Today's Veterinary Nurse, January 2018 by davidpsu

WINTER 2018 VOLUME 1, NUMBER 1

INSIDE: TOXICOLOGY TALK WINTER HOLIDAY TOXINS IMAGING DENTAL RADIOLOGY INFECTION DISCOSPONDYLITIS

An Official Journal of the NAVC ● todaysveterinarynurse.com

Otitis Externa INFLAMMATION OF THE EAR CANAL

EQUINE MEDICINE EQUINE PYTHIOSIS

They already have a lot to remember. Give them one less thing to forget.

No matter how busy life gets, at least you’ll know your patients are protected from fleas & ticks with BRAVECTO® Prescription-only BRAVECTO® provides up to 12 weeks* of extended protection against fleas & ticks with just one dose. Good for patients, good for compliance, good for your practice.

Ask your Merck Animal Health Rep about BRAVECTO® or Visit Bravectovets.com *BRAVECTO® kills fleas and prevents flea infestations for 12 weeks. BRAVECTO® Chew kills ticks (black-legged tick, American dog tick, and brown dog tick) for 12 weeks and also kills lone star ticks for 8 weeks.

Also available as a topical application.

Important Safety Information BRAVECTO Chews for Dogs: The most common adverse reactions recorded in clinical trials were vomiting, decreased appetite, diarrhea, lethargy, polydipsia, and flatulence. Bravecto has not been shown to be effective for 12-weeks’ duration in puppies less than 6 months of age. Bravecto is not effective against lone star ticks beyond 8 weeks after dosing. See full Prescribing Information on page 89. Copyright © 2018 Intervet Inc., d/b/a Merck Animal Health, a subsidiary of Merck & Co. Inc. All rights reserved. US/BRV/1117/0105

WINTER 2018 VOLUME 1, NUMBER 1

An Official Journal of the NAVC ● todaysveterinarynurse.com An Official journal of the

Editor in Chief Lynne Johnson-Harris, RVT LJohnson@NAVC.com An official journal of the NAVC, Today’s Veterinary Nurse is the trusted source for peer-reviewed clinical information in small animal veterinary medicine. Our goal is to enhance knowledge and encourage confidence, inspiring the highest quality of veterinary care. As an NAVC publication, our audience has access to world-class continuing professional development developed for the global veterinary health care community. Subscriptions (only): 630.739.0900, CDS/Today’s Veterinary Nurse 440 Quadrangle Drive, Suite E, Bolingbrook, IL 60440. Email subscription form to subscriptions@CDS1976.com or fax to 630.739.9700 Free subscriptions only to qualifying subscribers.* For a new subscription, confirmation, or renewal, please visit todaysveterinarytechnician.com to fill out an online form. For updates, please include your subscription ID from label. To have a form emailed or faxed to you, please contact us at our 800 number or email above and provide email or fax number. Change Name/Address or Cancel: Please use online form at todaysveterinarytechnician.com or contact us by phone, fax, or email subscriptions@CDS1976.com. Please provide the ID number (directly above your name on label) for positive identification. If the ID number is not available or legible, provide name and address as it appears on the label to allow identification of the subscription. *Qualifying Subscribers: veterinary nurses, veterinary technicians, veterinary assistants, veterinary technician students, and other members of the veterinary health care team in the United States. Eastern States Veterinary Association, Inc (NAVC) reserves the right to determine eligibility for a free subscription. WARRANTIES, LIMITATIONS. Except as expressly set forth herein, Eastern States Veterinary Association, Inc (NAVC) makes no warranties whatsoever, express, implied, or statutory. NAVC specifically disclaims any implied warranty of merchantability or fitness for a particular purpose. In no event will NAVC be liable to you or any third party for any indirect, punitive, special, incidental, or consequential damages (including loss of profits, use, data, or other economic advantage), however it arises, even if NAVC has previously been advised of the possibility of such damage. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. Entire contents ©2018 Eastern States Veterinary Association, Inc (NAVC).

Thomas M. Bohn, MBA, CAE Chief Executive Officer, NAVC TBohn@NAVC.com Laura C.S. Walker Chief Media Officer LWalker@NAVC.com Chris Kelly, Group Publisher CKelly@NAVC.com

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

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

Kathi L. Smith, RVT, VTS (Oncology) Portland Veterinary Specialists Portland, Maine Deborah A. Stone, MBA, PhD, CVPM StoneVPM Austin, Texas Daniel J. Walsh, MPS, RVT, LVT, VTS (Clinical Pathology) Purdue University (Retired)

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

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

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EDITOR’S LETTER

Get Ready, Here It Comes!

WINTER 2018

Lynne Johnson-Harris, RVT Editor in Chief

NAVTA CORNER

Veterinary Nursing Initiative Heather Prendergast, RVT, CVPM, SHPH and Ken Yagi, MS, RVT, VTS (ECC, SAIM)

31 ADVERTISER INDEX

VITAL SIGNS NUTRITION NOTES

Gastrointestinal Microbiota: An Introduction Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition)

This article examines the important role microbiota plays in the development, immune regulation, and maintenance of an animal’s GI health.

TOXICOLOGY TALK

Winter Holiday Toxins

Carrie Lohmeyer-Mauzy, CVT, BS

FROM THE FIELD

Focus on Overweight and Obesity in Dogs Kirk J. Breuninger, VMD, MPH

INTERNAL MEDICINE CASE REPORT

Peritoneal Dialysis: Following Urethral Obstruction and Acute Kidney Injury Courtney Waxman, CVT, VTS (ECC)

IDEAS INTO PRACTICE

Tackling Pet Obesity: It’s Not Easy, But It’s the Best Work! Esther Klok

Today’s Veterinary Nurse (ISSN 2575-8365 print and ISSN 2575-8373 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 Nurse (ISSN 2575-8365; print version) is published quarterly (Winter, Spring, Summer, Fall; 4x per year) by NAVC, 622 East Washington St, Ste 300, Orlando, FL 32801. POSTMASTER: Send all UAA to CFS (See DMM 507.1.5.2); NON-POSTAL AND MILITARY FACILITIES: send address corrections to CDS/Today’s Veterinary Nurse, 440 Quadrangle Drive, Ste E, Bolingbrook, IL 60440.

To read this issue online, visit todaysveterinarynurse.com

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FEATURES CONTINUING EDUCATION

Dangers of Hypothermia: Avoiding the Cold Brenda K. Feller, CVT, RVT, VTS (Anesthesia and Analgesia)

This article describes hypothermia dangers, causes, and risk factors; how to prevent or detect hypothermia; and how to treat it should it occur.

DERMATOLOGY

Otitis Externa Sandra Grable, AAS, CVT

INFECTION CONTROL

Discospondylitis: An Overview Heather Anderson, RVT, VTS (Neurology)

DENTAL RADIOLOGY

Dental Radiology: Positioning for Picture-Perfect Views

EQUINE MEDICINE

Equine Pythiosis: An Overview Sharon Klingler, RVT, VTS (Anesthesia and Analgesia, EVN)

Liane K. Shaw, BS, RVT and Cynthia Voglewede, BS, RVT, AVTCP-Canine/Feline

EXTRA MILE CAREER CHALLENGES

Animal Cruelty: Your Role in Identifying Abuse Lisa M. Smith, LVT, VTS (ECC)

Animal cruelty carries legal consequences that veterinary professionals need to understand in identifying abuse. Learn how to document and report cruelty.

WINTER 2018 VOLUME 1, NUMBER 1

INSIDE:

TOXICOLOGY TALK WINTER HOLIDAY TOXINS IMAGING DENTAL RADIOLOGY INFECTION DISCOSPONDYLITIS

FINAL THOUGHTS

Building Resiliency Through Our Story Julie Squires, CCFS

TABLE OF CONTENTS

An Official Journal of the NAVC â&#x2014;? todaysveterinarynurse.com

Otitis Externa INFLAMMATION OF THE EAR CANAL

EQUINE MEDICINE EQUINE PYTHIOSIS

ON THE COVER Sandra Grable, AAS, CVT, conducts an examination of the ear canal as a veterinary assistant restrains the pet. Photo courtesy of Bradley Leeb, University of Illinois

To read this issue online, visit todaysveterinarynurse.com

NOT ALL FLEA AND TICK CHEWS ARE CREATED EQUAL

Flea and tick protection that goes on and on and on...all month long

Recommend Simparica to your clients Simparica acts fast—it starts killing fleas within 3 hours and ticks within 8 hours*—and keeps going strong for 35 days* without losing effectiveness at the end of the month. Premium protection without the premium price— with our rebate offers and affordable price, you can compete against OTC brands and bring flea and tick protection back into your practice. IMPORTANT SAFETY INFORMATION: Simparica is for use only in dogs, 6 months of age and older. Simparica may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures. Simparica has not been evaluated in dogs that are pregnant, breeding or lactating. Simparica has been safely used in dogs treated with commonly prescribed vaccines, parasiticides and other medications. The most frequently reported adverse reactions were vomiting and diarrhea. See full Prescribing Information on the back of this page and at www.zoetisUS.com/SimparicaPI. *Studies show Simparica starts killing ticks in 8 hours and is ≥96.9% effective for 35 days against weekly reinfestations of Ixodes scapularis, Amblyomma americanum, Amblyomma maculatum, Dermacentor variabilis, and Rhipicephalus sanguineus.1,2

Learn more about Simparica. Contact Zoetis Customer Service at 1-888-ZOETIS-1 or 1-888-963-8471. References: 1. Six RH, Geurden T, Carter L, et al. Evaluation of the speed of kill of sarolaner (Simparica™) against induced infestations of three species of ticks (Amblyomma maculatum, Ixodes scapularis, Ixodes ricinus) on dogs. Vet Parasitol. 2016;222:37-42. 2. Six RH, Everett WR, Young DR, et al. Efficacy of a novel oral formulation of sarolaner (Simparica™) against five common tick species infesting dogs in the United States. Vet Parasitol. 2016;222:28-32. All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted. © 2017 Zoetis Services LLC. All rights reserved. SMP-00307

(sarolaner) Chewables

FOR ORAL USE IN DOGS ONLY CAUTION: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Description: SIMPARICA is a flavored, chewable tablet for administration to dogs over 6 months of age according to their weight. Each tablet is formulated to provide a minimum sarolaner dosage of 0.91 mg/lb (2 mg/kg) body weight. Sarolaner is a member of the isoxazoline class of parasiticides and the chemical name is 1-(5’-((5S)-5-(3,5-Dichloro-4-fluorophenyl)-5-(trifluoromethyl)-4,5-dihydroisoxazol-3-yl)-3’H-spiro(azetidine-3,1’-(2)benzofuran)-1-yl)-2-(methylsulfonyl)ethanone. SIMPARICA contains the S-enantiomer of sarolaner. The chemical structure of the S-enantiomer of sarolaner is: F F

F O

CI N

O O

S O

Indications: SIMPARICA kills adult fleas, and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis), and the treatment and control of tick infestations [Amblyomma americanum (lone star tick), Amblyomma maculatum (Gulf Coast tick), Dermacentor variabilis (American dog tick), Ixodes scapularis (black-legged tick), and Rhipicephalus sanguineus (brown dog tick)] for one month in dogs 6 months of age or older and weighing 2.8 pounds or greater. Dosage and Administration: SIMPARICA is given orally once a month at the recommended minimum dosage of 0.91 mg/lb (2 mg/kg). Dosage Schedule: Body Weight SAROLANER per Tablet (mg) Number of Tablets Administered 2.8 to 5.5 lbs 5 One 5.6 to 11.0 lbs 10 One 11.1 to 22.0 lbs 20 One 22.1 to 44.0 lbs 40 One 44.1 to 88.0 lbs 80 One 88.1 to 132.0 lbs 120 One >132.1 lbs Administer the appropriate combination of tablets SIMPARICA can be offered by hand, in the food, or administered like other tablet medications. 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 a dose is missed, administer SIMPARICA and resume a monthly dosing schedule. SIMPARICA should be administered at monthly intervals. Flea Treatment and Prevention: Treatment with SIMPARICA may begin at any time of the year. In areas where fleas are common year-round, monthly treatment with SIMPARICA can continue the entire year without interruption. To minimize the likelihood of flea re-infestation, it is important to treat all dogs and cats within a household with an approved flea control product. Tick Treatment and Control: Treatment with SIMPARICA can begin at any time of the year (see Effectiveness). Contraindications: There are no known contraindications for the use of SIMPARICA. Warnings: Not for use in humans. Keep this and all drugs out of reach of children and pets. For use in dogs only. Do not use SIMPARICA in cats. SIMPARICA should not be used in dogs less than 6 months of age (see Animal Safety). Precautions: SIMPARICA may cause abnormal neurologic signs such as tremors, decreased conscious proprioception, ataxia, decreased or absent menace, and/or seizures (see Animal Safety). The safe use of SIMPARICA has not been evaluated in breeding, pregnant, or lactating dogs. Adverse Reactions: SIMPARICA was administered in a well-controlled US field study, which included a total of 479 dogs (315 dogs treated with SIMPARICA and 164 dogs treated with active control once monthly for three treatments). Over the 90-day study period, all observations of potential adverse reactions were recorded. Table 1. Dogs with adverse reactions Adverse reaction sarolaner sarolaner active control active control N % (n = 315) N % (n =164) Vomiting 3 0.95% 9 5.50% Diarrhea 2 0.63% 2 1.20% Lethargy 1 0.32% 2 1.20% Inappetence 0 0% 3 1.80%

Additionally, one female dog aged 8.6 years exhibited lethargy, ataxia while posturing to eliminate, elevated third eyelids, and inappetence one day after receiving SIMPARICA concurrently with a heartworm preventative (ivermectin/pyrantel pamoate). The signs resolved one day later. After the day 14 visit, the owner elected to withdraw the dog from the study. For a copy of the Safety Data Sheet (SDS) or to report adverse reactions call Zoetis Inc. at 1-888-963-8471. Additional information can be found at www.SIMPARICA.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or http://www.fda.gov/AnimalVeterinary/SafetyHealth. Clinical Pharmacology: Sarolaner is rapidly and well absorbed following oral administration of SIMPARICA. In a study of 12 Beagle dogs the mean maximum plasma concentration (Cmax) was 1100 ng/mL and the mean time to maximum concentration (Tmax) occurred at 3 hours following a single oral dose of 2 mg/kg to fasted animals. The mean oral bioavailability was 86% and 107% in fasted and fed dogs, respectively. The mean oral T1/2 values for fasted and fed animals was 10 and 12 days respectively. Sarolaner is distributed widely; the mean volume of distribution (Vdss) was 2.81 L/kg bodyweight following a 2 mg/kg intravenous dose of sarolaner. Sarolaner is highly bound (≥99.9%) to plasma proteins. The metabolism of sarolaner appears to be minimal in the dog. The primary route of sarolaner elimination from dogs is biliary excretion with elimination via the feces. Following repeat administration of SIMPARICA once every 28 days for 10 doses to Beagle dogs at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, steady-state plasma concentrations were reached after the 6th dose. Following treatment at 1X, 3X, and 5X the maximum intended clinical dose of 4 mg/kg, sarolaner systemic exposure was dose proportional over the range 1X to 5X. Mode of Action: The active substance of SIMPARICA, sarolaner, is an acaricide and insecticide belonging to the isoxazoline group. Sarolaner inhibits the function of the neurotransmitter gamma aminobutyric acid (GABA) receptor and glutamate receptor, and works at the neuromuscular junction in insects. This results in uncontrolled neuromuscular activity leading to death in insects or acarines. Effectiveness: In a well-controlled laboratory study, SIMPARICA began to kill fleas 3 hours after initial administration and reduced the number of live fleas by ≥96.2% within 8 hours after flea infestation through Day 35. In a separate well-controlled laboratory study, SIMPARICA demonstrated 100% effectiveness against adult fleas within 24 hours following treatment and maintained 100% effectiveness against weekly re-infestations for 35 days. In a study to explore flea egg production and viability, SIMPARICA killed fleas before they could lay eggs for 35 days. In a study to simulate a flea-infested home environment, with flea infestations established prior to the start of treatment and re-infestations on Days 7, 37 and 67, SIMPARICA administered monthly for three months demonstrated >95.6% reduction in adult fleas within 14 days after treatment and reached 100% on Day 60. In well-controlled laboratory studies, SIMPARICA demonstrated ≥99% effectiveness against an initial infestation of Amblyomma americanum, Amblyomma maculatum, Dermacentor variabilis, Ixodes scapularis, and Rhipicephalus sanguineus 48 hours post-administration and maintained >96% effectiveness 48 hours post re-infestation for 30 days. In a well-controlled 90-day US field study conducted in households with existing flea infestations of varying severity, the effectiveness of SIMPARICA against fleas on Day 30, 60 and 90 visits compared to baseline was 99.4%, 99.8%, and 100%, respectively. Dogs with signs of flea allergy dermatitis showed improvement in erythema, papules, scaling, alopecia, dermatitis/pyodermatitis and pruritus as a direct result of eliminating fleas. Animal Safety: In a margin of safety study, SIMPARICA was administered orally to 8-week-old Beagle puppies at doses of 0, 1X, 3X, and 5X the maximum recommended dose (4 mg/kg) at 28-day intervals for 10 doses (8 dogs per group). The control group received placebo tablets. No neurologic signs were observed in the 1X group. In the 3X group, one male dog exhibited tremors and ataxia post-dose on Day 0; one female dog exhibited tremors on Days 1, 2, 3, and 5; and one female dog exhibited tremors on Day 1. In the 5X group, one female dog had a seizure on Day 61 (5 days after third dose); one female dog had tremors post-dose on Day 0 and abnormal head coordination after dosing on Day 140; and one female dog exhibited seizures associated with the second and fourth doses and tremors associated with the second and third doses. All dogs recovered without treatment. Except for the observation of abnormal head coordination in one dog in the 5X group two hours after dosing on Day 140 (dose 6). There were no treatment-related neurological signs observed once the dogs reached the age of 6 months. In a separate exploratory pharmacokinetic study, one female dog dosed at 12 mg/kg (3X the maximum recommended dose) exhibited lethargy, anorexia, and multiple neurological signs including ataxia, tremors, disorientation, hypersalivation, diminished proprioception, and absent menace, approximately 2 days after a third monthly dose. The dog was not treated, and was ultimately euthanized. The first two doses resulted in plasma concentrations that were consistent with those of the other dogs in the treatment group. Starting at 7 hours after the third dose, there was a rapid 2.5 fold increase in plasma concentrations within 41 hours, resulting in a Cmax more than 7-fold higher than the mean Cmax at the maximum recommended use dose. No cause for the sudden increase in sarolaner plasma concentrations was identified. Storage Information: Store at or below 30°C (86°F) with excursions permitted up to 40°C (104°F). How Supplied: SIMPARICA (sarolaner) Chewables are available in six flavored tablet sizes: 5, 10, 20, 40, 80, and 120 mg. Each tablet size is available in color-coded packages of one, three, or six tablets. NADA #141-452, Approved by FDA Distributed by: Zoetis Inc. Kalamazoo, MI 49007 Made in Switzerland

Revised: July 2016

50070900A&P

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

EDITOR’S LETTER

Get Ready, Here It Comes!

f you have not had the opportunity to attend the NAVC VMX (Veterinary Meeting and EXPO), now is your time to join us at the Orange County Convention Center in Orlando, Florida, February 3-7, 2018.

The VMX vision is to empower all members of the veterinary health care team to expand knowledge, sharpen skills and learn what is new and exciting in the industry to provide ongoing, high quality care to your patients. For veterinary nurses, there are sessions and hands-on labs designed to meet your level of experience on a variety of topics such as: avian handling, low-stress patient handling, cytology, ultrasound and wound management. Other hands-on labs include FEAR FREEsm, Technician Essentials, Technician Progressive Knowledge and Technician State of the Art. There are also sessions on personal health and well-being to ensure you stay connected on and top of your game. This year visit the re-designed VMX Expo Hall with over 700 exhibiting companies. The EXPO Innovation and Technology Center will feature the newest products and services in the VMX New Product Gallery and the Startup Circle. Visit NAVC Central to network and relax. Sit and watch NAVC Spark!, live recordings with the latest industry news. The Health and Wellbeing Center is designed to encourage you to pay attention to you and your personal health. Sessions will cover topics focusing on mental and professional health and diversity in the workplace. You can also schedule to have a rabies titer and other biochemical assays collected. Browse through the VMX Bookstore for publications and visit the VetFolio Booth to learn about all the online programs offered.

Have Some Fun! As always, it can’t be all work and no play. When not attending meetings, sessions, or hands-on labs, you’ll get to experience top entertainment from actor Michael J. Fox, conservationist and environmental journalist Jeff Corwin, and a high-energy concert featuring Matchbox Twenty’s Rob Thomas. Looking for adventure? Register for one of the tours and swim with the manatees in Homosassa Springs State Wildlife Park or get a first-hand look at veterinary care at SeaWorld. You can also pick up tickets to popular theme parks and dinner shows. Feel like going for a run? Register for the Fun(d) Run, where all proceeds benefit the WSAVA Foundation. Football fan? Attend the Big Game Event Sunday evening, and watch Super Bowl LII. With food, fun and football, what could be better?

Lynne Johnson-Harris, RVT Editor in Chief

‘‘

’’

There are multiple lunches and receptions just for veterinary technician/nurses. Stop by the partner-sponsored Today’s Veterinary Nurse Lounge in the EXPO Hall to relax, recharge and network. For more information about the NAVC VMX 2018, visit NAVC.com/conference. See you in the sun! TVN

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NAVTA CORNER

A word from the National Association of Veterinary Technicians in America

Veterinary Nursing Initiative

ithin our own profession lies confusion about the scope of duties of a CVT, RVT, LVT or LVMT. The names themselves cause confusion, but more importantly, state practice acts compound that confusion—if veterinary technicians are even mentioned. Credentialed Veterinary Technicians/Nurses play a vital role in patient care on a daily basis. While many VTs feel they complete more tasks than a human nurse, the responsibility is essentially the same—nursing care of patients. Heather Prendergast, RVT, CVPM, SHPH Co-Chair The Veterinary Nurse Initiative

When the public was surveyed about the role a veterinary technician performs in pet care, a majority do not know what the role is or what constitutes it. Also, they do not feel that schooling is a part of it, while they are certain about the scope of duties a nurse carries out, and the schooling that is required to become an RN. As a result, the Veterinary Nurse Initiative (VNI) believed there was a need to create change for the better and unite this phenomenal profession. Led by a working group of credentialed veterinary technicians, RNs and a strategist, VNI is aiming high to make changes in all 50 states to standardize credentialing, define the scope of practice, and protect the title. The working group is in the early stages of creating an executive committee made of industry support personnel to further develop and create change. The VNI was excited to learn of NAVC’s decision to support the standardized credentialing by changing the name of the publication from Today’s Veterinary Technician to Today’s Veterinary Nurse.

Ken Yagi, MS, RVT, VTS (ECC, SAIM) Co-Chair The Veterinary Nurse Initiative

‘‘

The amount of training veterinary technicians receive builds their knowledge and skills in many areas from patient care to radiography to nutrition.

’’

“The NAVC fully supports a single credential for veterinary nurses nationwide, and we believe it will improve the level of patient care, reduce pet owners’ confusion, and lead to an improved public perception for the great work these individuals are doing on a daily basis,” said Tom Bohn, CAE, Chief Executive Officer of the NAVC. Lynne E. Johnson, RVT, Editor in Chief of Today’s Veterinary Nurse noted, “I’m thrilled that NAVTA is leading the way with the Veterinary Nurse Initiative. The change to Today’s Veterinary Nurse shows the NAVC support and commitment to the profession and the initiative.” Banfield, Royal Canin, and BluePearl Veterinary Partners also lend their support to the VNI. “The amount of training veterinary technicians receive builds their knowledge and skills in many areas from patient care to radiography to nutrition,” says Brent Mayabb, DVM and Royal Canin’s Chief Veterinary Officer. “With this extensive training and their commitment to the profession, we fully support the NAVTA-led Veterinary Nurse Initiative to recognize the value veterinary technicians bring to pets and to the veterinary team.” According to Jennifer Welser, DVM, DAVCO, Chief Medical Officer at BluePearl Veterinary Partners, “We believe the Veterinary Nurse Initiative is an important step toward acknowledging the skill exhibited by our veterinary technicians. By supporting the effort, we are fully recognizing nursing as a valued profession in veterinary medicine.” The VNI will continue the movement in 2018 through legislative activities in select states, continue high level discussions with both veterinary and nursing alliances, and adding other sponsors to the executive coalition. TVN

NAVTA CORNER

Vital Signs NUTRITION NOTES — The Gastrointestinal Microbiota: An Introduction — 11 TOXICOLOGY TALK — Winter Holiday Toxins — 16 INTERNAL MEDICINE — Peritoneal Dialysis Following Urethral Obstruction & Acute Kidney Injury — 23 FROM THE FIELD — State of Pet Health: Focus on Overweight and Obesity in Dogs — 30 IDEAS INTO PRACTICE — Pet Obesity — 32

Your Veterinary News, Your Veterinary Life NAVCâ&#x20AC;&#x2122;s new online news and information network SPARK! is your source for weekly coverage of industry news, emerging trends and unique lifestyle stories within the veterinary community. Like the NAVC on Facebook to catch all of Spark!â&#x20AC;&#x2122;s new content and check out the latest videos now by visiting NAVC.com/Spark. /TheNAVC

NUTRITION NOTES

POPULATION CONTROL As we learn more about the composition and function of the microbiota, we will also need to address ways to keep this population as healthy and happy as the host it inhabits. The microbiota plays an important role in the development, immune regulation, and maintenance of health for all animals. Image courtesy of shutterstock.com/Jezper

MEET THE AUTHOR

Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition) Belleville, Michigan Ann is a 1983 graduate of Michigan State University. She has worked in general, emergency, and specialty practice, as well as education and management. Ann is active in her state, national, and specialty organizations and served on the organizing committees for the internal medicine and nutrition veterinary technician specialties. She has mentored over 15 fellow veterinary technician specialists. She has published over 45 articles in professional magazines, as well as book chapters, and is a coauthor of Nutrition and Disease Management for Veterinary Technicians and Nurses, now in its second edition.

VITAL SIGNS

The Gastrointestinal Microbiota: An Introduction

hen mammals are born, their gastrointestinal (GI) tract is sterile.1 Within the first 24 hours of life, microbes begin to populate the GI tract. The resulting microbial population is called the GI microbiota. Evolution has led to a stable, mutually beneficial relationship between the host and these microbes.1 This relationship is complex, and we are just beginning to understand the GI microbiota and how it influences health and disease.

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PEER REVIEWED

The microbiota is composed of living microorganisms, including bacteria, fungi, protozoa, viruses, parasites, and archaea (single-celled organisms known as prokaryotes).2 The GI tract of domestic animals is home to several hundred different genera of bacteria with >1000 phylotypes. These organisms outnumber the hostâ&#x20AC;&#x2122;s own cells by a factor of 100, totaling 1010 to 1014 (10 with 10 to 14 zeros after it!). Likewise, some genetic components (eg, DNA, mitochondria) of the microbiota exceed the hostâ&#x20AC;&#x2122;s by 100 times or more. The collective genome of the microbiota is called the microbiome or, sometimes, the second genome.3

COMPOSITION The microbiota is not confined to the GI tract. Every part of the body that communicates with the external world has its own microbiota, the composition of which can vary between and within various sites. For example, the skin microbiota is different from the respiratory tract microbiota, and the composition of the skin or respiratory microbiota can differ between the upper and lower respiratory tract and between the aural and the inguinal skin.3 The development of a healthy GI microbiota is critical to normal development and maintenance of health in the host, and an absence of the microbiota is incompatible with life3; however, the GI microbiota changes throughout the life of an animal, depending on factors such as species, environment, and health.3 Dietary changes can also affect the composition of the GI microbiota, with relatively small changes in dietary fiber causing significant and detectable changes in the microbiota (see Effects of Diet on the Microbiota).1 Production of metabolites by the resident microbiota is a driving force behind coevolution of the GI microbiota with the host.2 Because of this, the microbiota in any individual depends on the animalâ&#x20AC;&#x2122;s diet, environment, stage of life, disease state, and myriad other factors.3 The GI microbiota is one of the densest microbial populations on the planet, and alterations to it have been associated with various diseases for some time. Its composition is viewed as a moving target, with some general aspects being understood, but details remaining unclear.3

Bacteria Historically, the assessment of the bacterial microbiota relied heavily on bacterial culture. This method of identification has some serious limitations because

NUTRITION NOTES

a large percentage of the microbiota consists of bacteria that do not grow under conventional culture conditions, leading to an underestimation of the true bacterial numbers and diversity of species. Culture is also limited in that it is impractical for detection of a single species in billions of bacteria.3 Molecular methods for bacterial identification continue to evolve, allowing assessment of complex microbial populations and generating massive amounts of data.3 DNA gene sequencing through polymerase chain reaction allows better assessment of the true bacterial populations in the GI tract, but it is still only available through large research labs. Oxygen requirement is one of the biggest determinants of the microbiota. The differing oxygen levels present in the stomach, small intestine, and colon lead to different bacterial populations in each area. Aerobic bacteria (ie, bacteria that require oxygen for growth) are part of the microbiota of small intestine, while the large intestine is populated almost exclusively by anaerobic or facultative anaerobic bacteria (ie, bacteria that do not grow well in the presence of oxygen).4 The normal canine stomach typically contains high numbers of Helicobacter bacteria colonizing the superficial mucosa, gastric glands, and parietal cells.4 The colon also contains high numbers of mucosally associated bacteria, while the healthy small and large intestine have very few bacteria in the mucosa.4 The primary bacteria found in the intestinal tract of dogs and cats are Firmacutes (~40%), Bacteroides (~30%), and Fusobacteria species (~30%).1 Specific beneficial bacterial species found in the largest amounts in dogs include Enterococcus (Enterococcus faecium and Enterococcus faecalis) and lactic acid species. Beneficial species in cats include Lactobacillus, Enterococcus, and Bifidobacterium species.5

Other Components Although bacteria account for the bulk of the microbiota, archaea, viruses, fungi, and parasites are also present. The archaea most likely play a minor role and may be present simply from environmental exposure.3 The viral microbiota is likely vast, with a combination of bacteriophages and mammalian viruses. At present, there is no easy or cost-effective way to assess this population. There have been no studies of the fungal component of the microbiota.3

VITAL SIGNS

BENEFITS TO HOST A balanced microbial ecosystem is crucial to the host’s optimal health. Physiologically, the microbiota stimulates the immune system, helps in defense against invading pathogens, and provides nutritional benefits to the host (BOX 1).6

Immune System Stimulation The immune system consists of innate and adaptive mechanisms that protect the animal from environmental pathogens.7 The innate immune system functions independently of previous exposure to organisms and includes mechanical barriers such as the skin, mucus, and epithelial linings, as well as cellular components such as macrophages and neutrophils.7 The adaptive (or acquired) immune system consists primarily of B and T lymphocytes and relies on generation of immunologic memory to recognize specific invading agents after an initial exposure.7 This memory can be acquired through transfer of antibodies from colostrum, vaccination, or infection.7 The two systems are not entirely separate but act as a continuum with much overlap in response. Establishing a resident microbiota early in life is crucial for developing oral tolerance to normal bacterial and food antigens to prevent the onset of inappropriate immune response to these.4 This is usually accomplished through intake of colostrum during the early hours of life and through exposure to the maternal microbiota during birth, nursing, and cleaning. Animals that are born via cesarean section are not inoculated with maternal vaginal bacteria and show slower than expected immune development.5

BOX 1 Benefits of Gastrointestinal Microbiota2,3,5,6 ●

Forms a defensive barrier against potential pathogenic organisms

●

Aids in nutrient breakdown and energy release from the diet

●

Provides nutritional metabolites for enterocytes

●

Helps regulate the host immune system

●

Metabolizes substances (eg, drugs) that the host cannot

Typically, constant exposure to the microbial and antigenic components of the GI microbiota causes no problems for the host. Immunologic intolerance of the microbiota (caused by a congenital or immune system problem) can contribute to myriad infectious and inflammatory conditions, including diseases caused by opportunistic pathogens, allergies, metabolic diseases, neoplasia, and obesity.3

Defense Against Pathogens The GI microbiota defends the host against undesirable and pathogenic organisms by competing with them for adhesion sites and nutrients, secreting antimicrobial substances (bacteriocins), altering gut pH, assisting with GI transit time, and producing vitamins and growth factors for intestinal cells.2–6 As such, it plays a crucial part in the intestinal barrier system.

Digestion and Nutrients The nutritional benefits of the microbiota to the host include aiding in nutrient breakdown and energy release from food; providing nutritional metabolites for enterocytes in the form of the short-chain fatty acids (SCFAs) propionate, butyrate, and acetate; and metabolizing drugs and other xenobiotics that otherwise cannot be absorbed by the host.2,3,5,6 The GI microbiota is also important in the normal development of physiologic gut structures, and in specific pathogen-free (germ-free) animals, mucosal architecture is altered. Changes to the microbiota may lead to altered intestinal barrier function, damage to the brush border and enterocytes, increased competition for nutrients and vitamins, and increased deconjugation of intestinal bile acids.2 Damage to the intestinal absorptive surfaces such as the brush border and enterocytes directly affects the amount of energy extracted by the host from consumed food. If the bacterial population is not ideal, the microbiota can compete with the body for vital nutrients, decreasing the amount available for the host. Some bacteria produce nutrients required by the host, such as cobalamin; if these bacteria are not present, these nutrients are not available for the host. SCFAs produced by the microbiota provide energy directly to the intestinal cells, provide important growth factors for epithelial cells, help modulate the immune properties of the intestinal tract, inhibit pathogenic bacterial overgrowth through modulation of colon pH, and influence gastrointestinal motility.4 WINTER 2018

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EFFECTS OF DIET ON THE MICROBIOTA SCFAs are produced primarily from dietary fibers, which are defined as the edible portion of plants that is resistant to digestion by the host animal and absorption in the small intestine. Dietary fibers can be classified based on their physical or chemical characteristics and according to their effects on the bowel microflora; however, the most important characteristic for intestinal bacteria is fermentability.8 These fibers may be nonfermentable, such as cellulose and lignin; moderately fermentable, such as beet pulp, tomato pomace, and pea fiber; or highly fermentable, such as guar gum and pectin. Dietary fibers that can undergo bacterial fermentation include polysaccharides (eg, resistant starches, pectin, inulin, guar gum) and oligosaccharides (eg, fructooligosaccharides [FOS]).8 Most dietary fibers are polysaccharides, meaning they are composed of long strands of carbohydrates. The fermentability of a polysaccharide depends on the complexity of the molecule.

Complete fermentation produces hydrogen, carbon dioxide and water; incomplete fermentation produces methane, acetone, propionate, and butyrate.8 These products create a selection advantage for the bacterial species adapted for their use; therefore, a healthy microbiota helps perpetuate an environment that is beneficial to itself.

Butyrate Butyrate is an SCFA produced through bacterial fermentation. In most domestic species, including dogs, it is an energy source for colonocytes; in dogs, it is also used by enterocytes. Butyrate can also increase colonocyte proliferation, intestinal mucosal weight, water and electrolyte absorption, and brush border enzyme activity.8 These are all seen as positive effects from fermentable fibers in the diet. Fibers such as FOS, inulin, and resistant starch can lead to a significant increase in the production of butyrate, while fibers found in citrus pectin, citrus pulp, beet pulp, and cellulose yield relatively low levels of butyrate.8 This difference in butyrate production is directly related to the carbon structure of the individual fibers.

Prebiotics VITAL KNOWLEDGE

The microbiota is not confined to the GI tract. Every part of the body that communicates with the external world has its own microbiota.

Fermentation (complete or partial) is performed by the resident bacteria in the distal small intestine and large intestine.8 The degree to which each fiber is fermented and the by-products produced are influenced by the structure of the carbohydrate and the individual animalâ&#x20AC;&#x2122;s microbiota. Utilization of most fermentable fibers is never 100%, and most natural fiber sources contain a range of carbohydrates (monosaccharides, disaccharides, and polysaccharides) of varying fermentability.

NUTRITION NOTES

A fermentable dietary fiber that leads to a shift in the microbiota with a positive effect in the host animal is defined as a prebiotic. Positive effects include reduction in the mucosal adherence of pathogenic bacterial species, reduction in the numbers of pathogenic species, and immune modulation of the host.8 Certain fibers, such as FOS and inulin, can stimulate the growth and/or activity of intestinal bacteria such as Lactobacillus and Bifidobacterium species. It has been proposed that increasing the numbers of these nonpathogenic bacterial species may have the positive effects listed above.8 Ideally, prebiotics would be incorporated in the diet either as functional fibers in the ingredients or through the addition of actual vegetable products. While fiber supplements can be added to a diet, digestion is increased when the fibers are incorporated into the diet during manufacturing.4 Care must be taken to add only enough fermentable fiber to benefit the microbiota; too much fiber can cause GI distress through gas production or impaired motility. Fibers that lead to a higher concentration of butyrate in the proximal colon may

VITAL SIGNS

have more positive effects than less fermentable sources of fiber.8 Currently, insufficient information is available to make an informed therapeutic recommendation beyond the initial introduction of mixed fermentable fiber sources, and proceeding with trial and error may be best to see which source is most effective in a particular animal.8

EMERGING MARKERS OF DYSBIOSIS Dysbiosis refers to an imbalance in the microbiota of the animal. Maintaining a balance of the microbes is important for intestinal homeostasis, and changes in the microbiota may directly or indirectly influence the hostâ&#x20AC;&#x2122;s metabolic pathways.6 GI disease can be caused directly by invading pathogens, but also by dysbiosis caused by opportunistic resident bacteria or by altered communication between the innate immune system and the commensal microbes living in the intestine.2 Due to the complex interactions between intestinal absorption and microbial metabolism, the exact cause of changes in serum concentrations of serum metabolites is often unknown, but a better understanding of the physiologic pathways is helpful to potentially pinpoint specific diseases.6

Cobalamin and Folate Serum concentrations of cobalamin and folate are important, albeit indirect, markers for GI disease. The uptake of cobalamin (vitamin B12) and folate (vitamin B9) from the small intestine depends on several factors. Disorders that may affect serum cobalamin and/or folate concentrations include small intestinal inflammation, exocrine pancreatic insufficiency (EPI), and small intestinal bacterial overgrowth (SIBO). Cobalamin absorption is complex and requires a functioning GI tract. Major disorders that interfere with cobalamin uptake are EPI, distal or diffuse small intestinal inflammatory disease, and excess bacterial utilization of cobalamin in bacterial dysbiosis. Decreased absorption ultimately leads to metabolic consequences on a cellular level.6 Dietary folate is typically poorly absorbable. In dogs, the receptors responsible for folate uptake are located exclusively in the proximal small intestine. Therefore, increased serum folate concentrations can be seen with proliferation of folate-producing bacteria in proximal SIBO, but not in SIBO of the distal small intestine (ie, ileum) or large intestine. In contrast, diffuse inflammation in the proximal GI tract may lead to damage of folate receptors and decreased serum folate concentrations.6

Bile Acids Another important pathway that can be altered in GI disease is bile acid metabolism. Changes in intestinal bile acid metabolism have been implicated as an important factor in intestinal inflammation in human IBD patients as well as Clostridium difficile infection6; so far, these changes have not been studied in veterinary medicine. Unconjugated bile acids are toxic to epithelial cells, which may result in increased intestinal permeability from cellular damage. Altered bile acid profiles can lead to changes in fat absorption from the small intestine. Altered serum unconjugated bile acids have also been associated with altered small intestinal microbiota in dogs.6

VITAL KNOWLEDGE

Although bacteria account for the bulk of the microbiota, archaea, viruses, fungi, and parasites are also present.

D-Lactate A recent study has shown an increased serum D-lactate concentration in cats with various GI diseases. D-lactate is not normally found in any appreciable quantities in serum from mammals. The increase in serum D-lactate in cats with GI disease is possibly due to disturbances in the intestinal microbiota and increased bacterial production of D-lactate. An increase in D-lactate levels has been shown to lead to neurologic signs in some cats.6

CONCLUSION Associations between the intestinal microbiota and health or disease must be interpreted for what they are: associations and not necessarily causation.3 Separating causation and association can be difficult, particularly when there may be different influences on the disease process and microbiota, including differences in diet.3 NUTRITION NOTES continued on page 34

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TOXICOLOGY TALK

shutterstock.com/13Smile

DANGEROUS TREAT An influx of chocolate exposures is observed by APCC during the winter season because the agents are readily available to pets in the home. Examples of common forms of chocolate the APCC receives calls about include candy bars, snack mixes, brownies, cakes, cookies, and baking goods such as chocolate chips and cocoa powder.

MEET THE AUTHOR

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

Winter Holiday Toxins

he winter holiday season holds an abundance of dangers for domestic pets that could result in toxicosis. This article will focus on exposures to chocolate, grapes and raisins, and homemade playdough in dogs. Plants that dogs and cats are commonly exposed to during the winter months will also be discussed.

TOXICOLOGY TALK

Carrie has been working as a certified veterinary technician at the ASPCA Animal Poison Control Center (APCC) since 2007. She obtained her associateâ&#x20AC;&#x2122;s degree in veterinary technology from Parkland College in 2003 and her bachelorâ&#x20AC;&#x2122;s degree in natural resources and environmental science from the University of Illinois in 2006. She worked for 2.5 years at a small animal clinic while in college and has assisted with several research projects in fish and wildlife ecology. During her 10 years at the APCC, Carrie has gained a wealth of knowledge in the field of toxicology. She has been published in several peer-reviewed journals and is currently studying to become a board-certified toxicologist.

VITAL SIGNS

CHOCOLATE The APCC received more calls about chocolate than any other agent in 2016, averaging over 41 cases per day. An influx of chocolate exposures is observed by APCC during the winter season because the agents are readily available to pets in the home. Examples of common forms of chocolate the APCC receives calls about are candy bars, snack mixes, chocolate desserts (brownies, cakes, and cookies), and baking goods such as chocolate chips and cocoa powder. Chocolate contains 2 methylxanthines of toxicologic significance: theobromine and caffeine.1 The concentration of these methylxanthines differs between products (TABLE 1). White chocolate has a very low concentration of methylxanthines and has low toxicologic significance. Milk chocolate, dark chocolate (semi-sweet chocolate), baking chocolate (unsweetened chocolate), and cocoa powder have much higher concentrations of methylxanthines, and exposures to these more commonly result in toxicosis. Methylxanthine toxicosis causes stimulation of the cardiovascular and central nervous systems. The degree of toxicity is dose dependent. With low doses of chocolate, only mild gastrointestinal (GI) upset is observed. At cardiotoxic doses, more severe signs such as tachycardia, tachypnea, hyperthermia, cardiac arrhythmias, tremors, and seizures can develop. If exposure to chocolate is suspected or observed, an estimated dose of methylxanthines should be calculated. In an asymptomatic patient, this dose will determine whether decontamination or treatment is necessary (BOX 1).

Decontamination and Treatment Decontamination through emesis is recommended in patients that have ingested >35 mg/kg of methylxanthines. Doses lower than this are not expected TABLE 1 Concentration of Methylxanthines in Different Types of Chocolate TYPE OF CHOCOLATE White chocolate

CONCENTRATION OF METHYLXANTHINES a 1 mg/oz

Milk chocolate

65 mg/oz

Dark chocolate

165 mg/oz

Baking chocolate

400 mg/oz

Unsweetened cocoa powder

800 mg/oz

to cause serious clinical signs. With large exposures to chocolate that do not yield a toxic dose, emesis is recommended to prevent severe GI upset and to decrease the risk of pancreatitis. Emesis should be considered if the exposure occurred within the past 2 to 6 hours.2 Activated charcoal can help in preventing absorption of methylxanthines from the GI tract. However, charcoal can cause electrolyte changes and therefore is only recommended when a risk of severe toxicosis exists.

VITAL KNOWLEDGE

The APCC received more calls about chocolate than any other agent in 2016, averaging over 41 cases per day.

There is no antidote for chocolate toxicosis; therefore, treatment consists largely of supportive and symptomatic care.2 Propranolol is recommended in treating moderate to severe tachycardia,2 whereas muscle tremors can be managed with methocarbamol or diazepam.2 Diazepam is also recommended for the management of seizure activity.2 IV fluids are recommended to help increase excretion of methylxanthines,2 and the bladder should be emptied regularly to prevent reabsorption of methylxanthines through the bladder wall.2 The prognosis for chocolate toxicosis is generally considered good with successful decontamination and veterinary intervention.1 However, pets that present with seizures or tachyarrhythmias have a more guarded prognosis.2

GRAPES AND RAISINS Exposures to grapes and raisins are especially common during the winter season because these items are used in many holiday recipes and meals. Grapes, raisins, and zante currants belong to the genus Vitis, and ingestion can result in acute renal injury in

Amounts used by the APCC in calculating chocolate dose.

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BOX 1 Chocolate Dose Calculations To calculate a dose of chocolate, 3 pieces of information are needed: ●

The weight of the pet in kg

●

The amount of the agent ingested in grams or ounces

●

The estimated concentration of methylxanthines

Milk Chocolate

For example, consider a 15-kg dog that has ingested a 3.5-oz solid milk chocolate bar (solid meaning there are no nuts or fillings). Milk chocolate contains an estimated methylxanthine concentration of 65 mg/oz. To get the mg/kg dose of chocolate, the weight of the chocolate bar is multiplied by the concentration of methylxanthines, which is then divided by the pet’s weight in kg. 3.5 oz × 65 mg/oz = 227.5 mg / 15 kg = 15.166 mg/kg A 15-mg/kg dose of chocolate would be expected to cause only mild GI upset with a low risk of pancreatitis. No veterinary treatment would be required for this exposure.

Dark Chocolate

However, if this chocolate bar were made of dark chocolate, then the concentration of methylxanthines would be 165 mg/oz. 3.5 oz × 165 mg/oz = 577.5 mg / 15 kg = 38.5 mg/kg A 38.5-mg/kg dose of chocolate is not cardiotoxic, but could cause moderate GI upset, polydipsia, pancreatitis, and mild agitation or hyperactivity. In an asymptomatic patient, emesis would be recommended. With successful emesis, further veterinary care would not be required.

Baking Chocolate

Some milk and dark chocolate bars show a percentage of cacao on the label, which is generally seen on the front of the bar and not in the ingredient list. Cacao is unsweetened (baking) chocolate. If this percentage is observed, then an extra calculation must be done to obtain the bar’s estimated concentration of methylxanthines. A range of estimated concentrations exists, but the APCC uses those listed in TABLE 1. For example, if the label shows a 65% concentration of cacao, the APCC multiplies the percentage by 400 mg/oz. 0.65 × 400 mg/oz = 260 mg/oz When substituted into the previous equation, the 15-kg dog that ingested a 3.5-oz dark chocolate bar containing 65% cacao has an estimated chocolate dose of 60.67 mg/kg. 3.5 oz x 260 mg/oz = 910 mg / 15 kg = 60.67 mg/kg This dose is at a cardiotoxic level and can be expected to significantly stimulate the cardiovascular and central nervous systems. Hospitalization would be recommended. Calculating a dose of chocolate can be challenging, especially if the agent involved is a baked good such as a chocolate cake or brownie. Looking at the ingredients in the agent will help determine what concentration of methylxanthines should be used in the dosage calculation. With purchased baked goods or box mixes, the ingredients are commonly printed on the label. If the baked good was made from scratch, ask the owner what ingredients were used in the recipe, the amounts of each ingredient, and the amount of the baked good yielded.

dogs.3 The mechanism of action is unknown at this time. Although studies have evaluated these fruits for mycotoxins, pesticides, heavy metals, and vitamin D3,3 there have been no positive results for these nephrotoxins. Not all dogs that ingest grapes or raisins develop acute renal injury. A dose-response relationship, common to other toxic agents, has not been observed with Vitis exposures.4 Therefore, the severity of toxicosis does not depend on the amount of grapes or raisins ingested.

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Also, grape seed extract, grape juice, grape jelly, and wine have not been shown to cause Vitis toxicosis.5 Clinical signs may be delayed by several hours after the ingestion of Vitis species. Vomiting is common within the first 24 hours,4,6 followed by diarrhea, anorexia, lethargy, and abdominal pain.1,6 Oliguria or anuria may be observed days to weeks after the exposure as renal injury progresses.1 Elevated creatinine, blood urea nitrogen, calcium, and phosphorus can be observed 24 hours

VITAL SIGNS

after ingestion,6 whereas pathologic changes observed on blood chemistries may be delayed by several days.1,6

Decontamination and Treatment Any exposure to grapes or raisins should be considered significant, and decontamination via emesis and activated charcoal is recommended. Grapes and raisins have a tendency to sit in the stomach for prolonged periods of time6; therefore, emesis can be induced in asymptomatic patients up to 6 hours after the exposure.5 Protection of the kidneys is critical with exposures to Vitis species. IV fluid diuresis is recommended for 48 to 72 hours.6 A baseline blood chemistry should be obtained and rechecked every 12 hours for 72 hours to monitor renal function, and electrolytes should be monitored along with urinalysis. Furosemide, dopamine, or mannitol can be used to treat oliguria, while hemodialysis or peritoneal dialysis may be helpful in treating uremia.1 The prognosis is considered poor for pets that develop weakness, ataxia, oliguria, or anuria.1,6

HOMEMADE PLAYDOUGH Exposures to homemade playdough are not as common as exposures to chocolate or grapes and raisins. The ingestion of playdough, however, can result in rapid onset of a life-threatening toxicosis called hypernatremia, an excessive amount of sodium in the blood.

Onset of Hypernatremia Homemade playdough, used to make salt ornaments and other holiday crafts, is made from dough consisting of flour, table salt (sodium chloride), and water. Other ingredients such as vegetable oil, cornstarch, and cream of tartar are also used in some recipes. Homemade playdough contains a high concentration of salt. Some dough formulations contain 8 g of salt per tablespoon of dough.7 When the dough is ingested, an increase in sodium in the vasculature results in a fluid shift in the body, causing cellular dehydration and vascular expansion.7 Signs of salt toxicosis can be observed at a dose of 2 g of NaCl per kilogram of body weight, with the lethal dose at 4 g/kg.7 A dog is considered to be hypernatremic when the serum sodium concentration is >156 mEq/L.7 Clinical signs are commonly observed when the serum sodium concentration is >170 mEq/L.7 Vomiting develops within the first 2 hours of ingestion,5 followed by neurologic signs, including tremors and

seizures.8 Signs most commonly observed by the APCC include vomiting, anorexia, diarrhea, ataxia, polydipsia, trembling, weakness, tremors, and seizures.5

Decontamination and Treatment The treatment for acute salt toxicosis includes decontamination, management of clinical signs, and lowering serum sodium levels. With recent exposures (<2 hours) and in patients that are asymptomatic, emesis is recommended. Baseline electrolytes should be obtained and frequently monitored. Asymptomatic patients with a normal serum sodium concentration should be allowed free access to water after emesis has been managed and monitored closely for clinical signs. Patients that have clinical signs or elevations in serum sodium concentration should be started on IV fluids using a low-sodium fluid (D5W, 0.4% NaCl).5 Warm-water enemas at a dose of 5 to 10 mL/kg can be used in addition to IV fluids.5 A loop diuretic, such as furosemide, can be administered to aid in sodium excretion and to help prevent pulmonary edema caused by fluid overload.5 Patients exhibiting mild to moderate clinical effects that receive timely and aggressive treatment generally have a favorable prognosis.5 The prognosis is guarded in patients that have developed severe neurologic signs.5

PLANTS There are several popular holiday plants that dogs and cats may have the opportunity to ingest during the winter season that may remain in the home several months. They include: ●●

Christmas cactus

●●

Evergreen trees

●●

Holly

●●

Mistletoe

●●

Poinsettias

●●

Amaryllis

●●

Christmas kalanchoe

Exposures to Christmas cactus, evergreen trees, holly, mistletoe, and poinsettias commonly result in GI upset, but are unlikely to cause serious toxicosis. Amaryllis and Christmas kalanchoe can cause more serious signs, depending on the part of the plant WINTER 2018

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TABLE 2 Plant Quick Reference9,10 COMMON NAME

LATIN NAME

CLINICAL SIGNS

COMMENTS

Amaryllis

Hippeastrum spp.

Vomiting, diarrhea, anorexia, hypersalivation, hypotension, sedation, and seizures

Mild to moderate GI upset with small exposures to the leaves, flowers, and bulb. Large exposures to the bulb increase the risk for more severe GI signs, as well as hypotension, sedation, and seizures.

Christmas cactus

Schlumbergera truncata

Vomiting, diarrhea, anorexia, and depression

Signs are expected to be mild and self-limiting. Minimal treatment is required.

Christmas kalanchoe

Kalanchoe blossfeldiana

Vomiting, depression, lethargy, diarrhea, weakness, dyspnea, anorexia, tachycardia, and vocalization

Flowers are the most toxic. Most exposures only cause GI signs.

Evergreen trees (firs, pines, and spruces)

Abies, Pinus, Picea

Vomiting, anorexia, abdominal pain, and depression

Exposure to tree water containing tree preservatives is not expected to cause serious toxicosis, but mild GI upset is possible. Water that is not frequently changed could grow bacteria or fungi over time, possibly resulting in gastroenteritis if ingested.

Holly

Ilex aquifolium

Hypersalivation, vomiting, anorexia, diarrhea, head shaking, and lip smacking

GI irritation is due to the saponins in the leaves and berries.

Mistletoe

Phoradendron spp

Vomiting, diarrhea, depression, hypotension

Hypotension is uncommon.

Poinsettia

Euphorbia pulcherrima

Vomiting, hypersalivation, diarrhea, and dermal irritation

Historically, toxicity has been greatly exaggerated.

the pet is exposed to and the amount of the plant ingested. TABLE 2 lists the clinical signs that can be expected after ingestion of these plants. TVN

References 1. Bough M. Food-associated intoxications. In: Poppenga RH, GwaltneyBrant S, eds. Small Animal Toxicology Essentials. West Sussex: John Wiley and Sons; 2011:207-219. 2. Dolder LK. Methylxanthines: caffeine, theobromine, theophylline. In: Peterson ME, Talcott PA, eds. Small Animal Toxicology. 3rd ed. St. Louis: Saunders; 2013:647-652. 3. Gwaltney-Brant SM. Renal toxicity. In: Gupta RC, ed. Veterinary Toxicology: Basic and Clinical Principles. 2nd ed. Waltham: Academic Press; 2012:264-277. 4. Eubig PA, Brady MS, Gwaltney-Brant SM, et al. Acute renal failure in dogs after the ingestion of grapes or raisins: a retrospective evaluation of 43 dogs (1992-2002). J Vet Intern Med 2005;19:663-674. 5. ASPCA Animal Poison Control Center. Unpublished data 2017. 6. Mostrom MS. Grapes and raisins. In: Peterson ME, Talcott PA, eds: Small Animal Toxicology. 3rd ed. St. Louis: Saunders; 2013:569-572. 7. Tegzes JH. Sodium. In: Peterson ME, Talcott PA, eds. Small Animal Toxicology. 3rd ed. St. Louis: Saunders; 2013:807-810. 8. Thompson LJ. Sodium chloride (salt). In: Gupta RC, ed: Veterinary Toxicology: Basic and Clinical Principles. 2nd ed. Waltham: Academic Press; 2012:558-561. 9. Gwaltney-Brant SM. Christmastime plants. In: Peterson ME, Talcott PA, eds. Small Animal Toxicology. 3rd ed. St. Louis: Saunders; 2013:499-511. 10. Delaporte J, Means C. Plants. In: Poppenga RH, Gwaltney-Brant S, eds. Small Animal Toxicology Essentials. West Sussex: John Wiley and Sons; 2011:147-160.

About ASPCA

TOXICOLOGY TALK

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

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and restore the quality of life while you determine the cause of the itch2,6

To learn more, please visit www.APOQUEL.com Indications Control of pruritus associated with allergic dermatitis and control of atopic dermatitis in dogs at least 12 months of age. Important Safety Information Do not use APOQUEL in dogs less than 12 months of age or those with serious infections. APOQUEL may increase the chances of developing serious infections, and may cause existing parasitic skin infestations or pre-existing cancers to get worse. APOQUEL has not been tested in dogs receiving some medications including some commonly used to treat skin conditions such as corticosteroids and cyclosporines. Do not use in breeding, pregnant, or lactating dogs. Most common side effects are vomiting and diarrhea. APOQUEL has been used safely with many common medications including parasiticides, antibiotics and vaccines.

References: 1. Gadeyne C, Little P, King VL, Edwards N, Davis K, Stegemann MR. Efficacy of oclacitinib (Apoquel®) compared with prednisolone for the control of pruritus and clinical signs associated with allergic dermatitis in client-owned dogs in Australia. Vet Dermatol. 2014;25:512–e86. 2. Cosgrove SB, Cleaver DM, King VL, Gilmer AR, Daniels AE, Wren JA, Stegemann MR. Long-term compassionate use of oclacitinib in dogs with atopic and allergic skin disease: safety, efficacy and quality of life. Vet Dermatol. 2015;26(3):171-179. 3. Cosgrove SB, Wren JA, Cleaver DM, et al. A blinded, randomized, placebo-controlled trial of the efficacy and safety of the Janus kinase inhibitor oclacitinib (Apoquel®) in client-owned dogs with atopic dermatitis. Vet Dermatol. 2013;24:587-597. 4. Marsella R, Sousa CA, Gonzales AJ, Fadok VA. Current understanding of the pathophysiologic mechanisms of canine atopic dermatitis. JAVMA. 2012;241(2):194-207. 5. Cosgrove SB, Wren JA, Cleaver M, et al. Efficacy and safety of oclacitinib for the control of pruritus and associated skin lesions in dogs with canine allergic dermatitis. Vet Dermatol. 2013;24(5):479-e114. 6. Aleo MM, Galvan EA, Fleck JT, et al. Effects of oclacitinib and prednisolone on skin test sensitivity [abstract]. Vet Dermatol. 2013;24(3):297.

For more information, please see Brief Summary of full Prescribing Information on reverse. All trademarks are the property of Zoetis Services LLC or a related company or a licensor unless otherwise noted. © 2017 Zoetis Services LLC. All rights reserved. APQ-00496

Brief Summary of Prescribing Information For oral use in dogs only Caution: Federal (USA) Law restricts this drug to use by or on the order of a licensed veterinarian. Indications: Control of pruritus associated with allergic dermatitis and control of atopic dermatitis in dogs at least 12 months of age. Dosage and Administration: The dose of APOQUEL (oclacitinib maleate) tablets is 0.18 to 0.27 mg oclacitinib/lb (0.4 to 0.6 mg oclacitinib/kg) body weight, administered orally, twice daily for up to 14 days, and then administered once daily for maintenance therapy. APOQUEL may be administered with or without food. Dosing Chart Weight Range Weight Range Number of Tablets to be Administered (in lb) (in Kg) Low High Low High 3.6 mg 5.4 mg 16 mg Tablets Tablets Tablets 6.6 9.9 3.0 4.4 0.5 10.0 14.9 4.5 5.9 0.5 15.0 19.9 6.0 8.9 1 20.0 29.9 9.0 13.4 1 30.0 44.9 13.5 19.9 0.5 45.0 59.9 20.0 26.9 2 60.0 89.9 27.0 39.9 1 90.0 129.9 40.0 54.9 1.5 130.0 175.9 55.0 80.0 2 Warnings: APOQUEL is not for use in dogs less than 12 months of age (see Animal Safety). APOQUEL is not for use in dogs with serious infections. APOQUEL may increase susceptibility to infection, including demodicosis, and exacerbate neoplastic conditions (see Adverse Reactions and Animal Safety). Human Warnings: This product is not for human use. Keep this and all drugs out of reach of children. For use in dogs only. Wash hands immediately after handling the tablets. In case of accidental eye contact, flush immediately with water or saline for at least 15 minutes and then seek medical attention. In case of accidental ingestion, seek medical attention immediately. Precautions: APOQUEL is not for use in breeding dogs, or pregnant or lactating bitches. The use of APOQUEL has not been evaluated in combination with glucocorticoids, cyclosporine, or other systemic immunosuppressive agents. Dogs receiving APOQUEL should be monitored for the development of infections, including demodicosis, and neoplasia. Adverse Reactions: Control of Atopic Dermatitis In a masked field study to assess the effectiveness and safety of oclacitinib for the control of atopic dermatitis in dogs, 152 dogs treated with APOQUEL and 147 dogs treated with placebo (vehicle control) were evaluated for safety. The majority of dogs in the placebo group withdrew from the 112-day study by Day 16. Adverse reactions reported (and percent of dogs affected) during Days 0-16 included diarrhea (4.6% APOQUEL, 3.4% placebo), vomiting (3.9% APOQUEL, 4.1% placebo), anorexia (2.6% APOQUEL, 0% placebo), new cutaneous or subcutaneous lump (2.6% APOQUEL, 2.7% placebo), and lethargy (2.0% APOQUEL, 1.4% placebo). In most cases, diarrhea, vomiting, anorexia, and lethargy spontaneously resolved with continued dosing. Dogs on APOQUEL had decreased leukocytes (neutrophil, eosinophil, and monocyte counts) and serum globulin, and increased cholesterol and lipase compared to the placebo group but group means remained within the normal range. Mean lymphocyte counts were transiently increased at Day 14 in the APOQUEL group. Dogs that withdrew from the masked field study could enter an unmasked study where all dogs received APOQUEL. Between the masked and unmasked study, 283 dogs received at least one dose of APOQUEL. Of these 283 dogs, two dogs were withdrawn from study due to suspected treatment-related adverse reactions: one dog that had an intense flare-up of dermatitis and severe secondary pyoderma after 19 days of APOQUEL administration, and one dog that developed generalized demodicosis after 28 days of APOQUEL administration. Two other dogs on APOQUEL were withdrawn from study due to suspected or confirmed malignant neoplasia and subsequently euthanized, including one dog that developed signs associated with a heart base mass after 21 days of APOQUEL administration, and one dog that developed a Grade III mast cell tumor after 60 days of APOQUEL administration. One of the 147 dogs in the placebo group developed a Grade I mast cell tumor and was withdrawn from the masked study. Additional dogs receiving APOQUEL were hospitalized for diagnosis and treatment of pneumonia (one dog), transient bloody vomiting and stool (one dog), and cystitis with urolithiasis (one dog).

In the 283 dogs that received APOQUEL, the following additional clinical signs were reported after beginning APOQUEL (percentage of dogs with at least one report of the clinical sign as a non-pre-existing finding): pyoderma (12.0%), non-specified dermal lumps (12.0%), otitis (9.9%), vomiting (9.2%), diarrhea (6.0%), histiocytoma (3.9%), cystitis (3.5%), anorexia (3.2%), lethargy (2.8%), yeast skin infections (2.5%), pododermatitis (2.5%), lipoma (2.1%), polydipsia (1.4%), lymphadenopathy (1.1%), nausea (1.1%), increased appetite (1.1%), aggression (1.1%), and weight loss (0.7). Control of Pruritus Associated with Allergic Dermatitis In a masked field study to assess the effectiveness and safety of oclacitinib for the control of pruritus associated with allergic dermatitis in dogs, 216 dogs treated with APOQUEL and 220 dogs treated with placebo (vehicle control) were evaluated for safety. During the 30-day study, there were no fatalities and no adverse reactions requiring hospital care. Adverse reactions reported (and percent of dogs affected) during Days 0-7 included diarrhea (2.3% APOQUEL, 0.9% placebo), vomiting (2.3% APOQUEL, 1.8% placebo), lethargy (1.8% APOQUEL, 1.4% placebo), anorexia (1.4% APOQUEL, 0% placebo), and polydipsia (1.4% APOQUEL, 0% placebo). In most of these cases, signs spontaneously resolved with continued dosing. Five APOQUEL group dogs were withdrawn from study because of: darkening areas of skin and fur (1 dog); diarrhea (1 dog); fever, lethargy and cystitis (1 dog); an inflamed footpad and vomiting (1 dog); and diarrhea, vomiting, and lethargy (1 dog). Dogs in the APOQUEL group had a slight decrease in mean white blood cell counts (neutrophil, eosinophil, and monocyte counts) that remained within the normal reference range. Mean lymphocyte count for dogs in the APOQUEL group increased at Day 7, but returned to pretreatment levels by study end without a break in APOQUEL administration. Serum cholesterol increased in 25% of APOQUEL group dogs, but mean cholesterol remained within the reference range. Continuation Field Study After completing APOQUEL field studies, 239 dogs enrolled in an unmasked (no placebo control), continuation therapy study receiving APOQUEL for an unrestricted period of time. Mean time on this study was 372 days (range 1 to 610 days). Of these 239 dogs, one dog developed demodicosis following 273 days of APOQUEL administration. One dog developed dermal pigmented viral plaques following 266 days of APOQUEL administration. One dog developed a moderately severe bronchopneumonia after 272 days of APOQUEL administration; this infection resolved with antimicrobial treatment and temporary discontinuation of APOQUEL. One dog was euthanized after developing abdominal ascites and pleural effusion of unknown etiology after 450 days of APOQUEL administration. Six dogs were euthanized because of suspected malignant neoplasms: including thoracic metastatic, abdominal metastatic, splenic, frontal sinus, and intracranial neoplasms, and transitional cell carcinoma after 17, 120, 175, 49, 141, and 286 days of APOQUEL administration, respectively. Two dogs each developed a Grade II mast cell tumor after 52 and 91 days of APOQUEL administration, respectively. One dog developed low grade B-cell lymphoma after 392 days of APOQUEL administration. Two dogs each developed an apocrine gland adenocarcinoma (one dermal, one anal sac) after approximately 210 and 320 days of APOQUEL administration, respectively. One dog developed a low grade oral spindle cell sarcoma after 320 days of APOQUEL administration. To report suspected adverse events, for technical assistance or to obtain a copy of the MSDS, contact Zoetis Inc. at 1-888-963-8471 or www.zoetis.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth. Storage Conditions: APOQUEL should be stored at controlled room temperature between 20° to 25°C (68° to 77°F) with excursions between 15° to 40°C (59° to 104°F). How Supplied: APOQUEL tablets contain 3.6 mg, 5.4 mg, or 16 mg of oclacitinib as oclacitinib maleate per tablet. Each strength tablets are packaged in 20 and 100 count bottles. Each tablet is scored and marked with AQ and either an S, M, or L that correspond to the different tablet strengths on both sides. NADA #141-345, Approved by FDA Made in Italy

Distributed by: Zoetis Inc. Kalamazoo, MI 49007 February 2013

428007800A&P

INTERNAL MEDICINE CASE REPORT

VITAL SIGNS

ACUTE KIDNEY INJURY (AKI) is the abrupt inability of the kidneys to regulate solute and water balance. AKI includes oliguric renal failure, anuric renal failure, and severe uremia that is unresponsive to fluid therapy. Image courtesy of shutterstock.com/Deyan Georgiev

MEET THE AUTHOR

Courtney Waxman, CVT, VTS (ECC) VetMed Emergency and Specialty Hospital Phoenix, Arizona Courtney Waxman practices at VetMed Emergency and Specialty Hospital in Phoenix, Arizona. In 2008 Courtney graduated with her AAS in Veterinary Technology/Animal Health and obtained her CVT in 2009. She has spent the past 10 years working in emergency medicine and has presented technician case reports at the ACVIM Forum and IVECCS conferences, winning best case presentation at ACVIM 2017. Courtney has published continuing education articles in the NAVTA Journal and Today’s Veterinary Nurse. She is the Arizona state representative for NAVTA and the Technician’s Community Chairperson for Arizona’s state association. She lectures locally to referring veterinary practices, veterinary technology students, and the public on topics relating to emergency medicine. She obtained her VTS (ECC) in September 2017. Her special interests include mechanical ventilation, shock, cardiopulmonary resuscitation, environmental hazards, oneon-one case management, critical care nursing, and technician training.

Peritoneal Dialysis Following Urethral Obstruction and Acute Kidney Injury

his case report describes treatment of a feline patient with urethral obstruction. After admittance to the intensive care unit, he was also found to have unilateral ureteral calculi. He developed acute kidney injury (AKI), characterized by post renal azotemia, which was nonresponsive to medical therapy. After 72 hours of hospitalization, he underwent cystotomy and right ureterocystostomy.

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His AKI persisted after surgery (characterized by worsening azotemia, oliguria that progressed to anuria, and evidence of fluid intolerance), which ultimately required implementation of peritoneal dialysis (PD).

SIGNALMENT The patient was a 12-year-old neutered male domestic shorthair cat that weighed 7.5 kg.

HISTORY AND PRESENTING COMPLAINT The patient was presented to the emergency department for acute-onset anorexia, retching, and being abnormally vocal. When his owner picked him up at home, he seemed painful and bloated. His owner reported that he was uncomfortable throughout the evening. His owner also reported that he had recently been urinating outside the litter box. She believed that her husband’s recent disability caused him stress. The patient was an indoor-only cat with no prior health concerns.

INITIAL ASSESSMENT/ PHYSICAL FINDINGS On entry, the patient was bright, alert, and responsive. He was normothermic at 100.2°F, vocal, and ambulatory. He was eupneic at 30 beats/min, with clear lung sounds. He had a relative tachycardia at 220 beats/min, with strong, synchronous femoral pulses and no murmur appreciated on auscultation. His mucous membranes were pink and tacky with a capillary refill time of less than 2 seconds. He was normotensive; the Doppler systolic blood pressure was 162 mm Hg. He was painful on abdominal palpation, and he had a large, firm bladder.

FIGURE 1. Preliminary abdominal radiograph.

INTERNAL MEDICINE CASE REPORT

NURSING CARE TREATMENT PLAN I placed a 20-gauge cephalic IV catheter and started a 13-mL/kg (1/8 shock) IV crystalloid bolus. Blood was collected for point-of-care venous blood gas (VBG) measurement, as well as for a complete blood count. The VBG analyzer provided information about acid-base status, electrolytes, ventilation, lactate, glucose, PCV/total protein (TP), and blood urea nitrogen (BUN)/creatinine values. IV crystalloids were continued at 6.5 mL/kg per hour after the bolus, and 0.02 mg/kg IV buprenorphine (a partial opioid agonist) was administered for pain. Preliminary abdominal radiographs were also obtained (FIGURE 1). The patient was sedated with 0.2 mg/kg IV midazolam for urinary unobstruction. He was preoxygenated and then induced with 2 mg/kg IV propofol slowly titrated to effect. After intubation, flow-by oxygen was provided via mask around his endotracheal tube. He remained anesthetized with 1.5-mg/kg boluses of IV propofol as needed, for a total dose of 4 mg/kg. An electrocardiographic monitor was placed during the procedure to ensure normal heart rate and rhythm. By using sterile technique, I passed an open-ended tomcat catheter; hemorrhagic urine with grit-like material was noted. A sterile urine sample was collected for urinalysis. I was able to gently retropulse the urethra with sterile saline, and eventually placed a 3.5-Fr red rubber urinary catheter. I connected the catheter to a sterile closed collection set (FIGURE 2) and obtained an additional lateral radiograph to confirm placement. All vital signs remained within normal limits, and the patient’s anesthetic recovery was uneventful. After urinary catheterization, the patient was receiving 0.02 mg/kg IV buprenorphine q8h, and IV crystalloids were adjusted q4h on the basis of hourly urine output. His urine output

FIGURE 2. Catheter connected to a sterile closed collection set.

VITAL SIGNS

was quantified every 4 hours. Serial weights were measured every 6 to 8 hours. He was started on 30 mg/kg IV ampicillin-sulbactam (bacteriocidal antibiotic) q8h because of concern for infection. VBG revealed azotemia with a BUN of 42 mg/dL (reference range, 18 to 34 mg/dL) and creatinine of 2.6 mg/dL (reference range, 1.0 to 2.1 mg/dL). He had a normal acid-base status with a pH of 7.361 (reference range, 7.24 to 7.4), partial pressure of CO2 of 26.1 mm Hg (reference range, 25.9 to 41.7 mm Hg), and HCO3 of 14.9 mmol/L (reference range, 14.7 to 22.1 mmol/L). Electrolytes, lactate, and PCV/TP were within normal limits. His complete blood count was normal except for an elevated white blood cell count of 18,000 cells/mcL (reference range, 2870 to 17,020 cells/mcL). Urinalysis showed too numerous red blood cells to count, 1 to 3 white blood cells per high-power field, urine specific gravity of 1.021, and pH of 7.0. No crystals, casts, or bacteria were noted on sediment review. The initial abdominal radiographs showed cystic calculi and a urinary outflow obstruction secondary to the accumulation of crystalline debris and calculi within the distal urethra; the material was subsequently displaced into the bladder after catheterization. The patient had right renal mineralization in the retroperitoneal space (concerning for ureteral calculi); abdominal ultrasonography was recommended.

NURSING CARE PROGRESS

(reference range, 18 to 34 mg/dL) and creatinine of 3.7 mg/dL (reference range, 1.0 to 2.1 mg/dL). Electrolytes, acid-base status, and PCV/TP were all still within normal limits. Abdominal ultrasonography confirmed that the patient had a right ureteral obstruction with concurrent bilateral pyelonephritis. Throughout the day, the patient’s urine output steadily declined to the point of oliguria (urine output < 1 mL/kg per hour), and he gained 10% to 12% of body weight. Given the ultrasonographic findings and poor urine output, surgery for ureteral reimplantation and placement of a drain for possible PD was discussed. Because of their finances and the invasiveness of the procedure, the owners elected to continue medical management at this time.

VITAL KNOWLEDGE

Dialysis transfers water and solute from one compartment to another by means of diffusion across a semipermeable membrane (SPM).

Overnight, the patient’s urine output was normal, ranging from 1 to 2 mL/kg per hour. Repeat VBG showed worsened azotemia, with a BUN of 51 mg/dL

Glossary AKI acute kidney injury BUN blood urea nitrogen CRI constant rate infusion CRRT continuous renal replacement therapy IHD intermittent hemodialysis PCV packed cell volume PD peritoneal dialysis SPM semipermeable membrane TP total protein VBG venous blood gas

Because of the patient’s pyelonephritis, antibiotic coverage was increased by adding 5.5 mg/kg IV enrofloxacin q24h. Ampicillin-sulbactam frequency was decreased to q12h as a result of limited renal excretion. A trial dose of 1 mg/kg IV furosemide, a loop diuretic, was given to encourage polyuria; if urine output improved, additional doses or a constant rate infusion (CRI) would be considered. At 24 hours of hospitalization, VBG showed worsened azotemia, with a BUN of 63 mg/dL (reference range, 18 to 34 mg/dL) and creatinine of 5.2 mg/dL (reference range, 1.0 to 2.1 mg/dL); all other values were within normal limits. By 48 hours of hospitalization, the patient remained oliguric. Three days after presentation, the patient had surgery with a board-certified specialist, and the patient underwent cystotomy; a stone in his right ureter was dilated proximal to the lesion, so right

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ureterocystostomy (ureteral reimplantation of the right kidney) was done. A Jackson-Pratt drain was placed for possible PD. The patient did well under anesthesia, and his recovery was uneventful. His weight also improved, decreasing to a 5% gain over his entry weight (this change was suspected to have resulted from reestablishment of a patent urinary system and use of furosemide). After the procedure, VBG showed normal values with the exception of a BUN of 83 mg/dL (reference range, 18 to 34 mg/dL); creatinine was improved at 4.7 mg/dL (reference range, 1.0 to 2.1 mg/dL). The patient was started on IV fentanyl (a 100 times more potent opioid analgesic) CRI at 4 mcg/kg per hour. Jackson-Pratt drain production was quantified every 4 hours, and IV crystalloids were continued at 3.5 ml/kg per hour, to be adjusted according to urine output.

because of evidence of fluid overload. IV antibiotics and fentanyl CRI were continued as previously; 1 to 2 mg/kg IV furosemide was to be given as needed. Enteral nutrition was started at one quarter of his resting energy requirement (calculated as [body weight in kg • 70]0.75), and IV ketamine (a dissociative agent that works well on somatic pain and is accentuated by opioids) CRI was added at 2 mcg/kg per minute for multimodal analgesia.

After ureterocystostomy, the patient continued to have severe oliguria, verging on anuria (lack of urine production). He also began to develop peripheral and SC tissue edema. His owners were informed that despite surgery, the patient’s urine output was minimal, renal values continued to worsen, and evidence of fluid intolerance was developing. The team reiterated that PD was the only option available, and the inherent risks (electrolyte shifts, hyperglycemia, peritonitis) were discussed; his owners approved.

By using strict aseptic technique, I connected the dialysate infusion line to the Jackson-Pratt drain tubing (the bulb was removed) with a 3-way stopcock (FIGURE 5). I connected the third port on the 3-way stopcock to a separate sterile collection bag so that the dialysate/peritoneal fluid could accumulate and be

The patient’s dialysate (the mixture that passes through the membrane during dialysis) prescription was prepared by using 250 IU heparin + 2.5% dextrose in 1 L of lactated Ringer’s crystalloid solution (FIGURE 4). Heparin was added to prevent occlusion of the peritoneal catheter from fibrin, and dextrose was added as the osmotic agent.

I placed a 5-Fr nasoesophageal tube, as well as a 5-Fr • 13-cm triple-lumen jugular catheter (FIGURE 3). His IV crystalloids were discontinued

FIGURE 3. Placement of triple-lumen jugular catheter.

INTERNAL MEDICINE CASE REPORT

FIGURE 4. Lactated Ringer’s crystalloid solution.

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quantified. The Luer lock port sites were wrapped with sterile chlorhexidine-soaked gauze (FIGURE 6). The dialysate was infused over 15 minutes, then dwelled intra-abdominally for 30 minutes. Drainage via gravity was allowed for an additional 15 minutes. The dialysate infusion/drainage process was to be done every 3 hours.

4 hours, adjusted analgesic CRIs as needed for pain control, continued to measure urine output, placed a nasoesophageal feeding tube and triple-lumen jugular catheter, calculated and started enteral nutrition, used 3-syringe technique for venous sampling, and had knowledge of multiple drug/fluid type interactions.

As the primary nurse in the patient’s initial stabilization, my involvement continued through PD therapy. Initial nursing care focused on shock IV fluids, analgesia, total IV anesthesia, electrocardiographic monitoring, urinary catheter placement, laboratory testing, and diagnostic radiography. Once unobstructed, my focus was on close monitoring of parameters essential in renal patients, including mentation, vital signs assessed every 4 hours, Doppler blood pressure measured every 4 to 8 hours, measurement of urine output every 4 hours, urinary catheter care, and weight measurement every 6 hours. After surgery, I assessed pain by using the Colorado State University’s pain scale every

During PD, I provided one-on-one nursing care and management (FIGURE 7). For each PD infusion, I ensured strict sterility and accurate record keeping (volume in [medications, nutrition], dialysate in, dialysate out, urine output). I closely monitored the peritoneal catheter insertion site dressing for change in position or strikethrough. I also closely monitored for ongoing or worsening signs of fluid overload (development of nasal discharge, changes in respiratory rate/effort/pattern, changes in lung/heart sounds on auscultation, and spreading/worsening of peripheral edema). I also massaged the patient’s limbs and used passive range-of-motion exercises as part of physiotherapy to improve peripheral edema.

OUTCOME After initiation of PD, the patient’s urine output progressively improved. A furosemide CRI was started;

FIGURE 5. Dialysate infusion line connected to the Jackson-Pratt drain tubing with a 3-way stopcock.

FIGURE 6. Luer lock port sites wrapped with sterile chlorhexidine-soaked gauze.

INTERNAL MEDICINE CASE REPORT

FIGURE 7. The author and patient during the first PD perfusion.

VITAL SIGNS

restarting IV crystalloids was to be considered if the patient moved from oliguria to polyuria. Furosemide is a diuretic that works primarily on the loop of Henle portion of a nephron; it inhibits the body’s ability to reabsorb sodium, leading to increased excretion of water in urine. The furosemide CRI at 0.5 mg/kg per hour, in conjunction with increasing PD frequency to every 2 hours, resulted in the patient’s transitioning to polyuria. Unfortunately, he had sustained azotemia (BUN, 111 mg/dL [reference range, 18 to 34 mg/dL]; creatinine, 8.0 mg/dL [reference range, 1.0 to 2.1 mg/dL]). Because of the owners’ financial constraints, concern for residual renal function, and concern for long-term quality of life, his owners elected to humanely euthanize.

DISCUSSION AKI is the abrupt inability of the kidneys to regulate solute and water balance. AKI includes oliguric renal failure, anuric renal failure, and severe uremia that is unresponsive to fluid therapy. Azotemia is characterized by abnormally high levels of body waste compounds, primarily urea and creatinine. Azotemia can further be classified as prerenal, intrinsic renal, and postrenal. As it implies, prerenal refers to “before” the kidney, meaning azotemia is caused by other physiologic factors or disease processes (ie, hypovolemia, hypotension, dehydration, cardiac compromise, systemic inflammatory response syndrome). Intrinsic renal refers to direct damage to the kidney (ie, nephrotoxins, ischemia, infectious causes). Postrenal refers to azotemia caused by an outflow obstruction in which urine cannot be eliminated from the body (ie, urethral obstruction, urolithiasis, neoplasia). This patient’s AKI was from postrenal causes (urethral and ureteral obstruction). Dialysis transfers water and solute from one compartment to another by means of diffusion across a semipermeable membrane (SPM). In PD, the peritoneum serves as the SPM between the peritoneal cavity and the blood within the peritoneal capillaries. Dialysate (mixture that passes through the membrane) is prescribed to maximize elimination of uremic toxins, prevent depletion of normal blood solutes, replenish depleted solutes, and minimize physiologic and metabolic disturbances during and after dialysis sessions. PD is accomplished by instilling the dialysate mixture into the abdomen through a peritoneal catheter. The dialysate is allowed to dwell for a prescribed period and then is drained into a

waste bag. During the dwelling/draining period, fluid and solutes (primarily waste products: urea and creatinine) are drawn across the membrane through diffusion (solutes move across an SPM from an area of high to low concentration) and convection (movement of solutes with the flow of fluid).

VITAL KNOWLEDGE

Azotemia is characterized by abnormally high levels of body waste compounds, primarily urea and creatinine.

PD is mostly indicated in patients with AKI and is considered a temporary therapy to replace the function of the kidneys, giving them time to heal. Other dialysis options available in veterinary medicine are intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT). IHD is the removal of a patient’s blood so that it can be run through an artificial kidney machine (dialyzer). Uremic toxins are removed by diffusion across an SPM within the dialyzer (blood is circulated on one side, and dialysate is circulated on the other). The entire blood volume of the patient is treated, then returned. IHD takes 4 to 6 hours per treatment, with treatments done a set number of times per week. CRRT is essentially the same process as IHD except that it is done continuously. Limiting factors of IHD and CRRT include client cost and regional availability.

CONCLUSION This case was interesting in that it started as a routine condition that progressed to a dedicated, one-on-one nursing case. The importance of a thorough workup was essential in managing this patient’s whole disease process. Even though the outcome was not what we had hoped, this case demonstrated many aspects of renal care, management, and complications. TVN

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FROM THE FIELD

rom the Field shares insights from Banfield Pet Hospital veterinary team members. Drawing from the nationwide practice’s extensive research, as well as findings from its electronic veterinary medical records database and more than 8 million annual pet visits, this column is intended to explore topics and spark conversations relevant to veterinary practices that ultimately help create a better world for pets.

shutterstock.com/Dmitri Ma

MEET THE AUTHOR

Kirk J. Breuninger, VMD, MPH Banfield Pet Hospital Vancouver, Washington

Focus on Overweight and Obesity in Dogs

anfield Pet Hospital recently released its 2017 State of Pet Health Report, highlighting a widespread trend of overweight pets nationwide. This is the largest report of its kind, capturing medical data from more than 2.5 million dogs cared for by Banfield in 2016. According to this year’s report, 1 in 3 pets that visited a Banfield hospital last year was diagnosed as overweight or obese—and in the past 10 years, Banfield witnessed a 158% increase in overweight dogs.

FROM THE FIELD

Kirk J. Breuninger, VMD, MPH, is a member of the Banfield Applied Research and Knowledge (BARK) team, where he performs and disseminates research that contributes to advancing medical quality, patient safety, and medical decision making. He received his veterinary degree from University of Pennsylvania and his Master of Public Health degree from Temple University. He is an inaugural member of the AVMA Early Career Development Committee, was awarded the 2009 George B. Wolff Legislative Leadership Award, and was recognized as the 2015 Pennsylvania Veterinarian of the Year by the Pennsylvania Veterinary Medical Association.

VITAL SIGNS

The top 5 states with the highest prevalence of overweight dogs were Minnesota (41%), Nebraska (39%), Michigan (38%), Idaho (38%), and Nevada (36%). Indiana, New Mexico, Oregon, Utah, and Washington tied for fifth place at 34%. The prevalence estimates for each state are shown in FIGURE 1. How did your state do?

Obesity Cats

WA 34

MT 34

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TX 29

High Risk Medium Risk Low Risk No Banfield Hospital States with Highest Prevalence

DC 22

NC 26

TN 30 AR

MD 28

NJ 27

AL 21

FIGURE 1. 2016 overweight prevalence in dogs.

Treats should not make up more than 10% of a dog’s daily caloric consumption.

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PA OH

Risk Level

Give treats in moderation. Advise clients to take note of how many treats they give their dog per day.

Show, don’t tell. Educate your clients about body condition scoring, and show them how their pet ranks.

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NV CA

Prevention is key. Remind owners that regular check-ups and nutritional counseling can help keep their dogs at a healthy weight.

29 32

NH MA

Here are some tips and tricks for talking with your clients about their dog’s weight:

Clients can offer rewards other than food, such as belly rubs or playing with a favorite toy.

If food is given as a reward, clients can substitute low-calorie snacks such as baby carrots for high-calorie treats.

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For more client education tools, as well as a host of other resources, visit stateofpethealth.com. TVN

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VITAL PEER REVIEWED SIGNS

IDEAS INTO PRACTICE

WEIGHT WATCHERS Every pet needs an appropriate amount of high-quality speciesappropriate food, limited healthy treats, regular exercise, and play— all things that can be provided right at home. Encourage owners to opt for healthy treats that are low in fat or low in calories.

MEET THE AUTHOR

Esther Klok, Dierenkliniek Winsum The Netherlands

Tackling Pet Obesity: It’s Not Easy, But It’s the Best Work!

hen I started my career as a veterinary technician, I had my hands full of “normal” work. I gave advice about food and prevention methods at the front desk. I made X-rays at the request of the veterinarian and used the microscope in the lab. My job included keeping animals alive that were under anesthesia and being a good team member.

IDEAS INTO PRACTICE

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

VITAL SIGNS

We saw many overweight animals at our practice, but we were not really doing anything about it. However, one week early in my career, my boss suggested at a staff meeting that all the vet techs should do something “extra,” maybe start some type of program. I told my boss that I wanted to start a weight-loss program, and it became quite the thing!

Here are some rules we followed: ●●

●●

shutterstock.com/pakornkrit

A ROCKY BEGINNING Twenty years ago, this type of program wasn’t the “norm.” In fact, one of my bosses laughed about it and said he did not want to be there when I did “Weight Watchers” for dogs. My first thought was, Okay, it’s your business. But then I thought, Okay, I will show him it’s a good thing to do. I’ll show him it will bring good things for the animals and our practice. I’ve always have been the stubborn type, so I told my practice I would create a decent program that would work for everyone. My cheeks were burning when I came out of the meeting, but already, a few colleagues told me they liked the idea and wanted to help. That gave me the energy to hit the ground running.

BUILDING A SUCCESSFUL PROGRAM For me, these characteristics were important to building a successful program: ●●

It must be simple for every staff member and easy to execute.

●●

It should not be costly for the practice or pet owners.

●●

It should not be overly time-consuming.

●●

The results had to be clear for the staff and pet owners, so having good before/ after pictures were important.

Pet owners and pets would come in every 2 weeks for a weight consultation with a vet tech, with the first visit taking about 20 minutes. We would communicate with the owners and formulate a plan based on the pet’s age and target weight. For a plan to be successful, the whole staff should be informed about it, and at least one other staff member should conduct appointments with the client. The rest of the staff should talk to pet owners about your plan. That means vet techs and vets.

●●

Make a plan with good food. We use Hills r/d and Metabolic, but there are plenty of options. Give owners goodies to take home. When you do, all the “extras” will be under your control. Otherwise, the owners may give treats without telling you. Make a follow-up appointment right away. When pet owners must call for an appointment, they often forget. Or, when they think the animal didn’t lose weight, they probably won’t call. Do not give them a number of how much weight we want the animal to lose in 2 weeks. I only gave them the weight goal to attain. And I also didn’t tell them when that should be so they wouldn’t worry about how fast the pet should be losing weight.

VITAL KNOWLEDGE

Give owners goodies to take home. When you do, all the “extras” will be under your control. Otherwise, the owners may give treats without telling you.

THERE’S ALWAYS A SOLUTION One of my best learning experiences was with a dog named Bas that belonged to a pub owner. Bas was 36 kilos and should have weighed about 26, but the owner had 2 problems. First, he loved to give the dog snacks. Second, all the guests loved to do that, too! During the day, many of the tourists were sitting on the terrace and ordering tea or coffee. In Holland, that’s always served with a cookie. When the dog saw the order go out to the table, he would run outside and sit in front of the tourists. The dog had a big advantage. He had the most beautiful puppy eyes you have ever seen. So when he looked at the guests, they didn’t have the heart to eat the cookie themselves! In the evening,

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he’d do the same thing inside the pub, begging guests for the sausage they would get with their beer. When Bas started getting pain in his joints, the first thing we needed to do was have him lose weight. The owner had already tried that with another vet, but nothing had happened. So we had a nice long talk and made a plan. First, I crafted a sign 1 meter high by 1 meter wide. It said, “Bas has pain in his joints and cannot walk well anymore. We have to help him. Please do not feed anything to him except what you get from us.” Then we placed it in front of the pub. From that moment on, every time the pub served coffee and tea during the day, Hills t/d pallets were placed next to the cookie. Then, baked cookies of canned dry food were put next to every beer. And guess what? The people loved giving Bas healthy treats! In 2 weeks, Bas lost one kilo. We put the starting weight of the dog on the sign in front of the pub, and every 2 weeks, we put the weight he lost on it. All the regular clients saw it as a joint effort. In the end, Bas lost 10 kilos and didn’t show signs of pain anymore. Happy dog, happy owners, happy pub visitors. And, a really good advertisement for our clinic.

EVERYONE WINS It’s also important to report good results. Once the pet has lost weight, take the pet to the back of your practice and show your colleagues. Make the staff enthusiastic and proud as well. Then, if the owner gives permission, put before-and-after pictures with a short story on your website and social media page. Finally, don’t forget to frame a picture of the successful animals for a wall in your practice. When a pet loses weight, the owners usually feel so proud, they often tell everyone about it. They will enjoy the many compliments they get when they walk down the street with a super handsome dog or when their friends visit and see an active cat. Most importantly, follow your vet tech heart! I think we all love animals, but we also love people. Otherwise, we would have already quit our jobs. Let your heart speak when you start with a new animal, and good results will follow. Because at the end of the day, that’s really all you need. TVN

IDEAS INTO PRACTICE

NUTRITION NOTES continued from page 15

As we learn more about the composition and function of the microbiota, we will also need to address ways to keep this population as healthy and happy as the host it inhabits. The microbiota plays an important role in the development, immune regulation, and maintenance of health for all animals.3 TVN References 1. Middlebos IS, Vester Boler BM, Qu A, et al. Phylogenetic characterization of fecal microbial communities of dogs fed diets with or without supplemental dietary fiber using 454 pyrosequencing. PLOS One 2010;5(3):e9768. https://doi.org/10.1371/journal.pone.0009768. Accessed September 2017. 2. Suchodolski JS. The GI microbiome in domestic animals – contributions to health and disease. ACVIM Proc 2015. 3. Weese JS. The gut microbiota: can we predict and prevent gastrointestinal disease? ACVIM Proc 2015. 4. Suchodolski JS, Simpson K. Canine gastrointestinal microbiome in health and disease. Vet Focus 2013;23(2):22-28. 5. Weese JS. Beneficial bacteria: primer on probiotics and GI health. Nutramax Laboratories Quick Course handout. Available from researchgate.net/publication/287906095_Beneficial_bacteria_A_ primer_on_probiotics_and_GI_halth. 6. Suchodolski JS. Metabolic consequences of gut dysbiosis and inflammation. ACVIM Proc 2015. 7. Wolowczuk I, Verwaerde C, Viltart O, et al. Feeding our immune systems: impact on metabolism. Clin Dev Immunol 2008:639803. doi: 10.1155/2008/639803 8. Cave N. Nutritional management of gastrointestinal diseases. In: Fascetti A, Delany SJ, eds. Applied Veterinary Clinical Nutrition. Ames, IA: WileyBlackwell Publishing; 2012:177-182.

Glossary Prebiotic: A type of moderately fermentable fiber that can be used as an energy source by resident intestinal bacteria. Probiotic: A classification of live bacteria that are believed to confer benefits on the host when consumed. Saccharides: carbohydrates, including sugars; may be made of single molecules (monosaccharides), such as lactose, sucrose, and fructose; small groups of molecules (oligosaccharides), such as fructooligosaccharides; or chains of molecules (polysaccharides), such as inulin. Specific pathogen-free (germ-free) animal: Animals raised under laboratory conditions to prevent colonization by many normal bacterial species and are therefore guaranteed to be free of specific pathogens that may interfere with an experiment. Xenobiotic: Chemical substance found within an organism that is not normally naturally produced by or expected to be present in that organism; also, substances that are present in much higher concentrations than are usual3 .

NUTRITION NOTES

Perfectly fed. Chaos-free. Perfectly fed. Chaos-free.

The Weight is Over The Weight is Over

87% of pets lost weight. 87% ofFind pets lost weight. out how. Find out how.

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Features CE FEATURE — Hypothermia Under Anesthesia — 38 DERMATOLOGY — Otitis Externa — 50 IMAGING — How to Obtain the Optimal Dental Radiographs — 60 INFECTION CONTROL — Discospondylitis — 70 EQUINE MEDICINE — Equine Pythiosis: An Overview — 78

PEER REVIEWED

WARM RECEPTION When the patient arrives avoid patient contact with metal surfaces. Conduction occurs when a patient is placed on a metal table or when a footpad touches a metal IV pole. To prevent heat loss from conduction, ensure that the patient is fully insulated from any cool object. Heat loss is prevented by placing a blanket between the metal table and patient.

DANGERSTOXICOLOGY OF HYPOTHERMIA TALK

CONTINUING EDUCATION

ANESTHESIA

Dangers of Hypothermia Avoiding the Cold

MEET THE AUTHOR

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

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

ypothermia is a common yet preventable side effect of anesthesia and surgery. Too often, intraoperative hypothermia is overlooked or ignored.1 Unfortunately, many practices become accustomed to intraoperative and postoperative hypothermia because it is so common, or they are unaware that their patients are experiencing hypothermia because of lack of monitoring. However, just because patients routinely experience hypothermia does not make it acceptable. In this article, I will describe hypothermia dangers, causes, and risk factors; how to prevent or detect hypothermia; and how to treat it should it occur.

WHAT IS HYPOTHERMIA? Hypothermia under anesthesia is defined as a drop in body temperature below reference ranges. It is subclassified as mild (98°F to 99.9°F), moderate (96°F to 98°F), severe (92°F to 96°F), and critical (below 92°F) (TABLE 1).1 TABLE 1 Stages of Hypothermia in an Anesthetized Patient STAGE

TEMPERATURE RANGE

Mild

>98°F

Moderate

96°F–98°F

Severe

92°F–95°F

Critical

<92°F

Information obtained from reference 1.

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WHY IS HYPOTHERMIA A CONCERN? Hypothermia creates a variety of abnormal reactions in the body (TABLE 2). It affects metabolism, blood viscosity, cardiovascular function, and the amount of anesthetic drugs needed. It can also increase risk for infection and decrease immune function. For example, a possible link has been shown between the length and degree of hypotension that determines the degree of immune system dysfunction.2

Metabolism A patient’s metabolic rate decreases approximately 10% for each 1.8°F loss of body temperature.2 This lower metabolic rate results in reduced drug metabolism and elimination, which can lead to overdoses and prolonged recoveries.3 Cell sodium pump activity is decreased, which may cause cell edema. Electrolyte and pH imbalances may result in conditions such as hyperkalemia and acidosis.4

Blood Viscosity During hypothermic episodes, blood viscosity (thickness, stickiness) and packed cell volume (PCV) can increase after possible splenic contraction. Increased blood viscosity increases the amount of work the myocardium must do. Prothrombin time (PT) and partial thromboplastin time (PTT) increase, resulting in hypocoagulability, which can lead to excessive bleeding.4

Cardiovascular Response In addition to the increased demands on the myocardium, hypotension is common in hypothermic patients because of reduced sensitivity and reflexes of the baroreceptors, resulting in reduced cardiac output.4 Electrophysiologic changes can lead to bradycardia that is nonresponsive to anticholinergics, and myocardial irritability can increase the incidence of arrhythmias.4 At a body

temperature around 95°F, active vasodilation occurs, which will lead to hypotension. Below this temperature, thermoregulatory shivering does not occur.2 When the core body temperature falls below 94°F, thermoregulation is impaired and peripheral vasoconstriction is replaced with vasodilation, which promotes core body heat loss.5

Amount of Anesthetic Drug Needed As the patient’s temperature drops, so do the anesthetic requirements. Depression of central nervous system activity results in a reduced minimal alveolar concentration (MAC) (the amount of anesthetic gas vapor in the lungs needed for anesthesia). It is imperative that as the patient’s body temperature decreases, the amount of anesthetic drug be reduced to prevent overanesthetizing the patient.2 If the vaporizer is not reduced as the body temperature drops, the patient may go into a deeper plane of anesthesia and may hypoventilate. Hypoventilation in a hypothermic patient may result in hypercapnia (increased carbon dioxide in the blood).2

What Causes Hypothermia? Before hypothermia can be addressed, you must recognize why the patient is losing heat. The main causes are cold environment, altered thermoregulation of the body, and heat-loss mechanisms. Cold Environment Exposure to a cold environment is the most common cause of hypothermia.5 Environmental temperature is often beyond the technician’s control. For their own comfort, many surgeons prefer a cooler environment while gowned. Altered Thermoregulatory Response Alteration of the patient’s normal thermoregulatory response is the second most common cause of

TABLE 2 Effect of Hypothermia on Body Systems SYSTEM

DYSFUNCTION

Cardiovascular

Thermoregulatory dysfunction resulting in arterial vasodilation, increased blood viscosity, decreased cardiac output, increased cardiac dysrhythmia, coagulopathies, hypotension, bradycardia

Respiratory

Decreased respiratory rate, minute volume, and tidal volume

Neurological

Disrupted cerebral autoregulation and cerebral blood flow

Immune

Impaired wound healing and increased risk for infection

Metabolic

Decreased metabolism, leading to drug overdoses and prolonged recoveries

Information obtained from reference 5..

DANGERS OF HYPOTHERMIA

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hypothermia.5 This alteration may be caused by agents used in anesthesia but alone is not a reason to change the protocol; the benefits of these agents outweigh their potential side effects. In an awake patient, body heat is not distributed uniformly. The periphery (tail, legs) release or absorb heat as needed to maintain normothermia.2 During the first hour of anesthesia, a centrally mediated decrease in temperature threshold causes the body to redistribute blood flow to the periphery to compensate for the bodyâ&#x20AC;&#x2122;s misconception of excess heat, resulting in a drop in core body temperature.2 Many other physical factors contribute to heat loss during surgery, including lack of body fat, large body surface areas, vasodilation,6,7 and changes to hypothalamus function. Specific vasodilatory agents commonly used in anesthesia are acepromazine and gas inhalants. Gas inhalants cause dose-related vasodilation: the higher the vaporizer setting, the more vasodilation will occur and, thus, the potential for hypothermia will increase. Heat-Loss Mechanisms Heat loss can be categorized by mechanism. The 4 mechanisms are radiation, convection, conduction, and evaporation. Radiation: In the anesthetized patient, the most common mechanism for heat loss is radiation.2 Radiation occurs when an exchange of heat takes place between the body and environmental objects that are not actually in contact with the patient, independent of moving air. There is a loss of energy by transfer of infrared waves.2 Body heat, especially if the patient is experiencing vasodilation, is transferred to the cooler air surrounding it (eg, the heat dissipates away from the body). Convection: The second most common mechanism of heat loss is convection,2 which occurs as body heat is transferred to the air moving over the skin surface.2 The larger the body surface area, the more prone the patient is to hypothermia. In veterinary patients, although hair helps insulate the body to some degree, heat loss is accelerated from areas of exposed skin where the hair has been shaved. A shaved area or open body cavity can create extreme heat loss. Conduction: The transfer of body heat to a cooler surface is called conduction and occurs when any part of the body touches a cool surface. For example, conduction occurs when a patient is placed on a metal table or when a footpad touches a metal IV pole. To prevent heat loss from conduction, ensure that the patient is fully insulated from any cool object.

DANGERS OF HYPOTHERMIA

Evaporation: This mechanism of heat loss occurs when moisture on the skin or in the respiratory tract dissolves into the air, pulling with it heat from the body. Heat loss from evaporation can be prevented by being conscious of the amount of prep solution used, attempting to keep the patient dry, and carefully using a hair dryer after surgery to dry a wet patient. To prevent evaporation from the respiratory tract, carefully lowering the oxygen flow, if compatible with the breathing system and vaporizer, can be helpful in preventing heat loss.2

WHICH PATIENTS ARE AT HIGHEST RISK? Some patients are more prone than others to hypothermia, and they must be identified so special precautions can be instituted. Higher-risk patients include pediatric patients, geriatric patients, patients with very little body fat (eg, sight hounds and cachectic animals), and patients whose surgery involves an open body cavity.3

Pediatric Patients Physiologic differences in pediatric patients predispose them to hypothermia. Several factors increase this risk. Their ability to thermoregulate is immature; they have a high metabolic rate, a large body surface to body mass ratio, limited subcutaneous fat, and deterrents that limit shivering in the event of hypothermia.8

Geriatric Patients At the other end of life are the geriatric patients. These patients are likely to become hypothermic during anesthesia for the following reasons: decreased muscle mass prevents an effective shivering response, central nervous system changes decrease the ability to thermoregulate, basal metabolic rate is decreased, the patient may have hormonal alopecia or hair thinning, and distribution of fat diminishes its insulating properties. As an insulator, fat conducts one third as readily as other tissues, slowing the transfer of body heat.2 Geriatric patients tend to have more adipose tissue in the abdominal cavity than in subcutaneous areas.9

Thin Patients Patients who are cachectic, have some type of wasting disease, or are naturally thin (such as sight hounds) are prone to hypothermia while anesthetized. These patients have little muscle mass and minimal insulating fat.3

CONTINUING EDUCATION

Patients Undergoing Open Body Cavity Procedures Among surgical procedures that promote hypothermia, those that promote the most heat loss involve open abdominal or thoracic cavities. These surgical patients will be at higher risk for heat loss while under anesthesia.

WHAT IS THE CONNECTION BETWEEN ANESTHESIA AND HYPOTHERMIA? Although the patients listed above are at higher risk, all patients under anesthesia probably experience some degree of hypothermia. Overall, anesthesia decreases the basal metabolic rate by anywhere from 15% to 40%, which inhibits muscular activity and leads to decreased heat production.5 Inhalant gasses and injectable drugs can contribute to hypothermia.

dose dependent. Body temperature can be conserved by incorporating a multimodal anesthesia protocol allowing the vaporizer to be set at the lowest acceptable level for surgery. Thermoregulation can be altered by drugs such as alpha-2 agonists (dexmedetomidine), opioids, (hydromorphone, morphine, oxymorphone, fentanyl, and methadone), and gas inhalants.6 In humans, a temperature drop of 3.6°F to 5.4°F doubles the duration of nondepolarizing neuromuscular blocking agents.2 These effects do not indicate that these drugs should not be used in veterinary patients. Rather, they indicate that you should be aware of them and should plan interventions to prevent heat loss in these patients.

HOW CAN HYPOTHERMIA BE PREVENTED?

Oxygen The oxygen used with inhalation anesthesia is cold and can contribute to heat loss in patients during general anesthesia. Heat loss should be a consideration when choosing the type of anesthetic circuit to use. Nonrebreathing systems require a higher oxygen flow rate and, thus, are more apt to promote hypothermia.5

Other Anesthetic Drugs Some anesthetic drugs can lead to vasodilation, which can contribute to hypothermia. Fully dilated blood vessels lose heat 8 times faster than fully constricted vessels.5 Two of the most common vasodilatory drugs used in anesthesia are acepromazine and gas inhalants. It is important to remember that vasodilation caused by gas inhalants is

Preventing hypothermia involves consideration of several factors: common sense, mechanical intervention, and use of everyday objects that may be around a clinic. If your patients routinely have been experiencing hypothermia, you should try to understand when and how the heat loss is occurring, keeping in mind that using a multimodal approach will result in the best outcome (TABLE 3). The first step is identification of the problem, which is accomplished by monitoring body temperature. One way to monitor the temperature of an anesthetized patient is to use an esophageal thermometer. Most multimodal monitors come with the option that will supply a realtime, constant core temperature. If this option is not available, a manual rectal temperature taken every 5 minutes is usually adequate. However, rectal temperatures can be inaccurate, especially if fecal material is present.4 Temperature should be monitored from the time of premedication until the patient is well into recovery. Ideally,

TABLE 3 Ways to Combat Hypothermia TYPE

MATERIAL

OBJECTIVE

INDICATION

Passive

• • • •

Prevent heat loss

Normothermic or mildly hypothermic patient

Provides heat to body surface

Anesthetized patient experiencing moderate/ severe/critical hypothermia

Provides heat to body core

Patient undergoing open chest/abdomen surgeries or experiencing severe or critical hypothermia

Active External

Flannel blanket Space blanket Bubble wrap Plastic wrap

• Circulating warm water blankets • Forced warm air blankets • Inline IV warmer • Conductive fabric

Active Internal

•S terile, warm, pleural/peritoneal lavage • Warm IV fluids

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the patientâ&#x20AC;&#x2122;s temperature should be obtained at intake, before leaving the prep area, continuously during surgery, and postoperatively until the patient has maintained a normal body temperature for 2 to 3 consecutive hours. Every patient needs a warm environment from the time it receives premedication until it is fully recovered. We will now discuss heat-loss prevention according to surgical phase: preoperative, intraoperative, and postoperative.

Intraoperative Phase

Preoperative Phase

Active Warmers

Prewarming

The best defense against intraoperative hypothermia is use of an active multimodal approach. Maintaining body heat is much easier than regaining it after it is lost. There are 4 types of active, or mechanical, methods of warming an anesthetized patient that are approved for use with veterinary patients: inline fluid warmers, forced warm air systems, conductive fabrics, and circulating warm water blankets. These 4 methods are routinely used in human medicine and have proven effective and safe when used as directed.

An effective way to prevent hypothermia is to prewarm the patient before surgery. Prewarming raises the peripheral body temperature, which reduces the initial drop in core body temperature.2 However, the patient should not be overheated. Safe ways to prewarm a patient before surgery include putting hot water bottles (that have been warmed in the fluid incubator and insulated) in the cage of a conscious patient, supplying warm blankets, ensuring that the patient doesnâ&#x20AC;&#x2122;t come in contact with the cold metal cage walls, and adding a cage dryer on a low setting.10 Presurgical Preparation Surgical preparation can be a time of significant loss of body temperature. It is not unusual for a patient to lose up to 2.0Â°F during the first hour of anesthesia.6 To prevent heat loss during this phase, the patient should be insulated from cold surfaces. Techniques include padding the cage or run so the patient is not lying on a cold surface after premedication has been administered, padding the prep and surgery tables with bubble wrap and towels, and even ensuring that footpads are not touching cold surfaces such as an IV pole (FIGURE 1).

FIGURE 1. Layers, Hug-U-Vac, warm water blanket, huck pad. Image courtesy of Brenda Feller.

The choice of scrub solutions can also contribute to heat loss. For most preparations, the initial surgical scrub used in the prep area can be warmed. If the patient is at a higher risk for hypothermia, substituting warm sterile saline for alcohol will help reduce heat loss.6 Do not oversaturate the patient. Being prepared and preparing the patient quickly and efficiently can help reduce heat loss.

DANGERS OF HYPOTHERMIA

Inline Fluid Warmers An inline fluid warmer keeps IV fluids warm as they enter the patient and can be used along with other options to help maintain normothermia (FIGURE 2). Although using an incubator to warm the IV fluid bag before administration may seem like a good idea, most fluid pumps are incapable of delivering fluids at a rate that will not result in the fluid being at room temperature when it reaches the patient. Cooling begins the minute a bag of warmed fluids is removed from the incubator. Even with use of some type of insulation around the bag during surgery, cooling happens rapidly. But the real cooling occurs at the administration set. The average IV administration set has a priming volume of around

FIGURE 2. Inline fluid warmer. Courtesy of Brenda Feller.

CONTINUING EDUCATION

15 to 19 mL, which does not include the fluid held in the priming bulb at the top. Use of an extension set or T-port will add volume. If you consider an average 20-kg patient receiving fluids at 5 mL/kg/hour through a 15-mL IV administration set, the fluid will stay in the fluid line approximately 9 minutes (BOX 1). Because the environmental temperature of many surgery suites is in the 62°F to 68°F range (much lower than body temperature), 9 minutes is sufficient time for warmed fluid to cool to room temperature by the time it actually reaches the patient. For a cat, because of the lower flow rates, the fluid could be in the line for over 30 minutes! Inline fluid warmers are great for counteracting this heat loss if placed close to the patient. However, if the inline fluid warmer is close to the fluid bag, there is little to no advantage in using it. Placing the warmer close to the IV catheter, keeping in mind individual instructions on how close to the patient it can be, will promote heat conservation. This piece of equipment is easy to use and requires little maintenance to provide years of service.

Forced Warm Air Systems Another type of mechanical device is the forced warm air system, such as the Bair Hugger System (3m.com) (FIGURE 3). When used as directed, with the blankets supplied by the company, this system provides excellent body heat retention and maintains surgery site sterility.8 The blankets that come with the unit are designated for 1-time use and provide some degree of safety from contamination from the air that is being provided to the patient.8

FIGURE 3. Bair Hugger unit. Courtesy of Brenda Feller.

BOX 1 Calculating Heat Loss in an IV Fluid Line The following example shows how to calculate the length of time fluid stays in an IV administration set. A 20-kg patient is receiving fluid at 5 mL/kg/hour via an administration set with a 15-mL priming volume. Step 1. Calculate the fluid rate by multiplying body weight by fluid rate. 20 kg × 5 mL/hour = 100 mL delivered per hour Step 2. Divide the hourly rate by the administration set priming volume to discover how many times per hour the fluid in the administration set will be exchanged. 100 mL/15 mL = 6.66 times per hour Step 3. Calculate how many minutes the fluid will stay in the IV line by dividing 60 minutes by the times per hour the fluid will be exchanged. 60/6.66 = approximately 9 minutes This calculation indicates that the fluid stays in the administration line about 9 minutes before it reaches the patient. This calculation does not consider the fluid in the priming bulb, which will increase the time that the fluid is outside the fluid bag and exposed to room air. Because the amount in the bulb will vary and is not considered in the volume of the administration set, it cannot be accurately calculated.

Similar units have reusable blankets (FIGURE 4). Cloth blankets can be purchased for use with forced warm air systems and laundered between patients. Follow manufacturer’s instructions for cleaning and use. When using cloth blankets, I have successfully placed a fleece blanket over the cloth blanket to trap heat close to the body if the warming blanket is placed over the torso of the patient. If the surgeon is concerned about the circulating air these devices emit, one option is to start the unit after the patient is fully draped for surgery. Maintenance consists of changing an internal filter after a set number of hours of use.

FIGURE 4. Forced warm air with cloth blanket. Image courtesy of Jorvet.

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The warm water blanket can also serve as an inline fluid warmer if the IV line is run under the blanket.

Caution!

FUNDAMENTALS

Maintaining body heat is much easier than regaining it once it is lost.

Conductive Fabrics Other mechanical devices specifically designed for veterinary patients are conductive fabric warming devices (FIGURE 5). A product commonly used in veterinary medicine is the Hot Dog warming system (hotdogwarming.com). Conductive fabric warming devices do not blow hot air and have reusable blankets that can withstand cleaning. They have alarms that alert the team if the patient is overheated. Recently, the manufacturer has recommended replacing the blankets every 2 years. As always, follow manufacturerâ&#x20AC;&#x2122;s instructions.

Circulating Warm Water Blankets These devices consist of a pump that warms water (FIGURE 6), which is then delivered to a water blanket that can be placed over or under a patient (FIGURE 7). One disadvantage of these systems is that the blanket is made of a plastic material and can be damaged by puncture. To avoid blanket puncture, you can purchase a product that can be placed over the blanket to protect it or use the product only after the patient is anesthetized.

FIGURE 5. Space blanketâ&#x20AC;&#x201C;type device. Courtesy of Jorvet.

It is important to note that using unapproved methods for heat support may cause thermal burns. Patients who experience thermal burns experience severe pain and protracted healing of burned tissue and, in severe cases, may require euthanasia. Unfortunately, I have witnessed all of these side effects from use of unapproved heating sources during anesthesia. There are many products on the market that are not safe for patients that are unconscious and unable to move away from the heat source. Unsafe products include any product that is placed in the microwave (eg, discs, hot water bottles, rice socks), no matter how well they are insulated. When the products are microwaved, there are no safeguards to monitor the actual temperature of the products. These products are acceptable when the patient has the ability to move away from the source if they are too warm but not when the patient is unconscious or heavily sedated.6 Never use an electric heating pad made for humans on a veterinary patient because of the risk for burns and electric shock. Passive Warmers A wide variety of passive, or nonmechanical, methods can be used to help maintain a normal body temperature range in an anesthetized patient. Several items in this category are found in most practices.

Bubble Wrap Most practices have access to bubble wrap, which can be used in a variety of ways (FIGURE 8). It can be placed on a metal table, covered by a thick towel, to

FIGURE 6. Warm water circulating pump. Image courtesy of Jorvet.

DANGERS OF HYPOTHERMIA

FIGURE 7. Warm water blanket. Image courtesy of Jorvet.

CONTINUING EDUCATION

insulate the patient from the cold table and prevent conductive heat loss. Smaller pieces can be placed around limbs for insulation, or if the procedure is to be performed on a limb, the torso can be wrapped.2 Bubble wrap can be used in addition to some type of mechanical warming device that traps heat near the body. Bubble wrap should not be used on a conscious patient because of the risk of its being ingested. Bubble wrap should be discarded after use.

Clothing Heat loss can be reduced by placing baby socks, sweaters, or any other type of clothing on the patient anywhere not involved in the surgery site. These items can be placed on the extremities or torso.

Plastic Wrap Plastic wrap can be used for patients undergoing surgery on a limb. Simply covering the torso and the table, including a mechanical heat source like a circulating warm water blanket, will keep the heat produced by the body and the blanket contained within the plastic wrap. Patients undergoing dental prophylaxis should be kept dry to prevent heat loss through evaporation. An easy way to accomplish this is to place plastic wrap over the patientâ&#x20AC;&#x2122;s torso and then place a blanket over the plastic wrap. Plastic wrap should be used only for anesthetized patients. If plastic wrap is ingested by the patient, it has the possibility of becoming an intestinal obstruction.

FUNDAMENTALS

The best method to monitor body temperature under anesthesia is with an esophageal thermometer.

Although blankets alone will not keep patients warm, they are a great addition to other methods.

Low Oxygen Flow

Flannel blankets and space blankets placed over the patient trap the warm air near the patient and can mitigate heat loss (FIGURE 9). For best results, cover all parts of the patient, including the head and extremities.

A high oxygen flow rate can contribute to hypothermia; however, this risk can be reduced if the oxygen flow rate is calculated for the patient instead of being set arbitrarily high. An oxygen flow rate of 20 to 22 mL/kg/minute, which is more than twice the normal oxygen demand for a patient on a rebreathing circuit, provides adequate oxygen flow and reduces the amount of cool oxygen delivered to the patient.4 This means that a 20-kg dog would require only 400 mL (or 0.4 L) of oxygen per minute. The caveat to this rule is that to ensure accurate delivery of the gas inhalant, all vaporizers have a minimum low oxygen flow rate. This information is located in the instruction booklet, or technical services can provide this information about the vaporizer. Until the minimum flow rate for a particular vaporizer is verified, for safety, a minimum oxygen flow rate of 500 mL/minute can be used. Nonrebreathing

FIGURE 8. Layering, bubble wrap/towel. Image courtesy of Brenda Feller.

FIGURE 9. Flannel blanket. Image courtesy of Brenda Feller.

Blankets

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systems require a higher oxygen flow rate based on the weight of the patient (FIGURE 10). This rate will vary slightly among types of system and results in a 5-kg cat often requiring a higher oxygen flow rate (150 to 300 mL/kg/minute) on a nonrebreathing system than a 40-kg dog on a rebreathing system.

Carbon Dioxide Absorbent Viable (fresh) carbon dioxide absorbent acts as a natural heating source. The chemical reaction between the granules and carbon dioxide produces heat and moisture within the rebreathing circuit. This heating effect is another reason to change your carbon dioxide absorbent on a regular basis. The larger the patient, the more heat and moisture will be produced. Although this alone is not enough to keep a patient warm, it may help conserve heat.9

Postoperative Phase Postoperative shivering, in addition to prolonging recovery, increases oxygen demand, which may lead to the need for oxygen supplementation during recovery (FIGURE 5 and FIGURE 11). Severe shivering may induce pain through movement of areas that underwent surgery.2 In humans, hypothermia contributes to delayed wound healing and extended hospital stays even in the absence of wound infection.2

During the recovery period, you can use items you have around the hospital to keep your patient warm. A cage dryer is acceptable for warming patients conscious enough to be able to move away from the heat source. For small patients, an oxygen cage can provide heat, with or without the oxygen flowing. If the cage is not supplying oxygen and the patient is conscious, you can add insulated hot water bottles that have been warmed in a fluid incubator to produce heat in the oxygen cage.4 To prevent hyperthermia during the postoperative phase, active body warming should be discontinued after the rectal temperature reaches 98.5°F.5 However, a return of the patient’s body temperature to normal does not mean that the anesthetist’s job is done. The core body temperature can continue to drop. This phenomenon is called “afterdrop” and is a result of the cold peripheral blood being circulated back to the body core.5 The patient should be actively monitored until the body temperature is stable for 1 to 2 hours.

SUMMARY Hypothermia is an often overlooked condition that is easier to prevent than to treat. If not treated in a timely manner, hypothermia can have grave consequences. Postoperative hypothermia can cause prolonged recoveries and increased wound infections. Better anesthesia outcomes can be achieved when we identify causes of heat loss, take measures to avoid or counteract them, and incorporate active warming into our surgical protocols. TVN References 1. Ko J. Small Animal Anesthesia and Pain Management: A Color Handbook. London: Manson Publishing; 2013:154–155. 2. Mosing M. General principles of perioperative care. In: Duke-Novakovski T, deVries M, Seymour C, eds. BSAVA Manual of Canine and Feline Anaesthesia and Analgesia. 3rd ed. Quedgeley: British Small Animal Veterinary Association; 2016:16–19.

FIGURE 10. Nonrebreathing circuit with warm water bottle on oxygen line. Image courtesy of Brenda Feller.

3. Anesthetic complications (Chapter 6). In: Shelby A, McKune C, eds. Small Animal Anesthesia Techniques. Ames: Wiley-Blackwell; 2014:226. 4. Dugdale A. Veterinary Anesthesia Principles to Practice. Chichester: Wiley-Blackwell; 2010:313, 316. 5. Oncken A, Kirby R, Rudloff, E. Hypothermia in critically ill dogs and cats. Compendium J 2001;23(6):506–519. 6. Evans AT, Wilson DV. Anesthetic emergencies and accidents. In:Grimm K, Tranquilli W, Lamon L, eds. Essentials of Small Animal Anesthesia and Analgesia. 2nd ed. Chichester: Wiley-Blackwell; 2011:525. 7. DaCunha AF. Neonatal, pediatric, and geriatric concerns. In: Snyder L, Johnson R, eds. Canine and Feline Anesthesia and Co-Existing Disease. Ames: Wiley-Blackwell; 2015:313. 8. Moretti B, Larocca AM, Napoli C, et al. Active warming systems to maintain perioperative normothermia in hip replacement surgery: a therapeutic aid or a vector of infection? J Hosp Infect 2009;73(1):58-63. 9. Bryant S. Anesthesia for Veterinary Technicians. Ames: Wiley Blackwell; 2010:75.

FIGURE 11. Space blanket type blanket. Courtesy of Jorvet.

DANGERS OF HYPOTHERMIA

10. Macintire, D. K., Drobatz, K. J., Haskins, S. C. & Saxon, W. D. Manual of Small Animal Emergency and Critical Care Medicine, (John Wiley & Sons), https://www.bsava.com/Resources/Veterinary-resources/Scientificinformation/Animal-warming-products, accessed December 22, 2017.

CONTINUING EDUCATION

Dangers of Hypothermia: Avoiding the Cold LEARNING OBJECTIVES After reading this article, technicians should be able to identify hypothermia, pinpoint areas where body temperature is lost, and know passive and active ways to counteract it. They should understand the short- and longterm physiologic changes that occur during hypothermia and the importance of avoiding hypothermia during the preoperative, intraoperative, and postoperative periods.

1. A patient is said to experience severe hypothermia when the core body temperature is: a. 92°F–96°F b. below 92°F c. 96°F–98°F d. 99°F –100°F 2. The breathing circuit that will contribute the most to hypothermia is a: a. rebreathing circuit b. nonrebreathing circuit 3. Which warming device is approved for anesthetized patients? a. hot water bottles b. electric heating pads c. forced warm air system d. rice sock 4. A Hot Dog warming system a. circulates warm air b. circulates warm water c. uses conductive fabric d. is an inline fluid warmer 5. A disadvantage of using a high oxygen flow rate is that it: a. causes no change in body temperature b. causes a decrease in body temperature c. causes an increase in body temperature d. causes marked fluctuation in body temperature

The article you have read has been submitted for RACE approval for 1 hour of continuing education credit and will be opened for enrollment when approval has been received. To receive credit, take the approved test online for free at vetfolio.com/journal-ce. Free registration on VetFolio.com is required. Questions and answers online may differ from those below. Tests are valid for 2 years from the date of approval.

6. During hypothermia, the blood viscosity: a. stays neutral b. decreases c. increases d. varies unpredictably 7. Vasodilation due to hypothermia occurs at a body temperature of about: a. 92°F b. 90°F c. 95°F d. 98°F 8. Shivering causes: a. an increase in oxygen demand b. an increase in recovery time c. a decrease in oxygen demand d. a decrease in recovery time 9. When a patient has a footpad touching a metal IV pole, the patient is said to be losing heat through: a. Radiation b. Convection c. Evaporation d. Conduction 10. Afterdrop occurs when: a. the blood from the core is circulated back to the periphery b. the blood from the head is circulated to the core c. the blood from the major organs is circulated to the head d. the blood from the periphery is circulated to the core

NOTE Questions online may differ from those here; answers are available once CE test is taken at vetmedteam.com/tvp.aspx. Tests are valid for 2 years from date of approval. WINTER 2018

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OTOSCOPIC EXAMINATION Before the otoscopic examination begins, a skilled individual (such as a veterinary nurse or veterinary assistant), rather than the owner, should restrain the pet. This ensures that the petâ&#x20AC;&#x2122;s body and head remain as immobile as possible, which will optimize the examination and ultimately the comfort of the pet. Sandra Grable, conducts an examination of the ear canal. Photo courtesy of Bradley Leeb, University of Illinois

TOXICOLOGY TALK

FEATURES

DERMATOLOGY

Otitis Externa Inflammation of the Ear Canal MEET THE AUTHOR

Sandra Grable, AAS, CVT University of Illinois College of Veterinary Medicine

Sandra Grable, AAS, CVT, graduated from Parkland College’s veterinary technology program in Champaign, Illinois, in 1999 and began work at the University of Illinois Diagnostic Laboratory. In 2001, she became the technician for the dermatology and otology clinic. She has an interest in mycology and enjoys reading skin cytology slides and assisting her doctors with dermatologic procedures, especially video otoscopy. She has chaired roundtable discussions, given several lectures, written for online publications, and wrote a book chapter on dermatophytes. She is a charter member of the Academy of Dermatology Veterinary Technicians, which was officially recognized by the National Association of Veterinary Technicians in America in 2015.

titis externa is a common condition that is frequently seen in specialty dermatology clinics and small animal general practices.1,2 It is defined as inflammation of the ear canal with or without involvement of the pinna.1–3 Otitis is often considered a final diagnosis, but it is merely a clinical sign. The many factors that can contribute to otitis need to be addressed so that initial infections do not progress to chronic changes, such as irreversible structural damage to the ear canal and cartilage. STRUCTURES OF THE EXTERNAL CANAL The external ear consists of 3 structures: the pinna, the external ear canal (vertical and horizontal), and the tympanic membrane (TM). The pinna collects and transmits sound waves toward the TM.4 It is composed of auricular cartilage covered by skin. The vertical canal begins at the tragus, antitragus, and anthelix cartilages of the pinna; dogs may have few hairs at the entrance. Within the skin of the canals, hair follicles are present and the associated sebaceous and ceruminous glands produce cerumen. These secretions trap debris, protecting the canal and tympanum, and keep the TM flexible and moist.1,4 The TM, which is semitransparent and concave, separates the external and the middle ear. The angle of the TM differs between dogs and cats: 30 to 45 in dogs and 90 in cats.1,4–6 It has 2 distinct areas: the pars flaccida and the pars tensa (FIGURE 1). The pink, triangular portion that lies dorsally is the pars flaccida,

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which supplies blood to the pars tensa. The pars tensa is a thin, translucent or opaque region that stretches across the canal and may appear striated. The manubrium of the malleus is embedded in 1 of the 3 layers of the pars tensa and points rostral.5,6 This knowledge is helpful when viewing video otoscopy images of the TM to identify which ear you are observing.

CLASSIFICATION OF OTITIS Otitis externa is classified into 4 categories, which helps in identifying the problem: predisposing, primary, secondary, and perpetuating factors.

Predisposing Factors The predisposing factors of otitis do not cause ear disease. They only make the animal more susceptible to it or a more severe disease. Predisposing factors may be conformational, obstructive, or iatrogenic; increased moisture in the ear canal is also a predisposing factor.

can lead to an increase in cerumen production and debris accumulation, which seems to be more common in cocker spaniels, springer spaniels, and Labrador retrievers.1,7 Increased moisture in the ear canal can result from swimming, bathing, or high humidity. Obstructive factors may inhibit epithelial migration (self-cleansing mechanism of the canal), resulting in a secondary Malassezia species or bacterial infection from cerumen accumulation.1,7 For example, polyps and tumors (FIGURE 2) can prevent drainage of exudate, which predisposes ears to secondary infections. Common ear tumors include ceruminous and sebaceous gland tumors, inflammatory polyps, squamous cell carcinomas, mast cell tumors, and histiocytomas.1,7 Iatrogenic factors include hair plucking and trauma from overaggressive cleaning with cotton swabs, a common predisposition in cats.3 Hair plucking is standard grooming practice for dogs with excessive hairs in the canal, but it can damage the epithelial lining. Hair plucking is contraindicated in the normal ear because it can cause inflammation and predispose the animal to infection. In some cases, it may be indicated to prevent and manage otitis.1,7

Conformational factors are attributed to floppy pinnae, such as those seen in bloodhounds, cocker spaniels, and basset hounds. This ear conformation can create a warm, moist environment (increased humidity) due to insufficient ventilation, resulting in the potential for overgrowth of the normal commensal flora. Cats do not appear to be affected by conformational differences of the pinnae, as seen with the Scottish fold.3 Excessive hair in the canal, as seen in poodles and schnauzers, can also decrease ventilation and form hair mats that retain debris and create obstructions.7 Shar-peis have stenotic canals that may be predisposed to higher humidity levels and secretions, leading to overgrowth of normal microbial inhabitants.1,7 An increase in glandular tissue

Primary factors (BOX 1) are ultimately the reason otitis begins. Adverse food reactions have been reported in up to 40% to 52% of dogs with nonseasonal pruritus.9 Numerous clinical signs of adverse food reaction may be present; on the other hand, otitis externa may be the only sign.2,9,10 It has been reported that 7% of cats had otitis associated with adverse food reaction.1

FIGURE 1. Normal canine canal showing pars flaccida, pars tensa, manubrium of the malleus, and minimal cerumen.

FIGURE 2. Ceruminous gland adenoma in the canal of a dog.

Primary Factors

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Atopy is another common cause of otitis. Patients usually exhibit more clinical signs than otitis; however, as with adverse food reactions, it may be the only sign.1,2,10,11 Unlike adverse food reaction, it may initially be seasonal. Parasites, such as Sarcoptes, Notoedres, and Cheyletiella species and harvest mites, can cause pruritus and inflammation on or near the pinnae, which can lead to head shaking and scratching and secondary otitis externa.12 Otodectes cynotis (ear mites) are seen in up to 50% of otitis cases in cats and in 5% to 10% of cases in dogs.1 Chronic cases of Otodectes infestation may become secondarily infected with bacteria or yeast. Demodex mites may cause ceruminous otitis externa in dogs and cats.10,11 Otobius megnini, the spinous ear tick, which is found mainly in the southwestern United States, can attach to the lining of the external ear canal and cause inflammation and otitis externa and can be quite painful. Other hard ticks and harvest

mites may affect both dogs and cats; however, they usually infest the pinnae or proximal canal.10,11 Autoimmune and immune-mediated diseases (BOX 1) are rarely primary causes of otitis. Usually, the animal has other skin lesions on the body in addition to the otitis. Keratinization disorders and endocrinopathies (BOX 1) may alter keratin and cerumen gland production in the external ear, resulting in a ceruminous and seborrheic form of otitis externa.1,11,14,15 Again, clinical signs other than otitis are usually present. Foreign bodies, such as plant awns (FIGURE 3), dirt, debris, dried medication, loose hair, and dead insects can all be primary causes of otitis and result in secondary infection.1,8,10,11,13 Foreign bodies in

BOX 1 Primary Factors of Otitis1,8

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Atopy

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Adverse food reactions

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Parasites

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Contact dermatitis

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Autoimmune or immune-mediated diseases1,10,11,13

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Pemphigus foliaceus

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Pemphigus erythematosus

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Discoid lupus erythematosus

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Systemic lupus erythematosus

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B ullous pemphigoid

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Vasculitis

●

J uvenile cellulitis

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Keratinization disorders1,8,11,13,15

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Sebaceous adenitis

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Seborrhea

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Facial dermatosis of Persian cats

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Zinc-responsive dermatoses

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Vitamin A–responsive dermatoses

●

Endocrine disease1 ,8,11,13,15

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Hypothyroidism (most likely)

●

Hyperadrenocorticism

●

Foreign bodies FIGURE 3. (A) Removal of a plant awn from a dog using video otoscopy and forceps. (B) Awn after removal.

OTITIS EXTERNA

FEATURES

the ear usually present as unilateral otitis; however, they can be bilateral.1,11 Hunting and working dogs may be predisposed to foreign bodies.10

Secondary Factors Secondary factors of otitis (BOX 2) do not, in themselves, cause otitis. Rather, they are a result of a diseased ear and contribute to the primary factor. Secondary factors must be treated along with the underlying (primary) cause.1,2

Perpetuating factors of otitis are changes in the anatomy and physiology caused by the primary and secondary factors. These changes may include a loss of epithelial migration, edema, proliferative changes, stenosis, ruptured TM, otitis media, and even calcification of the canal.1,10,13

PHYSICAL EXAMINATION AND HISTORY It is important to obtain a complete history while keeping the predisposing and primary factors of otitis externa in mind.1 Age at onset can help to identify the primary cause. Parasites or food allergies should be considered in patients with onset at age <1 year.8,16 Atopy is a consideration from approximately age 6 months to 6 years.2,17 In older animals, although atopy is still possible, neoplasia or endocrinopathies should be considered.14 Dog breeds such as the cocker spaniel, Brittany spaniel, golden retriever, miniature poodle, and West Highland white terrier (to name a few) and Persian and Himalayan cats may have a predisposition.1,8,11

BOX 2 Selected Secondary Factors of Otitis1,3,11

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Infection Bacterial Yeast ● Fungal (rare) ● ●

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Contact reactions to medications in an already diseased ear

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E xcessive ear cleaning

Shutterstock.com/rebeccaashworth

Perpetuating Factors

PLAY IT BY EAR “Floppy ear” dog breeds, such as bloodhounds, cocker spaniels, and basset hounds, have a predisposition to otitis externa. This ear conformation can create a warm, moist environment due to insufficient ventilation, resulting in the potential for overgrowth of the normal commensal flora.

Clinical Signs Signs of otitis externa may include aural pruritus and head shaking (most common), odor, discharge, aural hematoma, pain, and intermittent head tilt.1,11 The concave aspect of the pinnae and the canal may be erythematous, edematous, and malodorous; have excoriations and discharge; and be painful on palpation.1,11 The firmness of the canals should be evaluated by gentle palpation of the outside of the canals. Less pliable canals are associated with proliferative changes and calcification. Ear canals that are calcified can rarely be managed with therapy and are generally considered candidates for surgery.1

Otoscopic Examination Before the otoscopic examination begins, a skilled individual (such as a veterinary technician or veterinary assistant), rather than the owner, should restrain the pet. This ensures that the pet’s body and head remain as immobile as possible, which will optimize the examination and ultimately the comfort of the pet. During this examination, visualize the tympanum and note any other observations, such as any exudate, lesions, foreign bodies, or pathologic changes. Normal canals should be pale pink; the presence of hairs is normal, especially near the TM, and minimal cerumen may be seen.6,8 WINTER 2018

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If the ears are painful, an examination will not be easy. Chemical restraint or general anesthesia may be necessary, or treatment to reduce inflammation may be needed before the ears can be effectively evaluated. Treatment may be indicated for as little as 4 days to 1 month or more, depending on the severity.1,2,11 If the otitis is unilateral, start with the unaffected ear because it will be nonpainful and the animal will be less resistant. Spread of infectious agents is also less likely; however, always change cones between ears or use disposable cones. When the cone of the otoscope is inserted, the intertragic incisure is a good landmark to determine the insertion.5 Be gentle and go slowly down the lateral wall. At the junction of the vertical and horizontal canal is a large ridge of cartilage called the auricular projection. Avoiding this area with the cone is critical; touching this area with the cone will inflict pain, and the patient may quickly lose patience. Before you reach this projection, gently lift, pull out, and slightly lower the pinna. This will help straighten out the canal and enable you to advance the cone just past the projection.5,18

FUNDAMENTALS

An otitis treatment plan that does not target the primary cause will result in recurrent otitis.

DIAGNOSTICS Cytology Cytologic evaluation should be done for every new otitis diagnosis and at every recheck before the decision is made to stop therapy. It is fast, easy, relatively noninvasive, and inexpensive and provides important information for treating otitis effectively. Characteristics of exudates or odor are not acceptable replacements for cytologic evaluation.

OTITIS EXTERNA

To perform cytologic evaluation: ●●

●●

●● ●●

Collect the exudate with a cotton-tipped applicator. Sample the vertical and horizontal canal by gently swabbing the sides of the canal. Roll the swab onto the slide in a thin film. You may use 1 slide for both ears. With the frosted edge of the slide closest to you, roll the left ear down the left side in a single line and the right ear down the right side in a single line. It is common practice to lightly heat-fix the slide with a match or lighter because cerumen is lipid in nature, although this may be unnecessary.19 Stain with Diff-Quik, rinse, and air dry. iew the prepared slide with a 100× oil lens V with the condenser all the way up, the rheostat turned up, and the diaphragm open.

To make a slide to view Otodectes species, collect the exudate, roll the swabs in a few drops of mineral oil on a glass slide, and place a coverslip on top. View under 10× magnification, with the condenser in the down position, the diaphragm closed, and the rheostat dimmed. Malassezia pachydermatis is a normal resident of the canine ear and can be found in cats as well; Malassezia sympodialis can also be isolated in the feline ear canal.8 Because Malassezia species are ubiquitous flora of canine and feline ears, it may be difficult to determine when to treat. Numbers on cytologic examination provide a guideline, along with clinical signs, history, and previous response to treatment. Common cocci found during cytology include Staphylococcus, Streptococcus, and Enterococcus species (gram positive). Bacilli (rod-shaped bacteria) are typically Pseudomonas species, coliform bacteria, or Proteus species (gram negative). In most cases, performing a Gram stain is unnecessary.12 Normal commensal bacteria may be found, but abnormal increases and the presence of leukocytes, which are not seen in the normal ear, indicate a secondary bacterial infection.8,12 While looking at the cytology slide for bacteria, yeast, and leukocytes, you may occasionally discover Demodex mites. They will appear large because you are viewing the slide under 100× oil immersion. Melanin granules may also be observed and should not be mistaken for cocci and/or rod bacteria. These can be differentiated by focusing up and down until you note the color of the structure, which is yellow to brown rather than purple. Quantify your findings and record them in the medical record for comparison on recheck.

FEATURES

Culture Culture may be performed if cytology results reveal bacteria and white blood cells when severe otitis externa is present and systemic antibiotics are indicated. Culture may not be useful when topical medications alone are used because topical therapies lead to higher concentrations of medication in the ear canal than systemic therapies.1 Samples for culture are obtained with the same method as used for cytology, using a sterile culturette.

Video Otoscopy Video otoscopes have become more common in private practices and are found in almost all dermatology specialty practices and universities. A video otoscope is simply an otoscope with a port and a monitor, and it is used to flush, suction, obtain biopsy specimens from any masses, and perform myringotomies. The video otoscope allows the veterinarian to obtain a primary diagnosis, such as foreign objects and parasites; visualize such factors as excessive exudate, erythema, and stenosis; and assess the TM.

Imaging Imaging examinations, such as computed tomography and magnetic resonance imaging, are often performed before surgery or video otoscopy to look for neoplasia or otitis media. Any masses should be biopsied and the specimens submitted to a dermatopathologist for histopathology.12

Other Tools Other diagnostic tools include skin scrapings, parasite trials, allergy work-ups, and laboratory evaluation. A pinnalâ&#x20AC;&#x201C;pedal reflex may be elicited by rubbing the edges of the pinna; the reflex is observed if the dog attempts to scratch with its hind leg. Although this reflex suggests the presence of Sarcoptes mites, other dermatologic conditions may elicit a similar response.9,20

FUNDAMENTALS

Signs of otitis externa may include aural pruritus and head shaking (most common), odor, discharge, aural hematoma, pain, and intermittent head tilt.

TREATMENT Always collect samples for cytology and culture (if indicated) and try to visualize the TM before cleaning the ears and instilling topical medications that the veterinarian has prescribed. Demonstrate to clients how to properly clean and medicate the ears before they leave the clinic and review the recommended treatment plan to ensure they understand the instructions. Recheck examinations with cytology are necessary and are usually scheduled in 2 to 4 weeks, before the patient stops any medications. Patient response determines duration of treatment, and client compliance is essential.

SUMMARY The key to a successful outcome is to use the classification system for otitis, find the underlying

Recurrent Otitis Patients with recurrent chronic otitis externa (FIGURE 4) should undergo food trials and an atopy work-up to determine whether food and/or environmental allergies may be the primary cause. Laboratory evaluation, such as a thyroid panel and adrenocorticotropic hormone stimulation test, may be considered as well.

FIGURE 4. Chronic proliferative otitis.

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PEER REVIEWED CYTOLOGIC EVALUATION should be done for every new otitis diagnosis and at every recheck before the decision is made to stop therapy. To perform cytologic evaluation collect the exudate with a cotton-tipped applicator. Sample the vertical and horizontal canal by gently swabbing the sides of the canal.

Photo courtesy of Bradley Leeb, University of Illinois

(primary) cause, and treat accordingly. A treatment plan that does not target the primary cause will result in recurrent otitis. The inflammation will continue and alter the normal anatomy of the ear. TVN

10. Harvey RG, Paterson S. Aetiology and pathogenesis of otitis externa. In: Otitis Externa, An Essential Guide to Diagnosis and Treatment. Boca Raton, FL: CRC Press; 2014:45-73. 11. Hnilica KA. Otitis externa. In Small Animal Dermatology: A Color Atlas and Therapeutic Guide. St. Louis: Elsevier; 2011:395-409.

References 1. Diseases of eyelids, claws, anal sacs and ears. In: Miller WH, Griffin CE, Campbell KL, eds. Muller & Kirk’s Small Animal Dermatology. 7th ed. St. Louis: Elsevier; 2013:724-773. 2. Noxon JO. Otitis in the allergic dog. In: Noli C, Foster A, Rosenkrantz W, eds. Veterinary Allergy. West Sussex: Wiley Blackwell; 2014: 175-181.

12. Angus, JC. Cytology and histopathology of the ear in health and disease. In: Gotthelf LN, ed. Small Animal Ear Diseases, An Illustrated Guide. 2nd ed. St. Louis: Elsevier EBook; 2005:41-75. 13. Paterson S. Otitis externa. In: Manual of Skin Diseases of the Dog and Cat. 2nd ed. West Sussex: Blackwell; 2008:162-172.

3. Kennis RA. Feline otitis: diagnosis and treatment. Vet Clin North Am Small Anim Pract 2013;43(1):51-56.

14. Endocrine and metabolic diseases. In: Miller WH, Griffin CE, Campbell KL, eds. Muller & Kirk’s Small Animal Dermatology. 7th ed. St. Louis: Elsevier; 2013:501-553.

4. Kumar A, Roman-Auerhahn R. Anatomy of the canine and feline ear. In: Gotthelf LN, ed. Small Animal Ear Diseases, An Illustrated Guide. 2nd ed. St. Louis: Elsevier EBook; 2005: 1-21.

15. Gotthelf LN. Primary causes of ear disease. In: Gotthelf LN, ed. Small Animal Ear Diseases, An Illustrated Guide. 2nd ed. St. Louis: Elsevier EBook; 2005:111-125.

5. Njaa BL, Cole LK, Tabacca N. Practical otic anatomy and physiology of the dog and cat. Vet Clin North Am Small Anim Pract 2012;42(6):1109-1126.

16. Hnilica KA. Canine food hypersensitivity. In: Small Animal Dermatology: A Color Atlas and Therapeutic Guide. St. Louis: Elsevier; 2011:183-188.

6. Gotthelf LN. Examination of the external ear canal. In: Gotthelf LN, ed. Small Animal Ear Diseases, An Illustrated Guide. 2nd ed. St. Louis: Elsevier Ebook; 2005:23-39.

17. Hnilica KA. Hypersensitivity disorders. In: Small Animal Dermatology: A Color Atlas and Therapeutic Guide. St. Louis: Elsevier; 2011:175-226.

7. Gotthelf LN. Factors that predispose the ear to otitis externa. In: Gotthelf LN, ed. Small Animal Ear Diseases, An Illustrated Guide. 2nd ed. St. Louis: Elsevier EBook; 2005:141-171. 8. Harvey RG, Paterson S. Approach to the diagnosis of otitis externa. In: Otitis Externa, An Essential Guide to Diagnosis and Treatment. Boca Raton, FL: CRC Press; 2014:13-44.

9. Hypersensitivity disorders. In: Miller WH, Griffin CE, Campbell, KL, eds. Muller & Kirk’s Small Animal Dermatology. 7th ed. St. Louis: Elsevier; 2013:363-431

OTITIS EXTERNA

18. Griffin CE. Otitis techniques to improve practice. Clin Tech Small Animal Pract 2006;21(3):96-105. 19. Griffith JS, Scott DW, Erb HN. Malassezia otitis externa in the dog: the effect of heat fixing otic exudate for cytological analysis. J Vet Med 2007;54(8):393-448. 20. Parasitic skin disease. In: Miller WH, Griffin CE, Campbell KL, eds. Muller & Kirk’s Small Animal Dermatology. 7th ed. St. Louis: Elsevier; 2013:284-341.

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Caution is recommended when using chlorhexidine in the ear when the status of the tympanic membrane is unknown. TrizEDTA® is a patented composition of Tromethamine, USP and Disodium EDTA, USP. U.S. Patent 6,538,155 REFERENCES Koch, S.N. (2012). Canine and Feline Dermatology Drug Handbook. Ames: Wiley-Blackwell. Finnegan, S, Percival, SL. EDTA: An Antimicrobial and Antibioﬁlm Agent for Use in Wound Care. Advances in Wound Care 2015: Jul 1 4(7); 415-421.

1 2

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X-RAY VISION With correct equipment and practice, all technicians can safely and efficiently produce high-quality dental radiographs.

MEET THE AUTHOR

Liane K. Shaw, BS, RVT Purdue University Veterinary Teaching Hospital Lafayette, Indiana

Liane K. Shaw, BS, RVT, is the diagnostic imaging instructional technologist at Purdue University. She earned an associate’s degree and bachelor’s degree in applied science at the Veterinary Technology Program at Purdue University. She then worked at a private practice for 7 years and was a supervisor for the clinic before coming back to Purdue University to pursue her love for teaching. In 2011 she received an award for teaching excellence from Purdue University and Elanco Animal Health. She has spoken at conferences about dental radiography and digital radiography. In 2017 she coauthored 2 articles on radiology positioning published in Today’s Veterinary Technician.

FEATURES

Take a Bite Out of

Dental Radiology Positioning for Picture-Perfect Views MEET THE AUTHOR

Cynthia Voglewede, BS, RVT, AVTCP-Canine/Feline Purdue University Veterinary Teaching Hospital Lafayette, Indiana

Cynthia Voglewede, BS, RVT, AVTCP-Canine/Feline, has taught at the Purdue University Veterinary Teaching Hospital since 1996. She earned her bachelor of science degree in biology education from Ball State University and later graduated from the Purdue University Veterinary Technology program. She was a founding member and treasurer for the Academy of Veterinary Technicians in Clinical Practice, which was approved in 2010. She received the Outstanding Staff Award in June 2015.

ental radiographs can be frustrating, time consuming, and overwhelming. However, if radiography is not performed, 50% of tooth anatomy will be left undiagnosed.1 Most veterinary dentists believe full-mouth intraoral dental radiographs should be routine with every cleaning, allowing the unexposed abnormality to be revealed.1 If dental radiographs are not taken, dental disease cannot be adequately diagnosed, monitored, and treated. Technicians must produce good-quality radiographs in order for a correct diagnosis to be given. To ensure a proper diagnosis, dental radiographs should include the entire crown and roots of the tooth or teeth of interest.2 This article will help veterinary team members refresh themselves about common dental radiography procedures. SAFETY Safety is always important when it comes to the production of x-rays. Radiation exposure in dental radiography is comparatively low, but one should always practice ALARA (as low as reasonably achievable).3 All personnel must be aware of their own radiation exposure and take all precautions necessary to reduce exposure. Staff should leave the room whenever possible. Radiation exposure can be minimized by using three simple methods: distance, shielding, and exposure time.3 In dental radiography, distance is the most helpful method. The inverse square law states that the x-ray beam intensity decreases to one fourth if the distance from the primary beam is doubled.5

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Staff should remain at a maximum distance from the x-ray beam to reduce exposure to scatter. If staff cannot be at least 6 feet from the primary beam, they should try to use approved 0.5-mm lead shielding.3 This shielding can consist of lead aprons that include a thyroid shield or a full-length lead shield. Minimize the length of exposure by using the shortest exposure time required to get a diagnostic image, and strive to achieve the best diagnostic image in the fewest exposures possible. Exposure will be minimized if all personnel practice ALARA. No radiation exposure is risk-free.3

EQUIPMENT Dental x-ray units (FIGURE 1) are most commonly purchased and used to produce dental radiographs. These units are portable or wall mounted. They have flexible arms that allow for optimal positioning and keep exposure to a minimum. These units often have fixed or preset peak kilovoltage (kVp) and milliamperageseconds (mAs) and a variable exposure time. The time is adjusted to accommodate the thickness of the area of interest being imaged. These units often have predetermined angles marked beside the tube head to

help with dental radiography positioning. This angle meter is typically set up to with the angle perpendicular to the ground at zero degrees. However, some models have the angle meter set to 90 degrees when perpendicular to the ground or floor. In this article, we assume that all angle meters on dental units are set to be 0 degrees when perpendicular to the ground. Veterinary medical x-ray units can also be used to produce dental radiographs. These units can be used only if the tube head and the focal film distance are adjustable (FIGURE 2). Focal film distance (FFD) or source image distance (SID) is the distance from the tube head to the recording surface, film, or receptor. Try to maintain a short FFD/SID to obtain a sharp image.2 The tube head must be maneuverable into multiple different planes to obtain diagnostic views. The drawback to this unit is that it may already be in use and is not portable; thus, using it to produce dental radiographs is inefficient. Transferring an anesthetized patient to another room can often be hectic. If a general radiology unit is used, a technique involving 60 to 85 kVp, about 10 mA, and an FFD/SID of 12 to 16 inches can be used.3

RECORDING THE IMAGE There are several ways to record dental images. Dental film is a nonscreen film that is composed of many layers. Dental film comes in many sizes, ranging from small (size 0) to large (size 4). Sizes 2 and 4 are commonly used in veterinary dentistry radiography. When whole quadrants or large patients are imaged, size 4 film should be used. Size 2 film is used for imaging individual teeth. No matter what size film is used, it is important to ensure that the size of film is sufficient for

FIGURE 1. An example of a wall mounted dental x-ray unit.

DENTAL RADIOLOGY

FIGURE 2. Full body machine showing the different axis.

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obtaining an image of the entire tooth, root to crown. Remember, almost half of the anatomy of the tooth is hidden under the gum line.5 Dental films can be processed by using a light proof chairside or tableside processor, or in an automatic processor. Films must be contained in a special processing mount before being placed in the automatic processor. No matter which method of processing is used, the technician must pay close attention to the final product. Improper processing can lead to many avoidable repeated radiographs. Computed (CR) and direct (DR) image recording sensors are also available. Digital dental sensors allow technicians to be more efficient and proficient at imaging while greatly reducing exposure.5 The sensors also allow for easier patient identification and interpretation. The indirect sensor (CR) uses a reusable photostimulable phosphor plate that is exposed to x-rays; the image is then converted to a digital image by a computer. This phosphor plate comes in the same sizes as traditional film. The plates degrade over time, and permanent artifacts can occur. DR gives an immediate digital image by converting x-rays to light energy and then into an electronic signal. This signal is sent directly to a computer screen for viewing in about 20 seconds. One drawback to DR is that the most affordable sensor is available only in a size 2; as a result, multiple views must be obtained for large teeth. These views can be rostral and caudal views or root and crown views. In switching to digital imaging, usage, price, radiation safety, and film storage should be considered (FIGURE 3).

VIEWS A full mouth series consists of rostral maxillary and mandibular views, right and left maxillary views, and right and left mandibular views. The rostral maxillary and mandibular views should include the canine teeth. Maxillary canine teeth are imaged in separate oblique views to prevent superimposition of the first and second premolars upon the canine tooth roots. Additional images or views may be needed for specific species or dental abnormalities.

POSITIONING Parallel technique and bisecting angles are the two most common positioning techniques used in veterinary dental radiology. Parallel technique is used for imaging the caudal mandibular premolars and molars, and the bisecting angle technique is used for all maxillary teeth and the rostral mandibular teeth. The sensor/film must be correctly placed and stable. Digital sensors are thicker and less pliable than film, and some creativity is often required to hold the sensor in a specific location. CR sensors are flimsy and very sensitive to pressure; thus, positioning devices are needed to ensure that the sensor is not damaged. Sensor/film positioning devices should be used to ensure proper placement and safety of the sensor. Examples include the following: ●●

●●

●● ●●

FIGURE 3. Different sensors: Top row film sizes 4 and 2 Bottom row: DR sensor sizes 0 and 2.

DENTAL RADIOLOGY

Small rubber-coated dental wedges or mouth props Children’s playdough or clay placed inside a plastic bag Small plastic-coated foam hair rollers Disposable gauze sponges or paper towel sheets (FIGURE 4)

FIGURE 4. Positioning aids.

FEATURES

The four Ps of dental radiography are used to ensure a high success rate: position of skull, placement of sensor/ film, point of tube head, and production of radiograph.

angle, or perpendicular to the film. This technique is simple but has limited use because of anatomic restrictions in the rest of the mouth (FIGURE 5).

Parallel Technique

Bisecting Angle Technique

One method of positioning a patient for parallel technique involves placing the patient in lateral recumbency with the side of interest facing up. The film/sensor will be placed intraorally on the lingual surface of the teeth. Film/sensor positioning aids should be used to keep the film/sensor in place. The film/sensor must be as parallel to the tooth of interest as possible. The sensor/film must also be placed so that the entire tooth of interest is contained within it, crown to root. The tube head or x-ray machine is then set at a 90-degree

To avoid image distortions, all other views can be acquired by using the bisecting angle technique. This technique is challenging to learn but can be easily mastered with practice. An analogy to help better understand or visualize the bisecting angle is to imagine a person standing on a bright sunny day. If the sun is high, the resulting shadow will be short. If the sun is setting, the shadow will be long. When the sun is at a moderate angle in the sky, the resulting shadow’s length will approximate the person’s height. This would be considered the bisecting angle.

FIGURE 5. Parallel technique.

FIGURE 7. Bisecting angle: Point the beam, perpendicular to bisecting angle.

FIGURE 6. Bisecting angle technique: Blue stick plane of the film going caudally, Yellow stick: Angle of tooth root to crown, Red stick: Bisecting angle.

FIGURE 8. Bisecting angle: without changing angle of the tube head point and center the tube head over the area of interest.

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In the technique discussed here, the patient is placed in sternal recumbency to obtain views of the maxillary teeth and in dorsal recumbency to obtain views of the mandibular teeth. The sensor/film should be placed intraorally beneath the area of interest, as if the patient is biting on it. Imagine a line parallel to the plane of the sensor/film, and another line parallel to the plane of the tooth from crown to root. These two lines will intersect, forming an angle. Divide (bisect) this angle in half and aim the tube head or primary beam perpendicular to this imaginary line,3 centering over the tooth of interest (FIGURES 6â&#x20AC;&#x201C;8). If the image is elongated, the x-ray beam has been aimed too parallel to the sensor/film (FIGURES 9 AND 10).

However, if the image is shortened, the beam has been aimed too perpendicular to the sensor/ film (FIGURES 11 AND 12). A radiograph is useful only if the information on it is accurate.

Imaging Specific Teeth To image the rostral mandibular incisors and canine teeth, the patient is placed in dorsal recumbency. Ensure that the palate is parallel to the table. Place the sensor/ film between the teeth and tongue in landscape or portrait orientation, depending on the size of the patient. The use of a positioning aid is always recommended. If the tongue becomes an obstacle, the senor/film may be placed below the tongue. This soft tissue opacity will not interfere with radiographic interpretation. Point the tube head at the bisecting angle line, approximately 15 to 25 degrees, and center the beam over the tooth of interest. If the root apices are not captured, place the sensor/film behind the canine teeth and move the tube head caudally without changing the bisecting angle to capture root tips. Because of the mandibular symphysis, the bisecting angle technique is used to produce radiographs of the

FIGURE 9. Elongation: The tube head is too parallel to film/ sensor.

FIGURE 11. Foreshortening: The tube head is too perpendicular to the film/sensor.

FIGURE 10. Elongation Radiograph: The tube head is too parallel to film/sensor resulting in elongated teeth.

DENTAL RADIOLOGY

FIGURE 12. Foreshortening Radiograph: The tube head is too perpendicular to the film/sensor resulting in short stubby teeth.

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rostral mandibular premolars. The patient is placed in dorsal recumbency with the skull parallel to the table. The sensor or film will be placed parallel to the table between the maxillary and mandibular premolars. The tooth of interest should be centered on the sensor. Aim the tube head perpendicular to the bisecting angle line and center it over the premolars of interest. The angle will be approximately 30 to 45 degrees.

FUNDAMENTALS

The four Ps of dental radiography are used to ensure a high success rate: position of skull, placement of sensor/ film, point of tube head, and production of radiograph.

To obtain radiographs of the caudal right or left mandibular teeth, the patient is placed in lateral recumbency with the side to be imaged facing up. To ensure that the skull is parallel to the table, place padding under the c-spine and beneath the tip of the nose. The sensor or film should be placed intraorally parallel to the mandible and tooth of interest on the lingual side. Depending on the size of the area of interest, one can place the film in portrait or landscape orientation. When the caudal molars are being radiographed, the sensor/ film is sometimes placed too deep into the soft tissue. Place the sensor/film even with the crowns. Aim the tube head perpendicular to the tooth of interest and sensor/ film and produce the radiograph. Try to include the entire tooth of interest in one radiograph, if possible. To image the rostral maxillary incisors and canine teeth, place the patient in sternal recumbency. Padding is typically needed at the base of the neck to ensure that the skull is parallel to the table. Place the sensor/ film in portrait or landscape orientation between the maxillary and mandibular incisors. A positioning aid is recommended to help hold the sensor/film in place. Determine the bisecting angle line and aim the tube head perpendicular to it, centering over the

DENTAL RADIOLOGY

maxillary incisors. The tube head is typically at a 20to 30-degree angle for this image. If the radiograph produced does not include all of the incisor and canine roots, move the sensor/film and tube head behind the canine teeth crowns and produce a second radiograph. To achieve oblique radiographs of the maxillary canine teeth, place the patient in sternal recumbency. Position the skull with padding so that it is parallel to the floor. The tip of the crown of the canine tooth should be placed at the corner of the sensor/film. Angle the film intraorally and caudally toward the opposite arcade to capture the root apex. Use a positioning aid as needed to keep the sensor/film in place. Aim the tube head perpendicular to the bisecting angle, centering over the canine tooth from a rostrolateral approach. The tube head should be at a 45-degree angle to the sensor/film. Use a film/sensor large enough to capture images of both the crown and the root. Alternatively, separate cranial and caudal views can be obtained. To obtain a caudal view, push the sensor caudal behind the crown of the canine tooth and recenter the tube head over the root. For imaging of the right or left maxillary premolars, the patient should be in sternal recumbency. The sensor/film should be placed intraorally beneath the maxillary teeth of interest. It will appear that the patient is biting on the sensor/film. Positioning devices are needed to ensure that the sensor/film is parallel to the table. Determine the bisecting angle and aim the tube head perpendicular to it, centering over the tooth or teeth of interest from a lateral direction. In dogs, the tube head should be at a 30- to 45-degree angle. Cats require a steeper angle (20 to 30 degrees) to minimize superimposition of the zygomatic arch. Three rooted teeth often require a second view in order to visualize both mesial roots. This is accomplished by rotating the tube head rostrally while maintaining the bisecting angle.

Glossary ALARA As low as reasonably achievable CR Computed image recording sensor DR Direct image recording sensor FFD Focal film distance kVp Peak kilovoltage mA Milliamperage-second SID Source image distance

FEATURES

CONCLUSION With correct equipment and practice, all technicians can safely and efficiently produce high-quality dental radiographs. Our goal as technicians is to allow the patient to receive an accurate diagnosis and appropriate treatment. Improper positioning or processing can lead to misdiagnosis. Handson labs or practice is an excellent investment and will greatly improve the learning curve. After the positioning techniques described here are mastered, progressing to obtain all dental radiographs in lateral recumbency may increase patient safety and decrease anesthesia time. A radiograph is only as useful as the information it depicts. For a sample positioning chart, visit todaysveterinarynurse.com/ clinic-resources to download a PDF of the chart. And last, personal safety should never be jeopardized to achieve a diagnostic radiograph.5 TVN References 1. Berg M. Diagnostic Dental Radiographs: a concise how to. DVM360 January 18, 2017. http://veterinaryteam.dvm360.com/diagnostic-dentalradiographs-concise-how 2. Holmstrom S. Veterinary Dentistry for the Technician and Office Staff. Philadelphia: Saunders; 2000:223-245. 3. Han C, Hurd C. Practical Diagnostic Imaging for the Veterinary Technician, 3rd ed. St. Louis: Elsevier Mosby; 2005:124-128. 4. Holmstrom St. Veterinary Dentistry: A Team Approach. St. Louis: Elsevier; 2013:241-287.

Courtesy of Green Paws vet clinic.

5. Brown M, Brown LC. Lavin’s Radiography for Veterinary Technicians, 6th ed. St. Louis: Elsevier; 2018:27-40, 394-446.

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BREED PREDISPOSITION Discospondylitis is most commonly seen in young to middle-aged medium- to large-breed dogs. Predisposed breeds include Great Danes, boxers, Rottweilers, English bull dogs, German shepherd dogs, Doberman pinschers, and Rhodesian ridgebacks. Courtesy of shutterstock.com/Best Dog Photo

TOXICOLOGY TALK

FEATURES

INFECTION CONTROL

Discospondylitis An Overview MEET THE AUTHOR

Heather Anderson, RVT, VTS (Neurology) The Ohio State University Veterinary Medical Center Columbus, Ohio

Heather Anderson works at The Ohio State University Veterinary Medical Center as a neurology/neurosurgery technician. She graduated with an associateâ&#x20AC;&#x2122;s degree in Veterinary Technology from Stautzenberger College in Ohio in 2003 and became a credentialed Veterinary Technician Specialist in 2016. She is a member of the Academy of Internal Medicine Veterinary Technicians and the National Association of Veterinary Technicians in America and enjoys teaching neurology to her 4th-year veterinary students.

iscospondylitis is an infection of the vertebral endplates and associated intervertebral disk. The infection typically starts in the vertebral end plate, then spreads to the adjacent intervertebral disc. The blood supply within the vertebral endplates consists of capillary beds with reduced blood flow velocity. Pores in the end plate that normally allow for distribution of nutrients also provide a route for organisms to enter the intervertebral disc. The minimal vascular supply of the intervertebral disc further enables infection within the disk.1 PATHOPHYSIOLOGY Infectious organisms can gain access to the disc space in many ways. Hematogenous spread of bacteria or fungi from the urogenital tract, oral cavity, heart valves, and skin is believed to be the most common method. Foreign-body migration, such as a plant awn, may introduce bacteria as migration occurs throughout tissues. Less commonly, discospondylitis occurs as an iatrogenic infection following spinal surgery or paravertebral injections.2 In cats, abscesses from bite wounds can cause discospondylitis by direct inoculation of bacterial organisms.1

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The most common causes of discospondylitis are coagulase-positive Staphylococcus pseudintermedius or Staphylococcus aureus. Less commonly, Streptococcus species, Escherichia coli, and fungal organisms (such as Aspergillus species) can be causes.3 Brucella canis can also cause discospondylitis and is an important infectious agent to consider in all suspected cases because of its zoonotic potential. B canis is transmitted by direct exposure to bodily fluids or transplacental transmission from mother to puppy. Precautions, such as routine hand washing, minimization of exposure to urine, and the wearing of gloves, should be taken until Brucella has been ruled out as a cause.4

SIGNALMENT/PRESENTATION Discospondylitis is most commonly seen in young to middle-aged medium- to large-breed dogs. Less commonly, it has been reported in small-breed dogs and cats. Predisposed breeds include Great Danes, boxers, Rottweilers, English bull dogs, German shepherd dogs, Doberman pinschers, and Rhodesian ridgebacks.2,5 Most dogs will display progressive clinical signs over several weeks, but vertebral pathologic fractures can cause acute deterioration.2 Clinical signs may be nonspecific and include systemic illness, such as depression, anorexia, pyrexia, and lethargy. Paraspinal hyperesthesia is the most common finding on neurologic examination. Gait abnormalities, such as ataxia, paresis, or paralysis, may be present if secondary spinal cord or nerve root compression occurs.2 When neurologic signs are present, they correlate to the location of the discospondylitis lesion; cervical vertebral column lesions may cause tetraparesis and neck pain; thoracolumbar lesions may cause pelvic limb paresis, proprioceptive ataxia,

FIGURE 1. Radiograph of the lumbar spine showing vertebral body endplates that are irregular with permeative lysis centered at the disc spaces (arrows). ÂŠThe Ohio State University

DISCOSPONDYLITIS: AN OVERVIEW

and back pain; and lumbosacral lesions may cause a stiff, stilted pelvic limb gait.1,2 Discospondylitis can affect any area of the vertebral column, but the most commonly affected sites are L7 to S1, caudal cervical, mid-thoracic, and the thoracolumbar spine. Multifocal lesions occur in 30% to 40% of cases.5

DIAGNOSTIC IMAGING Definitive diagnosis of discospondylitis is based on characteristic findings on spinal radiography in a patient with supportive clinical features. Typical radiographic findings include collapse of the affected disc space, lysis of the adjacent vertebral endplates, and bony proliferation of adjacent vertebral bodies (FIGURES 1 AND 2). Because multiple lesions are common, radiography of the entire spine should be performed to properly assess the extent and severity of disease.2 The patient should be sedated for spinal radiography to ensure proper positioning and an accurate assessment of the area of interest. It is important that the veterinary technician use caution when transporting and positioning a sedated patient with potential spinal lesions. Care should be taken to avoid patient manipulation and to prevent further injury. The main limitation of standard radiography is that radiographic changes may lag behind the onset of clinical signs in the first 2 to 4 weeks of infection. Patients with suspected discospondylitis and normal radiographs may still have the disease; radiography should be repeated every 1 to 2 weeks or more advanced imaging should be considered.2,6 Magnetic resonance imaging (MRI) and computed tomography (CT) have an increased sensitivity for

FIGURE 2. Radiograph of the lumbar spine showing lysis of the vertebral body and caudal endplate of L7 and the cranial endplate of S1 (arrow). ÂŠThe Ohio State University

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CT is useful to aid in identifying subtle endplate erosion, vertebral fractures, and vertebral subluxations and can aid in obtaining fine-needle aspirates.3,5 FUNDAMENTALS

Brucella canis can also cause discospondylitis and is an important infectious agent to consider in all suspected cases because of its zoonotic potential.

the diagnosis of discospondylitis and can be useful in revealing early lesions. MRI is superior for evaluating soft tissue structures, and its advantages over standard radiography include its visualization of the spinal cord and nerve roots, its high contrast resolution, and the ability to use contrast agents. The use of MRI in a patient with discospondylitis may reveal T2weighted increased signal intensity and T1-weighted decreased signal intensity in the intervertebral disc, vertebral end plates, and vertebral bodies (FIGURES 3 AND 4). Contrast enhancement is often observed in the endplates of the affected vertebrae, and inflammation in the surrounding muscles may also be highlighted.2,6 Compressive lesions that can potentially be surgically corrected, such as disc protrusion/ extrusion, vertebral subluxations, fractures, and concurrent epidural abscess, can be easily identified.

FIGURE 3. Sagittal T1-weighted MRI image of the lumbar spine with hypointensity and lysis of the vertebral endplates of T13-L1 and L1-L2 (arrows). ÂŠThe Ohio State University

DISCOSPONDYLITIS: AN OVERVIEW

HEMATOLOGIC EVALUATION AND MICROBIOLOGY Veterinary technicians play a vital role in the collection of laboratory tests and interpretation of the results. Blood values are often unremarkable, but leukocytosis characterized by neutrophilia and monocytosis can occasionally be seen on complete blood count. Leukocytosis is more common in dogs with associated endocarditis.1 Mild hypoalbuminemia and mild to moderate hyperglobulinemia are the most common abnormalities noted on the serum biochemistry panel.5 Ideally, treatment for discospondylitis is guided by culture and antibiotic sensitivity. A urine sample should be collected aseptically via cystocentesis and urinalysis, and culture/susceptibility may reveal a urinary tract infection as a possible source of infection. Blood cultures should be collected by using meticulous sterile technique (BOX 1). Blood cultures in dogs yield positive results in about 45% to 75% of cases, and urine cultures are positive in about 25% to 50% of cases.1 Serologic testing for Brucella antibody and Aspergillus antigen may be performed.5 Cerebral spinal fluid analysis is often normal, but increased protein concentration (albuminocytologic dissociation) or a neutrophilic pleocytosis is occasionally observed.1 When urine, blood cultures, and serology have not identified a cause, CT or fluoroscopy-guided fineneedle aspiration of the infected disc space may be performed under general anesthesia, or a surgical biopsy specimen from the lesion can be obtained

FIGURE 4. Sagittal T1-weighted MRI image of the lumbar spine with hypointensity of the caudal endplate of L7 and the cranial endplate of S1 (arrow). ÂŠThe Ohio State University

FEATURES

Case Report

enry was a 1.5-year-old male castrated great Pyrenees. He was presented to the Ohio State University Veterinary Medical Center for a progressive history of pain and difficulty rising. The owners reported that for the past 3 months, Henry would cry out when touched near his hind end and was no longer willing to climb stairs. Henry was taken to his general practitioner, who obtained radiographs of his pelvis and lumbar spine. The radiographs were found to be unremarkable. Henry was prescribed tramadol, 2.4 mg/kg (100 mg) PO q8-12h as needed for pain; deracoxib, 0.89 mg/kg (37.5 mg) PO q12h for pain; and gabapentin, 2.4 mg/kg (100 mg) PO q8-12h for pain. His owners noticed a slight improvement, but he remained painful most days. Upon arrival, Henry weighed 42 kg. Vital signs were temperature of 100.2°F, pulse of 120 beats/min, and respirations of 20 breaths/min. No murmurs or arrhythmias were auscultated; pulse quality was good and without pulse deficits. Thoracic auscultation revealed normal lung sounds. Mental status was appropriate. On gait analysis, Henry displayed difficulty rising from a lying position and had ambulatory paraparesis with no ataxia. His postural reactions were normal in the thoracic limbs and minimally decreased in the pelvic limbs. Henry exhibited pain upon spinal palpation of the lumbar and lumbosacral regions and pain with dorsal pressure on rectal exam. All other aspects of the neurologic and general physical exam were normal. Initial diagnostic testing included a complete blood count, serum biochemical profile, and spinal radiography. The complete blood count and serum biochemical profile were within normal limits. Radiography of the thoracic and lumbar spine revealed vertebral body endplates that were irregular, with permeative lysis centered at the disc space of T10 to T11, T13 to L1, L1 to L2, and the lumbosacral junction. Enlarged sublumbar lymph nodes were also noted. On the basis of these findings, discospondylitis was the primary differential diagnosis; MRI was recommended and scheduled for the following day. This was to determine the extent of the damage and to help direct further treatment of Henry’s condition. The following day, Henry was placed under general anesthesia and was positioned in dorsal recumbency in the MRI machine. T2-weighted, T1-weighted, short tau inversion recovery, and gradient echo images were obtained in 3 planes (sagittal, transverse, and dorsal). After administration of the contrast agent gadodiamide (0.2 mL/kg) 8.4 mL IV, additional T1-weighted images were acquired in the same 3 planes. Henry’s MRI revealed multiple vertebral endplates that were irregularly shaped and marginated with T2-weighted and T1-weighted hypointensity relative to the medullary cavity. The irregularities were centered at the disc space of T10 to T11, T13 to L1, L1 to L2, and the lumbosacral junction. Secondary compression of the lumbosacral spinal segments and associated nerve roots were also noted. On the basis of Henry’s signalment, history, and radiographic findings, his MRI results were most

consistent with multifocal discospondylitis and rightsided compression of the cauda equina secondary to extruded disc material, a cyst, or an abscess. After the MRI, cystocentesis for urine culture was attempted but a sample could not be collected. Blood was drawn for serologic testing for Brucella antibody. Three individual blood samples were also drawn aseptically from the jugular and both the right and left lateral saphenous veins at 30-minute intervals for blood cultures. Because animals may be intermittently or continuously bacteremic, obtaining multiple, separate samples is recommended to increase the likelihood of identifying the pathogen.7 While the blood results were awaited, Henry was continued on the tramadol, deracoxib, and gabapentin for pain relief, and cephalexin 24 mg/kg (500 mg) PO q12h was initiated. The blood samples sent to Cornell University showed a positive result for agglutination and negative result for agar gel immunodiffusion II. These results were inconclusive, and it was recommended that the test be repeated in 4 to 6 weeks. Within several days, all 3 blood cultures grew Brucella species, confirming that Henry was Brucella positive with secondary discospondylitis. At this point, Henry was now back in the care of his general practitioner. Brucella infection is a reportable zoonotic disease, and the following treatment protocol was made by the State Public Health Veterinarian. The cephalexin was to be discontinued, and Henry was to be started on doxycycline, 12.5 mg/kg (525 mg) PO q12h, and amikacin sulfate, 10 mg/kg (420 mg) SC q24h. The doxycycline was to be continued until 2 negative test results were obtained, while the amikacin was to be given for 1 week, followed by a rest period for 2 weeks, then repeated again on week 4. Because of the renal toxicity effects of aminoglycosides, it was recommended that Henry be monitored closely through biochemical profiles and urinalysis to confirm the use and continuation of amikacin; testing was to be done before week 1 and week 4 of drug therapy to confirm a negative result, based on the provided protocol. If a positive result remained, then the aminoglycoside protocol was to be repeated, along with continuation of doxycycline. Because of Brucella’s zoonotic potential, hospital employees who were exposed to Henry were notified. The university’s employee health service was notified, and each employee was briefed about the disease, symptoms, and Centers for Disease Control and Prevention protocol. Thankfully, no employees contracted the disease. Unfortunately, Henry was lost to follow-up in the months after his Brucella diagnosis, and his outcome is unknown. Henry’s case provides an excellent example of why it is important to consider B canis as an infectious agent in all suspected discospondylitis cases. It also emphasizes the importance of always using precautions, such as routine hand washing, minimization of exposure to urine, and wearing gloves while handling the patient, until Brucella has been ruled out as a cause.

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common pathogen, Staphylococcus species, should be initiated. Common antibiotics include cephalexin or amoxicillin (TABLE 1). In patients with severe neurologic compromise or signs of sepsis, IV antibiotics, such as cefazolin, should be considered for the first 5 to 7 days.3 If fungal disease is confirmed, discospondylitis should be treated with antifungal drugs, such as fluconazole or itraconazole. Dogs with fungal discospondylitis may require lifelong treatment with antifungal drugs.3 In cases of Brucella-positive dogs, combination therapy consisting of doxycycline and an aminoglycoside is indicated.5 Corticosteroids are generally contraindicated because of possible impairment of the immune system.3

BOX 1 Procedure for Obtaining Blood Cultures ●

Shave venipuncture sites to be used.

●

Clean skin by using surgical scrubbing procedures; allow to dry.

●

Clean stopper on top of culture tubes or bottles with 70% alcohol; allow to dry.

●

Perform venipuncture by using sterile gloves to palpate vein; collect blood by using a sterile syringe and needle or a closed-vacuum bottle system.

●

Inoculate blood culture bottle without changing needles.

●

I deally, obtain a blood sample of 5 to 10 mL from each site.

●

Cultures are spaced according to severity of illness, but most require 3 sets from 3 separate sites, spaced at intervals of 30 minutes to 1 hour.

Pain management is also an important part of the treatment of discospondylitis. Analgesics, such as nonsteroidal anti-inflammatory drugs, fentanyl patches, tramadol, gabapentin, or amantadine, may be indicated.3 Veterinary technicians play an important role in the assessment and management of pain. While in the hospital, patients should receive regular pain assessments. When the patient is being treated at home, the veterinary technician can keep in close contact with the owner to ensure patient comfort.

Data adapted from Sykes.7

Physical rehabilitation can also be used to help relieve pain and maintain full range of joint motion, limit loss of muscle mass, and prevent contractures and deterioration of joints during recovery from neurologic injury. This is achieved through controlled therapy techniques, such as passive range of motion, massage, thermotherapy, and neuromuscular electrical stimulation.

for culture. Unfortunately, the originating site of infection cannot always be identified. In these cases, empirical therapy is chosen according to the most commonly isolated infectious organisms.

TREATMENT The treatment of discospondylitis consists of antibiotics, pain medications, and cage rest. Longterm antimicrobial drug therapy must be instituted, ideally for a minimum of 6 to 8 weeks. In some cases, treatment may need to be extended by many months. While culture results are awaited, treatment for the most

Strict confinement is essential to avoid worsening discomfort in severely affected patients. Restrictions should include cage rest, restriction of exercise, and leash walking only for urination and defecation. Activity restriction may also prevent vertebral subluxations and herniation of

TABLE 1 Treatment Options According to Infectious Agents INFECTIOUS AGENT*

ANTIBIOTIC

DOSING

Staphylococcus intermedius2

Cephalexin Cefazolin

20-30 mg/kg PO q8h 20 mg/kg IV q6h

Streptococcus species2

Amoxicillin

20 mg/kg PO q12h

Enrofloxacin

5-11 mg/kg PO q12h

Doxycycline Gentamicin sulfate

12-15 mg/kg PO q12h 9-14 mg/kg IV, IM, SC q24h

Fluconazole Itraconazole

2.5-5 mg/kg PO q24h 5 mg/kg PO q24h

Escherichia coli2 Brucella canis4 Aspergillus species 4 *Superscript numbers are reference citations.

DISCOSPONDYLITIS: AN OVERVIEW

FEATURES

disc material. Although surgical decompression is rarely needed, destruction of the vertebrae can cause vertebral instability with secondary compression; in this case, decompressive surgery and stabilization may be indicated.2 Clinical improvement of signs associated with systemic illness and pain is expected in the first week of antibiotic therapy.3 It is important that patients return for followup neurologic exams and radiography every 1 to 2 months to monitor for disease progression and to help direct therapy. Progress is characterized by resolution of sclerosis of the bone, lysis of the bone, and vertebral fusion. Laboratory tests may also be repeated depending on the original source of the infection. Antibiotics should be continued until bone lysis resolves completely.5

Prognosis for patients with bacterial discospondylitis, especially those with minor neurologic deficits, is generally favorable. The prognosis is more guarded in patients with B canis infections, resistant bacterial infections, and severe neurologic deficits. Fungal discospondylitis is associated with poor prognosis; chronic recurrence and progression are likely.3

THE BIG

Veterinary technicians play a key role in the diagnosis, treatment, and management of discospondylitis. With the initiation of proper therapy, most patients carry a favorable outcome and the case can be a successful and rewarding one. Until zoonotic diseases, such as Brucella infection, have been ruled out as a cause of discospondylitis, the entire veterinary staff should use protective measures, such as routine hand washing, wearing of exam gloves, and minimizing exposure to urine and other body fluids. TVN References 1. Lorenz MD, Coates JR, Kent M. Pelvic limb paresis, paralysis, or ataxia. In: Handbook of Veterinary Neurology. 5th ed. St. Louis, MO: Elsevier Saunders; 2011:124-126. 2. Dewey CW, da Costa RC. Disorders of the cauda equina. In: Practical Guide to Canine and Feline Neurology. 3rd ed. Ames, IA: Wiley Blackwell; 2016:415-418.

PROGNOSIS

CONCLUSION

3. Platt SR, Olby NJ. BSAVA Manual of Canine and Feline Neurology. 4th ed. Gloucester, UK: British Small Animal Veterinary Association; 2013:266-269. 4. Sykes J. Canine brucellosis. In: Canine and Feline Infectious Diseases. St. Louis, MO: Elsevier; 2014:514-519. 5. Sykes J. Osteomyelitis, discospondylitis, and infectious arthritis. In: Canine and Feline Infectious Diseases. St. Louis, MO: Elsevier; 2014:820-825. 6. Carrera I, Sullivan M, McConnell F, Goncalves R. Magnetic resonance imaging features of discospondylitis in dogs. Vet Radiol Ultrasound 2010;52(2):125-131. 7. Sykes J. Laboratory diagnosis of canine and feline infectious diseases. In: Canine and Feline Infectious Diseases. St. Louis, MO: Elsevier; 2014:19-22.

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STANDING STILL Pythiosis insidiosum feeds on plant material and was originally believed to live in ponds that were not spring fed. More recently, it has been discovered that the organism can be found in standing and stagnant water and in the moist soil left after the water dries up. Photo courtesy of shutterstock.com/ Karen Givens

TOXICOLOGY TALK

FEATURES

EQUINE MEDICINE

Equine Pythiosis An Overview MEET THE AUTHOR

Sharon Klingler, RVT, VTS (Anesthesia and Analgesia, EVN) Premier Equine Veterinary Services Whitesboro, Texas Sharon Klingler RVT, VTS (Anesthesia, EVN) has been a veterinary technician for almost 40 years. She worked in private practice for almost 20 years where she worked in both an emergency and a general practice as the office manager, the anesthesia technician, and emergency technician. In 1997, Sharon joined the anesthesia department at the University of Georgia Veterinary Teaching Hospital to pursue a career as an anesthesia technician specialist. She is a credentialed member of the Academy of Veterinary Technicians in Anesthesia and Analgesia. and the Academy of Equine Nursing Technicians. At Georgia she was the emergency on-call anesthesia technician. Sharon joined the staff of Premier Equine Veterinary Services with Dr. William Rhoads in 2006. She currently provides MEET THE AUTHOR continued on page 83

ythiosis is a noncontagious disease caused by Pythiosis insidiosum, a fungus-like, protozoan organism. Until recently, it was considered to be a threat only to horses living in tropical or subtropical environments; however, it has been seen in many other areas of the United States, such as Illinois, New York, and even Wisconsin.1 Although dogs, cats, and even humans can be affected by pythiosis, horses are most commonly infected. EXPOSURE AND INFECTION

P insidiosum feeds on plant material and was originally believed to live in ponds that were not spring fed. More recently, it has been discovered that the organism can be found in standing and stagnant water and in the moist soil left after the water dries up.2 Animals become infected when it finds its way into small scratches or wounds or when they inhale or ingest spores. To date, there are no documented cases of animal-toanimal or animal-to-human infection. There has been no correlation to breed, age, or sex, so all horses are equally at risk if living in an infectious environment. Infection with P insidiosum can cause two types of disease: lesional and respiratory. The lesional form manifests as tumor-like masses and ulcerated lesions that can affect any part of the body. They can be cutaneous, subcutaneous, and/or intestinal. Rarely, with chronic pythiosis, lesions develop in the bones and lungs. Although relatively uncommon, lesional equine pythiosis can be fatal (>95% of cases) if it is not treated when it first develops.3 WINTER 2018

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lesion. If multiple granulomas appear, they tend to be in the same general area. If not diagnosed and treated, the masses grow very large and ulcerate. FUNDAMENTALS

Animals become infected with Pythiosis insidiosum when it finds its way into small scratches or wounds or when they inhale or ingest spores.

The lesions seem to be very pruritic. They have a strong odor, draining tracts, and a core lesion that is a hard mass called a â&#x20AC;&#x153;kunker.â&#x20AC;? They also produce a serosanguinous discharge that, along with loss of tissue, can lead to anemia. Lesions that erupt on parts of the body other than the limbs (eg, abdomen, chest, face) are usually circular and less lobulated.4

DIAGNOSIS AND TREATMENT Lesional Disease

In horses, the most common lesion locations are the lower legs. This is logical because the legs are more exposed to organisms present in stagnant water and grasses. The next most common site of lesions is the abdomen. Generally, horses only develop one

Histopathology of samples taken from the characteristic lesions can be helpful in diagnosing pythiosis by identifying microabscesses with eosinophils.3 However, the organism itself is very hard to identify in biopsy samples. A definitive diagnosis can be made using enzyme-linked immunosorbent assay (ELISA) testing

Case 1: Abdominal Lesion

his horse presented with a lesion on its abdomen (FIGURE 1). According to the owners, the lesion had progressed from a small sore over a relatively short time despite treatment with antifungal and antibiotic salves, Based on the appearance and history of the lesion, we obtained a blood sample for ELISA testing and started immunotherapy while waiting for the results. Within 48 hours, the diagnosis was confirmed; therefore, we continued treatment with injections given on days 7 and 21. FIGURE 2 is of the lesion on day 7. It has become smaller and has less black, necrotic-appearing tissue and less purulent discharge. FIGURE 3 is of the lesion on day 21. Again, the lesion is smaller and the tissue is healthier looking. There is normal tissue with hair growth around the outside of the remaining lesion where the original lesion once extended. At the 28-day recheck, a second course of immunotherapy was determined to be unnecessary. By day 56, the lesion was almost undetectable.

FIGURE 1.

FIGURE 2.

EQUINE PYTHIOSIS

FIGURE 3.

FEATURES

of serum for pythiosis antibodies (Pan American Veterinary Laboratories; pavlab.com).5 The results are characterized as positive, borderline, or negative. Patients with borderline results should be retested in 30 days to confirm the diagnosis before treatment; treatment may also be started without retesting. Because P insidiosum is not a true fungus, antifungal drugs have proven ineffective as therapy.6 Treatment of diagnosed pythiosis involves immunotherapy with a product that is described as a vaccine, although it cannot be used as preventive therapy. The full treatment protocol is a series of three 1-cc subcutaneous injections given on days 1, 7, and 21. The patient is rechecked on day 28, and if the lesion is smaller but not totally cured, a second 3-injection course can be administered.7 This immunotherapy protocol was developed in the 1980s, and the early form of the vaccine cured 100% of acute cases (horses infected for <60 days). It was less successful in chronically infected horses because of

immunosuppression in those patients caused by loss of proteins and electrolytes through the open wounds. A newer form of the therapeutic vaccine cured 50% of the chronic cases that had previously not been cured. The overall cure rate for acute and chronic cases combined is 75% with this product.6 Occasionally, surgical excision is needed to remove a larger lesion after it is shrunken by the 3-injection course of immunotherapy.

Respiratory Disease The respiratory condition caused by P insidiosum, Pythium-induced allergic syndrome, produces very mild clinical signs that include a sporadic, dry cough and clear nasal discharge. It is caused by ingestion of Pythium spores that have been trapped in hay that was grown on land where water sat stagnant, perhaps after a torrential rainfall or flood. The organisms still in the grass are picked up when the hay is baled. Horses may also inhale spores that are aerosolized when the wind blows up dirt that was once covered with stagnant water.

Case 2: Leg Lesions

he patient in FIGURES 4 through 6 had been treated for an extended period of time for summer sores. It was referred to us for a second opinion because of its worsening condition. Owing to the severity of the lesions on presentation (FIGURE 4), this horse was treated with 2 series of immunotherapy. FIGURE 5 is of the lesions on day 22, and FIGURE 6 was taken on day 45. Eventually this patient healed completely with minimal scarring, and it has returned to the show ring.

FIGURE 4.

FIGURE 5.

FIGURE 6.

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Bronchoscopic examination of horses with these clinical signs shows inflamed mucous membranes in the nose and throat. Definitive diagnosis is also done with ELISA testing, and treatment is the same as for the lesional disease. It is common to have multiple cases in the same training or boarding facility at the same time. In the practice where I work, most of the positive pythiosis cases we see are Pythium-induced allergic syndrome.

PRESENTATION: CASE EXAMPLES Although pythiosis was once considered rare in the United States, in 2015, the practice that I work in, located 60 miles north of Dallas, saw more than 100 positive cases in a 6-month period. Approximately 40% of these cases involved cutaneous lesions, some that were originally diagnosed as summer sores. When these did not respond to steroid injections, we tested

Case 3: Body Lesions

his patient presented with sores on its face (FIGURE 7) and lateral to its withers (Figure 8) that owners described as being the size of a quarter one day and the size shown in 1 week. They had been treating the sores with antifungal salve. Results of an ELISA test were positive for pythiosis, and we initiated treatment with the immunotherapy protocol. FIGURES 9 and 10 were taken on day 21. On day 28 after the initial 3-injection series, the patient was 75% improved and received 1 more immunotherapy injection. At recheck on day 60, the wounds were dry and 90% healed.

FIGURE 7.

FIGURE 8.

FIGURE 9.

FIGURE 10.

EQUINE PYTHIOSIS

FEATURES

them for pythiosis, and the results were positive. Included with this article are a few examples of how pythiosis cases present and respond to therapy. All cases described were treated with the newer form of the immunotherapeutic vaccine. TVN

THEHEART HEART OF OF THE HEART THE OF VETERINARY A VETERINARY A AVETERINARY MEDICAL TEAM MEDICAL MEDICAL TEAMTEAM ISTECHNICIAN A TECHNICIAN ISISA ATECHNICIAN WITH HEART WITH HEAR WITH HEART

References 1. Pythium insidiosum: epidemiology. Michigan State University Biomedical Laboratory Diagnostics Program. bld.natsci.msu.edu/research/pythiuminsidiosum/epidemiology/. Accessed September 2017. 2. Pythium insidiosum: history of infection. Michigan State University Biomedical Laboratory Diagnostics Program. bld.natsci.msu.edu/research/ pythium-insidiosum/history-of-infection/. Accessed September 2017. 3. Glass R. Horse pythiosis. Pan American Veterinary Laboratories. pavlab. com/pavlab/pythiosis-insidiosum/technical-papers/horse-pythiosis/. Accessed September 2017. 4. Marcella K. “Swamp cancer”: the increasing threat of equine pythiosis. DVM 360 Magazine March 1, 2011. veterinarynews.dvm360.com/swampcancer-increasing-threat-equine-pythiosis. Accessed September 2017. 5. Pythium insidiosum: serologic and molecular tests. Michigan State University Biomedical Laboratory Diagnostics Program. bld.natsci.msu. edu/research/pythium-insidiosum/serologic-and-molecular-tests/. Accessed September 2017. 6. Pythium insidiosum: equine. Michigan State University Biomedical Laboratory Diagnostics Program. bld.natsci.msu.edu/research/pythiuminsidiosum/equine/. Accessed September 2017.

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7. Pythium insidiosum allergenic extract [package insert]. Hutto, TX: Pan American Veterinary Laboratories.

Veterinary Specialty Center in suburban Chicago is looking for certified Veterinary Specialty Center inveterinary suburban Chicago is looking for cert Veterinary Specialty Center inand suburban Chicago is looking for certified veterinary technicians experienced assistants. veterinary technicians veterinary and experienced veterinary assistants. veterinary technicians and experienced assistants. Veterinary technicians at VSC enjoy: Veterinary Veterinary technicians at technicians VSC enjoy: at VSC enjoy: • Help with earning advanced credentials like Veterinary Technician • (VTS) Help with earning advanced credentials like Veterinary Technici • Help with earning advanced credentials like Veterinary Technician Specialist certification Specialist (VTS) certification Specialist (VTS) certification • Ample contact, control and autonomy with patient cases Ampleand contact, controlwith andpatient autonomy • Ample contact,• control autonomy caseswith patient cases • The chance to attend national and regional conferences The chance attend national and regional conferences • The chance to •attend nationaltoand regional conferences Full-time employee benefits include medical, dental, vision, life Full-time employee benefits include medical, dental, vision, life Full-time employee benefits include medical, dental, vision, lifeand insurance, longand short-term disability, pet insurance 401(k) insurance, long-disability, and short-term disability, insurance and 401( insurance, long- plans. and short-term pet insurance andpet 401(k) retirement retirement plans.retirement plans. Choose a collaborative, compassionate and cutting-edge work Choose acompassionate collaborative, compassionate andwork cutting-edge w Choose a collaborative, and cutting-edge environment. Choose VSC. environment. environment. Choose VSC. Choose VSC. Learn more and apply at vetspecialty.com/careers, or contact Learn and apply at vetspecialty.com/careers, or contact LearnSheila more at and applymore at vetspecialty.com/careers, or contact shaske@vetspecialty.com. Sheila at shaske@vetspecialty.com. Sheila at shaske@vetspecialty.com.

MEET THE AUTHOR continued from page 79

anesthesia to Dr. Rhoads’ surgical patients as well as serving as the office manager. She also assists Dr. Wendy Rhoads at All About Pets Animal Hospital. Over the years, Sharon has been involved with the American Association of Equine Veterinary Technicians and was a member of the organizing committee for the Equine Veterinary Nursing Academy and is now a charter member and Past President of the Academy. She is often asked to speak to technicians at both local and national conferences. Sharon resides in Whitesboro, Texas, with her daughter Megan and grandson Bradley. Sharon enjoys horseback riding, gardening, watching Bradley play sports, and taking care of her menagerie of animals.

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Extra Mile CAREER CHALLENGES — Animal Cruelty: Your Role in Identifying Abuse — 85 FINAL THOUGHTS — Building Resiliency Through Our Story — 90

CAREER CHALLENGES

VICTIMS AMONG US There is no universal definition of what constitutes animal abuse, cruelty, or neglect. Animal cruelty is not a medical determination but a legal one. Image courtesy of shutterstock.com/spillikin

MEET THE AUTHOR

Lisa M. Smith, LVT, VTS (ECC) Veterinary Specialty Center of Delaware Lisa has over 20 years of experience in the field of Veterinary Medicine. She studied Animal Science at the University of Delaware, and became an LVT in 2008. She obtained her Veterinary Technician Specialist Certification in Emergency and Critical Care in 2014, and graduated with a Master’s of Science degree in Veterinary Forensic Sciences from the University of Florida in 2016. Lisa manages more than 60 technicians in a specialty and emergency hospital in Delaware, also working on the floor in the Emergency Service and ICU. She also provides CE lectures to local technicians on various topics, including RECOVER based CPR training. Lisa also serves on the Board of the Delaware Veterinary Medical Association as the technician representative. Author portrait courtesy of Marlene Waeltz Photographie

EXTRA MILE

Animal Cruelty: Your Role in Identifying Abuse

eterinary professionals enter the field because of our love for animals and a desire to make them well. One of the most challenging aspects of our job is managing strong emotional responses when we are faced with a victim of animal cruelty. Acting as an advocate to see justice done on the victim’s behalf and doing our part in the medical-legal cases are key to managing those emotions.

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LEGAL ASPECTS There is no universal definition of what constitutes animal abuse, cruelty, or neglect. Animal cruelty is not a medical determination but a legal one. Each term has a different definition in each state. Even the definition of an animal varies from state to state. The forensic aspect of an animal cruelty case means that the information and evidence collected will end up in a court of law; veterinary forensic medicine is veterinary medicine practiced in a legal context. Another legal aspect of cruelty cases applies to the Fourth Amendment of the Constitution. Animals are considered property, and this affects how they are viewed in the eyes of the law. Thus, getting permission to examine the animal, perform a necropsy, or even take photographs must be obtained; otherwise, law enforcement must issue a search warrant. To determine an animal’s health, a veterinarian must be able to perform a physical examination and do diagnostic testing. Once these have taken place, the veterinarian can assess how the medical problem or injury occurred. Veterinarians and veterinary technicians can be summoned as witnesses in court when they have had contact with the animal.

CRUELTY CASES Whether small or large, cases can range from a single animal to hundreds of animals. Large-scale cases examples include hoarding, puppy mills, dogfighting, and cockfighting. There are also “sanctuaries,” “rescues,” and overcrowded shelters that do not provide proper care, creating hazardous environments similar to what is seen in a hoarding or puppy mill situation. ●●

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Hoarding: In hoarding situations, hoarders are often unable to comprehend the harm they have caused to the animals, which adds another layer to the challenge. Cats that come from hoarding situations are often inflicted with upper respiratory tract infections, parasitic infections, ocular disease, and dental disease and have behavioral and socialization problems. Dogs that come from hoarding situations are often in poor physical condition and health. They may have poor hair-coat and nails; be malnourished, dehydrated, and prone to skin infections; have parasitic infections; and have behavioral and socialization problems. Puppy mills: Puppy mill mothers are overbred and kept in cramped, unsanitary conditions. They are often not socialized and when placed in a normal environment exhibit behavioral problems, such as inappropriate urination, fear biting, not walking on a leash, or food aggression. These dogs are often bred despite having genetic abnormalities, and this negatively CAREER CHALLENGES

affects the animal’s life because of the chronic illness they cause. The puppies will be afflicted with these problems for the rest of their life; any diseases passed along may not be evident at the time of adoption. ●●

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Dogfighting: Dogs conditioned for fights commonly have scars and wounds in various stages of healing on their head, neck, legs, or thorax. Some dogs may have worn paw pads from conditioning on rough surfaces and very well-muscled physique, and they may exhibit behavioral tendencies, such as gameness with other dogs or fear.1 Pit bulls are often infected with Babesia gibsoni, a parasite associated with red blood cell destruction, which is believed to be transmitted by bites during fighting or from mother to puppy.2 Surprisingly, despite the stress and cruelty these dogs experience, if they are lucky enough to survive, they are remarkably resilient and can become wonderful family dogs. A behavior evaluation by a professional is essential in the rehoming process to make sure they are not a danger to other animals or people. Dogfighting is a felony in all 50 states and is also almost always linked to other crimes, such as illegal weapons, drugs, and gambling.3 Cockfighting: This blood sport is often a backyard/ basement operation wherein roosters are physically altered and forced to fight until one dies. Roosters have their feathers plucked or shaved, wattles trimmed, and spurs removed, and gaffes are placed to act as a weapon to inflict damage on the opposing bird.

Individual cases are brought to the veterinarian with anything from a false history to a known incident. Veterinarians and technicians are trusting and compassionate people by nature and sometimes are not willing to believe that the person who would abuse an animal would also be the one to bring it in for care. Giving people the benefit of the doubt is usually our default response; however, when a law is broken and a patient is harmed, we must consider nonaccidental injury (NAI) or neglect.

NONACCIDENTAL INJURY NAI occurs when a person intentionally harms an animal. Many types of injuries are caused by NAI. Blunt-force trauma can cause contusions, abrasions, lacerations, or fractures. Sharp-force trauma presents as stab wounds or incised wounds from a knife or blade (FIGURE 1). Features involving fractures that raise the index of suspicion for nonaccidental injury are multiple fractures, transverse fractures, fractures in more than one region of the body at once, fractures in various stages of healing, and delayed presentation.4 A 2016 study in the Journal of Forensic

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Sciences looked at NAIs and motor vehicle accidents (MVAs) and showed that NAIs were more likely to be fractures of the skull, teeth, vertebrae, and ribs; scleral hemorrhage; damage to claws; and older fractures. Bilateral rib fractures with no cranial-caudal pattern were more likely to be caused by NAI than by MVA.5 One of the most challenging aspects of a physical examination on an injured patient is distinguishing accidental injury from NAI. Repetitive injuries should always raise a red flag. Unfortunately, there is no certain indicator of abuse. However, the best way to start the analysis is to consider the force needed to cause the injury, location of the injury, and whether it matches the history and time frame. Other NAIs include gunshot wounds, sexual abuse, asphyxia, drowning, thermal injury, and poisoning. Gunshot wounds provide solid evidence to aid in the prosecution of the case. Projectile trajectory, wound examination, and proper collection of evidence (including recovering the projectile, radiographs, and wound photographs) are all important aspects in handling these cases. Sexual abuse is a difficult differential for any veterinarian to put on their list. However, it should be considered if physical examination shows trauma to the urogenital/rectal orifices or parts of the body where the animal is held for restraint. Although rare, it can occur, and it may not leave much physical evidence.6 Asphyxiation can result from suffocation,

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FIGURE 1. Nonaccidental injury caused by penetrating wound by an arrow.

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strangulation, hanging, drowning, or injury caused by high-heat items (hot water, cigarettes). We all know neighbors are often being accused of poisoning when an animal presents with an illness of unknown origin. However, poisoning or ingestion of a toxin can occur if someone is trying to retaliate against a person, eliminate neighborhood “pests” (ie, stray cats or barking dogs), or out of amusement or curiosity.1

ROAD TO SUCCESS

The American Animal Hospital Association advocates for hospitals to create a protocol for the identification and reporting of animal abuse and cruelty.

NEGLECT Neglect is the most common type of animal cruelty seen in the veterinary hospital. The question we must ask is whether the neglect warrants a criminal charge. Some forms of neglect may be corrected by client education, and some are clearly criminal, with any scenario in between. It is difficult for a prosecutor to prove intent, so evidence must be collected to document the animal’s condition. Neglected animals can present emaciated (as a result of long-term inadequate nutrition), excessively matted hair coat, an embedded collar, skin disease, or untreated wounds or diseases. An example of an extreme form of neglect is a severely matted dog whose fur is one large mat. The animal’s skin can also become ulcerated due to urine scald, compounded by the lack of oxygen to the skin by the matted fur. The tightness of the wet fur can cause strangulation of the limb, sometimes requiring amputation. Red flags should be raised when the history doesn’t match the physical examination findings. If the patient fell from arm’s height, could the injury have occurred? If you believe that it could not, ask open-ended questions. Suspicion should be raised if the history varies, the client fumbles through a story, the client’s behavior is odd or aggressive,

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the client shows a true lack of concern about the animal, or the client repeatedly responds “I don’t know” when asked what happened. An excellent resource exists for veterinary professionals, titled “Practical Guidance for the Effective Response by Veterinarians to Suspected Animal Cruelty, Abuse and Neglect,” is available online through the American Veterinary Medical Association.7

THE IMPORTANCE OF REPORTING No matter the type of abuse, the veterinarian should be prepared to contact the authorities to report the findings. In some states, veterinarians and/or technicians are mandated to report suspected abuse, cruelty, or neglect, just as physicians and nurses are mandated to report child abuse. Immunity laws are in place in some states for good faith reporting, which protects the reporter from liability. Suspicion for abuse is all a veterinarian or veterinary technician needs to have when filing a report. Even though veterinarians are concerned about the potential for harm to the business or the veterinarian’s reputation caused by negative media attention, social media, protesters, or decline in clientele, it is more common that the public will support the prosecution of a perpetrator of animal abuse. Consistent mandatory reporting and immunity laws in all 50 states would be helpful to remove the fear that prevents many veterinarians from reporting. Unfortunately, many states lack resources to follow up on cases once the report is filed. The American Animal Hospital Association advocates for hospitals to create a protocol for the identification and reporting of animal abuse and cruelty.8 It should be a responsibility of every veterinarian and technician to consider the importance of reporting and follow through. There is a documented link between animal cruelty and interpersonal violence, and it can be the tip of the iceberg when an abused animal ends up on your exam table. The National Link Coalition (nationallinkcoalition.org) provides numerous resources on the topic of animal abuse and its correlation with child abuse, elder abuse, domestic violence, and other violence. We have all heard that serial killers start by abusing animals in childhood, and although that is an extreme form of violence, a recent study in the International Journal of Juvenile Offender Therapy and Comparative Criminology found that the only statistically significant predictor of adult interpersonal violence was recurrent childhood animal cruelty, above race, education, and residence.9 So, when you report the abuse, you could be saving other lives—animal and human. To see the conclusion of this article, please visit todaysveterinarynurse.com.

NADA 141-426, Approved by FDA

Flavored chews for dogs. BRIEF SUMMARY (For full Prescribing Information, see package insert) Caution: Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Indications: Bravecto kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis) and the treatment and control of tick infestations [Ixodes scapularis (black-legged tick), Dermacentor variabilis (American dog tick), and Rhipicephalus sanguineus (brown dog tick)] for 12 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater. Bravecto is also indicated for the treatment and control of Amblyomma americanum (lone star tick) infestations for 8 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater. Contraindications: There are no known contraindications for the use of the product. Warnings: Not for human use. Keep this and all drugs out of the reach of children. Keep the product in the original packaging until use, in order to prevent children from getting direct access to the product. Do not eat, drink or smoke while handling the product. Wash hands thoroughly with soap and water immediately after use of the product. Precautions: Bravecto has not been shown to be effective for 12-weeks duration in puppies less than 6 months of age. Bravecto is not effective against Amblyomma americanum ticks beyond 8 weeks after dosing. Adverse Reactions: In a well-controlled U.S. field study, which included 294 dogs (224 dogs were administered Bravecto every 12 weeks and 70 dogs were administered an oral active control every 4 weeks and were provided with a tick collar); there were no serious adverse reactions. All potential adverse reactions were recorded in dogs treated with Bravecto over a 182-day period and in dogs treated with the active control over an 84-day period. The most frequently reported adverse reaction in dogs in the Bravecto and active control groups was vomiting.

NADA 141-459, Approved by FDA

(fluralaner topical solution) for Dogs

(fluralaner topical solution) for Cats

BRIEF SUMMARY (For full Prescribing Information, see package insert)

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

Indications: Bravecto kills adult fleas and is indicated for the treatment and prevention of flea infestations (Ctenocephalides felis) and the treatment and control of tick infestations [Ixodes scapularis (black-legged tick), Dermacentor variabilis (American dog tick), and Rhipicephalus sanguineus (brown dog tick)] for 12 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater. Bravecto is also indicated for the treatment and control of Amblyomma americanum (lone star tick) infestations for 8 weeks in dogs and puppies 6 months of age and older, and weighing 4.4 pounds or greater. Contraindications: There are no known contraindications for the use of the product. WARNINGS Human Warnings: Not for human use. Keep this and all drugs out of the reach of children. Do not contact or allow children to contact the application site until dry. Keep the product in the original packaging until use in order to prevent children from getting direct access to the product. Do not eat, drink or smoke while handling the product. Avoid contact with skin and eyes. If contact with eyes occurs, then flush eyes slowly and gently with water. Wash hands and contacted skin thoroughly with soap and water immediately after use of the product. The product is highly flammable. Keep away from heat, sparks, open flame or other sources of ignition. Precautions: For topical use only. Avoid oral ingestion. Use with caution in dogs with a history of seizures. Seizures have been reported in dogs receiving fluralaner, even in dogs without a history of seizures. Bravecto has not been shown to be effective for 12-weeks duration in puppies less than 6 months of age. Bravecto is not effective against Amblyomma americanum ticks beyond 8 weeks after dosing. Adverse Reactions: In a well-controlled U.S. field study, which included a total of 165 households and 321 treated dogs (221 with fluralaner and 100 with a topical active control), there were no serious adverse reactions. Percentage of Dogs with Adverse Reactions in the Field Study

Percentage of Dogs with Adverse Reactions in the Field Study Adverse Reaction (AR) Vomiting Decreased Appetite Diarrhea Lethargy Polydipsia Flatulence

Bravecto Group: Active Control Group: Percentage of Dogs Percentage of Dogs with the AR During the with the AR During 182-Day Study the 84-Day Study (n=224 dogs) (n=70 dogs) 7.1 14.3 6.7 0.0 4.9 2.9 5.4 7.1 1.8 4.3 1.3 0.0

In a well-controlled laboratory dose confirmation study, one dog developed edema and hyperemia of the upper lips within one hour of receiving Bravecto. The edema improved progressively through the day and had resolved without medical intervention by the next morning. For technical assistance or to report a suspected adverse drug reaction, contact Merck Animal Health at 1-800-224-5318. Additional information can be found at www. bravecto.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/ AnimalVeterinary/ SafetyHealth. How Supplied: Bravecto is available in five strengths (112.5, 250, 500, 1000, and 1400 mg fluralaner per chew). Each chew is packaged individually into aluminum foil blister packs sealed with a peelable paper backed foil lid stock. Product may be packaged in 1, 2, or 4 chews per package. Distributed by: Intervet Inc (d/b/a Merck Animal Health) Madison, NJ 07940 Made in Austria Copyright © 2014 Intervet Inc, a subsidiary of Merck & Company Inc. All rights reserved 154545 R1

Adverse Reaction (AR) Vomiting Alopecia Diarrhea Lethargy Decreased Appetite Moist Dermatitis/Rash

Bravecto Group: Percent of Dogs with the AR During the 105-Day Study (n=221 dogs) 6.3% 4.1% 2.7% 2.7% 1.4% 0.9%

Control Group: Percent of Dogs with the AR During the 84-Day Study (n=100 dogs) 6.0% 2.0% 11.0% 2.0% 0.0% 0.0%

In the field study, two dogs treated with Bravecto with no prior history of seizures each experienced a seizure. One dog had two seizures a day apart about 18 days after its first dose. The dog was started on antiepileptic medication and had no additional seizures during the study. A second dog had a seizure 76 days after its first dose and 3 days after starting fluoxetine for separation anxiety. The fluoxetine was discontinued and the dog experienced no additional seizures during the study. One dog treated with Bravecto was observed by the owner to be off balance for about 30 minutes five days after its first dose and had no similar observations after the second dose. One dog with a history of seizures had a seizure the day after the second dose of the active control. In two well-controlled laboratory dose confirmation studies, one dog developed mild to moderate redness, flaking, crusts/scabs and alopecia at the treatment site from Day 1 through 14 after application of Bravecto on Day 0, and one dog developed self-limiting generalized erythema (possible allergic reaction) one day after treatment with Bravecto.

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

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

Vomiting Pruritus Diarrhea Alopecia Decreased Appetite Lethargy Scabs/Ulcerated Lesions

7.6% 5.4% 4.9% 4.9% 3.6% 3.1% 2.2%

Control Group: Percent of Cats with the AR During the 84-Day Study (n=87 cats) 6.9% 11.5% 1.1% 4.6% 0.0% 2.3% 3.4%

In the field study, two cats treated with fluralaner topical solution experienced ataxia. One cat became ataxic with a right head tilt 34 days after the first dose. The cat improved within one week of starting antibiotics. The ataxia and right head tilt, along with lateral recumbency, reoccurred 82 days after administration of the first dose. The cat recovered with antibiotics and was redosed with fluralaner topical solution 92 days after administration of the first dose, with no further abnormalities during the study. A second cat became ataxic 15 days after receiving its first dose and recovered the next day. The cat was redosed with fluralaner topical solution 82 days after administration of the first dose, with no further abnormalities during the study. In a European field study, two cats from the same household experienced tremors, lethargy, and anorexia within one day of administration. The signs resolved in both cats within 48-72 hours.

In a European field study in cats, there were three reports of facial dermatitis in humans after close contact with the application site which occurred within 4 days of application.

In a European field study, there were three reports of facial dermatitis in humans after close contact with the application site which occurred within 4 days of application.

For technical assistance or to report a suspected adverse drug reaction, or to obtain a copy of the Safety Data Sheet (SDS), contact Merck Animal Health at 1-800-224-5318. Additional information can be found at www.bravecto.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth.

For technical assistance or to report a suspected adverse drug reaction, or to obtain a copy of the Safety Data Sheet (SDS), contact Merck Animal Health at 1-800-224-5318. Additional information can be found at www.bravecto.com. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDAVETS or online at http://www.fda.gov/AnimalVeterinary/SafetyHealth.

How Supplied: Bravecto is available in five strengths for use in dogs (112.5, 250, 500, 1000, and 1400 mg fluralaner per tube). Each tube is packaged individually in a pouch. Product may be supplied in 1 or 2 tubes per carton.

How Supplied: Bravecto is available in three strengths for use in cats (112.5, 250, and 500 mg fluralaner per tube). Each tube is packaged individually in a pouch. Product may be supplied in 1 or 2 tubes per carton.

Distributed by: Intervet Inc (d/b/a Merck Animal Health) Madison, NJ 07940 Made in the USA.

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FINAL THOUGHTS

POSITIVE PERCEPTIONS The way you interpret something will dictate how you respond. The story you tell yourself and others is entirely up to you. Image courtesy of shutterstock.com/santypan

MEET THE AUTHOR

Julie Squires, CCFS Rekindle, LLC

Building Resiliency Through Our Story

ccording to the American Psychological Association, resilience is “the process of adapting well in the face of adversity, trauma, tragedy, threats, or significant sources of stress.”1 Essentially, it means “bouncing back” from difficult experiences. What makes something difficult? The answer is…our brain does. Our experiences are not difficult until we have a thought that makes them so. (Stay with me on this.)

FINAL THOUGHTS

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, lab animal research facilities, and other animal organizations. Julie has 25 years of experience within the veterinary field and with leading organizations. She has developed and executed training, workshops, and 1:1 coaching for major companies in the animal health industry. She obtained her certification as a compassion fatigue specialist through the Traumatology Institute. Julie’s clients also gain from her experience as a certified life coach and corporate wellness specialist.

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When you look at the facts of any experience and don’t get tangled up in the story your mind wants to create, you will find that you have some options.

animals in her care. She accepts that euthanasia is part of what she signed on to do. Does she love that part of her job? No. Yet she knows she can honor her animals’ sacrifice and give them a humane ending. She chooses to tell people her story from a neutral place: I work with animals in research. We learn from them and give them a peaceful death.

In fact, you have a choice in how you interpret anything. That includes any situation, any patient, any client, any organizational change, and any coworker’s behavior.

HERE COMES THE DRAMA

How you adapt or bounce back from something is determined by how you handle it in your mind. There are the facts, but it is what you make of those facts that determines your ability to be resilient.

Earlier this year, an international veterinary association magazine interviewed me for an article on compassion fatigue. They also asked for a photo of me to include with the article, so I sent one of me and my beloved pug, Ernie. A few days later, I received a reply from the editor informing me that they “do not use photos of dogs or cats with known animal welfare issues such as brachycephalic breeds.”

You always have 3 options in response to any situation: empowerment, neutrality, or drama.

EMPOWER YOURSELF

What?

Jennifer is an LVT I recently met in Louisiana. After she attended a compassion fatigue workshop of mine for animal workers, she contacted me to share her story.

My mind was going crazy, creating all kinds of stories about how they must think I’m a terrible person for having pugs, etc. I was feeling attacked, victimized, and offended. Mind you, the editor’s words were not attacking, victimizing or offensive…I created all that in my mind.

She told me how she worked in disaster relief during the aftermath of Hurricane Katrina. She witnessed unspeakable tragedy, including the suffering and death of animals. Yet this is what she told me: “I was so honored and proud to be able to help those that I could. I know I saved a lot of lives in the weeks I was in New Orleans.”

SPECIALIZE IN EQUINE CARE

Jennifer could’ve easily told me about all the horror she witnessed and how unfair it all was. She could have described how there wasn’t enough help for the animals and how many animals died. But she didn’t. She chose to tell her story from a place of empowerment. She knew she couldn’t control much of the situation, but what she could control, she was going to own.

NEUTRAL IS AN OPTION Megan is a CVT in Illinois and a former coaching client of mine. She works in lab animal research, and part of her responsibility includes euthanizing the animals. When we started working together, Megan was suffering from compassion fatigue and was very attached to thinking how unfair it is that these animals have to be euthanized. She also felt it was unfair that she is often the one to do it and that we have to use animal models in research.

Wilson College’s equi-assist concentration within the veterinary medical technology major gives graduates the training and skills to provide equine nursing veterinary care in a horse’s home environment.

Now, Megan thinks about it completely differently. She owns her role as a caregiver and welfare advocate for the

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wilson.edu/eqa-tvn

YOUR STORY. YOUR FUTURE.

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So because I had created this story in my mind, I wanted to add to the plot. I shot off an email to my pug’s breeder, who happens to be a veterinarian. Within minutes she responded and supported my outrage. I then texted a dear friend of mine, an owner of 2 Boston terriers (Brachycephalics Unite!). Bingo! She too joined the story I was creating in my mind.

Is it to change the way international veterinary associations view pugs? No. Is it to help the veterinary community know what compassion fatigue is and offer relief from their suffering? Yes. So I aligned with my purpose of helping the veterinary community, sent in a new picture (sans pug), and now I tell the story like this: This international veterinary association doesn’t use photos with brachycephalic breeds, so I sent in another one.

End of Act 1. Act 2. My mind offered me the “solution” of dropping out of the article. If they don’t like who I am—someone who adores pugs—then there is no place for me in the article. (Ridiculous, I know. But my mind was on a roll now.)

While it may have taken some time for me to get to that place, this is an example of how we always have options in our interpretation of anything. The way you interpret something will dictate how you respond. The story you tell yourself and others is entirely up to you.

This is an example of option drama. Something happened (“no pugs in our magazine please!”), and I rallied others to join my outrage and strengthen it, to prove how “right” I was. I considered opting out of the article in passive-aggression.

RESISTING REALITY How we bounce back or return to our normal state after experiencing something challenging is an integral part of veterinary medicine—and life. The severity and frequency of trauma makes a difference. The less time we have between events, tragedies, and adversity, the more vulnerable we are to staying stuck in what I call “resisting reality.” When we resist reality, we suffer. When we spend our energy wanting things to be different than they are, we pay a big price.

I’m smart enough to know not to fire off emails in the heat of the moment, and once a little time had passed, I asked myself this question: What is my purpose here?

Fully AVMA-CVTEA accredited

Horrific and tragic things happen. Animals are euthanized, sometimes at young ages. Animals are abused and neglected. So are people. Children get sick and die. So do animals. Humans do terrible things. So do animals. It’s all part of life.

Veterinary Technician Associate Degree

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We deserve to feel sad sometimes, to grieve the loss of a being that touched our hearts in a profound way. It’s okay to feel what we feel. As a matter of fact, it is vital to feel what we feel. But remember you have options in how you tell the story to yourself and to others. You can tell just the facts (neutral), describe how you rose above it (empowerment), or get caught up in your story and create a whirlwind of emotion (drama) that has no benefit.

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Reference

PENN FOSTER COLLEGE, ADMINISTRATIVE OFFICE 14300 N. Northsight Blvd., Scottsdale, AZ 85260 PENN FOSTER CAREER SCHOOL 925 Oak Street, Scranton, PA 18515

1. American Psychological Association. The Road to Resilience. https:// www.apa.org/helpcenter/road-resilience.aspx. Accessed August 2017. 653G

FINAL THOUGHTS

Fast is Good. Faster is Better.

Dogs taking metronidazole

4.4 DAYS

until diarrhea improvement

Dogs taking metronidazole plus FortiFlora®

2.8 DAYS

until diarrhea improvement1

PROBIOTIC 2

Help dogs with diarrhea improve faster by pairing Purina® Pro Plan® Veterinary Diets FortiFlora® with metronidazole. In a study of dogs with diarrhea, dogs given FortiFlora® in addition to metronidazole showed improvement in just 2.8 days, as opposed to 4.4 days for dogs on metronidazole alone.1 To learn more, visit PurinaProPlanVets.com.

1. Fenimore A, Groshong L, Scorza V, Lappin MR. Evaluation of Enterococcus faecium SF68 supplementation with metronidazole for the treatment of nonspecific diarrhea in dogs housed in animal shelters. J Vet Intern Med. 2012;26:793. 2. Kantar Millward Brown Veterinary Tracker, 2016. Purina trademarks are owned by Société des Produits Nestlé S.A.

TRESADERM® (thiabendazole, dexamethasone, neomycin sulfate solution) Dermatologic Solution Brief Summary: Before using TRESADERM, please consult the product insert, a summary of which follows: CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. WARNING: For topical use in dogs and cats. Avoid contact with eyes. Keep this and all drugs out of the reach of children. DESCRIPTION: TRESADERM Dermatologic Solution contains the following active ingredients in units per mL: 40mg thiabendazole, 1mg dexamethasone, 3.2mg neomycin (from neomycin sulfate); and inactive ingredients: glycerin, propylene glycol, purified water, hypophosphorus acid, calcium hypophosphite, about 8.5% ethyl alcohol and about 0.5% benzyl alcohol. INDICATIONS and USAGE: TRESADERM aids in the treatment of certain bacterial, mycotic, and inflammatory dermatoses and otitis externa in dogs and cats. The amount to apply and frequency of treatment are dependent upon the severity and extent of lesions. Five to fifteen drops of TRESADERM should be instilled in the ear twice daily. In treating dermatoses affecting areas other than the ear, the surface of the lesions should be well moistened (2-4 drops per square inch) twice daily. The volume required will be dependent upon the size of the lesion. PRECAUTIONS: Application of TRESADERM should be limited to a period not longer than 1 week. On rare occasions, application of the product may result in erythema or discomfort in the treated area. Erythema of the treated area can last from 24 to 48 hours. When applied to fissured or denuded areas, transient discomfort can follow with the expression of pain usually lasting 2-5 minutes. While systemic side effects are not likely with topically applied corticosteroids, the possibility of such side effects should be considered if use is prolonged or extensive. If signs of salt and water retention or potassium excretion are noticed, such as increased thirst, weakness, lethargy, reduced urine output, gastrointestinal disturbances or increased heart rate, treatment should be discontinued and appropriate measures taken to correct the electrolyte and fluid imbalance. The full FDA-approved product insert can be found at http://www.merial.us/ SiteCollectionDocuments/TRESADERM-PI.pdf. For technical assistance, to request a Safety Data Sheet or to report suspected adverse events, call 1-877-217-3543. For additional information about adverse event reporting for animal drugs, contact FDA at 1-888-FDA-VETS, or http://www.fda.gov/AnimalVeterinary.

TRESADERM® Dermatologic Solution aids in the treatment of certain bacterial, mycotic, and inflammatory dermatoses, such as:

• Anti-fungal

✔ Flea Allergy Dermatitis ✔ Focal Pyoderma ✔ Otitis Externa ✔ Ringworm ✔ Hot Spots

• Anti-inflammatory

TRUST TRIPLE ACTION TRESADERM • Anti-bacterial

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.