary Science at The University of Queensland, Australia

Wendy is a veterinarian with a PhD and specialist qualifications in veterinary anesthesia and critical care. She works at the School of Veterinary Science, University of Queensland, Australia, as a clinical anesthetist, lecturer, and researcher in the areas of anesthesia, analgesia, and critical care.

WARM UP Wrapping the pediatric patient in a warm towel can reduce the stress of restraint.

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Anesthesia for Pediatric Patients

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pediatric patients are highly dependent on heart rate to maintain cardiac output and blood pressure.4 They have less functional contractile tissue, limited cardiac reserve, and low ventricular compliance and therefore a reduced ability to increase stroke volume.5 The sympathetic nervous system is underdeveloped, and these patients may have poor vasomotor control and reduced baroreceptor reflexes, which make them less able to tolerate blood loss and maintain blood pressure.6 Bradycardia may therefore profoundly affect cardiac output and subsequently blood pressure. Although they are likely to rapidly respond to fluid loading, pediatric animals are less tolerant of fluid overload than adult dogs and cats. Pulmonary reserve is also limited in pediatric patients. Compared with adults, anatomic differences such as a large tongue and less rigid airway cartilage can predispose pediatric patients to upper airway obstruction. Additionally, the ribcage is more pliable, the intercostal muscles weaker, the lungs less compliant, and the overall work of breathing is greater than in adults, thus facilitating airway collapse and respiratory fatigue.3,7 Neonates have a reduced inspiratory reserve volume compared with adults, and increases in minute volume are achieved by increasing respiratory rate.3 Functional residual capacity is reduced, respiratory chemoreceptors are immature, and oxygen demand is decreased, all of which predispose young animals to be at risk for rapid desaturation and hypoxemia during the perianesthetic period.7 The susceptibility of young puppies and kittens to hypoxemia and respiratory fatigue necessitates oxygen supplementation throughout the anesthetic period and highlights the importance of careful monitoring of the respiratory system so that intermittent positive-pressure ventilation can be swiftly commenced if required. The renal and hepatic systems are immature in very young patients. One of the main considerations for sedation and anesthesia is the metabolism, biotransformation, and excretion of drugs. An exaggerated effect and prolonged duration of action may be observed, and the technician may need to adjust and reduce dose rates and dosing intervals accordingly. Pediatric patients are prone to hypoglycemia because of minimal glycogen stores and poor gluconeogenesis.8 Blood glucose monitoring and the administration of glucose-containing fluids may be beneficial during anesthesia. Renal function is also reduced compared with adult dogs and cats, adding to the reduced tolerance of fluid overloading and hypotension. Thermoregulation is impaired in pediatric patients, and their larger body surface area relative to body weight and minimal fat reserves make them extremely

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TECHPOINT 

In very small patients, an uncuffed ET tube may be preferable to maximize airway diameter and decrease resistance of breathing. vulnerable to hypothermia. In addition, most anesthetic agents affect the thermoregulatory center, and hypothermia may result. This can produce many deleterious effects, including decreased metabolic rate, increased susceptibility to infection, myocardial depression, respiratory depression, and delays in drug metabolism. Hypothermia significantly reduces the minimum alveolar concentration (MAC) of inhalational agents because of the decrease in metabolic rate. PREANESTHESIA PREPARATION A complete physical examination is the cornerstone for any animal undergoing sedation or anesthesia. From the observations that are noted during this examination, the technician will be able to formulate the appropriate anesthetic plan. Because of the minimal glycogen stores in the liver of the pediatric patient, withholding of food should be kept to a minimum. Unweaned puppies and kittens should not be fasted, and patients older than 6 weeks of age that are eating solid food need to be fasted only for a maximum of 3 to 4 hours before general anesthesia.5 Prolonged fasting of these patients may result in hypoglycemia and dehydration and predispose them to hypothermia. Withholding of water is unnecessary. The minimum laboratory evaluations should include packed cell volume, total protein, and blood glucose. Further evaluation of the patient’s biochemical and hematologic status should be performed if indicated. Any fluid deficits or electrolyte imbalances should be corrected before anesthesia if possible. If possible, avoid repeated blood sampling, which may cause volume depletion in a very small patient. Equipment When planning to induce anesthesia in a pediatric patient, the correct equipment must be available. A selection of ET tubes of appropriate sizes should be readily accessible, along with a laryngoscope with a good light source and an appropriately sized blade. In very small patients, an uncuffed ET tube

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may be preferable to maximize airway diameter and decrease resistance of breathing. If a cuffed ET tube is used, care must be taken not to overinflate the cuff because the tracheal tissue is very fragile. The use of laryngeal mask airway has been reported in kittens; however, the incidence of lower esophageal reflux was greater when compared with ET tubes.9 Owing to the small patient size and tidal volume, an increase in apparatus dead space is of significant concern. Causes of increased dead space include ET tubes that are too long and inappropriately sized wye-piece and capnograph connectors. FIGURE 1 demonstrates a capnograph with rebreathing due to an increase in apparatus dead space in a small patient. Therefore, oxygen supply and a breathing circuit with a pediatric-sized wye-piece and bag should be available to assist with ventilation in small patients. Nonrebreathing systems may be a better choice in most of these patients to reduce breathing resistance and to facilitate faster changes in anesthetic concentration if inhalational agents are used. Unfortunately, the fresh high gas flow rate required by these circuits (2–3 times respiratory minute volume) may predispose the patient to hypothermia. Because of the high risk of desaturation in these patients, the importance of preoxygenation with an appropriately sized mask before induction of anesthesia cannot be overemphasized. Equipment for monitoring the various organ systems during the perianesthetic period should be available and used until the patient has recovered and is able to maintain normal homeostasis. To reduce the risk of accidental fluid overload, equipment for administering IV fluids, such as pediatric burettes, fluid pumps, and syringe pumps, is advisable.

FIGURE 1. Increased inspired carbon dioxide due to an increase in apparatus dead space in a small patient.

CONTINUING EDUCATION

An accurate weight for all patients is of the utmost importance, particularly for small patients, in which an overdose of fluids or drugs can have a catastrophic effect. With very small patients, it is advisable to use a small scale that can give an accurate weight in grams (FIGURE 2). PREMEDICATION Neonatal patients are seldom premedicated; however, with the possible exception of extremely debilitated or ill patients, premedication is beneficial in pediatric/ young dogs and cats. The use of a balanced drug combination can alleviate stress and significantly decrease the subsequent amounts of induction and maintenance agents required. Drugs that are short acting and reversible are recommended. Drug selection and dose depend on the patient’s age and physiologic status. In very young patients, the blood–brain barrier is more permeable, and central nervous system responses to drug administration may be exaggerated. The altered drug uptake, metabolism, distribution, and excretion of drugs by neonatal patients compared with pediatric and adult animals should also be taken into account. Regardless of the drug chosen, care must be taken with drug doses because this subset of patients is also less able to tolerate absolute or relative overdoses.

FIGURE 2. A puppy being weighed on an infant scale for accuracy.

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The 4 main classes of drugs used as premedicants in pediatric patients are opioids, benzodiazepines, anticholinergics, and tranquilizers (TABLE 1). These drugs can be used alone or in combination. Opioids Opioids in general have very little effect on cardiac contractility but may produce a vagally mediated reduction in heart rate. Consequently, anticholinergic drugs are often coadministered with opioids.5,7 The µ agonists (fentanyl,morphine, methadone, hydromorphone, and oxymorphone) provide the best analgesia but cause greater cardiovascular and respiratory depression than the partial µ agonists (buprenorphine) and the κ agonist/µ antagonists (butorphanol). These latter drugs provide only

moderate analgesia but may be a more appropriate choice depending on the procedure and analgesic requirements. Full µ agonists may be reversed with specific antagonists such as naloxone if undesirable or prolonged drug effects occur. Benzodiazepines Benzodiazepines usually do not provide reliable sedation in healthy adult patients, but they are often quite effective in young patients. Midazolam and diazepam cause minimal cardiovascular depression and provide good muscle relaxation. Benzodiazepines do not provide any analgesia, so they are best used in combination with an opioid. Similar to opioids, benzodiazepines may be reversed with the antagonist flumazenil if required.

TABLE 1 Suggested Drug Doses for Pediatric Small Animalsa CLASS

DOSE (MG/KG) AND ROUTE

COMMENTS

Atropine

0.02–0.04 SC, IM, IV

Anesthetic adjuvant, treatment/prevention of bradycardia

Glycopyrrolate

0.01–0.02 SC, IM, IV

ANTICHOLINERGICS

BENZODIAZEPINES AND TRANQUILIZERS Diazepam

0.1–0.4 IV

IM, SC uptake unreliable; more effective when used in conjunction with an opioid

Midazolam

0.1–0.3 SC, IM, IV

More effective when used in conjunction with an opioid; shorter duration of action than diazepam

Flumazenil

0.1 IV

Benzodiazepine antagonist, short duration of action

Acepromazine

0.005–0.02 SC, IM, IV

Use with caution

Methadone

0.05–0.3 SC, IM, IV

Good analgesia

Morphine

0.05–0.25 SC, IM

Good analgesia; vomiting may occur

Buprenorphine

0.005–0.02 SC, IM, IV

Slow onset of action

Butorphanol

0.1–0.3 SC, IM, IV

Mild pain only, may provide good sedation

Hydromorphone

0.03–0.07 SC, IM, IV

Good analgesia

Oxymorphone

0.03–0.07 SC, IM, IV

Good analgesia

Naloxone

0.01–0.1 IV

Opioid antagonist; all analgesia reversed, short duration of action

Propofol

1–4 IV

Hypotension, apnea common

Ketamine with or without diazepam

0.15–0.3/1.5–3 IV

Etomidate

1–2 IV

Alfaxalone

1–2 IV

OPIOIDS (use lower-end doses in cats)

INDUCTION AGENTSb

Doses are extrapolated from adult doses. Combining drug groups provides balanced premedication. Drug doses should be further reduced for neonatal patients. Induction dose rates are for premedicated patients and should be titrated slowly to effect.

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T ECHP O I N T 

All clinically used inhalation agents produce some degree of doserelated cardiovascular and respiratory depression. Anticholinergics Anticholinergics are often indicated in neonatal and pediatric patients.5,7 Because cardiac output in pediatric patients depends on heart rate, care should be taken to maintain heart rate. The use of atropine or glycopyrrolate may also be indicated in patients with high vagal tone or in procedures that are likely to stimulate a vagal reflex. Tranquilizers Acepromazine. Although acepromazine, a phenothiazine, is one of the most common drugs used in premedication in veterinary medicine, it should mostly be avoided in very young patients. It may cause hypotension and heat loss due to vasodilatation, and young patients are less able to compensate for these effects. α2-Adrenergic Agonists. The use of α2-adrenergic agonists is best avoided in neonatal and pediatric dogs and cats owing to their potential to cause significant vasoconstriction and bradycardia. This is of particular importance in pediatric patients because of their rate-dependent cardiac output. TABLE 1 lists suggested dosages of commonly used drugs for pediatric patients. ANESTHETIC INDUCTION AND MAINTENANCE Induction of anesthesia is achieved by the administration of injectable drugs or by the use of inhalational agents. Preoxygenation with 100% oxygen for at least 3 minutes using a facemask is recommended before the induction of anesthesia. Injectable drugs have the benefit of minimizing patient stress and causing a rapid loss of consciousness, which facilitates rapid control of the airway. However, venous access is required for administration, and this may prove challenging in conscious pediatric patients. Injectable Drugs The injectable drugs commonly used as induction agents are propofol, ketamine/diazepam, etomidate, and alfaxalone (TABLE 1). All injectable anesthetics have side effects that need to be considered when selecting the most appropriate drug.

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CONTINUING EDUCATION

All the injectable drugs require some degree of hepatic metabolism and renal clearance. When used in patients with immature renal and hepatic function, duration of action and recovery may be prolonged. An exception may be propofol because it has some degree of extrahepatic metabolism. Accurate dosing of injectable induction agents is important. It is often beneficial to dilute the concentration of a particular drug with a compatible diluent to assist in titration. All of the injectable agents have the potential to produce respiratory depression, so the veterinary technician needs to be able to take rapid control of the airway, supply oxygen, and ventilate when necessary. Propofol Propofol is a short-acting hypnotic agent that can be used for the induction and maintenance of anesthesia via incremental doses or infusion. It can cause dosedependent bradycardia, vasodilatation, and respiratory depression and should be titrated to effect. Propofol is highly lipid soluble and requires hepatic metabolism, although some extrahepatic metabolism does occur. Ketamine Ketamine, a dissociative anesthetic, is often used in combination with a benzodiazepine as an induction agent. Ketamine has a rapid onset of action, causes minimal cardiovascular depression, and provides a short duration of analgesia. Ketamine often produces a transient increase in blood pressure and cardiac output due to stimulation of the sympathetic nervous system.10 Etomidate Etomidate is a short-acting, nonbarbiturate IV anesthetic agent. It causes minimal adverse cardiovascular effects and is less likely to cause a significant drop in blood pressure than other induction agents. Etomidate produces minimal respiratory depression. Alfaxalone Alfaxalone in cyclodextrin (Alfaxan; alfaxan.com) is a neurosteroid agent that interacts with the γ-aminobutyric acid (GABA) type A receptor to produce anesthesia and muscle relaxation. At clinical doses it has good cardiovascular stability and causes minimal respiratory depression.11,12 Alfaxalone was found suitable for use as an anesthetic induction agent in cats and dogs <12 weeks of age.13,14 Cats <12 weeks of age were reported to better maintain heart rate when anesthesia was maintained with alfaxalone alone compared with an alfaxalone/isoflurane group.14 Maintenance anesthesia using alfaxalone

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Anesthesia for Pediatric Patients

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may be of particular value in pediatric patients because cardiac output is heart rate dependent. Inhalation Agents All clinically used inhalation agents produce some degree of dose-related cardiovascular and respiratory depression. Isoflurane and sevoflurane are sometimes used for induction of anesthesia when IV or intraosseous access cannot be obtained. Sevoflurane has a lower solubility in blood than isoflurane, resulting in more rapid uptake (induction) and elimination (recovery). A small, well-fitting facemask with minimal dead space should be used for inhalation induction (FIGURE 3). Wrapping the patient in a warm towel can reduce the stress of restraint. Uptake of anesthetic is rapid in the neonate, and the therapeutic index is narrow, so care must be taken not to overdose the patient. Local Anesthetic Techniques Local anesthetic techniques can be used to provide analgesia and anesthesia and to reduce the dose requirement of maintenance anesthetic agents. Because of the small size of veterinary neonatal and pediatric patients, the potential to overdose the patient and cause toxicosis exists. Therefore, the correct dose of local anesthetic (mass of drug per kilogram of body weight) should be carefully calculated, checked, and recorded.

FIGURE 3. A small well-fitting mask with minimal dead space should be used to preoxygenate and/or for inhalant induction.

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TECHPOINT 

The width of the occlusion cuff should be approximately 40% of the circumference of the limb. An incorrectly sized cuff will result in a falsely high or low reading. SUPPORT AND MONITORING The goal of monitoring is to provide information to aid technicians in assessing the patient’s physiologic status and providing the most appropriate anesthesia/ analgesia plan for each patient. When developing a plan, the anesthetist should identify any potential disturbances that may occur under anesthesia, such as hypotension and hypothermia. The technician can then formulate the best approach to avoiding these physiologic changes, taking into account the signalment and current health status of the patient. In veterinary medicine today, we have many electronic monitoring devices, but all monitors have limitations and should never replace a skilled, knowledgeable technician. When monitoring, one measurement gives a window into a dynamic situation, whereas repeated measurements provide a better indication of the dynamic picture. Trends have more meaning than single values. Tissue perfusion can be assessed subjectively by pulse quality, capillary refill time, and mucous membrane color. Heart rate and rhythm can be assessed using a stethoscope, an esophageal stethoscope, or electrocardiography. Blood pressure can be monitored invasively via an arterial catheter and transducer, but this can be technically challenging in a smaller patient. Noninvasive measurements of blood pressure (NIBP) are performed using a Doppler or oscillometric monitor. NIBP measurement may not always accurately predict blood pressure, and no treatment decision should be based on one measurement alone15; however, these monitors are useful for monitoring general blood pressure trends. Care must be taken to choose the correct size of occlusion cuff. The width of the cuff should be approximately 40% of the circumference of the limb. An incorrectly sized cuff will result in a falsely high or low reading. Pulse oximetry gives an indication of the adequacy of circulation and oxygenation. A pulse oximeter indicates

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the presence of pulsatile blood flow. Peripheral vasoconstriction, decreases in pulse amplitude, or arrhythmias are likely to affect signal quality. Respiratory function can be subjectively assessed by respiratory rate and depth. Capnography provides a measurement of the carbon dioxide content of respiratory gases and therefore is a good indicator of the adequacy of respiratory function. Accuracy can be hampered by small tidal volumes in pediatric patients as well as the dilutional effect of high fresh gas flow rates. Adapters for a capnograph are usually attached between the ET tube and breathing circuit and thus may contribute substantially to the apparatus dead space. This may be resolved by attaching a needle to the sampling tube and inserting it directly into the ET tube (sidestream sampling) (FIGURE 4). If ventilation is required, care must be taken because the small tidal volumes of these patients increase the risk for barotrauma from overzealous ventilation. Airway pressures should not exceed 15 to 20 cm H2O (10–15 cm H2O in the open thorax). Fluid therapy is beneficial to provide hemodynamic support and replace insensible losses; however, it is advisable to use a fluid pump or a syringe pump that will deliver an accurate volume of fluid to decrease the risk of fluid overloading. If neither of these is available, a microdrip set with a burette is an acceptable alternative. Fluid rates should not exceed 10 mL/kg/h (unless in the setting of acute hemorrhage). Maintenance of adequate serum glucose may require fluids containing dextrose, such as 2.5% to 5% dextrose in lactated Ringer’s solution. If solutions containing dextrose are not available, glucose can be added to the replacement or maintenance fluids. Regular monitoring of blood glucose while the animal is under anesthesia is advisable.

CONTINUING EDUCATION

Temperature probes placed into either the esophagus or rectum should be used and provide a reliable indication of body temperature. Hypothermia should be treated as soon as possible. Patients can begin to lose body temperature once they are premedicated. Many options to conserve body temperature exist. The use of temperature-controlled heating mats (eg, resistive polymer blanket), hot water bottles, or warm air blankets; wrapping extremities; and warming IV and irrigation fluids may all beneficial. Extreme care must be taken to avoid thermal burns, keeping all heating modalities close to body temperature if possible. Airway humidifiers and warmers must be used cautiously in pediatric patients because they may increase apparatus dead space. Warmed solutions should be used for presurgical skin preparation. Alcohol should only be applied to the animal immediately before surgery because it exacerbates heat loss via evaporation. Preinduction patient warming is well documented in human patients and is becoming more common in veterinary medicine. Veterinary studies have shown that patients prone to hypothermia, such as pediatric patients, benefit from forced-air warming 20 to 30 minutes before induction. Prewarming decreases the temperature gradient between the body’s periphery and core, reducing the heat loss that typically occurs during the first hour of anesthesia16 (FIGURE 5). POSTANESTHESIA As with recovery of any patient, care must be taken to assess the adequacy of respiratory and circulatory function, and support should be provided if necessary. Hypothermic patients shiver on recovery, which may increase oxygen demands by up to 300%.17 It is advisable to administer supplemental oxygen to shivering patients to maintain tissue oxygenation. Active warming must be instigated in hypothermic patients.

FIGURE 4. To eliminate mechanical dead space from a mainstream adapter, (A) a surgical needle may be connected to sidestream sampling tubing and inserted directly into the lumen of the endotracheal tube, or (B) an endotracheal tube adapter with a sampling port may be used.

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Appropriate analgesia should always be provided by systemic administration of analgesic drugs as well as the use of local blocks, if possible. Pediatric patients may not exhibit overt signs of pain because of survival instincts; thus, recognition of pain can be more challenging. Do not assume that an animal is not in pain because it is exhibiting no obvious signs of pain. Opioid analgesics are good choices, although care must be taken to monitor for adverse effects such as respiratory depression. Therefore, as with all drugs in pediatric patients, doses should be carefully calculated when administered and preferably titrated to effect. Nonsteroidal anti-inflammatory drugs require extensive hepatic metabolism and consequently may not be the most appropriate choice in pediatric patients. Repeated doses should definitely be avoided. Normal feeding should resume as soon as possible, and unweaned puppies or kittens should be returned to their mothers as soon they are able to suckle. With adequate preparation and understanding of the unique physiologic and anatomic differences present in pediatric patients, the anesthetist can provide excellent care for these patients. 

FIGURE 5. Prewarming the pediatric patient using a forced-air warming blanket is beneficial.

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TECHPOINT 

Capnography provides a measurement of the carbon dioxide content of respiratory gases and therefore is a good indicator of the adequacy of respiratory function.

References 1. Bartges J, Boynton B, Vogt AH, et al. AAHA canine life stage guidelines. JAAHA 2012;48(1):1-11. 2. Vogt AH, Rodan I, Brown M, et al. AAFP-AAHA: feline life stage guidelines. J Feline Med Surg 2010;12(1):43-54. 3. Sharma A, Ford S, Calvert J. Adaptation for life: a review of neonatal physiology. Anaesthes Intens Care Med 2011;12(3):85-90. 4. Holden D. Paediatric patients. In: BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. Gloucester, England: British Small Animal Veterinary Association; 2007:296-302. 5. Grubb T, Perez Jimenez T, Pettifer G. Neonatal and geriatric patients. In: Grimm KA, Lamont LA, Tranquilli WJ, et al, eds. Veterinary Anesthesia and Analgesia. 5th ed. Ames, IA: John Wiley & Sons; 2015:983-987. 6. Fox MW. Developmental physiology and behaviour. In: Canine Pediatrics. Springfield, IL: CC Thomas; 1966. 7. Fávaro da Cunha A. Neonatal, pediatric, and geriatric concerns. In: Snyder LBC, Johnson RA, eds. Canine and Feline Anesthesia and Co-existing Disease. Ames, IA: John Wiley & Sons; 2015:310-319. 8. Agarwal R. Neonatal anesthesia. In: Duke J, ed. Duke’s Anaesthesia Secrets. Philadelphia: Mosby Elsevier; 2006:364-380. 9. Sideri AI, Galatos AD, Kazakos GM, Gouletsou PG. Gastrooesophageal reflux during anaesthesia in the kitten: comparison between use of a laryngeal mask airway or an endotracheal tube. Vet Anaesth Analg 2009;36(6):547-554. 10. Wright M. Pharmacologic effects of ketamine and its use in veterinary medicine. JAVMA 1982;180(12):1462-1471. 11. Muir W, Lerche P, Wiese A, et al. Cardiorespiratory and anesthetic effects of clinical and supraclinical doses of alfaxalone in dogs. Vet Anaesth Analg 2008;35(6):451-462. 12. Whittem T, Pasloske KS, Heit MC, Ranasinghe MG. The pharmacokinetics and pharmacodynamics of alfaxalone in cats after single and multiple intravenous administration of Alfaxan at clinical and supraclinical doses. J Vet Pharmacol Ther 2008;31(6):571-579. 13. O’Hagan B, Pasloske K, McKinnon C, et al. Clinical evaluation of alfaxalone as an anaesthetic induction agent in dogs less than 12 weeks of age. Aust Vet J 2012;90(9):346-350. 14. O’Hagan BJ, Pasloske K, McKinnon C, et al. Clinical evaluation of alfaxalone as an anaesthetic induction agent in cats less than 12 weeks of age. Aust Vet J 2012;90(10):395-401. 15. Clarke K, Trim C, Hall LW. Patient monitoring and clinical measurement. In: Veterinary Anaesthesia. 11th ed. London: Elsevier; 2014:19-63. 16. Read M. Physiology and prevention of perianaesthetic hypothermia. Presented at World Congress of Veterinary Anaesthesiology, Cape Town, South Africa, 2012. 17. Muravchick S. Preoperative assessment of the elderly patient. Anesthesiol Clin North Am 2000;18(1):71-89, vi.

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Canine Multicentric Lymphoma: An Overview

Kriste Sears-Sein, RVT, VTS (Oncology) University of California, Davis

Lymphoma (more properly termed lymphosarcoma) is a cancer of lymphocytes that affects approximately 13 to 24 dogs per 100,000 annually and accounts for up to 24% of all canine neoplasias in the United States.1 It is characterized by an abnormal population of lymphocytes, which are an important part of the immune system. B lymphocytes (or B cells) produce antibodies in response to specific antigens. These antibodies “lock on” to the antigen, thus marking it for destruction by the T lymphocytes (or T cells). The determination of cell origin as B cell or T cell gives important predictive information on response and survival times in lymphoma patients. Lymphoma usually arises in lymphoid tissues, such as the lymph nodes, spleen, and bone marrow, but can be found anywhere in the body. Multicentric lymphoma, which involves multiple lymph nodes and may also affect the spleen, liver, and/or bone marrow, accounts for approximately 80% of canine lymphoma cases.

Kriste has been working in the veterinary field in and around Sacramento, California, since 1997. After receiving her RVT in 1999, she began working in emergency and holistic medicine, which sparked her interest in the human–animal bond and quality-of-life focus in veterinary medicine. In 2008 she received her veterinary technician specialist certification in oncology, and since then has lectured around the United States on various topics related to cancer and compassionate care. She has been working as the Medical Oncology Supervisor at the University of California, Davis, since 2010.

Shutterstock/Tatiana Katsa

DIAGNOSIS Patients with multicentric lymphoma often present with only the clinical sign of enlarged peripheral lymph nodes; however, a patient may present with any number of nonspecific clinical signs, such as lethargy, weight loss, anorexia, or polyuria/polydipsia. Other differential diagnoses for generalized lymphadenopathy include fungal, viral, bacterial, or parasitic infections, and a thorough travel history should be obtained.1

WARNING SIGNS Patients with multicentric lymphoma often present with only the clinical sign of enlarged peripheral lymph nodes; however, a patient may present with any number of nonspecific clinical signs, such as lethargy, weight loss, anorexia, or polyuria/polydipsia.

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Canine Multicentric Lymphoma: An Overview PEER REVIEWED

Lymph node biopsy is the gold standard for diagnosing lymphoma. High-grade lymphoma, which is characterized by the proliferation of large, immature lymphoblasts, can often be diagnosed with simple fine-needle aspiration (FNA) of the affected nodes. FNA should be performed on a lymph node that is unlikely to be associated with reactivity; therefore, it is best to avoid aspiration of the submandibular lymph nodes if another affected lymph node is available. Reactive lymph nodes have a more mixed population of lymphocytes, with lymphoblasts making up only approximately 50% of the population; plasma cells are common. CLASSIFICATION Grade and stage are often important in classifying cancers and determining prognosis. Grade is determined by histopathology and refers to how aggressively a tumor is expected to behave. Factors considered in grading include invasiveness, degree of necrosis, cellular atypia, and mitotic index.1 Stage refers to how far the tumor has spread in the body (BOX 1). Grade Grade is a very important prognostic factor for lymphoma. Low-grade lymphoma, also known as small-cell lymphoma, is characterized on cytology by a relatively homogeneous population of small, mature lymphocytes that may not look different from a normal lymph node population. Biopsy is necessary to further evaluate whether a cancerous process is present. Small-cell lymphoma progresses more slowly than large-cell, or high-grade, lymphoma. On cytology, high-grade lymphoma is characterized by a monomorphic population of large, immature lymphoblasts, which are approximately the size of a neutrophil or larger. Left untreated, it is a

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TECHPOINT 

Lymphoma usually arises in lymphoid tissues, such as the lymph nodes, spleen, and bone marrow, but can be found anywhere in the body. fast-moving, aggressive process that generally proves fatal in 6 to 8 weeks. Fortunately, its rapid progression makes it very responsive to chemotherapy, and because it is a systemic cancer, chemotherapy is the cornerstone of treatment. Stage Lymphoma is classified by the staging system in BOX 1. Staging, especially for multicentric lymphoma, may not be as prognostic as for solid tumors, such as sarcomas or carcinomas.1 Staging tests should consist of a serum biochemical profile, a complete blood count with differential, thoracic radiography, abdominal ultrasonography, and potentially a bone marrow evaluation. A baseline measurement of all affected lymph nodes should be obtained, as should a thorough cardiac evaluation. If a murmur or arrhythmia is appreciated on auscultation, echocardiography should be considered because cardiac disease may warrant a change to the chemotherapy plan. Some of the laboratory abnormalities that may be seen at presentation are: ÆÆ Leukopenia may be present if the bone marrow is involved because of crowding of the normal marrow tissue by cancerous cells. This is called myelophthisis and can present a treatment

BOX 1 Lymphoma Staging System  Stage I: involvement of only 1 lymph node  Stage II: involvement of multiple peripheral lymph nodes on 1 side of the diaphragm  Stage III: generalized lymphadenopathy (or lymphadenomegaly)  Stage IV: involvement of liver and spleen  Stage V: involvement of bone marrow involvement or extranodal sites (eg, eye, kidney) FIGURE 1. A patient receiving rabacfosadine for lymphoma. She is allowed to position herself comfortably with minimal restraint for the infusion.

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challenge—administration of chemotherapy may cause the white cell count to drop further, leaving the patient susceptible to infection. Conversely, the patient may have leukocytosis secondary to circulating cancer cells (leukemia) or a stress leukogram. ÆÆ Thrombocytopenia may be secondary to bone marrow involvement or immune mediated. ÆÆ Hypercalcemia of malignancy is a paraneoplastic syndrome that is commonly associated with T-cell lymphoma. It is due to the tumor producing parathyroid hormone–related protein, which mimics parathyroid hormone in the body, although the reason for the protein production is unknown. Hypercalcemia is a medical emergency because, if persistent, it can lead to renal failure (BOX 2). Confirmation of hypercalcemia of malignancy requires a specific panel of tests. ÆÆ Azotemia may be present because of many factors, including dehydration, persistent hypercalcemia leading to calcification of the renal cortex, or renal involvement of the lymphoma. ÆÆ Elevated liver enzymes may be present if the liver is involved. Depending on severity, liver involvement may warrant alteration of the chemotherapy protocol because many of the drugs used are metabolized by the liver. Impaired clearance of chemotherapeutics can lead to increased side effects or a relative overdose. Treating the lymphoma with drugs that do not require hepatic clearance may allow the enzyme levels to normalize, and then the protocol may be adjusted.

BOX 2 Treating Hypercalcemia in Lymphoma Patients The most important and effective way to lower calcium levels in lymphoma patients is to treat the underlying cause (ie, the lymphoma). Initiation of l-asparaginase and steroid therapy to reduce the population of cancer cells leads to the reduction of calcium levels. Often, however, lymphoma patients present with dehydration and require aggressive fluid therapy. After adequate hydration is achieved, a diuretic, such as furosemide, may be considered. Corticosteroids should not be administered before confirmation of the lymphoma diagnosis because rapid reduction of the tumor burden can make definitive diagnosis difficult or impossible. A bisphosphonate (pamidronate, zoledronate) may be administered to lower the calcium levels; however, treating the lymphoma is still the goal, and care must be taken to protect the kidneys during administration.

CONTINUING EDUCATION

Substage Lymphoma is further classified by substage, either a or b, which simply refers to how the patient is doing clinically. A patient that presents with a normal appetite and energy level would be classified as substage a, whereas a patient that is feeling poorly on presentation would be substage b. Patients that do not feel well on presentation have an overall poorer response rate and prognosis. It is better to initiate therapy while the patient is feeling well than to wait until the patient is compromised. Immunophenotype Another diagnostic tool that adds prognostic information is phenotyping. This can be determined via several tests, including flow cytometry, clonality, immunohistochemistry, and immunocytochemistry. B-cell lymphoma is associated with longer survival and better quality of life.1,2 CHEMOTHERAPY Treatment Goals The goal of lymphoma treatment is to induce clinical remission, indicated by lack of measurable disease, while retaining a high quality of life. Because lymphoma is a systemic disease, chemotherapy is the foundation of treatment. Using calculated lower doses that are used by human oncologists usually keeps side effects minimal and short term; however, some patients may require hospitalization, and death from tumor lysis syndrome can occur. A common client misconception is that administering chemotherapy to animals is in some way inhumane. This stems from assumptions about the goals of cancer therapy in companion animals and the incidence of side effects from therapy. It can be helpful to the client to present cancer therapy as treatment of a chronic condition, similar to treatment of renal or heart disease. Many clients are willing and able to administer daily medication or SC fluids, and a weekly chemotherapy visit is much less daunting when framed in those terms. Treatment Options Many options are available for lymphoma treatment, varying in cost and survival time. As stated before, median survival time for untreated high-grade lymphoma is 6 to 8 weeks. Treating with prednisone can improve quality of life and result in 2 to 3 months of survival time. Treatment with a combination chemotherapy protocol that includes doxorubicin results in an average first remission time of 8 to 10 months and a median survival of 1 year. Adding in half-body radiation therapy appears to increase overall survival times for canine lymphoma patients.1,3

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Most chemotherapy protocols have 2 phases: induction and consolidation. The induction phase consists of weekly treatments designed to place the pet into remission rapidly. It is more dose intensive than the consolidation phase, which is designed to kill any remaining tumor cells and requires less frequent treatment. Lymphoma is ideally managed with a combination of drugs. Several different protocols are used, but most are based on a combination of drugs commonly abbreviated as CHOP, or L-CHOP. The drugs are as follows: ÆÆ L (l-asparaginase): This enzyme degrades the amino acid asparagine. Asparagine, which is synthesized by normal cells, is necessary for protein synthesis; however, lymphoma cells are unable to synthesize asparagine. Rapidly dividing cells need to produce large amounts of protein to progress through the cell cycle. If deprived of asparagine, they cannot progress and thus undergo apoptosis.

FIGURE 2. A patient waiting for treatment.

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 The most significant adverse reaction seen with l-asparaginase is hypersensitivity. Patients with prior exposure to the drug are predisposed to hypersensitivity reactions. Premedication with diphenhydramine and dexamethasone sodium phosphate, as well as SC administration of the drug, minimizes these reactions. Pancreatitis and coagulopathies (secondary to decreased protein synthesis) are also seen with l-asparaginase to a lesser extent.  Significant myelosuppression is rare unless l-asparaginase is given simultaneously with vinca alkaloids. The mechanism of this interaction is unknown, but it is thought that l-asparaginase may inhibit liver function, thus interfering with hepatic excretion of vinca alkaloids. It is reported that up to 25% of canine patients treated with vincristine and l-asparaginase concurrently will develop significant myelosuppression. It is common to “split” induction in clinically ill lymphoma patients (ie, separate administration of the drugs by several days) to minimize this toxicosis.1,2,4 ÆÆ C (Cyclophosphamide): This alkylating agent interferes with DNA replication and RNA transcription. It is nonspecific for cell cycle phase. It can be given intravenously or in capsule form. Side effects can include sterile hemorrhagic cystitis. Cyclophosphamide is not substantially myelosuppressive at the doses used in veterinary medicine.1,2,4 ÆÆ H (Doxorubicin): This anthracycline antineoplastic antibiotic intercalates with DNA, thereby inhibiting protein synthesis and promoting the formation of free radicals. It is nonspecific for cell cycle phase. Although doxorubicin does have antimicrobial activity, it is considered too toxic to be used as an antimicrobial; instead it is used for its antitumor activity against a wide range of neoplasms.1,2,4  Familiarity with the side effects of doxorubicin is extremely important for the administrator. The drug can have both acute and cumulative effects. Doxorubicin can cause immediate histamine-mediated hypersensitivity reactions (pruritus, dyspnea, or vomiting in dogs). It is also associated with cumulative cardiotoxicity; therefore, thorough cardiac evaluation is needed before each dose. Any new murmurs or arrhythmias warrant echocardiography.1,2,4  Doxorubicin should be administered only by a trained individual because it is a severe vesicant, and administration outside of the vein results in severe, progressive tissue necrosis.

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ÆÆ O (Vincristine): This vinca alkaloid antitubulin agent is derived from the periwinkle plant. It is specific for cell cycle phase, inhibiting cell division during metaphase by binding to microtubular proteins in the mitotic spindle. It is generally not significantly myelosuppressive at the doses used in veterinary patients.2 Vincristine is the vinca alkaloid of choice for lymphosarcoma.  Side effects of this drug include paralytic ileus, peripheral neuropathy, and syndrome of inappropriate antidiuretic hormone secretion.  Vincristine is a vesicant and must be administered with care by a trained technician through a perfectly placed butterfly or over-the-needle catheter. ÆÆ P (Prednisone): A corticosteroid, prednisone directly kills cancer cells but can lead to drug resistance if used long term. It is often incorporated into multiagent protocols over the short term. Side Effects Myelosuppression Myelosuppression occurs secondary to damage caused by the chemotherapeutic agent to precursor cells in the bone marrow. The circulating neutrophil life span is 5.5 to 7.6 hours; thrombocytes, approximately 10 days; and erythrocytes, approximately 73 days.5 The blood cells with the shortest life span are the first to show damage; therefore, decreased neutrophil and platelet counts are most commonly seen clinically. Presenting signs can include pyrexia, petechiae, pallor, and weakness, although many patients with low white blood cell counts and platelet counts are clinically normal. It is important to check the neutrophil counts at the nadir to ensure the pet does not require prophylactic antibiotics. Patients receiving chemotherapy are not generally immunosuppressed. Rather, it is more accurate to state that they are myelosuppressed (ie, their bone marrow function is altered). These patients do not lose their acquired immunity, but they are susceptible to bacterial infections if their neutrophil counts drop too low. The difference between immunosuppression and myelosuppression is important because clients often ask whether they should curtail their dog’s activities during chemotherapy. As long as the pet is feeling well, it should be able to get groomed, go swimming, and generally enjoy its life. Gastrointestinal Chemotherapy can cause gastrointestinal (GI) toxicosis through 2 mechanisms of action. The first is through direct stimulation of the chemoreceptor

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trigger zone. This is most common with the drugs cisplatin and dacarbazine, and it causes acute vomiting on the day of treatment. The second is through direct damage to the epithelium of the small intestine. The absorptive surface of the small intestine consists of numerous villi that are lined by a single layer of nonproliferating epithelial cells. These cells are replaced by cells that migrate upward from the crypts, which lie between and at the base of the villi. The high rate of cell proliferation in the crypts of the intestine makes these cells more vulnerable to the cytotoxic effects of chemotherapy.6 Direct damage to the intestinal epithelium results in vomiting, diarrhea, or inappetence, usually beginning 3 to 5 days after treatment. Translocation of normal gut flora resulting from intestinal damage can be a key source of bacterial infection. The consequences of significant GI toxicosis (dehydration, weight loss, financial burden of hospitalization, and treatment delay) can diminish client enthusiasm for continuation of treatment. Use of antiemetics and antidiarrheals is key. In patients with a history of GI complications from a particular agent, prophylactic therapy is often initiated 3 to 5 days before subsequent treatment. NURSING CONSIDERATIONS Quality of life is the number 1 priority in these patients. It is generally understood that the goal of therapy is not to achieve a cure, but to extend the patient’s life at as high a quality of life as possible. Luckily, pain is not often an important factor for lymphoma patients, but nausea and diarrhea can significantly affect quality of life if not recognized and addressed.

FIGURE 3. Ultrasound image of a spleen showing the characteristic “chicken wire” appearance of lymphoma.

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Nutrition and Hydration Dogs can be subtle in their signs of nausea. Instruct clients to watch for such signs as salivation or lip-licking, or simply encourage them to treat for presumed nausea in the case of food avoidance. Especially in the short term, it is less important what the pet eats; clients should favor feeding highly desirable foods, such as baby food or plain rotisserie chicken. Warming canned food (to make it more fragrant) can coax a pet to eat. Hydration is another important factor to consider. In human patients, dehydration can contribute to headaches and increased sensitivity to other painful stimuli. This cannot be adequately assessed in veterinary patients, but it is reasonable to assume they experience similar discomfort. Teach clients to assess skin turgor and oral “tackiness” as tools to help manage their pets’ hydration status and how to administer SC fluids as indicated.

Glossary Alkylating agent Drugs that prevent a cell from reproducing by damaging its DNA. Atypia The condition of being irregular or not conforming to type.a Complete remission Complete resolution of measurable tumor burden. Intercalate To insert between.a Lymphoblast A morphologically immature lymphocyte.a Median survival The point at which half of the patients have died and half of the patients are still alive. Differs from mean survival in that patients at either extreme (early deaths or long-term survivors) do not affect the median. Mitotic index In a population of cells, the ratio of the number of cells undergoing mitosis (cell division) to the number of cells not undergoing mitosis. Monomorphic Maintaining one form through all stages of development.a Nadir The point after chemotherapy when the lowest white blood cell count occurs. The nadir differs for various chemotherapy agents, but is 7 to 10 days after administration for most drugs. Phenotype The physical, biochemical, and physiological makeup of an individual as determined by genetics and environment.a Reactivity Inflammation and swelling of local lymph nodes resulting from inflammation of tissue and subsequent increase in white blood cells. Tumor lysis syndrome Electrolyte and metabolic disturbances (eg, hyperkalemia, hyperphosphatemia, hypocalcemia) resulting from release of tumor cell contents into the blood stream, either spontaneously or in response to therapy. Vesicant Blistering agent. Dorland’s Illustrated Medical Dictionary. 30th ed. Philadelphia, PA: Saunders; 2003. a

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Management of Clinical Signs If a pet becomes anorectic or dehydrated, many supportive care options exist, but the main objective should remain the same: quality of life. A feeding tube may not be a viable long-term option; the same holds true (perhaps even more so) with syringe feeding. Instead, focusing on the underlying causes of inappetence or medically managing the clinical signs may yield better results. Antiemetics, such as ondansetron, maropitant, or metoclopramide, or appetite stimulants, such as mirtazapine, can sometime induce a pet to eat willingly. Other Considerations Obesity is common in these patients. Between prednisone administration and caregivers’ desire to “spoil” the pet for its remaining time, significant weight gain can occur. To avoid overdoses, attention should be paid to chemotherapy doses if the pet is continuously gaining weight. Having a little extra weight in case of illness is not a bad idea in these patients, but too much can lead to orthopedic and other issues. A word on diet: Many pet owners are very dedicated and wish to do everything possible to support their pets through this process. Commonly, the first step for them is to radically overhaul the pet’s diet regimen, switching to “natural” or “cancer” diets, or potentially feeding raw or home-formulated diets. This is to be discouraged, especially in the beginning stages of treatment. It can be difficult to assess whether a pet is experiencing GI toxicosis from chemotherapy or simply GI upset from a sudden change in its food or an adverse reaction to supplements. If clients wish to change their pet’s diet, instruct them on how to make a gradual change, ideally after the induction phase of chemotherapy is over. Encourage them to find a commercially available dog food, rather than home cooking, because many homecooked diets are not nutritionally complete. If the client insists on home cooking, referral to a veterinary nutritionist is appropriate. Under no circumstances do I advise feeding raw diets to cancer patients because of the risk for systemic infection from unprocessed meat. SUPPLEMENTS Many commercial supplements advertise immune support or other benefits for cancer patients. Most have not been evaluated by a regulatory body to determine their safety or efficacy, and drug interactions can occur.7 “Natural” does not mean something is safe or without side effects; vincristine is derived from the periwinkle plant, after all. Additionally, some of the intended benefits of the supplement may run counter to the goals of cancer treatment. An example is antioxidant supplementation. Both chemotherapy

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vet-dc.com) are two new therapies available to the veterinary oncology team, but more research is needed to evaluate their merits compared with current standards of care. In all cases, preserving quality of life and the human–animal bond remains the goal of all veterinary cancer therapy going forward. 

and radiation therapy promote oxidative damage to kill cancer cells. The protective effects of antioxidants may extend to the cancerous cells as well as the normal tissue.2 Consultation with a veterinarian who is well versed in supplement therapy and its application during chemotherapy should be considered. If the patient is inappetent, it may be wise to stop supplement therapy and gradually reintroduce it if appetite returns. From a quality-of-life standpoint, simply reducing the number of medications a patient is taking daily to the minimum necessary may be a relief to both patient and caregiver.

References 1. Hemapoietic tumors. In: Withrow S, Vail D. Small Animal Clinical Oncology. 4th ed. Philadelphia: Saunders Elsevier; 2013: 608-631. 2. Diagnosis of cancer. In: Moore AS, Frimberger AE. Oncology for Veterinary Technicians and Nurses. Ames, IA: Wiley-Blackwell; 2010: 24. 3. Lurie DM, Gordon IK, Théon AP, et al. Sequential low-dose rate half-body irradiation and chemotherapy for the treatment of canine multicentric lymphoma. J Vet Intern Med 2009;23(5):1064-1070. 4. Plumb D. Veterinary Drug Handbook. 8th ed. Ames, IA: WileyBlackwell; 2015: 81-82, 362, 1087. 5. Feldman B, Zinkl J, Jain N. Schalm’s Veterinary Hematology. 5th ed. Baltimore: Lippincott Williams & Wilkins; 2000. 6. Tannock I, Hill R. The Basic Science of Oncology. 4th ed. New York: McGraw-Hill; 2005. 7. Complementary and alternative medical therapies. In: Moore AS, Frimberger AE. Oncology for Veterinary Technicians and Nurses. Ames, IA: Wiley-Blackwell; 2010: 90-93.

LOOKING AHEAD There are many more approaches to managing canine lymphoma patients—the L-CHOP chemotherapy protocol is only the most commonly used. These drugs were adapted for use from human oncology. Research is being done to implement new therapies that are tailored to canine patients. Monoclonal antibody therapy and rabacfosadine (Tanovea CA-1;

Christi Semmler, BS, CVT, RALAT Faculty Instructor of Veterinary Technology Eastern Wyoming College • VetFolio User Since 2015 See how Cristi puts VetFolio to work:

Teaches 65-70 students each semester

Signing Up “At the NAVC Conference in 2015, I chatted with one of the reps at the booth. I found out that there was no subscription fee for educators, so I looked into signing up. I liked the different types of courses available. As an educator, I like to be on the cutting edge of veterinary education so I can give students a heads-up on what’s new in the industry.”

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“If I’m working on my CE, I’m usually at home. I use VetFolio to look for specific examples for my students. I’ll watch a course at home and assign it as a module in class, and ask them to bring their certificate in to show they completed it. If I tell students “This is how it is” about a certain topic, they may not take it as well from me, but coming from experts in the field, it really has weight. We frequently use VetFolio courses to enhance the information in class.”

Becoming a Pro Pro tip: “Go into specific continuing education and search for something you’re interested in. You may need to generalize your search term a little to find what you’re looking for. I probably spent 30 hours over the Christmas 2015 break doing continuing education just because I felt like it.”

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Institutional Animal Care and Use Committee Chair

“I think the Certificate Course series are great for students to take and put on their resumes. I think it makes them look more knowledgeable in the eyes of potential employers.”

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MDR1 Genetic Testing: What You Need to Know The American Kennel Club currently recognizes 30 breeds of dogs in its herding-breed group. Within that group are some of the most recognizable and beloved dog breeds in the world, including the collie and Australian shepherd. These dogs are common patients in most veterinary practices. The study of genetics is revealing more about canine history and health than ever before. For example, hidden in the genetic code of many herding-breed dogs is a mutation that increases their susceptibility to drug toxicosis. Public awareness about this defect is increasing, but many websites dispense confusing information to breeders and owners. As an important component of client communication in the veterinary hospital, veterinary technicians can help sort out misinformation and assist clients in making decisions about the health of their dog. In addition, technicians must recognize which dogs are at risk and which drugs to avoid or administer with a reduced dose.

Rebecca Connors, LVT Washington State University

Rebecca has been employed at the Veterinary Clinical Pharmacology Laboratory at Washington State University since 2011. After graduation from the Michigan State University Veterinary Technology Program, she worked in several small- and mixed-animal veterinary practices in Michigan and Arizona. In 1996 she became the neurology technician at Washington State University’s Veterinary Teaching Hospital, followed by a 6-year stretch as a cardiology technician for Ohio State University’s Veterinary Medical Center. In 2008 she returned to Washington State University to work in veterinary genetics and Holter interpretation. She lives in Idaho with her husband, 2 sons, and a variety of dogs and cats.

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MDR1 MUTATION In 2001, Katrina Mealey, DVM, PhD, discovered that collies and other dogs with herding-breed heritage have a defect in the MDR1 (multidrug resistance 1) gene.1 The nomenclature for the MDR1 gene also includes the designation ABCB1 gene (adenosine triphosphate–binding cassette transporter). The MDR1 mutation causes a change in the code for an important component of the blood–brain barrier, P-glycoprotein.

FAMILY TIES Just like people, dogs inherit 1 copy of a gene from the father and 1 from the mother. A complete genome therefore contains 2 copies of each gene (1 from each parent).

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P-glycoprotein In normal dogs, P-glycoprotein functions as a pump, moving potentially toxic compounds out of the central nervous system (CNS). It also transports substrate drugs across cell membranes and out of the body. This occurs at the level of biliary canaliculi, intestinal epithelial cells, and renal proximal tubular epithelial cells. Prescribed medications can therefore behave in a predictable manner when proper dosing instructions are followed. However, when the MDR1 mutation is present, P-glycoprotein is severely truncated, rendering it ineffective. Substrates for P-glycoprotein, including many common medications, remain in the CNS at toxic levels or are otherwise incorrectly metabolized or excreted. This can lead to severe and potentially fatal adverse drug reactions. Additionally, further research has revealed that P-glycoprotein plays a role in the regulation of the hypothalamic-pituitary-adrenal axis.2 In dogs that are homozygous for the MDR1 mutation (BOX 1), this important hormonal feedback system does not function normally, causing lower cortisol levels. The effects become apparent under periods of high stress, such as illness or extreme physical activity. These dogs may respond poorly to such increased energy demands and exhibit evidence of relative adrenal insufficiency. In some cases, physiologic doses of corticosteroids are indicated. AFFECTED BREEDS In the 1980s, when new parasiticides, such as ivermectin, were introduced, collie owners and veterinarians began reporting adverse drug reactions. Dog owners attempted to identify which dogs were most likely to have a reaction by using phenotypic qualities, such as coat color or

BOX 1 Inheritance of MDR1 Mutation Just like people, dogs inherit 1 copy of a gene from the father and 1 from the mother. A complete genome therefore contains 2 copies of each gene (1 from each parent). If a dog inherits 1 normal copy of the gene and 1 mutant copy, the dog is considered heterozygous for the mutation and is reported as mutant/normal. A dog with 2 abnormal copies is called homozygous, or mutant/ mutant. A dog that does not carry any copies of the mutation is referred to as normal/normal. It is confusing to refer to genetic results as “positive” or “negative” because the meaning in some contexts can be ambiguous. Similarly, the MDR1 mutation is a dominant genetic trait, so the use of the word “carrier” for heterozygous dogs is incorrect. Both heterozygous and homozygous dogs can show drug toxicosis when given P-glycoprotein substrates.

markings. A common adage at the time was “white feet, don’t treat,” meaning that dogs with white feet were thought to be more susceptible to ivermectin toxicity. Because of early reports of ivermectin toxicity in collies, that breed became the early model for researchers to discover more about this genetic mutation. It became clear that not only collies, but also other herding-breed dogs, possessed this abnormal genetic code. A Herding Dog Gene By using advanced evolutionary genetic techniques, scientists traced the history of this mutation over time.3 It first appeared in a herding dog in Great Britain in the late 19th century, before the collie breed even originated. This anonymous dog may have possessed some desirable feature or skill, which meant that it passed its genes on to numerous descendants. Unknown to generations of breeders, the MDR1 mutation was passed on as well. Eventually, dog breeds became more clearly defined. As new breeds developed from older ones, the genetic heritage followed. By analyzing how far back in the canine family tree a breed broke off from the foundation stock, geneticists can predict which descendant breeds potentially carry the mutation (BOX 2). The MDR1 mutation has been identified in 10 herding breeds, 2 sighthound breeds, and herdingbreed mixed dogs (TABLE 1).4 Collies have one of the highest frequencies—approximately 70% are homozygous or heterozygous for the mutation. Australian shepherds and Shetland sheepdogs are also

TABLE 1 Breeds Affected by the MDR1 Mutation4 BREED Collie

Long-haired whippet

Australian shepherd

Australian shepherd, mini

McNab collie

Silken windhound

English shepherd

Shetland sheepdog

German shepherd

Herding-breed cross

Mixed breed

Old English sheepdog Border collie

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affected. The high incidence of the MDR1 mutation in long-haired whippets and silken windhounds is believed to be due to use of an affected herding dog to introduce a desirable trait at some point in the breed’s history.

DRUGS AFFECTED Ivermectin Ivermectin is the drug most commonly associated with toxicosis, although many other drugs may

BOX 2 Collie Family Tree The historic relationships between contemporary collie breeds are shown in the University of California, Davis breed descendant tree in FIGURE A. This is a simplified form; there have been other, lesser influences. Many breeds in addition to collie breeds are descended from the Roman cattle dogs, herding spitzes, and Celtic dogs. However, this tree shows only the collie and collie-related breeds that descended from the working shepherd dogs/collies of Great Britain. This tree is not meant to imply that there was only one type of each ancestral shepherd dog. Throughout Britain there were many local variations/subtypes between and within regions, as well as common types across and within regions, a situation that is too complicated to be shown on this simple relationship chart.

Breed Descendant Tree pre-Celtic and Celtic dogs

before 410 A.D.

Roman cattle dog dogs of the Angles/Saxons

early Middle Ages to 1860s

dogs of the Vikings/herding spitz old working collie of Great Britain and Ireland 1860s to early 1900s

selection for sheepdog trials in addition to farm work

continued selection for farm/ranch work

Rough & Smooth Collie, Victorian type

Border Collie

Australia

Great Britain and Ireland

Kelpie Australian Cattle Dog by 1940s

unrecognized strains such as German Koolie

selection for bench show

North America

Bearded Collie of Scotland Welsh Sheepdog

various local strains of sheepdog/ cattle dog

Shetland Sheepdog

English Shepherd Australian Shepherd

McNab

Rough & Smooth show type continues to change

The show Collie breed includes a diverging range of types around the world, varying between

by 1900s

British show type, Rough & Smooth Collie

FIGURE A. University of California, Davis breed descendant tree. This chart shows historic relationships between contemporary collie breeds. Selection for show by 1990, in some cases well before. Reprinted with permission of the creator, Linda Rorem.

U.S. show type, Rough & Smooth Collie

Victorian type still exists but is no longer accepted show type in most countries

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MDR1 Genetic Testing: What You Need to Know PEER REVIEWED

also cause adverse reactions (BOX 3).5 Because of the public’s awareness of ivermectin-associated problems, many breeders and websites recommend avoiding all products containing this drug, including heartworm preventive agents. It is true that higher concentrations of ivermectin, such as those used for treating mange and other parasites, should not be administered to MDR1-affected dogs. However, dog owners should know that the doses of US-produced heartworm preventive agents recommended by manufacturers and approved by the Food and Drug Administration are safe for dogs with the mutation. Conversely, off-label use of higher concentrations of large-animal ivermectin formulations for heartworm prevention has led to fatal consequences and should be avoided. In addition, care should be taken to keep dogs away from large animals that have been wormed with ivermectin. Even dogs that are unaffected by the MDR1 mutation may be exposed to toxic doses of this medication if they consume the feces of recently wormed cattle, horses, and sheep. Other Affected Drugs Veterinary staff may not be able to avoid using other medications on the known substrate list, especially when anesthesia or cancer treatments are necessary. With some analgesics and chemotherapeutic agents, a reduced dose is recommended. A common over-the-counter antidiarrheal (loperamide) is also a known substrate. Veterinary technicians should be aware of the patient’s MDR1 status when an owner is giving this medication to treat diarrhea. The veterinary team may need to suggest alternatives until MDR1 testing is complete. Drug Misconceptions A common misconception found on many breed websites is that metronidazole is a problem drug for

BOX 3 Drugs Affected by the MDR1 Gene Mutation 5  Acepromazine

 Milbemycin

 Apomorphine

 Moxidectin

 Butorphanol

 Paclitaxel

 Doramectin

 Selamectin

 Doxorubicin

 Vinblastine

 Erythromycin

 Vincristine

 Ivermectin

 Vinorelbine

 Loperamide

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

TECHPOINT 

Coat color, markings, and sex are not predictors of dogs affected by MDR1, despite the handy “white feet” rule. MDR1-affected dogs. Metronidazole is prescribed for protozoal and anaerobic bacterial infections. This drug is known to cause dose-related neurologic side effects, but this is not related to P-glycoprotein function. Additionally, vaccination reactions are caused by immune-mediated issues, which are unrelated to the MDR1 mutation. However, clients with affected dogs may be apprehensive about giving any medications or vaccinations because of misleading information on public websites. This is a case where the veterinary technician can play an important role in preventing false information from keeping pet owners from making good treatment decisions. CLINICAL SIGNS Dogs exhibiting clinical signs of drug toxicosis should be evaluated quickly. MDR1-related drug toxicosis of the CNS often presents as vague neurologic signs, such as weakness, lethargy, ataxia, and disorientation. The owner may report that the pet has been stumbling and bumping into things. In severe cases, the patient will become nonambulatory and even comatose, and ventilator-assisted respiration may be necessary. If the inducing medication has a reversal agent, such as naloxone for loperamide, it should be administered per the manufacturer’s recommendations. However, for affected dogs, the most important treatment is intensive supportive care, including IV fluids, nutritional support, and diligent patient monitoring. Recovery may be a lengthy process requiring the owner to be aware of the extent of the nursing care and expenses involved. MDR1-affected dogs receiving chemotherapeutic agents that are P-glycoprotein substrates are at increased risk for neutropenia, thrombocytopenia, and adverse gastrointestinal effects. Therefore, other options, such as alternative medications or dose reductions, should be investigated. PREVENTION Unless a patient has a clear pedigree from a non–herding breed line, caution is advised before administering a known MDR1 toxic drug to any dog, especially mixed breeds. As mentioned,

The power’s in the process ANTINOL’s patented process ensures each dose delivers a concentrated blend of EPA, DHA, ETA, and other beneficial fatty acids with their active properties intact1 Enhances comfort and mobility in dogs: • In a veterinary assessment, up to 90% of dogs showed enhanced mobility2* • In a separate study, dogs showed enhanced mobility within just 2 weeks3 • Safe for long-term daily use Visit www.antinolforpets.com for more information. *90% of dogs in one group showed enhanced mobility; 88% of dogs in a second group showed enhanced mobility References 1. Wolyniak CJ, Brenna JT, Murphy KJ, Sinclair AJ. Gas chromatography-chemical ionization-mass spectrometric fatty acid analysis of a commercial supercritical carbon dioxide lipid extract from New Zealand green-lipped mussel (Perna canaliculus). Lipids. 2005;40(4):355-360. 2. Data on file. 3. Data on file.

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appearance alone is not a good indicator of the presence of herding-breed heritage. Before the advent of genetic testing, it was necessary to guess which dogs would develop adverse drug reactions. Today, as part of a routine annual physical examination or initial new patient visit, the technician can discuss MDR1 testing with owners of herding-breed dogs or dogs that are potential herding-breed mixes. A test for the MDR1 mutation is available through the laboratory that first discovered the mutation, the Veterinary Clinical Pharmacology Laboratory at Washington State University (vcpl.vetmed.wsu.edu). The test can be performed with a cheek swab test kit or EDTA whole blood. The owner can directly order the test kit from the laboratory, or the veterinary staff can collect and submit the sample. In addition, the veterinary technician can play a role in advising a dog owner of responsible breeding practices. In breeds with an MDR1 mutation frequency of >30%, eliminating all affected dogs from the gene pool is not recommended because of the risk for increasing the incidence of other undesirable genetic traits or health problems. It is possible, with knowledge of the MDR1 status of both the sire and the dam, to thin out affected dogs from the population over time (TABLE 2). Recently, the MDR1 genetic defect has also been identified in cats,6 and ongoing research is looking at potential new drugs that are P-glycoprotein substrates.

CONCLUSION The veterinary technician’s role places us squarely at the heart of recognizing risks, clinical signs, and preventive measures to keep our patients safe. One area where this comes into play is pharmacogenetics, the study of drug response or drug behavior based on an individual’s genetic makeup. It is a growing field in human and veterinary medicine, and the hope of veterinary pharmacogeneticists is to discover more about species, breed, and individual variations that put animals at risk for adverse drug reactions. Learning about pharmacogenetics and risk factors such as the MDR1 genetic defect can give technicians the knowledge they need to further protect patients against adverse drug reactions.  References 1. Mealey KL, Bentjen SA, Gay JM, Cantor GH. Ivermectin sensitivity in collies is associated with a deletion mutation of the mdr1 gene. Pharmacogenetics 2001;11(8):727-733. 2. Mealey KL, Gay JM, Martin LG, Waiting DK. Comparison of the hypothalamic-pituitary-adrenal axis in MDR1-1Δ and MDR1 wildtype dogs. J Vet Emerg Crit Care 2007;17(1):61-66 3. Neff MW, Robertson KR, Wong AK, et al. Breed distribution and history of canine MDR1-1Δ, a pharmacogenetics mutation that marks the emergence of breeds from the collie lineage. Proc Natl Acad Sci U S A 2004;101(32):11725-11730. 4. Affected breeds. Washington State University Veterinary Clinical Pharmacology Laboratory website. vcpl.vetmed.wsu.edu/ affected-breeds. Accessed July 2017. 5. Problem drugs. Washington State University Veterinary Clinical Pharmacology Laboratory website. vcpl.vetmed.wsu.edu/ problem-drugs. Accessed July 2017. 6. Mealey KL, Burke NS. Identification of a nonsense mutation in feline ABCB1. J Vet Pharmacol Ther 2015;38(5):429-433.

NORMAL/NORMAL MALE

NORMAL/MUTANT MALE

MUTANT/MUTANT MALE

NORMAL/NORMAL FEMALE

100% Normal/normal puppies

Normal/normal and/or normal/ mutant puppies

100% Normal/mutant puppies

NORMAL/MUTANT FEMALE

Normal/normal and/or normal/ mutant puppies

Any combination of puppies

Normal/mutant and/or mutant/ mutant puppies

MUTANT/MUTANT FEMALE

100% Normal/mutant puppies

Normal/mutant and/or mutant/ mutant puppies

100% Mutant/mutant puppies

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TABLE 2 MDR1 Breeding Pair Combinations and Outcomes

todaysveterinarytechnician.com FINAL THOUGHTS

FINAL THOUGHTS

A Personal Journey to Mindfulness What is mindfulness? It’s a common buzzword today, but do we really understand what it is? Wikipedia provides the following definition: “Mindfulness is the psychological process of bringing one’s attention to the internal experiences occurring in the present moment.” Yet this definition leaves room for interpretation. What I have learned is that everyone’s understanding of it is as unique as their individual mind, body, and soul. I have elected to dedicate my lifework to the concept of mindfulness: to provide a framework to help others find their unique, authentic path to sustainability within veterinary medicine. I call this framework living the path toward Recognize, Embrace, Connect. RECOGNIZE When I first thought of living in a mindful state, I pictured a Buddhist monk up on a distant mountaintop, sitting cross-legged with his eyes closed, where birds flew around him while he was in a blissful trance— a “Zen state of being.” As I pictured this—being the high-achieving, anxious individual that I am with a drive for organization, routine, and super-perfectionism—I saw it as a state completely beyond my reach. The first step I found toward everyday mindfulness is that recognizing where we are and the emotions we have does not mean living in a calm Zen state all the time. It doesn’t mean that we will never have “negative” emotions. I realized that not only is it okay to feel anger, sadness, resentment, frustration, and even despair at times, it is normal. I am normal. In the past, when these emotions presented themselves, I found myself in a space of what I call Name, Blame, Judge. When I felt fear or sadness, I wanted to blame or judge someone for how I felt. Often, I blamed people around me, but more commonly, I blamed myself. I was a bad human being for not being that monk on the mountaintop, living in that Zen state no matter what came my way. Before I could even come close to the next stage of embracing any situation, I found I had to recognize how I felt and then give myself permission for the space I was in. I had to be mindful of my body’s reaction to the stress, whatever situation was upon me, and then recognize that it was a situation that would pass. I had to allow myself to find the space to not judge myself for my reaction; rather, to let my reaction be present and acknowledge it. This allowed me to fall into the next stage, Embrace.

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

Kim Pope-Robinson, DVM, CCFP 1 Life Connected Consulting

Dr. Pope has been in veterinary medicine for more than 20 years, practicing in both the large and small animal sectors. In addition, she supported the position of a multi-unit manager for a large corporate practice and spent time in the pharmaceutical sector working with specialists and universities. Her career has provided her a unique understanding of the stresses involved with maintaining a career in this industry, and she now dedicates her time to providing wellbeing support for the profession. She provides this support through 1-on-1 coaching, through customized team events, and as a dynamic speaker. She is also the author of The Unspoken Life, which explores the concepts of Recognize, Embrace, Connect in more detail. In the end, Dr. Pope truly believes that we are all 1 Life Connected.

TODAY’SVETERINARYTECHNICIAN

September/October 2017

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

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

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

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

N1 17 13 13 7 5

% (n=415) 4.1 3.1 3.1 1.7 1.2

Oral active control

N2 25 2 7 4 9

% (n=200) 12.5 1.0 3.5 2.0 4.5

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

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

EMBRACE As I work to embrace a situation, there is one tool I use to help me be more resilient: meditation. I’ll be honest, I don’t meditate the way some people might picture it, like someone sitting on a pillow in a corner in front of some candles and a Buddhist statue with their eyes closed, looking similar to that monk on the mountaintop. I’m not against that method, nor do I deny the benefits it can provide. It’s just that my preference for meditation involves a pair of running shoes and an extra large dose of nature. “Meditation is a practice where an individual operates to train the mind or induces a mode of consciousness, either to realize some benefit or for the mind to simply acknowledge its content without becoming identified with that content or as an end in itself.” This definition, also from Wikipedia, says nothing about pillows or candles. Again, it’s open to interpretation. Running in nature brings a certain peace and quiet to my mind that I don’t achieve with anything else I do. I am not pushing my athletic ability, I am just one with my surroundings, taking in smells, sights, and sounds as I work through some unknown distance and often some unknown emotion that comes up during the run. CONNECT As we recognize our state and embrace our situation, the final stage in the framework is to Connect to the space around us. What does this mean? Say a client has limited resources (money). We may immediately judge them: they don’t love their pet, they waited too long, clients are stupid and you can’t fix stupid, etc. This reaction stems from feeling inadequate in not being able to help the pet. We feel shame and unworthiness, and we turn it into anger with the client. How can we connect to the situation instead of allowing it to represent us? One path might be to find a reason to justify the client’s position and to relate to the human in the equation. Another might be to acknowledge our frustration and anger in a way that restores us at the end of the day— instead of attacking the client, attack the pavement with a run. Personally, I fight to stay on “a” path every single day. It is an active process. When I feel “negative” emotions begin to present themselves, I ask myself: Am I running toward name, blame, judge and spiraling down to a place of disconnection with the world and an overall desire to not continue on? Or do I choose to move toward Recognize, Embrace, Connect and find a place of mindfulness? Our solutions to internal happiness and wellbeing are unique to each of us, and I do not have the answer for your personal mindfulness. But the framework I’ve outlined can allow you to find the unique path you deserve. So I ask you, in your journey to mindfulness and in finding that authentic career in veterinary medicine, what does Recognize, Embrace, Connect mean to you and how does it show up in your career within the veterinary industry? And more importantly, how will it show up in your life in general? 

TODAY’SVETERINARYTECHNICIAN

September/October 2017

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

Data on file at Merial.

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.