Today's Veterinary Technician, January 2016

ENDOCRINOLOGY CANINE DIABETES MELLITUS

DENTISTRY FROM THE EXAM ROOM TO THE DENTAL SUITE

NEUROLOGIC REHABILITATION THE TECHNICIAN’S ROLE

NUTRITION FELINE CHRONIC KIDNEY DISEASE

DERMATOLOGY SCRATCHING THE SURFACE OF CANINE ALLERGIES

TODAY’SVETERINARYTECHNICIAN |

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EMERGENCY/ CRITICAL CARE

SHOCK

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Smart is…

6-in-1 protection.

Take parasite protection further with a broad coverage chewable dogs will love.

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Offer chewy, tasty, and easy coverage against both internal and external parasites. To order, contact your distributor or call your Virbac representative at 1-844-4-VIRBAC (1-844-484-7222).

Dogs should be tested for heartworm prior to use. Mild hypersensitivity reactions have been noted in some dogs carrying a high number of circulating microfilariae.

Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention. Please see full product label for more information, or visit www.virbacvet.com.

References: 1. Trifexis® [product label]. Indianapolis, IN: Elanco; 2014.

2. Heartgard® Plus [product label]. Duluth, GA: Merial Inc; 2011. * A. caninum. † Prevents flea eggs from hatching; is not an adulticide. © 2015 Virbac Corporation. All Rights Reserved. SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation.

TRIFEXIS is a registered trademark of Elanco. HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. 8/15 15724

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TODAY’SVETERINARYTECHNICIAN An Official Journal of the N VC

JANUARY/FEBRUARY 2016

VOLUME 1, NUMBER 1 Vice President of Content and NAVC Medical Director Beth Thompson, VMD BThompson@NAVC.com

Editor in Chief

Today’s Veterinary Technician is proudly published by the NAVC

Publisher Nick Paolo, MS, MBA NPaolo@NAVC.com Executive Editor Robin Henry RHenry@NAVC.com

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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 & Analgesia, Surgery) Oakland Veterinary Referral Services, Bloomfield Hills, Michigan Kathi L. Smith, RVT, VTS (Oncology) Portland Veterinary Specialists Portland, Maine

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

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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 me chantability or fitness for a particular purpose. In no event will N VC 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 ©2016 Eastern States Veterinary Association, Inc (NAVC).

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Contents

TODAY’SVETERINARYTECHNICIAN An Official Journal of the N VC

JANUARYFEBRUARY2016

Volume 1, Number 1

PEER-REVIEWED CE Scratching the Surface of Allergies in Dogs KIM HORNE, AAS, CVT, VTS (DERMATOLOGY)

Pruritus caused by allergies is a common presenting complaint in canine patients. Making sure clients understand the complexity of diagnosis and treatment is essential to successfully determining the responsible allergy and establishing lifelong treatment plans for these dogs.

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Shock: An Overview BRANDY TABOR, CVT, VTS (EMERGENCY AND CRITICAL CARE)

Shock is a life-threatening condition that can lead to cell death and organ failure. This article provides a brief review of the pathophysiology, types, stages, and treatment of shock.

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The Ins and Outs of Managing Feline Chronic Kidney Disease MELANIE CODI, LVT, CVT, VTS (NUTRITION)

Nutrition is a key component in managing cats with chronic kidney disease. Read this article for an overview of the goals of nutritional management in these patients, as well as considerations when helping clients choose an appropriate diet for affected cats.

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Canine Diabetes Mellitus: It’s About the Sugar MANDY FULTS, BS, LVT, CVPP, VTS (CLINICAL PRACTICE—CANINE/FELINE)

Successful management of diabetes mellitus encompasses accurate monitoring, appropriate nutrition, and proper insulin administration.

Veterinary technicians play critical roles in educating clients about all these aspects of their pet’s care.

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FEATURES Veterinary Technicians and Neurologic Rehabilitation

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MARY ELLEN GOLDBERG, BS, LVT, CVT, SRA, CCRA

Increasing Clients’—and Your Own—Dental Awareness from the Exam Room to the Dental Suite PATRICIA M. DOMINGUEZ, BS, LVT, VTS (DENTISTRY)

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TODAY’SVETERINARYTECHNICIAN VETERINARY VETERINARYTECHNICIAN

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An Official Journal of the N VC

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!

A H w

. d e s s e r p m i Dogs are Bronchi-Shield® ORAL is making a happy vaccine experience the new normal.

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— Rebecca Ruch-Gallie, DVM, MS

Give dogs and their owners an enjoyable vaccine experience — only with BRONCHI-SHIELD ORAL. Bronchi-ShieldORAL.com Reference: 1. Data on file, BRONCHI-SHIELD ORAL package insert, Boehringer Ingelheim Vetmedica, Inc.

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BRONCHI-SHIELD is a registered trademark of Boehringer Ingelheim Vetmedica, Inc. © 2015 Boehringer Ingelheim Vetmedica, Inc. CAN0415002 15667

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TODAY’S VETERINARY TECHNICIAN

Contents

An Official Publication of the N VC

JANUARYFEBRUARY2016

Volume 1, Number 1

COLUMNS Editor’s Letter | What Moves Me?

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

Career Challenges | Keeping It Fresh: How to Rejuvenate Your Career

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

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

Dosage Schedule

What Moves You? | Normal? No Way! Dream to RVT+ KARINA BENISH, MSED, RVT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

Final Thoughts | Be With What Is JULIE SQUIRES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42 60 80

CLIENT HANDOUTS Canine Urine Marking ................................ . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55 Feline Urine Marking................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57

Advertiser Index ...... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 ON THE COVER

Alex Botkin, a veterinary technician in training, monitors Angel, a patient at Animal Emergency & Specialty Center, Parker, CO. Cover image by Brian Walski/Colorado Visions.

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Praziquantel per Number of chewable chewables

Milbemycin Oxime per chewable

Lufenuron per chewable

2 to 8 lbs.

2.3 mg

46 mg

22.8 mg

One

8.1 to 25 lbs.

5.75 mg

115 mg

57 mg

One

25.1 to 50 lbs.

11.5 mg

230 mg

114 mg

One

50.1 to 100 lbs.

23.0 mg

460 mg

228 mg

One

Body Weight

JENNIFER YURKON, CVT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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

Over 100 lbs.

Administer the appropriate combination of chewables

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

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

Contraindications There are no known contraindications to the use of SENTINEL SPECTRUM. Warnings Not for use in humans. Keep this and all drugs out of the reach of children.

Precautions Treatment with fewer than 6 monthly doses after the last exposure to mosquitoes may not provide complete heartworm prevention.

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

Mild, transient hypersensitivity reactions, such as labored breathing, vomiting, hypersalivation, and lethargy, have been noted in some dogs treated with milbemycin oxime carrying a high number of circulating microfilariae. These reactions are presumably caused by release of protein from dead or dying microfilariae.

Do not use in puppies less than six weeks of age.

Do not use in dogs or puppies less than two pounds of body weight.

The safety of SENTINEL SPECTRUM has not been evaluated in dogs used for breeding or in lactating females. Studies have been performed with milbemycin oxime and lufenuron alone.

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

To report suspected adverse drug events, contact Virbac at 1-800-338-3659 or the FDA at 1-888-FDA-VETS.

Today’s Veterinary Technician (ISSN 2162-3872 print and ISSN 2162-3929 online) does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products and claims contained therein. The publisher, Eastern States Veterinary Association, Inc (NAVC), disclaims any liability for any damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective authors and do not necessarily represent the opinions of the NAVC nor its Editorial Advisory Board. NAVC does not guarantee nor make any other representation that the material contained in articles herein is valid, reliable, or accurate; nor does the NAVC assume any responsibility for injury or death arising from any use, or misuse, of same. There is no implication that the material published herein represents the best or only procedure for a particular condition. It is the responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly available. Today’s Veterinary Technician is published Jan/Feb, Mar/Apr, July/August, Jul/Aug, Sept/Oct, Nov/Dec (6x per year) by NAVC, PO Box 390, Glen Mills, PA. 19342.

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Information for Owner or Person Treating Animal Echinococcus multilocularis and Echinococcus granulosus are tapeworms found in wild canids and domestic dogs. E. multilocularis and E. granulosus can infect humans and cause serious disease (alveolar hydatid disease and hydatid disease, respectively).

Owners of dogs living in areas where E. multilocularis or E. granulosus are endemic should be instructed on how to minimize their risk of exposure to these parasites, as well as their dog’s risk of exposure. Although SENTINEL SPECTRUM was 100% effective in laboratory studies in dogs against E. multilocularis and E. granulosus, no studies have been conducted to show that the use of this product will decrease the incidence of alveolar hydatid disease or hydatid disease in humans. Because the prepatent period for E. multilocularis may be as short as 26 days, dogs treated at the labeled monthly intervals may become reinfected and shed eggs between treatments.

Manufactured for: Virbac AH, Inc. P.O. Box 162059, Ft. Worth, TX 76161 NADA #141-333, Approved by FDA © 2015 Virbac Corporation. All Rights Reserved.

SENTINEL and SPECTRUM are registered trademarks of Virbac Corporation.

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Editor’s Letter What Moves Me?

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

T

show you it’s possible to follow the feelings in your heart he 2016 NAVC Conference and make them reality. The first person to move me in th theme is “What Moves You?” direction of my dreams was my uncle, a veterinarian. As a On the surface, this may seem like child, I was afraid of my uncle because we always seemed a simple question. Take a moment to visit him when he had a white coat on and a syringe and to think about it, though. Is it what needle in hand. As a young adult, I spent summers working inspires you? Or who? Or where in his veterinary hospital. An MSU graduate, he had learned you’re going? Or all of the above? of a new MSU program for veterinary technology. For Of course, like so many various reasons, I didn’t really want to be a veterinarian; veterinary technicians, animals however, I did want to work with animals. So off I went to “move me.” As far back as I can remember, I have always MSU and never looked back! loved and wanted to work with animals. One of the first Both what is in my heart and the people who help make experiences that convinced me I had made the right my dreams bigger than I ever imagined loom large in my career choice in becoming a veterinary technician was the life. So do the opportunities that have appeared, sometimes “adoption” of my cat Rhubarb. I was on my way home seemingly randomly, through my relationships. After I from a double shift in the ICU at the veterinary hospital at proudly received my LVT degree, I worked in a small animal Michigan State University (MSU). I was exhausted and practice. An opportunity arose to questioning my new career. It was train others when the veterinary pouring rain, the roads were teaching hospital at MSU created quiet…and in front of me, I saw veterinary technician teaching someone throw what looked like positions. I taught veterinary a stuffed animal out of a car technician and veterinary students window. As it turned out, the in the medicine and ICU wards. “stuffed animal” was a wee calico Later, I took a research position kitten. I scooped her up and took with a cardiologist, moving to her back to the hospital, where we University of California-Davis. worked with her all night, all the Then I went into industry, first wit while thinking how cruel people IDEXX and then with Pfizer can be to animals. Rhubarb was Equine, where I learned the covered with fleas, cold, and meaning of networking with malnourished. But she rallied and mentors and colleagues. I moved survived and became the funniest, with the chances presented to me, most loving cat, warming my life which allowed me to change and for 18 years. Helping her, I knew I grow. Ultimately, that resulted in had found the right profession. me working with the NAVC, (I also became a crazy cat lady, starting in 1990, and becoming adopting multiple cats abandoned not only the first veterinary by others.) technician to sit on the Board of But there’s another aspect to Directors, but also, eventually, “what moves you” that’s equally Emme, my 12-year-old golden retriever, is a President in 2013. What moved important. It’s the part where retired show dog who now enjoys a leisurely someone takes the time to life playing with squeaky toys, romping in the me then was working behind the scenes of an amazing conference encourage you, teach you, and snow, and swimming in the lake.

TODAY’SVETERINARYTECHNICIAN VETERINARY VETERINARYTECHNICIAN

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January/February 2016

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Editor’s Letter

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What Moves Me?

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Lynne Johnson-Harris, LVT, RVT

and continuously striving to make the attendees’ experience better every year.

At the NAVC, I am constantly amazed by the ongoing growth and expansion of the learning opportunities we provide to all members of the veterinary healthcare team.

That’s what moves us. The NAVC listened to veterinary technicians’ special needs for education, recognition, and career growth. The cornerstone of our response is this journal. When I was presented with the offer of leading it, I jumped at the chance. With this first issue of Today’s Veterinary Technician, we are adding a voice for an important community of veterinary healthcare providers who are arguably the backbone of the profession. You! I am a veterinary technician, just like you, and I remain amazed at how veterinary technicians and assistants make great practices possible by doing the endless job of nursing, adapting to changes in technology and medicine, and constantly improving ourselves and our profession. There is no great care for animals without us.

We should be proud and loud.

As with mine, your passions might change over time, so what passion moves you? Tell us your story. Raise your voice, share, and be heard. I want this journal to be our collective voice with all the good, the bad, and the messy (literally!) parts we live through every day. Contact me at ljohnson@navc.com and tell me what you think, whether about your educational and professional needs or about your feelings regarding the issues we face today. Give the NAVC the chance to raise awareness of the work we do supporting veterinarians and caring for and about animals. This journal is our gift to you, but it can’t grow without you. Sign up at todaysveterinarytechnician.com to get your own copy. Tell your colleagues. Let us hear you!

What moves me today? It is much more than just my lifelong love of animals; it is being part of a profession that continues to grow and thrive in the service of animals everywhere. What moves me today is all of you.

What moves you? 

Pudercat, my 12-year-old, very dilute tortie, purrs as she thinks about sleeping on the warm printer or lying on my keyboard, ultimately deleting e-mail messages.

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

Description: NexGard® (afoxolaner) is available in four sizes of beef-flavored, soft chewables for oral administration to dogs and puppies according to their weight. Each chewable is formulated to provide a minimum afoxolaner dosage of 1.14 mg/lb (2.5 mg/ kg). Afoxolaner has the chemical composition 1-Naphthalenecarboxamide, 4-[5- [3-chloro-5-(trifluoromethyl)-phenyl]-4, 5-dihydro-5-(trifluoromethyl)-3-isoxazolyl]-N-[2-oxo-2-[(2,2,2-trifluoroethyl)amino]ethyl.

Indications: NexGard kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of Black-legged tick (Ixodes scapularis), American Dog tick (Dermacentor variabilis), Lone Star tick (Amblyomma americanum), and Brown dog tick (Rhipicephalus sanguineus) infestations in dogs and puppies 8 weeks of age and older, weighing 4 pounds of body weight or greater, for one month.

Dosage and Administration: NexGard is given orally once a month, at the minimum dosage of 1.14 mg/lb (2.5 mg/kg).

Dosing Schedule: Body Weight 4.0 to 10.0 lbs.

10.1 to 24.0 lbs.

24.1 to 60.0 lbs.

60.1 to 121.0 lbs.

Over 121.0 lbs.

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

NexGard can be administered with or without food. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes to ensure that part of the dose is not lost or refused. If it is suspected that any of the dose has been lost or if vomiting occurs within two hours of administration, redose with another full dose. If a dose is missed, administer NexGard and resume a monthly dosing schedule.

Flea Treatment and Prevention: Treatment with NexGard may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with NexGard should continue the entire year without interruption.

To minimize the likelihood of flea reinfestation, it is important to treat all animals within a household with an approved flea control product.

Tick Treatment and Control: Treatment with NexGard may begin at any time of the year (see Effectiveness).

Contraindications: There are no known contraindications for the use of NexGard.

Warnings: Not for use in humans. Keep this and all drugs out of the reach of children. In case of accidental ingestion, contact a physician immediately.

Precautions: The safe use of NexGard in breeding, pregnant or lactating dogs has not been evaluated. Use with caution in dogs with a history of seizures (see Adverse Reactions).

Adverse Reactions: In a well-controlled US field study, which included a total of 333 households and 615 treated dogs (415 administered afoxolaner; 200 administered active control), no serious adverse reactions were observed with NexGard.

Over the 90-day study period, all observations of potential adverse reactions were recorded. The most frequent reactions reported at an incidence of > 1% within any of the three months of observations are presented in the following table. The most frequently reported adverse reaction was vomiting. The occurrence of vomiting was generally self-limiting and of short duration and tended to decrease with subsequent doses in both groups. Five treated dogs experienced anorexia during the study, and two of those dogs experienced anorexia with the first dose but not subsequent doses.

Table 1: Dogs With Adverse Reactions.

Treatment Group Afoxolaner

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

N1 17 13 13 7 5

% (n=415) 4.1 3.1 3.1 1.7 1.2

Oral active control

N2 25 2 7 4 9

% (n=200) 12.5 1.0 3.5 2.0 4.5

1 Number of dogs in the afoxolaner treatment group with the identified abnormality.

2 Number of dogs in the control group with the identified abnormality.

In the US field study, one dog with a history of seizures experienced a seizure on the same day after receiving the first dose and on the same day after receiving the second dose of NexGard. This dog experienced a third seizure one week after receiving the third dose. The dog remained enrolled and completed the study. Another dog with a history of seizures had a seizure 19 days after the third dose of NexGard. The dog remained enrolled and completed the study. A third dog with a history of seizures received NexGard and experienced no seizures throughout the study.

To report suspected adverse events, for technical assistance or to obtain a copy of the MSDS, contact Merial at 1-888-6374251 or www.merial.com/NexGard. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth.

Mode of Action: Afoxolaner is a member of the isoxazoline family, shown to bind at a binding site to inhibit insect and acarine ligand-gated chloride channels, in particular those gated by the neurotransmitter gamma-aminobutyric acid (GABA), thereby blocking preand post-synaptic transfer of chloride ions across cell membranes. Prolonged afoxolaner-induced hyperexcitation results in uncontrolled activity of the central nervous system and death of insects and acarines. The selective toxicity of afoxolaner between insects and acarines and mammals may be inferred by the differential sensitivity of the insects and acarines’ GABA receptors versus mammalian GABA receptors.

Effectiveness: In a well-controlled laboratory study, NexGard began to kill fleas four hours after initial administration and demonstrated >99% effectiveness at eight hours. In a separate well-controlled laboratory study, NexGard demonstrated 100% effectiveness against adult fleas 24 hours post-infestation for 35 days, and was ≥ 93% effective at 12 hours post-infestation through Day 21, and on Day 35. On Day 28, NexGard was 81.1% effective 12 hours post-infestation. Dogs in both the treated and control groups that were infested with fleas on Day -1 generated flea eggs at 12- and 24-hours post-treatment (0-11 eggs and 1-17 eggs in the NexGard treated dogs, and 4-90 eggs and 0-118 eggs in the control dogs, at 12- and 24-hours, respectively). At subsequent evaluations post-infestation, fleas from dogs in the treated group were essentially unable to produce any eggs (0-1 eggs) while fleas from dogs in the control group continued to produce eggs (1-141 eggs).

In a 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of NexGard against fleas on the Day 30, 60 and 90 visits compared with baseline was 98.0%, 99.7%, and 99.9%, respectively.

Collectively, the data from the three studies (two laboratory and one field) demonstrate that NexGard kills fleas before they can lay eggs, thus preventing subsequent flea infestations after the start of treatment of existing flea infestations.

In well-controlled laboratory studies, NexGard demonstrated >97% effectiveness against Dermacentor variabilis, >94% effectiveness against Ixodes scapularis, and >93% effectiveness against Rhipicephalus sanguineus, 48 hours post-infestation for 30 days. At 72 hours post-infestation, NexGard demonstrated >97% effectiveness against Amblyomma americanum for 30 days.

Animal Safety: In a margin of safety study, NexGard was administered orally to 8 to 9-week-old Beagle puppies at 1, 3, and 5 times the maximum exposure dose (6.3 mg/kg) for three treatments every 28 days, followed by three treatments every 14 days, for a total of six treatments. Dogs in the control group were sham-dosed. There were no clinically-relevant effects related to treatment on physical examination, body weight, food consumption, clinical pathology (hematology, clinical chemistries, or coagulation tests), gross pathology, histopathology or organ weights. Vomiting occurred throughout the study, with a similar incidence in the treated and control groups, including one dog in the 5x group that vomited four hours after treatment.

In a well-controlled field study, NexGard was used concomitantly with other medications, such as vaccines, anthelmintics, antibiotics (including topicals), steroids, NSAIDS, anesthetics, and antihistamines. No adverse reactions were observed from the concomitant use of NexGard with other medications.

Storage Information: Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F).

How Supplied: NexGard is available in four sizes of beef-flavored soft chewables: 11.3, 28.3, 68 or 136 mg afoxolaner. Each chewable size is available in color-coded packages of 1, 3 or 6 beef-flavored chewables.

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

1050-4493-03 Rev. 1/2015

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FLEA AND TICK control dogs run to, not from…

NexGard® (afoxolaner) for dogs is: POWERFUL so it keeps killing fleas and ticks all month long EASY to give because it’s soft and beef-flavored

Dogs love it!

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Data on file at Merial.

®NexGard is a registered trademark, and FRONTLINE VET LABS is a trademark of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved.

NEX16TRADEAD (01/16).

TODAY’SVETERINARYTECHNICIAN VETERINARY VETERINARYTECHNICIAN

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

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ARTICLE 1 1 CR E DIT

Scratching the Surface of Allergies in Dogs Kim Horne, AAS, CVT, VTS (Dermatology)

P

University of Minnesota

ruritus—a classic sign of allergic disease—is a common complaint described by dog owners.

The skin is the largest organ of the body and acts as a barrier, offering protection from environmental elements as well as the development of infection. When the skin barrier is disrupted by the allergic process, many secondary problems can develop and increase the pruritus level, further contributing to patients’ discomfort (FIGURE 1).

Allergic skin and ear diseases are common problems in canine patients, and many of the clinical presentations are similar. Sometimes, these problems are not the primary reason for an appointment. For example, clients bringing their dogs in for vaccination may ask to have the skin or ears checked because they have noticed a rash, observed their dog licking or scratching, or smelled an odor from the haircoat or ears.

The types of allergies seen most often in canine patients are flea alle gy dermatitis (FAD; hypersensitivity to flea saliva), food hypersensitivit , and atopic dermatitis. These diseases are frustrating for both owners and the veterinary team. To make matters worse, such diseases are only controllable, not curable. The goal is to find the cor ect therapeutic recommendation to best manage each patient’s condition.

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Kim is a member of the dermatology service at University of Minnesota Veterinary Medical Center.

She is a charter member of the Academy of Dermatology Veterinary Technicians and its current president. Kim is also an active member of the Minnesota Association of Veterinary Technicians and NAVTA, actively participating in committees. She has spoken at many national meetings, has several publications to her credit, and is currently working on a dermatology text for veterinary technicians.

Kim received her degree from University of Minnesota’s Technical College of Waseca.

In her spare time, she enjoys hiking, kayaking, and spending time with her family.

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Veterinary technicians are in a unique position to be involved in all aspects of managing these cases, starting with ensuring good client communication at the initial contact, then collecting a complete history, performing the physical examination, and relaying this information to the veterinarian. After the doctor has created the differential diagnosis, technicians often assist with performing diagnostic procedures and providing detailed information to owners. Following up with clients to obtain progress reports and ensuring the scheduling of necessary recheck appointments help the veterinarian with patient management. All of these factors are essential to success.

BEFORE THE DERMATOLOGIC EXAMINATION Information collected when a client calls to make an appointment can alert veterinary technicians that an animal has a dermatologic condition and will require a longer appointment. It is imperative to communicate that the owner who is most familiar with the dog’s history should be the one present for the examination and to ensure that the owner is aware of the increased appointment length.

Clients should be instructed to bring a list of any current or previous medications and topical products

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(including over-the-counter preparations) that have been used as well as diets fed. Sending clients a dermatology history questionnaire to fill out befo e the appointment is a great way to collect important information and gives them time to reflect on their pets’ de matologic problems, which allows them to provide more accurate details during the appointment. If a client is unable to complete the form in advance, he or she should be asked to arrive early to complete it before the examination. The questionnaire is also a good resource if a dog experiences a recurrence or if different skin problems develop in the future.

DURING THE EXAMINATION Patient signalment, historical details, and physical examination findings can p ovide clues to which allergy is the likely culprit. Having the ability to see, touch, and smell the affected body organ is an advantage for both the veterinary staff and owners.

Collecting an accurate patient history is an art and requires excellent communication skills. Technicians who can listen well and guide clients into providing a chronological sequence of the relevant dermatologic details are valuable assets to the veterinary team. BOX 1 lists some important questions to ask when obtaining a patient history. A basic diet history should be collected initially; a more thorough diet history can be obtained later if needed. Because many dogs with allergies are pruritic, collecting information regarding the pruritus level is also

important. Clients need to be educated that dogs with pruritus may not only scratch but also rub, lick, or chew their skin. For each type of behavior noted, clients should be questioned about how often it occurs, what areas of the body are involved, and how intense it is.

Finally, clients should be asked to provide a total pruritus score using either a numerical scale (0 [no itchiness] to 10 [constant itching]) or a visual analog score, which can be found in many resources.1,2 All observations should be documented in the medical record and can be compared at follow-up appointments to determine changes in pruritus level throughout treatment.

WHICH ALLERGY IS CAUSING THE PROBLEM? Although collecting historical information can be time consuming, presenting comprehensive patient overviews to veterinarians can help narrow the list of differentials and allow the most efficient and cost-e fective diagnostic plan to be implemented. Determining which allergy or combination of allergies is affecting an animal can be a challenging process. Making an accurate diagnosis quickly allows a treatment plan to be initiated sooner and, ideally, provides patient relief (and satisfies clients) earlie . It is critical to inform clients that diagnostic tests and treatment trials do not always provide immediate answers and may be performed to rule out conditions while all possible causes of a problem are being investigated. Owners should

BOX 1 Important Questions to Ask When Obtaining a Patient History When did you first notice these clinical signs How did the problem start, and how has it changed?

Has the dog had any type of skin or ear condition previously?

What types of treatment and medications have been used, and which ones helped improve the condition?

Is the dog itchy?

Which came first: the lesions or the itch Is the problem year-round, or does it occur seasonally?

Are any other pets in the household showing similar signs?

FIGURE 1. Dog with atopic dermatitis. The superficia pyoderma (with pustules) is indicative of a secondary bacterial infection.

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Are any humans in the household having any skin problems?

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Books you’ll rely on as much as your morning coffee

Just like you turn to your morning cup of joe to get your day started, you’ll turn to AAHA Press time and time again to help your practice function smoothly.

Check out our latest practical, easy-to-use titles!

Visit press.aaha.org or call 800-883-6301 to order.

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understand that each patient is unique and that, once the allergy is identified and being t eated, time is needed to determine which therapeutic options are best for their pet.

Because FAD is the most common pruritic skin disease seen in dogs living in warm climates,1 it makes sense to manage potential or existing flea p oblems before investigating other allergic conditions. Although not all dogs are allergic to fleas, dogs with AD can become extremely pruritic after just a few fleabites. The most common age of onset is 3 to 5 years, although dogs of any age can be affected. Clinical signs tend to be very typical and are nonseasonal in temperate climates (FIGURE 2).

Food hypersensitivity is typically seen in very young dogs and in older dogs with a first-time skin p oblem.

Older dogs with food hypersensitivity typically become allergic to one or more ingredients in their regular diet or treats after consuming the offending food component(s) for at least 2 years.1 It is usually a nonseasonal condition (most dogs eat the same diet year-round).

Atopic dermatitis is a complex disease estimated to occur in 3% to 27% of the canine population.1 In these patients, environmental allergens such as dust, pollens, and mold spores are absorbed via the respiratory tract or oral mucosa, or percutaneously owing to impairment of the skin’s barrier function, and cause an inflammatory esponse of the immune system. Clinical signs are usually seen in patients aged 1 to 3 years but can develop in dogs as young as 6 months. Atopic

FIGURE 2. Dog with typical clinical signs and distribution pattern (dorsal lumbosacral area) of flea allergy dermatitis 12

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dermatitis is not often diagnosed in patients older than 7 years. Depending on the allergen(s), atopic dermatitis can be a seasonal or nonseasonal condition. Many patients may show seasonal problems initially and progress to nonseasonal signs as they become sensitive to more allergens.

There is a suspicion that atopic dermatitis has a genetic component1; therefore, intact dogs with atopic dermatitis should not be bred. Puppies born during the allergy season may also have more potential to develop atopic dermatitis.

Dogs with atopic dermatitis may be more prone to developing a flea alle gy, and it has been speculated that foods may be fla e factors for dogs with atopic dermatitis.1 Some patients have a combination of food hypersensitivity and atopic dermatitis. The clinical presentations of these two diseases are similar (FIGURE 3). A good history may give clues as to which type of allergy is more likely causing clinical signs; atopic dermatitis is more common.

Although contact dermatitis has been reported in dogs, it is considered a rare cause of pruritic skin disease.1 DIAGNOSTIC TESTS Flea Allergy Dermatitis A diagnosis of FAD may be determined after assessing the history (age of onset, duration and seasonality of signs, known or suspected environmental flea exposu e) and physical examination findings (pruritus, compatibl clinical signs, and lesion type and distribution pattern).

Fleas may be found during the physical examination. If

FIGURE 3. Dog with typical clinical signs and distribution pattern of atopic dermatitis or food hypersensitivity.

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not, diagnostic testing options for FAD include combing for fleas, intrade mal testing with flea alle gen, and measurement of IgE levels through serum testing, although this last test has less sensitivity.1 Because the absence of fleas and/or flea feces does not rule out AD, the diagnosis is best confi med by implementing strict flea-cont ol measures and getting a positive patient response.

Food Hypersensitivity Although intradermal and serum allergy tests are available, they are not accurate methods for diagnosing food allergies. The ideal test to diagnose or rule out a food allergy is a strict food elimination diet lasting 8 to 10 weeks. After the diet history is reviewed, a novel protein and carbohydrate or a hydrolyzed protein diet should be chosen for the trial. This often means feeding a homecooked or prescription diet. The switch to the new diet should be gradual to prevent gastrointestinal problems.

While this sounds like a simple test, it actually can be quite difficult. Elimination diets can be expensive, especially for large-breed patients or when multiple dogs must be fed the same diet to ensure a strict trial. Owners must understand that nothing but the elimination diet should pass the affected dog’s lips during these 8 to 10 weeks—which means no treats, no table food, no rawhides, and no flavo ed chews or toothpastes are allowed. Chewable medications (even monthly heartworm preventives) should be switched to a nonchewable

formulation. For the trial to be successful, it is critical that owners follow all instructions properly.

Veterinary technicians are often the ones to educate and support clients throughout the diet trial, starting with an explanation of why such a “test” is necessary. Ideally, veterinary technicians should also contact clients midway through the trial to get patient progress reports, ensure clients are following instructions, answer any questions, and provide support and encouragement to continue the trial. Concerns should be brought to the veterinarian’s attention.

When a patient returns for a recheck at the end of the trial, the next step is based on observed improvement in clinical signs. If a strict trial was performed and there has been no improvement, food hypersensitivity can be ruled out, the dog can return to its normal diet, and other causes of skin problems can be pursued.

For dogs that improve on the elimination diet, the next step is the challenge: the dog is fed the previous diet and observed for recurrence of clinical signs, which typically develop within 2 weeks. Some owners may be unwilling to do the challenge, but it is the step that verifies that improvement was related to the elimination diet, not a change in season, a new medication, or shampoos used to treat secondary infections. Clients should be instructed that their dog does not need to become miserable again.

If the dog is truly food allergic, clinical signs will recur; as soon as they do, the diagnosis of food hypersensitivity is confi med and the test diet is reinstated.

FIGURE 4. Dog with positive (raised erythematous) reactions on an intradermal allergy test.

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TECHPOINT

Scratching the Surface of Allergies in Dogs

The goal is to find the therapeutic combination that controls clinical signs and makes the patient comfortable; however, determining what works best for an individual patient takes time.

Atopic Dermatitis There is no diagnostic test for atopic dermatitis. After ruling out other causes of pruritic skin diseases, the presumptive diagnosis is made based on the patient’s history and clinical signs. Relevant details that aid veterinarians in making a diagnosis include: Age of onset Pruritus level (pruritus is often present before clinical signs develop) Areas affected (face, feet, axillae, ventral neck, ventral abdomen, inguinal area) Changing or progressive clinical signs Seasonal or year-round signs, with or without seasonal exacerbations After diagnosis, intradermal (FIGURE 4) or serum allergy tests are used to identify the offending environmental allergens so that they can be avoided (although this is often impractical) or used for therapeutic immunotherapy. To identify all offending allergens, it is often recommended to delay allergy testing until the dog has shown clinical signs for a minimum of 1 year. It may also be beneficial to test dogs that are affected seasonally shortly after their allergic season. Again, these tests are not used for diagnosing atopic dermatitis and should only be performed when clients are willing to use immunotherapy.

Food Hypersensitivity Dogs with food allergies should be fed an appropriate diet, and accidental exposure to any offending allergens must be prevented. Some owners are content with feeding the test diet for maintenance. Others may want to switch to a less expensive over-the-counter diet or to try a homemade diet. This is another opportunity to educate clients about the importance of reading labels to ensure that all ingredients are novel; it may be necessary to contact the manufacturer to determine if the equipment used to produce the diet is dedicated solely to the food in question, eliminating the risk of contamination by other ingredients. If owners choose to prepare a homemade diet, they should be referred to a veterinary nutritionist to formulate a complete and balanced diet.

TREATING THE ALLERGIC DOG Flea Allergy Dermatitis Many flea-cont ol products are available, and veterinary technicians should be knowledgeable about the products offered at their practice, including the mechanism of action and proper administration. The initial goals when treating dogs with FAD are to relieve pruritus, treat secondary infections, and use specific cont ol measures to quickly reduce fleabite exposu e. The goals of an ongoing flea-cont ol program include killing adult fleas on dogs, killing immature flea stages in the envi onment, and preventing reinfestation. Educating clients and setting realistic expectations are critical for success. Ensuring that owners use products as labeled (e.g., not bathing dogs for 48 hours before or after application of spot-on formulations) and demonstrating how to apply products are helpful.

Treatment failures do occur and are often attributed to inadequate treatment of the environment, failure to treat all animals in the household, poor selection of products, and owner noncompliance. Taking the time to educate owners initially and following up throughout treatment should lead to better patient management.

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Atopic Dermatitis For dogs with seasonal allergies, owners may choose medical management. Many options exist. Having a good rapport with owners to determine what products will best fi their time, physical, and financial constraints imp oves client compliance. For patients with year-round atopic dermatitis, clients may be interested in trying allergen-specific immunotherapy. Intradermal testing is still considered the gold standard to identify allergens, although serum testing is more practical in general practice. Some dermatologists perform both tests and choose allergens for immunotherapy after reviewing all test results, taking into account the dog’s history and allergen exposure. Whichever testing methodology is used, proper withdrawal time of medications known or suspected to interfere with test results (e.g., antihistamines, glucocorticoids, cyclosporine, tricyclic antidepressants with antihistaminic properties [doxepin and amitriptyline], antiinflammatories [niacinamid and fatty acids]) should be followed. |

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Immunotherapy Clients can be taught to administer subcutaneous immunotherapy injections at home. Various injection schedule protocols are available, and many have a maintenance schedule of about every 1 to 3 weeks. Although adverse effects are rare and can vary in severity (localized pruritus to anaphylaxis), clients should be made aware of them and instructed to contact the clinic immediately if seen.

Sublingual immunotherapy (SLIT) is an option that has recently become available. This therapy must be administered directly into the oral cavity (not put into food/treats), and dogs should not eat or drink for 10 minutes before or after administration. SLIT may be preferred to injections because of the ease of administration; however, when choosing which type of immunotherapy to try, clients need to understand that oral immunotherapy is given twice daily every day and requires a greater time commitment than subcutaneous injections.

It may take up to a year to determine the level of efficacy of immunotherap , although patients may show improvement by 6 months. If no or minimal response is seen after 1 year, immunotherapy may be discontinued; symptomatic therapy is the next best option. If the patient improves, immunotherapy is generally continued for life.

The mechanism of action of immunotherapy is complex and not completely understood; however, the reported success rate is 50% to 80%.1 Adjunctive Therapies To best manage their disease, most dogs benefit f om some type of adjunctive therapy in addition to immunotherapy.

Selection of adjunctive therapies depends on many factors.

Veterinary technicians should be familiar with all the treatment options to discuss with owners after veterinarians have made recommendations.

Topical products such as shampoo therapy are safe and can be very beneficial. Medicated shampoos not only

TABLE 1 Antihistamines for Controlling Mild Pruritus in Dogs ANTIHISTAMINE

DOSE

Diphenhydramine

2–4 mg/kg PO q8–12h

Chlorpheniramine

4–8 mg/dog (maximum of 0.5 mg/kg) PO q8–12h

Clemastine

0.05–1.5 mg/kg PO q12h

Amitriptyline

1–2 mg/kg PO q12h

Hydroxyzine

2 mg/kg PO q12h

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help remove allergens from the skin but also can be prescribed for specific skin conditions. Some shampoos are drying, and a conditioner or rinse can be added if necessary. Frequent bathing (1 to 2 times/week) may be recommended, and it is important that the shampoo be allowed to contact the skin for 10 to 15 minutes before rinsing well.

For dogs with chronic otitis, periodic ear cleaning with a good-quality ear cleaner may be recommended in combination with treatment of existing ear infections and as a preventive against future ear infections. Clients should be taught how to properly clean their dog’s ears according to the veterinarian’s instructions.

Antihistamines (TABLE 1) are another option for dogs with mild pruritus. Many products are available, and in general, they are not expensive and rarely have serious adverse effects. An antihistamine trial can be performed to determine which, if any, will work for the patient. Clients should be instructed to give each antihistamine one at a time for 1 to 2 weeks; they should keep a record of how pruritic their dog is and call the clinic if any side effects are observed. If an antihistamine controls the pruritus, the dog can be maintained on it. Seasonal patients may benefit f om starting the antihistamine before the onset of allergen exposure.

Essential fatty acids (EFAs) are another safe option and are not too expensive. They may be used to reduce pruritus, decrease production of inflammatory mediators, and improve the skin’s barrier function. To determine the efficacy of E As, a treatment trial of 8 to 12 weeks is necessary. Efficacy of E As may be enhanced when they are used in conjunction with antihistamines or glucocorticoids. If effective, they may even allow the glucocorticoid dose to be reduced. Another potential benefit of E A therapy is improved coat quality.

EFAs can be incorporated into the diet or given orally in capsule or liquid form. Although the ideal dosage of EFAs is still unknown, most dermatologists aim for a daily calculated dosage of both eicosapentaenoic acid (EPA; 180 mg/10 lb/day) and docosahexaenoic acid (DHA; 120 mg/10 lb/day)3; many veterinary labeled products are available.

Glucocorticoids are generally inexpensive and usually effective at reducing pruritus. While they may be a great option for dogs with seasonal signs, they should be used cautiously in patients needing year-round therapy. Oral steroids are preferred over injectable agents for several reasons: better dosage control, ease in adjusting dosage, and ability to discontinue administration if severe side effects develop. An every-other-day dosing schedule is

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Scratching the Surface of Allergies in Dogs

When veterinary technicians successfully communicate realistic expectations of both the time and financial commitments needed to treat allergic diseases, the end result should be better managed pets and happier clients.

preferred to minimize side effects. Clients should be informed of both short- and long-term adverse effects of glucocorticoids and educated about the importance of yearly monitoring. Dogs on year-round steroid therapy have a higher incidence of urinary tract infections4; thus, regular chemistry profile, urinalysis, and urine cultu e (collected via cystocentesis) tests are recommended.

Cyclosporine is an immunosuppressive drug that may be used as a sole agent for treating atopic dermatitis and may have steroid-sparing benefits. Administration for 4 to 6 weeks may be needed to see results, and the recommended dose range is 3.3 to 6.7 mg/kg PO q24h.3 It is recommended to use the microemulsion form for better absorption of the drug. Reported adverse effects include vomiting, diarrhea, gingival hyperplasia, and hypertrichosis.

The disadvantage of cyclosporine is that it is expensive.

Collecting a detailed medication history is important because cyclosporine interacts with a number of other drugs. Concurrently administering ketoconazole can increase cyclosporine blood levels, and this interaction can be used advantageously to decrease the required cyclosporine dose (possibly decreasing cost for owners, especially when treating large breeds). Dogs on yearround cyclosporine therapy have a higher incidence of urinary tract infections,5 and monitoring these patients yearly (as described for glucocorticoids) is suggested.

Oclacitinib is the newest treatment approved for treating canine atopic dermatitis for patients at least 12 months old. It is an immunomodulatory drug that is used to reduce the itch sensation and inflammation. It typicall provides a rapid decrease in pruritus with minimal adverse effects (vomiting, diarrhea, decreased appetite, weakness, lethargy). Baseline laboratory work and frequent rechecks with laboratory tests are important to monitor efficac , side effects, and outcome of long-term treatment with this new therapy.

It is beneficial to ensu e that any secondary infections are identified. Cytology is a g eat diagnostic test for skin and ear infections. Appropriate antimicrobial therapy should help dogs feel more comfortable, and superficia infections should typically be treated for a minimum of 3 weeks (treatment should be continued for 1 week after resolution of clinical signs3); dogs should be reexamined and cytology performed before discontinuing therapy.

Clients should be aware that skin and ear infections are likely to recur until the underlying allergy is identifie and controlled.

MANAGING ALLERGIC DOGS For patients that have multiple allergic conditions, successfully managing one condition may reduce clinical signs. This can alter how the other allergies are treated and may allow medications with lesser side effects to be effective at controlling clinical signs.

CONCLUSION It is critical that owners understand that their dogs’ allergies will never be cured. The goal is to find the therapeutic combination that controls clinical signs and makes the patient comfortable; however, determining what works best for an individual patient takes time.

Educating clients about the specific alle gic disease affecting their dog should increase compliance. When veterinary technicians successfully communicate realistic expectations of both the time and financial commitments needed to treat allergic diseases, the end result should be better managed pets and happier clients. 

References 1. Miller WH, Griffin CE, Campbell KL. Muller and Kirk’s Small Animal Dermatology. 7th ed. St. Louis: Elsevier; 2013.

2. Hill PB. Canine pruritus scale. www.cliniciansbrief.com/sites/default/files/sites cliniciansbrief.com/files/CaninePruritisScale.pdf. Accessed November 2015.

3. Koch SN, Torres SMF, Plumb DC. Canine and Feline Dermatology Drug Handbook.

Ames, IA: Wiley-Blackwell; 2012.

4. Torres SM, Diaz SF, Nogueira SA, et al. Frequency of urinary tract infection among dogs with pruritic disorders receiving long-term glucocorticoid treatment. JAVMA 2005;227(2):239-243.

5. Peterson AL, Torres SM, Rendahl A, Koch SN. Frequency of urinary tract infection in dogs with inflammatory skin diso ders treated with oral ciclosporin alone or in combination with glucocorticoid therapy: a retrospective study. Vet Dermatol 2012;23(3):201-205.

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CE Test Article 1 Scratching the Surface of Allergies in Dogs The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

1. When is the ideal time for veterinary technicians to become involved with allergic patients? a. At the initial point of contact by the client b. When diagnostic tests need to be performed c. At the end of the visit, to provide client education d. After the initial visit, contacting clients as a follow-up 2. Which fact is helpful when determining the most likely type of allergy in a pruritic patient? a. Age of onset b. Signalment c. Seasonal versus nonseasonal condition d. All of the above 3. Which allergic condition is considered to be the most common in warm climates? a. Contact dermatitis b. Flea allergy dermatitis c. Food hypersensitivity d. Atopic dermatitis 4. Which of the following conditions would likely present as seasonal pruritus? a. Flea allergy dermatitis in a dog living in Florida b. Food hypersensitivity c. Atopic dermatitis in a dog allergic to trees d. Atopic dermatitis in a dog allergic to house dust 5. A 9-year-old dog presents with pruritus and has never had skin or ear problems before.

Which allergic condition is most likely in this patient? a. Contact dermatitis b. Flea allergy dermatitis c. Food hypersensitivity d. Atopic dermatitis

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6. Dogs with environmental allergies do not commonly absorb allergens via the a. Respiratory tract b. Alimentary tract c. Oral mucous membranes d. Skin 7. What is the best way to diagnose atopic dermatitis? a. Perform an intradermal allergy test. b. Perform a serum allergy test. c. Limit the dog’s exposure to the outdoors and look for signs of improvement. d. There is no diagnostic test.

8. What is the best way to diagnose food hypersensitivity? a. Perform an intradermal allergy test. b. Perform a serum allergy test. c. Switch the dog to a different commercial diet. d. Perform a food elimination diet trial.

9. Which of the following medications does not need routine patient monitoring with laboratory tests? a. Antihistamines b. Glucocorticoids c. Cyclosporine d. Oclacitinib 10. When educating the owner of an intact pet, veterinary technicians should advise against breeding a dog with ________, which may have a genetic component. a. contact dermatitis b. flea alle gy dermatitis c. food hypersensitivity d. atopic dermatitis

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TRESADERM (thiabendazole-dexamethasoneneomycin sulfate solution) Dermatologic Solution CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: Dermatologic Solution (thiabendazole-dexamethasoneTRESADERM® neomycin sulfate solution) contains the following active ingredients per ml: 40 mg thiabendazole, 1 mg dexamethasone, 3.2 mg neomycin (from neomycin sulfate). Inactive ingredients: glycerin, propylene glycol, purified water, hypophosphorous acid, calcium hypophosphite; about 8.5% ethyl alcohol and about 0.5% benzyl alcohol.

INDICATIONS:Dermatologic solution TRESADERM is indicated as an aid in the treatment of certain bacterial, mycotic, and inflammatory dermatoses and otitis externa in dogs and cats. Both acute and chronic forms of these skin disorders respond to treatment with TRESADERM. Many forms of dermatosis are caused by bacteria (chiefly Staphylococcus aureus, Proteus vulgaris and Pseudomonas aeruginosa). Moreover, these organisms often act as opportunistic or concurrent pathogens that may complicate already established mycotic skin disorders, or otoacariasis caused by Otodectes cynotis. The principal etiologic agents of dermatomycoses in dogs and cats are species of the genera Microsporum and Trichophyton. The efficacy of neomycin as an antibacterial agent, with activity against both gram-negative and gram-positive pathogens, is well documented.

Detailed studies in various laboratories have verified the significant activity thiabendazole displays against the important dermatophytes.

Dexamethasone, a synthetic adrenocorticoid steroid, inhibits the reaction of connective tissue to injury and suppresses the classic inflammatory manifestations of skin disease. The formulation for TRESADERM combines these several activities in a complementary form for control of the discomfort and direct treatment of dermatitis and otitis externa produced by the above-mentioned infectious agents. DOSAGE AND ADMINISTRATION: Prior to the administration of Dermatologic Solution TRESADERM, remove the ceruminous, purulent or foreign materials from the ear canal, as well as the crust which may be associated with dermatoses affecting other parts of the body. The design of the container nozzle safely allows partial insertion into the ear canal for ease of administration. The amount to apply and the frequency of treatment are dependent upon the severity and extent of the lesions. Five to 15 drops should be instilled in the ear twice daily. In treating dermatoses affecting other than the ear the surface of the lesions should be well moistened (2 to 4 drops per square inch) with Dermatologic Solution TRESADERM twice daily. The volume required will be dependent upon the size of the lesion. Application of TRESADERM should be limited to a period of not longer than one week. PRECAUTIONS: On rare occasions dogs may be sensitive to neomycin. In these animals, application of the drug will result in erythema of the treated area, which may last for 24 to 48 hours. Also, evidence of transient discomfort has been noted in some dogs when the drug was applied to fissured or denuded areas. The expression of pain may last 2 to 5 minutes. Application of Dermatologic Solution TRESADERM should be limited to periods not longer than one week. While systemic side effects are not likely with topically applied corticosteroids, such a possibility should be considered if use of the solution is extensive and prolonged. If signs of salt and water retention or potassium excretion are noticed (increased thirst, weakness, lethargy, oliguria, gastrointestinal disturbances or tachycardia), treatment should be discontinued and appropriate measures taken to correct the electrolyte and fluid imbalance. Store in a refrigerator 36°-46°F (2°-8°C).

WARNING: For topical use in dogs and cats. Avoid contact with eyes. Keep this and all drugs out of the reach of children. The Material Safety Data Sheet (MSDS) contains more detailed occupational safety information. To report adverse effects in users, to obtain an MSDS, or for assistance call 1-888-637-4251. HOW SUPPLIED: Product 55871Dermatologic Solution TRESADERM Veterinary is supplied in 7.5-ml and 15-ml dropper bottles, each in 12-bottle boxes.

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IMPORTANT SAFETY INFORMATION: TRESADERM is for topical use only in dogs and cats. On rare occasions, application of the product may result in erythema or discomfort in the treated area. Discomfort in the treated area can last from 24 hours to 48 hours. ®TRESADERM is a registered trademark of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved. TRE15TRADEADD (01/16).

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Peer-Reviewed

ARTICLE 2 1 CR E DIT

Shock: An Overview

S

Brandy Tabor, CVT, VTS (ECC)

hock is a sequela of trauma and diseases commonly seen in emergency practice, such as heart failure, inflammatory conditions (e.g., pancreatitis), or sepsis. The common deficiency that shock patients share is decreased delivery or utilization of oxygen.

Shock is defined as inadequate cellular energy production or decreased cellular oxygen utilization related to decreased blood flow tha leads to cell death and organ failure.1 Inadequate energy production is exemplified by dec eased oxygen delivery. In traumatized patients, this may be due to hemorrhage; in patients with heart failure, it may be related to decreased cardiac output; and in patients with inflammator conditions, it may be secondary to maldistribution and inappropriate vascular resistance. Decreased cellular oxygen utilization is seen in septic shock and with certain toxins.1

Animal Emergency & Specialty Center Parker, Colorado

Brandy Tabor, CVT, VTS (ECC), is a senior emergency/ critical care technician at Animal Emergency & Specialty Center in Parker, Colorado. She is also chair of the Academy of Veterinary Emergency and Critical Care Technicians Credentials Committee, a board moderator with Veterinary Support Personnel Network, and an instructor of several courses at VetMedTeam.com. While pursuing her bachelor’s degree in equine science at Colorado State University, Ms. Tabor worked as an assistant in the critical care unit at the CSU Veterinary Teaching Hospital. There, the talented and knowledgeable nursing staff inspired her to become a veterinary technician specialist in emergency and critical care.

PATHOPHYSIOLOGY OF SHOCK To understand the pathophysiology of shock, one must understand how oxygen is delivered to, and used by, cells.

Oxygen Delivery Hemoglobin, the body’s oxygen carrier, is found within red blood cells. Each molecule of hemoglobin is able to bind up to 4 molecules of oxygen. This oxygen is then off-loaded to cells for use in energy production.

Normally, the amount of oxygen delivered to the cell is 2 to 4 times the amount required, depending on the tissue, which ensures an adequate supply. However, oxygen delivery depends on adequate perfusion of tissue. If tissues 20

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are not perfused with blood, then oxygen is not delivered to the cells, regardless of the oxygen content of the blood.2 Based on the formulas in BOX 1, a decrease in oxygen delivery can be secondary to an increase in afterload, as well as a decrease in heart rate, stroke volume, and the concentration or saturation of hemoglobin.2

Heart Rate Several factors that affect cardiac output and blood pressure, including the stretch of the vascular walls, partial pressures of oxygen and carbon dioxide in the blood, and pH, play important roles in regulation of heart rate in shock patients.

Changes in the mean arterial pressure (MAP) trigger changes in heart rate. An increase in MAP causes bradycardia and vasodilation, while a decrease causes tachycardia and vasoconstriction.2 These changes are mediated by baroreceptors in the heart and great vessels. Although baroreceptors do not affect heart rate directly,2 they are sensitive to the stretch of vascular walls and provide feedback that can promote or inhibit vasoconstriction.

High-pressure vascular baroreceptors, located in arterial walls, sense increases in stretch when MAP rises and the reduction when it falls. When MAP is low, the activity of these baroreceptors decreases, prompting an increase in sympathetic nervous system activity and vasoconstriction.3 Low-pressure baroreceptors sense decreases in effective circulating volume due to decreased blood volume, with similar results.

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When blood volume is low, vasopressin is released, which decreases sodium secretion. Residual sodium in the vascular space causes an increase in plasma osmolarity, which helps hold water in the vascular lumen.4 Depending on the type of shock, affected patients may have a low MAP, low blood volume, or both. However, depending on the stage of shock and the ability of the patient to compensate through these mechanisms, the heart rate may be increased, normal, or decreased.3 A decrease in cardiac output results in an increase in partial pressure of carbon dioxide (PaCO2) and a decrease in

pH and partial pressure of oxygen (PaO2). Chemoreceptors (found primarily in the brain) sense changes in blood PaCO2, PaO2, and pH secondary to a drop in cardiac output, resulting in tachycardia in an attempt to increase cardiac output. If a change in cardiac output does not alter these values, there is no reflex tachyca dia.2 Hemoglobin Saturation and Concentration The affinity of hemoglobin for oxygen is elatively low, but it increases as each molecule of oxygen binds (i.e., as hemoglobin saturation with oxygen increases). As oxygen is off-loaded to tissue, the affinity dec eases again, facilitating further off-loading of oxygen. Hemoglobin can also bind carbon dioxide, carbon monoxide, and nitric acid.2 When these are bound to hemoglobin, they prevent the binding of oxygen, causing decreased oxygen saturation and leading to tissue hypoxia and shock despite normal oxygenation of the blood.

Some conditions can increase the affinity of hemoglobi for oxygen, thereby decreasing off-loading of oxygen to tissue. These include alkalosis, hypocapnia, hypothermia, and methemoglobinemia. They may be caused by respiratory disease (e.g., decreased fraction of inspired oxygen, shunt, pneumonia, asthma, hypoventilation) or cardiac disease (e.g., pericardial effusion, cardiac tamponade, congestive heart

Oxygen delivery (DO2): Product of cardiac output (CO) and oxygen content of arterial blood (CaO2)

DO2 = CO × CaO2 Cardiac output (CO): Product of stroke volume (SV) and heart rate (HR)

CO = SV × HR Oxygen content of blood (CaO2): Product of hemoglobin concentration in blood (Hb), a factor of 1.39, and oxygen saturation of hemoglobin (SaO2)

CaO2 = ([Hb × 1.39] × SaO2)

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Shock: An Overview

Angel, a patient at Animal Emergency & Specialty Center, Parker, CO, receives care from Alex Botkin, a technician in training. Image by Brian Walski/Colorado Visions.

BOX 1 Formulas for Oxygen Delivery

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failure).2 The common end result is a decrease in oxygen delivery at the cellular level, again leading to shock.

A decrease in oxygenated hemoglobin content in the blood may also be caused by a decrease in hemoglobin concentration, as seen in anemia.

Stroke Volume Stroke volume is determined by preload, afterload, and cardiac contractility.2 Preload is determined by the stretching of ventricular cardiac cells in response to the presence of blood in the ventricle (venous return).

Contractile response is related to the magnitude of the stretch; therefore, the greater the stretch, the stronger the contraction. Any decrease in ventricular filling (e.g., decreased venous return) decreases preload and, as a result, cardiac output and blood pressure.4 Afterload is the force required by the heart to eject blood. The pressure generated by the ventricle must exceed the pressure on the aortic valve in order for blood to be ejected. An increase in afterload (e.g., an elevated diastolic blood pressure) decreases stroke volume.4 If stroke volume decreases, both cardiac output and oxygen delivery decrease, leading to shock.

Oxygen Utilization Normally, mitochondria are responsible for consumption of 98% of the body’s oxygen.1 Through aerobic metabolism,

they use oxygen to produce the bulk of energy used in the body in the form of adenosine triphosphate (ATP).1 A decrease in oxygen delivery to the cell leads to anaerobic metabolism, which is a relatively inefficient method of energy production, producing 2 ATP for every molecule of glucose rather than the 36 ATP produced through aerobic metabolism.3 In addition, anaerobic metabolism produces lactate, which can be monitored (SEE MONITORING).4 In shock patients, prolonged anaerobic metabolism and the resulting decrease in ATP causes sodium and calcium to accumulate in energy-depleted cells. This increases the osmotic pull and water enters the cell, causing cellular swelling and death.2 Ischemia of the cell causes production of inflammatory mediators, leading to an inc ease in capillary permeability, vasodilation, leukocyte activation, and mitochondrial dysfunction.

Shock also manifests when a cell is unable to utilize oxygen. One example is cyanide toxicosis: this process disrupts the electron transport chain of cellular respiration, leading to a decrease in energy production, which prevents use of oxygen by the cell and causes hypoxia and shock despite a normal arterial oxygen concentration.1 When oxygen is reintroduced to the cell, reperfusion injury can occur. In this situation, radical oxygen species (HO–, O2–, H2O2) are produced. These compounds cause further cellular dysfunction, an increase in cellular permeability, damage to the DNA, and the breakdown of proteins.5

TABLE 1 Clinical Signs Associated with Each Stage of Shock in Dogs PHYSICAL EXAMINATION FINDINGS

COMPENSATORY SHOCK

EARLY DECOMPENSATORY SHOCK

LATE DECOMPENSATORY SHOCK

Temperature

Normal to low normal (98°F–99°F)a

Slight to moderate hypothermia (96°F–98°F)

Moderate to marked hypothermia (<96°F)

Heart rate

Tachycardia (>180 bpm)

Tachycardia (>150 bpm)

Bradycardia (<140 bpm)

Mucous membrane color

Normal to pale (hyperemic in distributive shock)

Pale

Pale to gray/muddy

Capillary refill tim

Normal to slightly prolonged (<1 sec; rapid in distributive shock)

Prolonged (<2 sec)

Prolonged (≥2 sec)

Respiratory rate

Tachypnea (>50 breaths/min)

Tachypnea (>50 breaths/min)

Bradypnea

Blood pressure

Slight hypotension to normal (70–80 mm Hg)

Mild to moderate hypotension (50–70 mm Hg)

Marked hypotension refractory to fluid therapy (<60 mm Hg

Mentation

Responsive

Obtunded

Obtunded to stuporous

Adapted with permission from Thomovsky E, Johnson PA. Shock pathophysiology. Compend Contin Educ Pract Vet 2013;35(8):E1-E9. a Values in parentheses are approximate.

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Shock: An Overview

TYPES OF SHOCK There are many ways to categorize shock. Three main categories of shock are described here: circulatory, metabolic, and hypoxic.1 Circulatory Shock Circulatory shock occurs when there is a decrease in effective circulating volume, as perceived by the baroreceptors. To have an adequate effective circulating volume, the body must have both adequate blood volume and adequate blood pressure. This category of shock is divided into 3 subcategories: cardiogenic, hypovolemic, and distributive.4 Cardiogenic Shock Cardiogenic shock occurs when effective circulating volume decreases despite normal or increased blood volume and appropriate systemic resistance. This type of shock is caused by decreased stroke volume due to a decrease in contractility and can be seen in patients with heart failure, such as those with congestive heart failure, cardiac tamponade, or cardiac arrhythmias.1 Clinical signs are similar to those of other types of shock, with the addition of one or all of the following: Advertiser Index COMPANY

PRODUCT

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American Society for the Prevention of Cruelty to Animals

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6, 7

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DM Dietetic Management

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purinaveterinarydiets.com

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PNC Bank

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UltraScope

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ultrascopes.com

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inside front cover

Veterinary Product Laboratories

Duralactin

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V.E.T. Pharmaceuticals

Epizyme

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9

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Shock: An Overview

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cardiac murmurs, arrhythmias, bloody froth coming from the mouth or nose, orthopnea, and cyanosis.

Hypovolemic Shock Hypovolemic shock occurs when blood volume is decreased through hemorrhage, third space fluid distribution, or dehydration. Loss of whole blood may be caused by an external wound or internal bleeding, such as that seen with an intraabdominal mass. Trauma may result in a hemoperitoneum or hemothorax. Inflammation (such as tha seen with pancreatitis) causes capillaries to become “leaky,” leading to fluid loss into body cavities (thi d spacing).

Dehydration may be due to vomiting or diarrhea.1 Distributive Shock Distributive shock occurs when the body is unable to maintain vasoconstriction of blood vessels. This causes systemic vasodilation, leading to hypotension despite normal cardiac function and effective circulating volume.

This condition occurs with severe anaphylaxis or any other disease process that causes severe inflammation (e.g., pancreatitis, pyelonephritis, hepatitis).1 Sepsis (the presence of infection with systemic signs of inflammation) is a common cause of distributive shock.

Septic shock is diagnosed when hypotension secondary to sepsis is nonresponsive to adequate fluid esuscitation.6 Several factors contribute to septic shock, including bacterial endotoxins, cytokines (tumor necrosis factor , multiple interleukins) that act as proinflammatory mediators, radical oxygen species released from leukocytes (increasing permeability of the capillaries), and nitric oxide (causing prolonged vasodilation).7

Clinical signs associated with distributive shock are different than those seen with other classifications of shock. Patients often present with strong pulses, hyperemic mucous membranes, rapid capillary refill time, and elevated temperature.

Metabolic Shock Metabolic shock is seen when oxygen delivery to the cell is normal, but the cell is unable to utilize oxygen for energy production. Causes of metabolic shock include hypoglycemia, cyanide poisoning, or mitochondrial dysfunction.1 Hypoxic Shock Hypoxic shock results from impaired oxygen delivery to cells. It may be secondary to a decrease in the oxygen content of blood, as seen in anemia (decreased hemoglobin concentration), decreased hemoglobin saturation, or respiratory disease. Alternatively, the oxygen content of the blood may be normal, but oxygen off-loading may be inadequate.

Patients may have coexisting types of shock. As an example, sepsis can cause widespread inflammatio and vasodilation, leading to distributive shock, while simultaneously decreasing the cells’ ability to utilize oxygen, causing metabolic shock.

STAGES OF SHOCK Clinical signs associated with each stage of shock in dogs and cats are summarized in TABLES 1 AND 2.

Compensatory As previously mentioned, baroreceptors in the heart and

TABLE 2 Clinical Signs Associated with Each Stage of Shock in Cats PHYSICAL EXAMINATION FINDINGS

COMPENSATORY SHOCK

EARLY DECOMPENSATORY SHOCK

LATE DECOMPENSATORY SHOCK

Temperature

Normal to low normal (<97°F)a

Slight to moderate hypothermia (<95°F)

Moderate to marked hypothermia (<90°F)

Heart rate

Severe tachycardia (>240 bpm) or mild bradycardia (160–180 bpm)

Moderate tachycardia (>200 bpm) or bradycardia (120–140 bpm)

Mild tachycardia (>180 bpm) or severe bradycardia (<120 bpm)

Mucous membrane color

Pale (hyperemic in distributive shock)

Pale to white

Pale to gray/muddy

Capillary refill tim

Normal to slightly prolonged (<1 sec; rapid in distributive shock)

Prolonged (<2 sec)

Prolonged (≥2 sec)

Respiratory rate

Tachypnea (>60 breaths/min)

Tachypnea (>60 breaths/min)

Bradypnea

Blood pressure

Slight hypotension to normal (80–90 mm Hg)

Mild to moderate hypotension (50–80 mm Hg)

Marked hypotension refractory to fluid therapy (<50 mm Hg

Mentation

Responsive

Obtunded

Obtunded to stuporous

Adapted with permission from Thomovsky E, Johnson PA. Shock pathophysiology. Compend Contin Educ Pract Vet 2013;35(8):E1-E9. a Values in parentheses are approximate.

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vasculature sense decreases in systemic blood pressure.

Initially, in response to decreased oxygen delivery, the body increases blood flow to the tissues. This is accomplished b increasing cardiac output via an increase in heart rate.8 As a result, blood pressure can be normal due to compensatory mechanisms in this stage.3 Pale mucous membranes and an increased capillary refill time a e due to peripheral vasoconstriction, while decreased temperature is due to vasoconstriction in the gastrointestinal tract. Respiratory rate and effort are normal or increased to compensate for oxygen deficienc . Decreased mentation secondary to decreased blood flow or oxygenation in the brain may be observed.

Decompensatory Decompensatory shock occurs when the body is no longer able to compensate for the decrease in oxygen delivery. In this stage, the respiratory rate drops owing to a decrease in function of the respiratory muscles. Blood pressure decreases despite tachycardia and may be nonresponsive to fluid esuscitation. As blood gas abnormalities worsen, the patient may become obtunded and hypothermic.3 Late Decompensatory Patients may demonstrate bradycardia and hypotension that does not respond to aggressive fluid therap . The capillary response time becomes more prolonged, and mucous membranes often appear pale or gray/muddy.

The respiratory rate and effort continue to fall owing to failure of the respiratory muscles in response to hypoxia and hypercapnia. The partial pressure of carbon dioxide increases and, in the absence of a reflex tachyca dia response, causes a decrease in myocardial force and, subsequently, a decrease in cardiac output.8 TREATMENT Treatment should focus on increasing oxygen delivery to, and extraction by, the tissues. This can be accomplished by providing supplemental oxygen, increasing effective circulating volume with crystalloids or colloids, increasing hemoglobin concentration via blood products, and increasing cardiac output with medications.9 An intravenous catheter should be placed to allow vascular access. To deliver a large amount of fluids in a short amount of time, use a large-bore, short catheter. If venous access is not possible, place an intraosseous catheter for use until a peripheral catheter is placed.

Oxygen Supplementation Patients experiencing shock will benefit f om oxygen supplementation. This can be accomplished using several 26

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methods, including flow-by oxygen, a mask, nasal cannulas, or an oxygen cage.

Flow-by Oxygen Flow-by oxygen is a quick and easy method of providing oxygen when a patient is presented. The tubing is placed at the patient’s nose and provides oxygen at a concentration of 25% to 45%.10 While quick and easy, this method is not ideal because it requires a high flow rate and staff to hold the tubing in place. Some patients do not like the feeling of the oxygen flow in their face and become agitated.10 Facemask Oxygen can also be delivered via a facemask, which allows a lower oxygen flow rate and delivers a higher pe centage of oxygen (35%–55% if delivered at a rate of 6–10 L/min) compared with flow-by oxygen. It is important that the oxygen mask be the right size and fit for the patient 10 If it is too loose, oxygen will escape; if it is too tight, the patient will rebreathe carbon dioxide.10 Again, some patients may not tolerate the mask and may become agitated. These patients may accept the mask more readily if the diaphragm is removed. While this decreases the chance of the patient rebreathing carbon dioxide, it allows oxygen to escape, decreasing the percentage of oxygen provided.

Nasal Cannula Once the patient is stable and hospitalized, nasal cannulas can be placed in one or both nostrils to provide long-term oxygen supplementation. A single cannula can deliver 30% to 50% oxygen at a flow rate of 100 to 150 mL/kg min, while 2 cannulas can increase the delivered oxygen concentration to as much as 70%.10 Oxygen Cage An oxygen cage is an excellent choice for a patient that may not tolerate placement of nasal cannulas (e.g., cats, brachycephalic breeds). Most oxygen cages can provide 40% to 50% oxygen.10 Fluid Resuscitation Crystalloids While they are the most important aspect of resuscitation in critical patients, crystalloids should be used with caution because aggressive administration can cause a positive fluid balance (fluid overload), which can be detrimental t the patient.11 Within 30 to 60 minutes of administration,

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With rapid recognition, appropriate treatment, and vigilant monitoring, many patients that suffer from shock can survive.

Colloids The use of hydroxyethyl starch (HES) has been controversial for many years. In human studies, prolonged usage has been shown to increase the risk of acute kidney injury, coagulopathies, and mortality.11 Later-generation colloids (tetrastarches) have been shown to be safer owing to their increased clearance, meaning there is less tissue and plasma retention, which decreases the risk of adverse effects.11 Human studies have shown that while HES restores the effective circulating volume more quickly than crystalloids, overall, there is no difference in benefit between the two with regard to end-point hemodynamic stabilization.11 In these studies, those receiving HES required a lower vasopressin dose and maintained a higher central venous pressure, which is an indicator of blood volume. They also had a more rapid restoration of hemodynamic stability.

Improvements in blood lactate, heart rate, and blood pressure were similar to those receiving crystalloids.11 Human studies have shown that acute kidney damage secondary to use of HES is multifactorial. The hyperviscosity of the colloid causes ischemia leading to acute kidney injury; stasis of flow th ough the kidneys during filtration causes obstruction of the tubular lumen; and osmotic nephrosis causes swelling of the proximal renal tubular cells. Later-generation colloids are less nephrotoxic, but the same complications still occur.11 Human studies have also shown that HES has negative, dose-dependent affects on coagulation. It inhibits platelet adhesion and aggregation by binding to the platelet surface and also decreases the expression of glycoprotein receptors on the surface of the platelet (an important step in platelet adhesion).11 As with acute kidney damage, these complications are more severe with early-generation colloids.11 HES also binds to von Willebrand factor and factor VIII, accelerating their clearance. Clinical bleeding associated with HES administration has not been confi med in studies specific to veterinary medicin 11; however, bleeding complications have been observed in veterinary patients.

For this reason it is important to consider potential complications when using HES in patients with a coagulopathy or renal disease.

Isotonic Crystalloids Studies in human patients have shown that, when given in high volumes and at rapid rates, 0.9% saline has the potential to cause hypernatremia and hyperchloremia because of the high sodium and chloride concentrations.11 An isotonic crystalloid that more closely resembles plasma levels of sodium and chloride is recommended, making lactated Ringerâ&#x20AC;&#x2122;s solution, Normosol-R, and Plasma-Lyte the preferred choices for resuscitation.11 These fluids have been shown to cause fewer complications as well as decrease the risk of mortality.11 Hypertonic Saline Hypertonic saline is a crystalloid solution that contains a higher concentration of sodium and chloride relative to plasma12; however, it is administered in smaller volumes than isotonic crystalloids. Hypertonic saline increases plasma osmolarity, pulling water into the vascular space from the interstitial space, thereby expanding plasma volume. The resulting volume expansion is greater than the volume infused and quickly increases cardiac output and contractility as well as the MAP. This effect lasts anywhere from 20 minutes to 3 hours.12 The smaller volume required makes this an ideal fluid choice for patients that may not tolerate large volumes, such as those with head trauma or cardiac disease.9 Hypertonic saline is is available in several concentrations, ranging from 7% to 23%. Hypertonic saline with a concentration of 7% is safe to use in a peripheral vein, is administered at a dose of 2.5 to 5 mL/kg, and should be given no faster than 1 mL/kg/min. If a higher concentration is used (e.g., 23%), it should be diluted before injecting or it will cause hemolysis. The effects of any concentration of hypertonic saline last longer if it is used in conjunction with a colloid. A 23% concentration of hypertonic saline can be mixed with a colloid at a ratio of 1:2.5.12

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As with all medications, hypertonic saline has unwanted side effects. A transient, dose-dependent increase in sodium and chloride will occur. Pulling fluid f om the interstitial space will worsen any dehydration; therefore, hypertonic saline should be avoided in dehydrated patients.

If used in the face of dehydration, it must be accompanied by an isotonic crystalloid to restore interstitial fluid 12

60% to 80% of crystalloids have diffused out of the vascular space and into the interstitial space.11 Because of this, multiple fluid boluses may be equired.

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In veterinary medicine, the use of vasopressors and inotropic drugs is preferred before risking injury with high volumes of crystalloids and HES.11 Blood Products In patients in a normal resting state, anemia can be well tolerated and oxygen delivery can be maintained.

However, in patients with trauma and acute loss of blood volume, the associated stress, inflammation, and pain contribute to decreased oxygen delivery.2 Patients can tolerate a blood loss of 10% to 15%, but once blood loss reaches 20% of total blood volume, transfusion is required.

Not all patients that are suffering from shock require blood products, but those that do (e.g., patients with hypovolemic shock) benefit f om transfusions. If clotting values are elevated, fresh whole blood or fresh frozen plasma can be administered.1

Gastroprotectants Mucosal damage is common in patients with shock due to stress-related mucosal disease.1 Hypovolemia, decreased cardiac output, and vasoconstriction associated with shock lead to splanchnic hypoperfusion and reduced mucosal blood flo , gastrointestinal motility, and bicarbonate secretion, with subsequent development of an acute stress ulcer.

Options to prevent or treat stress-related mucosal disease include histamine2 receptor antagonists, proton pump inhibitors, and sucralfate. Histamine2 receptor antagonists (famotidine, ranitidine) and proton pump inhibitors (omeprazole, pantoprazole) decrease acid production.14 Sucralfate is a gastrointestinal protectant that forms a paste when it comes in contact with hydrochloric acid, binding to the ulcer site and forming a barrier that prevents additional damage from gastric acids.

Cardiovascular Support Catecholamines are recommended if the patient is not responding to fluid therap . Multiple catecholamine receptors are present throughout the cardiovascular system (TABLE 3). As a result, several catecholamines can be used for cardiovascular support, including dopamine, dobutamine, norepinephrine, vasopressin, and epinephrine.

Antiemetics Patients experiencing shock may also develop nausea and may benefit f om antiemetics (dolasetron, maropitant citrate) to address or prevent vomiting.

Additional Therapies

Physical Examination Physical monitoring is ideal and should include palpating pulses and noting their strength, auscultating the heart while palpating the pulse and noting any asynchronous pulses, and closely watching mucous membrane color as well as the capillary refill time. Auscultating the lungs and noting any increase in respiratory rate and effort are also vital.

Hypoxia can be indicated by dyspnea, tachypnea, anxiety, or restlessness. Cyanosis also indicates hypoxia, but it is important to understand that a hemoglobin concentration >5 g/dL is necessary to detect cyanosis. If the hemoglobin concentration is lower than this, a hypoxic patient will not appear cyanotic.10

Antibiotics Antibiotics should be administered within 1 hour of suspicion or diagnosis of sepsis because delay of antibiotic administration is associated with increased mortality.1 In the authorâ&#x20AC;&#x2122;s experience, use of broad-spectrum antibiotics is recommended because it is unlikely a specific pathogen can be identified within this time frame.

TABLE 3 Catecholamine Receptors and Locations13 RECEPTOR TYPE

LOCATION

Alpha-1 Beta-2

Vascular smooth muscle

Beta-1

Myocardium

Dopaminergic-1

Renal, coronary, and mesenteric microvasculature

Dopaminergic-2

Synaptic nerve terminals

Vasopressin-1

Vascular smooth muscle

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MONITORING Monitoring the patient during and after resuscitation is very important.

Blood Analysis Packed cell volume indicates the potential oxygen-carrying capacity of blood. The hemoglobin content of the blood can be estimated as one-third of the packed cell volume; for example, a patient with a packed cell volume of 30% is expected to have a hemoglobin content of 10 g/dL. A hemoglobin concentration >8 g/dL is necessary to maintain oxygen delivery.1 Total protein should be

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TECHPOINT

Peer-Reviewed

evaluated in conjunction with the packed cell volume. A total protein <3.5 g/dL indicates that oncotic pull is less than adequate and colloids would be beneficial 1 Serial blood lactate monitoring provides information regarding the patient’s perfusion status and helps guide fluid therap . Lactate is produced when oxygen delivery is minimal. When blood lactate levels are elevated, hypoperfusion is already present. The degree of hypoperfusion can be estimated based on the blood lactate value. The normal blood lactate level is <2 mmol/L. Mild hypoperfusion is indicated by a blood lactate level of 3 to 4 mmol/L, moderate hypoperfusion by a level of 4 to 6 mmol/L, and severe hypoperfusion by a level of >6 mmol/L.15 Once perfusion is restored, the blood lactate level should drop rapidly. Serial lactate monitoring is more useful than a single measurement.16 Blood Pressure Blood pressure monitoring is important when evaluating cardiovascular status. Direct, invasive blood pressure monitoring is the gold standard but is not widely available. Indirect, noninvasive monitoring is often more practical and can be conducted via Doppler ultrasonic or oscillometric methods.1 Cuff size should be appropriate: in dogs, the cuff width should be 40% of the circumference of the leg at the chosen location; in cats, the circumference should be 30% to 40%.1 A cuff that is too large will result in a falsely decreased reading, while the reading will be falsely elevated with a cuff that is too small. With the patient in lateral recumbency, the cuff should be placed over a peripheral artery at the level of the heart.1 Readings are more accurate if the cuff is placed above the carpus (forelimb) or below the hock (hindlimb). Inaccurate results may be obtained if the patient is hypothermic or experiencing vasoconstriction.

A clear understanding of the pathophysiology, clinical signs, and treatment of shock will aid in improving nursing care. experiences hypoxia, cardiac arrhythmias in the form of ventricular premature contractions may be seen. These are not usually a concern unless the heart rate is elevated (>180 beats/min) or they are multifocal.17 Urinalysis Urine output should be monitored closely: in dogs, a urinary catheter can be placed; in cats, a litterbox can be weighed. If the patient does not have a urinary catheter in place or will not use a litterbox, a peri-pad can be placed under the patient and weighed to monitor urine output. Urine output should be at least 1 mL/kg/h when a patient is receiving fluid therap . A decrease in urine output can indicate a decrease in renal function but may also indicate inadequate fluid esuscitation.

In addition to urine output, the urine specific gravit (USG) should be monitored closely. In a dehydrated patient with normal renal function, urine will be concentrated, with a USG >1.045. In a patient that is receiving intravenous fluids and has been adequately esuscitated, USG will be in the range of 1.008 to 1.012 (isothenuria). A USG >1.014 can indicate inadequate fluid esuscitation.

Electrocardiography Monitoring a continuous electrocardiogram allows technicians to evaluate the patient’s heart rate closely without disturbing the patient. If the myocardium

CONCLUSION Technicians play a critical role in the treatment of shock patients. A clear understanding of the pathophysiology, clinical signs, and treatment of shock will aid technicians in improving their nursing care. With rapid recognition, appropriate treatment, and vigilant monitoring, many patients that suffer from shock can survive. 

References 1. Hopper K, Silverstein DC, Bateman S. Shock syndromes. In: DiBartola SP, ed. Fluid, Electrolyte, and Acid-Base Disorders in Small Animal Practice. 4th ed. St. Louis: Elsevier; 2012:557-583.

2. Bliss S. Anemia and oxygen delivery. Vet Clin North Am Small Anim Pract 2015;45(5):917-930.

3. Thomovsky E, Johnson PA. Shock pathophysiology. Compend Contin Educ Pract Vet 2013;35(8):E1-E9.

4. Boulpaep EL. Regulation of arterial pressure and cardiac output. In: Boron WF, Boulpaep EL, eds. Medical Physiology: A Cellular and Molecular Approach. 2nd ed.

Philadelphia: Elsevier; 2009:554-576.

5. Vajdovich P. Free radicals and antioxidants in inflammatory p ocesses and ischemiareperfusion injury. Vet Clin North Am Small Anim Pract 2008;38(1):31-123, v.

6. Schoor CA, Zanotti S, Dellinger RP. Severe sepsis and septic shock. Virulence 2014;5(1):190-199.

7. Worthley LI. Shock: a review of pathophysiology and management. Part II. Crit Care Resusc 2000;2(1):66-84.

8. Boulpaep EL. Integrated control of the cardiovascular system. In: Boron WF, Boulpaep EL, eds. Medical Physiology: A Cellular and Molecular Approach. 2nd ed.

Philadelphia: Elsevier; 2009:593-609.

9. Peterson NW, Moses L. Oxygen delivery. Compend Contin Educ Pract Vet 2011; 33(1):E1-E7.

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10. Manning AM. Oxygen therapy and toxicity. Vet Clin North Am Small Anim Pract 2002;32(5):1005-1020, v.

11. Cazzolli D, Prittie J. The crystalloid-colloid debate: consequences of resuscitation fluid selection in veterinary critical ca e. J Vet Emerg Crit Care 2015;25(1):6-19.

12. Kyes J, Johnson JA. Hypertonic saline solutions in shock resuscitation. Compend Contin Educ Pract Vet 2011;33(3):E1-E8; quiz E9.

13. Haskins SC. Catecholamines. In: Silverstein DC, Hopper K, eds. Small Animal Critical Care Medicine. St. Louis: Elsevier; 2015:829-836.

14. Konturek PC, Brzozowski T, Konturek SJ. Stress and the gut: pathophysiology, clinical

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Shock: An Overview

consequences, diagnostic approach and treatment options. J Physiol Pharmacol 2011;62(6):591-599.

15. Boag AK, Hughes D. Assessment and treatment of perfusion abnormalities in the emergency patient. Vet Clin North Am Small Anim Pract 2005;35(2): 319-342.

16. Laforcade A, Silverstein DC. Shock. In: Silverstein DC, Hopper K, eds. Small Animal Critical Care Medicine. 2nd ed. St Louis: Elsevier; 2015:26-30.

17. Pariaut R. Ventricular tachyarrhythmias. In: Silverstein DC, Hopper K, eds. Small Animal Critical Care Medicine. St. Louis: Elsevier; 2015:255-259.

CE Test Article 2 Shock: An Overview The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

1. Inadequate fluid esuscitation, in the early stages of shock, can be indicated by a. Bradycardia b. Hypertension c. Decreased urine output d. Hyperthermia

6. Adequate fluid esuscitation in a cat may be indicated by a a. USG of 1.010 b. Blood lactate of 4.2 c. Mean arterial blood pressure of 60 mm Hg d. Temperature of 96°F

2. A decrease in oxygen delivery can be seen with an increase in a. Preload b. Afterload c. Heart rate d. Contractility

7. A blood pressure cuff for a canine patient should measure what percentage of the circumference of the patient’s leg? a. 30% b. 40% c. 50% d. 60%

3. Chemoreceptors in the brain respond to a decrease in cardiac output only if it causes a change in blood a. pH b. Lactate c. Pressure d. Hemoglobin

8. Hydroxyethyl starches can cause a coagulopathy by binding to and accelerating clearance of a. Factor III b. Factor VI c. Factor VIII d. Factor XI

4. ___________ increases hemoglobin’s affinit for oxygen. a. Hyperthermia b. Hypercapnia c. Acidosis d. Methemoglobinemia

9. Severe inflammation that causes capillarie to become “leaky” can cause hypovolemic shock via a. Blood loss b. Third spacing c. Dehydration d. Increasing oncotic pull

5. A patient with a packed cell volume of 36% has an expected hemoglobin of a. 3.6 g/dL b. 9 g/dL c. 12 g/dL d. 36 g/dL

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An Official Journal of the N VC

10. Compensatory distributive shock differs from other types of shock in that patients exhibit a. Hypothermia b. Tachycardia c. Prolonged capillary refill tim d. Hyperemic mucous membranes

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Adapted with permission from the 2015 Tampa AAHA Yearly Conference Proceedings ©American Animal Hospital Association (aaha.org).

Peer-Reviewed

Veterinary Technicians and Neurologic Rehabilitation

C

onditions that require neurologic physical rehabilitation in humans include stroke, traumatic brain injury, and spinal cord injury.1 Physical rehabilitation therapy is beneficial and effective to help return or improve function lost as a result of these conditions in some patients.2 Neurologic disease is unique in that physical therapy has a critical role in maintenance and recovery of function. Dysfunction of the nervous system can cause loss of motor and autonomic function and a range of sensory abnormalities, including loss of sensation (analgesia), abnormal sensations (paresthesia), and heightened sensitivity to stimuli (hyperesthesia).3 Articles in the veterinary literature support the usefulness of rehabilitation in recovery from neurologic injury and nonsurgical management of neurologic conditions.4 Several neurologic disorders affecting small animals are amenable to rehabilitation, including paresis, muscle atrophy, muscle contractures, pressure ulcers, and pain.4 Additional indications include postoperative rehabilitation (e.g., intervertebral decompression surgery), central or peripheral nerve injuries, wobbler syndrome, fib ocartilaginous embolism (e.g., type III disc disease), degenerative myelopathy (management of current presenting signs), and balance/vestibular problems.5

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THE ROLE OF VETERINARY TECHNICIANS As part of the veterinary rehabilitation team, credentialed veterinary technicians, under the supervision and direction of licensed credentialed rehabilitation veterinarians, are an integral part of caring for hospitalized recumbent or neurologic patients.

Although technicians can work in this field without being c edentialed, the American Association of Rehabilitation Veterinarians strongly discourages this practice.

Rehabilitation veterinarians examine patients and determine the best treatment options for each patient.

Rehabilitation technicians then carry out prescribed therapies. They also play an integral role in educating clients and communicating with clients about daily progress.

Troubleshooting technique with the prescribed exercises and discussing pain management with supervising veterinarians help ensure that treatment plans are effective.

Physical rehabilitation during recovery from neurologic disorders is important not only for strengthening and increasing flexibility but also for reducing pain and improving quality of life.6 Understanding the potential complications and risks—and implementing strategies to minimize them—can reduce the duration of hospitalization, improve patient comfort, and promote faster return to function. Rehabilitation

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

Mary Ellen is a graduate of Harcum College and the University of Pennsylvania.

She has been an instructor of anesthesia and pain management for VetMedTeam since 2003. In 2007, she became a surgical research anesthetist certified through the Academy of Surgical Research. In 2008, she became the executive secretary of the International Veterinary Academy of Pain Management. In addition, she is on the Proposed Organizing Committee for the Academy of Physical Rehabilitation Veterinary Technicians for the formation of a NAVTA recognized VTS-physical rehabilitation program.

Mary Ellen has written several books and contributed to numerous chapters regarding anesthesia, pain management, and rehabilitation. She has worked in various aspects of veterinary medicine ranging from small animal to zoo animal medicine.

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Rehabilitation technicians carry out prescribed therapies and play an integral role in educating and communicating daily progress to clients.

practitioners or therapists perform neurologic examinations to document patients’ current neurologic status and become familiar with individual animals’ response to therapies to measure progress.

Neurolocalization and determination of the severity of the lesion and pain status are the primary focus of the examination. Deep pain sensation, ability to stand and support weight, duration of disease, and presence of motor and bowel/bladder function are key factors influencing p ognosis for recovery.4 ESTABLISHING RECOVERY GOALS Short-term goals are the component skills established at each phase of rehab that are needed to attain long-term goals. Short-term goals are essentially subskills required for basic daily functional needs (e.g., sitting upright, toileting, eating or drinking with minimal or no assistance) and help identify specific a eas of limitation. Establishing patient needs though goal setting helps formulate the at-home treatment plan given to clients.7 Long-term goals define the patient s expected level of performance at the end of the rehabilitation process.

Technicians note the amount of independence, assistance, supervision, and equipment or environmental adaptation necessary to ensure the safety of pets and clients.

Understanding which problems can be addressed and influenced, and which cannot, is crucial in defini realistic expectations.

RISKS AFFECTING HOSPITALIZED RECUMBENT OR NEUROLOGIC PATIENTS Rehabilitation therapy for neurologic patients places a profound emphasis on nursing and supportive care to protect the patient from complications and preserve tissue strength and function during the recovery period.8 Several adverse conditions can affect these patients (BOX 1).

BOX 1 Conditions Adversely Affecting Hospitalized Recumbent or Neurologic Patients9 Prolonged or permanent loss of mobility and independence secondary to disuse atrophy

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Urine scald Depression Self-inflicted traum

Chronic pain

Reduced lung capacity and compliance

Decubital ulcers

Obesity

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PATIENT POSITIONING Credentialed rehabilitation practitioners or therapists and their credentialed rehabilitation veterinary technicians must be cognizant of the risks facing recumbent patients. Skin, vascular, and pulmonary integrity can be compromised if patients are not turned on a proper schedule. Positioning changes and skin integrity (along with other vital signs) are important and should be noted on patient charts. Patients should be positioned on either side in lateral recumbency, in sternal recumbency, and sitting and standing, if possible.

Bolsters (positioning blocks or rolls of towels) can be used to help patients maintain such postures, keep an extremity in a neutral (i.e., normal) position, and improve patients’ overall visual perspective while hospitalized.10 PAIN ASSESSMENT Neurologic patients are at a higher risk for experiencing pain.11 This may be due to a healing surgical procedure, muscle spasms, or nerve pain. Manual therapy, ice, heat, electrostimulation, and therapeutic ultrasound may be used depending on the severity and phase of recovery (acute versus subacute). Precautions must be taken with each therapeutic modality for patients with altered pain sensation or lack of pain perception. Pain-free animals are relaxed and cooperative and recover more quickly and completely, and owners are much happier and more compliant with recommendations when their pets are comfortable.12 Multimodal pain management is always advisable for painful patients and is recommended by the 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.13 Therefore, pain medications should be used to allow for patient comfort.

THERAPY FOR RECUMBENT PATIENTS Therapy for neurologic patients entails physically challenging them and pushing them to improve, but sessions should end on a positive note with ample praise

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Veterinary Technicians and Neurologic Rehabilitation

BOX 2 Additional Therapeutic Exercises and Options for the Neurologic Patient16 Proprioceptive neuromuscular facilitation (PNF patterns) istock.com/BanksPhotos

Joint distraction (veterinarians only)

Vibration Ice massage Muscle tapping Weightbearing techniques Postural reflexe

Tactile sensory stimuli Tellington touch Wringing the limb Acupressure/laser acupuncture Client education in lifestyle management (accommodations in home environment for patient mobility) during recovery

Rhythmic stabilizations

Treadmill exercise

Ball rocking

Underwater treadmill or supported swimming

Tensor bandaging

Supported standing

Joint compressions (veterinarians only)

and encouragement. The purposes of the exercises are to stimulate proprioceptive fibers, encourage joint flui circulation, and enhance circulation to adjacent tissues.14,15 General guidelines for neurologic rehabilitation include frequent, low-duration exercises to avoid overexertion.

Carts or slings Splints or orthotics

Patients should be encouraged to do as much as possible for themselves within their functional capabilities.

Patients that are unable to support themselves may be encouraged to stand with the assistance of appropriate slings or harnesses while eating and drinking. This helps

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promote strength and is also an excellent opportunity for weightbearing or weight-shifting exercise. Encouraging patients to ambulate and stretch for treats is an easy early mobility exercise. For patients that lack proprioception (awareness of where their body is in space), placing food near their paws and limbs can increase body awareness. A few exercises are described below; more are listed in BOX 2.

Weight-Shifting Exercises Encouraging correct posture is a key component of all mobilization exercises. FIGURE 1 demonstrates correction of hindlimb placement for manual weight-shifting to the hind end. Weight-shifting first to the right side and then to the hind end is accomplished by using a treat. The therapy ball peanut provides the required support for this patient, while the boots and mat improve foot traction.

Postural Transitions Details about the level of assistance patients need to get up from a down position (i.e., slight assistance versus full body support) should be recorded in the medical record.

Example transitions include lateral to sternal recumbency (FIGURE 2), sternal recumbency to sit (FIGURE 3), and sit to stand (FIGURE 4). Assisted sling walking is a great way to provide patients with safe ambulation and weightbearing; several slings are available (FIGURE 5).

NURSING CARE FOR RECUMBENT PATIENTS Patients presenting with neurologic disorders with incoordination (ataxia) or weakness (paresis) have the potential to become recumbent. Because these patients are not steady on their feet, providing nonslippery surfaces is essential. Moreover, recumbent patients require soft bedding that does not “bottom out” to the floor to avoid decubital ulcers (bed sores). Frequent turning schedules help avoid such complications and also prevent hypostatic pneumonia or atelectasis.4,16 BOX 3 provides an overview of additional key therapeutic considerations for neurologic patients.

Bladder Management As a general rule, recumbent patients cannot or will not urinate voluntarily and require frequent bladder assessment

FIGURE 1. Encouraging correct posture is the key component of mobilization exercises. The use of a physioball encourages weightbearing and may be necessary with neurologic patients. Used with permission of The NAVTA Journal.

FIGURE 2. Assisting patients with coordination and flexion of limbs is equired when shifting weight from lateral to sternal recumbency. Using “cookie stretches” (providing the patient with a treat to motivate it to reach further) encourages working muscles necessary for going from lateral to sternal recumbency. Used with permission of The NAVTA Journal.

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STAY ON GARD against heartworm disease PLUS hookworms and roundworms.

1

Data on file at Merial.

®HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved.

HGD15PRETESTTRADEADS (01/16).

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TREATS AND CONTROLS 3 SPECIES OF HOOKWORMS

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

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Peer-Reviewed

or management in the form of catheterization or manual expression. Urinary function usually returns in patients with thoracolumbar disease (only pelvic limbs affected) as soon as they are weakly ambulatory. Patients with cervical disease (all four limbs affected) regain voluntary urination earlier but may be reluctant to urinate because they are unable to adopt a posture for urination. Diseases of the lumbosacral spinal cord are an exception: these patients have urinary difficulties despite etaining the ability to walk.

It is important to teach patient caregivers how to palpate the bladder and assess bladder function.

Understanding patient urinary function is critical to determine whether urination is voluntary. When pressure in the bladder exceeds that of the urethral sphincter, urine will leak out, which may be misinterpreted as voluntary urination. Therefore, other measures are needed to assess the presence of voluntary urination. With proper training, bladder size can be assessed before and after urination.

All urination should be recorded in the medical record, along with a notation of whether it was voluntary, expressed manually, or expelled via a catheter. Urinalysis

should preferably be performed on admission; urine should then be tested with a dipstick for the presence of white blood cells and protein every 2 to 4 days.

Appropriate bladder management in recumbent patients includes regular walks outside (at least 3 times daily) to encourage patients to urinate. For patients unable to urinate, the bladder can be manually expressed, intermittent catheterization can be implemented, or an indwelling catheter can be placed. Urine should be expressed every 4 to 6 hours depending on bladder size, or the urine bag should be checked at the same interval. The amount of urine produced should be noted in the patient record. In addition, prescription medication to aid in bladder voiding can be prescribed at the discretion of the veterinarian.

Additional nursing care includes providing bedding that either absorbs liquids or allows them to pass through and away from the patient’s skin (e.g., acrylic bedding). If incontinence pads are used, care must be taken to avoid placing the pad directly beneath the patient’s skin because the urine simply disperses across the pad, resulting in increased contact time and leading to urine scalds. Acrylic

FIGURE 3. Veterinary technicians can encourage patients to move from sternal recumbency into the sitting position by assisting them with stifle flexion, limb positioning, and co ect foot placement as required. It may be necessary to physically place patients in these positions at the beginning of neurologic recovery. Using cookie stretches encourages the patient to try to place itself. Used with permission of The NAVTA Journal.

FIGURE 4. From a sitting position with stifles in flexion and ap opriate support, technicians can assist patients to stand and sit back down, guiding the animal only as needed. Cookie stretches can be a huge motivation factor for food-motivated patients. Used with permission of The NAVTA Journal.

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Veterinary Technicians and Neurologic Rehabilitation

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.

FIGURE 5. This is a small selection of available slings.

Some slings can be made from bandages or towels; others can be purchased from various vendors. Used with permission of The NAVTA Journal. absorbent bedding should be placed directly beneath the patient, followed by the incontinence pad; this prevents multiple layers of bedding from becoming soiled and avoids having recumbent patients lie in their own urine. Finally, patients should be kept clean and dry at all times. Soiled bedding should be removed promptly.

Long hair should be clipped if necessary to enable hygiene management and allow accurate assessment of the development/progression of urine scalding.

Bowel Management Fecal incontinence mainly affects dogs with severe lumbosacral disease, which can lead to a lack of voluntary control over defecation and severe soiling. Cats with neurologic problems have a tendency toward constipation and megacolon. Patients must be kept clean and dry at

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.

Keep this and all drugs out of the reach of children.

In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans.

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

BOX 3 Key Therapeutic Points18

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.

Bladder care must be initiated for incontinent animals to prevent atony and treat infections.

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.

Attention to bedding and hygiene helps prevent decubital ulcers.

Neuromuscular electrical stimulation may be used to strengthen muscle.

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.

Massage can reduce muscle spasms and pain.

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.

Passive range of motion is used to maintain joint motion and health.

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.

Assisted standing, balancing, and various types of exercise are incorporated, depending on the animal’s neurologic status.

®HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved. HGD15PRETESTTRADEADS (01/16).

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all times. Lactulose may be used, especially in cats, if constipation is suspected; unlike the situation in dogs, manual evacuation is difficult in cats. In addition, patient receiving opioid analgesia should be monitored closely for constipation due to reduced intestinal motility, and pelvic trauma patients should be monitored for tenesmus. Both patient groups may need treatment to aid in defecation.

Respiration Recumbency alone can lead to secondary complications, including atelectasis and aspiration pneumonia independent from the disease process itself. Hypoventilation can also be caused by neurologic disease processes severe enough to cause recumbency in all four limbs (e.g., a slipped disc in the neck, brain disease). Patients with generalized lower motor neuron disease affecting the laryngeal and pharyngeal muscles and the esophagus (e.g., myasthenia gravis) are particularly predisposed to aspiration pneumonia.

The respiratory pattern and rate should be recorded on a regular schedule: up to every 4 to 6 hours in severely affected patients, less often in stable patients. If aspiration pneumonia is suspected, temperature should be checked at least twice daily to monitor for pyrexia (raised body temperature or fever).

Preventive nursing care is crucial for a positive outcome in these patients. Several measures can be taken to help prevent respiratory complications. Patients should be turned every 4 to 6 hours, with the goal of maintaining a sternal position as often as possible using appropriate padding. The details of each change of position should be noted in the medical record (e.g., from sternal to left lateral to sternal to right lateral to sternal).

Water and food should be offered only when patients are in a sternal position. Someone should sit with patients while they eat. It is beneficial for patients to maintain an upright position for 30 minutes after feeding to decrease the risk of regurgitation and aspiration pneumonia.

Coupage, also known as percussion therapy, is indicated for dogs with pneumonia to dislodge mucus that can then be expelled from the body while coughing.

If tolerated, coupage should be performed each time patients are turned if aspiration or hypostatic pneumonia is suspected; however, radiologic evaluation should be carried out to confi m pneumonia and repeated to monitor progress or deterioration in lung fields. Coupag is contraindicated in thoracic trauma patients. Thoracic auscultation should be performed at least once daily to identify abnormalities, which should be reported to the veterinarian immediately. Postural physiotherapy 40

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techniques can also be implemented to aid in removal of excess secretions in combination with nebulization and coupage.

Skin Care Recumbent patients are at risk for developing dermatitis secondary to urine scald and fecal soiling and even more so for the development of decubital ulcers over pressure points. In addition, skin abrasions can develop if patients drag themselves or a limb over rough ground. Several steps can be implemented to prevent skin complications.

In addition to the guidelines presented under BLADDER MANAGEMENT, appropriate padding should be used around pressure points, and bony prominences/pressure points should be systematically checked twice daily to monitor for skin redness or early development of decubital ulcers. Regular turning (every 4 to 6 hours, as discussed above) and massage of prominences/pressure points to increase local blood flow can help p event skin problems.

Treatment of Skin Complications Skin complications may develop despite good nursing care. Veterinarians must assess patients and prescribe any medications or therapy. The veterinarian may also recommend the following measures: Dermatitis can be cleaned with a dilute chlorhexidine solution followed by thorough drying and application of a barrier cream.

Excessive moisture around affected areas must be avoided, as should application of thick layers of barrier cream; the latter harbors and insulates bacteria.

Applying a dilute solution of bicarbonate of soda and cooled boiled water is very effective for urine scalds or irritation of the testes. The area should be doused and left to dry at room temperature. This can be repeated 3 to 4 times daily.

If decubital ulcers develop, pressure over that region must be avoided. This can be accomplished by using a cushion (doughnut).

Dead tissue can be debrided.

Elizabethan collars should be used to prevent patients from licking or chewing the region.

CONCLUSION Neurologic rehabilitation can be among the most challenging and rewarding work for the veterinary team. Determining time for recovery is often the most difficult task. Recovery times can be extremely variable and are intrinsically linked to the neurologic condition, underlying medical conditions, and neurologic status at time of presentation for rehabilitation.4

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Veterinary Technicians and Neurologic Rehabilitation

The time needed for treatment by both the veterinary team and owners must be considered. It is often not feasible to perform all exercises and modalities for a single patient, and some exercises may not be applicable or possible in certain patients. Each patient requires an individualized rehabilitation protocol specifically designed for the neu ologic condition, owner

expectations, level of participation and time commitments of caregivers, and expertise of the veterinary team.

Credentialed rehabilitation veterinary technicians are the “eyes and ears” for rehabilitation veterinarians and physical therapists. They are the ones educating clients and performing recommended treatments. 

References 1. Jorge LL, de Brito AM, Marchi FH, et al. New rehabilitation models for neurologic inpatients in Brazil. Disabil Rehabil 2015;37(3):268-273.

2. Brody LT. Mobility impairment. In: Hall CM, Brody LT, eds. Therapeutic Exercise: Moving Toward Function. Philadelphia, PA: Lippincott Williams & Wilkins;1999:57-83.

3. Olby N, Halling KB, Glick TR. Rehabilitation for the neurologic patient. Vet Clin North Am Small Anim Pract 2005;35(6):1389-1409.

4. Drum MG. Physical rehabilitation of the canine neurologic patient. Vet Clin North Am Small Anim Pract 2010;40(1):181-193.

5. Sharp B. Companion animal practice: Physiotherapy in small animal practice. In Practice 2008;30:190-199.

6. Lorenz MD, Coates JR, Kent M. Pain. In: Handbook of Veterinary Neurology. 5th ed.

St. Louis, MO: Elsevier/Saunders; 2010:429.

7. Sturges BK, Woelz J. Physical rehabilitation for the neurological patient. 2nd Annu Proc Vet Neurol Symp 2005. University of California, Davis. www.ivis.org/ proceedings/neuroucdavis/2005/sturges2.pdf. Accessed December 9, 2015.

8. Sims C, Waldron R, Marcellin-Little DJ. Rehabilitation and physical therapy for the neurologic veterinary patient. Vet Clin North Am Small Anim Pract 2015;45(1):123-143.

9. Abramson CJ. Nursing care for the “down” dog. Proc Am Anim Hosp Assoc Conf 2009:721-722.

10. Francis M. Rehabilitation for patients with neurological diseases. Proc ACVIM Forum 2007. June 6-9; Seattle, WA. www.vin.com/members/cms/project/defaultadv1.aspx?pId=

11237&meta=Generic&catId=31866&id=3860398. Accessed November 20, 2015.

11. Thomas WB, Olby N, Sharon L. Neurologic conditions and physical rehabilitation of the neurologic patient. In: Millis D, Levine D, eds. Canine Rehabilitation and Physical Therapy. 2nd ed. Philadelphia, PA: Saunders/Elsevier; 2014:609-627.

12. McCauley LM, Van Dyke JB. Therapeutic exercises. In: Zink MC, Van Dyke JB, eds.

Canine Sports Medicine and Rehabilitation. Ames, IA: Wiley-Blackwell; 2013:132-157.

13. Epstein ME, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain management guidelines for dogs and cats. J Am Anim Hosp Assoc 2015;51:67-84.

14. Panko J. In hospital rehabilitation of recumbent and neurologic patients. NAVTA J 2014 June/July:18-25.

15. Edge-Hughes L. Therapeutic exercises for the neurological patient. The Canine Fitness Centre. 2013. www.caninefitness.com. Accessed November 20, 2015.

16. Olby N. Patients with neurological disorders. In: Lindley S, Watson P, eds. BSAVA Manual of Canine and Feline Rehabilitation, Supportive and Palliative Care: Case Studies in Patient Management. Gloucester, UK: BSAVA; 2010:168-193.

17. Calvo G. Rehabilitation nursing goals. Proc WSAVA/FECAVA/BSAVA World Congress 2012. Apr 12-15; Birmingham, UK. www.vin.com/members/cms/project/defaultadv1. aspx?pId=11349&meta=VIN&catId=34744&id=5328190. Accessed November 20, 2015.

18. Davidson JR. Rehabilitation of spinal cord injury. Proc 81st Western Vet Conf 2009.

Feb 15-19; Las Vegas, NV. www.vin.com/members/cms/project/defaultadv1.aspx?pId= 11277&meta=VIN&catId=33036&id=3985430. Accessed November 20, 2015.

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Career Challenges

Keeping It Fresh: How to Rejuvenate Your Career

W

ould you like to be more appreciated for, challenged by, and rewarded for the way you take care of your patients, educate clients, assist your teammates, and build your current practice?

What about growing in a new position within your practice? Do you take advantage of continuing education (CE) opportunities from multiple sources? This article reviews options to assist you in expanding your veterinary medical knowledge by using continued learning and education to become more invested in your career and embracing change.

Jennifer Yurkon, CVT Altitude Veterinary Consulting Wellington, CO Jennifer grew up on a dairy farm in Western New York, where she quickly learned that she loved to take care of animals. In SUNY Delhi’s Veterinary Science Technology program, she discovered that she not only enjoyed being part of a nursing team, but also had a knack for leading one.

Since that time, she has taken on many leadership roles in veterinary medicine.

BE OPEN TO CHANGE All too often, we as veterinary technicians become complacent with our day-to-day routines and end up resisting change because we fear the unknown. When this happens, it does not take us long to begin to feel stagnant in our careers. We forget what made us want to become a part of this amazing profession in the first place, and going to work every day becomes “just a job.” If you feel this way, you are not alone! Fear of change is a huge factor inhibiting our ability to grow in our careers and our personal lives. One of my favorite books is Who Moved My Cheese?, by Spencer Johnson, MD.1 Dr. Johnson discusses change and fear as we grow in our lives and adapt to new situations. Although the story is

istock.com/svetikd

Jennifer and her husband are owned by an Australian shepherd, Roo; a Boston terrier, Zoom; two cats, Stinger and Chewy; and a “very boisterous” guinea pig, Miss Piggy. They are both active in the Larimer County 4H program, especially with meat quality assurance and dairy cattle projects, and attend numerous continuing education meetings for veterinary medicine.

TECHNOLOGY OPTIONS Webinars, teleconferences, and self-paced programs are excellent ways to get CE when you can’t take the time away from the practice to go in person.

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T E CHP O I N T

Career Challenges

Change is inevitable, and how we deal with it shapes our future path.

Are you ready for change?

CONTINUE TO LEARN The challenges we face in practice every day are real. They range from burnout to compassion fatigue, difficult and dangerous work, bullying, underappreciation, long hours, and low wages. However, we also experience inspiration, satisfaction, and miracles on a regular basis. This is what keeps us going through the difficult times and eminds us why we got into this field in the first place. Sometim we need something more, though. Setting goals and working toward achieving them can provide you with the motivation you need to feel useful, accomplished, and fresh in your career. My grandfather taught me to strive to learn something new every day. This mantra has served me well throughout my life and has always challenged me to reach new heights. CE has afforded me the opportunity to make this a reality.

There are many options for CE events that you can attend in person. National conferences like the North American Veterinary Conference (NAVC), CVC, Western Veterinary Conference (WVC), and American Veterinary Medical Association (AVMA) Annual Convention take place throughout the year. Local and state conferences and symposia held at larger practices are also great opportunities.

Attending conferences in person has advantages. In addition to some well-deserved time away from your normal routine, you have the opportunity to connect with like-minded individuals and share insights, ideas, and experiences. You also have the opportunity to visit with the many vendors who attend these events. Exhibit halls are a great place to network and learn about new products, current trends in technology, and advancements to make your patients’ lives happy and healthy.

If you have difficulty getting to CE events in person there are several other ways to participate in learning opportunities. Technology is an increasingly pervasive force in our society. Do you take advantage of the online options available to you? Webinars, teleconferences, and self-paced programs are excellent ways to get CE when you can’t take the time away from the practice to go in person.

PLAN TO GROW Does your practice evaluate your skills, abilities, and knowledge on a regular basis? Have you identified you personal areas for growth and improvement? Performance evaluations can be intimidating if you are worried about what your employer may identify as areas of needed improvement. However, evaluations can also be empowering. Hold yourself accountable for your actions, take feedback to heart, make an honest effort to realize where you can improve, and then take action. Although many of the practices I worked in provided financia compensation for CE, I was the one who was most responsible for my own personal development. Blackwell’s suggests creating your own “individual development plan.”

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These plans outline a 70/20/10 model of development, in which 70% of learning is acquired through on-the-job training, 20% from mentoring, and 10% from CE.2 Having a plan of action can help you decide which CE options will help you maximize your growth potential.

Many states require CE and personal development for credentialed veterinary technicians. To find out what your state requirements are, you can contact the National Association of Veterinary Technicians in America (navta. net) or your state professional licensing department.3

simple, the message is powerful: change is inevitable, and how we deal with it shapes our future path. Are you ready for change?

When I look back on my career, I realize how important change was in leading me to develop new skills, follow new career paths, and foster new interests. In each practice where I have worked, I was fortunate to have owners who provided compensation for my continued education.

According to Blackwell’s 2014 Five-Minute Veterinary Practice Management Consult, 64% of responding practices pay a CE allowance to their full-time veterinary technicians.

The median allowance value in 2014 was $300.2 We need to use the allowances our practice owners have allotted for our education and growth and take advantage of every opportunity. Does your current employer offer a CE allowance? Your success in your career and in the practice hinges on it.

For me, each new challenge in my career presented me with an opportunity to step out of my comfort zone and explore new horizons. Change may be something personal, such as developing new ways to communicate with peers and clients, or professional, such as learning how to care for a species you are unfamiliar with. Regardless, there are many resources available to make your learning experiences and transitions smooth and successful.

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In addition to online programs, mobile apps are becoming quite popular. They include formularies, dosage calculators, study aids, and more, and are designed to assist you in improving efficiency and contributing to your knowledge base. Taking the time to explore some of these options and bringing them to your practice will benefit you and your team What if you can’t go to a conference in person, or technology is not your thing? You can seek out in-practice education opportunities. Lunch-and-learns are a great option. Whether provided by the doctors in your practice or by preferred vendors, these brief sessions allow you to fit education opportunities and lunch into your busy schedule. Multitasking at its best!

SHARE YOUR PROGRESS Regardless of how you take advantage of technology and learning opportunities, it is important to share what you learn. Bring the information back to your team. Write a brief summary or prepare a presentation and share your knowledge. This is the best way not only to digest what you have learned and integrate new ideas, skills, and procedures into your current practice but also to demonstrate the value you bring to the practice. Your practice owners will appreciate your efforts and will be more likely to invest in your CE and that of the whole team. To realize the full reward of sharing and implementing what you’ve learned, think like your practice owner. This may help you understand how you can improve practice profitability and communicat the value and importance of what you’ve learned.

The end result of continued learning is continual growth, leading to improved patient care, client care, and success for the practice.

What keeps you motivated in your current position as a veterinary technician? What are you most passionate about? When you consider your CE and the areas of change that you would like to see within your practice, concentrate on the aspects you are most interested in.

Pursuing these goals will bring personal fulfillment and serve as the catalyst to stimulate furthering your education and that of your teammates. Your fellow team members will be motivated to pursue further education in the areas they are passionate about and will bring that knowledge back to the practice. The end result of continued learning is continual growth, leading to improved patient care, client care, and success for the practice. Everybody wins.  References 1. Johnson S. Who Moved My Cheese? New York, NY: G. P. Putman’s Sons; 1998.

2. Ackerman L. Blackwell’s Five-Minute Veterinary Practice Management Consult. 2nd ed. Ames, IA: Wiley-Blackwell; 2014: 300, 301, 532, 533.

3. National Association of Veterinary Technicians in America website. www.navta.net.

CONTINUING TO LEARN National conferences offer the opportunity to connect with like-minded individuals; share insights, ideas, and experiences; and visit with vendors. Exhibit halls are a great place to network and learn about new products, current trends in technology, and advancements to make your patients’ lives happy and healthy.

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CE

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ARTICLE 3 1 CR E DIT

The Ins and Outs of Managing Feline Chronic Kidney Disease

M

Melanie Codi, LVT, CVT, VTS (Nutrition)

anaging chronic kidney disease in cats can be a daunting task and is often frustrating for owners as well as practitioners and technicians. The goal in managing chronic renal disease is not to reverse the disease but to help maintain and/or improve the petâ&#x20AC;&#x2122;s quality of life, offer support for the owners, and slow progression of the disease through various treatment options.

Cornell University Veterinary Specialists Stamford, CT

WHAT DO THE KIDNEYS DO? The kidneys play a major role in maintaining homeostasis within the body. Their primary responsibilities are to excrete water-soluble waste through the urine, help with endocrine function (by producing erythropoietin, angiotensin II, and calcitriol), maintain electrolyte balance, and filter toxins out of th blood. Nephrons (the functional units of the kidney) are made up of many parts, each playing a vital role in maintaining homeostasis (TABLE 1).

Compared with other species, cats have a high proportion of nephrons with longer loops of Henle, allowing their urine specific gravity to exceed 1.080 in some cases.1 Thus, dilute urine in a cat can be of concern, and further diagnostic testing may be needed to determine the cause.

Some patients with early kidney disease may present for a regular examination with no clinical signs, 46

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

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and an elevated creatinine level may be an incidental finding. Others may present with intermittent or acute vomiting, polyuria and/or polydipsia, lethargy, dehydration, weight loss, decreased appetite, or anorexia.

Patients may need further workup to determine the cause of these clinical signs; if serum creatinine levels are elevated, further diagnostic and laboratory tests are indicated to rule out other causes and/or stage kidney disease.

STAGING KIDNEY DISEASE Before kidney disease is treated, patients should be staged with the International Renal Interest Society (IRIS) staging system (TABLE 2). This system is based on laboratory tests and clinical signs. It is important to know the serum creatinine concentration in all diagnosed cats to develop a treatment plan, even before substaging can begin.

However, creatinine levels can be influenced by many factors, including dehydration and cachexia.

These values must be rechecked in dehydrated patients after they have become adequately hydrated to determine whether dehydration is a contributing factor. Factors for substaging include urine protein:creatinine ratios and arterial blood pressure measurements. A comprehensive guide on IRIS staging can be found at www.IRIS-kidney.com.

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TABLE 1 Components of Nephrons COMPONENT

FUNCTION

Proximal tubule

Reabsorbs glucose, amino acids, bicarbonate, filte ed protein, and phosphate

Loop of Henle (ascending and descending limbs)

Enables urine to be concentrated; generates urea

Distal tubule

Controls sodium, potassium, calcium, and hydrogen ions

Collecting duct

Facilitates urea and water permeability and reabsorption of water

New testing/staging for renal disease includes symmetric dimethylarginine (SDMA) testing (available through IDEXX Laboratories). This test is an endogenous marker of glomerular filtration rate, and its esults may aid in the treatment of chronic kidney disease in cats, helping healthcare providers recognize which patients are at risk before creatinine levels become elevated.

measurable amounts of urea in blood) and uremic (showing clinical signs associated with urea in blood) are often nauseous and at risk for becoming anorectic; thus, to prevent anorexia and hepatic lipidosis, it is preferable for these cats to eat some of the “wrong” diet than none of the “right” diet. To avoid the development of food aversion, prescription renal diets should not be introduced to hospitalized patients. These diets should only be fed to patients that feel well enough to eat them in a stress-free environment. Many factors go into making a feline prescription renal diet, and some nutrients are more important than others in terms of managing this disease.

TABLE 3 outlines key nutritional recommendations for cats with chronic kidney disease.

NUTRITIONAL MANAGEMENT OF FELINE KIDNEY DISEASE The goals of nutritional management in feline kidney disease are to slow progression and control signs of uremia to achieve and/or maintain a better quality of life for patients. However, patients that are azotemic (have

TABLE 2 International Renal Interest Society Staging System for Chronic Kidney Disease in Cats STAGE

FELINE SERUM CREATININE LEVELS (mg/dL)

I

<1.6.

II

1.6–2.8

Mild azotemia; clinical signs absent or mild

III

2.9–5.0

Moderate azotemia; clinical signs present

IV

>5.0

COMMENTS Nonazotemic; +/– abnormal renal palpation; trending increase in creatinine concentrations

Severe azotemia; clinical signs present

Urine Protein:Creatinine Value

Substage

<0.2

Nonproteinuric (NP)

0.2–0.4

Borderline proteinuric (BP)

>0.4

Proteinuric (P)

Systolic Blood Pressure (mm Hg)

Arterial Pressure (AP) Substage/Renal Damage

<150

AP0 (minimal risk)

150–159

AP1 (low risk)

160–179

AP2 (moderate risk)

>180

AP3 (high risk)

International Renal Interest Society. IRIS Staging System for CKD. www.iris-kidney.com/pdf/n378.008-iris-website-staging-of-ckd-pdf.pdf. Accessed December 2, 2015.

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TABLE 3 Key Nutritional Factors/Recommendations for Cats with Chronic Kidney Disease3 DIETARY COMPONENT

RECOMMENDATION

Water

Parenteral fluids if dehydrated; ecommend canned/moist foods; free-choice water

Protein

28%–35% (dry-matter basis)

Phosphorus

0.3%–0.6% (dry-matter basis)

Sodium

<0.4% (dry-matter basis)

Potassium

0.7%–1.2% (dry-matter basis); if cat is hyperkalemic, switch to lower-potassium food

Water Water intake is of utmost importance in all kidney patients.

Polyuria can quickly lead to dehydration. Frequent vomiting and bouts of anorexia also contribute to dehydration in these patients much more quickly than in healthier cats.

Feeding canned diets that are high in moisture (>75% as-fed basis), adding water to the existing canned or dry diet, and making sure all water bowls are cleaned daily may encourage water consumption. Circulating water fountains can be provided for cats that like to drink running or dripping water, and multiple water bowls should be offered throughout the home. Also, the size and depth of water bowls may need to be considered, and different types of water (e.g., distilled, warm, cold) may need to be tried.

Canned diets are preferred because of their water content.

When further diluting diets to increase water consumption, it must be taken into consideration that the calorie:volume ratio is also being diluted, and pets may need to consume a greater volume of food to maintain body weight.

Energy Requirements and Calories Renal patients should be offered a variety of foods to see which they prefer, although preferences may differ from day to day and even meal to meal. Many flavors an consistencies of food are available, and getting patients to consume enough calories to prevent fat and muscle loss is imperative. Cats should consume sufficient calories t maintain their body weight and meet their daily energy requirement (BOX 1). Because fat contains more than 2.5 times more calories than protein and carbohydrates, higher-fat diets are often used in kidney patients; kidney diets are therefore more palatable and energy dense.

Feeding several small meals daily helps patients reach their energy requirements and minimizes nausea associated with gastric distention and bilious vomiting syndrome.

Protein Protein restriction is much discussed and extremely controversial in managing kidney disease in animals.

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Depending on the stage of renal disease, protein restriction may be warranted. It is not clear whether dietary protein levels are detrimental to managing kidney disease, but supplying enough high-quality protein to maintain muscle mass while moderately restricting protein intake helps decrease urine protein:creatinine ratios and improve signs of azotemia.2,3 Uremia and azotemia stem from degradation of endogenous protein, such as catabolism of muscle for energy, and excessive dietary protein. A high-quality, moderately protein-restricted diet is recommended in IRIS stages III and IV and whenever clinical signs of kidney disease are present. Feeding such a diet decreases nitrogenous waste while supplying adequate protein to help prevent muscle loss, hypoalbuminemia, anemia, and amino acid deficienc . Although providing a moderately protein-restricted diet will not slow the rate of disease progression, it has been shown to help with signs of uremia and to improve blood urea nitrogen levels,2 which can help the pet feel better, thus, hopefully, leading to a better quality of life. Protein restriction should not be implemented unless renal patients have clinical signs of disease, such as nausea, vomiting, and lethargy. No studies have been published indicating that a high-protein diet is a primary cause of kidney disease, but moderate protein restriction has been shown to be beneficial in patients with existing renal disease and clinical signs.2,3 Phosphorus Phosphate retention, caused by reduced glomerular filtration of phosphorus, is ext emely common in kidney disease. Phosphate retention can lead to secondary hyperparathyroidism and hypocalcemia, as well as renal mineralization, further contributing to renal damage.3 The increase in phosphate causes parathyroid hormone to be secreted, which in turn triggers the release of phosphate from bone. Release of parathyroid hormone in these patients is counterproductive and can lead to hypocalcemia. The first step in minimizing phosphorus

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T E C HP O I N T

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Renal patients should be offered a variety of foods to see which they prefer, although preferences may differ from day to day. Getting patients to consume enough calories to prevent fat and muscle loss is imperative.

OTHER FACTORS TO CONSIDER B Vitamins Because of anorexia, dehydration, and polyuria associated with chronic kidney disease, vitamin B supplementation may be warranted. B vitamins are water soluble, and kidney patients are likely to become deficient th ough water losses.

Blood tests can be used to assess cobalamin (B12) and folate (B6) levels, but patients eating a complete and balanced commercial kidney diet may not need extra supplementation unless they have underlying gastrointestinal disease; some of these vitamins can be synthesized by the intestinal bacteria and are absorbed by parts of the small intestine.

The easiest supplementation in patients that are dehydrated and/or anorectic is subcutaneous or intravenous administration of a vitamin B complex or subcutaneous administration of vitamin B12 on a strict schedule.

Sodium Sodium restriction is another controversial topic in the management of feline kidney disease. Previously, it was thought that excessive sodium intake could be detrimental to the kidneys and cause hypertension. Managing hypertension in feline patients is important because of the potential secondary effects of chronic hypertension, such as further kidney, eye, heart, and brain damage. There have been no studies showing that sodium restriction controls hypertension or slows disease progression in cats.2 Currently, antihypertensive medications are considered the standard of care for cats with hypertension, rather than dietary sodium restriction. However, dietary sodium restriction may still be warranted to help reduce oxidative stress and sodium retention in feline kidney patients. Most prescription diets that are considered “renal friendly” contain low amounts of sodium and phosphorus and a moderate amount of high-quality protein.

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Potassium Hypokalemia can develop because of increased loss of potassium through the kidneys, inadequate dietary potassium intake, or acidifying diets.2 Signs of hypokalemia include generalized muscle weakness and a stiff gait. Hypokalemia has been shown to decrease the effects of antidiuretic hormone, leading to polyuria. Impaired protein synthesis and weight loss are also significant side e fects of hypokalemia.

Supplementation should be considered in patients that have renal disease and a low serum potassium concentration. Potassium supplementation in the form of potassium gluconate or potassium citrate is often recommended, while potassium chloride should be avoided because of its acidifying properties.2 Hyperkalemia can result in anuria or oliguria in kidney patients and is considered a medical emergency.

Hyperkalemia can cause cardiac arrhythmias, and patients must be placed on continuous electrocardiographic monitoring and treated with medications to facilitate excretion of potassium. In patients that are nonsymptomatic and nonoliguric, long-term treatment may be necessary.

retention is to decrease dietary phosphorus intake, to help slow the progression of kidney disease. Within 2 to 4 weeks of initiating a phosphorus-restricted diet, plasma phosphorus levels should be rechecked to make sure they are decreasing. If they remain unchanged or if the patient will not eat a reduced-phosphorus diet, intestinal phosphate binders may need to be prescribed by the veterinarian. Intestinal phosphate binders help patients excrete phosphorus through the gastrointestinal tract instead of through the kidneys, thus decreasing the workload on the nephrons.

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Omega-3 Fatty Acids The use of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) along with antioxidants (vitamins E and C) has been shown to reduce renal oxidative damage in dogs, but no studies have been done in cats.3 Adding fish oil with th correct EPA and DHA doses may be beneficial to feline kidne patients; however, administration must be initiated with caution, because diarrhea and decreased platelet adhesion |

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leading to anemia are potential side effects. Because of the potential complications, this therapy is recommended only in patients that are euhydrated and stable.

Acid–Base Balance The kidneys play a significant ole in the regulation of acid–base homeostasis. Cats that present with kidney disease are often acidotic because of their inability to excrete hydrogen ions and reabsorb bicarbonate. Metabolic acidosis can increase the catabolism of muscle and decrease the formation of bone mineral. Metabolic acidosis is also responsible for renal azotemia and can worsen hypokalemia as a result of potassium moving out of the cells and into the urine. Alkalinization therapy (e.g., sodium bicarbonate, potassium citrate, calcium carbonate) is often recommended in patients with chronic acidosis to prevent the effects of

BOX 1 Calculating Daily Energy Requirement for Neutered Cats with Renal Insufficiency3 RER = 70(BWkg)0.75 DER (kcal) range = 1.1 × RER to 1.4 × RER For example, in a 4-kg cat: 70(4 kg)0.75 = 198 kcal/day = RER RER

× 1.1 = 218

RER

× 1.4 = 277 kcal/day

DER range = 218–277 kcal/day To calculate this, input the following on a calculator: 1. BWkg

× BWkg × BWkg (4 x 4 x 4) = 64

2. √, √ (hit square root twice) = 2.82 3.

× 70 = (multiply by 70, then equal sign to get the RER) = 198

4.

× 1.1 = (multiply by 1.1, then equal sign

to get the low end of the DER range) = 218

5. Clear 6. 198 × 1.4 = (to get the high end of the DER range) = 277 BWkg = body weight in kilograms DER = daily energy requirement RER = resting energy requirement (amount of calories needed to perform essential body functions)

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catabolism, nausea, and vomiting. Acidifying diets (such as diets formulated for struvite crystalluria) should be avoided.

If multiple disease conditions exist concurrently, consultation with a veterinary nutritionist may be warranted to determine the best dietary option.

Constipation Dehydration, decreased gastrointestinal motility, and side effects of medications often lead to constipation in cats with kidney disease. Ensuring hydration by providing enteral or parenteral fluids may help with ch onic constipation issues; stool softeners, laxatives, and increasing moderately fermentable fiber intake may also be beneficia WHAT IF THEY WON’T EAT? Transition to a new food should be gradual over 14 to 28 days, and diets should be started in a nonstressful environment. Coaxing techniques can be used to encourage pets to eat. As mentioned, the risk for food aversion can be reduced by not introducing renal diets while patients are hospitalized. Warming food and offering different textures (canned, dry, morsels, etc.) can help encourage pets to eat.

Hand feeding and providing different feeding areas in the home can be beneficial. ide, shallow bowls should be used to prevent the whiskers from touching the sides of the bowl. Also, elevated feeding bowls can provide relief in older cats with arthritis or hypokalemic patients with muscle weakness. Veterinarians may prescribe appetite stimulants (e.g., mirtazapine, cyproheptadine, catnip); side effects associated with these medications can differ among patients, so owners and doctors must weigh the benefits and risks. Antinausea medications can also be beneficial in azotemic patients that may have a decreased appetite due to gastric uremia, nausea, and/or vomiting.

Tuna juice, gravy, or low-sodium chicken broth (without onions or garlic) can be mixed with or placed on top of food to coax eating and increase water consumption. These items are sometimes high in sodium and are not complete and balanced, so they should be used only through the transition period, not long term.

For cats that are not eating enough to maintain body weight, feeding tubes may needed. Nasogastric tubes work well for hospitalized patients that are not stable enough to undergo anesthesia; however, the small diameter of the tube limits feeding choices to liquid-only diets. Esophagostomy tubes require anesthesia, but placement is a quick procedure and the tubes are easily maintained by owners at home.

Recovery is minimal, and kidney-appropriate diets can be made into a slurry and fed through the esophagostomy tube; water can be administered to help provide hydration.

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T E C HP O I N T

Chronic feline renal disease requires lifelong treatment and can be challenging for the veterinary staff, patients, and their families.

Communication between veterinary staff and owners about treatment options helps ensure that affected pets have a good quality of life.

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The Ins and Outs of Managing Feline CKD

nutritional content of many people foods can also be researched on the USDA National Nutrient Database (http://ndb.nal.usda.gov/). Before recommending table foods that are kidney appropriate, it is best to ensure that no concurrent medical conditions exist. Treats and table food should consist of no more than 10% of total caloric intake to ensure patients receive all their vitamins and minerals from their complete and balanced food.

Educating owners about why phosphorus and moderate protein restriction is so important in kidney patients makes them more likely to comply.

SUPPORT FOR OWNERS Telling owners that a pet has kidney disease can be met with much concern and confusion. Some people feel that such a diagnosis is an immediate death sentence, while others are overwhelmed and unsure of what to expect.

Owners should be given a few days to think about the diagnosis and treatment options, but it is important to follow up. A phone call after diagnosis to offer advice and emotional support and to answer any questions helps ensure that pet owners are compliant with

Some enteral medications may also be given through the tube to decrease stress to patients as well as owners.

Home-cooked meals, although neither convenient nor economical, may be used short term (or long term with added vitamin and mineral supplements). Any long-term homemade diet should be formulated under the direction of a boarded veterinary nutritionist.

Cats that are stressed may prefer to eat in a quiet environment with less traffic or no other animals p esent.

Food bowls should be kept away from litterboxes to avoid contamination. Food and water should be fresh and changed frequently. Feline pheromone collars and diffusers may also be helpful for anxious cats that are not feeling well, although these have not been researched extensively.

Discussing low-protein and low-phosphorus treats and table food options can increase owner compliance in keeping pets on a strict, kidney-friendly diet. Owners often show their love to their pets by offering treats.

Encouraging owners to use dry renal-appropriate kibble or kidney-friendly “people food” as treats helps ensure compliance while giving owners options. Table foods that are lower in phosphorus and protein include white pasta, melon, white bread, honey, and rice cakes. It is important to check the nutritional label of human foods to determine if the food is appropriate for pets because ingredients and levels vary among brands. The TODAY’SVETERINARYTECHNICIAN VETERINARY VETERINARYTECHNICIAN

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CE Test Article 3 The Ins and Outs of Managing Feline Chronic Kidney Disease The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

1. The purpose of phosphorus restriction in feline renal disease is to a. Reverse the signs of kidney damage b. Slow the progression of kidney disease c. Decrease nausea d. Increase appetite 2. A cat with a serum creatinine of 3.1 mg/dL is considered to be in IRIS stage a. I b. II c. III d. IV 3. In addition to serum creatinine levels, which laboratory values can help stage renal disease? a. Blood urea nitrogen and blood pressure b. Potassium and sodium c. Urine protein:creatinine ratio and blood urea nitrogen d. Blood pressure and urine protein:creatinine ratio 4. Which of the following is an appropriate way to increase appetite in azotemic cats? a. Offering high-protein foods b. Adding potassium citrate to their fluid regimen c. Administering appetite stimulants d. Offering renal-appropriate diets in the hospital 5. Which of the following diets should not be fed to cats with renal disease because of its acidifying properties? a. Prescription kidney diet b. Struvite crystalluria diet c. Restricted phosphorus diet d. Moderately restricted protein diet

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6. Which potassium supplement should be avoided in cats with chronic kidney disease because of its acidifying properties? a. Potassium bromide b. Potassium citrate c. Potassium chloride d. Potassium gluconate 7. What is the baseline daily energy requirement (DER) for a neutered 3-kg adult cat with kidney disease? a. 170–220 kcal/day b. 240–290 kcal/day c. 100-150 kcal/day d. 340-380 kcal/day 8. What is the purpose of protein restriction in a renal diet? a. Slow the progression of renal disease b. Decrease the clinical signs associated with renal disease c. Decrease phosphorus reabsorption d. Avoid amino acid deficienc 9. In cats with kidney disease, oliguria or anuria can be caused by a. Hyperkalemia b. Hypokalemia c. Hepatic lipidosis d. Metabolic alkalosis 10. One way to avoid constipation in feline renal patients is by a. Using cobalamin therapy b. Administering antidiarrheal medications c. Feeding dry food d. Providing enteral and parenteral fluids

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Glossar y Antidiuretic hormone: Hormone released by the pituitary that raises blood pressure, restricts blood vessels, and reduces excretion of urine As-fed basis: Measurement of a specific nutrient in food, including moisture content Dry-matter basis: Measurement of a specific nutrient in food minus the moisture content Hepatic lipidosis: Liver disease occurring in malnourished and/or anorectic cats, in which the body converts fat into usable energy, causing fat to build up in the liver cells Parathyroid hormone: Hormone released by parathyroid glands that regulates calcium and phosphorus levels in the blood Serum creatinine: Measurement of the level of creatinine, a byproduct of muscle metabolism excreted by the kidneys, in the blood Urine specific gravity Test that measures the concentration of urine

recommendations given by the veterinary staff. Written educational materials provide owners with correct information, rather than potential misinformation from biased or uneducated sources on the Internet. Assuring owners that they are doing the best that they can and that the entire healthcare team is working together also increases compliance. Establishing a consistent routine for treatments and follow-up visits helps reduce stress for owners and patients alike.

Chronic feline renal disease requires lifelong treatment and can be challenging for the veterinary staff as well as the patients and their families. It is important to remember that nobody is prepared for this diagnosis, but communication between veterinary staff and owners about treatment options helps ensure that affected pets have a good quality of life. ď Ž

References 1. Pibot P, Biourge V, Elliot D. Dietary therapy for feline chronic kidney disease.

In: Encyclopedia of Feline Clinical Nutrition. Italy: Royal Canin/Aniwa SAS; 2008:248-283.

2. Elliott DA. Nutritional management of kidney disease. In: Fascetti A, Delaney S, eds. Applied Veterinary Clinical Nutrition. Ames, IA: Wiley-Blackwell; 2012:251-263.

3. Hand M, Thatcher C, Remillard R, et al. Nutritional management of kidney disease.

Small Animal Clinical Nutrition. 5th ed. Topeka, KS: Mark Morris Institute; 2010:765-800.

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CLIENT HANDOUT

Canine Urine Marking Urine marking is a natural, instinctive behavior in dogs, but it becomes inappropriate when dogs urinate in the house.

Urine marking is most common with sexually intact male dogs, but intact female dogs and neutered dogs may also mark.

Underlying medical reasons for inappropriate urination, such as urinary tract infections, should be ruled out before a diagnosis of marking behavior is made.

In one study, neutering was found to resolve the problem of urine marking in about half of cases. Urine marking issues can be more difficult to esolve in dogs that are not neutered.

Behavior modification, envi onmental treatment, and elimination of anxiety triggers can help to eliminate the behavior. To remove urine odor completely, odor eliminators with enzymes or bacteria must be used to clean up urine marks.

What Is Canine Urine Marking?

Canine urine marking is a natural, instinctive behavior in dogs, but it is not appropriate inside the house. Dogs, especially sexually intact male dogs, urinate on objects to leave a message for other dogs (e.g., claiming their territory).

Urine marking behavior usually begins when the dog reaches sexual maturity.

What Causes Canine Urine Marking?

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An intact male dog is most likely to mark when there is a female dog in heat nearby. Intact female dogs are also prone to mark when they are in heat.

New items are frequent targets for urine marks. However, because urine marking is a form of communication, any dog may mark if another dog has urinated anywhere in the house. Unless the scent of the urine is completely removed, the marking behavior is likely to continue.

Use odor eliminators with enzymes or bacteria in them to completely remove the odor.

Any anxiety-producing situation can trigger urine marking as well. Workmen in the house, the arrival of a new baby, or visiting relatives can all produce anxiety in a dog. Even the addition of a new TV or a new computer may threaten a dog so that it feels compelled to mark the packing boxes. Rest assured, your dog is not trying to get back at you. It’s just doing what comes naturally.

How Is Canine Urine Marking Diagnosed?

Your veterinarian will start by discussing when, where, and how often the behavior occurs. A workup should be conducted to rule out medical disorders that may be causing the problem. If there are no medical causes, your veterinarian will need to determine if incomplete housetraining or other behavioral conditions are playing a role. Even if there is a medical component to the behavior, there will be a learned aspect as well. This learning may need to be modified onc the medical condition is resolved.

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Canine Urine Marking continued How Can It Be Treated?

In most cases, overcoming urine marking requires multiple steps:

Many dogs won’t urinate where they eat, so you can also try feeding your dog in the location it used to mark.

Neutering. If the dog is sexually intact, neutering is the first step to emove any hormonal influence for the urine marking behavior. Once the surgery is performed, behavior modification can begin to reinforce urine marking in acceptable locations.

Scent elimination. It is important to remove the scent of previous urine marks with a good enzymatic or bacterial cleaner. Camouflaging the odor with another scent is not effective. An enzymatic cleaner can help neutralize the scent to prevent recurrences of the behavior. Many dogs won’t urinate where they eat, so you can also try feeding your dog in the location it used to mark.

Positive reinforcement. Never punish a dog for urine marking. Punishment can create more anxiety, which may only exacerbate the problem. Instead, you need to supervise your pet closely. If you see the dog starting to eliminate inside, interrupt him or her by asking for a competing behavior like come or sit. Then bring the pet outside. When the dog urinates outside, reward him or her with praise and treats. Make sure to bring your dog outside frequently, always providing rewards for appropriate urination outdoors.

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Confinement During retraining, it helps to limit your dog’s access to frequently marked areas. You may need to confine your dog to a room or small area by shutting doors or by using baby gates or a crate. You can also use a technique called

the “umbilical cord,” in which you use your dog’s leash to keep your dog close to you while inside so that you can better monitor his or her behavior. As your dog’s behavior improves, you can gradually increase his or her freedom in the house. Be careful to frequently exercise your dog to keep him or her from becoming agitated with long periods of confinement Minimize anxieties. If you can identify the factors that are causing your dog anxiety, remove them or minimize their importance. With a new baby, for example, you can desensitize your dog by gradually increasing the amount of time your dog is exposed to the new baby. At the same time, you can use tactics known as counterconditioning techniques. These include classical counterconditioning, such as associating the baby with items your dog wants, like food, petting, and praise, and operant counterconditioning, which involves reinforcing calm behaviors such as “sit” and “down” to replace excited behaviors like jumping up and mouthing when near the baby.

You may also consult your veterinarian about an Adaptil (dog appeasing pheromone) diffuser. By mimicking the pheromones produced by a mother dog to give her puppies a sense of calm and well-being, this product can help ease anxieties in dogs.

Medications. If your dog has a high level of anxiety, you can consult your veterinarian for medications. There are many types of appropriate medications to address anxiety in dogs. These drugs may take 4 to 6 weeks to make a difference. However, behavior modification is always the first choice a should continue, even with medications. 

© 2016 Today’s Veterinary Technician. Created by Vetstreet and peer-reviewed by Today’s Veterinary Technician. Brought to you by VetFolio. Today’s Veterinary Technician grants permission to individual veterinary clinics to copy and distribute this handout for the purposes of client education. For a downloadable PDF, please visit www.todaysveterinarytechnician.com.

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CLIENT HANDOUT

Feline Urine Marking Feline urine marking is a normal form of communication between cats. It is usually related to stress. Cats do not typically use urine marking to claim territorial boundaries.

Urine marking occurs most commonly in male cats that have not been neutered.

A cat that is urine marking typically stands upright with its tail erect and sprays a small amount of liquid on walls and other vertical surfaces. However, other postures may be seen.

A diagnosis is made once other medical and behavioral reasons for urinating outside the litterbox have been ruled out. If a cat has learned to urinate outside the litterbox due to a medical issue, behavior modification will be needed in addition to medical t eatment.

Neutering or spaying the cat is the most effective initial treatment.

Other treatment includes methods to reduce stress in the cat’s environment. Medication can be added if your veterinarian feels it is necessary.

What Is Feline Urine Marking?

istock.com/ByeByeTokyo

Feline urine marking is a behavior in which cats mark a location with urine to reduce their stress. Often, it occurs near doors and windows as a way to communicate to neighborhood tomcats wandering through the yard. Although this is a normal behavior in cats, most owners consider it unacceptable when it occurs in the house. Any cat can exhibit marking behaviors, but male cats that have not been neutered tend to mark more often. Urine marking is most often seen in multicat households.

Although sex hormones may be behind some urine marking, stress and anxiety also are causes. Any changes in the household, such as the addition of other pets, workers in the house, or a recent vacation by the owner, may compel the cat to become stressed and urine mark.

What Are the Signs of Urine Marking?

A cat that is urine marking typically stands upright with its tail erect and sprays a

small amount of liquid on walls and other vertical surfaces. However, other postures may be seen, and marking cats may spray on horizontal surfaces or items, such as bedding or laundry.

How Is Urine Marking Diagnosed?

Your veterinarian will probably want to check a urine sample to make sure that your cat doesn’t have a medical reason for urinating outside the litterbox. If the urinary tract is inflamed, infected, or irritated by urinary crystals, there are treatments that can relieve the signs and encourage the cat to return to the litterbox. Some other medical conditions, such as bladder stones, hyperthyroidism, diabetes, and kidney or liver disease, also can cause a cat to urinate outside the litterbox. Your veterinarian may recommend additional tests, such as blood work and x-rays, to investigate these and other possibilities.

There may be other reasons why your cat is eliminating outside the litterbox.

TODAY’SVETERINARYTECHNICIAN TODAY’SVETERINARYTECHNICIAN VETERINARY VETERINARYTECHNICIAN

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Feline Urine Marking continued

How Is Urine Marking Treated?

The most effective initial treatment for urine marking is to neuter or spay your cat, if it has not been done already.

However, once the behavior has been learned, behavior modification may be needed even after neutering or treatment for a medical disorder.

Reducing stress in the cat’s environment may also help. Ask your

veterinarian or a member of the veterinary staff who specializes in behavior for recommendations on resources to help you understand what may be causing your cat stress. Synthetic pheromone products (e.g., Feliway) are available in spray or plug-in diffuser forms. These products have a calming effect on many cats and may reduce the cat’s response to stressors.

To discourage neighborhood cats from approaching doors and windows, consider using a spray deterrent that is activated by motion detectors. You also should supply your cat a place to escape from children or other pets in the household, such as a room, cubby, or perch. Anti-anxiety medications may be appropriate in some cases. 

istock.com/elenaleonova

The most effective initial treatment for urine marking is to neuter or spay your cat, if it has not been done already.

Cats are fastidious creatures, and may avoid the box if it is not clean enough, if they don’t like the scent or texture of the litter, or if the box is located near a high traffic a ea in the house.

Once other causes of inappropriate elimination are ruled out, a diagnosis of feline urine marking may be made.

© 2016 Today’s Veterinary Technician. Created by Vetstreet and peer-reviewed by Today’s Veterinary Technician. Brought to you by VetFolio. Today’s Veterinary Technician grants permission to individual veterinary clinics to copy and distribute this handout for the purposes of client education. For a downloadable PDF, please visit www.todaysveterinarytechnician.com.

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IS URINE SPRAYING A PROBLEM FOR YOUR CLIENTS? Feliway® helps reduce urine spraying in 90% of cats.* Feliway® is clinically proven to help reduce or eliminate problem behaviors by mimicking the natural pheromones pets use to communicate. It has a calming effect on cats to help make the home a happier place for everyone and everything.

Feliway® can also help with these issues: • Scratching • Travel

• Veterinary Exams • Adoption

Best behavior starts here. ™

Feliway.com/us Feliway® is a registered trademark of Ceva Santé Animale, S.A. Best behavior starts here.™ trademark is property of Ceva Animal Health, LLC. *Mills DS, Mills CB. Evaluation of a novel method for delivering a synthetic analogue of feline facial pheromone to control urine spraying by cats. Vet Record 2001; 149;197-199

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/FeliwayUS Feliway.com/us

All cats are unique, results may vary. For best results, use Feliway for a minimum of 30 days along with a behavior modification plan.

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What Moves You?

Normal? No Way! Dream to RVT+ Karina Benish, MSEd, RVT Ramona, CA At 3 years old, I told my parents I wanted to be a veterinarian. I took in all the injured animals found in the neighborhood, fought for many lives, and wept, too.

I started my official medical ca eer in human medicine with the US Army. After 6 years, I moved to an area with a nearby veterinary reserve unit. I still had a huge interest in veterinary medicine, so I went to the unit and asked if I could join! As luck would have it, they had a critical shortage of food inspectors. They took me in and sent me to food inspector school. I was hooked from the first da . Working with animals was what I was meant to do…but although I found food inspection fascinating, I didn’t get to work directly with the animals much. In my civilian life, I still took in injured animals, and I started working for a veterinary clinic.

Time went by and I attended as many veterinary medical continuing education opportunities as I could. I had to learn everything. Pharmacology fascinated me, anesthesia compelled me, dermatology and dentistry were extremely satisfying to treat (no one needs to tell you you’ve done a great job!), and emergency and critical care gave me an adrenaline high. My passion for veterinary medicine led me to become an RVT. Had my educational opportunities and other responsibilities been different, I likely would have pursued a doctor of veterinary medicine degree. Instead, I became the best veterinary technician I could be, always reaching for more knowledge.

I dabbled briefly in esearch at a veterinary facility that performed preclinical human and veterinary trials for new devices and drugs. I founded a 501(c3) horse rescue and began to expand my knowledge of equine medicine, a process that continues to this day. While working at a very large specialty hospital, I was privileged to gain more experience in internal medicine, radiation oncology, nuclear medicine, surgery, emergency and critical care, and dermatology. The number of incredibly brilliant people at this facility blew my mind and spurred me to educate myself even more. I really found technician Nirvana when I started to teach veterinary technician students at a private college. This was the greatest achievement of my career. I was able to assist others to realize the passion I have for veterinary medicine.

My passion for learning has led me to get a master’s degree and landed me my current position in biotech, where I am working with some of the best minds in innovative regenerative veterinary medicine. Some of my coworkers have graduated from MIT; some have come from around the globe. We consult with the best human regenerative medicine minds in the world. As the clinical development division manager, I work with the most unusual

For its 2016 Conference, the NAVC asked veterinary professionals to share their stories: What drives you?

What inspires you?

What moves you?

Throughout the year, Today’s Veterinary Technician will be publishing veterinary technicians’ answers to these questions.

What moves you?

Do you have a story you’d like to share? Send it to us at TVTech_submissions@NAVC.com.

Submissions should be approximately 500 words or less and may be posted on our website or edited for publication in the journal.

Tell us your story!

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Gaining the trust of a rescued horse takes time and a lot of patience. Here, Karina works with Triton, a Bureau of Land Management mustang, on trust building and acceptance exercises. cases and new technology. I speak with veterinarians on a level I didn’t think achievable when I was a new technician, and I am in the most cutting-edge phase of my career!

As I write this, I think my take-home message for each and every veterinary colleague is to look within. Find the

tiny spark that got you to try veterinary medicine…find it, feed it, nurture it, and then let it go. See where it takes you.

Follow it down the roads and byways as it meanders through the different aspects of our profession. You will go on the journey of a lifetime...if you follow the spark! 

The Smith’s dog just ate ______ and she’s ______.

Lethargic

Drooling

Panting

For expert toxicology advice, call:

Vomiting

Hyperactive

888.426.4435 *A consultation fee may apply.

Accidents Happen. That’s Why We’re Here.

With over 2.5 million cases handled since 1978, the ASPCA Animal Poison Control Center is the leading animal poison control center in the country. Available 24/7/365, our staff of board certified toxicologists and emergency medicine specialists, veterinarians, veterinary technicians, and veterinary assistants, are dedicated to providing you with the most up-to-date toxicology information when you need it most.

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INCREASING CLIENTS’—AND YOUR OWN — DENTAL AWARENESS FROM THE

Exam Room TO THE Dental Suite

C

Patricia M. Dominguez, BS, LVT, VTS (Dentistry)

ongratulations! You have decided to improve the dental services your practice offers to pet owners by becoming an advocate for pets’ oral health. This can be a daunting task, but by bringing awareness to disease that is often forgotten because it is masked by many animals, you will be helping your patients live healthier, longer lives.

Gotham Veterinary Center New York, NY

GETTING STARTED Agree on the Message I have been fortunate enough to travel to many general practices in the United States as well as in other countries. One constant factor I see in practices that successfully improve their patients’ oral health is that the entire team has decided to make dentistry important. When everyone is on the same page, owners receive a unified message about dental health throughout their entire experience in the practice. However, if dentistry is important to only a few staff members, owners often receive mixed messages about their pets’ oral health, which inadvertently sabotages any efforts to grow dental services.

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Patricia received her bachelor’s degree in biology and Spanish literature from Syracuse University in 1999 and was subsequently licensed in veterinary technology at SUNY Delhi. In 2003, she became the primary dental technician at Shaker Veterinary Hospital in Albany, New York, which, through improvements to its dental program and extensive client and community education, earned the Hill’s National Pet Dental Health Month Award 2 years in a row.

One of the first to become a credentialed veterinary dental technician specialist through the Academy of Veterinary Dental Technicians, Patricia is the president elect of the academy and an adjunct professor at Westchester Community College.

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on by the entire staff. Every staff member should feel comfortable explaining the practice’s views on oral care and what treatment options it can provide. BOX 1 lists several organizations with resources that practices can use to help create a high-quality dental program or assess their current dental services.

To help reinforce these messages with clients, the practice should create a take-home oral health information packet that includes the following: A description of what happens when a patient is being considered for a dental procedure—the preanesthetic examination, preanesthetic bloodwork, a complete dental evaluation, and discussion of a treatment plan A complete list of the dental services the hospital provides, including what the team does during each dental procedure Authorization of consent if the client cannot be reached during the procedure Information on payment options in case full payment is not possible A guide to oral care products and how to keep the pet’s teeth clean at home after a dental procedure You can start changing owner— and staff—perception of dental services simply by using the correct terms. Most dental procedures are not “just a dental” or “just a prophy.”

A true dental prophylaxis is

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Image courtesy of Patricia M. Dominguez.

performed to prevent periodontal disease. In most patients, dental procedures to restore oral health involve treating periodontal disease. Be sure to convey this to owners during office visits and dental consultations.

regular examination room, the dental suite, or a separate area of the waiting room. Try to avoid explaining procedure details, treatment plans, and estimates in public areas. Dental procedures tend to be higher-priced services and should be discussed privately with owners.

Most owners do not want their pets to live with infection or pain; however, they are sometimes limited by their financial situation

Designate a Dental Area Most animal care facilities are busy and noisy, which can make it difficult to discuss important matters with owners This is especially true when it comes to involved oral treatment plans. To minimize distractions, designate an area in the practice that can be used as a “dental room” or a “dental corner.” This area should be quiet and have good lighting so that you can see everything in the patient’s mouth before talking to clients about your observations, assessments, and recommendations for a treatment plan.

If a designated room is not possible, a relatively private, quiet area is the next best thing. This can be a

Choose Your Teaching Tools A dental area also gives you a place to keep educational tools within easy reach to show to pet owners. As your dental services grow, it may make more sense to keep these items in each examination room to display dental awareness throughout the practice. Veterinary product manufacturers and distributor representatives may be able to help you find some of these educational tools

BOX 1 Where to Find More Information on Dentistry and Dental Services Veterinary dentistry is not yet offered in every veterinary school and veterinary technology program. According to the American Veterinary Dental College, only 7 veterinary schools in the United States offer a dental residency program. The programming that exists is still fairly new and not always available to all students. Veterinary professionals interested in furthering their dental knowledge are encouraged to seek continuing education from the Academy of Veterinary Dental Technicians, the American Veterinary Dental College, the American Veterinary Dental Society, the Veterinary Dental Forum, or any of the veterinary dental training centers located across the country.

Academy of Veterinary Dental Technicians

www.avdt.us

American Veterinary Dental College

www.avdc.org

American Veterinary Dental Society

www.avds-online.org

Journal of Veterinary Dentistry

www.jvdonline.org

Oral Care Guidelines

www.oralatp.com

Veterinary Dental Forum

www.veterinarydentalforum.com

Veterinary Oral Health Council

www.vohc.org

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TECHPOINT

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Plastic skull models: These are available with or without gum tissue, removable teeth, and pathology.

Personally, I find the clea , soft models with removable teeth enlightening. Owners are often shocked to see how large tooth roots are and that many teeth have multiple roots.

Bone skull models: These are very useful when showing owners how close tooth root structures are to the sinuses and eye orbits.

Dental charts/posters: These charts can show owners how periodontal disease can progress and lead to other issues affecting the heart, lungs, liver, and kidneys.

Photo album of oral pathology: This can be a handheld album or a digital one. The important thing is to highlight common conditions so that you can refer to photographs when explaining a certain condition.

Photo guide to a complete dental procedure: This type of guide is comforting for owners who have never had a dental procedure explained before. It should be set up as a step-by-step album that takes owners through the preanesthetic visit all the way to the dental discharge. This album can also be handheld or digital.

Promote Your Practice Showcasing the importance of dental care in your practice should not just stay within the hospital walls.

Social media can also be a powerful tool for promoting oral health. Social media accounts can be maintained by a knowledgeable, dedicated team member or outsourced to a veterinary-specific company gea ed toward increasing your online presence. You can also use your practice’s website, newsletter, and e-mail database to distribute information about dental awareness.

Reaching out to the community can include promoting educational events at local pet stores, adoption centers, or training classes. Another way to bring current and potential clients to your practice is to host an open house. This will allow you to showcase your facility, staff, and services. You can focus on a particular topic, such as oral health, or open it up to a variety of topics. Such events can help you develop a more personal relationship with owners and educate them on issues affecting their pets’ health.

Educate Yourself To properly communicate canine and feline dental pathology to owners in the examination room, you must be completely familiar with evaluating the teeth and skull structure of all the breeds that come into your practice.

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In a successful dental program, everyone in the practice agrees on the importance of oral health for all patients. owner understand the need for treatment if an abnormality is noted during a physical examination.

Communicating During the Initial Examination By incorporating a thorough oral examination into regular physical examinations, the veterinary staff can begin to teach a new generation of pet owners to recognize oral care as part of good overall care. Unfortunately, oral health has typically been overlooked in the past. Educating pet owners about the benefits of good oral health takes extra time and effort, especially when much of the physical examination is focused on vaccines, nutrition, ear and skin issues, and other presenting problems.

Most discussions and evaluations of oral health are conducted during a pet’s annual wellness examination.

However, any opportunity to assess the pet’s oral health is appropriate. When you discuss oral health with clients, remember that it may be the first time they have hea d any in-depth information about their pet’s teeth. Take the time to sit down and really get to know the pet’s oral history.

Ask open-ended questions about what the pet likes to chew on, what it likes to eat, and whether it has ever displayed any unusual behaviors involving chewing or its face (e.g., excessive drooling, pawing at the face). Listen to the owner’s concerns and ask for descriptions of any facial or chewing behaviors that the pet will not display in the examination room. Owners tend to be unaware of dental issues because the pet continues to eat. You must convey to them that eating is not an accurate indicator of a pain-free mouth. Most patients continue to eat even with severe oral disease.

After a thorough oral history has been documented, the physical examination can be performed. The mouth should be examined last, as patients that tolerate auscultation and abdominal palpation may object to the intrusive act of having their mouth opened. If the patient is very painful or aggressive, mild restraint may be necessary to conduct a proper assessment.

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Why Should We Worry About Pets’ Oral Health?

A healthy mouth is a healthy body! It’s as true for pets as it is for people. In human medicine, periodontal disease has been linked to many disease processes.1 Based on studies done by the American Veterinary Dental Society, 85% of adult pets have some stage of dental disease. The bacteria found in dental plaque and tartar can also have harmful effects on the heart, lungs, kidneys, and liver. The veterinary profession has come a long way, and we are at the point where good oral health goes hand in hand with overall patient care. Veterinary technicians need to be advocates for our patients and their teeth. It is no longer acceptable to think that because they are eating, then they must be fine. e know better, so we must do better!

Veterinary professionals and owners need to be able to recognize the signs of dental disease before they progress to larger problems. The following is a list of common signs that a pet may be experiencing a dental problem: Bad breath, plaque, tartar: All of these indicate the presence of bacteria in the mouth. Remember, if it’s clean, it doesn’t smell!

Excessive drooling: This can sometimes be a sign of pain when holding the mouth closed, a salivary problem, or even an oral malignancy.

Red, swollen, or bleeding gums: Take this as a “red flag” f om the mouth alerting you to something going on below the gum tissue that needs to be addressed.

Facial swelling, nasal or eye discharge: The root structures of the maxillary teeth are extremely close to the sinus cavities and eye orbits. Infection in a tooth root is likely to spread to another area quickly.

Changes in chewing or eating habits: Many pets adopt new chewing behaviors if eating a particular way causes pain.

Going to food but not eating: Pets can display this behavior if the pain of chewing has become too much for them to bear.

Swallowing food whole: This behavior keeps pets from having to use painful teeth when eating.

Dropping food from the mouth: This behavior is observed when the pet tries to chew its food but cannot complete the chewing motion because the affected teeth elicit a pain response.

Tooth loss: The underlying problem has not been fixed simply because the o fending tooth has fallen out. It takes a long time for a tooth to become so diseased that it simply comes out of its socket.

istock.com/Lemmer_Creative

Reference 1. American Veterinary Dental College. Periodontal disease. Accessed www.avdc.org/periodontaldisease.html. December 1, 2015.

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An initial oral examination, without sedation, should include an inspection of the eyes, muzzle, nasal passages, and lymph nodes to detect ocular discharge, suborbital swelling, or nasal discharge. The size and symmetry of the submandibular lymph nodes should be assessed to detect any abnormalities. If possible, the patient’s mouth should be opened to view the tongue and palate. Any lesions, ulcers, defects, discolorations, and masses should be noted.

Malocclusions can cause tooth-to-tooth and tooth-to-soft tissue trauma. Proper assessment of the patient’s occlusion requires examination of the teeth, their relation to each other, and the gingival tissue. Discussing findings with owners at the time of the physical examination can help you properly treat the patient on the day of the dental procedure.

The relationship between the credentialed veterinary technician and the veterinarian is instrumental in making this presentation to the client as seamless as possible. The veterinarian is responsible for making the diagnosis and emphasizing the importance and need for treatment. An educated credentialed veterinary technician armed with dental knowledge can point out abnormal findings to both the pet owner and the veterinarian. The team mentality will always help you promote better dental care for your patients.

Addressing Major Concerns and Dispelling Myths The best way to handle clients who are hesitant about scheduling an oral health procedure is with education and patience. Clients may have all kinds of preconceived notions based on friends’, family, or personal experiences with veterinary dentistry. The only way to calm their fears and address their concerns is to take the time to talk to them and to use your professional knowledge to answer whatever questions they have. Below are some common questions, based on my experience.

Isn’t anesthesia bad for my pet?

When it comes to high-quality dental procedures, the top two concerns are usually anesthesia and cost. These are very sensitive subjects for most owners and are best handled in the privacy of an examination room. This becomes a perfect opportunity to shine and showcase how the practice has addressed them.

As long as your practice is providing high-quality anesthesia, you can be confident in explaining your protocols to owners and reassuring them that you are making anesthesia as safe as possible for their pet. Again, this takes some time and effort; however, the rewards are great for the pet, the owner, and the practice. This is your opportunity to go over the reasons why preanesthetic examinations and bloodwork are required and why 66

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intravenous catheters, fluid therap , and surgical monitoring are important. If you can, it might even help to show owners the dental suite so that they can see for themselves how advanced the equipment is. However, be sure the room is perfect first—owners will pick up on even the smallest fl , which can lower their confidence in the practice.

Describing your anesthesia protocols is how you can distinguish your practice as a high-quality facility when an owner states they can have a “dental” done for $100 elsewhere. A difference in price often means a difference in quality. You can explain to clients that although almost every practice offers dental services, these services are not necessarily equal from practice to practice.

Isn’t my pet too small for anesthesia?

All dogs and cats are prone to periodontal disease, but in smaller dogs, teeth tend to be crowded or rotated, creating reservoirs for food, hair, and bacteria. Without regular home care, problems requiring professional treatment can result very quickly. Regardless of patient species, breed, or size, proper anesthesia protocols help ensure the safety of all dental patients.

Isn’t my pet too old for anesthesia?

Since pets do not come with expiration dates, it is hard to say how old is too old for a dental procedure. Age is not a disease, but periodontal disease is. As long as the patient is otherwise healthy, has normal physical examination findings and has normal results on preanesthetic diagnostic tests— and your practice is doing high-quality anesthesia and pain management—there is no reason not to perform a dental procedure in an older pet. If the patient’s health is compromised, further evaluation may be needed before considering an anesthetic procedure. A cardiologist or anesthesiologist can give recommendations for anesthetic protocols that can help avoid negative situations.

Before the dental procedure begins, the veterinarian should assess the patient and assign an ASA (American Society of Anesthesiologists) grade so that everyone involved in the procedure is aware of any increased risks.1 Knowing the patient’s ASA grade allows the anesthetic team to review emergency protocols before any complications can arise.

Why is it so expensive?

Dentistry can be a high-ticket item. It is usually an expense for which owners are not prepared, because most dental procedures are not simply cleanings—they are really major procedures involving oral surgery. Answering this question is another opportunity for you to explain all the protocols

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your practice follows. A visual step-by-step guide, as described on page 64, can be a great asset in addressing many questions owners have about cost.

At the same time, you should help make it possible for owners to treat their pets. Become familiar with pet insurance plans and financing options available in your area. At my practice, we file all the insurance claim fo ms for our clients. We find that by st eamlining the process this way, our clients are reimbursed sooner and with fewer complications. Because insurance claims can be confusing and often require interpretation of medical records, the staff member completing these forms should be knowledgeable about the different companies and plans offered. Most pet insurance companies provide staff education via webinars to help practices stay up-to-date with their policies.

My practice offers two payment plan options to allow owners to schedule payment amounts that fit into their monthly budget. Clients do not want their pets to be in pain or to suffer from untreated oral disease. If given financing options, many owners choose to t eat their pets to get them healthy and comfortable.

even people in the veterinary profession assumed this was true, partly because of a fear of anesthesia and even dentistry. We now know that it is not true, and now that we know better, we are obligated to do—and teach—better.

Almost all dogs and cats continue to eat no matter what ailments they are experiencing. This is true for one simple reason—the instinct for survival. To help owners better relate, ask them to put themselves in their pet’s situation: for example, to imagine they are stuck on a deserted island with a broken or abscessed tooth. Would they stop eating? Certainly not! They would continue to eat, drink, breathe, and live day to day. They would not be totally healthy or comfortable, but they would learn how to live with the pain. That is what pets do. Their “desert island” is their inability to communicate in words.

However, you can explain that animals do express pain through their actions. Although they may not be able to say that one of their right lower molars is moving, they may eat their food only on the left side of their mouth. Others may opt to swallow their food whole, shy away from dry food altogether, or stop chewing on their toys. Asking owners to think about whether they have observed these or other abnormal behaviors can help them understand what their pet is “saying” about their oral health.

Owners may tell you that they have always had pets and none of the others needed dental work, or that

If my pet were in pain, wouldn’t he/she stop eating?

Many pet owners still hold on to the notion that their pet cannot be in pain because it continues to eat. For years,

Recommended Reading istock.com/fotoedu

American Veterinary Dental College. Dental Scaling Without Anesthesia.

Accessed December 1, 2015. www.avdc.org/dentalscaling.html.

Bednarski R, Grimm K, Harvey R, et al. AAHA Anesthesia Guidelines for Dogs and Cats. Accessed December 1, 2015. www.aaha.org/graphics/original/ professional/resources/guidelines/anesthesia_guidelines_for_dogs_and_cats.pdf.

Bellows J. Feline Dentistry: Oral Assessment, Treatment, and Preventative Care. Ames, Iowa: Wiley-Blackwell; 2010.

Epstein M, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP Pain Management Guidelines for Dogs and Cats.

Accessed December 1, 2015. www.aaha.org/public_documents/professional/guidelines/2015_aaha_aafp_pain_ management_guidelines_for_dogs_and_cats.pdf.

Gorrel C. Saunders Solutions in Veterinary Practice: Small Animal Dentistry. London, UK: Elsevier; 2008.

Gorrel C, Derbyshire S. Veterinary Dentistry for the Nurse and Technician. Oxford, UK: Butterworth-Heinemann; 2005.

Holmstrom SE, Bellows J, Juriga S, et al. 2013 AAHA Dental Care Guidelines for Dogs and Cats. Accessed December 1, 2015. www.aaha.org/public_documents/professional/guidelines/dental_guidelines.pdf.

Lobprise H. Blackwell’s Five Minute Veterinary Consult Clinical Companion Small Animal Dentistry. Ames, Iowa: Wiley-Blackwell; 2012.

Perrone J. Small Animal Dental Procedures for Veterinary Technicians and Nurses. Ames, Iowa: Wiley-Blackwell; 2013.

Tutt C. Small Animal Dentistry: A Manual of Techniques. Ames, Iowa: Wiley-Blackwell; 2007.

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another veterinarian said oral health was not a problem.

Again, this comes down to education and is by no means a reason to let a patient suffer in silence.

My groomer brushes my pet’s teeth. Isn’t that enough?

Some groomers offer toothbrushing as a convenience for owners. However, even with regular grooming, this means that pets have their teeth brushed only every 6 to 8 weeks.

Studies have shown that brushing the teeth fewer than 3 to 4 times a week is not beneficial to the overall health of the oral cavity.2 Can’t you do it without anesthesia?

Nonanesthesia dental services are becoming popular among owners as an alternative to cleanings under anesthesia. I believe all veterinary technicians should be aware of the American Veterinary Dental College’s position statement on this practice (SEE RECOMMENDED READING). A high-quality dental procedure should include charting, scaling, polishing, probing, and radiographic evaluation of all tooth surfaces. Become familiar with the services being offered in your area and how they affect your practice.

On the Day of the Dental Procedure Communication When an owner comes to drop off a pet for a dental procedure, clear communication is vital. The team must know the owner’s wishes when it comes to consenting to treatment during the procedure. It is best to discuss

FIGURE 1. Normal dental occlusion in a dog. ©American Veterinary Dental College, used with permission.

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possible treatment outcomes with owners before or during the procedure so they are not surprised when they come to pick up their pet. You can help avoid problems by requesting all possible contact information for anyone who has the ability to make medical decisions while the pet is under anesthesia. You can also add an option to the practice’s consent forms that allows owners to decide what they would like you to do if they cannot be reached during the procedure despite all efforts to contact them.

Assessment It is important to check the pet’s occlusion before intubation and call attention to any abnormalities seen. An overview of normal findings is p esented below; credentialed veterinary dental technicians should be familiar with common abnormalities and able to describe them to clients.

A normal bite is called a scissor bite (FIGURE 1). Any deviation results in a malocclusion. The scissor bite is one in which the upper incisors are in front of the lower incisors. The mandibular canine teeth tip out buccally and sit between the maxillary third incisor and the maxillary canine tooth. This space is referred to as the diastema.

Cats and dogs have three basic skull shapes, which are generally dictated by breed. The most common is the mesocephalic. This is a balanced facial profile, seen i breeds such as in German shepherds, Labradors, and domestic shorthairs. The second is the brachycephalic. This produces a shorter snout and an underbite, as is found in pugs, bulldogs, and Persians. The third is the

FIGURE 2. Modified riadan chart (feline). Courtesy of David Crossley, BVetMed, MRCVS, Fellow AVD, DEVDC.

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dolichocephalic. These animals have long, narrow muzzles, as in greyhounds, collies, and oriental cat breeds. Knowing how the teeth should line up in a normal occlusion for each skull type makes it easier to identify abnormal occlusions.

the permanent medical record. Even removal of a deciduous tooth requires notation on a dental chart because the patient’s oral cavity has been evaluated and altered. The chart provides a permanent record of what was done for future reference if the patient returns for other dental procedures. This allows the team to evaluate changes in the oral cavity and adjust treatment plans for teeth being monitored.

Each individual tooth must be evaluated during a dental procedure. Imagine that you have 42 little patients in a dog and 30 little patients in a cat. Each patient needs to be examined and a treatment plan made for it. A periodontal probe and explorer should be used find any defects, periodontal pockets, swellings, and lesions. Any findings should be ecorded on the dental chart and discussed with the veterinarian so that the appropriate treatment can be recommended. Dental radiography is essential in determining which teeth can be saved and which are beyond repair.

Charting Once the patient is safely under anesthesia, a complete oral examination can begin. Knowing the dental formulas for cats and dogs is necessary to accurately assess what is present in the mouth and what is missing (BOX 2). There are two formulas for each species: deciduous and adult.

The main difference between these formulas is the addition of molars, which have no deciduous counterparts, to the adult formula. Deciduous teeth, otherwise known as baby teeth, are the first set of teeth to develop in diphyodon mammals. Diphyodont animals have two successive sets of teeth, a deciduous set and a permanent set.

The modified riadan system (FIGURES 2, 3, AND 4) is the currently accepted method for numbering teeth in veterinary dentistry. In adult animals with permanent teeth, teeth in the right upper quadrant are numbered in the 100s; in the left upper quadrant, the 200s; in the left lower quadrant, the 300s; and in the right lower quadrant, the 400s. Charts for juvenile animals with deciduous teeth follow the same pattern, using numbers in the 500s, 600s, 700s, and 800s, respectively.

Missing teeth are skipped, as for the upper first p emolar and the lower first and second p emolars in cats.

For proper recordkeeping, all abnormalities must be noted on the patient’s dental chart, which becomes part of

Cleaning and Radiography It is important to remove bacteria from the subgingival spaces where periodontal disease begins. A cosmetic cleaning that only addresses the crowns of the teeth is not sufficient. P oper anesthetic protocol, using oxygen and a gas inhalant delivered through a cuffed endotracheal tube to keep an open and protected airway, allows technicians to scale and polish all surfaces of the teeth, both above and below the gumline, safely and effectively.

FIGURE 3. Modified riadan chart (canine). Courtesy of David Crossley, BVetMed, MRCVS, Fellow AVD, DEVDC.

FIGURE 4. Modified riadan chart (juvenile). Courtesy of David Crossley, BVetMed, MRCVS, Fellow AVD, DEVDC.

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Dental radiographs are necessary to properly evaluate the health of all tooth and root structures. The crown of a canine tooth is roughly about one-third of the total structure—the tip of the iceberg! Most oral pathology is discovered using dental radiography, and digital dental radiography has become the standard of care when providing high-quality dental services. With proper training, a credentialed veterinary technician should be able to obtain a complete set of dental radiographs in less than 10 minutes for a dog and less than 5 minutes for a cat. This is a skill that must be taught by a trained professional. Once mastered, it becomes an invaluable tool.

Proper positioning and technique is one part of the radiographic assessment; however, interpretation of radiographs requires a separate skill set. This is why it is imperative for the veterinarian and the veterinary technician to work as a team to provide a high-quality oral health procedure for each patient.

Monitoring and Discharge Once the procedure is complete, it is essential to monitor the patient not only through recovery but also through discharge. Many unfortunate outcomes are due to poor anesthetic monitoring or poor recovery protocols. In my experience, it is valuable to keep the intravenous catheter in place until the patient is discharged in case of an emergency situation.

Owners should meet with the veterinarian or veterinary technician after the procedure to discuss everything that was done during the procedure. This is the perfect time to showcase the practice’s quality of care by giving the owner copies of the digital pictures and radiographs of the pet’s mouth. These images show the extent and value of what has been done and give the owner something to refer to when checking on the pet’s home care progress. The owner should also receive printed discharge instructions that outline short-term home care instructions, such as how to

BOX 2 Canine and Feline Dental Formulas Canine Dental Formulas Deciduous teeth: 2 × (I 3/3, C 1/1, P 3/3) = 28 Permanent teeth: 2 × (I 3/3, C 1/1, P 4/4, M 2/3) = 42 Feline Dental Formulas Deciduous teeth: 2 × (I 3/3, C 1/1, P 3/2) = 26 Permanent teeth: 2 × (I 3/3, C 1/1, P 3/2, M 1/1) = 30 C = canine, I = incisor, M = molar, P = premolar

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We should start being proactive rather than reactive when it comes to dental issues. administer postprocedure medications, as well as longterm guides to maintaining the pet’s oral health and developing a home oral care regimen. Presenting all this information in a packet is truly your opportunity to shine.

It is up to veterinary technicians to make sure owners are properly educated on how to care for their pet’s mouth at home. Ideally, this should be done at the time of discharge, again at the recheck visit, and later through a callback system. A callback system enables you to reach out to owners, ask how the home care regimen is going, and support them in taking care of their pet’s oral health. If the owner has not been successful with your initial home care recommendation, you can discuss other options. For example, if a pet will not cooperate with toothbrushing, or if an owner cannot fit brushing into their schedule, dental wipes or chews, oral gels or rinses, dental diets, or food or water additives may be easier options. In these cases, it may be best to recommend a recheck visit to assess the oral cavity.

CONCLUSION Once owners realize that their pet’s oral health is important to your practice, they will begin to believe in its value.

Veterinary technicians can no longer ignore the fact that oral care is integral to the overall health and well-being of all our patients. We should start being proactive rather than reactive when it comes to dental issues. By starting the conversation with owners from their very first visit, we ca teach them that oral health is an important part of our complete care for their pet.

If we do a better job of communicating the importance of dental care and the signs of dental disease to our clients, we have a better chance of increasing owner compliance when it comes to oral care. It is my dream that within the next 20 years, we will not have to spend so much time convincing pet owners that dental care is integral to their pets’ health. They will have learned that home care should be part of a daily routine and that professional oral cleanings should be performed regularly.  References 1. Academy of Veterinary Technicians in Anesthesia and Analgesia. American Society of Anesthesiologists (ASA) Physical Status Scale. Accessed December 1, 2015. www.avtaa-vts.org/asa-ratings.pml.

2. Tromp JA, van Rijn LJ, Jansen J. Experimental gingivitis and frequency of tooth brushing in the beagle dog model. Clinical findings. J Clin Periodontol 1986;13(3):190-194.

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ARTICLE 4 1 CR E DIT

Canine Diabetes Mellitus: It’s About the Sugar

D

iabetes mellitus is an endocrine disorder characterized by insufficient p oduction of insulin in the body (type 1, or insulin-dependent, diabetes) or a resistance to the hormone itself (type 2 diabetes).

Dogs typically develop type I diabetes. Other forms of diabetes mellitus in dogs include gestational diabetes and forms resulting from a variety of disorders and/or drugs.

Achieving remission in the latter patients is extremely rare, even with correction of the underlying problem.

Treatment of diabetes mellitus can pose many challenges, depending on the type and degree of involvement.

Presenting clinical signs for patients with diabetes mellitus commonly include polyuria and polydipsia (PU/ PD). Additional signs can include lethargy, weight loss, and increased appetite, the degrees of which depend on the duration of disease and whether diabetes mellitus is the sole disorder or if additional disease processes are involved. Diabetes mellitus tends to be diagnosed most often in middleaged to older dogs, with overweight, intact females at greatest risk.1

PATHOPHYSIOLOGY The pancreas is an organ with both exocrine and endocrine functions.

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

Mandy is a veterinary technician with more than 15 years of experience. She is currently employed with Comanche Trail Veterinary Center in Liberty Hill, Texas, as the clinical care coordinator.

She earned her veterinary technology degree in 2001 and her bachelor of science degree in agriculture economics from Texas A&M University.

Currently, she is pursuing a master’s degree in veterinary biomedical science, with small animal endocrinology as her primary interest.

Endocrine Function During and after intestinal absorption of glucose and other nutrients into the blood supply, the endocrine aspect of the pancreas becomes active as groups of cells, called islets of Langerhans, synthesize and secrete hormones that are released directly into the blood supply. These hormones are used for maintaining glucose homeostasis.2 Most notable are insulin and glucagon, derived from beta and alpha cells, respectively. These 2 hormones have an inverse relationship: when blood glucose levels are elevated, insulin is secreted, and when blood glucose levels are low, glucagon is secreted.

Insulin receptors are found on all cell membranes throughout the body3; therefore, when insulin is released into the blood (in response to increasing levels of glucose), it stimulates the uptake, utilization, and storage of glucose in tissues, as well as amino acid uptake and synthesis of fatty acids. As glucose

Exocrine Function The exocrine aspect of the pancreas aids in digestion and absorption of nutrients, including glucose, by releasing a variety of enzymes through the pancreatic duct. Glucose is TODAY’SVETERINARYTECHNICIAN VETERINARY VETERINARYTECHNICIAN

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absorbed through the small intestine with the aid of a cotransporter across the intestinal membrane, where a cascade of physiologic sequences continues the transport until the glucose molecule reaches the blood supply. Once in the blood, glucose is either utilized for energy production or stored as glycogen in the liver or skeletal muscles for later use. This normal process of postprandial (after eating) glucose storage prevents blood glucose surges, helping to maintain a normal physiologic state.2

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levels decline, glucagon counters the effects of insulin by increasing blood glucose. Glucagon’s effect is mainly at the level of the liver, stimulating glycogenolysis (the process by which glycogen is converted to glucose), and gluconeogenesis (the process by which noncarbohydrate sources are broken down into glucose). However, glucagon’s physiologic role is much more complex.3 Insulin and glucagon work synergistically to maintain glucose homeostasis.

Development of Diabetes The development of diabetes mellitus can be multifactorial.

For example, it can occur secondary to the loss of beta cell function and subsequent lack of insulin production, and/or it can be associated with insulin antagonism for a variety of reasons. Predisposing factors include immune-mediated beta cell destruction, chronic pancreatitis, and obesity, as well as other diseases or infections that can cause insulin antagonism.4 By the time diabetes mellitus is diagnosed, the resultant chronic state of hyperglycemia has usually already caused irreversible damage to the pancreatic beta cells.

Therefore, dogs, except for very rare exceptions, always have insufficient insulin p oduction (type I diabetes), with twicedaily injections of insulin required for optimal management.

Considering the many conditions that can be associated with diabetes mellitus, it may be necessary to 72

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Diabetes mellitus is a common endocrinopathy seen in small animal practices. Upon diagnosis, it is paramount to treat this disorder promptly to avoid the debilitating metabolic disturbances that can result.

screen for complicating factors that can pose challenges to successful management (BOX 1).

CLINICOPATHOLOGIC ASSESSMENT Patients with diabetes mellitus usually present with PU/PD, lethargy, polyphagia, and weight loss, with PU/PD as the primary clinical sign.

Polyuria and Polydipsia With chronic hyperglycemia, the number of glucose molecules within the proximal renal tubules exceeds the capacity of the available transport molecules to remove them. The resulting retention of glucose in the renal tubules increases the osmotic gradient. Water reabsorption becomes compromised, and water begins to follow the higher concentration of glucose into the urine, resulting in polyuria. This is called osmotic diuresis secondary to exceeding the overall renal threshold of glucose (>180 mg/ dL).5 The consequence of osmotic diuresis is polydipsia, a compensatory mechanism to help prevent dehydration.

Laboratory Analysis In patients with noncomplicated diabetes mellitus, serum biochemical profile analysis eveals hyperglycemia, with the remaining profile typically un emarkable. Urinalysis results

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include glucosuria due to blood glucose levels exceeding the proximal renal tubular threshold for reabsorption.6 Additional abnormal urinalysis results may include altered urine pH and proteinuria, depending on whether a urinary tract infection is present. Other parameters tend to be unremarkable; white blood cell count, urine specific gravit (USG), and urobilinogen and nitrite levels are unreliable when dry chemistry analysis (i.e., reagent strip) is used.7 If USG is evaluated using a refractometer, the result is typically between 1.025 and 1.035. This mildly reduced range (concentrated range, >1.030)8 is due in part to effects of osmotic diuresis and subsequent polydipsia resulting in urine dilution, but despite the severity of PU/PD, the value remains higher than expected due to the presence of glucose molecules. These molecules can increase USG by 0.008 to 0.010. USG values <1.020 may indicate a concurrent disease process.4

MANAGEMENT Management of diabetes mellitus starts with selecting an appropriate insulin type, evaluating the patient’s diet history, considering the patient’s body condition score, and developing short- and long-term treatment plans that are best for both the patient and the owner.

The most important facet of this process is good communication with the owner. Owners need to realize the variables involved with treatment of diabetes mellitus and the money and time commitment required. Consulting on short- and long-term goals of management is crucial and ultimately encourages improved owner compliance. To start the consulting process, see the questions and concerns outlined in BOX 2.

BOX 1 Diabetic Ketoacidosis

BOX 2 Questions and Considerations for Owners of Dogs with Diabetes Mellitus

Diabetes mellitus can become “complicated” and lead to a state called diabetic ketoacidosis (DKA).

This usually occurs if a secondary disease process is present, such as chronic pancreatitis, or if diagnosis of diabetes mellitus is delayed, resulting in a long-term increase in plasma glucose levels.

What is the patient’s home feeding schedule?

What diet and how much of it is fed at each meal? Are any treats given (be specific)

Other metabolic and chronic systemic inflammator states have also been associated with progression of otherwise uncomplicated diabetes mellitus into DKA. For instance, obesity is an area of interest with regard to the inflammatory cytokines p oduced and the adverse role they play in physiologic homeostasis.5

Are there other pets in the household? If so, can they be separated from the patient at meal time?

Is the owner able to administer insulin injections?

Is he or she willing to learn?

Does the patient need to lose weight? Gain weight? Neither?

An extensive study of DKA treatment is not within the scope of this article; therefore, to briefly summarize, the goals are to

Is the owner able to perform glucose curves at home? If so, recommend purchasing a quality glucometer that is reliable in dogs (e.g., AlphaTRAK 2).

hospitalize the patient, address the physiologic derangements through the correction of hydration and acid– base imbalance, and

Explain to the owner that, during the regulation period, glucose curves will need to be performed every 7 to 10 days, either in the hospital or at home. This time period allows the body to adjust to the calculated insulin dosage and enables the clinician to determine the efficacy of th chosen dose.

correct and maintain a relatively normal blood glucose level via administration of a shortacting, regular insulin, which allows the patient to recover from its debilitated state and regain a normal appetite.

Explain that regulating diabetes mellitus is a process and that complicating factors may be involved, which may require additional diagnostics and management approaches.

Once appetite returns to normal, the type of insulin used can be switched from regular insulin to an intermediate- or long-acting product.

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glucose, amino acids, and fatty acids in the urine and subsequent increased protein catabolism for energy utilization (gluconeogenesis). This is all secondary to a lack of insulin production and/or insulin resistance inhibiting cellular uptake of these nutrients.

Polyphagia Polyphagia results from the patient being nutritionally compromised, with loss of lean body mass due to loss of

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TABLE 1 Intermediate-Acting Insulins for Dogs INSULIN

ONSET OF ACTION

PEAK EFFECT

DURATION OF ACTION

FORMULATION

NOTES

Same amino acid sequence as canine insulin

Lente porcine zinc suspension9,10

Immediate

Neutral protamine Hagedorn (NPH)9

0.5–3 h

2–10 h

8–20 h

40 U/mL Only FDA-approved insulin for use in dogs with diabetes mellitus

2–8 h

6–18 h

100 U/mL

Recombinant human insulin

INSULIN ADMINISTRATION

MONITORING

Formulations Exogenous insulin preparations used in dogs for long-term management include intermediate- and long-acting formulations. Each type of insulin has different handling requirements; therefore, careful attention to manufacturer recommendations is important to allow for maximum efficacy of p oduct. For example, some formulations require gentle mixing of the insulin suspension, while others require vigorous shaking. Each insulin preparation requires a specific insulin syringe. vailable formulations used in dogs are listed in TABLES 1 AND 2.

So which insulin type do you choose? Factors influencin selection may include the size of the dog, the clinician’s personal preference, and insulin availability and cost. There is no real right or wrong selection. Owners need to understand that one insulin type may not result in adequate regulation; therefore, the patient may need to switch formulations later.

Glucose Curves Glucose curves should be performed to interpret the response and duration of the selected insulin type and dosage. To perform a curve, measurement of the blood glucose level every 2 hours throughout a 12-hour period is necessary. The 3 aspects of the curve are the peak, nadir, and curve level/duration between these 2 points (FIGURE 1).

A strong clinical indicator that the patient is becoming regulated is the reduction or resolution of PU/PD and a noticeable improvement in the patient’s activity level.

Continued weekly glucose curves are still required to fine-tune glucose levels. The curve is di ferent for all patients, and determining an adequate curve is based on clinical assessment and the quality of the curve.

Ultimately, the curve can help caregivers closely monitor the patient for periods of prolonged or acute

Administration Patient sensitivity to exogenous insulin is variable, as is the potency of various insulin types (e.g., insulin detemir). As a result, all patients should be started on a low dose that is increased incrementally every week until the desired glucose curve is achieved. Dosage and frequency should be determined on a case-by-case basis.

Recommended starting doses range from 0.25 to 0.5 U/kg, and are most commonly given every 12 hours with a meal.

Insulin is ideally administered after a full meal is consumed.

However, a dose given 10 to 15 minutes before feeding can be advantageous in certain situations because it allows timelier onset of the insulin. Caution must be exercised, though, and the patient’s eating habits must be considered when using this method because if the patient does not eat, a hypoglycemic episode can result.

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FIGURE 1. Normal 12-hour glucose curve. Characteristics of the curve include the highest blood glucose level (peak) and the lowest (nadir). On this curve, the peak is seen at 8:00 AM and the nadir at 2:00 PM. The curve also illustrates the duration of response to insulin and the level at which the glucose is maintained throughout the day. Evaluating full glucose curves is an invaluable tool in regulation and management of diabetes mellitus.

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TABLE 2 Long-Acting Insulins for Dogs INSULIN

FORMULATION

NOTES Synthetic insulin analogue that binds to plasma proteins and is released slowly

Insulin detemir11

Initial starting dose of 0.1 U/kg (significantly less than other insulins

100 U/mL

Due to potency, currently only used in large dogs Pharmacokinetics/pharmacodynamics still being evaluated in dogs Recombinant human insulin FDA-approved for use in cats in 2009

Protamine zinc insulin (PZI)12

40 U/mL

Recent studies support use in dogs with diabetes mellitus Due to cost and higher dose requirements, typically not first choice for use in dog Previous formulations were pork/beef derived and removed from market in 2008

hypoglycemia, insulin resistance, and duration of insulin action and make an accurate dosage change, if needed.

Somogyi Effect Persistent, and even increasing, levels of hyperglycemia despite increasing insulin dosages warrant close attention to the glucose curve. The phenomenon termed the Somogyi effect results from insulin overdose and subsequent hypoglycemia (glucose <60 mg/dL). To counteract this acute hypoglycemic crisis, the sympathetic nervous system triggers a release of epinephrine and other counterregulatory hormones, which promote hepatic glycogenolysis and gluconeogenesis. They also act directly on skeletal muscles to produce lactate, which the liver converts to glucose. This response leads to an acute and rapid spike in blood glucose, which can easily be missed with routine spot glucose checks.2 The Somogyi effect can be detected on a full glucose curve as a rapid drop in blood glucose, typically seen within the first few hours after insulin injection (FIGURE 2).

If this phenomenon is occurring, the patient must start back at a low insulin dosage, monitored by repeated glucose curves weekly and with only small incremental increases in dosage until the desired dosage and effect are achieved. If, after full curves are performed and no drop in glucose is apparent, persistent hyperglycemia with little to no response to the exogenous insulin is seen, insulin resistance needs to be considered.

Hypoglycemia A hypoglycemic episode is characterized by onset of lethargy and weakness and can advance into disorientation and even seizures, depending on severity. Prompt treatment can be achieved by either feeding a meal or applying a syrup to the buccal membranes. With more advanced levels of hypoglycemia, emergency intervention using intravenous 50% dextrose may be warranted.9

FIGURE 2. The Somogyi effect is illustrated in this graph by the sharp decline in blood glucose (<60 mg/dL) between the hours of 8:00 and 10:00 AM. The body immediately responds to the crisis by releasing counterregulatory hormones, causing an acute spike in blood glucose. The patient remains persistently hyperglycemic thereafter. Without performing full glucose curves, this phenomenon can be easily missed and hyperglycemia mistaken for inadequate insulin dosing or insulin resistance.

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Insulin Resistance Insulin resistance is defined as having a persistent blood glucose curve of >200 mg/dL at an insulin dosage greater than 1.0 to 1.5 U/kg.13 At this point, it is crucial to confi m that the insulin is being handled and administered correctly by the owner, that the correct insulin syringe is being used (U-40 versus U-100), and that the insulin is not outdated. |

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Once this checklist is complete, exploring reasons of insulin resistance is warranted. Resistance can be secondary to a variety of disorders, such as infections (e.g., urinary tract infection), hyperadrenocorticism, pancreatitis, hypothyroidism, and obesity. Therefore, performing additional diagnostics is necessary to identify and treat the underlying cause of resistance.

The level of added fiber within such foods is still being evaluated, but studies suggest that added fiber allows for a reduction in overall calories, which translates to better glycemic control.16 The fat content of the diet should be based on concurrent illness and adjusted to an appropriate level. For example, a patient with diabetes mellitus and concurrent pancreatitis should be fed a diet lower in fat.16

Fructosamine and Urine Glucose Monitoring Fructosamine is a glycated serum protein complex that reflects average blood glucose concentration over the previous 1 to 3 weeks.14 Fructosamine testing results should always be used in conjunction with full glucose curves and the clinical history to judge glycemic control.

A recent study evaluating fructosamine levels in 24 canine patients with compensated (controlled) diabetes revealed that 17 had a fructosamine level >500, which is indicative of poor glycemic control.15 Urine glucose monitoring in the home setting, using a urine reagent strip, may help identify persistent hypoglycemia, hyperglycemia, and/or ketonuria. This test is for screening only, and insulin adjustments should never be based on these results alone. Caution must be taken with interpreting the results of both fructosamine and urine glucose testing. However, results of these tests may indicate the necessity to perform a full glucose curve, making these tests valuable tools.

Diet Selection There is no magic formula to determine the correct diet for a dog with diabetes mellitus. Therefore, all factors need to be considered when making a selection, such as body condition score, concurrent disease processes (e.g., pancreatitis, obesity), food palatability, food caloric density in relation to volume being fed, and cost. Overall, the most important aspect of selecting a diet is to ensure it is highly digestible, with complex carbohydrates, and—even more important—that the patient will eat it.

The ultimate goal behind diet selection is for the diet to be used synergistically with exogenous insulin to promote glycemic control, thereby avoiding glucose spikes. A diet with complex carbohydrates (e.g., fiber) p omotes slower digestion and absorption of glucose and, as a result, a more constant level of blood glucose throughout the day.

As a rule, it is best to avoid semi-moist diets, as these formulations contain simple carbohydrates that influence postprandial blood glucose spikes, and the glycerol coating used to keep them moist is quickly converted to glucose once consumed. Some patients, in the author’s experience, can be very selective about their diet; therefore, compromising with the patient on diet selection may need to be considered, even if the selected diet is not ideal. TABLE 3 lists some basic considerations when choosing a diet for a diabetic dog.

NUTRITION There is much controversy concerning the optimal diet for a diabetic dog. Options include a high complex carbohydrate–low protein diet or a high protein–low carbohydrate diet.

TABLE 3 Key Nutritional Considerations in Diets for Dogs with Diabetes Mellitus17 ITEM Water

CONSIDERATION Fresh water should be available at all times.

Canned food is not required.

Soluble fibers are a e preferred, such as fructo-oligosaccharide, inulin, pectin, and mucilage.

Carbohydrate

Insoluble fibers, such as cellulose and psyllium, may help with satiet . <55% dry matter carbohydrate; 7% to 18% fibe Moderate to high protein content is recommended.

Protein

Highly digestible (>82%), high-quality protein is preferred. <15% to 35% dry matter

Fat

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Canine Diabetes Mellitus: It’s About the Sugar

BOX 3 Calculating RER and MER Patient: Schnauzer

Body condition score: 3/5

Weight: 13.6 kg

Chosen diet: 300 kcal/cup (8 oz)

CALCULATION

FORMULA

1. RER

70 × (BWkg)

2. MER

1.6 × RER

1.6 × 495.6 = 793 kcal/day

3. Diet (total daily amount)

MER ÷ (kcal/cup)

793 ÷ 300 = 2.6 cups/day

4. Diet (amount/feeding)

(cups/day) ÷ 2

2.6 cups/day ÷ 2 = 1.3 cups q12h

0.75

PATIENT REQUIREMENTS or 30 × (BWkg) + 70

70 × (13.6)0.75 = 495.6 kcal/day

Amount to Feed Once a diet is selected, determination of how much of it to feed is based on the calculated daily kilocalories required to meet the patient’s need to maintain, gain, or lose weight. This amount is then divided equally with each insulin injection. Ideally, the patient needs to eat its fully calculated meal with each injection every 12 hours to allow accurate evaluation of the efficacy of the administe ed insulin in conjunction with the selected diet.

To calculate the patient’s daily kilocalorie requirement, the patient’s daily resting energy requirement (RER) must first be dete mined. The patient’s body condition score is then used to choose the appropriate energy factor needed to determine metabolic energy requirement (MER). The MER factor can range from 0.8 to 2 depending on whether the patient needs to lose, gain or maintain weight.17 Once the patient’s daily kilocalorie needs are known, the selected diet can be evaluated for kilocalories per can or cup and the daily amount divided to be fed in equal amounts with each insulin injection. An example of this calculation, using approximate values, is provided in BOX 3.

Glucose Monitoring When the patient is on an appropriate diet, metabolic changes associated with proper nutrition may cause insulin sensitivity to increase, resulting in a drop in blood glucose.

Therefore, continued monitoring of glucose every 3 to 6 months until the desired effects are achieved is recommended to avoid potential hypoglycemia.

References 1. Rand J. Clinical Endocrinology of Companion Animals. Ames, IA: Wiley-Blackwell; 2013:143-168.

2. Cunningham JG, Klein BG. Textbook of Veterinary Physiology. 4th ed. Philadelphia: Saunders Elsevier; 2007:347-349, 392, 446-447.

3. Wantanabe M, Hayasaki H, Tamayama T, Shimada M. Histologic distribution of insulin and glucagon receptors. Braz J Med Biol Res 1998;31:243-256.

4. Nelson RW, Couto G. Small Animal Internal Medicine. 4th ed. Philadelphia: Mosby Elsevier; 2009:767-784.

5. O’Neill S, Drobatz K, Satyaraj E, Hess R. Evaluation of cytokines and hormones in dogs before and after treatment of diabetic ketoacidosis and in uncomplicated diabetes mellitus. Vet Immunol Immunopathol 2012;148(3-4):276-283.

6. Reine NJ, Langston CE. Urinalysis interpretation: how to squeeze out the maximum information from a small sample. Clin Tech Small Animal Pract 2005;20(1):2-10.

7. Callens AJ, Bartges JW. Urinalysis. Vet Clin North Am Small Animal Pract 2015;45(4):621-637.

8. International Renal Interest Society. IRIS Staging System for CKD. www.iris-kidney. com/pdf/n378.008-iris-website-staging-of-ckd-pdf.pdf. Accessed December 2, 2015.

9. Boothe DM. Small Animal Clinical Pharmacology and Therapeutics. 2nd ed.

Philadelphia: Saunders; 2011.

10. Monroe WE, Laxton D, Fallin EA, et al. Efficacy and safety of a purified p cine insulin zinc suspension for managing diabetes mellitus in dogs. J Vet Intern Med 2005;19:675-682.

11. Fracassi F, Corradini S, Hafner M, et al. Detemir insulin for the treatment of diabetes mellitus in dogs. JAVMA 2015;247(1).

12. Maggiore AD, Nelson RW, Dennis J, et al. Efficacy of p otamine zinc recombinant human insulin for controlling hyperglycemia in dogs with diabetes mellitus. J Vet Intern Med 2012;26:109-115.

13. Hess RS. Insulin resistance in dogs. Vet Clin North Am Small Animal Pract 2010; 40(2):309-316.

14. Studdert VP, Gay OC, Blood GC. Saunders Comprehensive Veterinary Dictionary, 4th ed. Philadelphia: Saunders Ltd; 2011.

15. Claus P, Gimenes AM, Castro JR, et al. Fructosamine levels do not agree with clinical classification egarding diabetic compensation in diabetic dogs under treatment (abst). J Vet Intern Med 2014;28:1034-1035.

16. Fascetti AJ, Delaney SJ. Nutritional management of endocrine diseases. In: Applied Veterinary Clinical Nutrition. Hoboken, NJ: John Wiley & Sons; 2012:289-300.

17. Zicker SC, Nelson RW, Kirk CA, Wedekind KJ. Endocrine disorders. In: Hand MS, Thatcher CD, Remillard RL, et al, . Small Animal Clinical Nutrition. 5th ed. Topeka, KS: Mark Morris Institute; 2010:559-584.

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CONCLUSION Diabetes mellitus is a common endocrinopathy seen in small animal practices. Upon diagnosis, it is paramount to treat this disorder promptly to avoid the debilitating metabolic disturbances that can result. How this disease develops is still not completely understood, and research on the topic continues. Regardless, it is important to recognize its clinical signs when they present and to have a working understanding of the clinicopathologic assessment process, including knowledge of how to regulate the patient and to recognize potential complications that may develop during short- and long-term treatment efforts. 

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CE Article 4

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Canine Diabetes Mellitus: It’s About the Sugar

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Peer-Reviewed

CE Test Article 4 Canine Diabetes Mellitus: It’s About the Sugar The article you have read is RACE approved for 1 hour of continuing education credit. To receive credit, take the approved test online at VetMedTeam.com. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

1. Diabetes mellitus in dogs is most commonly associated with insulin resistance. a. True b. False 2. Which is the primary clinical sign associated with uncomplicated diabetes mellitus? a. Lethargy b. Polyuria and polydipsia c. Decreased appetite d. Weight gain 3. Within the islets of Langerhans, which cells synthesize and secrete insulin and glucagon, respectively? a. Beta cells, gamma cells b. Alpha cells, beta cells c. Delta cells, acinar cells d. Beta cells, alpha cells 4. The Somogyi effect is characterized by a. Persistent hypoglycemia b. Acute hypoglycemia with rebound hyperglycemia c. Insulin resistance d. None of the above 5. Management of canine diabetes mellitus requires a. Owner compliance b. Exogenous insulin therapy c. Client communication d. All of the above

6. Glucosuria occurs when blood glucose exceeds ____________ mg/dL. a. 140 b. 160 c. 180 d. 200 7. The development of diabetes mellitus can be multifactorial. Predisposing factors that may play a role include a. Chronic pancreatitis b. Obesity c. Hyperadrenocorticism d. All of the above 8. Proper insulin handling is important; therefore, all insulin preparations should be gently mixed before administration. a. True b. False 9. Glucose is stored in the liver as a. Globulin b. Glycogen c. Glucagon d. Gastrin 10. Glucose curves are performed once every ____________ days, until an adequate curve is achieved. a. 2–5 b. 4–7 c. 7–10 d. 12–15

COMING SOON!

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The Diet That Revolutionized the World of Feline Diabetes Launched in 2000, DM Dietetic Management® was the first high protein/low carbohydrate therapeutic diet for the nutritional management of feline diabetes.

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Final Thoughts

Be With What Is Nurses eat their young.

I’d never heard that phrase before my training to become a compassion fatigue specialist. It’s what happens when a new nurse hits a unit occupied by veteran nurses. At the first sign o the newcomer’s vulnerability, the seasoned nurse says, “Hey, honey, you better get used to this real quick and just suck it up!”

Julie Squires Rekindle, LLC

And this is how we become hardened. This is exactly the moment we start building that protective shield around us. Replace “nurse” with “veterinary technician” or “veterinarian” or “receptionist.” We are all that “nurse.”

When did you lose your naiveté?

I once facilitated a workshop in which a veterinarian said to me, “In vet school, we learned to work at an insane pace, skipping meals and sleep, and were told to just suck it up. I never even thought about how crazy it was until I look back on it now. Wow.” Perhaps the pace and expectations are inhumane? Perhaps a profession built on empathy and compassion needs to first extend it to oneself You’ve done nothing wrong. It was your training that was wrong. You were never taught how to ensure your own well-being before you offer your help to another.

Yet in my workshops, I see the strain on the faces in the room. The veterinary technicians are often just waiting for me to tell them that the way they feel is normal.

We build up walls around ourselves and around our hearts for mere protection. It’s a brilliant idea, except it doesn’t work.

We can’t selectively choose which emotions we are going to let in: Sadness? Nope. Despair? Definitely not. Anger? No. Joy? Su e! It doesn’t work that way.

As Brené Brown says, when we numb the painful emotions, we also numb the positive emotions.1 So then how do we protect our vulnerable hearts, yet still be empathetic and compassionate? There’s a big question with a big answer.

It starts with being with what is, or mindfulness. This is a practice.

Mindfulness asks us to be in the moment, in the actual experience without judging it or having expectations about it. We are hardly ever truly in the moment. Right now, as you are reading this, you are likely also thinking about something else, something you are doing later or something that occurred earlier. We live our lives through the cacophony of our minds.

Julie is a compassion fatigue specialist who brings a unique perspective and approach to support the sustained energy and passion of animal workers.

Her company, Rekindle LLC, offers on-site compassion fatigue training to veterinary hospitals, animal shelters, and other animal organizations.

Julie has more than 20 years of experience within the veterinary field and wit leading organizations. She has developed and executed training, workshops, and 1:1 coaching for major companies in the animal health industry. She obtained her certification as a compassio fatigue specialist through the Green Cross Academy of Traumatology and has also completed training from The Figley Institute and Traumatology Institute. Julie’s clients also gain from her experience as a certifie health and wellness coach and corporate wellness specialist.

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My friends, an untrained mind is like a drunken monkey stung by a bee.

An untrained mind constantly produces suffering. I’ve often said I am a student of suffering. It’s a lifetime of suffering that led me to do the work that I do around compassion fatigue. Compassion fatigue is suffering, and I know the way out. |

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Final Thoughts

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Be With What Is

istock.com/aspenrock

How do we protect our vulnerable hearts, yet still be empathetic and compassionate?

There’s a big question.

So back to the mind. Its job is to keep you safe, so it’s constantly scanning your life to find ways to do that. This is noble job. However, one of its most basic—and outdated— responses is to create fear and separation. We no longer live in a world where a predator is around every corner. We no longer have to be on guard every moment of every day.

We’ve earned the right to enjoy and be in the moment that is happening right now. In order to get there, we need to train ourselves to quiet the hamster wheel in the mind— that mind that is constantly pointing out where we’ve fallen short or aren’t enough.

cashier line. But wishing things were other than they are takes us out of the moment and toward suffering.

3. Savor. We all can relate to savoring a great meal or a decadent dessert. Do we also savor the good moments of life? Do we savor the joyful moments in the practice? When the long-term case goes home or when the really sick kitty beats the odds and recovers? As human beings, we have a negativity bias that causes us to focus on the negative aspects of things.2 But by allowing the good moments to really sink in, we become uplifted and filled. And filled is the opposite o empty, which is what many in helping professions feel most of the time. So the next time you experience something nice, sweet, or beautiful, let it linger in your heart for a bit longer. Feel how good it feels, and let it permeate you.

I can tell you that by incorporating those practices into your daily life, you will start to rejuvenate and become reinvigorated.

I’ve witnessed it personally. I can also tell you that you will begin to work from a place of abundance rather than depletion.

Perhaps for the very first time 

How do you do that, you might be asking?

1. Connect to your breath. Your breath is your connection to the present moment. Close your eyes and just notice your inhalation and exhalation. Don’t change it, just notice it. Notice the rise and fall of your chest and/or belly as it rides the wave. I do this every morning for 15 minutes and it sets the entire tone for my day. It’s my time with God. 2. Be with what is. Most of the time, we are busy wishing things were other than they are. Wishing we were on a vacation, thinner, sleeping, richer, had more friends, a better relationship, a different meal, and were on a different TODAY’SVETERINARYTECHNICIAN VETERINARY VETERINARYTECHNICIAN

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References 1. Brown B. The Gifts of Imperfection: Let Go of Who You Think You’re Supposed to Be and Embrace Who You Are. Center City, MN: Hazelden Publishing; 2010.

2. Marano HE. Our brain’s negative bias. Psychol Today 2003. www.psychologytoday.com/ articles/200306/our-brains-negative-bias. Accessed December 10, 2015.

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The plaque-blocking shield is invisible, but the benefits are quite obvious.

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