The Modern Equine Vet - December 2020 by The Modern Equine Vet

The Modern

Equine Vet www.modernequinevet.com

Break the Back Pain Cycle Reversing Anesthesia Controlling Severe Asthma Ask the Nutritionist? Recognizing Ionophore Toxicity Technician Update: Deb Reeder on Mitigating Risk

News From the AAEP 2020 Annual Meeting

Vol 10 Issue 12 2020

TABLE OF CONTENTS

COVER STORY

4 Break the Back Pain Cycle, Then Hit the Gym Cover: Shutterstock/mariait

ASK THE NUTRITIONIST

How To Recognize Ionophore Toxicity........................................................................................ 3 ORTHOPEDICS

Bone Drug Can Linger in Horse Blood, Urine.............. 8 SURGERY

Is Flumazenil a Good Choice for Reversing Anesthesia?......................................................10 RESPIRATORY

Nasal Spray Controls Severe Equine Asthma ............14 TECHNICIANS UPDATE

RISK in the Equine Practice: The Technician’s Role in Recognition and Prevention ...........................16

ADVERTISERS Purina Animal Nutrition.....................................................................................3 Merck Animal Health..........................................................................................5 Zoetis......................................................................................................................7 AAEVT......................................................................................................................9

American Regent Animal Health/BetaVet...................................................11 Shanks Veterinary Equipment........................................................................14 American Regent Animal Health/Adequan.................................................15

The Modern

Equine Vet SALES: Matthew Todd • Matthew Gerald EDITOR: Marie Rosenthal ART DIRECTOR: Jennifer Barlow CONTRIBUTING WRITERS: Paul Basillo • Adam Marcus COPY EDITOR: Patty Wall Published by PO Box 935 • Morrisville, PA 19067 Marie Rosenthal and Jennifer Barlow, Publishers PERCYBO media  publishing

Issue 12/2020 | ModernEquineVet.com

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SPECIAL ADVERTISING SECTION

Ask the

Nutritionist DR. ROBERT JACOBS, PH.D., EQUINE INNOVATION MANAGER, PURINA ANIMAL NUTRITION

Ask the Nutritionist is a monthly column featuring questions answered by PhD equine nutritionists and sponsored by Purina Animal Nutrition. Have a nutrition question you want to see featured? Email Marie Rosenthal. For clinics looking for specific nutrition advice, submit your question here.

What signs should I look for in clients’ horses related to ionophore toxicity? What do feed manufacturers do to protect against feed contamination? Feed contamination is a critical risk of feed manufacturing for which all reputable feed manufacturers should account. Proper “feed hygiene” is crucial to minimize the health risks to horses due to physical, chemical or biological contamination. Horse feed contaminated with ionophores is especially problematic, and feed manufacturers should remain diligent with safety protocols to prevent cross-contamination.

c. Date of purchase d. M anufacturer’s date code (typically printed on the packaging or the tape sewn on the end of the feed bag ) See graphic left. 5. Contact the feed manufacturer to file a report and submit a feed sample for analysis. Various commercial laboratories can analyze feeds for ionophore contamination.

Ionophores are a class of antibiotics that may be added to poultry and cattle diets as growth-promoting agents and as potent coccidiostats. These compounds function to alter the membrane potential of certain tissues, and in horses, can result in a multitude of aberrant clinical symptoms. Often, the first clinical symptom observed in horses afflicted with ionophore toxicities is sudden death. However, other clinical signs may develop, including unexplained colic, ataxia, diarrhea and excessive urination. Ionophores affect various body tissues, including cardiac muscle, skeletal muscle and the nervous system; therefore, symptoms are typically non-specific. Bloodwork on horses with suspected ionophore toxicity may show elevated muscle enzymes. Horses may have individual tolerances to ionophore toxicities. Still, it is widely accepted that any presence of ionophores in equine feeds is considered toxic and levels as low as 1.4 mg per kg of body weight can be lethal. Treatments for ionophore toxicity are largely palliative and supportive, and survivors are known to have long-term health effects. WHAT TO DO If ionophore contamination is suspected, the horse owner and veterinarian should take these steps: 1. Gather all suspect feed and securely quarantine it from other feed products. 2. Cease feeding suspect feed to other horses. 3. Take a sample of the feed for future analysis and store it in a temperature-controlled environment. 4. Gather relevant information about the feed, including: a. Name of product b. Place of purchase

Ionophore contamination is typically the result of a mistake or improper feed hygiene protocols. The Purina® FeedGuard® Nutrition System is an example of a feed hygiene protocol and is one of the industry’s most innovative quality-assurance programs. As part of this program, it is required that all equine feeds are manufactured within a 100-percent, ionophore-free manufacturing system. But opportunities for contamination still exist outside the feed manufacturing plant. Care should be taken to prevent bulk horse feed from being transported or stored in locations that have previously held feed containing ionophores. If you or your clients have questions about feed hygiene, contact the feed manufacturer and inquire about their protocols and how they ensure the safety of their horse feeds. Contact a Purina Ph.D. nutritionist for consultations through Purina Customer Service, 800-227-8941 or visit EquineVetNutrition.com to submit your question.

LOOKING FOR NUTRITION RESOURCES? Find helpful nutritional management information for common equine conditions and request feed coupons for your clients on the new EquineVetNutrition.com page. Have a question you want to see featured? Please send them to modernequinevet@gmail.com.

ABOUT THE AUTHOR Dr. Robert Jacobs, Ph.D., is the Equine Innovation Manager at Purina Animal Nutrition. He is responsible for conducting research to understand how nutrition impacts various areas of equine physiology. SPONSORED BY PURINA ANIMAL NUTRITION

ModernEquineVet.com | Issue 12/2020

LAMENESS

Break the Back Pain Cycle, Then Hit the Gym By Paul Basillio

Most of the work in the management of equine back

pain comes down to the diagnosis. After a thorough history, physical exam and imaging, it’s important to not let all of that important diagnostic work go waste with an incomplete or improper treatment plan, according to Erin Contino, MS, DVM, DACVSMR. The 2 pillars of that treatment plan are breaking the pain cycle and increasing or restoring strength, function, and stability, according to Dr. Contino, assistant professor in equine sports medicine at the Colorado State University College of Veterinary Medicine and Biomedical Science’s Equine Orthopaedic Research Center.

Shutterstock/Rolf Dannenberg

Anti-inflammatories

“For me, the cornerstone of breaking the pain cycle is corticosteroids,” she said in a virtual presentation at the 66th Annual AAEP Convention. “They’re potent, they’re effective, they’re great anti-inflammatories, and I find them to be one of the most effective ways to get ahead of the game in treating back pain.” The diagnosis will dictate where steroids should be injected. For impinging or overriding spinous processes,

Issue 12/2020 | ModernEquineVet.com

the drug could be injected between the affected processes, although in some cases the interspinous ligament might not be injectable. “You can’t typically inject into a healthy ligament, so sometimes you have to go just a bit abaxially with your needle placement,” Dr. Contino explained. “You’re diluting the corticosteroid out in enough volume that it will diffuse to the entire area.” A combination of corticosteroid injections and the muscle relaxant methocarbamol is another common treatment in Dr. Contino’s practice. She gives it twice daily for 2 weeks, then tapers once daily for another 2 weeks. Keep in mind the dose allowed under US Equestrian Federation (USEF) rules, because often doses used to treat back are higher than what is permitted by USEF. For thoracolumbar articular facet joint osteoarthritis, she typically uses triamcinolone diluted with saline instead of hyaluronic acid with or without amikacin. Nonsteroidal anti-inflammatories (NSAIDs) are a staple treatment for back pain in humans, but Dr. Contino hasn’t found that to be the case in horses. “I typically only use a nonsteroidal if I’m combining

The Science of

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Ask your Merck Animal Health Equine representative about REGU-MATE® or call 800-521-5767. IMPORTANT SAFETY INFORMATION: Avoid skin contact. Always wear protective gloves when administering REGU-MATE®. This product is contraindicated for use in mares with a previous or current history of uterine inflammation. Pregnant women, or women who suspect they are pregnant, should not handle this product. For complete safety information, please read product label. 1

Data on file. Merck Animal Health.

2 Giralda Farms • Madison, NJ 07940 • merck-animal-health-usa.com • 800-521-5767 Copyright © 2020 Intervet Inc., d/b/a/ Merck Animal Health, a subsidiary of Merck & Co., Inc. All rights reserved. US-REG-200500001

LAMENESS

REGU-MATE® (altrenogest) Solution 0.22% Intervet/Merck Animal Health ORAL PROGESTIN FOR USE IN ANIMALS ONLY SOLUTION 0.22% (2.2 mg/mL) For suppression of estrus in mares. Suppression of estrus allows for a predictable occurrence of estrus following drug withdrawal in mares with ovarian follicles 20 mm or greater. Suppression of estrus will facilitate: • Attainment of regular cyclicity during the transition from winter anestrus to the physiological breeding season. • Management of prolonged estrus conditions. • Scheduled breeding during the physiological breeding season. WARNING: DO NOT USE IN HORSES INTENDED FOR HUMAN CONSUMPTION. Keep this and all medication out of the reach of children.

Shockwave therapy can be useful for thoracolumbar pain.

CAUTION Federal law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION Regu-Mate® (altrenogest) Solution 0.22% contains the active synthetic progestin, altrenogest. The chemical name is 17α-allyl-17βhydroxyestra-4,9,11-trien-3-one. The CAS Registry Number is 850-52-2. The chemical structure is:

Each mL of Regu-Mate® (altrenogest) Solution 0.22% contains 2.2 mg of altrenogest in an oil solution. ACTIONS Regu-Mate® (altrenogest) Solution 0.22% produces a progestational effect in mares. INDICATIONS Regu-Mate® (altrenogest) Solution 0.22% is indicated to suppress estrus in mares. Suppression of estrus allows for a predictable occurrence of estrus following drug withdrawal. This facilitates the attainment of regular cyclicity during the transition from winter anestrus to the physiological breeding season. Suppression of estrus will also facilitate management of prolonged estrus conditions. Suppression of estrus may be used to facilitate scheduled breeding during the physiological breeding season. CONTRAINDICATIONS Regu-Mate® (altrenogest) Solution 0.22% is contraindicated for use in mares having a previous or current history of uterine inflammation (i.e., acute, subacute, or chronic endometritis). Natural or synthetic gestagen therapy may exacerbate existing low-grade or “smoldering” uterine inflammation into a fulminating uterine infection in some instances. PRECAUTIONS Various synthetic progestins, including altrenogest, when administered to rats during the embryogenic stage of pregnancy at doses manyfold greater than the recommended equine dose caused fetal anomalies, specifically masculinization of the female genitalia. DOSAGE AND ADMINISTRATION While wearing protective gloves, remove shipping cap and seal; replace with enclosed plastic dispensing cap. Remove cover from bottle dispensing tip and connect luer lock syringe (without needle). Draw out appropriate volume of ReguMate® solution. (Note: Do not remove syringe while bottle is inverted as spillage may result.) Detach syringe and administer solution orally at the rate of 1 mL per 110 pounds body weight (0.044 mg/kg) once daily for 15 consecutive days. Administer solution directly on the base of the mare’s tongue or on the mare’s usual grain ration. Replace cover on bottle dispensing tip to prevent leakage. Excessive use of a syringe may cause the syringe to stick; therefore, replace syringe as necessary. DOSAGE CHART Approximate Weight in Pounds

Dose in mL

770

880

990

1100

1210

1320

WHICH MARES WILL RESPOND TO REGU-MATE® (altrenogest) SOLUTION 0.22%: Extensive clinical trials have demonstrated that estrus will be suppressed in approximately 95% of the mares within three days; however, the post-treatment response depended on the level of ovarian activity when treatment was initiated. Estrus in mares exhibiting regular estrus cycles during the breeding season will be suppressed during treatment; these mares return to estrus four to five days following treatment and continue to cycle normally. Mares in winter anestrus with small follicles continued in anestrus and failed to exhibit normal estrus following withdrawal. Response in mares in the transition phase between winter anestrus and the summer breeding season depended on the degree of follicular activity. Mares with inactive ovaries and small follicles failed to respond with normal cycles post-treatment, whereas a higher proportion of mares with ovarian follicles 20 mm or greater in diameter exhibited normal estrus cycles post-treatment. Regu-Mate® (altrenogest) Solution 0.22% was very effective for suppressing the prolonged estrus behavior frequently observed in mares during the transition period (February, March and April). In addition, a high proportion of these mares responded with regular estrus cycles posttreatment SPECIFIC USES FOR REGU-MATE® (altrenogest) SOLUTION 0.22%: SUPPRESSION OF ESTRUS TO 1. Facilitate attainment of regular cycles during the transition period from winter anestrus to the physiological breeding season. To facilitate attainment of regular cycles during the transition phase, mares should be examined to determine the degree of ovarian activity. Estrus in mares with inactive ovaries (no follicles greater than 20 mm in diameter) will be suppressed but these mares may not begin regular cycles following treatment. However, mares with active ovaries (follicles greater than 20 mm in diameter) frequently respond with regular post-treatment estrus cycles. 2. Facilitate management of the mare exhibiting prolonged estrus during the transition period. Estrus will be suppressed in mares exhibiting prolonged behavioral estrus either early or late during the transition period. Again, the posttreatment response depends on the level of ovarian activity. The mares with greater ovarian activity initiate regular cycles and conceive sooner than the inactive mares. Regu-Mate® (altrenogest) Solution 0.22% may be administered early in the transition period to suppress estrus in mares with inactive ovaries to aid in the management of these mares or to mares later in the transition period with active ovaries to prepare and schedule the mare for breeding. 3. Permit scheduled breeding of mares during the physiological breeding season. To permit scheduled breeding, mares which are regularly cycling or which have active ovarian function should be given Regu-Mate® (altrenogest) Solution 0.22% daily for 15 consecutive days beginning 20 days before the date of the planned estrus. Ovulation will occur 5 to 7 days following the onset of estrus as expected for non-treated mares. Breeding should follow usual procedures for mares in estrus. Mares may be regulated and scheduled either individually or in groups. ADDITIONAL INFORMATION A 3-year well controlled reproductive safety study was conducted in 27 pregnant mares, and compared with 24 untreated control mares. Treated mares received 2 mL Regu-Mate® (altrenogest) Solution 0.22% /110 lb body weight (2 x dosage recommended for estrus suppression) from day 20 to day 325 of gestation. This study provided the following data: 1. In filly offspring (all ages) of treated mares, clitoral size was increased. 2. Filly offspring from treated mares had shorter interval from Feb. 1 to first ovulation than fillies from their untreated mare counterparts. 3. There were no significant differences in reproductive performance between treated and untreated animals (mares & their respective offspring) measuring the following parameters: • interval from Feb. 1 to first ovulation, in mares only • mean interovulatory interval from first to second cycle and second to third cycle, mares only. • follicle size, mares only. • at 50 days gestation, pregnancy rate in treated mares was 81.8% (9/11) and untreated mares was 100% (4/4). • after 3 cycles, 11/12 treated mares were pregnant (91.7%) and 4/4 untreated mares were pregnant (100%). • colt offspring of treated and control mares reached puberty at approximately the same age (82 & 84 weeks respectively.) • stallion offspring from treated and control mares showed no differences in seminal volume, spermatozoal concentration, spermatozoal motility, and total sperm per ejaculate. • stallion offspring from treated and control mares showed no difference in sexual behavior. • testicular characteristics (scrotal width, testis weight, parenchymal weight, epididymal weight and height, testicular height, width & length) were the same between stallion offspring of treated and control mares. REFERENCES Shoemaker, C.F., E.L. Squires, and R.K. Shideler, 1989. Safety of Altrenogest in Pregnant Mares and on Health and Development of Offspring. Eq. Vet. Sci. (9); No. 2: 69-72. Squires, E.L., R.K. Shideler, and A.O. McKinnon. 1989. Reproductive Performance of Offspring from Mares Administered Altrenogest During Gestation. Eq. Vet. Sci. (9); No. 2: 73-76. WARNING For oral use in horses only. Keep this and all other medications out of the reach of children. Do not use in horses intended for human consumption. HUMAN WARNINGS: Skin contact must be avoided as Regu-Mate® (altrenogest) Solution 0.22% is readily absorbed through unbroken skin. Protective gloves must be worn by all persons handling this product. Pregnant women or women who suspect they are pregnant should not handle Regu-Mate® (altrenogest) Solution 0.22%. Women of child bearing age should exercise extreme caution when handling this product. Accidental absorption could lead to a disruption of the menstrual cycle or prolongation of pregnancy. Direct contact with the skin should therefore be avoided. Accidental spillage on the skin should be washed off immediately with soap and water. INFORMATION FOR HANDLERS: WARNING: Regu-Mate® (altrenogest) Solution 0.22% is readily absorbed by the skin. Skin contact must be avoided; protective gloves must be worn when handling this product. Effects of Overexposure There has been no human use of this specific product. The information contained in this section is extrapolated from data available on other products of the same pharmacological class that have been used in humans. Effects anticipated are due to the progestational activity of altrenogest.Acute effects after a single exposure are possible; however, continued daily exposure has the potential for more untoward effects such as disruption of the menstrual cycle, uterine or abdominal cramping, increased or decreased uterine bleeding, prolongation of pregnancy and headaches. The oil base may also cause complications if swallowed.In addition, the list of people who should not handle this product (see below) is based upon the known effects of progestins used in humans on a chronic basis. PEOPLE WHO SHOULD NOT HANDLE THIS PRODUCT 1. Women who are or suspect they are pregnant. 2. Anyone with thrombophlebitis or thromboembolic disorders or with a history of these events. 3. Anyone with cerebral-vascular or coronary-artery disease. 4. Women with known or suspected carcinoma of the breast. 5. People with known or suspected estrogen-dependent neoplasia. 6. Women with undiagnosed vaginal bleeding. 7. People with benign or malignant tumors which developed during the use of oral contraceptives or other estrogencontaining products. 8. Anyone with liver dysfunction or disease. Accidental Exposure Altrenogest is readily absorbed from contact with the skin. In addition, this oil based product can penetrate porous gloves. Altrenogest should not penetrate intact rubber or impervious gloves; however, if there is leakage (i.e., pinhole, spillage, etc.), the contaminated area covered by such occlusive materials may have increased absorption. The following measures are recommended in case of accidental exposure. Skin Exposure: Wash immediately with soap and water. Eye Exposure: Immediately flush with plenty of water for 15 minutes. Get medical attention. If Swallowed: Do not induce vomiting. Regu-Mate® (altrenogest) Solution 0.22% contains an oil. Call a physician. Vomiting should be supervised by a physician because of possible pulmonary damage via aspiration of the oil base. If possible, bring the container and labeling to the physician. Store at or below 25°C (77°F). HOW SUPPLIED Regu-Mate® (altrenogest) Solution 0.22% (2.2 mg/mL). Each mL contains 2.2 mg altrenogest in an oil solution. Available in 1000mL plastic bottles. Manufactured for: Intervet Inc., d/b/a Merck Animal Health, 2 Giralda Farms, Madison, NJ 07940

Made in France NADA # 131-310, Approved by FDA 01/07 141990 R1

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it with gabapentin if I suspect neuropathic pain,” she said. “I also sometimes use systemic corticosteroids—typically prednisolone—as a last resort in horses that are unresponsive to other treatments, if I have a suspicion that they have dorsal root ganglionitis or wind-up pain.”

Bisphosphonates

Tiludronate is a potential treatment for horses with thoracolumbar osteoarthritis. A study in 2007 found that tiludronate showed significant improvement in dorsoventral flexibility vs. controls at 60 days, but not at 120 days. “There are certain times for when it’s indicated,” Dr. Contino said, “and that’s when you have osseous pathology. I measure kidney values prior to giving it, and I never give it with NSAIDs because of the extra load it places on the kidneys. You can cause kidney failure, and there have also been reports of colic, although in my experience it’s more common with tiludronate compared with clodronate.”

Extracorporeal shockwave therapy

Dr. Contino uses shockwave therapy on a lot of horses with thoracolumbar pain. “The only reason to not use it is because of the cost,” she said. “It is expensive, but it’s highly effective.” She shared a recent paper that involved 12 riding horses with thoracolumbar pain. Results showed that after 2 or 3 treatments, the mechanical nociceptive threshold increased in all horses, indicating the horses were less painful. The increase continued out to 56 days. “Clinically, some horses benefit from a single treatment, but if you do it in a series of 3 or 4, you will likely see more of an effect,” she said. “It’s a great way to break the pain cycle, especially in horses where you can’t use corticosteroids.” While shockwave therapy is not permitted under FEI rules, it can be used on the back if it’s more than 12 hours prior 6

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to competition under USEF rules.

Building Strength

After breaking the pain cycle, it’s time for the horse to get to the gym. Dr. Contino discussed a study that evaluated 4 types of stretches (cervical extension, cervical flexion, and right and left lateral bending) on the multifidus muscle. The stretches were performed 5 days per week, and after 3 months the horses had increased cross-sectional area at all 6 levels the authors reviewed. There was also improved symmetry between the right and left sides. Another study showed that the addition of gymnastic exercises—including pelvic tilts, backing the horse in hand, doing small circles, and raised pole walking—to dynamic mobilization exercises resulted in a greater increase in the cross-sectional area of the multifidus muscle when compared with dynamic mobilization alone. “We also use elastic resistance bands with a lot of our rehab horses and horses with back pain,” Dr. Contino added. A recent study showed that after 4 weeks, horses had decreased rotation and mediolateral movement in the thoracolumbar spine. For the first week, the horses were typically just being familiarized with the bands, but after that the horses used the bands in increasing amounts of time for fewer days each week. “This evidence suggests we’re increasing their dynamic stability,” she said. Whole-body vibration, which involves the horse standing on a vibrating vertical platform, also has some evidence showing improved symmetry of the multifidus muscle. The frequency, amplitude, acceleration and direction that the platform vibrates in can vary from brand to brand, but placing a horse on a vibration plate for 30 minutes 5 times a week has shown some positive results. “In my clinical experience, I don’t find this to be nearly as good as the core exercises,” she added. MeVEcae

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ORTHOPEDICS

Racing bodies have strict rules about the administration of tiludronic acid in horses. breaking down existing bone—is banned in animals younger than 3.5 years of age, in whom it can significantly retard skeletal growth; and within 30 days of a race, as it can act as an analgesic that might mask a painful injury to bone that racing might worsen. However, most conventional testing does not detect tiludronic acid in either the urine or blood of animals. Although bisphosphonates are difficult to detect, some labs are able to use special methods to screen for bisphosphonates, but such tests may not be performed regularly, making the drugs vulnerable to abuse by un-

scrupulous veterinarians, trainers and breeders. As the researchers note, “Conditions of sales of most bloodstock auction companies globally now have specific statements relating to detection of bisphosphonates in horses sold through them, with the condition that the sale may be rendered void by the purchaser if bisphosphonates are detected in blood samples collected within a specified period following the ‘fall of the hammer’.” The new study suggests those periods might be too short: Tiludronic acid can linger in the body for years — you just have to know how to look for it. Led by Chris Riggs, PhD, DEO, DECVS, MRCVS, director of the Equine Welfare Research Foundation, and chief advisor of Veterinary Science at the Hong Kong Jockey Club, the researchers used a technique called ultra-high performance liquid chromatography-high resolution mass spectrometry (UHPLC-HRMS) to search for traces of tiludronic acid in 24 horses that had received injections of the drug for various approved clinical conditions. At the club, veterinarians can administer tiludronic acid only if they first receive permission from the head of the center. “The necessary use of all equine medications and all clinical procedures are strictly controlled and monitored at the Hong Kong Jockey Club, which has provided us with excellent treatment records and traceability of our horses to conduct this survey,” Dr. Riggs told Modern Equine Vet. “Given that a proportion of a dose of bisphosphonate drug administered to an animal binds to mineral in bones throughout the body and effectively becomes ‘locked’ into the skeleton, it was reasonable to hypothesize that we might detect a low concentration of the drug in blood and urine a very long time after a dose was administered as it is slowly released during the slow but steady process of background bone metabolism. We wished to test this hypothesis.” The UHPLC-HRMS tests revealed traces of tiludronic acid in all 24 of the samples, 2 of which had been taken from horses that had received single injections of the drug 3 years earlier. Concentrations of the medication typically were lower in urine than in blood, but not always, according to the researchers. MeV

For more information: Riggs C, et al. Tiludronic acid can be detected in blood and urine samples from Thoroughbred racehorses over three years after last administration. Equine Vet J. 2020 Nov 28 [Epub ahead of print]. https://pubmed.ncbi.nlm.nih.gov/33247964/ 8

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Shutterstock/dikkenss

Bone Drug Can Linger in Horse Blood, Urine By Adam Marcus Traces of a tightly regulated drug to treat bone loss in horses can appear in blood and urine for 1,000 days or longer after even a single injection of the medication, researchers in Hong Kong have found. Tiludronic acid belongs to a class of agents called bisphosphonates, which physicians and veterinarians use to prevent fractures in people, and to treat navicular lameness in horses. Racing bodies have strict rules about the administration of tiludronic acid in horses; the medication—which inhibits the skeleton from

Is Flumazenil a Good Choice for Reversing Anesthesia? B y

P a u l

B a s i l l i o

There is little doubt that benzodiazepines are valuable co-induction agents for maintaining a balanced anesthesia regimen in horses. The drugs modulate and potentiate the actions of the neurotransmitter gamma-aminobutyric acid (GABA) at central GABAA receptors, which results in muscle relaxation, coupled with a reduction in anesthetic drug requirements and an extended anesthetic duration. Plus, they tend not to compromise cardiovascular function. However, benzodiazepines are long-actingâ&#x20AC;&#x201D;the biological half-life of diazepam is anywhere from 7 to 21 hours, and the median terminal half-life for midazolam ranges from 3.6 to about 7 hours. Drug effects could last even longer as a result of altered hepatic blood flow. Horses are susceptible to compromised gas exchange during and following administration of general anesthesia due to pulmonary atelectasis and ventilation perfusion mismatch. Coupled with the long half-lives of benzodiazepines, respiratory depression and ataxia may last well after anesthesia and compromise recovery. Enter flumazenil. The GABA receptor antagonist competitively blocks the benzodiazepine binding site on the GABAA receptor complex. In humans and companion animals, flumazenil offers an improvement in respiratory depression caused by benzodiazepines and enhances recovery from general anesthesia. However, the literature falls short of direct examinations of the use and effects of the drug in the horse. To narrow the knowledge gap, Hope Douglas, VMD, DACVS (Large Animal), a resident in anesthesia at New Bolton Center in Kennett Square, Pa., Klaus Hopster, DVM, PhD, DECVAA, Bernd Driessen, DVM, PhD, DACVAA, DECVPT, and their colleagues recently published a study in the Equine Veterinary Journal that investigated the effects of flumazenil in horses induced with midazolam-ketamine and maintained with isoflurane and oxygen. The study involved 6 healthy horses between the age of 2 and 18 years (average age, 11 years) who had not undergone a prior general anesthesia event. Breeds included 3 Standardbreds, 1 Thoroughbred-

Shutterstock/thomas koch

SURGERY

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The link between RAPID ONSET and LONG-ACTING RELIEF of pain & inflammation1 BetaVet ® (betamethasone sodium phosphate & betamethasone acetate injectable suspension) is indicated for the control of pain and inflammation associated with osteoarthritis in horses. Learn more at www.betavetequine.com or call 1-800-458-0163. Please see Brief Summary of Full Prescribing Information on the following page.

INDICATION: BetaVet ® is indicated for the control of pain and inflammation associated with osteoarthritis in horses.

IMPORTANT SAFETY INFORMATION For Intra-Articular (I.A.) Use in Horses.

CONTRAINDICATIONS: BetaVet ® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in cleft palate in offspring and in other congenital anomalies including deformed forelegs, phocomelia and anasarca. Therefore, before use of corticosteroids in pregnant animals, the possible benefits to the pregnant animal should be weighed against potential hazards to its developing embryo or fetus. Human Warnings: Not for use in humans. For use in animals only. Keep this and all medications out of the reach of children. Consult a physician in the case of accidental human exposure. PRECAUTIONS: Corticosteroids, including BetaVet ®, administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Due to the potential for exacerbation of clinical signs of laminitis,

PP-BV-US-0027_FullPg_Ad.indd 1

glucocorticoids should be used with caution in horses with a history of laminitis, or horses otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, such as NSAIDs or other corticosteroids, should be approached with caution. Due to the potential for systemic exposure, concomitant use of NSAIDs and corticosteroids may increase the risk of gastrointestinal, renal, and other toxicity. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet ® (n=119) or a saline control (n=120) at five percent (5%) and above were: acute joint effusion and/or local injection site swelling (within 2 days of injection), 15% BetaVet ® and 13% saline control; increased lameness (within the first 5 days), 6.7% BetaVet ® and 8.3% saline control; loose stool, 5.9% BetaVet ® and 8.3% saline control; increased heat in joint, 2.5% BetaVet ® and 5% saline control; and depression, 5.9% BetaVet ® and 1.6% saline control. DOSAGE AND ADMINISTRATION: Shake well immediately before use. Use immediately after opening, then discard any remaining contents. RX ONLY References: 1. Trotter GW. Intra-articular corticosteroids. In: McIlwraith CW, Trotter GW, eds. Joint Disease in the Horse. Philadelphia: W.B. Saunders; 1996; 237–256.

5/17/2019 9:15:15 AM

BRIEF SUMMARY OF PRESCRIBING INFORMATION (Betamethasone Sodium Phosphate and Betamethasone Acetate Injectable Suspension) 6 mg betamethasone per mL For Intra-Articular (I.A.) Use in Horses CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATION: BetaVet® is indicated for the control of pain and inflammation associated with osteoarthritis in horses. DOSAGE AND ADMINISTRATION: Shake well immediately before use. CONTRAINDICATIONS: BetaVet® is contraindicated in horses with hypersensitivity to betamethasone. Intra-articular injection of corticosteroids for local effect is contraindicated in the presence of septic arthritis. WARNINGS: Do not use in horses intended for human consumption. Clinical and experimental data have demonstrated that corticosteroids administered orally or parenterally to animals may induce the first stage of parturition when administered during the last trimester of pregnancy and may precipitate premature parturition followed by dystocia, fetal death, retained placenta, and metritis. Additionally, corticosteroids administered to dogs, rabbits and rodents during pregnancy have resulted in cleft palate in offspring. Corticosteroids administered to dogs during pregnancy have also resulted in other congenital anomalies including deformed forelegs, phocomelia and anasarca. Therefore, before use of corticosteroids in pregnant animals, the possible benefits to the pregnant animal should be weighed against potential hazards to its developing embryo or fetus. Human Warnings: Not for use in humans. For use in animals only. Keep this and all medications out of the reach of children. Consult a physician in the case of accidental human exposure. PRECAUTIONS: Corticosteroids, including BetaVet®, administered intra-articularly are systemically absorbed. Do not use in horses with acute infections. Acute moderate to severe exacerbation of pain, further loss of joint motion, fever, or malaise within several days following intra-articular injection may indicate a septic process. Because of the anti-inflammatory action of corticosteroids, signs of infection in the treated joint may be masked. Appropriate examination of joint fluid is necessary to exclude a septic process. If a bacterial infection is present, appropriate antibacterial therapy should be instituted immediately. Additional doses of corticosteroids should not be administered until joint sepsis has been definitively ruled out. Due to the potential for exacerbation of clinical signs of laminitis, glucocorticoids should be used with caution in horses with a history of laminitis, or horses otherwise at a higher risk for laminitis. Use with caution in horses with chronic nephritis, equine pituitary pars intermedia dysfunction (PPID), and congestive heart failure. Concurrent use of other anti-inflammatory drugs, such as NSAIDs or other corticosteroids, should be approached with caution. Due to the potential for systemic exposure, concomitant use of NSAIDs and corticosteroids may increase the risk of gastrointestinal, renal, and other toxicity. Consider appropriate wash out times prior to administering additional NSAIDs or corticosteroids. ADVERSE REACTIONS: Adverse reactions reported during a field study of 239 horses of various breeds which had been administered either BetaVet® (n=119) or a saline control (n=120) were: acute joint effusion and/or local injection site swelling (within 2 days of injection), 15% BetaVet® and 13% saline control; increased lameness (within the first 5 days), 6.7% BetaVet® and 8.3% saline control; loose stool, 5.9% BetaVet® and 8.3% saline control; increased heat in joint, 2.5% BetaVet® and 5% saline control; depression, 5.9% BetaVet® and 1.6% saline control; agitation/anxiety, 4.2% BetaVet® and 2.5% saline control; delayed swelling of treated joint (5 or more days after injection), 2.5% BetaVet® and 3.3% saline control; inappetance, 3.4% BetaVet® and 2.5% saline control; dry stool, 1.7% BetaVet® and 0% saline control; excessive sweating, 0.8% BetaVet® and 0% saline control; acute non-weight bearing lameness, 0.8% BetaVet®and 0% saline control; and laminitis, 0.8% BetaVet® and 0% saline control.

CLINICAL PHARMACOLOGY: Betamethasone is a potent glucocorticoid steroid with anti-inflammatory and immunosuppressive properties. Depending upon their physico-chemical properties, drugs administered intra-articularly may enter the general circulation because the synovial joint cavity is in direct equilibrium with the surrounding blood supply. After the intra-articular administration of 9 mg BetaVet® in horses, there were quantifiable concentrations of betamethasone (above 1.0 ng/mL) in the plasma. EFFECTIVENESS: A negative control, randomized, masked field study provided data to evaluate the effectiveness of BetaVet® administered at 1.5 mL (9 mg betamethasone) once intra-articularly for the control of pain and inflammation associated with osteoarthritis in horses. Clinical success was defined as improvement in one lameness grade according to the AAEP lameness scoring system on Day 5 following treatment. The success rate for horses in the BetaVet® group was statistically significantly different (p=0.0061) than that in the saline group, with success rates of 75.73% and 52.52%, respectively (back-transformed from the logistic regression). ANIMAL SAFETY: A 3-week target animal safety (TAS) study was conducted to evaluate the safety of BetaVet® in mature, healthy horses. Treatment groups included a control (isotonic saline at a volume equivalent to the 4x group); 1X (0.0225 mg betamethasone per pound bodyweight; BetaVet®); 2X (0.045 mg betamethasone per pound bodyweight; BetaVet®) and 4X (0.09 mg betamethasone per pound bodyweight; BetaVet®). Treatments were administered by intra-articular injection into the left middle carpal joint once every 5-days for 3 treatments. Injection site reactions were the most common observations in all treatment groups. Injection site reactions were observed within 1 hour of dosing and included swelling at the injection site, lameness/stiffness of the left front limb, and flexing the left front knee at rest. The injection site reactions ranged from slight swelling (in many horses on multiple days in all treatment groups) to excessive fluid with swelling, pain, and lameness (4x group only). Injection site reactions were observed most commonly on treatment days, and generally decreased in number and severity over subsequent days. The incidence of injection site reactions increased after the second and third injection (number of abnormalities noted on day 10 > day 5 > day 0). In the BetaVet® treated groups the number and severity of the injection site reactions were dose dependent. The 4X BetaVet® group had the highest overall incidence of and severity of injection site reactions, which included heat, swelling, pain, bleeding, and holding the limb up at rest. The control group and 4X group (which received similar injection volumes) had a similar incidence of injection site reactions; however, the severity of reactions was greater in the 4X group. Absolute neutrophils were statistically significantly higher in the BetaVet® treated groups as compared to the control group. Trends toward a decrease in lymphocytes and eosinophils, and an increase in monocytes were identified in the BetaVet® treated groups after the initial dose of BetaVet®. Individual animal values for white blood cells generally remained within the reference range. BetaVet® treated horses also had a trend toward increased blood glucose after the initial dose. Some individual animals showed mild increases in blood glucose above the reference range. SHAKE WELL BEFORE USING NADA 141-418, Approved by FDA For customer care or to obtain product information visit www.betavetequine.com or call 1-800-458-0163. To report an adverse event please contact American Regent Animal Health at (800) 734-9236 or email pv@americanregent.com.

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SURGERY

No negative

cross, 1 Quarter Horse, and 1 Warmblood. Premedication with IV xylazine 0.5 mg/kg was split up as 0.3 mg/kg 5 to 10 minutes and 0.2 mg/kg 3 to 5 minutes prior to induction. The horses were induced with IV midazolam 0.05 mg/kg and IV ketamine 2.2 mg/kg with head and tail rope assistance. Following induction and positioning in left lateral recumbency, the horses were connected to a large animal rebreathing circuit—they breathed spontaneously through each anesthesia event. Anesthesia was maintained for 90 minutes with isoflurane in oxygen at an end-tidal isoflurane concentration of 0.9% to 1.3% and an FiO2 concentration of >90%. After 90 minutes of anesthesia time, baseline cardioventilatory measurements were obtained each minute for 10 minutes. Then, a bolus of either saline or flumazenil was given over 10 minutes. Flumazenil doses were 20 µg/kg (high dose) or 10 µg/kg (low dose). Each horse’s cardioventilatory parameters were monitored at 1-minute intervals until 10 minutes after administration of the bolus. Recovery was also recorded, and the tapes were reviewed and evaluated on a 115-point recovery scoring system by 3 board-certified specialists.

significant difference between flumazenil administration and overall recovery score, although the authors note that this could have been due to the subjective nature of the scoring system. “To more objectively assess the relationship between benzodiazepine reversal and ataxia and muscle weakness, our future investigations will use accelerometry to assess recovery characteristics,” they wrote. “Future studies using a larger cohort of horses will better characterize the effect of flumazenil administration on muscle strength and coordination.”

physiologic

consequences

were observed

from flumazenil administration.

Results

No horses sustained any injuries as a result of the procedures, and no negative physiologic consequences were observed as a result of flumazenil administration. Flumazenil showed a dose-dependent significant difference in several parameters vs. placebo, including SpO2, mean arterial pressure, inspiratory:expiratory ratio, minute volume of ventilation, and peak inspiratory pressure. Flumazenil also shortened the time to sternal recumbency, the time to first attempt to rise, and the time to standing. On review of the recovery videos, there was no

Clinical impact

This is the first study to evaluate flumazenil as a benzodiazepine reversal agent in horses, and the results appear to track with those in humans and small animal species, the researchers said. While the researchers note that there were some limitations to the study—most notably, that healthy horses were evaluated—they are confident that flumazenil administration can aid horses in anesthesia recovery. “Considering the effects on [minute volume of ventilation] and recovery time, flumazenil could be used clinically in cases for which a prolonged anesthetic recover is undesirable,” they wrote. “It has potential value for systemically compromised horses undergoing general anesthesia, in which benzodiazepine clearance may be significantly altered. Thus, the administration of flumazenil may be indicated to improve ventilatory function and shorten recovery time in critically ill horses that are at risk for perianesthetic complications.” Next up for the research team is a pharmacokinetic study of flumazenil. “By continuing to explore the pharmacology of flumazenil, we hope to provide further evidence to support the use of this reversal agent to improve equine anesthetic recovery,” Dr. Douglas said. MeV

For more information: Douglas H, Hopster K, Cerullo M, et al. The effects of flumazenil on ventilatory and recovery characteristics in horses following midazolamketamine induction and isoflurane anaesthesia. Equine Vet J. 2020 Nov. 21 [Epub ahead of print]. http://beva.onlinelibrary.wiley.com/doi/10.1111/evj.13391

ModernEquineVet.com | Issue 12/2020

RESPIRATORY

Nasal Spray Controls Severe Equine Asthma By Adam Marcus A novel form of the corticosteroid ciclesonide appears safe and effective for treating severe equine asthma, according to the results of a large, prospective trial in Europe. The nasal formulation led to a statistically significant reduction in asthma symptoms over the 10-day study, which included more than 220 animals with severe asthma related to their stable or pastures. A safety analysis found no adverse events attributable to the therapy, which is marketed in the United States as Aservo EquiHaler (Boehringer Ingelheim Animal Health). The new formulation is a pro-drug of ciclesonide

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called des-ciclesonide. The medication is administered by a nasal applicator that sprays a low-velocity mist of tiny particles—nearly all of which are 5 µm in diameter or smaller—deep into the animals’ airways. There the particles bind to receptors in the airway epithelium with 12 times the affinity of dexamethasone and 100 times the affinity as conventional ciclesonide.

In the study, 95% of horses tolerated Aservo EquiHaler nasal spray, and 90% of owners complied with treatment. Animals in the study received 140 metered doses of the drug over a 10-day period. “We saw that the ciclesonide-treated group resulted in a 73.4% response rate and the placebo-treated group in a 43.2% response rate,” said R. Scott Pirie, BVM&S, PhD, the chair of equine clinical sciences at the University of Edinburgh, who presented the findings at the 2020 virtual convention of the American Association of Equine Pracitioners (presentation S1001). Moreover, horses that received the nasal spray experienced a much larger drop in a weighted clinical score of 9 asthma-related criteria, including nasal discharge, cough, and bronchial and tracheal noises, as assessed by their owners compared with animals in the placebo group, Pirie said—7.2 points 3. versus 3.8, respectively (P<0.0001). According to Pirie, 95% of the horses in the study tolerated the nasal spray, and more than 90% of owners complied with the treatment, he added. Pirie noted that the researchers could not rule out the possibility that some of the horses improved in the study because the allergen load in their environments lessened. However, he added, the owners were instructed not to take any special measures that might have such an effect, or to make the load worse. MeV The study was funded by Boehringer Ingelheim.

There’s nothing else like it. Over the past 30 years, Adequan® i.m. (polysulfated glycosaminoglycan) has been administered millions of times1 to treat degenerative joint disease, and with good reason. From day one, it’s been 2, 3 the only FDA-Approved equine PSGAG joint treatment available, and the only one proven to. Reduce inflammation Restore synovial joint lubrication Repair joint cartilage Reverse the disease cycle When you start with it early and stay with it as needed, horses may enjoy greater mobility 2, 4, 5 over a lifetime. Discover if Adequan is the right choice. Talk to your American Regent Animal Health sales representative or call (800) 458-0163 to order. BRIEF SUMMARY: Prior to use please consult the product insert, a summary of which follows: CAUTION: Federal law restricts this drug to use by or on the order of a licensed veterinarian. INDICATIONS: Adequan® i.m. is recommended for the intramuscular treatment of non-infectious degenerative and/or traumatic joint dysfunction and associated lameness of the carpal and hock joints in horses. CONTRAINDICATIONS: There are no known contraindications to the use of intramuscular Polysulfated Glycosaminoglycan. WARNINGS: Do not use in horses intended for human consumption. Not for use in humans. Keep this and all medications out of the reach of children. PRECAUTIONS: The safe use of Adequan® i.m. in horses used for breeding purposes, during pregnancy, or in lactating mares has not been evaluated. For customer care, or to obtain product information, visit www.adequan.com. To report an adverse event please contact American Regent, Inc. at (800) 734-9236 or email pv@americanregent.com. Please see Full Prescribing Information at www.adequan.com.

www.adequan.com 1 Data on file. 2 Adequan® i.m. Package Insert, Rev 1/19. 3 Burba DJ, Collier MA, DeBault LE, Hanson-Painton O, Thompson HC, Holder CL: In vivo kinetic study on uptake and distribution of intramuscular tritium-labeled polysulfated glycosaminoglycan in equine body fluid compartments and articular cartilage in an osteochondral defect model. J Equine Vet Sci 1993; 13: 696-703. 4 Kim DY, Taylor HW, Moore RM, Paulsen DB, Cho DY. Articular chondrocyte apoptosis in equine osteoarthritis. The Veterinary Journal 2003; 166: 52-57. 5 McIlwraith CW, Frisbie DD, Kawcak CE, van Weeren PR. Joint Disease in the Horse.St. Louis, MO: Elsevier, 2016; 33-48. All trademarks are the property of American Regent, Inc. © 2020, American Regent, Inc. PP-AI-US-0372 02/2020

TECHNICIAN UPDATE

RISK in the Equine Practice: The Technician’s Role in Recognition and Prevention By Deborah B. Reeder, BA, AS, RVT, VTS-EVN The most important area to address in management is risk, which can involve safety issues, legal problems, claims against the practice from clients or employees or co-owners, to the public. Yes—the equine veterinary practice does have an impact on public health . . . Is your practice prepared and protected? Why is the equine practice a unique potential for risk? There are many reasons. For instance, we often receive instructions from trainers, not the actual owner. It is sometimes difficult to determine who makes the financial and medical decisions for the horse (syndicates). There is a resistance to pay at the time of service. It is just the nature of the horse industry; it is full of risk. There are unrealistic expectations. And through all of these, technicians play an important role because we often wear many hats. We can be asked to do what may be questionable ethically, legally, beyond our skill level, or potentially against policies and procedures. So how to we identify risk? The first discussion is of course the legal one. What constitutes malpractice and how do we avoid it. The three C’s of malpractice are: Competence, Communication and Compassion. If you are above question in these 3 areas, you can usually avoid malpractice issues or risk. Animals are considered property, however, sentimental value is coming soon to a court near you. To show that a veterinarian or member of the staff has exhibited professional negligence, someone must prove that there has been a lack of duty of care, a breech of that duty and damages. One of the key areas in which a practice can prove competence is to show that it supports the staff in participating and attending continuing education (CE). If the technician staff is competent (i.e., trained and attends regular CE) the risk is lowered, and there is less likelihood of someone proving negligence. Communication to the client and among staff is a clinical skill that is often overlooked, and probably the most common cause for complaints and increased risk. Make sure that clients are fully informed of all procedures, costs, risks associated with any of the procedures or medications, the best and 16

Issue 12/2020 | ModernEquineVet.com

worst case scenarios, the doctors and staff involved in the care, the hours of care, and verifying that the clients understand all they were told or read. A nod of understanding in a moment of fear or financial paralysis facing a colic surgery is not enough. Informed consent is not just a signature on a form, it is a process of dialogue. Another important issue to avoid litigation is demonstrating how much we care. Compassion for horses is why many of us are in this field, and yet with the harried hours, the rush to get to surgery, the overwhelming caseload, the fear that it might be too late, or the lack of confidence in a definitive outcome can often be interpreted as not caring, being short, cold, or profit driven. Communicating compassion is key to the client, to the owner, to the daughter, to the husband trying to understand. It is our responsibility to provide it along with the best medical care we can. Be candid when something goes wrong. Talk to the client directly and honestly. Keep accurate notes. Advise staff not to discuss the situation with anyone. Other areas of risk that can be managed in the equine practice involve the consent forms and the estimates.These are absolute musts. They must be from the owner and they can be via the telephone—however it needs to be noted as such. The owner must be advised as to any and all risks associated with a medication (especially if it is off-label), and procedures, the nature of the treatments, who will be performing all procedures and treatments, as well as the potential outcome. And the risk needs to be communicated throughout treatment. By law, the consent forms need to be obtained by the veterinarian in charge of the case—to the degree that this is not done, there is risk. Medical records are how you prove in court that you were due diligent and provided the horse with the best care possible. Equine practices need to do better than just the minimum standards if they want to avoid future risk. The records need to be complete, legible, factual, contemporaneous, correct, and they can be computerized. Do a records audit 2–3 times a year. Be the consummate professional when recording, reviewing or correcting the medical records. Will they stand up in a court of law—and can you stand behind them? Written consent and medical records management are by far the most important areas of risk management in the equine practice. If you do these

wrong, you will be destroyed professionally, so will the practice. Creating and maintaining medical records is the single most imHERE ARE 10 PRACTICAL TIPS IF FACED WITH POTENTIAL LITIGATION portant responsibility of the equine technician. Make sure they are cor1. Take a breath, slow down, respond in a 6. Don’t speak with the complaintant rect, accurate and information is put professional manner and take the 2–3 7. Don’t make alterations in the into the record in a timely manner. minutes to have that conversation records Note that any physical images, such 2. D on’t assume that you, the DVM or 8. Report to your insurer as radiographs and ultrasound imthe practice is in the wrong. ages, belong to the practice that cre9. Respond thoughtfully 3. Secure the evidence ated them. The information in the 10. Contact a lawyer images are the property of the client. 4. Understand the Board Rules States determine how long pa5. Be prompt tient records, including images, should be maintained, however, a minimum of 10 years is a good rule of thumb. Note all conversations, including phone and electronic communications, such as texts. ployee and all potential employees—as well as your inRemember this old saying: “If it is not in the medical surance company— go a long way in reducing your risk. record . . . it did not happen.” This may seem like an area that technicians would One of the most common complaints heard by not have to be involved in . . . and yet, most of the lawyers or before state boards is “I never would have negligence cases reported were directed at or directly consented if I had been informed of the risks.” involved technicians. The challenges are: We are vulnerable, so we must be diligent. 1. We assume the client understands, because they The best way you can prevent or minimize risk to nod their head or don’t say anything yourself, to your career and to your practice is to be dili2. We are rushed gent in observing where your practice is at risk, take steps 3. We delegate important conversations to other staff to identify those areas, and implement steps to secure who may not be skilled enough to explain systems to stop further risk. Research the State Board 4. We have poor communication skills. (Don’t use Rules and Regulations in your state, find out what the law euphemisms for death and euthanasia as a posays about your areas of responsibility and level of supertential risk.) vision, as well as FMLA and labor laws. Are you being The veterinary-client relationship is also at risk. We asked to do things that are questionable or that would put have a responsibility to guard the personal and financial you at risk? Are you being asked to go on salary so you do information of the patient or owner. not have to be paid overtime? One of the challenges we may face is knowing who the The best defense you have is education. Become inowner is; for instance, in a divorce proceeding, the illegal formed on the laws that could affect and or protect you. possession of a horse, or theft. Do you truly—without a Most veterinarians are not trying to take advantage of shadow of a doubt—know and can prove the ownership you or the law—they simply do not know. Their focus of the horse before you perform a procedure? is on providing medical care to the patient, diagnosing Another area often overlooked in the equine practice and performing surgery. Your responsibility is to assist is safety. Safety regarding equipment that works properthem in doing so to the highest standards of care possible, ly—doors, vehicles, stanchions etc. Staff knowing how to which includes minimizing risk for yourself, the client, operate all equipment is a major concern. the patient, the doctor and the practice. Be the difference There is huge risk involved in working around horses. for your practice . . . it will get noticed. MeV Is training provided on safe horsemanship? Are there signs posted regarding the risk of working around horses, About the Author x-rays, restraint, new surroundings, fear, pain, loud noisDeborah B. Reeder, BA, AS, RVT, VTS-EVN, is the es—all of these factors play heavily into increased risk. executive director of American Association of Equine Veterinary Technicians and Associates. Providing a plan showing how you are addressing all of these areas in your practice and showing this to each emModernEquineVet.com | Issue 12/2020

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ORTHOPEDICS