NZ Vet Nurse Journal September 2019 by Kathy Waugh

VOLUME 25 No. 91 SEPTEMBER 2019

Oriental cat behaviour Palliative care NZVNA conference review Equine ileocaecal bypass

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CONTENTS

04 04

VO LUME 2 5 No. 91 SEPT EMB E R 201 9

EXECUTIVE COMMITTEE OFFICERS President Julie Hutt PO Box 35831 Browns Bay Auckland 0753 021 599 059 president@nzvna.org.nz

06 08

Vice-President Amy Ross 021 852 664 vicepresident@nzvna.org.nz

Treasurer & Membership Secretary Kathy Waugh 021 843 277 treasurer@nzvna.org.nz

JOURNAL EDITOR

Assistant Editor: Catherine Taylor catherine.ellen.taylor@gmail.com

EDITORIAL BOARD Exotics: Kylie Martin Equine: Lyn Hobbs OSH: Libby Leader CPD: Christina Searle and Patricia Gleason

COVER: Photograph of ‘Annie’ by Ali Little

NZVNA FORMS The registration or list badge order forms, merchandise order forms and new membership forms can now all be found on the website www.nzvna.org.nz or by emailing membership@nzvna.org.nz.

Membership Secretary report by Kathy Waugh

Letter from the Editor by Antoinette Ratcliffe

CPD Corner: Focus on soft skills by Patricia Gleason

A guideline for modifying a compulsive behaviour in an Oriental cat by Melissa Monehan Palliative care: providing ‘a good death’ for your patients by Antoinette Ratcliffe

National Secretary Luanne Corles 027 472 1072 secretary@nzvna.org.nz

Antoinette Ratcliffe journal@nzvna.org.nz

President’s report by Julie Hutt

The New Zealand Veterinary Nursing Association would like to thank Hill’s™ Pet Nutrition NZ, our gold sponsors, for their continued support of the NZVNA and the veterinary nursing profession.

CAV Clinical Update: Comparison between flow-by oxygenation and facemask oxygenation on the partial pressure of arterial oxygen in sedated dogs by Andrew Dart, Christina Dart and Adrian Wong

18 21 22 26

NZVNA Sub-Committee announcement by Amy Ross Book review by Cindy Paton 2019 NZVNA Conference review by Johanna Bloxham, Samantha James and Georgina Green

Equine case study: Ileocaecal bypass by Lyn Hobbs

OUR VISION Caring for our community by promoting excellence in animal healthcare. DISCLAIMER The New Zealand Veterinary Nursing Association Journal is published by the New Zealand Veterinary Nursing Association Incorporated (NZVNA). The views expressed in the articles and letters do not necessarily represent those of the NZVNA or the editor, and neither the NZVNA nor the editor endorse any products or services advertised. The NZVNA is not the source of the information reproduced in this publication and has not independently verified the truth of the information. It does not accept any legal responsibility for the truth or accuracy of the information contained herein. Neither the NZVNA nor the editor accepts any liability whatsoever for the contents of this publication or for any consequences which may result from the use of the information contained herein or advice given herein. The provision is intended to exclude the NZVNA, the editor and its staff from all liability whatsoever, including liability for negligence in the publication or reproduction of the materials set out herein.

NZVNA

President’s report With Veterinary Nurse Awareness Week coming up in October, I want you to think about how your veterinary practice promotes the qualified veterinary nurse and veterinary technologist. I see many veterinary practices have a website where they have ‘meet the team’ but do you have ‘meet our veterinary nurses’? Could you encourage your practice to promote you online, not only with a photo and a blurb, but also your role as a veterinary nurse within the practice? We are especially proud of our qualified veterinary nurses who play a crucial role in our veterinary care team. The veterinary nurses run their own clinics, care for our hospitalised patients and assist with surgical and medical procedures. The veterinary nursing team are qualified and registered veterinary nurses. Registration is currently voluntary, but the veterinary nursing profession is currently moving towards full regulation. Having a great veterinary nursing team helps ensure your pet is receiving the best care and attention they deserve. Many pet owners do not know or understand that someone does not have to hold a recognised qualification to call themselves a veterinary nurse. They also may not know what a registered veterinary nurse (RVN) is. On the flip side, many pet owners are not even aware there IS a qualification for veterinary nursing. Can YOU change that perception

from within your practice? You could make a difference and help educate the public on our great profession. We have the opportunity to promote the role of the veterinary nurse within the local community, and to reinforce the value and professionalism of veterinary nurses to the public during Veterinary Nurse Awareness Week. Your clinic should be promoting that their veterinary nurses and veterinary technologists are qualified and hold registration. Having the information proudly displayed in the clinic can promote the veterinary nurse role in practice and shine a light on the industry. Registered veterinary nurses undergo a minimum of two years full-time equivalent training, and must complete 20 hours of approved continuing education per year along with clinical hours. Registered veterinary nurses are trained in many clinical skills and have knowledge of disease processes and patient care requirements. You know this, now it’s time to let your clients know what YOU know! So how are you going to promote that you are a qualified, registered veterinary nurse? Pet owners need to know that when they walk through the door of your veterinary practice, their pet is in the hands of a qualified veterinary nurse. Julie

Membership Secretary report On 20th April 2019 the notice of AGM was sent to all members and included a proposal as follows: Proposal to increase membership fees The last time there was an increase in membership fees was 2014, prior to that in 2006, therefore it is proposed that membership fees be increased as follows: Full member and Associate Member $90.00 Student Member $55.00 4 September 2019

If any member objects to these membership fee increases they should notify the President, Julie Hutt at president@nzvna.org.nz as soon as possible. The motion was passed at the AGM of the NZVNA on 14th June – there had been one objection prior to the meeting. Membership fees have now been increased accordingly. Kathy

NZVNA

Letter from the Editor I don’t know about you, but I’ve found that it’s definitely been harder to get out of bed and participate in life as a productive human being during the colder months this year - it’s been much nicer to stay in bed with the cat and a good book. In saying that, working on the journal has been a productive use of my time… even if I am usually found wearing my pyjamas hunched over the laptop in front of the heat pump. With this in mind, the NZVNA Executive Committee (EC) is looking for volunteers to join the newly created NZVNA Sub-Committees. Vice President Amy Ross has written about the requirements of each portfolio so please take a look at page 18 to see if any of these areas are of interest to you. The portfolio jobs may be something you have previous experience with, or could be something you’d like to learn more about. Either way, the EC would love to hear from enthusiastic people who want to become

part of the NZVNA team. Disclaimer: some of these jobs will require you to wear day time clothes and not pyjamas. This edition also features Melissa Monehan’s article ‘A guideline for modifying a compulsive behaviour in an Oriental cat’, along with Lyn Hobbs’ case study ‘Equine ileocaecal bypass’, and the 2019 NZVNA conference review written by Georgina Green, Samantha James and Johanna Bloxham - all of which are pyjamafriendly reading. All published articles will be up for nomination for the Angela Payne award, which is announced at the annual NZVNA conference. This year I’d like to congratulate Katrina Lowe for her award-winning article Refeeding Syndrome. Well done Katrina! If you are considering writing an article for the journal, please email me at journal@nzvna.org.nz for further details. Antoinette

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CPD CORNER

Focus on soft skills By Patricia Gleason

Soft skills is the current terminology used to refer to those personal traits that have ultimate value in the workplace, school, and many other aspects of life. Soft skills is an umbrella term that encompasses people skills, social skills and personal attributes (Robles, 2012). Specific skills such as communication, and personal attributes that span other personal traits like integrity, courtesy, responsibility, professionalism and work ethic, are all perceived to be the most important by business leaders (Robles, 2012). Research shows soft skills predict success in life, that these skills can produce success in an individual, and that focus on developing these skills should be a key focus of learning and development in the public and private domain (Heckman, James & Kautz, 2012). So how much focus do you have on developing your soft skills as part of your continuing professional development?

After her career in biodiversity conservation, Patricia completed her Diploma in Veterinary Nursing (Distinction) at Massey University, and worked in veterinary clinics in the Bay of Plenty and Waikato before becoming a veterinary nurse educator. She is a founding member of the Allied Veterinary Professional Regulatory Council. She now works in a learning and development role coaching staff and teams in the education sector.

6 September 2019

Most veterinary nurses come to this career because of their deep respect and concern for animals and wanting to play a role in ensuring optimal welfare. Many veterinary nurses strive to be the trusted professional who veterinarians can rely on to complete any task, whether it be direct patient care or working with owners. Strong communication skills are essential to play this role effectively. This is why the education program you completed had those activities or assignments where you gave presentations, role-played scenarios, made a sales or product pitch, led mock team meetings, and completed group work. All of these were ways to develop your interpersonal communication skills, in preparation for working within the fast-paced and often stressful environment of a veterinary clinic, becoming part of a team and for working alongside clients. It was a way to hone the soft skills your current and future employer wants in all employees. An essential part of ensuring the highest standards of care for our patients is working with their owners. Veterinary nurses are expected to educate clients about conditions, treatment, nutrition, ongoing care and administering medications, as

well as answering questions and providing advice. We may need to calm clients in some situations when they are stressed or upset, and assist them to provide the best care they can for their pets. Continuing education around the latest treatment regimes or products is one part of providing optimal patient care, but we shouldn’t overlook further developing our skills around communicating effectively with our clients. Veterinary nurses and veterinary technologists need to be confident and competent to play this critical role in practice. Clear and confident communication is essential in most professions, and there are millions of resources available to help individuals grow, enhance and refine their communication skills for different purposes, in different contexts. Try a google search if you don’t believe me – I searched ‘developing confidence in communication’ and got 189 million results. Even looking at the approved list of CPD on the NZVNA website brings up over 20 courses aimed at some aspect of communication. Developing strong communication skills is one of the most valuable things you can do for yourself, as it brings confidence for your career and your relationships. Recognise that improving communication skills is a journey and is an essential part of your focus for continued/continuing professional development. Now the question is how much focus will you put on growing your soft skills? If you need help getting started, check out what is already available as approved CPD on the NZVNA website. References Heckman, J., & Kautz, T. (2012). “Hard evidence on soft skills,” Labour Economics, Elsevier, vol. 19(4), pages 451-464. Retrieved from: https://www. nber.org/papers/w18121 Robles, M. (2012). Executive Perceptions of the Top 10 Soft Skills Needed in Today’s Workplace. Business Communication Quarterly, Volume: 75 issue: 4, page(s): 453-465. Retrieved from: https://www.researchgate.net/ publication/258126575_Executive_ Perceptions_of_the_Top_10_Soft_Skills_ Needed_in_Today’s_Workplace

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CAT BEHAVIOUR

A guideline for modifying a compulsive behaviour in an Oriental cat By Melissa Monehan Dip VN

Melissa Monehan graduated in 2018 with a Diploma in Veterinary Nursing from UCOL, Palmerston North. This article is an abridged version of a behaviour assignment she wrote as part of her Diploma in Veterinary Nursing. Melissa is passionate about animal behaviour and is interested in completing further education in this field in the future.

8 September 2019

Introduction This article summarises the underlying causes of persistent sock stealing behaviour in a two year old male castrated pedigree Burmese cat (referred to by the pseudonym Buster), and will describe a tailor-made behavioural modification plan for his owners to implement. As this behavioural modification plan is based on current scientific knowledge of feline behaviour, it is hoped that it will result in the eventual resolution of this problem behaviour.

regarding Buster’s behavioural issue suggests a genetic predisposition to wool sucking because: • He is a Burmese pedigree cat • The problem first occurred at the age of six months, which is the typical onset of puberty in male cats, and this behavioural issue frequently occurs close to this stage in feline development (Beaver, 2003) • He shows a preference for socks, which typically have a thick texture that is similar to that of wool

Background information Buster’s problem behaviour is stealing socks from the neighbours’ houses and hiding these in his cat bed. The onset of the behaviour was first noted at six months of age, and is becoming more frequent. Buster’s owners, a couple, both work. There are no children or other pets in the household, and a cat door ensures free access to the outdoors.

However, the theory that a genetic predisposition causes this behaviour is anecdotal and has not yet been scientifically proven (Beaver, 2003; Landsberg et al., 1997; Shaw, 2015).

Possible causes for Buster’s behaviour Genetic predisposition Beaver (2003) states that Oriental cats can be genetically predisposed to kleptomania, yet it is important to note that Buster has chosen to exclusively steal and collect socks, which are usually of a thick texture and are generally woven from cotton. Pica is defined as an animal’s tendency to ingest non-food items. In felines, it often manifests as wool sucking/chewing. The theory is that Buster is collecting socks for the purpose of sucking or chewing on them, as their texture is appealing to him. However, his owners will need to definitively confirm this by observing him during this practice, or by examining the socks he has already stolen for signs of sucking, chewing and licking (Beaver, 2003). Pica is reported to be more prevalent in Oriental cat breeds such as Siamese or Burmese cats (Beaver, 2003; Case, 2010; Landsberg, Hunthausen & Ackerman, 1997). The current evidence

Medical causes As with any behavioural issue, it is essential to rule out medical causes before implementing a behaviour therapy plan for an animal. Feline leukaemia and feline immunodeficiency virus (FIV) have been reported to cause abnormal behaviours in cats. If a cat is displaying unusual behaviour, then this warrants diagnostic testing to check for the above diseases. In addition, a neurological examination should be conducted by the veterinarian to rule out brain tumours. Beaver (2003) notes that systemic or neurological diseases rarely result in the clinical signs of pica, and it is more likely that pica in felines results from some form of psychological distress. Displacement behaviour Cats are equipped with finely tuned senses and are highly motivated to detect and hunt small moving prey. Due to their intrinsic motivation to hunt, a well-fed cat may still hunt and bring prey back to their home territory (Heath, 2005). In Buster’s case, he is not ‘hunting’ per se, but is performing a displacement or conflict behaviour – a natural and normal behaviour that is performed outside of it’s usual context as a form of relieving

CAT BEHAVIOUR

stress and/or tension (Beaver, 2003; Case, 2010; Landsberg et al., 1997). Shaw (2015) suggests that a specific trigger within the animal’s environment is the impetus for this behaviour. Compulsive behavioural disorder When an animal regularly performs a displacement or conflict behaviour, this may foreshadow a compulsive behavioural disorder (Shaw, 2015). Stereotypies are also a component of compulsive behavioural disorder, and they are defined as any repetitive behaviour that does not appear to be goal-oriented (Landsberg et al., 1997; Shaw, 2015). Compulsive behaviour is defined as any behaviour that stems from typical behaviour, yet it has developed over time into any behaviour that is now abnormal because

it is exaggerated, repetitive, or it is now being performed out of usual context (Landsberg et al., 1997; Shaw, 2015). This behaviour does not occur in a vacuum; it is triggered by a sensation of stress and/or conflict (Shaw, 2015). Buster’s propensity for stealing socks (and possible subsequent sucking and/or chewing) is a repetitive behaviour that is performed with no obvious end-goal, as he is simply collecting the socks that he has stolen in his bed. Separation anxiety The human-cat relationship may be identified as a possible source of stress that is instrumental in the development of behavioural problems in cats. Bernstein (2005) states that a cat may present with clinical signs of separation anxiety during

prolonged periods of time away from his owner(s), and this is a result of the deep bond between the domestic feline and his human owner. Possible signs of separation anxiety in cats include excessive vocalization, inappropriate urination/ defecation, and other undesirable behaviours (Beaver, 2003; Case, 2010; Landsberg et al., 1997). Shaw, 2015 argues that ongoing exposure to a specific stressor or conflict causes a lowering of the threshold for the compulsive behaviour to be performed, and once this threshold has lowered enough, the animal will perform the compulsive behaviour at the first sign of stress/conflict. There are also some instances where a compulsive behaviour becomes ingrained to the extent that the animal will perform it when it is not feeling stressed (Landsberg et al., 1997). In addition, owners may initially find some forms of compulsive behaviour amusing and will reinforce it by paying special attention to the animal when it performs this behaviour (Landsberg et al., 1997; Shaw, 2015). It is typical for us, as human beings, to find the concept of sock-stealing cats highly amusing – after all, there are Instagram accounts dedicated to these cats! A behaviour modification programme for Buster Justification There are some caveats to the implementation of a behaviour modification programme. For example, a behavioural modification programme may only be necessary when the behaviour in question is dangerous in some way to the animal, or it is a disturbance to the owner (Landsberg et al., 1997). Buster’s behavioural issue has significant health ramifications, as ingestion of wool or part of a sock may cause a potentially fatal intestinal obstruction (Beaver, 2003). In addition, it has social ramifications for his owners, as their neighbours are likely to become displeased at continually having to replace their socks.

Photograph by Heikkisiltala [CC BY 3.0 (https://creativecommons.org/licenses/by/3.0)]

Essential criteria All medical causes of this behavioural issue must be definitively ruled out for a behaviour modification programme to be successful, so a full veterinary September 2019 9

CAT BEHAVIOUR

examination is warranted before starting a behaviour modification programme (Landsberg et al., 1997). As there is no one-size-fits-all approach to treating animal behaviour problems, it is crucial that a behaviour modification programme is customised to the individual animal and their presenting behaviours, as well as the trigger(s) for these behaviours (Campbell, Martin & Ritchie, 2015). The individualised behaviour modification programme must meet the following criteria: • It is easy for the owner to understand and it provides clear guidance on appropriate behaviour management techniques that will help to reduce the behaviour • It allows for flexibility and slight modifications as necessary to meet the animal’s learning needs all at stages of the programme • Achievement outcomes at each stage are measurable and progress at each stage is easy to evaluate (Case, 2010) Behaviour management techniques Technique 1: Identify and remove the trigger for this behaviour Veterinary behaviourists often advocate for the removal of a trigger/stimulus in order to manage a behavioural issue (Beaver, 2003; Case, 2010; Landsberg, et al., 1997; Martin et al., 2015). However, any behaviour modification programme must be customised to suit the animal’s needs (Martin et al., 2015), and preventing Buster from accessing the outdoors would be pointless, as he is likely to continue this behaviour if he does gain outdoor access in the future. Also, changing Buster’s lifestyle so that he is an indoor-only cat is likely to reduce his levels of daily enrichment, which will exacerbate his feelings of boredom and stress. It may also be counterproductive in that his inability to access socks will increase his anxiety and worsen the problem without actually addressing the root cause of the problem (Landsberg, et al., 1997). If long periods of time spent alone is the impetus for Buster’s behaviour, then one solution is for the owners to investigate whether one or both can take annual leave during the period of the behaviour modification programme. This is because the avoidance of a known trigger for a behaviour reduces the likelihood that 10 September 2019

Buster will continue to steal socks during the period of the treatment plan (Shaw, 2015). Alternatively, they could inquire into the possibility of flexible working hours or working from home for one or more days during the week. However, depending on the industries that they operate in, this may be an impracticable idea. Therefore, it is essential that the other suggestions in this treatment plan are followed carefully.

• Use interactive food puzzle toys to increase Buster’s level of mental stimulation. These are ideal because he is currently feed adlib. • Use tall cat trees to increase the amount of indoor territory available to Buster. These create enrichment because they encourage climbing and exploration, as well as providing areas to sit and hide (Martin et al., 2015)

Technique 2: Increase the amount of environmental enrichment Increasing the level of environmental enrichment in an animal’s day-to-day life is strongly recommended for reducing an animal’s stress levels, particularly when they are suffering from a compulsive behaviour disorder. It increases the amount of mental stimulation they receive, as well as providing them with more exercise opportunities (Landsberg, et al., 1997; Martin et al., 2015). Environmental enrichment means the cat’s home environment is adapted so that: • They have increased opportunities to play and participate in normal cat behaviours • They have a consistent period where they have positive interactions with their owner(s) daily (Case, 2010; Landsberg, et al., 1997; Martin et al., 2015)

Technique 3: Implement a desensitisation programme A desensitisation programme aims to habituate the animal to fearful or aggressive stimuli via exposure at a very low level of intensity (that does not evoke a fear response), which is gradually increased over time in response to the animal’s reactions (Case, 2010). The desensitisation process should coincide alongside the counter-conditioning process (described below) for maximum benefit. It is important to note that Buster’s progress may be variable, and if or when his progress declines at any point, it will be necessary to go back to the previous step. Therefore, the owners’ flexibility is essential to the success of this plan (Case, 2010). For Buster, a tentative desensitisation plan could occur as follows: • Buster is placed in a small room and is provided with interactive food puzzle toys, as well as other toys that he enjoys playing with while his owners leave for a short period initially (i.e. ten minutes). They do not pay any attention whatsoever to him upon departure or arrival - this is an effective treatment for his separation anxiety because it decreases his arousal levels (Shaw, 2010) • After one week, this may be increased to 30 minutes, but he is given access to the rest of the house • After each week (or according to Buster’s progress), increase the time that Buster is left at home alone by an incremental 30 minutes each time. The incremental 30 minute increases should be made on the proviso that there are no incidents of sock stealing. These increases can occur until they gradually reach the total time that the owners are away for during the day (Case, 2010; Landsberg et al., 1997)

At present, Buster gains environmental enrichment from being allowed to go outside as desired throughout the day. However, the apparent dilemma is that this provides him with multiple opportunities to wander the neighbourhood and steal socks. From the standpoint of environmental enrichment, access to the outdoors is beneficial for cats as it increases their levels of mental stimulation via adequate opportunities to explore, and it allows them to exhibit their natural behaviours (Martin et al., 2015). Tips for environmental enrichment: • Implement morning and afternoon periods of interactive play for Buster at set times. Use a variety of different cat toys that encourage his natural hunting behaviours such as hunting, stalking and pouncing; examples of suitable toys include balls, stuffed mice and stuffed toys/feathers attached to a pole (Case, 2010; Martin et al., 2015)

CAT BEHAVIOUR

Technique 4: Implement a counterconditioning programme Counter-conditioning is the process where an animal is prompted in some way to respond to a specific stimulus, in a way that is now incompatible with its initial response. For example, a dog that previously jumped up on people as a greeting is instead taught to sit when it greets people – an undesirable behaviour is replaced with a desirable behaviour (Case, 2010; Landsberg et al., 1997; Shaw, 2015). Counter-conditioning is carried out by exposing an animal to a fearful stimulus at a level that does not cause a fear response, while distracting them by feeding high-value treats. This process has the effect of gradually habituating the animal to the previously fearful stimulus, by teaching them to associate the once fearful stimulus with an enjoyable activity, i.e., eating treats (Case, 2010; Shaw, 2015). For Buster, the act of retrieving his favourite treats from interactive food puzzle toys may have the effect of replacing his anxiety at his owners leaving with a feeling of happiness/satisfaction at playing with a food puzzle. This training technique may also be useful in teaching Buster that instead of stealing socks to cope with feeling anxious and/or lonely, he can play with his food puzzle (Shaw, 2015). Technique 5: Ignore undesirable behaviour(s) Whenever Buster’s owners observe him carrying or playing with stolen socks, they must ignore him completely, as attention of any type is known to reinforce undesirable behaviours (Landsberg et al., 1997; Shaw, 2015). Although this is likely to be difficult, they are advised to think of ways to ignore him (i.e. by leaving the room) only when the undesirable behaviour is occurring; Buster’s other needs must be met in a timely manner. Initially, Buster’s behaviour is likely to worsen as he is resorting to an ingrained default behaviour, therefore, his owners must continue to studiously ignore him whenever they notice him stealing socks. However, the initial worsening of undesirable behaviour is a normal part of his learning process (Shaw, 2015).

Avoid punishment at all costs Although specific punishment techniques are often the cornerstone of an effective training programme, these are reserved for training animals whose behaviours are not anxiety based (Case, 2010; Martin et al., 2015; Shaw, 2015). The hypothesis is that this cat’s behaviour is due to separation anxiety and/or a potential genetic predisposition - punishment is detrimental to resolving an anxiety-based behavioural issue and is likely to damage the feline-human bond. Also, sufficient punishment follows strict criteria that must be consistently adhered to, meaning that it is often misused by animal owners (Shaw, 2015). Additional suggestions for anxiety-based behavioural issues Antidepressant drugs As pica is often a clinical sign of a compulsive behaviour disorder in Oriental cats, it may be necessary for a veterinarian to prescribe an antianxiety medication to help manage anxiety. Appropriate drugs include the tricyclic antidepressants clomipramine/ amitriptyline and fluoxetine, a selective serotonin reuptake inhibitor (Beaver, 2003; Case, 2010; Landsberg et al., 1997; Shaw, 2015). The prescription of one of these drugs may be particularly beneficial if Buster repeatedly displays marginal progress during the behavioural modification programme detailed above. Implement a consistent daily routine A routine where feeding, playtime and training occur at regular times is thought to assist in alleviating anxiety in animals, because it creates predictability. Also, switching to feeding twice daily (at set times) has been proven to decrease stress and to increase interest in food treats (Shaw, 2015). Conclusion Based on the information available, it is hypothesised that the origin of Buster’s behavioural issue is a compulsive disorder that is triggered by a chronic state of stress, as a result of his owners working and being away from home for extended periods. It may be relatively difficult to rectify this behaviour, due to current anecdotal evidence that implies that Oriental cats are genetically predisposed to wool sucking. However, this does

not mean that an active programme of systematic desensitisation and habituation is pointless. Although more comprehensive information is required from his owners, Buster will benefit significantly from a consistent schedule of enjoyable interactions with his owners, environmental enrichment, and possibly pharmacological interventions. If Buster’s owners make concerted efforts to follow his behaviour modification plan to the letter, then the prognosis for modifying his sock-stealing behaviour is good (Beaver, 2003; Case, 2010; Landsberg et al., 1997; Martin et al., 2015; Shaw, 2015). References Beaver, B.V. (2003). Feline Behavior: A Guide for Veterinarians. St Louis, MO: Elsevier Saunders. Bernstein, P.L. (2005). The Human-Cat Relationship. In I.Rochlitz, (Eds.), The Welfare of Cats (pp. 47 – 89). Dordrecht, The Netherlands: Springer. Case, L.P. (2010). Canine and Feline Behavior and Training: A Complete Guide to Understanding Our Two Best Friends. Clifton Park, NY: Delmar Cengage Learning. Heath, S.E. (2005). Behaviour Problems and Welfare. In I.Rochlitz, (Eds.), The Welfare of Cats (pp. 91 – 118). Dordrecht, The Netherlands: Springer. Landsberg, G., Hunthausen, W., & Ackerman, L. (1997). Handbook of Behaviour Problems of the Dog and Cat. Oxford, United Kingdom: Reed Educational and Professional Publishing Ltd. Martin, D., Campbell, L.M., & Ritchie, M.R. (2015). Problem prevention. In D. Martin & Shaw, J.K., (Eds.), Canine and Feline Behavior for Veterinary Technicians and Nurses (pp. 145 - 202). Ames, IA: WileyBlackwell Ltd. Martin, K.M. & Martin, D. (2015). The Role of the Veterinary Technician in Animal Behavior. In D. Martin & Shaw, J.K., (Eds.), Canine and Feline Behavior for Veterinary Technicians and Nurses (pp. 1 – 29). Ames, IA: Wiley-Blackwell Ltd. Shaw, J.K. (2015). Specific Behavior Modification Techniques and Practical Applications for Behavior Disorders. In D. Martin & Shaw, J.K., (Eds.), Canine and Feline Behavior for Veterinary Technicians and Nurses (pp. 204 – 279). Ames, IA: Wiley-Blackwell Ltd. September 2019 11

PALLIATIVE CARE

Palliative care: providing ‘a good death’ for your patients By Antoinette Ratcliffe LVN, NZVNJ Editor

What is a good death? Field and Cassel (1997) defined it as ‘one that is free from avoidable distress and suffering for the patient, family, and caregivers’. Even though this is a phrase used to refer to the human patient with a terminal illness, as veterinary nurses we have the means to carry out palliative care support to provide a good death for our terminal patients. The Palliative Care Handbook (2016), published by Hospice New Zealand, describes the primary goal of palliative care as optimizing the quality of life for patients and their families by preventing problems, delaying their onset and reducing their severity. In veterinary medicine, a combination of factors are driving the need for palliative care to be recognised and plans made to

Antoinette is the New Zealand Veterinary Nurse journal editor and has been a qualified veterinary nurse since 2007. She currently works part-time in a small animal practice in Wellington and spends the rest of the week working in her taxidermy studio.

12 September 2019

address this. Advances in diagnostics and specialisation in the industry mean patients are living longer, facing multiple health issues, and need complex care plans in their senior years (Valie, 2019). Having a thoughtful end-of-life (EOL) conversation has, therefore, become more critical than ever before. When a pet is diagnosed with a terminal illness, owners are not only faced with the news but the many treatment options that might be available, including euthanasia. Will they choose to euthanize their pet before the pain and condition become worse? Euthanize when the pet’s quality of life becomes affected? Euthanize when medications can no longer control the pain or symptoms? Or choose to let their pets die at home naturally, while

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September 2019 13

PALLIATIVE CARE

ensuring that other measures to alleviate pain and distress are in place? These are all questions required to develop a personalised palliative care plan that will prioritize the owners’ wishes and the most important things that need managing in terms of the patients quality of life. Develop a personalised palliative care plan While the veterinarian will discuss with the owner the specific aspects of the pet’s care, medications and nutritional needs, it is important that an interdisciplinary team approach is utilised in the palliative care plan. Veterinary nurses can assist by demonstrating and teaching techniques to owners (for example, administering subcutaneous fluids or medications) that will cause the least amount of stress to the owner-pet relationship. These steps are an essential part of any palliative care plan because for EOL care to be successful, not only must the client be willing and able to implement the treatment plan, but the patient must also be a willing participant (Bishop et al., 2016). An individualized palliative care plan should consist of: • A revisit schedule: set up a revisit or check-in schedule where owners can ask further questions about the illness. These appointments can also be a time where owners and veterinarians can make adjustments to the pet’s care plan. Revisits may be made up of a mixture of veterinary and veterinary nurse consults, depending on clinic protocols or the progress of the illness. • Repeat prescriptions: veterinarians need to record any repeat prescriptions on the pet’s record for veterinary nurses to dispense as required. Providing owners with a pain management scale, such as the Glasgow Composite Measure Pain Scale (canine or feline), will help them assess their pet’s level of comfort and advocate for them accordingly. • A supportive therapy plan: the veterinarian may prescribe medications such as antiemetics, appetite stimulants, antibiotics for chronic infections associated with the disease, or multimodal pain relief. Veterinary nurses need to be able to answer 14 September 2019

•

questions from the owners about these medications, and their potential side effects. Toilet accessibility: owners need to check that the pet can easily access their elimination sites. For example, arthritic cats may need a litter tray inside if using the cat door has become problematic. Litter trays should have low edges, so it’s easier for them to step in and out of. Nutritional assessment: care should be taken to perform a thorough dietary assessment, and the pet’s body condition score and weight recorded at every visit to the clinic. Adjustments can then be made to their diet to maintain a balanced nutrition and calorie intake as needed, and supportive therapy medications may need to become part of the pet’s care plan as the disease progresses. The owner will need to monitor for changes in eating and drinking habits, and should also be advised that it is a normal part of the dying process for food and water intake to decrease. Mobility assessments: the pet’s mobility will become compromised over time, so it is essential that owners are made aware that they may need to provide a non-slip surface for their pet’s living space. Moving litter trays so that cats have easier access to them will avoid potential toileting accidents, and providing a set of stable steps up to their favourite part of the couch or bed, or a ramp up to the car for dogs, will also help ease discomfort. Gentle handling techniques may need to be discussed. Remind owners that the pet’s access to environment hazards may need to be restricted. Rest and comfort considerations: ask the owner to check the pet’s sleeping environment. Is the bedding comfortable? Is it a peaceful place for them to rest? Can it be kept at a comfortable temperature with ventilation control? The owner will need to readjust the sleeping environment regularly as the illness progresses. Social wellbeing: maintaining the pet’s regular social activities as the illness allows will help with their social

wellbeing. However, the owner will need to observe interactions with other pets as there can be hierarchical changes within the group, which may make this activity detrimental to the pet’s social and emotional wellbeing. • Emotional wellbeing: remind the owner to avoid leaving the pet on its own for extended periods. Instead, advise them to offer regular opportunities for play and provide environmental enrichment when they are away, as this can also help with mental stimulation and emotional wellbeing. • Monitoring signs of withdrawal and depression: the owner will play a large part in maintaining their pet’s emotional wellbeing by managing incontinence, minimizing exposure to stress and changes of routine, keeping up good hygiene and grooming, and regularly assessing the pet’s willingness to

PALLIATIVE CARE

receive any treatments. Remind them how important this is in monitoring the pet’s will to live. If the owners observe signs of withdrawal or depression, they need to discuss this behaviour with the veterinarian. • Emergency contact numbers: provide the owners with emergency contact numbers, such as the closest afterhours veterinary clinic. Owners should also be advised to take all medications their pet is currently prescribed to any after-hours veterinary clinic appointments, so that the veterinarian is aware of them when prescribing other medications. • Disaster Emergency Kit upgrade: remind owners that their pet’s medications will also need to be part of their Disaster Emergency Kit – this should already include a cat carry cage for each cat, a leash or harness for each dog, and may also need to include items such as slings or a cart to transport dogs with mobility issues. EOL expectations For owners, knowing more about the illness which their pet is facing and what to expect during the EOL process, will give them more control of the situation. This will allow them to make educated decisions about further treatment. Having a palliative care plan and making time to talk with the owner about the illness means there will be less opportunity for surprises. Euthanasia Once people have made the decision, they have given it a tremendous amount of thought - more than they may let on during a traditional veterinary appointment (Goldburg, 2014). The best thing we can do for them and their pet is to support them through the process. Discussing what they would like to do with the body ahead of time can give owners something to think about in terms of honouring their pet. If an owner would like to keep the body at home for an extended amount of time, recommend that the pet rests in a cold room with ice packs (double ziplock bagged). Family and friends can then come to visit the pet and family, similar to a tangihanga (more commonly

known as a tangi). Care should be taken to supervise other pets around the deceased. Burial Information about home burial should also be given to the client; for example, they will have to arrange to prepare a grave approximately 1 - 1.2m deep to bury their pet. Placing a plant or memorial to mark the grave will not only be a lovely gesture of remembrance, but will serve as a marker if the owner decides to do any landscaping in the future, and hopefully provide a deterrence to other pets who may want to dig in the same area. Communicating with younger family members Being truthful about death allows children to learn a biologically accurate understanding of it, that it is not an altered state of living (i.e., living in a casket underground), regardless of social, emotional and religious beliefs of the afterlife (Slaughter, 2019). A child’s knowledge or emotional reaction to death is often underestimated by adults, due to their limited language ability (Gabb, Owens and MacLeod, 2013). Euphemisms like ‘she’s resting’, ‘she’s gone to a better place’, or ‘we lost her’ can be confusing for children (Slaughter, 2019). Supporting owners who have younger family members through an anticipated death can be incredibly hard, and it helps take some pressure off the owners by providing useful resources such as https://www.skylight.org.nz/resources/ death-and-dying/anticipated-death. Grief While we know that grief is the natural response to loss and that it is a dynamic process that changes over time, some pet owners may need to access professional counselling or grief support. An excellent place to find more information is Skylight (www.skylight.org.nz), where there are a variety of resources for all age groups to help with the grieving process. References Bishop, G., Cooney, K., Cox, S., Downing, R., Mitchener, K., Shanan, A., Soares, N, Stevens, B., & Wynn, T. (2016.) Endof-Life Care Guidelines. Journal of the American Animal Hospital Association.

52(6) 341-356. https://doi.org/10.5326/ JAAHA-MS-6637 Field, M., & Cassel, C. (1997). Approaching Death: Improving Care at the End of Life. Washington DC: National Academy Press Gaab, M., Owens, G., & MacLeod, R. (2013). Caregivers’ Estimations of Their Children’s Perceptions of Death as a Biological Concept, Death Studies, 37(8), 693- 703. https://doi.org/10.1080/074811 87.2012.692454 ScienceTeller19 (2019, April 16) Virginia Slaughter - How Modern Children Learn About Death [Video file]. Retrieved from https://www.youtube.com/ watch?v=frxrWwXhoW0 Goldburg, K. (2014). Saying Good-Bye: Making the best end-of-life decisions requires focusing on what matters. Retrieved from https://www.iaahpc.org/ images/BarkArticleSpring2014Goldberg. pdf MacLeod, R., Vella-Brincat, J., & Macleod, S. (2016). The Palliative Care Handbook: guidelines for the clinical management and symptom control. (8th Ed.) Retrieved from http://www.hospice.org. nz/cms_show_download.php?id=1243 Valie, H. (2019). Palliative care for pets. Vet Voice. Retrieved from https:// www.vetvoice.com.au/articles/ palliative-care-for-pets/ Resources Penfield, J. (2018). When Kiwis reach the ceiling of treatment: managing dying in modern New Zealand. In E. Johnson (Ed.), Death and dying in New Zealand (1st ed., pp 35-49) Christchurch, NZ: Freerange Press. Reid, J., Scott, E. M., Calvo, G., Nolan, A. M, Hughes, J., & Lascelles, D. (2007). Glasgow Composite Measure Pain Scale (GCMPS - SF) Canine. Retrieved from: https://www.wsava.org/WSAVA/media/ PDF_old/Canine-CMPS-SF_0.pdf Reid, J., Scott, E. M., Calvo, G., & Nolan, A. M. (2015). Glasgow Composite Measure Pain Scale (GCMPS) Feline. Retrieve from: http://www.aprvt.com/ uploads/5/3/0/5/5305564/cmp_feline_ eng.pdf Skylight Trust. (n.d.). Resources for ‘loss of a pet’. Retrieved from https:// www.skylight.org.nz/search/ results?topic_ids%5B%5D=59 September 2019 15

CAV CLINICAL UPDATE

Comparison between flow-by oxygenation and facemask oxygenation on the partial pressure of arterial oxygen in sedated dogs By Andrew Dart BVSc, PhD, Dip ACVS, Dip ECVS, Christina Dart DrMedVet, DVSc, MVSc, DipACVA, Adrian Wong BVSc, Eduardo Uquillas DVM

Contact: Research and Clinical Training Unit, Veterinary Teaching Hospital, Camden, University of Sydney. andrew.dart@sydney.edu.au

This article is reprinted with the permission of the Companion Animal Veterinarians Branch of the NZVA 16 September 2019

Oxygen supplementation is often a critical component of treatment in emergency situations, particularly where the patient is suffering from, or at risk of developing hypoxaemia. Common techniques described to supplement the inspired fraction of oxygen (FiO2) include intranasal catheters, an oxygen hood, an oxygen collar, an oxygen box, a face mask, and flow-by oxygen. Flow-by oxygen and face mask supplementation are often preferred by veterinarians because they use equipment already available in most practices, and both techniques are simple and convenient to set up and use. Flow-by oxygen supplementation is the easiest to set up and to execute. It requires an oxygen source, an anaesthetic machine and breathing system that relies on placing the oxygen supply in close proximity to the nose of the patient, at a flow rate sufficient enough to produce an ‘oxygen cloud’ around the patient. Face mask oxygen supplementation involves the delivery of oxygen to a tight-fitting face mask and delivers oxygen more efficiently. However, this technique can be limited by the tolerance of the patient to the mask. Resistance from the patient to the mask can increase the oxygen demand and undermine the efficacy of the oxygen supplementation. So flow-by oxygen is often preferred by practitioners, particularly in non-sedated dogs. There is little information evaluating the efficacy of flow-by oxygen as a method of oxygen supplementation. Our study, recently published in the New Zealand Veterinary Journal (Wong et al, 2019), aimed to correct this deficit. In this study, 20 mixed-sex and mixed breed dogs, weighing >15 kg, were each exposed to both face mask oxygen

supplementation and flow-by oxygen supplementation for five minutes. The dogs were sedated for the study with 0.015mg/kg of medetomidine and 0.5mg/kg methadone administered intramuscular (IM), 20 minutes prior to oxygen supplementation. A baseline sample of arterial blood was taken from an indwelling arterial catheter before the dogs were exposed to either forms of oxygen supplementation. The order the two forms of oxygen supplementation were administered were randomly assigned to each animal. There was a ‘washout’ period where dogs breathed room air for 15 minutes between the two periods of oxygen supplementation. Additional arterial samples were collected at the end of the first five minute period of oxygen supplementation, at the end of the washout period, and following the second first period of oxygen supplementation. This constituted a total of four arterial samples per dog; two samples were taken after breathing room air and two samples taken after five minutes of oxygen supplementation using each of the two treatment protocols. Arterial samples were subjected to a blood gas analysis and, in particular, the partial pressure of oxygen (Pa02) was determined. Oxygen supplementation via a face mask was delivered through a Mapleson type D breathing system with a reservoir bag, at a flow rate of 3L/minute. The size of the reservoir bag was selected based on each patient’s vital capacity volume (5x10 mL/kg body weight). The face mask was modified to minimise leakage of oxygen, by stretching a latex glove over the opening of the mask with a small hole through which the dog’s nose could be passed, providing a tight seal (Figure 1). The same face mask was used for all patients. Oxygen supplementation

CAV CLINICAL UPDATE

delivered using a flow-by technique used a modified Mapleson type D breathing system, connected to an anaesthetic machine with an oxygen flow rate of 3L/ minute. The end of the breathing tube was held 2cm from the patient’s nares (Figure 2). The mean PaO2 in arterial samples taken from the dogs after five minutes of face mask oxygen supplementation was 371.3 mmHg (95% confidence interval = 312.3– 430.3), which was higher than in samples taken after they received five minutes of flow-by oxygen supplementation (182.2 mmHg; 95% confidence interval = 153.4– 211; p<0.001). The mean PaO2 in samples taken after receiving either form of oxygen supplementation was higher than in samples taken after the dogs had been breathing room air (82.43 mmHg; 95% confidence interval = 73.4-91.4; p<0.001). There was no association between sex, age, weight or breed of dogs and blood gas parameters or rectal temperature. This study was performed on healthy, sedated dogs. The mean PaO2 of the sedated dogs breathing room air was at the lower end of the reported range in otherwise healthy, unsedated dogs (81–103 mm Hg). Sedation with an opioid or an alpha-2 agonist alone has little to no impact on PaO2, but the combination of the two can lead to mild hypoxemia. This may explain the low-normal mean oxygen in the dogs while breathing room air.

Face mask oxygenation creates a reservoir of oxygen by continuously filling the mask and the proximal tube with fresh oxygen, displacing the expired carbon dioxide. This reservoir of enriched oxygen is available to the patient during inspiration. In comparison, flow-by oxygenation relies on the formation of an oxygen cloud in front of the patient. In the absence of a discrete reservoir of enriched oxygen, the dilution of the oxygen escaping from the tube with ambient air during inspiration reduced a fraction of inspired oxygen compared to the face mask technique. When using flow-by oxygen supplementation, the distance from the oxygen source to the patient is an important factor determining its effectiveness. Positioning the oxygen source 2cm from the nose of the patient consistently produces a greater inspired fraction of oxygen than when the source is 4cm from the nose, irrespective of flow rates. Furthermore, the values obtained at 4cm are highly variable. This would suggest that when using flow-by oxygenation a more reliable effect will be achieved if the opening of the tube is maintained within 2cm of the patient. Various oxygen flow rates have been suggested for both face mask and flow-by oxygen supplementation. Some textbooks recommend oxygen flow rates as high as 6–8 L/minute for flow-by oxygenation, and 6–10 L/minute for face mask oxygenation, to obtain a FiO2 of 0.24–0.45 and 0.35–0.55, respectively. Other

Figure 1. Oxygen supplementation via face mask.

experimental studies suggest increased oxygen flow rates, with either technique for oxygen supplementation, leads to minimal increases of FiO2. It would appear much lower flow rates are adequate and higher flow rates are unnecessary and wasteful. A flow rate of 0.5L/minute for face mask oxygenation and 2L/minute for flow-by oxygenation may be adequate to achieve a PaO2 of at least 70 mmHg in healthy patients. However, the oxygen flow rate may need to be increased to accommodate patients with compromised respiratory function and this should be considered. A flow rate of 3L/minute in this study achieved increases in the PaO2 of dogs exposed to flow-by and face mask oxygen supplementation two to four times the level of dogs breathing room air, and would seem to be a good starting point for dogs with respiratory compromise. Oxygen supplementation delivered using a face mask was more effective than flow-by oxygen supplementation in raising PaO2. However, the results of this study suggest flow-by delivery of oxygen at a flow rate of 3L/minute and distance of 2cm from the nose is a suitable alternative for oxygen supplementation when a face mask is not tolerated. Reference Wong AM, Uquillas E, Hall E, Dart CM, Dart AJ. Comparison of the effect of oxygen supplementation using flow-by or a face mask on the partial pressure of arterial oxygen in sedated dogs, New Zealand Veterinary Journal 67, 36-39, 2019

Figure 2. Oxygen supplementation delivered via flow-by technique.

September 2019 17

NZVNA

NZVNA Sub-Committee announcement By Amy Ross RVN, NZVNA Vice President

Last year the NZVNA Executive Committee (EC) identified the need to review and update the governance and structure of the EC, to ensure our organisation remains sustainable as well as being able to grow in the future. We started this process by developing a strategic plan for 2018-2021, with the purpose to chart a course for the next three years. The strategic plan was designed to be flexible and to cope with future changes within the veterinary industry in New Zealand. On Friday 14th June 2019, at the NZVNA AGM, Julie Hutt (NZVNA President) announced the development of four Sub-Committees, to assist the EC with supporting and advancing the veterinary nursing and technologist profession within New Zealand. We are currently looking for expressions of interest from our full and student members that are wanting to assist with the future development of our veterinary nursing community. The sub-committees are: Membership The purpose of the Membership SubCommittee is to: • Support the vision and objectives of the NZVNA, especially concerning improving retention of existing members and securing new members • Detail membership benefits to existing and new members • Develop new membership benefits • Work with the NZVNA EC to research and recommend a range of merchandise for sale at the conference and online store • Carry out membership satisfaction surveys and report findings to the NZVNA EC (surveys may be on an annual or biennial basis) • Investigate educational scholarship opportunities • Manage Vet Nurse Awareness Week • Assist with developing and promoting the Vet Nurse of the Year award

18 September 2019

Continuing Professional Development (CPD) The purpose of the Continuing Professional Development (CPD) SubCommittee is to: • Support the vision and objectives of the NZVNA • Write CPD quizzes from appropriately sourced journal articles and conference papers, keeping a record of articles used and when quizzes are placed online • Help source CPD events to be listed on the CPD calendar. This can be online as well as face-to-face CPD events. • Ensure CPD covers a variety of interests to meet our member’s needs eg equine, large animal, small animal, avian, exotics, practice management • Source topics of interest and speakers for webinars and e-CPD • Align with roadshows and keep a calendar of events • Develop a national conference speaker list and maintain a relationship with them • Work with Journal Sub-Committee to source articles • Develop minimum standards for accredited CPD • Marketing/Accrediting of industry CPD • Make recommendations of case-by-case CPD point allocation • Develop and review online resources and clinic posters for our members Media – Social Media The purpose of the Media - Social Media Sub-Committee is to: • Support the vision and objectives of the NZVNA • Develop content for the NZVNA Facebook page and groups as well as the Instagram account to create awareness and industry matters to promote engagement of our members and followers • Moderate the NZVNA Facebook page • Secure content and other items of interest for eNewsletters, the NZVNA website and other media channels as deemed appropriate

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NZVNA

• Moderate the NZVNA website • Present ideas to the NZVNA EC for opportunities to further enhance the membership benefits in regards to editorial and communications Media – Journal* The purpose of the Media-Journal SubCommittee is to: • Support the vision and objectives of the NZVNA

If you would like further information or you would like to complete an Expressions of Interest form, please email me at vicepresident@nzvna.org.nz.

• Secure external content and other items of interest for publication in the New Zealand Veterinary Nurse Journal (NZVNJ) • Edit material for each individual’s area of content

The full Terms of Reference for the four Sub-Committees are available on our website www.nzvna.org.nz.

*Please note that this Sub-Committee is already in place as the Editorial Board and is currently full.

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BOOK REVIEW

Practical Veterinary Dental Radiography Reviewed by Cindy Paton

Authors: Brook A Niemiec, Jerzy Gawor and Vladimir Jekl Published: 2018 Publisher: CRC Press, Taylor and Francis Group, LLC 368 pages (hardback) $139.41 (BookDepository.com, price sourced June 2019)

This textbook is a treasure trove of information and images for a dental geek like me. It covers all aspects of dental radiographs, beginning with the importance and indications of dental radiography. With thousands of photos and radiographs that clearly illustrate common pathology of the teeth, above and below the gum line, this bookâ&#x20AC;&#x2122;s well-written text clearly explains each image in depth. The first chapter is a short explanation of marketing dental radiography, pointing out the importance of dental radiographs from a clinicâ&#x20AC;&#x2122;s point of view. It discusses how educating all veterinarians, veterinary nurses, veterinary technologists and frontline veterinary staff, and getting them on board, would dramatically enhance the buy-in of clients who already understand the importance of dental radiographs for themselves. There are chapters dedicated to the equipment needed for digital imaging, radiographic positioning and techniques, and one that discusses hand developing dental radiography films for those not fortunate enough to have digital dental radiology. The textbook also covers techniques to eliminate common errors (such as incorrect angulation of the tube head, and under or overexposed plates), along with procedures of how to remedy these common problems. More substantial veterinarian-based chapters in the textbook cover topics such as endodontic disease, issues with the enamel of the tooth, proliferative lesions, tumours and pathologies related to nasal cavities, temporomandibular joint

and mandibular symphysis issues. I found the detailed chapter on rabbits, ferrets and other rodents fascinating in regards to the comparisons of their dentition with the species I see regularly, and to learn that they suffer very similar complaints. There is a lot more to dental health for these species than trimming maloccluded incisors, for example, loose and broken teeth, missing and extra teeth, and tooth root abscesses are some of the more common complaints. The final chapter compares referral practice options of Magnetic Resonance Imaging (MRI), Computed Tomography (CT) and Cone-Beam Computed Tomography (CBCT), briefly discussing the differences between them and the pros and cons of each. The most limiting factor is access to this hi-tech level of imaging and the associated costs. As a veterinary nurse who performs dental descale and polishes regularly, I see a variety of pathology. After learning more of the correct terms, I find that now I am more confident in my terminology when I report my findings to the veterinarian on handing the case over, having read this textbook. I found this book to be engaging because it explains the normal, and not so typical, in plain language and has become my go-to for any out of the ordinary findings to satisfy my curiosity. With a general knowledge of dental terminology, I think any veterinary nurse or veterinary technologist with interest in dentistry would get a lot out of this textbook and highly recommend it for any veterinary clinic library.

September 2019 21

CONFERENCE

2019 NZVNA Conference review Taking the lead: Companion animal stream By Johanna Bloxham RVN Samantha James RVN Forrest Hill Vet Clinic, Auckland

This year the annual New Zealand Veterinary Nursing Association (NZVNA) Conference was held at the Heritage Hotel in Auckland, on June the 14th and 15th, and we were lucky enough to attend. Registrations opened early at 7.45am, giving us the chance to sign in, pick up our lanyards, grab a goody bag and a coffee, followed by a quick look at the eye-catching and informative stands of the conference sponsors. We were all welcomed into the conference room for the opening ceremony at 8.20am, and the first talk of the day by keynote speaker Dan Brockman. Dan’s talk on the care and management of accidental wounds provided us with a more extensive understanding of assessing and choosing the best approach needed to manage an accidental wound, along with the differences between passive vs active dressings, adherent vs non-adherent, and different cleaning and bandaging techniques. This talk followed into his next topic, ‘Looking after the post wound reconstruction patient and recognising complications’. He covered skin grafting, skin closure, monitoring for fluid accumulation, suture lines, and infection, using a series of case studies to provide thorough examples of each process. We learnt that the choice of reconstruction and the execution of the procedure is vital to the outcome of the wound reconstruction. 22 September 2019

Next up was morning tea, where we were able to grab a light refreshment, a third coffee for the day, had the opportunity to say hello to our lovely reps at their stalls and, of course, collect the odd handful of lollies and chocolates for a wee sugar boost! After morning tea, Wendy Jarnet gave her talk, ‘Anxiety and the veterinary nurse’. This was highly engaging, and our personal favourite talk of the entire conference, as we both feel that this aspect of veterinary nursing often gets swept under the rug and is not highlighted enough in our profession. From her personal experience, and even our own, we can empathise. We are all aware that worldwide, veterinary industry professionals have a high rate of suicide, and we all know how difficult the industry can be - and often we take these stresses home with us. We work in a profession where we are trying to keep clients happy, keep costs down, and make sure the veterinarians are happy, with little pay, a heavy workload, and long hours, not to mention the grief that comes with losing a patient who has been under your nursing care for some time. Wendy gave us a list of signs to look for when anxiety is affecting you or someone you know. She also gave us a variety of techniques to deal with these symptoms titled ‘How to make anxiety your entire female dog’ - a phrase which the whole room had a giggle about. Wendy discussed the many options out there if you need help, and that it’s just about finding the right one for you. We were also reminded that NZVNA runs a wellness programme, Vitae, for veterinary nurses in stress. Information on accessing this can be found in the ‘Members Only’ section of the NZVNA website. Next was the Annual General Meeting, where we heard portfolio reports from the executive committee who successfully run and manage the NZVNA on a voluntary

basis. They do a fantastic job and are always working tirelessly to improve the profession and standards. After lunch, we had the pleasure of listening to Elena Saltis. She spoke about physiotherapy and how the veterinary nurse can implement simple and easy techniques to aid the patient’s recovery, get them on their feet quicker, and/ or improve their mobility. We took away how important and necessary physiotherapy is for patient recovery. She highlighted how easily overlooked the use of physiotherapy in practice is, and how it can help rehabilitate our patients, improving their quality of life. Afternoon tea was quickly followed by Dan Brockman’s last talk of the day, ‘Nursing the thoracic surgery patient: optimising recovery’. This isn’t something most of us would see or utilise every day as it usually happens at specialist and referral centres, but we learnt some new things that we can bring out when the opportunity arises. Before we knew it, it was happy hour! We were greeted with complimentary drinks and another chance to chat with the reps at the sponsors’ stands before we headed to dinner at 7pm. At the dinner, each sponsor company had a decorated table. Some of us continued the night after dinner by heading out to town. The Hill’s Pet Nutrition breakfast was worth getting up early for, and was a cure-all for the punishing night before. We have to ask, how many professions would have people who can talk about poo at 7am, with a hangover? We really are a special bunch. Our keynote speaker Dan Brockman then started his first talk of the day, ‘Ureteric obstruction in cats: no easy treatment means lots of diligent aftercare’. We learnt that this is not an easy case to tackle, and that diagnostic techniques are important in determining whether these cases can

CONFERENCE

be surgically or medically managed. Frequent observation, and recording of improvement or deterioration, in these cases is recommended.

aversions. This was then followed by relating discussions for abdominal nursing and nutritional requirements for post intestinal surgical patients.

Nick Cave followed this and elaborated by discussing ‘Nutritional considerations in the post-obstructive cat - focusing on short AND long term issues’. It is critical to find the right food for each patient in these cases, and knowing which foods are useful for dissolving ureteric obstructions. We were also reminded of how important it is to not feed the patients a prescribed diet in-clinic, as they can form food

Sarah Hill from the Animal Referral Centre was next with ‘A case-based approach to understanding a complete blood count and biochemistry panels’. Sarah was hugely informative and went into great detail about the various blood values. This helped us have a better understanding of how to read blood test results and more knowledge as to what it means when these levels are elevated or decreased.

One more talk from Dan on stabilising animals with acute abdomen conditions, and then it was closing ceremony time! Overall, we thought the conference was very informative, touching on a wide range of topics from great key speakers. Our biggest takeaways were how to manage acute conditions, how important and effective physiotherapy for the patient is and, most of all, how important it is to take care of your own mental health. “In case you needed a reminder… be kind to yourself, always, in all ways” (Wendy Jarnet).

Taking the reins: Equine stream review By Georgina Green RVN Waikato Equine Veterinary Centre

My workmates and I were awake at sparrow’s fart on a rather chilly morning, and we hit the road at 5am to ensure we arrived at the Heritage hotel in time for the cooked breakfast. It seems us nurses will do almost anything for a free feed! On arrival at the hotel we went to register, and to collect our lanyards and our very flash goody bags. We then filed into the equine conference room, which soon became jam-packed with enthusiastic equine nurses. The first speaker was Dr Kylie Huxford, talking on the benefits of rehabilitation for our equine patients. Kylie’s lecture covered cryotherapy, heat therapy, hydrotherapy, proprioception activities, shockwave, therapeutic ultrasound, lowlevel laser, and transcutaneous electrical nerve stimulation. Kylie’s passion was clearly evident and her knowledge on the subject abounds. Next up was Dr Noel Power, speaking about ‘Hooves: assessing a horse’s foot’.

Noel is a highly engaging communicator and he used extremely effective images, which grabbed one’s attention and helped us understand how to assess the hoof.

Dr Guy Alexander covered ‘Case Reports: Splenic abscess and skin grafting’. It was very interesting to see real-life cases and the steps that were taken, the

Morning tea was upon us and we all hustled off to check out the trade stands. There were lots of freebies to be had (including worming pastes for us horsey folk), and games to be played to allow us a chance to win some fab prizes; I was top of the darts leaderboard for all of about two minutes! Dr Guy Alexander delivered an interesting talk on the equine surgical patient, which was followed by a very filling lunch. Lucky we still had some interesting talks to come, otherwise we may have fallen asleep due to the amount of carbs consumed! After lunch, Chris Barris provided a particularly thought-provoking session on the topic of ‘Gastric ulcers: the cause and treatment’. He had a very cunning way of gaining audience participation by way of ‘beanie bribery’ - those who asked questions received a free beanie. One of Chris’ slides read: ‘He who asks the question is ignorant in that moment. He who does not ask the question remains ignorant for life’ (Confucius, 500BC).

| Above: Georgina attempting to claim darts champion at the Bayer stand

September 2019 23

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reasons for choices (what went well and what he would do differently), and the final outcome. Afternoon tea brought more freebies from the trade stands and the winners of the games were awarded their prizes. Dr Kylie Huxford provided an extremely educational and detailed session covering case studies on equine rehabilitation. The case studies comprised of back pain, tendon injury, and massage and stretching. Last up was Dr Noel Power, who provided an enthusiastic and entertaining session on advanced reproductive techniques. I, for one, had never before heard of a Pizzly (a polar bear crossed with a grizzly), which has occurred not through artificial insemination but due to global warming, and I have also never heard of collecting eggs from a mare being likened to playing pool as you retrieve them!

| Above: Lyn Hobbs and Frith Alexander at the Shoof stand

On behalf of the equine delegates, I would like to thank the NZVNA for establishing the equine stream at this year’s conference. In particular, Lyn Hobbs (the head nurse at Waikato Equine Veterinary Centre), who joined the NZVNA committee two years ago with a view to encouraging an increase in equine focus for us equine nurses. I believe I speak on behalf of us all in saying that we are most grateful for your efforts and thank you for providing us with such awesome, knowledgeable and inspiring speakers at this year’s conference. | Above: Alona Parfonova checking out the Bayer stand

| Above: Slide from Wendy Jarnets talk ‘Anxiety and the veterinary nurse’

24 September 2019

| Above: Keynote speaker Dan Brockman

Auckland, New Zealand | 6-8 April 2020 | wvac2020.com

WVAC 2020 Auckland, New Zealand The 36th World Veterinary Association Congress (WVAC 2020) will be held 6–8 April 2020. A full and prestigious programme includes the 7th WVA Global One Health Summit with high-level support of the United Nations’ Food and Agriculture Organization, the World Organisation for Animal Health, and the World Health Organization. WVAC 2020 provides a unique opportunity for all branches of the veterinary profession globally to come together in New Zealand to explore the challenges that face animal health and welfare, and demonstrate the value of the profession for the public good in a changing world.

Small animal veterinary nurses can look forward to:

We’re delighted to offer a high-quality, three-day scientific programme with 13 conference streams featuring world-class speakers in clinical education, public health and biosecurity, animal welfare, veterinary business and research.

• Vicki Walsh (NZ) » Anaesthesia

Equine veterinary nurses can look forward to:

Companion animal and equine nursing streams will feature on 6 and 7 April.

• DeeAnn Wilfong (US) » Foal care

• Dan Chan (UK) » Emergency and critical care » Nutrition for the critically ill » Transfusion medicine

The best part about this amazing learning and collegial experience is that it is in the wonderful harbour city of Auckland – your gateway to all the attractions and hospitality of beautiful New Zealand. WVAC 2020 is the perfect opportunity to mix vocation and vacation. We’d love to see you in the City of Sails!

• Cristy Secombe (AUS) • Chris Pearce (UK)

Subscribe to our newsletter at www.wvac2020.com or like us on Facebook.

EQUINE

Equine case study: Ileocaecal bypass By Lyn Hobbs CVN, RAT, NZVNA Executive Committee member Waikato Equine Veterinary Centre

Patient details Name: Mana Species: Equine Breed: Thoroughbred Age: 8 years Colour: Bay Sex: Mare Weight: 395kg History Mana initially presented to the clinic because her owner was concerned that she seemed to be laying down a lot and was slow in general. Mana’s worming was up to date, she had normal faeces, no signs of weight loss and didn’t appear colicky. Her blood tests came back all within normal ranges. A faecal egg count was also carried out with no eggs or worms seen. Mana was given an intravenous (IV) injection of Catosal® (equine dose 10 - 25mL) 15mL, and Hemoplex™ (1mL/50kg) 7mL IV, and prescribed an oral course of omeprazole paste 50mg/mL (500mg/500kg) once daily (SID) for suspected stomach ulcers. Patient assessment Mana was presented back at the clinic 11 days later as the owner noticed marked weight loss and mild signs of colic, unresponsive to conservative therapy. Mana was quiet but alert and responsive on admission to the clinic, her heart rate was normal at 40 beats per minute (bpm), but her temperature was elevated at 38.9°C (normal range: 37.5 - 38.5°C).

Lyn is the head veterinary nurse at Waikato Equine Veterinary Centre in Cambridge. She has been at the clinic for six and a half years, and enjoys the fast paced environment where no day is ever the same. Lyn studied through Otago Polytechnic while working full time and raising a young family. Her hard work and dedication have paid off, and she is proud of her accomplishments so far. She was voted onto the NZVNA Executive Committee in 2017 to help give a voice for equine and large animal veterinary nurses.

26 September 2019

Mana was sedated with xylazine 100mg/ mL (0.6-1.0mL/100kg) 1.5mL IV and butorphanol 10mg/mL (1mL/100kg) 0.5mL IV. An ultrasound of her abdomen was performed which showed signs consistent with a partial obstruction of the ileum, leading to marked distention and thickening of the bowel anterior to the abnormality (Quinn, 2019). The owner was advised that surgery to perform an exploratory laparotomy to assess the diseased bowel, and potentially perform a bypass around the constricted area of

bowel, was recommended. The owner consented, and surgery was scheduled for three days later, as the mare was in a stable condition. Mana was monitored over the next two days and she remained comfortable. She was brought into a stable the night before her scheduled surgery, and was given dinner which consisted of two dippers of FibreProtect® and one dipper of Dunstan Breed & Grow™ (each dipper contains 2L of dry volume), and water was provided in her stable. The morning of surgery Mana was nil by mouth. Before surgery Mana was weighed and had a physical exam undertaken by the anaesthetist. Her heart and lungs were auscultated and parameters recorded; being an already compromised patient Mana’s vitals were slightly abnormal (see Figure 1). Pre anaesthetic preparation Mana’s surgery was performed under general anaesthesia. The surgical nurse set up surgery with the equipment and instruments required, comprised of: 1 x diathermy machine and bi-polar handpiece 1 x suction unit 1 x laparotomy drape set 2 x colic gowns, gloves, hats and masks 2 x laparotomy sponges (pack of five) 2 x sterile hand towels 2 x large bowel forceps 1 x No. 22 scalpel blade 1 x No. 10 scalpel blade 1 x mare uterine flushing tube (UFT) 2 x warmed 5L Lactated Ringer’s Solution (LRS) 1 x sterile belly lubricant 4 x sterile swabs (packs of 20) 1 x 14G needle 1 x penrose drain 1 x Fish 5 x 0 Vicryl® packs 1 x 2-0 Monocryl® pack 1 x 0 Prolene® pack And an equine surgery kit, consisting of: 1 x size 3 scalpel handle

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1 x size 4 scalpel handle 1 x pair rat tooth tissue forceps 1 x pair smooth tissue forceps 1 x pair Adson tissue forceps 2 x pairs of Metzenbaum scissors 2 x pairs of Mayo-Hegar needle holders 4 x pairs straight mosquito forceps 1 x instrument pin 6 x Backhaus towel clamps 10 x sterile swabs Mana was prepped for surgery. A 14G Intraflon jugular catheter was placed and sutured in. This would be used for Mana’s IV drugs and fluids. Mana received the following preoperative drugs: Meloxicam injectable 20mg/mL (3mL/kg)

12mL IV

Gentamycin 100mg/mL (6.6mg/kg)

28mL IV

Depocillin® 12000 iu/kg BID (10000 - 30000iu/kg)

18mL IM

IV sedation of: Acepromazine 10mg/ mL(0.25-0.5mL/50kg) Xylazine 100mg/mL (0.6-1.0mL/100kg) Intramuscular (IM) sedation/analgesia of: Acepromazine 10mg/mL (0.25-0.5mL/50kg) Morphine 30mg (0.2-0.6mg/kg) Morphine 10mg (0.1-0.2mg/kg)

Figure 1: Mana’s pre anaesthetic parameters Mana’s parameters

Normal parameters

Heart rate (HR)

40 beats per minute

36 - 44 beats per minute

Respiratory rate (RR)

12 breaths per minute

8 - 12 breaths per minute

Mucus membrane (MM)

slightly pale

pink

Capillary refill time (CRT)

<3sec

<2-3sec

Temperature

36.9°C

37.2 - 38.3°C

Total protein (TP)

7.4 g/dL

5.6-7.6g/dL

Packed cell volume (PCV)

38%

32 - 48%

Weight

395kg

400 - 600kg

0.5mL IV 1.5mL IV

0.5mL IM 1mL IM 1mL IM

Mana was walked around to the knockdown box. Her hooves were picked out, and her shoes were removed to prevent injury to Mana from raised clinches (nails) nicking her legs on recovery, and also to protect the rubber floor. Her mouth was washed out with water so it was clean and no evidence of food or shavings was seen. This procedure ensures no food or debris passes into the trachea with the endotracheal tube. Mana was slowly walked into the knockdown box and stood against the wall. A swing door in the knockdown box is used to aid in the dropping of the horse. The anaesthetist sedated Mana with xylazine 4.5mL IV, and we waited until Mana was heavily sedated, with her head dropping and no reactions to sounds around her.

| Above: Mana on initial presentation

The anaesthetist then proceeded to give Mana her anaesthetic induction agents of ketamine 100mg/mL (2.2mg/kg) 13mL IV and diazepam 5mg/mL (12mL/450kg) 4mL IV. After induction, the catheter was flushed with heparinised saline, and the team gently pushed the knockdown box’s swing door onto Mana to assist her fall. Mana’s head collar was held and she was gently pushed backwards as she began to fall, landing sternal. The knockdown box’s swing door was then opened to let her down into lateral recumbency. Her head collar was removed, her hooves were taped over to keep dirt out of surgery and stop her from ripping the recovery

| Above: Mana’s abscessed mouth

September 2019 27

EQUINE

floor on recovery. The anaesthetist placed a 24mm endotracheal tube. Mana was lifted into surgery on a hoist and placed in dorsal recumbency for her surgery. Mana’s abdomen was clipped, and aseptic preparation of the surgical site was performed using chlorhexidine skin scrub with a contact time of eight minutes. Methylated spirits was then applied to remove any remaining chlorhexidine. Her surgical site preparation was finished with tincture spray. The surgical nurse also placed a urinary catheter so Mana’s bladder could be emptied throughout surgery to prevent large volumes of urine spilling into the surgical suite. The surgeon and surgical nurse scrubbed in and draped the surgical site ready for the procedure to begin. The surgeon found that the last part of Mana’s small intestine (ileum) had become markedly thickened and showing signs of scarring, resulting in a tiny opening into the caecum. The surgeon opted to do an ileocaecal anastomosis, bypassing the diseased section of bowel by hand sewing a new opening of approximately 5cm. During the anastomosis, Mana’s heart rate and blood pressure increased so a bolus of ketamine 2.5mL was given IV. Her HR dropped to 45bpm five minutes after giving the bolus, then stabilised to 40bpm ten minutes after giving the bolus. Her BP remained stable.

Her CRI was stopped 20 minutes before the end of surgery. Once the surgical site was closed, Mana’s anaesthetic was turned off, and she was hoisted into the recovery box at 1.30pm and positioned in lateral recumbency and extubated at 1.58pm. She was administered 8mL of xylazine 100mg/mL (0.6-1.0mL/100kg) IV to aid in a smooth recovery. This relaxes the horse, and they tend to stay down longer and don’t rush to stand up before they are ready. Mana recovered well and stood up at 2.30pm; her head collar was then placed as she could be lead back to her box safely. She was taken back to her box at 3pm. Surgery time was one hour and fifteen minutes, anaesthetic time one hour and forty minutes. Post-op After surgery Mana’s temperature dropped to 34.9°C and her heart rate had slowed to 34bpm. A stable rug was put on her, and the windows in her box were closed. Mana had her HR, temperature, CRT, MM and gut sounds checked every two hours after surgery. By 4pm her temperature had increased to 35.8°C, and her heart rate had increased to 36bpm, she had no gut sounds. Mana was given a 10L bolus of LRS at 5pm and her evening medications were given. These consisted of an antibiotic

After the resection was completed, the surgeon pushed some of the intestinal contents through the new opening. This is to test the integrity of sutures placed in the new bypass for patency of the repair as any leakage into the abdomen would cause a life-threatening infection. The intestines were put back in the abdomen, and the surgeon closed the site using a combination of absorbable and nonabsorbable sutures. Throughout the surgery, Mana was kept on a dobutamine (Dobutamine 2 - 20ug/ kg/minute) constant rate infusion (CRI) of 0.05mg/kg/hour to maintain mean arterial pressure (MAP) greater than or equal to 70mmHg. Mana also received lidocaine 2% (1.3mg/kg) drip at the rate of 1 drop/3 sec initially then 1 drop/5 sec over five minutes halfway through surgery (lidocaine 1.3mg/ kg loading dose over 15 minutes then drop to 0.05mg/kg/minute). 28 September 2019

| Above: Lyn pointing to the thick band of bowel

injection of Depocillin® (equine dose 1mL/25kg) 20mL IM, and 4mL IV flunixin meglumine 50mg/mL (1mL/45kg) for analgesia. Mana was rechecked at 8pm; her heart rate was 56bpm, temperature 38.6°C, CRT <2sec, MM were pink, and her gut sounds were quiet. As flunixin meglumine had already been administered, no additional medications were administered. Day one after surgery Mana’s heart rate was 44bpm, her temperature was 38.1°C, MM pink and CRT was <1sec. She had produced four soft faeces and urinated overnight. She was given Depocillin (equine dose 1mL/25kg) 20mL IM, gentamycin 100mg/mL (6.6mg/ kg) 27mL IV, meloxicam 15mg/mL (0.6mg/ kg) 8mL orally (PO) and four scoops of Bio-Sponge™ which was mixed into a paste and syringed PO. A PCV and TP were repeated in-house. Mana’s PCV was 36% and TP 4.1g/dL. Mana’s vitals were retaken at 2.30pm. Her temperature had spiked to 39.6°C, and her heart rate was 80 bpm, MM were pink, CRT < 2sec and she had no gut sounds. It was opted to place a Mila long stay catheter aseptically and start Mana on fluids. Two 5L bags of LRS spiked with 50ml Calci Tat® 4.6g/100mL, and 50mL potassium chloride

EQUINE

Mana was rechecked at 8.30pm, and her heart rate had increased again to 64bpm, her temperature had also increased to 38.8°C, and her MM were described as ‘injected’ (or bright red). More fluids were hung for the night: two 5L LRS, spiked with 25mL Calci Tat, and 25mL potassium chloride in each and administered at the maintenance rate 60-75mL/kg/day (30L/ day/500kg). Day three after surgery Mana still had diarrhoea, but her vitals were improving, her appetite was poor, but she liked to pick at grass. Her heart rate was nearly within normal limits at 48bpm, her temperature was 37.9°C, MM were pink, CRT <3sec, and despite her diarrhoea, her gut sounds were normal. She was given 5mL IV flunixin meglumine 50mg/ mL (1mL/45kg), Protexin 20mL PO, 15mL electrolyte paste PO, and four scoops of Bio-Sponge™ paste PO. | Above: The new bypass finished

was administered using a large bore IV drip set at the maintenance rate 60-75mL/ kg/day (30L/day/500kg). The surgeon was suspicious that Mana was developing colitis so her antibiotics were stopped that afternoon and precautionary drugs were charted: 5mL IV flunixin meglumine 50mg/ mL (1mL/45kg), omeprazole paste 50mg/ mL (500mg/500kg) 10mL PO, Protexin® 20mL PO, and 15mL electrolyte paste PO.

Her vitals were taken and showed that her heart rate was 56bpm, her temperature was 37.4°C, CRT <2sec, MM were pink, and she had no gut sounds. Her in house PCV was taken and read 38%, her TP was down to 3.1g/dL. She was given 3mL IV flunixin meglumine 50mg/mL (1mL/45kg), omeprazole paste 50mg/mL (500mg/500kg) 10mL PO, Protexin 15mL PO, and 20mL electrolyte paste PO.

Mana’s vitals were retaken at 5pm her temperature and heart rate had come down, and she had produced one faecal motion. Her heart rate was 60bpm, temperature 38.6°C, MM were pink, CRT <3sec, and she had no gut sounds. Mana’s check at 12am was similar, except that her temperature was down to 38.4°C, and her gut sounds were nil on the left and right lower, nil right upper, but quiet left upper.

More fluids were administered; two 5L LRS bags were administered using a large bore IV drip set with 50mL Calci Tat 4.6g/100mL with 50mL potassium chloride at the maintenance rate of 60-75mL/kg/day (30L/ day/500kg).

Day two after surgery The surgeon was correct; Mana had developed colitis. She had not eaten overnight. The isolation protocols were put into place, and Mana was isolated with appropriate personal protective equipment placed outside her stable consisting of overalls, gloves, boots, and a foot bath.

The 5pm check was undertaken, and Mana was given her medications. Her TP and PCV were rechecked, where another drop in her total protein was discovered, now down to 2.7g/dL. Her heart rate was 52bpm, her temperature was 38.1°C, and she had active gut sounds. Mana was sedated with xylazine 100mg/mL (0.6-1.0mL/100kg) 1mL, and butorphanol 10mg/mL (1mL/100kg) 1mL IV, and administered colloids as an IV bolus 15 minutes (five bags of Voluven® 4mL/kg and one bag of StarQuin® 4mL/kg). Mana’s diarrhoea was profuse at this stage.

Another two 5L LRS spiked with potassium chloride each were hung for the day and administered at the maintenance rate 60-75mL/kg/day (30L/day/500kg). At the owner’s request Mana’s teeth were checked. She was found to have some sharp edges, so these were rasped back. Mana also had a gastroscope to check the integrity of her surgical site, and everything looked to be functioning well. Mana had her afternoon check at 5pm. Her heart rate was still within normal limits at 44bpm, the temperature was at the high end of normal at 38.2°C, her CRT <3sec, MM were pink, and she had active gut sounds. She was given Protexin 20mL PO, 15mL electrolyte paste PO, four scoops of Bio-Sponge paste PO and omeprazole paste 50mg/mL (500mg/500kg) 10mL PO. Mana still had profuse diarrhoea. She had also developed a thrombosed vein of the left jugular with subsequent swelling of the muzzle and nose on the same side due to poor venous drainage. Jugular vein thrombosis significantly is higher in horses in post-op pain/shock as they can develop hypercoagulable state. Her catheter was removed. Day four after surgery Mana’s morning check was normal. It was decided to change her pain relief from September 2019 29

EQUINE

flunixin meglumine to meloxicam. Her diarrhoea was still very watery. As Mana still wasn’t eating well, the surgeon was happy for the veterinary nurses to put her outside in a small grass yard to encourage eating and she was to be brought back inside if it got too hot. Her vitals remained stable throughout the day. Her afternoon check and medications were given. She had a little more consistency to her faeces that evening, so she was allowed to stay outside for the night in her yard. Her belly bandage was removed, and she was given Protexin 20mL PO, 15mL electrolyte paste PO, four scoops of BioSponge paste PO and omeprazole paste 50mg/mL (500mg/500kg) 10mL PO. Day five after surgery Mana’s vitals remained stable. She had one soft faecal movement, but we had managed to turn a corner in her recovery. Her heart rate was normal at 44bpm, her temperature was also normal at 37.2°C, CRT <2sec, her MM were pink, and her gut sounds were normal. She was given meloxicam 15mg/mL (0.6mg/kg) 8mL PO, Protexin 20mL PO, 15mL electrolyte paste PO, four scoops of Bio-Sponge paste PO.

Unfortunately, there was some discharge from the surgical site. It was elected to put Mana back on antibiotics, and she was charted Sulpha-T Paste™ 30mL/500kg twice daily for five days. Due to Mana’s depressed immune system the surgeon felt antibiotics would be beneficial. A belly bandage was re-applied after the site had been cleaned with 0.9% saline solution. Despite the discharge from the surgical site, the surgeon was happy for Mana to go home. Mana was discharged from the clinic that afternoon with instructions on how to keep her surgical site clean and also with the following instructions on the medications she was to continue with at home: • Omeprazole 10mL once daily orally for 14 days • Protexin probiotic 20mL twice daily orally for six days • Bio-Sponge paste 29g once daily orally for two days • Sulpha-T 25 mL twice daily orally for five days Patient progress Mana had a lot to overcome postoperatively. Having ileoceacal bypass

surgery was the easy part. The colitis, thrombosed vein, swelling of the head and muzzle, low total protein and discharge from the surgical site all played a big role in Mana’s complicated recovery. The nursing of Mana was intensive with many after hours spent with her. When Mana returned home, her obstacles were still plenty. She was very thin with a body condition score two out of five. Mana developed abscesses on her mouth and jaw filled with thick globular pus due to her immune system being compromised. Mana did slowly regain her appetite, her abscesses also cleared up, and her cheeky temperament returned. Only now, three months later, is Mana starting to regain her top line and muscle mass. The only visual changes to see are her scar on her abdomen and a vascular cheek which is a result of the thrombosed vein. She has a good appetite now and is a happy and content horse. References Dingemans, K. (2019) Anaesthesia record: Patient Mana. Unpublished record. Quinn, G. (2019). Surgical report: Patient Mana. Unpublished case notes.

Mana stayed in a box during the day as it was very hot outside, she was taken out for 15 minute hand grazing every few hours. Her afternoon check was again stable, and she had one soft faecal motion. Her heart rate had remained stable at 42bpm, her temperature at 38.2°C, she had pink MM, her CRT was <2sec, and her gut sounds were normal. She was given Protexin 20mL PO, 15mL electrolyte paste PO, four scoops of Bio-Sponge paste PO and omeprazole paste 50mg/mL (500mg/500kg) 10mL PO. She was put out to a small grass yard for the night. Day six after surgery Mana was brought in from the yard, her vitals still stable and her faeces still soft but more normal appearance. Her heart rate was within normal limits at 44bpm, her temperature was 37.9°C, CRT <2sec, MM were pink, and her gut sounds were normal. She was given meloxicam 15mg/ mL (0.6mg/kg) 8mL PO, and four scoops of Bio-Sponge and Protexin 20mL PO. 30 September 2019

| Above: Mana and Lyn four months after her surgery

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