The NAVTA Journal August/September 2017 by NAVTA Journal

JOURNAL

VETERINARY NURSING IN ACTION

AUG / SEPT 2017

SPECIAL FOCUS: EMERGENCY AND CRITICAL CARE

IN THIS ISSUEâ&#x20AC;¦

The Smoldering Effects of Smoke Inhalation

Patient Comfort, 44 Correlating Care, and Outcomes

50 Losing Your Breath

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Here’s why Duralactin products should be a key part of your treatment of inflammation and joint conditions. • Suitable for long-term use and high-risk pets (hepatitis, renal, GI) • Easy once-a-day dosage • Palatable, with a variety of flavors and dosage types • Multiple formulations for canines and felines SATISFACTION GUARANTEED

Duralactin® products come with a risk-free, 100% money-back guarantee. If your clients are not completely satisfied with any of the products, they are eligible for a refund or product replacement.

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

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CE as needed, when needed.

TABLE OF CONTENTS

50 ON THE COVER

IN THIS ISSUEâ&#x20AC;¦

04 Executive Board Report 06 State Association Updates 17 Compassionate Fatigue 20 Veterinary Support Staff Unleashed

22 Cachexia in Chronically Ill Patients

Julie Palmucci, CVT has been in the veterinary profession over 29 years and is currently practicing at Harlingen Veterinary Clinic in Belle Mead, NJ. Julie loves to educate clients and provide patient care, along with successfully running the veterinary practice. Photo courtesy of Nick Mistretta; Mistretta Design Group.

28 The Smoldering Effects of Smoke Inhalation

37 The Essentials of Shock 44 Creature Comforts 50 Case Study: Losing Your Breath

52 Case Study:

Hypernatremia

56 Case Study:

An Ethical Dilemma

59 Through the Eyes 61 B rief Media and Mission Rabies

63 P ursuing a

Behavior Specialty

CORRECTION NAVTA June/July 2017 Through the Eyes pg. 57-58 Our apologizes from Kalico Desgin for the mislabeled photographs of Ellen Carozza, LVT and Maureen Susi, RVT.

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA NEWS

JOURNAL

NAVTA Executive Director: Julie Legred, CVT P.O. Box 1227, Albert Lea, MN 56007 Phone: 888-99-NAVTA | Fax: 507-489-4518 info@navta.net | www.navta.net

2017 NAVTA EXECUTIVE BOARD President: Mary Berg BS, RLATG, RVT, VTS (Dentistry) President Elect: Kara M. Burns, MS, MEd, LVT, VTS (Nutrition), VTS-H (Internal Medicine, Dentistry) Secretary: Beckie Mossor, RVT Treasurer: Eric Zamora-Moran MBA, RVT, VTS (Anesthesia & Analgesia) Member at Large: Stephen Cital, RVT, RLAT, SRA, VTS (Lab Animal) Member at Large: Erin A. Spencer, M.Ed., CVT, VTS (ECC) Past President: Rebecca Rose, CVT COMMITTEE CHAIRS NAVTA Booth Representative: Virginia Rudd, CVT, RVT NAVTA CE Committee: Vicky Ograin MBA, RVT, VTS (Nutrition) NAVTA CVTS Committee: Ed Carlson, CVT, VTS (Nutrition) NAVTA Global Outreach Committee: Ken Yagi, BS, RVT, VTS (ECC, SAIM) and Linda Markland, RVT NAVTA Legal Committee: Megan Brashear CVT, VTS (ECC) NAVTA Membership Committee: Liza Wysong Rudolph BAS, CVT, VTS (CP-Canine/Feline, SAIM) NAVTA National Credential and Title Change Task Force: Ken Yagi, BS, RVT, VTS (ECC, SAIM) and Heather Prendergast, RVT, CVPM NAVTA Public Relations Committee: Stephen Cital, RVT, RLAT, SRA, VTS (Lab Animal) NAVTA SCNAVTA Committee: Beckie Mossor, RVT NAVTA State Representative Committee: Ken Yagi, BS, RVT, VTS (ECC, SAIM) NAVTA Veterinary Assistant Committee: Dennis Lopez, M.ED, B.SCI, LVT THE NAVTA JOURNAL Editor in Chief & Website Coordinator Heather Prendergast, RVT, CVPM Associate Editor in Chief Kara Burns, MS, M.Ed., LVT, VTS (Nutrition) Editorial Board Katie Larsen, DVM Rachel Lutz, BS, LVT Betsy Hensley, CVT Pat Telschow, BS, LVT Design Kalico Design | www.kalicodesign.com Printing and Fulfillment Boelte-Hall, LLC | www.boelte.com Opinions and statements in The NAVTA Journal are those of the authors and not those of NAVTA, unless so stated. NAVTA assumes no responsibility for, and does not warrant the accuracy or appropriateness of, recommendations or opinions of the authors or of any product, service, or technique referred to in The NAVTA Journal. Published advertisements in The NAVTA Journal are not an endorsement of any product or service.

NAVTA EXECUTIVE BOARD REPORT The Executive Board of the National Association of Veterinary Technicians in America is extremely pleased to update you with the many ongoing initiatives of the 2017 year. First and foremost, NAVTA has worked hard to be involved in many industry and manufacture programs, allowing more opportunities for veterinary technician growth. The following list is just a few organizations NAVTA is involved with, with the goal of creating reduced costs or free educational opportunities: • Fear Free • Partners for Healthy Pets • American Veterinary Medical Association (AVMA) • American Association of Veterinary State Boards (AAVSB) • Association of Veterinary Technician Educators (AVTE) • Association of American Veterinary Medical Colleges (AAVMC)

• Merck: Diabetes and Vaccinology online CE modules

• BI: Complimentary membership to NAVTA to promote our profession

• Merck Champions for Care online certification

• NAVTA Veterinary Technician Lounge at Central Veterinary Conference (CVC – Kansas City and San Diego) and Western Veterinary Conference (WVC)

• Zoetis: Diabetes and Noise Aversion online CE modules • PRN: Pain management online CE modules • BI: Tech Champions initiative (HW, Fleas/ticks, dentistry, intestinal parasites, etc)

• Continuing Education tracts at NAVC, CVC and WVC

NAVTA Committee Quick Review: • The AVA Committee is currently in curriculum review • The Legal Committee is currently revamping the SCNAVTA and NAVTA bylaws • CVTS is working on revising VTS guidelines • A CVTS Ad Hoc Committee was formed to complete CVTS Guideline revisions • The SCNAVTA Committee working on items for the AVTE meeting and booth in August

• The Membership Committee is reviewing database profile information to ensure we have data to make decisions relating to our profession • The CE Committee is developing tracks at future conferences • The Global Outreach Committee is ensuring we have a presence and a voice concerning the veterinary technology and nursing profession at a global level (see Committee Spotlight)

• The PR Committee continues to promote NAVTA, as well as educating about the profession • The State Representative Committee is developing leaderships symposiums held twice each year, as well as developing resources for the state and the National District Representative System NAVTA will continue to seek opportunities to represent the Veterinary Technician/Nurse Profession. As always, we look forward to member feedback as we continue moving forward.

- NAVTA Executive Board 4

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NAVTA NEWS

GLOBAL OUTREACH COMMITTEE The Global Outreach Committee fosters relations with international veterinary organizations to promote the profession and gain insight from veterinary professionals around the globe. Activities of the committee include information exchange, sharing of resources, and discussions of the veterinary technician profession with those in foreign countries. NAVTA is a member of the International Veterinary Nurses and Technicians Association (IVNTA) which grants all NAVTA members the ability to receive full membership status with full member countries of the association (for a list, visit http://www.ivnta.org). The committee is also in discussions with the World Small Animal Veterinary Association regarding our involvement in developing the field of veterinary nursing globally. Major committee activities this cycle included attending the IVNTA meeting and Irish Veterinary Nurses Association (IVNA) annual congress.

IVNTA Meeting IVNTA is an association of member countries which seeks to foster and promote links with veterinary nursing staff worldwide by communication and co-operation. Linda Markland and Kenichiro Yagi, as the NAVTA International Liaisons, attended the biennial meeting in conjunction with the Irish Veterinary Nurse Association Annual Congress in Galway, Ireland on May 27-28 2017.

The meeting included representatives from The Registered Veterinary Technologists and Technicians of Canada, The British Veterinary Nursing Association, Irish Veterinary Nurses Association, Veterinary Nurses Council of Australia (VNCA) and NAVTA. Our discussions included member countries and their inclusion and participation in the organization. With more countries involvement, we are able to identify the challenges and trends that occur in the veterinary profession on an international level. IVNTA included a panel discussion of the participating countries to discuss the state of veterinary nursing and challenges experienced by each country. The conclusions drawn from the panel discussion indicate that each country is experiencing challenges in long term sustainability of the profession. Key reasons identified for the challenge include low retention rates (average longevity of 5-7 years) that is largely related to a lack of job fulfillment from poor utilization, low wages, and lack of public understanding of the role. As all of the member countries are experiencing most of these challenges it is important that we work together, sharing not only the challenges, but the successes that are experienced. NAVTA is helping to facilitate the communication between countries to continue the dialog, and has provided perspectives on team structure, technician utilization, and the future of the profession in the United States. It is proposed that the next general meeting of the IVNTA be hosted by the VNCA at their 2019 annual congress in Cairns, Australia in March or April of that year. Respectfully submitted, Linda Markland Kenichiro Yagi

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA NEWS

STATE ASSOCIATION UPDATES Rhode Island Veterinary Technician Update Happy Summer from RIVTA! RIVTA is paying it forward! We are contributing to our local veterinary technician college, New England Institute of Technology, located in East Greenwich, Rhode Island. This accelerated Veterinary Technology program has flushed our state with eager graduates who have obtained their CVT’s by taking and passing the VTNE. A $1,000 scholarship will be presented to a superior student in October 2017. We are happy to show our appreciation towards the program by rewarding students with financial aid.

Left to right: Liza Wysong Rudolph BAS, CVT, VTS (CP-Canine/Feline, SAIM), Samantha Knell, RVT, and Nicki Castagna, RVT

Maryland Veterinary Technician Association The Maryland Veterinary Technician Association had a non-profit booth at the American College of Veterinary Internal Medicine Conference in early June. We were able to meet some of our charter members in person, and had a handful of new members join while at the conference. In addition, we met many technicians from around the country and many people gave us words of encouragement and support as well as thanking us for starting the organization. This was a successful outreach event for us to begin exposing MDVTA to others! We hope to attend more consumer events like this that will expose us to the general public in Maryland. Thank you everyone, for your continued support along the way! — Nicki Castagna, RVT, MVTA President

We have been busy brainstorming for our 2018 symposium. We are excited to add another track to our schedule, making a total of three 6-hour lecture tracks and one hands-on track showcasing CPR and Radiology Techniques. Lecture ideas include behavior, practice management, cytology, and cardiomyopathy. Members responded well to a RIVTA Facebook poll asking for lecture ideas about exotics and pocket pets. A lot of great ideas are coming through! —Christen Owen, CVT, RLATG

Virginia Association of Licensed Veterinary Technicians The Virginia Association of Licensed Veterinary Technicians is pleased to announce the launch of our new website at www.valvt.org. Here you will find our constitution, contact information for the executive board members, local CE opportunities, as well as job opportunities. If you have any additional comments or would like to place an advertisement on the site, please email VALVT association coordinator, Victoria Staples at valvtinc@gmail.com. There has recently been many proposed changes that will impact the veterinary field tremendously. We urge our members to read all emails from the Virginia Board of Veterinary Medicine, Virginia Association of Licensed Veterinary Technicians, and National Association of Veterinary Technicians of America. Please be sure to visit the Virginia Town Hall website during open comment periods to make sure your voice is heard. These public comment periods are currently open; we encourage you to share the link with your non-veterinary friends, allowing them to express their opinion(s) as well. Planning for the VALVT Annual Fall Conference is in full swing and we are excited to offer a wide variety of topics to our members this year on Saturday, September 16, 2017 at Blue Ridge Community College in Weyers Cave, VA. Please continue to visit our website for the most up to date information. We are looking forward to a great educational weekend and will be kicking off the weekend with a reunion social. Visit our social media websites for details! *Don't forget the 8 hours of CE requirement for this year* —Kendall Blackwell, LVT, VALVT Vice President, NAVTA VA State Rep

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NAVTA NEWS

STATE ASSOCIATION UPDATES Kansas Veterinary Technician Association The Kansas Veterinary Technician Association awarded their annual student scholarship to a well deserving vet tech student. The $250 KVTA Scholarship is awarded annually to one qualified applicant who the executive board believes will make a significant contribution to the Veterinary Technology field. To be eligible, the applicant must be enrolled as a full-time student in a Veterinary Technology program in the state of Kansas, carry a 3.0 GPA, and must also be a member of the Student Veterinary Technology Association. Each applicant must submit an application along with an essay on why they chose to become a Veterinary Technician and an idea on how to better the profession. KVTA had some great applications this year and is excited to have so many bright, passionate individuals getting ready to join our profession. The KVTA Executive board would like to congratulate Amalia Rose Werner for being chosen as the recipient of the 2017 KVTA Scholarship for $250.00. Ms. Werner is a student of Colby Community College and a student member of the KVTA. Amalia Werner, KVTA Scholarship recipient, and Melissa Stomberg, BS, RVT, Program Instructor

—Vicky Ograin, RVT, VTS Nutrition

Tennessee Veterinary Technician Association The TVTA offers a $500 scholarship to an outstanding student from each of the five AVMA accredited veterinary technology programs in the state. The criteria includes community service and financial need. The program directors from each school choose the scholarship winner.

The Scholarship winners for 2017 include:

Upcoming TVTA CE opportunities include:

• Richard Watkins; Columbia State Community College

• East Tennessee: Tennessee Veterinary Technician Association Fall Conference

• Katie Johnson; University of Tennessee Martin • Hailey West; Volunteer State Community College

• Gatlinburg, TN September 30-October 1, 2017. Edgewater Hotel and Conference Center

• Julianna Durand; Lincoln Memorial University

West Tennessee: Tennessee Veterinary Technician Association Conference to be held at the University of Tennessee Martin campus November 4-5, 2017.

Congratulations to these hard-working and well deserving students!

For more information go to www.TNVTA.org or contact us at tennvta@gmail.com

• Brittany Taylor Jackson; Chattanooga State Community College

—Mary Hatfield, AS, BS, M.Ed., LVMT, LAT, NAVTA State Representative

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA NEWS

STATE ASSOCIATION UPDATES Washington State Association of Veterinary Technicians Washington State Association of Veterinary Technicians is very excited to introduce our 2017-2018 board! As the newly elected President I am amazed at the amount of energy and dedication from each of these individuals. I look forward to working with every board member and continuing to keep communication open amongst our membership and NAVTA. • Past President – Ryan Frazier

New Hampshire Veterinary Technicians Association The New Hampshire Veterinary Technicians Association (NHVTA) would like to congratulate the recent graduates from our veterinary technology programs. We are excited to see your success as you all prepare for your national board exams. The 4th Annual Spring Symposium was held in May and featured speakers Ed Carlson, CVT, VTS (Nutrition) and Patty Pate, CVT, VTS (ECC), CCFE. They both did an amazing job, making the symposium a great success. Plans have already begun for the 5th Annual Spring Symposium as we work on offering two tracks. We are working on updating the membership portal, making licensing and renewal a smoother process. Elections will be held in the fall for all active members. To stay on top of the news around the state, including job postings and CE opportunities follow us on Facebook and subscribe to our newsletter. www.nhvta.org.

• President – Jade Velasquez • President Elect – Nicole LaForest • Vice President – Heidi Hirt • Secretary – Benita Altier • Treasurer – Lori Lutskas • Finance – Renee Neideigh • ByLaws – Angela Miranda • Program – Laura Tautz-Hair • Membership – Shari Hultberg

—Bonnie Miller, BS, CVT, VTS(ECC) NAVTA State Representative, NH

North Carolina State Association The NCAVT held our annual Spring Conference at North Carolina College of Veterinary Medicine on April 8th, 2017. This year our conference included four lecture tracks including small animal, large animal, management, and an industry track. Additionally, we offered two web lab opportunities, dental nerve blocks, and bandaging. Our many presenters included Dr. Ernie Ward, Dr. Richard Ford as well as talented Registered Veterinary Technicians within our state. To kick off our annual spring conference, the NCAVT along with Merial/Boehringer Ingelheim offered Technicians and support staff a one-hour continuing education opportunity on intestinal parasites. Participants then enjoyed the venue and networked with peers.

• Nominations – Melanie Long • Career Center Coordinator – Sheila Miller • Newsletter Editor – Christina Ojanen • Government Affairs Liaison – Nancy Muir & Leslie Montgomery We would love to see more technicians become involved. For more info on our association, please go to www.WSAVT. org. As with many other states, Washington does have a shortage of licensed veterinary technicians. If you are looking for a position, please feel free to see local job listings at www.wsavt.info/careers. —Jade Velasquez, LVT WSAVT President 8

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This spring, we participated in the North Carolina College of Veterinary Medicine Open House. This is an annual opportunity at the college that allows the public to tour the facilities and learn more about veterinary medicine. The NCAVT was there to educate the public on the role of veterinary technicians/veterinary nurses. To illustrate our profession, we played our Association video that includes imagery of what a veterinary technician /veterinary nurse does on a daily basis. To see our video, please visit our website NCAVT.org. Additionally, we promoted several schools within our state that offer approved AVMA technician programs. Finally, the NCAVT would like to take a moment to thank Mrs. Amanda Dillard, RVT, LATG for her many years of service and dedication to our executive board. Over the past 9 years, Amanda held many positions including Vice President, President and most recently Secretary. Her passion and support of our profession have helped drive the success of our association. From the NCAVT Executive Board and NCAVT Members, Thank you, Amanda, for your years of service! —Maureen L. Susi, RVT NCAVT Secretary

NAVTA NEWS

STATE ASSOCIATION UPDATES The Oregon Veterinary Technician and Assistant Association (OVTAA)

Ohio Association of Veterinary Technicians

Greetings from Oregon! In June, a call for nominations was sent out to our general membership for the following executive officer positions:

Where has the summer gone? After a quiet and slow start to the season, we have been in full swing putting the finishing touches on Discovery 2017. We are very excited to be in a new, beautiful venue just north of Worthington and will be able to offer wet labs this year mixed in five different day long tracts offering a total of nine hours of continuing education from some amazing speakers. Our exhibit area has grown offering more insight and support for technicians. As if all that isn’t enough to entice technicians to come celebrate themselves, we also have some pretty sweet swag coming their way. If you’ll be in our neck of the woods mid-October, come check out Discovery 2017. For more information about Discovery, please visit our website www.OhioRVT.org.

• President • President-Elect • Recording Secretary • Four Member-At-Large positions Voting will take place in July and we will announce our newly elected officers in the next edition of the state association updates! Volunteers are needed for the Oregon Veterinary Medical Association State Fair Booth. This year, the OVMA booth will focus on allergies and skin disorders, including causes (ectoparasites, food allergies and environmental causes) and treatments. The OVTAA will be doing shifts at the booth on Sunday, September 3rd and we would love your help! Volunteers will receive free admission to the fair. Our website is currently under construction, so please contact us via Facebook for the most up to date information. You can also email any inquiries to Danielle Nelson, our new webmaster, at danielle.ovtaa@gmail.com. The OVTAA executive board meets the second Wednesday of every month. These meetings are open to all members and we would love to see you there! —Tiah Schwartz, CVT, NAVTA State Representative, Oregon

Vermont Veterinary Technician Association The VVTA is honored to have had our first in cahoots continuing education meeting with ETHOS. We loved working with a great company and enjoyed their speakers. This really helped our board members recharge! The VVTA board has sent out extensive surveys to our Vermont technicians and veterinarians to determine what employees seek in their employment, and what employers seek in their employees. We have received a high number of responses from both groups and look forward to developing some solutions for our profession. The VVTA Fall Continuing Education Meeting will be held on November 5, 2017. We look forward to welcoming Dr. Donna Raditic, DVM, DACVN, CVA of Nutrition and Integrative Medicine Consultants in Athens, GA. She will be lecturing on Nutrition in Practice, covering topics such as Facts, Fallacies and Myths in Pet Nutrition, Nutritional Assessments of Patients with Different Health Issues, and Understanding Pet Food Labels. We are thankful that Dr. Raditic is spending some time with us and invite veterinary nurses and their doctors from neighboring states to join us. Stay cool and enjoy the beauty of summer!!

Our board is still experiencing a positive upswing with new district representatives eager to help technicians. We are especially excited about this to help spread the word about technicians and the NAVTA Veterinary Nurse initiative. With our expanding board, we are also benefitting from an increase in association membership. Through the hard work of district representatives, we are able to be available at small, local continuing education meetings and offer direct links to board members for convenience to all technicians in Ohio. We are working hard focusing on how to keep technicians connected throughout Ohio and hope to continue strengthening that bond. We are looking forward to an amazing second half of 2017. — Christie Myers RVT, VTS (Clinical Practice- Canine/Feline) Vice President of the Ohio Association of Veterinary Technicians, State and District V Representative to NAVTA

—Deborah Glottmann, CVT VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA NEWS Wyoming Veterinary Technician Association The Wyoming Veterinary Technician Association has been very busy this spring, hoping to increase awareness of our association and benefits available to technicians by being involved with the association. President Tom Page presented to the veterinary technician students at Eastern Wyoming College in Torrington, Wyoming. The students on the WVTA board felt the information shared was helpful. The Wyoming Veterinary Technician Association scholarship deadline was June 30th. We will announce the name of the deserving Wyoming resident and veterinary technician student in July, and

the scholorship will be awarded during our annual fall continuing education meeting in September.The fall continuing education is coming together well. It is scheduled for Saturday September 23rd in Casper, WY. Guest speaker Lori Fuehrer, CVT, VTS (Neurology, Anesthesia/Analgesia) will be covering multiple topics about anesthesia, analgesia, and monitoring anesthetized patients. Registration forms are available on our website at www.wyvta.org/continuing-education.pml —Melanie Beardsley, CVT

applicants for the number of seats. Bergen Community College in Paramus, NJ, will be graduating 30 students in August. Camden County College, in Camden, NJ, had the second largest graduating class in the last few years—30 students in 2017! They received full accreditation from the AVMA in April, purchased a digital scanner and reader for radiology, and the program has formed a Memorandum of Understanding with Salem County College.

Graduation Picture for Class 13 of the Veterinary Assistant Program at Brookdale Community College with “Treasure”, our stuffed training mannequin.

New Jersey Veterinary Technician Association School is out for summer! We are proud to share our graduation picture of Class #13 of the NAVTA Approved Veterinary Assistant Program at Brookdale Community College (in collaboration with Red Bank Veterinary Hospital). The students did a great job and are excited to start their careers in the veterinary field after they complete their AVA exam. Every semester Brookdale coordinates a career fair for these graduates with local veterinary employers following the graduation, and we are excited about the many AVA’s working in New Jersey! Our CVTs have really enjoyed having these educated assistants assist them in their daily duties in the hospital as it has made them much more efficient in their technician tasks. For information on the program, visit www.brookdalecc.edu/continuinged/healthcare/vet-assistant. New Jersey also has 3 other NAVTA Approved VA programs in NJ – Morris County School of Technology, Mercer County College and Ocean County College. For more information on these programs, check out the veterinary assistant page on the NAVTA website. Our 2 veterinary technician programs in NJ are bursting at the seams with applicants! They typically have double the number of 10

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Even with all the summer fun going on at our beautiful NJ beaches and lively boardwalks, we are busy planning for the Atlantic Coast Veterinary Conference, (ACVC), taking place October 9th – 12th at the Atlantic City convention center. We will have NJVTA board members at the booth in the exhibit hall throughout the conference, as well as the Technician Lounge, which will be in a new location this year. We will also have a NAVTA booth right next to the NJVTA booth, so technicians and assistants can also stay current with the Veterinary Nurse initiative. Information regarding ACVC can be found at www.acvc.org. The Membership Committee continues to credential technicians in NJ – currently we have 615 in our membership database! For information regarding becoming credentialed, or renewing your credentials, visit http://njvta.com/membership-renewal. Our website is full of the latest and greatest information – check out www.njvta.com for the most current updates! —Janet McConnell, CVT NAVTA State Representative, NJ Students participate in a Fluid Therapy workshop instructed by Karen Norton, CVT, where they get comfortable with fluid pumps and how to safely remove an IV catheter.

HEARTGARD

TRUST. 1 2

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

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

PREVENTS HEARTWORM DISEASE

TREATS AND CONTROLS 3 SPECIES OF HOOKWORMS

TREATS AND CONTROLS 2 SPECIES OF ROUNDWORMS

OWNERS PREFER IT1 AND DOGS LOVE IT2

NAVTA NEWS

SPECIALTY UPDATES Academy of Veterinary Surgical Technicians The Academy of Veterinary Surgical Technicians is looking forward to hosting a great continuing education track for veterinary surgical technicians during the American College of Veterinary Surgeon’s Summit, October 11-14, 2017, in Indianapolis, Indiana. Wednesday’s pre-conference offerings include a loco-regional anesthetic techniques wetlab, where attendees will have the opportunity to perform a variety of nerve blocks (e.g., ring, brachial plexus and intra-articular blocks, epidural analgesia and more!) on dog and cat cadaver models. This class still has a few open spots- enroll today before it’s too late! Thursday will include topics ranging from surgical toxicological emergencies to managing patient airways, and weight management programs. Antibiotic concerns and client compliance issues will complete the first full day of the technician program. Don’t forget to join AVST Thursday evening as we welcome our newest

members during AVST Pinning Ceremony, immediately followed by the AVST General Membership Meeting. On Friday, there are 5 burgeoning surgical technicians vying for the Dr. Joel Woolfson Memorial Scholarship during the AVST Case Report Presentation competition. Attendees will also garner information on how veterinary technicians can build their career and avoid fatigue, followed by a wide range of orthopedic topics. Saturday’s presentations will include the use of 3D printers and how to best utilize technicians in a mobile surgical practice, as well as information encompassing a variety of soft tissue surgeries, including burn management and the latest on infection control for the surgical patient. If you plan to attend, be sure to visit the AVST booth in the exhibit hall, where you can enter our raffle to win a set of Medipaw (www.medivetproducts.com) bandage covers.

Registration to the American College of Veterinary Surgeon’s Summit opened May 15, 2017. See www.acvs.org for more information. Are you looking for exciting, new opportunities to work in a surgical environment? Be sure to check out our website (www.avst-vts.org) for the latest job postings for surgical veterinary technicians! The AVST has several members who enjoy sharing cutting edge surgical information with other passionate veterinary professionals. Please contact the AVST for more information about our experienced speakers, availability and topics. — Heidi Reuss-Lamky, LVT, VTS (Anesthesia and Analgesia, Surgery)

Academy of Veterinary Nutrition Technicians The Academy of Veterinary Nutrition Technicians held its credentialing examination in June, 2017 in Washington, DC. The examination was held immediately prior to the AAVN Symposium and the ACVIM Forum. Three candidates sat the examination this year. Additionally, AIMVT and AVNT had a Q & A session for interested individuals. Hill’s Pet Nutrition sponsored the pinning ceremony and reception for AIMVT and AVNT – thank you to Hill’s for all they do for the technician profession! Elections for the Board of Directors were held immediately prior to ACVIM with the following individuals making up the 2017/2018 AVNT Board – • Kara M. Burns – president • Ann Wortinger – president elect • Vicky Ograin – secretary • Ed Carlson – treasurer • Tammy Moyers – member at large • Nicola Ackerman – member at large

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Candidates planning to sit for the 2018 examination have been advised to begin collecting cases October 1, 2016 through September 30, 2017. Case report guidelines and instructions, the case report form, and a case example can be found on the AVNT web site.

The Academy of Veterinary Nutrition Technicians can be reached through:

If you are considering pursuing a VTS (Nutrition), please contact the AVNT and we will provide a mentor to help answer any questions about the process.

• Website | www.nutritiontechs.org

Please check the AVNT website periodically for updates. Look for continuing education offerings, updates to the suggested reading list, etc.

• Twitter | @nutritiontechs

• e-mail | nutritiontechs@aol.com

• Facebook | Academy of Veterinary Nutrition Technicians (AVNT)

—Kara M. Burns, MS, MEd, LVT, VTS (Nutrition) President, Academy of Veterinary Nutrition Technicians

NAVTA NEWS

SPECIALTY UPDATES chewables

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

The ADVT organizing committee after the pinning ceremony. Congratulations to the VTS (Dermatology) members for their outstanding contributions and achieving this long-awaited goal! Standing L to R: Jennie Tait (ADVT Secretary), Missy Streicher, Carol George (ADVT Treasurer), Nina Toebe, Jackie Davis (ADVT Member-at-Large), Chantelle Tebaldi. Seated L to R: Kim Horne (ADVT President) and Sandy Grable (ADVT President-Elect) Submitted by Kim Horne, CVT VTS (Dermatology)

The Academy of Dermatology Veterinary Technicians The Academy of Dermatology Veterinary Technicians (ADVT) has been very busy since being inducted as an Academy recognized by NAVTA. ADVT administered their first credentialing examination in April 2017, held in conjunction with the annual North American Veterinary Dermatology Forum in Orlando, Florida. In addition to the exam, a half day CE session and two roundtable sessions were held specifically for veterinary technicians. ADVT also hosted the biannual regents meeting and annual general business meeting. Eight organizing committee members officially became VTSs with a pinning ceremony that was held

at the ADVT (VTS) informational meeting – which was generously sponsored by Hill’s. A big thank you to Stallergenes Greer for providing breakfast at the membership business meeting and to VetriMAX for hosting a dinner reception for the Charter VTS and exam candidates. ADVT currently has 28 candidates working towards their VTS. Awareness of the Academy is on the increase with interest from around the globe, including Europe and Australia! Visit ADVT at www.vetdermtech.com for more information. ADVT has a technician listserve allowing networking with colleagues that have an interest in dermatology, as well as being a great resource for any questions.

Academy of Veterinary Ophthalmic Technicians The Academy of Veterinary Ophthalmic Technicians (AVOT) will hold their annual CE meeting in Baltimore, Maryland from October 11th-October 13th 2017. At this year’s meeting, AVOT will be providing their first VTS testing for their accepted candidates.

Dog Weight

Chewables Per Month

Ivermectin Content

Pyrantel Content

Color Coding 0n Foil Backing and Carton

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

1 1 1

68 mcg 136 mcg 272 mcg

57 mg 114 mg 227 mg

Blue Green Brown

HEARTGARD Plus is recommended for dogs 6 weeks of age and older. For dogs over 100 lb use the appropriate combination of these chewables. ADMINISTRATION: Remove only one chewable at a time from the foil-backed blister card. Return the card with the remaining chewables to its box to protect the product from light. Because most dogs find HEARTGARD Plus palatable, the product can be offered to the dog by hand. Alternatively, it may be added intact to a small amount of dog food. The chewable should be administered in a manner that encourages the dog to chew, rather than to swallow without chewing. Chewables may be broken into pieces and fed to dogs that normally swallow treats whole. Care should be taken that the dog consumes the complete dose, and treated animals should be observed for a few minutes after administration to ensure that part of the dose is not lost or rejected. If it is suspected that any of the dose has been lost, redosing is recommended. HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors), potentially carrying infective heartworm larvae, are active. The initial dose must be given within a month (30 days) after the dog’s first exposure to mosquitoes. The final dose must be given within a month (30 days) after the dog’s last exposure to mosquitoes. When replacing another heartworm preventive product in a heartworm disease preventive program, the first dose of HEARTGARD Plus must be given within a month (30 days) of the last dose of the former medication. If the interval between doses exceeds a month (30 days), the efficacy of ivermectin can be reduced. Therefore, for optimal performance, the chewable must be given once a month on or about the same day of the month. If treatment is delayed, whether by a few days or many, immediate treatment with HEARTGARD Plus and resumption of the recommended dosing regimen will minimize the opportunity for the development of adult heartworms. Monthly treatment with HEARTGARD Plus also provides effective treatment and control of ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). Clients should be advised of measures to be taken to prevent reinfection with intestinal parasites. EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development of the adult stage. HEARTGARD Plus Chewables are also effective against canine ascarids (T. canis, T. leonina) and hookworms (A. caninum, U. stenocephala, A. braziliense). ACCEPTABILITY: In acceptability and field trials, HEARTGARD Plus was shown to be an acceptable oral dosage form that was consumed at first offering by the majority of dogs. PRECAUTIONS: All dogs should be tested for existing heartworm infection before starting treatment with HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult heartworms and microfilariae before initiating a program with HEARTGARD Plus. While some microfilariae may be killed by the ivermectin in HEARTGARD Plus at the recommended dose level, HEARTGARD Plus is not effective for microfilariae clearance. A mild hypersensitivity-type reaction, presumably due to dead or dying microfilariae and particularly involving a transient diarrhea, has been observed in clinical trials with ivermectin alone after treatment of some dogs that have circulating microfilariae. Keep this and all drugs out of the reach of children. In case of ingestion by humans, clients should be advised to contact a physician immediately. Physicians may contact a Poison Control Center for advice concerning cases of ingestion by humans. Store between 68°F - 77°F (20°C - 25°C). Excursions between 59°F - 86°F (15°C - 30°C) are permitted. Protect product from light. ADVERSE REACTIONS: In clinical field trials with HEARTGARD Plus, vomiting or diarrhea within 24 hours of dosing was rarely observed (1.1% of administered doses). The following adverse reactions have been reported following the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering, convulsions and hypersalivation. SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability of ivermectin. The dose regimens of HEARTGARD Plus and HEARTGARD are the same with regard to ivermectin (6 mcg/kg). Studies with ivermectin indicate that certain dogs of the Collie breed are more sensitive to the effects of ivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds. At elevated doses, sensitive dogs showed adverse reactions which included mydriasis, depression, ataxia, tremors, drooling, paresis, recumbency, excitability, stupor, coma and death. HEARTGARD demonstrated no signs of toxicity at 10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies, support the safety of HEARTGARD products in dogs, including Collies, when used as recommended. HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant or breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea collars, dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with HEARTGARD Plus in a heartworm disease prevention program. In one trial, where some pups had parvovirus, there was a marginal reduction in efficacy against intestinal nematodes, possibly due to a change in intestinal transit time. HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (see DOSAGE section) for dogs of different weights. Each strength comes in convenient cartons of 6 and 12 chewables. For customer service, please contact Merial at 1-888-637-4251.

Please visit our website for more details about the annual meeting as well as the credentialing process. Natalie Herring, LVT, VTS (Ophthalmology, OC) — www.avot-vts.org

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA NEWS

SPECIALTY UPDATES Academy of Internal Medicine for Veterinary Technicians

Technician Case Report winner Courtney Waxman receives her plaque from AIMVT Member at Large Colleen Douglas

This year's forum was held at the Gaylord National Resort in National Harbor, MD right outside of Washington, DC

AIMing for Excellence! The Academy had a successful annual conference in conjunction with the ACVIM Forum, held in Washington DC at the Gaylord National Resort. AIMVT administered the VTS examination to 20 candidates in the subspecialties of Cardiology, Neurology, Oncology, and Small Animal Internal Medicine. 14 new Internal Medicine VTSs were pinned at the Pinning Ceremony and Reception was held, which was generously sponsored by Hill’s:

privilege of watching eleven very interesting presentations, including our winner Courtney Waxman, who presented a case of Peritoneal Dialysis Following Urethral Obstruction and Acute Kidney Injury.

• Large Animal – Christopher Rizzo and Mary English

AIMVT presented three full days of Internal Medicine Technician programming at the ACVIM Forum, covering all of the subspecialties of the Academy. All technician lectures were packed with standing room only, cementing our place as the largest bloc of attendees each year. Working closely with our College is important to us and we look forward to planning for next year’s Forum, held in Seattle, June 2018.

Sentier's Michelle Roach gives a "hands on" demonstration of the Vetcorder to AIMVT candidate Lisa Price

• Cardiology – Kristen Antoon • Neurology – Abbey Hertel, Heather Myers and Christy Servies • Oncology – Madeline Levesue, Niquita Parker, and Diana Smith • Small Animal – Yvonne Brandenburg, Ashley DiPrete, Samantha Kowalski, Jessica Shissler, and Lynda Vermillion The day before the Forum opened, AIMVT and the Academy of Veterinary Nutrition Technicians (AVNT) held a half-day of Technician Case Reports. We had the

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On Friday night of the Forum, the subspecialties had separate dinners with their members. The Cardiology technicians met at the Irish Pub in National Harbor, while the Small and Large Animal technicians had a wonderful dinner at Succotash, sponsored by Sentier, Vetcorder and VetTechXpert. Looking forward, we are developing an Academy Speakers’ Bureau to help our members spread their Internal Medicine knowledge to conferences and educational events everywhere, as well as a Writers’ Bureau for those members who

AIMVT President Liz Hughston and Executive Director Linda Merrill plan for the Academy's Q&A at the Forum

would rather write than speak publicly. The Academy has received a record number of letters of Intent to Apply so we will have a very busy fall reviewing applications for new Academy members! —Liz Hughston, President, Academy of Internal Medicine for Veterinary Technicians

Buster’s playmates miss him. It won’t be for long, because you prescribe PREVICOX.® Who isn’t sad when a dog is in too much osteoarthritis pain to play? So trust PREVICOX as your go-to NSAID because PREVICOX: • Provides efficacy both pet owners and veterinarians notice In a field study, after 30 days of use: – 96% of pet owners saw improvement in their dogs1 – Veterinarians saw improvement in 93% of dogs1 • Is rapidly absorbed—detected in plasma levels within 30 minutes2 • Is convenient with once-daily dosing

PUT RELIEF IN MOTION

Important Safety Information As a class, cyclooxygenase inhibitory NSAIDs may be associated with gastrointestinal, kidney or liver side effects. These are usually mild, but may be serious. Pet owners should discontinue therapy and contact their veterinarian immediately if side effects occur. Evaluation for pre-existing conditions and regular monitoring are recommended for pets on any medication, including PREVICOX. Use with other NSAIDs, corticosteroids or nephrotoxic medication should be avoided. Refer to the Prescribing Information for complete details. Merial is now part of Boehringer Ingelheim. REFERENCES: 1. Pollmeier M, Toulemonde C, Fleishman C, Hanson PD. Clinical evaluation of firocoxib and carprofen for the treatment of dogs with osteoarthritis. Vet Rec. 2006;159(17):547-551. 2. Data on file at Merial. ®PREVICOX is a registered trademark of Merial. ©2017 Merial, Inc. Duluth, GA. All rights reserved. PVX15TRADEADA-R (07/17).

CHEWABLE TABLETS Brief Summary: Before using PREVICOX, please consult the product insert, a summary of which follows: Caution: Federal law restricts this drug to use by or on the order of a licensed veterinarian. Indications: PREVICOX (firocoxib) Chewable Tablets are indicated for the control of pain and inflammation associated with osteoarthritis and for the control of postoperative pain and inflammation associated with soft-tissue and orthopedic surgery in dogs. Contraindications: Dogs with known hypersensitivity to firocoxib should not receive PREVICOX.

Post-Approval Experience (Rev. 2009): The following adverse reactions are based on post-approval adverse drug event reporting. The categories are listed in decreasing order of frequency by body system: Gastrointestinal: Vomiting, anorexia, diarrhea, melena, gastrointestinal perforation, hematemesis, hematachezia, weight loss, gastrointestinal ulceration, peritonitis, abdominal pain, hypersalivation, nausea Urinary: Elevated BUN, elevated creatinine, polydypsia, polyuria, hematuria, urinary incontinence, proteinuria, kidney failure, azotemia, urinary tract infection

Warnings: Not for use in humans. Keep this and all medications out of the reach of children. Consult a physician in case of accidental ingestion by humans. For oral use in dogs only. Use of this product at doses above the recommended 2.27 mg/lb (5.0 mg/kg) in puppies less than seven months of age has been associated with serious adverse reactions, including death (see Animal Safety). Due to tablet sizes and scoring, dogs weighing less than 12.5 lb (5.7 kg) cannot be accurately dosed. All dogs should undergo a thorough history and physical examination before the initiation of NSAID therapy. Appropriate laboratory testing to establish hematological and serum baseline data is recommended prior to and periodically during administration of any NSAID. Owners should be advised to observe for signs of potential drug toxicity (see Adverse Reactions and Animal Safety) and be given a Client Information Sheet about PREVICOX Chewable Tablets.

Neurological/Behavioral/Special Sense: Depression/lethargy, ataxia, seizures, nervousness, confusion, weakness, hyperactivity, tremor, paresis, head tilt, nystagmus, mydriasis, aggression, uveitis

For technical assistance or to report suspected adverse events, call 1-877-217-3543. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDAVETS or http://www.fda.gov/ AnimalVeterinary/SafetyHealth

In some situations, death has been reported as an outcome of the adverse events listed above. For a complete listing of adverse reactions for firocoxib reported to the CVM see: http://www.fda.gov/downloads/ AnimalVeterinary/SafetyHealth/ProductSafetyInformation/UCM055407.pdf

Precautions: This product cannot be accurately dosed in dogs less than 12.5 pounds in body weight. Consider appropriate washout times when switching from one NSAID to another or when switching from corticosteroid use to NSAID use. As a class, cyclooxygenase inhibitory NSAIDs may be associated with renal, gastrointestinal and hepatic toxicity. Sensitivity to drug-associated adverse events varies with the individual patient. Dogs that have experienced adverse reactions from one NSAID may experience adverse reactions from another NSAID. Patients at greatest risk for adverse events are those that are dehydrated, on concomitant diuretic therapy, or those with existing renal, cardiovascular, and/or hepatic dysfunction. Concurrent administration of potentially nephrotoxic drugs should be carefully approached and monitored. NSAIDs may inhibit the prostaglandins that maintain normal homeostatic function. Such anti-prostaglandin effects may result in clinically significant disease in patients with underlying or pre-existing disease that has not been previously diagnosed. Since NSAIDs possess the potential to produce gastrointestinal ulceration and/or gastrointestinal perforation, concomitant use of PREVICOX Chewable Tablets with other anti-inflammatory drugs, such as NSAIDs or corticosteroids, should be avoided. The concomitant use of protein-bound drugs with PREVICOX Chewable Tablets has not been studied in dogs. Commonly used protein-bound drugs include cardiac, anticonvulsant, and behavioral medications. The influence of concomitant drugs that may inhibit the metabolism of PREVICOX Chewable Tablets has not been evaluated. Drug compatibility should be monitored in patients requiring adjunctive therapy. If additional pain medication is needed after the daily dose of PREVICOX, a non-NSAID class of analgesic may be necessary. Appropriate monitoring procedures should be employed during all surgical procedures. Anesthetic drugs may affect renal perfusion, approach concomitant use of anesthetics and NSAIDs cautiously. The use of parenteral fluids during surgery should be considered to decrease potential renal complications when using NSAIDs perioperatively. The safe use of PREVICOX Chewable Tablets in pregnant, lactating or breeding dogs has not been evaluated. Adverse Reactions: Osteoarthritis: In controlled field studies, 128 dogs (ages 11 months to 15 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27mg/lb (5.0 mg/kg) orally once daily for 30 days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed adverse reactions during the study. Adverse Reactions Seen in U. S. Field Studies Adverse Reactions Vomiting Diarrhea Decreased Appetite or Anorexia Lethargy Pain Somnolence Hyperactivity

PREVICOX (n=128) 5 1 3 1 2 1 1

Active Control (n=121) 8 10 3 3 1 1 0

PREVICOX (firocoxib) Chewable Tablets were safely used during field studies concomitantly with other therapies, including vaccines, anthelmintics, and antibiotics. Soft-tissue Surgery: In controlled field studies evaluating soft-tissue postoperative pain and inflammation, 258 dogs (ages 10.5 weeks to 16 years) were evaluated for safety when given PREVICOX Chewable Tablets at a dose of 2.27 mg/lb (5.0 mg/kg) orally approximately 2 hours prior to surgery and once daily thereafter for up to two days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study. Adverse Reactions Seen in the Soft-tissue Surgery Postoperative Pain Field Studies Adverse Reactions Vomiting Diarrhea Bruising at Surgery Site Respiratory Arrest SQ Crepitus in Rear Leg and Flank Swollen Paw

Firocoxib Group (n=127) 5 1 1 1 1 1

Control Group* (n=131) 6 1 1 0 0 0

*Sham-dosed (pilled) Orthopedic Surgery: In a controlled field study evaluating orthopedic postoperative pain and inflammation, 226 dogs of various breeds, ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group were evaluated for safety. Of the 226 dogs, 118 were given PREVICOX Chewable Tablets at a dose of 2.27 mg/lb (5.0 mg/ kg) orally approximately 2 hours prior to surgery and once daily thereafter for a total of three days. The following adverse reactions were observed. Dogs may have experienced more than one of the observed reactions during the study. Adverse Reactions Seen in the Orthopedic Surgery Postoperative Pain Field Study Adverse Reactions Vomiting Diarrhea Bruising at Surgery Site Inappetence/ Decreased Appetite Pyrexia Incision Swelling, Redness Oozing Incision

Firocoxib Group (n=118) 1 2** 2 1 0 9 2

A case may be represented in more than one category. *Sham-dosed (pilled). **One dog had hemorrhagic gastroenteritis.

Control Group* (n=108) 0 1 3 2 1 5 0

Hepatic: Elevated ALP, elevated ALT, elevated bilirubin, decreased albumin, elevated AST, icterus, decreased or increased total protein and globulin, pancreatitis, ascites, liver failure, decreased BUN Hematological: Anemia, neutrophilia, thrombocytopenia, neutropenia Cardiovascular/Respiratory: Tachypnea, dyspnea, tachycardia Dermatologic/Immunologic: Pruritis, fever, alopecia, moist dermatitis, autoimmune hemolytic anemia, facial/muzzle edema, urticaria

Information For Dog Owners: PREVICOX, like other drugs of its class, is not free from adverse reactions. Owners should be advised of the potential for adverse reactions and be informed of the clinical signs associated with drug intolerance. Adverse reactions may include vomiting, diarrhea, decreased appetite, dark or tarry stools, increased water consumption, increased urination, pale gums due to anemia, yellowing of gums, skin or white of the eye due to jaundice, lethargy, incoordination, seizure, or behavioral changes. Serious adverse reactions associated with this drug class can occur without warning and in rare situations result in death (see Adverse Reactions). Owners should be advised to discontinue PREVICOX therapy and contact their veterinarian immediately if signs of intolerance are observed. The vast majority of patients with drug-related adverse reactions have recovered when the signs are recognized, the drug is withdrawn, and veterinary care, if appropriate, is initiated. Owners should be advised of the importance of periodic follow up for all dogs during administration of any NSAID. Effectiveness: Two hundred and forty-nine dogs of various breeds, ranging in age from 11 months to 20 years, and weighing 13 to 175 lbs, were randomly administered PREVICOX or an active control drug in two field studies. Dogs were assessed for lameness, pain on manipulation, range of motion, joint swelling, and overall improvement in a non-inferiority evaluation of PREVICOX compared with the active control. At the study’s end, 87% of the owners rated PREVICOX-treated dogs as improved. Eighty-eight percent of dogs treated with PREVICOX were also judged improved by the veterinarians. Dogs treated with PREVICOX showed a level of improvement in veterinarian-assessed lameness, pain on palpation, range of motion, and owner-assessed improvement that was comparable to the active control. The level of improvement in PREVICOX-treated dogs in limb weight bearing on the force plate gait analysis assessment was comparable to the active control. In a separate field study, two hundred fifty-eight client-owned dogs of various breeds, ranging in age from 10.5 weeks to 16 years and weighing from 7 to 168 lbs, were randomly administered PREVICOX or a control (sham-dosed-pilled) for the control of postoperative pain and inflammation associated with soft-tissue surgical procedures such as abdominal surgery (e.g., ovariohysterectomy, abdominal cryptorchidectomy, splenectomy, cystotomy) or major external surgeries (e.g., mastectomy, skin tumor removal ≤8 cm). The study demonstrated that PREVICOX-treated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with soft-surgery. A multi-center field study with 226 client-owned dogs of various breeds, and ranging in age from 1 to 11.9 years in the PREVICOX-treated groups and 0.7 to 17 years in the control group was conducted. Dogs were randomly assigned to either the PREVICOX or the control (sham-dosed-pilled) group for the control of postoperative pain and inflammation associated with orthopedic surgery. Surgery to repair a ruptured cruciate ligament included the following stabilization procedures: fabellar suture and/or imbrication, fibular head transposition, tibial plateau leveling osteotomy (TPLO), and ‘over the top’ technique. The study (n = 220 for effectiveness) demonstrated that PREVICOX-treated dogs had significantly lower need for rescue medication than the control (sham-dosed-pilled) in controlling postoperative pain and inflammation associated with orthopedic surgery. Animal Safety: In a targeted animal safety study, firocoxib was administered orally to healthy adult Beagle dogs (eight dogs per group) at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated dose of 5 mg/kg, there were no treatment-related adverse events. Decreased appetite, vomiting, and diarrhea were seen in dogs in all dose groups, including unmedicated controls, although vomiting and diarrhea were seen more often in dogs in the 5X dose group. One dog in the 3X dose group was diagnosed with juvenile polyarteritis of unknown etiology after exhibiting recurrent episodes of vomiting and diarrhea, lethargy, pain, anorexia, ataxia, proprioceptive deficits, decreased albumin levels, decreased and then elevated platelet counts, increased bleeding times, and elevated liver enzymes. On histopathologic examination, a mild ileal ulcer was found in one 5X dog. This dog also had a decreased serum albumin which returned to normal by study completion. One control and three 5X dogs had focal areas of inflammation in the pylorus or small intestine. Vacuolization without inflammatory cell infiltrates was noted in the thalamic region of the brain in three control, one 3X, and three 5X dogs. Mean ALP was within the normal range for all groups but was greater in the 3X and 5X dose groups than in the control group. Transient decreases in serum albumin were seen in multiple animals in the 3X and 5X dose groups, and in one control animal. In a separate safety study, firocoxib was administered orally to healthy juvenile (10-13 weeks of age) Beagle dogs at 5, 15, and 25 mg/kg (1, 3, and 5 times the recommended total daily dose) for 180 days. At the indicated (1X) dose of 5 mg/kg, on histopathologic examination, three out of six dogs had minimal periportal hepatic fatty change. On histopathologic examination, one control, one 1X, and two 5X dogs had diffuse slight hepatic fatty change. These animals showed no clinical signs and had no liver enzyme elevations. In the 3X dose group, one dog was euthanized because of poor clinical condition (Day 63). This dog also had a mildly decreased serum albumin. At study completion, out of five surviving and clinically normal 3X dogs, three had minimal periportal hepatic fatty change. Of twelve dogs in the 5X dose group, one died (Day 82) and three moribund dogs were euthanized (Days 38, 78, and 79) because of anorexia, poor weight gain, depression, and in one dog, vomiting. One of the euthanized dogs had ingested a rope toy. Two of these 5X dogs had mildly elevated liver enzymes. At necropsy all five of the dogs that died or were euthanized had moderate periportal or severe panzonal hepatic fatty change; two had duodenal ulceration; and two had pancreatic edema. Of two other clinically normal 5X dogs (out of four euthanized as comparators to the clinically affected dogs), one had slight and one had moderate periportal hepatic fatty change. Drug treatment was discontinued for four dogs in the 5X group. These dogs survived the remaining 14 weeks of the study. On average, the dogs in the 3X and 5X dose groups did not gain as much weight as control dogs. Rate of weight gain was measured (instead of weight loss) because these were young growing dogs. Thalamic vacuolation was seen in three of six dogs in the 3X dose group, five of twelve dogs in the 5X dose group, and to a lesser degree in two unmedicated controls. Diarrhea was seen in all dose groups, including unmedicated controls. In a separate dose tolerance safety study involving a total of six dogs (two control dogs and four treated dogs), firocoxib was administered to four healthy adult Beagle dogs at 50 mg/kg (ten times the recommended daily dose) for twenty-two days. All dogs survived to the end of the study. Three of the four treated dogs developed small intestinal erosion or ulceration. Treated dogs that developed small intestinal erosion or ulceration had a higher incidence of vomiting, diarrhea, and decreased food consumption than control dogs. One of these dogs had severe duodenal ulceration, with hepatic fatty change and associated vomiting, diarrhea, anorexia, weight loss, ketonuria, and mild elevations in AST and ALT. All four treated dogs exhibited progressively decreasing serum albumin that, with the exception of one dog that developed hypoalbuminemia, remained within normal range. Mild weight loss also occurred in the treated group. One of the two control dogs and three of the four treated dogs exhibited transient increases in ALP that remained within normal range. Made in France Marketed by: Merial, Inc., Duluth, GA 30096-4640, U.S.A. 1-877-217-3543 NADA 141-230, Approved by FDA Rev. 09-2015 ®PREVICOX is a registered trademark of Merial. ©2016 Merial, Inc., Duluth, GA. All rights reserved.

PROFESSIONAL PULSE

WHAT IS

COMPASSION FATIGUE ….AND HOW CAN WE AVOID IT? Education is the first step! Debra A. Bjorling

Compassion fatigue results from continuous exposure to heart-wrenching or traumatic events. It occurs from a depletion of our emotional resources. It happens when a person gives and gives of their physical and emotional energy…. and then has nothing left for themselves.

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

PROFESSIONAL PULSE

How do we know we have it?

Symptoms are varied and differ from person to person. Each person will deal with critical events in their own way, based on their own beliefs, life experiences, and values. Compassion fatigue can be a sense that one can never do enough. It can present as chronic exhaustion or physical ailments such as gastrointestinal problems or recurrent colds.

to cry when she was explaining the euthanasia procedures she had assisted with the previous week.

Other symptoms may include trouble concentrating, frustration with the job, isolation from others, feeling hopeless and sad, or feeling numb.

We comfort crying children as well as adults who have lost their best friend. Helping families through this difficult time is emotionally draining and demanding for every staff member.

Compassion fatigue is often mistaken for “burnout,” which is a similar condition. While burnout will be cured with a job change, compassion fatigue has to do with the type of job you have chosen and how you work. The very reason you are in the veterinary field has put you at a higher risk for compassion fatigue.

While helping families through the process of a terminal diagnosis or euthanasia, we cannot help but feel the emotions coming from these grieving families. As human beings, we absorb the feelings and emotions that are around us. We grieve with them, and we remember our own losses too. We have to remind ourselves that it is OK for us to grieve and show our own emotions at that time; to normalize it and express it.

I have personally seen tearfulness and sleep problems in veterinary technicians I have worked with. One young person could not fall asleep at night due to worrying about the patients he had left that evening, calling during the night to be updated on their status, even though he had handed his patients over to other technicians who were perfectly capable. Another woman started

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Compassion fatigue is something I have to worry about in my office. As a pet funeral home operator, we take care of grieving families, including those who have lost their pet in a traumatic event.

“Compassion Fatigue is responsible for the loss of some of the most brilliant, caring people in the veterinary profession.” Dr. Greg Ogilvie, DVM, DACVIM

PROFESSIONAL PULSE

What can we do about it?

We all need to practice self-care and healing: • Be kind to yourself

• Make time to take care of yourself.

• Have fun on a regular basis.

• I ncrease your awareness with education

• Rediscover activities that bring you happiness and joy.

• Find a relaxation technique that works for you.

• E xercise regularly and have healthy eating habits.

• Have a transition routine for the end of your workday that helps you put the stresses of work behind you.

• Take a walk in the park and enjoy nature or listen to music.

• Learn how to “detach” yourself from work each day. Try to leave work at work.

• Give yourself permission to grieve when you lose a patient.

• C larify and establish boundaries so that you can have balance in your life, what works for you and what doesn’t.

You and your co-workers can create a buddy system so everyone will have someone to talk to. Find one friend that you can share your thoughts with and you can be a friend to that person also. If you see your buddy go through a particularly “critical incident” or traumatic time with a pet or family, have that buddy take a break, take a walk or maybe even just go have a cry with some privacy. You can cover for that person during a ten minute break, and that buddy can cover for you and be a friend to you. Create a support system among all the staff at your hospital.

“Self care is never a selfish act; it is simply good stewardship of the only gift I have, the gift I was put on earth to offer to others.” Parker Palmer The staff can foster informal “debriefing sessions” with co-workers after a particularly difficult incident. Take five minutes to discuss what happened and how everyone felt about it, just to get your thoughts and feelings out. If you can’t get together that day, have a debriefing session at the end of the week. A hospital should also try to maintain an atmosphere of humor. Literature on compassion fatigue says to seek happiness and joy in your everyday life, and that even the littlest thing can make a difference for you. (Compassion Fatigue Awareness Project) I happened to pick up a book by Rick Hanson called “Hardwiring Happiness” and Rick says: “Each day is like a winding path strewn with pearls and diamonds, emeralds and rubies, each one an opportunity for a positive experience. Most people hurry by without noticing them.”

• Know when to ask for help.

Rick says:

• Look at the small things in your life, the good moments. • Think of the good you have done each day. • Think of some of the pleasurable, fulfilling and meaningful times you have had. • Think of your accomplishments. • Think of the people who have seen the light in you and the people who love you. • Think of the future, the good that can happen, the love you will give and the love you will receive. • Thinking in this way brings us inner strength and RESILIENCE.

When you take care of yourself each day, you will return to work refreshed and ready for the challenges. Consider the wonderful work you do every day. Healing pets and working with people can be very rewarding, but don’t forget to also take care of yourself. Remember: You cannot pour from an empty cup!

Debra A. Bjorling, RPFD, PBC Debra A. Bjorling is a Certified Pet Bereavement Counselor. She is the owner and operator of Hamilton Pet Meadow Funeral Home, Pet Cemetery and Crematory in New Jersey, established 1998. She is Past President and a Board Member of the International Association for Pet Cemeteries and Crematories; the IAOPCC sets standards for pet aftercare, including an accreditation program. Debra is also on the Board of Directors of the Association for Pet Loss and Bereavement. The APLB has continuing education and a RACE Accredited Pet Loss Certification program. Check out details at APLB.org

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PROFESSIONAL PULSE

CARING FOR YOUR COWORKERS Hosted by Jade Velasquez, LVT, Founder of

In Veterinary Support Staff Unleashed,

Veterinary Support Staff Unleashed

we talk a lot about self-care. This includes taking time to do the things you enjoy, physically, mentally and spiritually taking care of yourself. Self-care is crucial to being able to remain a happy, healthy participant in veterinary medicine. This month however, we took some time to talk about how we take care of our coworkers. We all know that working at a veterinary hospital can be taxing, not just on us, but on our friends and colleagues we work with. Finding ways to support our team and show them how much we appreciate their hard work is so important to maintaining good morale. We never know another’s struggle and sometimes small acts can mean a lot to people. For me seeing someone leave a thank you card on my desk, leaving me my favorite soda with a post it note decorated with a smiley face or even just bringing me coffee have all been small rays of sunshine in a dreary day. Putting a

smile on someone’s face is one of the best gifts we can give. So, I asked VSSU members; how do you care for your coworkers? • “I bake, give small gifts, and lighten the mood with my sarcasm, movies quotes and general sass.” – Carrie McGuire-Loveall, BS, RVT • “When it’s me and one other tech on Saturday overnights in ER, I will sometimes bring healthy dip and go snacks like pico de gallo and salsa, fruit bowls, etc.” – Sarah Alyounes, LVT • “I try really hard to say thank you to just about everyone for their help with whatever thing they did even if it is “their

job.” I think a simple “thank you” goes a long way. Also, we try and help each other get out on time and if someone is getting stuck late I’ll always ask to see what they need before walking out the door.” – Samantha Rowland Carpenter, LVT, VTS (Anesthesia) • “Definitely saying thank you. Telling team members you appreciate them and why. Words of encouragement. Allowing them to be human and have their bad moments. We’re a close-knit team of 2 techs, 1 reception and 1 DVM at the moment. We work with each other 5 days a week. We are a family. I feel so blessed to be where I am, and I believe they feel the same way!”

A lot of times we spend more time with our coworkers than we do our own families. On average, most of us work anywhere from an eight to twelvehour day, more in specialty or emergency clinic settings. – Hannah Ebarb, veterinary assistant/ veterinary technology student We have to enjoy our team and look at team building as a way to build on our relationships. Work families, like all families will undergo stress, change and not everyone will always get along. But by taking opportunities to show our team we care about them we can truly encourage that positive family dynamic.

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

Also available for cats

VETERINARY ASSISTANT EDUCATION

CACHEXIA

Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition)

IN CHRONICALLY ILL PATIENTS Learning Objectives After completion of this article, participants will be able to define and identify cachexia, and implement dietary management for patients.

Cachexia is a multifactorial syndrome characterized by progressive weight loss that is often accompanied by anorexia.1 Unlike weight loss seen with starvation or anorexia, cachexia is distinguished by a loss of adipose tissue with accompanying loss of lean body mass, primarily muscle. Non-muscle protein, such as in the organs, is preserved in cachexia, but not in starvation. In dogs with illness or injury, amino acids from lean body mass are the primary source of energy instead of glucose from carbohydrate during normal digestion.2 Significant loss of mineral content in the bones can also contribute to the overall weakness in many cachexic patients.1

This Article is NOT RACE APPROVED. However, Veterinary Assistants can take the exam at VetMedTeam.com and receive 1 CE credit that can be applied toward their AVA designation.

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VETERINARY ASSISTANT EDUCATION

Score

Muscle Mass

Normal muscle mass

Moderate muscle wasting

Marked or severe muscle wasting

Overcoat syndrome

Decreased muscle is found under a heavy layer of fat, making assessment more difficult.

Physical Assessment Muscle is easily palpable over the temporal bones, ribs, lumbar vertebrae, and pelvic bones. Bony prominences are not visible when viewed from a distance. A thin layer of muscle covers the temporal bones, ribs, lumbar vertebrae, and pelvic bones. Bony prominences are slightly visible from a distance.

No muscle covers the temporal bones, ribs, lumbar vertebrae, and pelvic bones. Bony prominences are highly visible from a distance.

Suspect this syndrome when the history and the physical assessment do not match. Marked wasting can be felt over the bony prominences.

Table 1. Muscle Condition Scoringa Buffington T, Holloway C, Abood S. Nutritional assessment. Manual of Veterinary Dietetics. St. Louis, MO: Elsevier Saunders; 2004:5.

The beginning phase of cachexia can be very subtle, even in obese animals, and many clients may perceive the associated changes as simply “growing old.”3 When evaluating a patient for cachexia, it is important to remember that cachexia is a process—the loss of lean body mass— and not an end-stage syndrome.4 A similar syndrome known as sarcopenia is also common in dogs and cats; however, sarcopenia is the loss of lean body mass associated with aging in the absence of disease.4 The loss of lean body mass has a deleterious effect on strength, immune function, and survival.3 This loss can first be noticed over the epaxial, gluteal, scapular, and temporal muscles2 and is easily detected during a routine physical examination (Table 1). There does not appear to be a cause-and-effect relationship between anorexia and cachexia: cachexia-associated weight loss often exceeds weight loss expected from only a decrease in caloric intake.1 Cachexia is a profound state of general illness, malnutrition, and disability that can affect animals with cancers,

tumors can induce many of these changes in the patient’s body. Most cancer cells use anaerobic glycolysis at a higher rate than normal tissue to generate adenosine triphosphate for energy.1 In general, cancer cells cannot obtain a significant amount of energy from aerobic glycolysis or fat oxidation.6 Anaerobic glycolysis results in a gain of energy for tumor cells and a net loss of energy for the patient as well as the generation of a large amount of lactic acid that the patient must convert to glucose.6

Assessment

cardiac disease, renal disease, and other significant illnesses and injuries.5 Loss of 25% to 50% of lean body mass compromises the immune system and affects muscle strength, with death resulting from infection, pulmonary failure, or both.5

Causes

The presence of cachexia increases patient morbidity and can adversely affect a patient’s quality of life.4 Early identification of cachexia and subsequent intervention can be important for improving the success of treatment and the quality of life of patients and owners.

The primary cause of cachexia is alterations in the body’s metabolism of carbohydrate, fat, and protein.6 These metabolic alterations can lead to anorexia, fatigue, weight loss, impaired immune function, and malnutrition.6 Cachexia is often due to various cancers, and the associated

The Phases of Cachexia

The three phases of cachexia identified in humans are presumed to be the same in dogs and cats (Table 2). In the first phase, the patient does not exhibit clinical signs, but biochemical changes include an

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

VETERINARY ASSISTANT EDUCATION Phase

Clinical Findings

Physical Findings

Laboratory Findings

None readily found

Increased lactate level; increased insulin level; changes in amino acid and lipid profiles

Anorexia; depression

Weakness; anorexia; depression; altered food preferences; cyclical appetite

Weight loss (decreased body condition score); muscle loss over the epaxial, gluteal, scapular, and temporal muscles (decreased muscle condition score)

Significant physical changes associated with loss of lean body mass, fat, and bone

Decreased plasma albumin level

Negative nitrogen balance

Table 2. The Phases of Cachexia4,6

increase in the lactate level due to glycolysis; an increase in the insulin level, causing peripheral insulin resistance; and alterations in the amino acid and lipid profiles.6 In the second phase of cachexia, clinical signs can include anorexia, weight loss, and depression. Many owners attribute these early signs to their pet “getting old” and do not recognize the clinical significance. The final phase is characterized by marked loss of body fat and protein stores, severe debilitation, weakness, and biochemical evidence of negative nitrogen balance.6 If untreated, cachexia can cause death.

Biochemical Changes

The biochemical changes caused by cancer or another disease lead to inefficient energy use by the patient and enhanced energy use by the tumor or the disease process.6 The prevalence of glucose 24

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intolerance and insulin insensitivity (resistance) requires limitation of the amount of carbohydrate and careful selection of the type of carbohydrate used in foods for affected animals. With the patient and the tumor having obligatory protein requirements, a negative nitrogen balance is often seen in cachexia patients. If this imbalance is not corrected, it leads to increased loss of skeletal muscle, hypo albuminemia, compromised immunity, impaired gastrointestinal function, and delayed wound healing, as is seen in any condition that impairs protein use by the body. Loss of lean body muscle accounts for most of the weight loss in animals and humans with cancer, cachexia, and other chronic diseases, such as kidney disease and congestive heart failure. Although reduced food intake is a significant contributor to this loss, decreased nutrient absorption and increased metabolic alterations also trigger loss of muscle rather than fat.4 One of the metabolic alterations is a decrease in leptin production, which is inversely related to the intensity of the inflammatory response created by the body: as the leptin level decreases, inflammatory mediators increase, causing increased production of inflammatory cytokines.1 Leptin—a protein with hormone-like activities—is produced by adipocytes (fat cells); it causes a decrease in appetite and an increase in energy expenditure. These

cytokines contribute to anorexia, increase energy requirements, and increase catabolism of lean body mass.3

Dietary Management

While the wasting process associated with cachexia cannot be reversed through nutritional supplementation alone, manipulation of patients’ nutrient intake can be beneficial in managing some of the effects of cachexia on the body.1 Adequate nutrition can be key to managing cachexia by providing calories, protein, and fat, resulting in the modulation of cytokine production.3 It may not be intuitive that nutrition modulates cytokine production. Specific dietary recommendations should consider the phase of cachexia as well as the patient’s energy needs, current and past nutritional status, and ability or willingness to eat.6 Because these patients do not tend to eat well, dietary recommendations should consider routes of nutrition that do not require voluntary consumption of food.

Studies using animal models have shown that supplementation using the omega-3 fatty acids EPA and DHA can help to prevent cachexia and metastatic disease processes.6 Omega-3 fatty acids produce less potent inflammatory mediators than do omega-6 fatty acids. When the body uses omega-3 fatty acids to produce cytokines, the inflammatory response is decreased in proportion to the level of omega-3 fatty acids in the diet. Preferentially increasing the amount of omega-3 fatty acids in the diet and, therefore, their availability in the body can help to increase the production of less inflammatory cytokines. Dr. Freeman3 recommends 40 mg/kg of EPA and 25 mg/kg of DHA per day. Based on the common formulation of most fish oil capsules, a patient would need ~1 g (1 capsule) per 10 lb. of body weight per day.3 Many recovery diets already incorporate this concentration, so additional supplementation is not recommended. The caloric distribution in the food should emphasize calories from fat and protein rather than carbohydrate since we know that glucose is the preferred fuel of tumor cells, but fatty acids and amino acids are not.6 The goal is to feed the patient and starve the tumor cells. In an ideal food, 50% to 60% of calories would be from fat, 30% to 50% from protein, and the remaining percentage from carbohydrate.6 A diet’s protein level should be at the upper limit recommended by AAFCO (Association of American Feed Control Officials), and the protein should be high quality to facilitate digestibility and use by the body. A protein level of 30% to 50% dry matter is recommended with dogs at the lower end and cats at the higher end.6 In relation to energy intake, the minimum recommended protein intake is 5.14 g/100 kcal with 6 to 7 g/100 kcal preferred.3 Because tumor cells preferentially use glucose for energy, selecting a carbohydrate with a low glycemic index can provide a slower release of carbohydrate-generated glucose into the bloodstream than would a carbohydrate with a high glycemic index. The glycemic index is used to measure how quickly a carbohydrate source is converted into glucose during digestion. Rice has one of the highest glycemic indexes; barley,

VETERINARY ASSISTANT EDUCATION not impossible, for the average clinician, technician, or client. A board-certified veterinary nutritionist can help clients formulate a diet that is acceptable to their pets and provides the best possible nutrition. Several excellent therapeutic diets meet the recommended diet profile for cachexia patients and can be fed orally or by tube.

sorghum, and corn have much lower glycemic indexes.6 Moderately soluble fibers can also be used to slow the entry of glucose into the bloodstream with the added benefit of providing additional short-chain fatty acids specifically for enterocytes.

Feeding Methods

Enteral feeding is always preferred if the patient has a functional gastrointestinal tract. Oral feeding of a canned or dry pet food should be the first choice for cachexia patients.6 When a patient is unwilling or unable to consume the desired amount of food orally, various feeding tubes can be used. The patient must be able to consume at least 85% of its resting energy requirement for oral feeding to be used. If this amount cannot be voluntarily consumed, alternative ways of supplying nutrition must be considered. Tube selection should be based on the patient’s condition, the desired period of use, and the owner’s willingness to feed at home. The only tubes that are appropriate for at-home use are esophagostomy and gastrostomy tubes. Tube selection is based on the patient’s ability to undergo anesthesia, the doctor’s skill level, the availability of special equipment (an endoscope) and nursing care, and the overall cost to the client. Diet selection should also be based on the route selected for feeding. The energy density of a diet fed through a feeding tube can directly affect the success of feeding. A food that has a low energy density may contribute to vomiting or osmotic diarrhea due to a high feeding volume or poor digestibility.6 Feeding multiple, small meals frequently is easier on the patient, although this may not be easier on the client. Small meals decrease the incidence of nausea related to feeding, increase the transit time of food through the stomach, and help ensure that the nutrition is usable by the animal.6

Conclusion

While cachexia can be a fairly obvious sign of biochemical imbalances within the body, the condition has often been present for a while by the time physical changes are seen. We need to know how to feed our patients during treatment for cancer or other diseases. By recognizing the physiologic changes caused by disease and cancer, we can recommend diets that can help patients (rather than allowing a tumor or a disease to progress), resulting in more positive patient outcomes and a better quality of life for patients and clients.

References

1. Tisdale M. Mechanisms of cancer cachexia. Physiol Rev 2009;89(2):381-410. 2. Freeman LM, Rush JE. Cardiovascular diseases: nutritional modulation. In: Pibot P, Biourge V, Elliott D, eds. Encyclopedia of Canine Clinical Nutrition. Aimargues, France: Royal Canin; 2006:321-336. 3. Freeman LM, Rush JE. Nutritional management of cardiovascular diseases. In: Fascetti AJ, Delaney SJ, eds. Applied Veterinary Clinical Nutrition. Ames, IA: Wiley-Blackwell; 2012:304-307. 4. Freeman LM. Cachexia and sarcopenia: emerging syndromes of importance in dogs and cats. J Vet Intern Med 2012:26:3-17. 5. Saker K, Remillard RL. Critical care nutrition and enteral-assisted feeding. In: Hand MS, Thatcher CD, Remillard RL, et al, eds. Small Animal Clinical Nutrition. 5th ed. Topeka, KS: Mark Morris Institute; 2010:441-442. 6. Case L, Daristotle L, Hayek M, Raasch M. Nutritional care of cancer patients. Canine and Feline Nutrition. 3rd ed. Maryland Heights, MO: Mosby Elsevier; 2011:479-486.

Home-cooked diets can be used in the short term to tempt a patient to eat; longterm use of these diets must be approved by a nutritionist. Homemade diets are frequently unbalanced and therefore detrimental to animals. Calculating the energy density, amounts of nutrients and micronutrients in homemade diets is difficult, if VETERINARY NURSING IN ACTION | AUG/SEPT 2017

VETERINARY ASSISTANT EDUCATION

Article Questions 1. Cachexia is distinguished from simple weight loss by loss of this tissue?

4. D uring what phase of cachexia does the owner first notice physical changes in their pet?

a. bone mass

a. first phase

b. insensible tissue

b. second phase

c. lean body mass

c. third phase

d. organ mass

d. final phase

2. Cachexia is not typically seen in association with what disease process?

5. EPA and DHA are types of what class of nutrients?

a. cancer

a. omega 3 fatty acids

b. renal disease

b. non-essential fatty acids

c. cardiac disease

c. pro-inflammatory fatty acids

d. osteodysplasia

d. highly-fermentable carbohydrates

3. Cachexia is associated with changes in which body system?

a. nutrient metabolism

b. chemical digestion in the duodenum

c. blood cell production in the marrow

d. hepatic transformation of drugs

CONTINUING EDUCATION

QUIZ ONLINE visit VetMedTeam.com and log in with your Vet Med Team Profile.

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Ann Wortinger BIS, LVT, VTS (ECC, SAIM, Nutrition) Ann is a 1983 graduate of Michigan State University, and got her specialty certification in Emergency/ Critical Care in 2000, in Small Animal Internal Medicine in 2008 and in Nutrition in 2013. She has worked in general, emergency, specialty practice, education and management. Ann is active in her state, national and specialty organizations, and served on the organizing committees for Internal Medicine and Nutrition. She has also mentored over 18 fellow VTSs, and has worked on a variety of committees and positions. She has over 50 published articles in various professional magazines as well as book chapters and a book, Nutrition and Disease Management for Veterinary Technicians and Nurses in its second edition in 2016 coauthored with Kara Burns. Ann received the 2009 Service Award for her state association (MAVT), the 2010 Achievement Award for the Academy of Internal Medicine for Veterinary Technicians (AIMVT), and in 2012 received the Jack L. Mara Memorial Lecture Award presented at NAVC.

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NAVTA 2018 call for

NOMINATIONS

As a member of the Executive Board, oﬃcers have the opportunity to: • Be involved in the growth and development of the veterinary technology profession on a national level.

• Serve as a source of information and resource for not only the Association members but also the general public.

• Gain knowledge, personal career growth, recognition and advancement. • Network at local, national and international levels.

Executive Board Positions Available For 2018

The NAVTA Executive Board adopts these guidelines to assist the Nominating/Election Task Force appointed by the President in identifying candidates who are well qualified for the NAVTA offices for which they have been nominated. This task force will secure the written acceptance of all nominees before preparing the nomination slate or ballot. All active members will be sent a ballot or link to an on-line ballot to be returned or completed by the appointed date. Potential Board members should understand the commitments and duties required of the NAVTA Executive Board and their position. These commitments and duties need highly motivated team players who are self-starting individuals and have a passion for propelling the veterinary technician profession forward. There will be travel and time requirements of each Board member for conferences and monthly telephone Board meetings. Candidates also acknowledge that this is a volunteer position and is not a paid position on the Board.

www.NAVTA.net

VETERINARY NURSING VETERINARY ASSISTANTEDUCATION EDUCATION

This program was reviewed and approved by the AAVSB RACE program for 1 hour of continuing education in jurisdictions which recognize AAVSB RACE approval. Please contact the AAVSB RACE program if you have any comments/concerns regarding this programâ&#x20AC;&#x2122;s validity or relevancy to the veterinary profession.

Learning Objective - Readers should understand the immediate and delayed effects of smoke inhalation in animals. They should be able to determine the threats of injury after exposure to a fire and that there are consequences that manifest hours to days later that can quickly alter a patientâ&#x20AC;&#x2122;s status. They will obtain knowledge needed to diagnose and treat the toxicities that can result from smoke inhalation. Readers will also gain an overview of patient care and treatments for thermal and lung injury. 28

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VETERINARY VETERINARYASSISTANT NURSING EDUCATION

THE SMOLDERING EFFECTS OF SMOKE INHALATION Michele Hinks CVT, VTS (ECC)

House fires are known to be associated with devastating injuries. Not only are there loved ones at risk, the gravity of the situation is often compounded by the loss of home, property, and sometimes life. Smoke inhalation can cause thermal injury, delayed lung injury, and asphyxiation. Depending on levels of exposure and circumstances, a victim could have an excellent prognosis with an anticipated full recovery or the consequences could be fatal. Some questions we should ask owners upon presentation include the duration of exposure, the nature of the location of the fire (closed or open space), what the source of the smoke was, and the extent of any other injuries. The risk of lung damage is increased when the smoke is in an enclosed area. The severity of injury is directly correlated to the duration of exposure.1 Smoke inhalation can occur without external injury. If there are burns, the risk of mortality is increased. With extensive burns, the patient will need more fluid therapy and sedation or anesthesia to treat the wounds. Both of those treatments can cause complications. Some signs to look for when smoke inhalation is expected are difficulty breathing, increased respiratory rate, open mouth breathing in cats, coughing, stridor, and carbonaceous discharge. 2, 3 Upon initial presentation, the patient could show signs of ocular irritation; tearing, coughing, or wheezing may be present; and the patient may be having laryngospasms or bronchospasms. If there are dermal burns on the face or neck, the patient was exposed to

very high temperatures and you should assume there is thermal trauma to the airway. They may be ataxic, weak, lethargic, foaming at the mouth, or smell like smoke. They can have burns on the eyes or in the mouth and upper airway. Oropharyngeal blistering may be present. In more serious cases the animal may have seizures or be comatose.4

Thermal Injury

Thermal injuries usually affect the upper airway except for when steam is involved. Steam is a better conductor of heat than dry air. The nasal and oropharyngeal areas have a thermoregulatory system that is efficient in heat exchange and cools or warms gas before it is delivered to the lungs. When a victim inhales steam, there is an increased chance of more severe injury to the lower airway because the temperature is even hotter than that of dry air. Steam will still be at a very damaging temperature when is passes the thermoregulatory system.5 Steam can cause laryngotracheitis, bronchitis, and alveolitis.4

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VETERINARY NURSING EDUCATION

Gizmo, a 5 year old intact male domestic short hair cat that was rescued from a house fire.

It could take one to twelve hours for swelling and edema to form in the oral cavity and upper airways, but it can still occur up to 72 hours after the initial trauma. Due to the delay in edema formation, these patients are at risk of delayed airway obstruction. The combination of burns causing edema, loss of oncotic pressure, and fluid resuscitation can be a recipe for disaster.1 Water-soluble chemicals in smoke, such as ammonia, adhere to the mucosa of the upper airways. This causes the release of inflammatory mediators and free radicals. This will then increase microvascular membrane permeability. The increase in permeability causes a fluid shift from the intravascular space to the upper airway tissue. Swelling and edema formation ensues.4 With the formation of airway swelling and edema, the patient may need to be intubated to maintain an airway. A very swollen airway can be difficult or impossible to intubate. In such cases, placing a tracheostomy tube may be necessary. Signs that the patient is developing edema are orthopnea and ptyalism from difficulty swallowing. It is vital to practice sterile technique when caring for tracheostomy sites and patients intubated for long periods of time to decrease their risk of bacterial pneumonia. Smoke inhalation increases the risk of bacterial pneumonia because alveolar 30

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macrophage function is decreased. Bacterial pneumonia can also occur secondary to intubation or tracheostomy contamination or from sepsis after burns. Secondary bacterial infection can decrease the chance of survival.2 Another component that can lead to lower airway obstruction is the weakening of the mucociliary escalator. Many of the damaged epithelial cells in the airway die and slough. Under normal circumstances, the ciliated cells and mucus would bring carbonaceous soot and cell debris up so one could cough them out. With the increase in cell debris and decrease in ciliated cell action, bronchorrhea develops and settles in the lungs.5 Smoke inhalation will also cause a reflex bronchoconstriction which can hinder ventilation and clearance of secretions. There is an increase in the presence of inflammatory cells, protein rich exudates, and mucus as well.4

Lung Injury

Delayed lung injury can occur 24 to 48 hours after the incident. Some signs of pulmonary complications are tachypnea, dyspnea, coughing, a decrease in breath sounds upon auscultation, wheezes, rales, and rhonchi.1 The presence of smoke and heat affects pulmonary surfactant activity, which can lead to atelectasis. Pulmonary edema occurs from the increased

permeability of microvasculature, which is enhanced by the presence of burns. Lung compliance is reduced from alveolar atelectasis and the presence of pulmonary edema. Ventilation -perfusion mismatch, acute lung injury, and acute respiratory distress syndrome are some other potential outcomes.2

Smoke consists of products of incomplete combustion. Some of those products are carbon monoxide, hydrogen cyanide, nitrogen dioxide, hydrogen chloride, benzene, aldehyde, and ammonia. Carbonaceous soot particles by themselves are not toxic, but they have the ability to carry other toxic substances and increase their exposure to the respiratory tract, causing topical irritation and obstruction. These particles also take time to be cleared.1 Hydrogen chloride reacts with mucous membranes to form hydrochloric acid. The combination of hydrochloric acid and acrolein and aldehyde (by-products of the combustion of wood) cause protein denaturation and cell death in the pulmonary tissues. This leads to bronchospasms and bronchorrhea.4, 3

VETERINARY NURSING EDUCATION Toxicants

Polytetrafluorethylene (PTFE or teflon®) fumes can cause malaise, fever, and respiratory irritation. It can cause chemical pneumonitis and is lethal to birds. PTFE inhalation exposure can be caused by overheating cookware, burning of hair spray, dry lubricants, and water-proofing sprays.1 Both carbon monoxide and hydrogen cyanide cause asphyxiation. The patient may have already suffered from hypoxia from a decreased fraction of inspired oxygen (FiO2) when the smoke inhalation occurred. Fire consumes oxygen and produces carbon dioxide (CO2). Reduction of FiO2 to 15% results in dyspnea, and at 10% the victim will have dyspnea and altered mentation. In conditions between 8 and 10%, there will be loss of consciousness and death in less than eight minutes.4

Carbon Monoxide Poisoning

Carbon monoxide (CO) is colorless and odorless. The incomplete combustion of any organic material can produce it. It can cause headaches, nausea, dizziness, weakness, tachypnea, tachycardia, seizures, hypotension, and coma. A healthy person in normal circumstances should have a CO level of 1 to 3% and these normal levels of carboxyhemoglobin (COHb) are due to erythrocyte and hemoglobin breakdown.2 CO begins to induce serious effects when the COHb level exceeds 15%. CO levels of greater than 30% will cause neurologic dysfunction, and at levels greater than 50% there may be loss of consciousness, apnea, or death.2, 6 CO competitively binds with hemoglobin in red blood cells to form carboxyhemoglobin. This decreases the body’s ability to transport oxygen. CO will bind to two of the four heme groups that are in each molecule of hemoglobin. This can decrease hemoglobin’s oxygen carrying capacity by 50%. Hemoglobin has an affinity for CO that is 230-270 times greater than that of oxygen. Carboxyhemoglobin also shifts the oxyhemoglobin dissociation curve to the left. This decreases the ability of hemoglobin to release bound oxygen to tissues.3, 2, 6 CO can also cause direct cellular toxicity by binding to the heme proteins

of myoglobin and cytochrome a3. This impedes cytochrome a3, which has crucial activity in the electron transport chain of the mitochondria. Apnea is also a risk due to CO’s depressive effects on the cells within the central nervous system. CO can alter cellular enzymes, sequester leukocytes, produce nitric oxide in the neurons, cause lipid peroxidation, or lead to reperfusion injury. CO also binds to cardiac and skeletal muscle myoglobin. This causes minimal effects alone but exacerbates the other factors leading to tissue hypoxia.2 Neurologic abnormalities can be acute or delayed. The acute neurological signs may be caused by CO and cyanide toxicity. Potential outcomes for a patient suffering from only CO poisoning are full recovery with or without transient hearing loss, recovery with permanent central nervous system abnormalities, or death. Signs of exposure to an asphyxiate are central nervous system depression, muscle weakness, lethargy, and an obtunded mentation. If the patient is in a coma the prognosis is grave.1 After smoke inhalation, new neurologic signs have been reported in dogs two to six days later. In humans, this is known as delayed neurophsychiatric syndrome. Signs can develop 2-240 days after CO toxicity.2 Delayed neurologic effects that have been reported are being dizzy, confused, having memory loss, depression, amnesia, change in speech or mood, and problems walking.5, 7 Cyanide is produced from the pyrolysis of many nitrogen containing materials such as nylon, wool, silk, asphalt, and many plastics. Cyanide poisoning inhibits cytochrome a3 of mitochondrial cytochrome oxidase in the electron transport chain. When this enzyme is inhibited, oxygen cannot be utilized by the cells. The cells will eventually die from asphyxiation in the presence of adequate oxygen they cannot use. With a halt in the electron transport chain, the body must convert to work anaerobically. It will convert glucose to pyruvate through glycolysis, and then it will use fermentation to convert pyruvate to lactate.5 This will lead to metabolic acidosis reflected by lactate elevation. This also results in decreased adenosine triphosphate synthesis and depletes energy stores.2

Some cyanide binds to hemoglobin to form cyanohemoglobin, which cannot carry oxygen. In the brain, cyanide will cause central inhibition of the respiratory center, resulting in hypoventilation. Cyanide toxicity also leads to myocardial depression and a further decrease in cardiac output.2 Signs of cyanide toxicity are initially excitement, increased respiratory rate and effort, dyspnea, tachycardia, muscle fasciculation, and ataxia. As the toxicity progresses signs include seizures, arrhythmias, apnea, coma, and cardiac arrest. Mucous membranes appear bright red and venous blood is cherry red due to the increased oxygen content. Oxygenated blood is delivered to the body and much of it will return in the veins without the oxygen being unloaded. Some people can detect the aroma of almonds on the patient’s breath.1

Diagnostics

Diagnostics for smoke inhalation can be confusing. Upon initial presentation, thoracic radiographs can be normal. Pulmonary changes 24-36 hours later may reveal atelectasis, pulmonary edema, and hyperinflation. If bacterial pneumonia develops, typical findings are a more pronounced alveolar pattern with air bronchograms.2,7 Late changes are fibrosis and bronchiolitis obliterans. Changes on a thoracic CT will occur before radiographs. It can reveal peribronchial ground glass opacities and peribronchial consolidations. A CT of the brain can show cerebral hypoxia. There may be ischemia and injury to the globus pallidus which can be an indicator of carbon monoxide poisoning.1 Carboxyhemoglobin does not greatly alter the partial pressure of oxygen dissolved in blood (PaO2) or the oxygen saturation in arterial blood (SaO2).4 As respiratory complication progresses, an arterial blood gas may reveal hypoxemia, hypercarbia, and an increased

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VETERINARY NURSING EDUCATION alveolar-arterial oxygen gradient. A very high lactate may be indicative of cyanide poisoning, as the cells are forced to perform anaerobic metabolism. Smoke inhalation induced acidosis may be respiratory, metabolic, or both in origin. A finding of metabolic acidosis after fluid resuscitation and normal cardiac output can be a marker of impaired oxygen delivery from CO or cyanide poisoning. Blood cyanide concentration levels would be ideal but are not often available. Regardless, treatment should be initiated rapidly and not postponed while waiting for test results.2 A pulse oximeter reading will not be helpful when hemoglobin is altered by smoke inhalation. The pulse oximeter can read falsely normal as it cannot differentiate the wavelengths for oxyhemoglobin, carboxyhemoglobin, and methemoglobin. In cyanide toxicity, the hemoglobin can be fully oxygenated but the cells are unable to utilize the oxygen. Co-oximetry and certain arterial blood gas machines can differentiate between carboxyhemoglobin, methemoglobin, and oxyhemoglobin.7, 1, 2 The Masimo rainbow® CO-Oximeter is a non-invasive option and the Radiometer CO-OX analyzer and Nova arterial blood gas analyzers are also available. Arterial or venous samples can be used with a co-oximeter; however, arterial blood is ideal. The CO reading will be altered as soon as oxygen therapy is administered. A bronchoscopy and laryngoscopy can be performed to assess tissue damage. It is crucial to weigh the risks and benefits of these procedures because there might be a need for serial exams and general anesthesia is required each time.8 Positive findings for smoke inhalation on these exams will mean a positive diagnosis for smoke inhalation. Negative findings do not rule out smoke inhalation injury, especially considering the delay in manifestation of signs. With smoke inhalation, you may find subglottic injury, erythema, charring, soot deposits, edema, and mucosal ulceration. Trans-tracheal aspiration or endotracheal wash can also be beneficial to diagnose bacterial pneumonia but may require multiple samples, depending on duration of hospitalization. These should be considered later during hospitalization if the patient is stable enough to undergo 32

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the procedure to evaluate organism growth secondary to smoke inhalation injury.1, 5

Treatment

The goals in treating a patient who has suffered from smoke inhalation are to deliver oxygen, manage respiratory distress, maintain hydration with intravenous fluids, administer antidotes for potential toxicities, suppress inflammation, alleviate pain, and prevent infection. As stated earlier, upper airway obstruction may not be an initial threat, but obtaining a secure airway may be necessary if edema and swelling obstruct the upper airway and become life threatening. In these situations, an endotracheal tube should be placed or tracheostomy performed. Bypassing the upper airway and the need for sedation will increase the risk for developing pneumonia. Once an airway is established, strict sterile technique and maintenance is advised. The endotracheal or tracheostomy tube will need frequent suctioning of secretions. Humidification of the airway and gentle coupage will help loosen secretions.2, 7, 8, 1

Maintaining the patient’s hydration is imperative in these circumstances. After smoke exposure, they will have increased fluid losses nd lung secretions can be very thick. Proper hydration status will help maintain cardiovascular stability. Many of these patients are also experiencing pain from irritation from the smoke and some have burns as well. Pain medications should be considered and can also provide a light sedative effect. Some patients may come in agitated from dyspnea or have neurologic symptoms and need chemical restraint, especially those who already have swelling in the upper respiratory tract. 2, 7 A ventilator may be required for a patient that cannot adequately ventilate or is approaching respiratory failure. Mechanical ventilation is necessary when a patient is severely hypoxic, hypo-ventilating regardless of therapy, or has extreme respiratory effort leading toward

exhaustion. Atelectasis is common after smoke inhalation because surfactant activity is compromised. The use of positive end-expiratory pressure (PEEP) on a ventilator can help open collapsed alveoli and prevent further collapse. With the recruitment of collapsed alveoli, ventilation and perfusion matching should improve. A ventilator can deliver higher FiO2 levels and takes over the work of breathing for the patient. The use of mechanical ventilation does increase the risk of infections such as ventilator-associated pneumonia. 2, 7 Carbon monoxide has a half-life of four to six hours at room air (21% FiO2). When the amount of dissolved oxygen in the blood is increased, oxygen can compete with carbon monoxide for hemoglobin binding sites. Some of the dissolved oxygen does reach tissues as well. If the patient is intubated and placed on 100% FiO2, the half-life is reduced to 40-60 minutes.2, 3 Providing any oxygen supplementation will decrease the half-life of CO, so the use of an oxygen cage, mask, or nasal cannulas can all be beneficial. Improvement has been seen when firefighters or paramedics supplement animals with oxygen on the scene or in transport.9, 6 As soon as possible, the FiO2 should be reduced to a target of 40% to avoid oxygen toxicity. Displaced carbon monoxide is eliminated by being exhaled through the lungs. Oxygen therapy can also be incorporated to prevent delayed neurologic sequelae because hypoxia and reperfusion may play a role in this complication. However, excess oxygen can also contribute to reperfusion injury, so titrating the FiO2 down when it is safe to do so is important. Hyperbaric oxygen therapy at a level of 2 atmospheres reduces CO’s half-life to 15-30 minutes.5 This will provide more expedient clearance of CO and is a good option for more stable patients. In the chamber, there is not easy or quick access to a critical patient.6 Oxygen therapy is also beneficial in the case of cyanide toxicity, as it can increase the rate of displacement of cyanide from cytochrome oxidase. This enables the electron transport chain to function again. Two antidotes for cyanide are the combination of sodium nitrite and sodium

VETERINARY NURSING EDUCATION thiosulfate or hydroxycobalamin. The sodium nitrite and sodium thiosulfate antidote is not ideal in smoke inhalation patients because it induces methemoglobinemia. Methemoglobin hinders the binding of oxygen to hemoglobin. The combination of increased levels of methemoglobin and carboxyhemoglobin can greatly reduce the bodyâ&#x20AC;&#x2122;s oxygen carrying capacity.2 The use of hydroxycobalamin (Vitamin B12A) may be more favorable in victims of smoke inhalation. Hydroxycobalamin binds free cyanide, which then forms cyanocobalamin. Cyanocobalamin is excreted in urine. The use of this drug can cause a reddish discoloration of the mucous membranes, skin, and urine. Hydroxycobalamin can cause a decrease in heart rate and blood pressure, so the patient should be closely monitored.2, 1

The use of prophylactic antibiotics is generally discouraged as the mechanisms above involve a sterile initial injury and antibiotics select for resistant infections.

external burns as well. Anticonvulsants may be needed for patients having seizures as a neurologic complication.

If pneumonia is suspected, performing a culture and sensitivity, and treating with broad spectrum antibiotics is recommended.2 The use of glucocorticoids is controversial because they may increase the risk for bacterial pneumonia.9, 10 Intravenous fluids should be administered with extra attention in monitoring hydration status. Fluid overload can cause pulmonary edema, which can cause further complications in a patient with respiratory difficulty. This is even more important to consider in patients that have

Smoke and high temperatures can cause ocular irritation and corneal ulcers. Oral ulcerations may also be present and can be very painful. Eye lubrication and antibiotic treatment are necessary and an oral rinse with antiseptic and analgesics can help with oral pain. Bronchodilators such as terbutaline, aminophylline, or inhaled albuterol sulfate should be given to treat the reflex bronchoconstriction and bronchospasms brought on by smoke.2 In human medicine, inhaled racemic epinephrine is used to induce bronchodilation and vasoconstriction to reduce airway edema due to its alpha and beta receptor stimulant properties.5 Saline nebulization will

Radiograph showing a moderate diffuse bronchial pulmonary pattern, consistent with inflammation of the bronchi from smoke.

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VETERINARY NURSING EDUCATION humidify the airway and thin secretions. Mucolytics like bromhexine or acetylcysteine can help clear secretions by thinning mucus. Acetylcysteine also acts as an oxygen free radical scavenger. Antitussives should be avoided because they can reduce the animalâ&#x20AC;&#x2122;s effort to clear their airway.2

Conclusion

The potential risks to a patient change over time after smoke exposure. In the early hours after exposure, the effects of carbon monoxide, cyanide, and methemoglobin are present. In the following hours to days, pulmonary edema is the most significant threat and can progress rapidly. There is also a risk for potential secondary infection. Days to weeks after insult, late central nervous system damage can be seen, and in this time frame complications such as sepsis and pneumonia may arise.4 There is a retrospective study on smoke exposure in dogs (Drobatz, Smoke exposure in dogs: 27 cases (1988-1997). JAVMA. November 1999) 9 and cats (Drobratz,

Smoke exposure in cats: 22 cases (19861997).10 In the article on dogs, 59% of the patients survived with little to no complications after smoke inhalation injury. 11% of the patients experienced complicated hospitalizations, and 30% of the patients were euthanized or died.9 In the article on cats, the survival rate was 91%.10 This data shows just how variable the outcomes can be for a victim of smoke exposure. There tends to be a grace period before symptoms fully manifest in smoke inhalation victims. It is best to be prepared for the worst and monitor these patients very closely for any indication of decline. Supportive care is vital in these patients. Due to the many contributing factors in these cases, the outcomes for victims of smoke inhalation can be unpredictable initially. Despite the findings on presentation, the prognosis should be guarded until the maladies have had adequate time to develop.

Michele Hinks, BS, CVT, VTS (ECC) Michele currently lives in New Jersey with her husband, son, chocolate lab and three cats. Michele became a CVT in New Jersey in 2006 and received her B.S. at Ramapo College of N.J. in 2009. In 2014, she earned her VTS in emergency and critical care. She currently works at NorthStar VETS in the ICU and as a nursing and blood bank supervisor. Her interests include CPR, transfusion medicine, ventilator therapy, and teaching. In her free time she enjoys going to the beach or hiking with her family.

A special thank you to Barbara Maton DVM, DACVECC, for reviewing this article and always helping our team pursue the gold standard of veterinary medicine.

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References

1. Cope RB. Merck Manual Veterinary Manual. http:// www.merckvetmanual.com. 2016. http://www.merckvetmanual.com/toxicology/smoke-inhalation/overview-of-smoke-inhalaton. Accessed January 20, 2017. 2. Silverstein DC, Hopper K. Small Animal Critical Care Medicine. St. Louis: Saunders Elsevier; 2009. 3. Norkus CL. Veterinary Technician's Manual for Small Animal Emergency and Critical Care. Chichester: Wiley-Blackwell; 2012. 4. Kevin T. Fitzgerald PDDaAAFAC. Smoke Inhalation. Clinical Techniques in Small Animal Practice. October 2006;21:205-214. 5. Jeffrey S. Guy MD, FACS- Smoke Inhalation Injury [podcast]. Nashville ; 2011. 6. Christopher L. Mariani DVM D(. Full recover following delayed neurologic signs after smoke inhalation in a dog. Veterinary Emergency and Critical Care Society. 2003;13(4):235-239. 7. Julien Guillaumin DV,DaKHBPD. Successful outcome in a dog with neurological and respiratory signs following smoke inhalation. Journal of Veterinary Emergency and Critical Care. 2013;23(3):328-334. 8. Lindsay Vaughn DD, Nicole Beckel DDaPWV. Severe burn injury, burn shock, and smoke inhalation injury in small animals. Part 2:diagnosis, therapy, complications, and prognosis. Journal of Veterinary Emergency and Critical Care. 2012;22(2):187-200. 9. Kenneth J. Drobatz DDD, Lynn M. Walker V, Joan C. Hendricks VPD. Smoke exposure in dogs: 27 cases (1988-1997). JAVMA. November 1999;215(9):1306-1310. 10. Kenneth J. Dobratz DDD, Lynn M. Walker V, Joan C. Hendricks VpD. Smoke exposure in cats: 22 cases (1986-1997). JAVMA. November 1999;215(9):1312-1316.

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Article Questions 1. Which of the following can increase the risk of bacterial pneumonia after a smoke inhalation injury? a. Placement of endotracheal tube or tracheostomy tube b. Decreased alveolar macrophage function c. The administration of bronchodilators d. Both A and B

2. Which of the following is not considered a by-product of incomplete combustion present in smoke? a. Hydrogen cyanide b. Aldehyde

4. I n cyanide poisoning, which metabolic pathway is inhibited? a. Glycolysis b. Krebs cycle c. Fatty acid biosynthesis d. Electron transport chain

5. W hich of these drugs are used to treat bronchoconstriction and bronchospasms? a. Terbutaline b. Hydroxycobalamin c. Albuterol Sulfate d. Both A and C

c. Magnesium hydroxide d. Carbon monoxide

3. What is the best test to run if you suspect carbon monoxide poisoning? a. Chest radiographs b. Co-oximetry c. Pulse-oximetry

CONTINUING EDUCATION

QUIZ ONLINE visit VetMedTeam.com and log in with your Vet Med Team Profile.

d. Urinalysis ÂŽ

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VETERINARY NURSING EDUCATION

THE ESSENTIALS OF

SHOCK Courtney Waxman, CVT

Learning Objectives After reading this article, participants will be able to define shock, understand the different types and phases of shock, and learn how emergent nursing care should be provided based on the type and phase of shock.

WHAT IS SHOCK? Shock is considered a dynamic and complex clinical syndrome. It is a condition that is common in our patients and often difficult to define and understand. Early identification of shock and implementation of therapy is paramount to having a successful patient outcome. Shock can be defined as inadequate cellular energy production.1 It can also be defined as a condition in which tissue and cellular oxygen delivery does not meet oxygen demand. What this means is that shock occurs secondary to poor tissue perfusion, which causes poor oxygen delivery to vital tissues.2 It is important to note that shock is not a single entity, but rather the result of an underlying insult.

Types of Shock

Shock has been classified into many different types based on the different pathophysiologies. The three main types of shock are hypovolemic, distributive, and cardiogenic, with hypovolemic shock being the most common type seen in small animal medicine. Other types of shock that have been classified include obstructive, metabolic and hypoxemic shock, but for the purpose of this article, focus will be on the three main types. Depending on

the disease process that is the cause of shock, it is not uncommon for patients to experience more than one type of shock. Regardless of the type, the goal of addressing shock is to optimize oxygen delivery to tissues.

Oxygen Delivery

Oxygen delivery is the amount or volume of oxygen carried to tissues each minute.2 Oxygen delivery to tissues is dependent on the oxygen level in blood (arterial oxygen content) and on the bodyâ&#x20AC;&#x2122;s ability to circulate blood to tissues (cardiac output). The factors that affect oxygen delivery include heart rate, stroke volume, mean arterial blood pressure, systemic vascular resistance and hemoglobin concentration.2 While calculation of oxygen delivery is not possible, it is important to understand the concept and how changes in any of the factors diminish oxygen delivery to tissues, thus promoting shock.2 VETERINARY NURSING IN ACTION | AUG/SEPT 2017

VETERINARY NURSING EDUCATION Pathophysiology of the Different Shock States Hypovolemic shock occurs when there is a decrease in circulating blood volume. Hypovolemia occurs most commonly from blood loss (hemorrhage), gastrointestinal loss (vomiting, diarrhea), urinary loss (polyuria), burn wounds, third-spacing of fluids, or decreased intake of fluids.1, 3 The loss of circulating blood volume results in decreased venous return to the heart (preload), which decreases cardiac output.1 In an effort to raise circulating blood volume, compensatory mechanisms are initiated. These mechanisms include stimulating the sympathetic nervous system, which is the body’s fight-or-flight response. Sympathetic activity causes vasoconstriction and increased contractility of the heart in order to increase cardiac output.1 There is also a baroreceptor response in which mediators (norepinephrine, epinephrine, cortisol) are released from the adrenal gland. Norepinephrine and epinephrine increase heart rate, increase contractility, and cause vasoconstriction.2 Cortisol works by enhancing the effects of norepinephrine and epinephrine on blood vessels.2 Additionally, as blood perfusion priority is given to other vital organ systems (i.e. heart, lungs, brain), decreased renal perfusion activates the renin-angiotensin-aldosterone system. This system is responsible for conserving water and sodium by releasing aldosterone and antidiuretic hormone, which in turn increases intravascular volume.1 Distributive shock occurs when there is ineffective or inappropriate circulation and distribution of blood volume. This means there is adequate blood volume, but inadequate perfusion of said blood volume. This leads to a maldistribution of blood flow, in which vessels dilate and create peripheral blood pooling. During vasodilation, the vessels expand, making the normal blood volume insufficient and causing the blood to be displaced away from the heart and central circulation.2 Distributive shock occurs most commonly from vasodilatory states, such as sepsis, systemic inflammatory response syndrome (SIRS), anaphylaxis, heatstroke, or adverse drug reactions.3 In some texts, obstructive shock has been subcategorized under distributive shock. Obstructive shock refers to 38

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a physical obstruction of blood flow within the circulatory system. The obstruction causes an increase in systemic vascular resistance, which also leads to maldistribution of blood.1 The most common example of obstructive shock is gastric dilatation volvulus (GDV), because as the stomach dilates and rotates, it occludes the caudal vena cava. Cardiogenic shock occurs when there is pump failure, causing failure of forward blood flow. This occurs when there is adequate blood volume but reduced cardiac output from cardiac dysfunction.1 Forward flow failure refers to decreased venous return to the aorta and systemic circulation.1 Without a normal functioning heart pump, tissue ischemia results from lack of blood perfusion and circulation. Causes of cardiac dysfunction include dysrhythmias, poor contractility, valvular disease, structural or anatomical defects, and congestive heart failure.1, 2 Cardiac dysfunction results in an increased heart rate, decreased stroke volume, decreased cardiac output, decreased blood pressure, increased systemic vascular resistance, and increases in pulmonary pressures.1 The main sign associated with cardiogenic shock is respiratory in nature.

Phases of Shock

The first stage of shock is known as the compensatory phase. During this time, the body has received an insult and is initiating a systemic response to compensate for decreased oxygen delivery to tissues. In this early stage, it may not be as clinically obvious that shock is occurring, as compensatory mechanisms are working to maintain cardiac output and tissue perfusion. Clinical signs of this phase include mild changes in mentation, tachycardia (heart working harder to maintain cardiac output), prolonged capillary refill time (from vasoconstriction), tachypnea (from decreased oxygen), adequate to bounding pulse quality (heart trying to maintain perfusion), normal blood pressure (from vasoconstriction and tachycardia).1, 3 The second stage of shock is known as early decompensatory shock. The animal enters this phase after compensatory mechanisms have failed, and the body begins to succumb to prolonged poor

oxygen delivery to tissues. Clinical signs include a moderate to severe depression in mentation, moderate to severe tachycardia, poor pulse quality, pale mucous membranes, hypotension, and cool extremities.1, 3 The third and final stage of shock is known as late decompensatory shock. Progression to this phase indicates prolonged hypoperfusion, or lack of oxygen to tissues, and leads to organ failure and ultimately death. This phase is characterized by an obtunded or stuporous mentation, bradycardia, severe hypotension, and absent pulse quality.1, 3

Shock Index

Shock itself is difficult to measure, as there are currently no tools available to assess tissue oxygen status. 4 In the human field, something called the shock index was developed as a simple way to quantify the severity of shock and response to therapy.2 The shock index is equal to the heart rate divided by the systolic blood pressure. A pilot study was performed at Tufts University and published in 2013 that looked at using the shock index in dogs in the emergency setting. Their results established a reference shock index interval in dogs of 0.37-1.3, and concluded that the shock index may be advantageous as a tool to identify poor tissue perfusion in the presence of seemingly normal cardiovascular parameters.2, 4

Initial Assessment and Recognition of Shock In addition to historical information, physical exam findings can also help in diagnosing shock. When performing a physical assessment to determine if a patient is in shock, focus should be on the six perfusion parameters to evaluate the patient’s circulatory status. These paraemters include mentation, heart rate, pulse quality, mucous membrane color, capillary refill time, and extremity temperature. Mentation is the first parameter to assess when approaching the patient to begin the assessment. Decreased cerebral function from lack of oxygen supply is perhaps the earliest outward sign of shock. A change in cerebral perfusion alters an animal’s mentation

within seconds. When classifying a patient’s mentation, it can be classified as normal/alert, dull/depressed/obtunded (slowed/inappropriate response to sensory stimuli), stuporous (unconscious but rousable to noxious stimuli) or comatose (unconscious and unresponsive). Heart rate is the second parameter performed when completing a physical assessment. It is expected for an animal in shock to be tachycardic, as tachycardia is the body’s compensatory response to hypoperfusion and inadequate oxygenation. Tachycardia is generally accepted as a heart rate greater than 160-180bpm in dogs and greater than 200bpm in cats.1, 5 During auscultation, it should also be noted if there are any irregularities in the heart rate, which can indicate an arrhythmia and would warrant performing an electrocardiogram (ECG). Elevations in heart rate can occur secondary to other factors (i.e. excitement, anxiety, stress, exercise, pain), so a physical finding of tachycardia should be assessed in addition to other parameters that could suggest shock. Pulse quality should be taken in conjunction with heart rate auscultation when performing the initial assessment. Pulse quality refers to the difference between the systolic and diastolic arterial blood pressure. Pulse quality is reflective of adequate stroke volume, (amount of blood pumped by the heart each beat). As stroke volume is one of the determinants of cardiac output, a change can indicate compromised cardiac output, which occurs in shock. The most common sites to obtain a pulse pressure are the femoral or dorsal pedal arteries. An animal’s pulse quality can be described as normal (a steady pulsation against the finger that is synchronous with the heart rate), weak (a lighter than normal pulsation against the finger), bounding (a harder than normal pulsation against the finger), or absent (lack of pulsation against the finger). A normal pulse is indicative of normal stroke volume. Weak pulses are concerning for decreased stroke volume, poor contractility, or peripheral vasoconstriction.1 It should also be noted whether or not pulse deficits (absent pulses during cardiac contraction) are present, as they are also an indicator of inadequate stroke volume. Bounding pulses are reflective

VETERINARY NURSING EDUCATION of systolic-diastolic difference in arterial blood pressure, which is concerning for increased stroke volume and vasodilation.5 Absent pulses indicate a failure in appropriate peripheral perfusion. Mucous membrane color can be evaluated by looking at the patient’s gums and provides information about peripheral capillary perfusion. Normal mucous membrane color is pink, which indicates normal oxygenated hemoglobin in red blood cells present in the capillary beds.5 During the circulatory problems associated with shock, mucous membrane color changes in response to changes in perfusion. Pale mucous membranes are indicative of blood loss and vasoconstriction, which can occur from hypovolemic or cardiogenic shock states. Injected (reddened) mucous membranes are indicative of vasodilation, which can occur from distributive shock states. Capillary refill time (CRT) provides further information about peripheral perfusion.1 It is evaluated by applying pressure to the mucous membranes (pushing blood away from the capillary beds), and then counting how long it takes for color to return. A prolonged CRT suggests poor perfusion from peripheral vasoconstriction, as with hypovolemic and cardiogenic shock states.1 A rapid CRT suggests a hyperdynamic (systolic-diastolic difference) state, which is associated with distributive shock states.1 Extremity temperature is evaluated by feeling the paws and distal limbs of a patient, which should normally be warm to the touch. Cool extremities indicate poor perfusion, as cardiac output diverts blood flow to the central circulation.2 This shunting of blood is intended to preserve blood flow to vital organs.2 In addition to the six perfusion parameters, blood pressure measurements should also be obtained. Blood pressure is sometimes the first thought-of parameter to measure in cases where shock is a concern. Too often, shock definitions have been associated around hypotension, which is misleading as to what shock actually is. Hypotension is perhaps the most common abnormality, as blood pressure is the

product of cardiac output and systemic vascular resistance, and both are compromised in shock states. Blood pressure measurements can be taken either indirectly, using oscillometric or Doppler methods, or directly, using an arterial catheter. Depending on the text references, hypotension is generally accepted as either a systolic arterial blood pressure of less than 80mmHg or a mean arterial blood pressure of less than 60mmHg.1,5 To ensure consistency, the same limb and same cuff size should be used each time a blood pressure reading is taken. The diagnosis of shock is based on getting a thorough patient history provided by the owner and discovering abnormal perfusion parameters during the initial assessment of the patient.

Biomarkers

When an animal is suffering from shock, there is inadequate oxygen delivery to meet tissue demands.4 This results in the body shifting from a state of aerobic (with oxygen) to anaerobic (lack of oxygen) metabolism. Lactate is a by-product of anaerobic metabolism, and blood lactate concentration is a well-known biomarker of tissue perfusion and prognostic indicator.2, 4, 5 Lactate elevation (greater than 2.5mmol/L) is reflective of severe cellular oxygen deficiency. Serial measurements of lactate can be done to help diagnostically evaluate tissue and oxygen perfusion status, and can be used to trend improvement. It has been suggested that the rate of lactate clearance is a predictor of patient outcome and shock reversal.5

Hypovolemic and Distributive Shock Treatment The treatment of hypovolemic and distributive shock states is to administer fluid resuscitation to increase intravascular volume, improve systemic perfusion, and restore oxygen delivery to tissues. During each therapeutic intervention, the patient should be reassessed to determine the next steps in treatment. The first step is obtaining venous access. Venous access in a shock patient can sometimes be difficult to obtain due to compromised perfusion from

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VETERINARY NURSING EDUCATION cardiovascular compromise (i.e. hypotension, cold extremities). However, it is most ideal to place a large gauge, short length IV catheter in the cephalic vein. IV catheter size is preferably 18-gauge in medium to large sized dogs and 20-gauge in small dogs and cats. Smaller gauge IV catheters create increased resistance to fluid flow, which is counterproductive, as shock fluid resuscitation involves providing rapid, large volume therapy. The cephalic vein is preferred as it allows for easier access, reduces the likelihood of contamination from GI or urinary losses, allows for better visualization of the vessel, is closer to the heart, and reduces potential issues with patient mal-positioning or occlusion. Depending on the severity of shock at the time of presentation, it also may be worthwhile to place multiple peripheral IV catheters (i.e. large-volume fluid resuscitation, simultaneous crystalloid and blood product administration). It is also worth mentioning that saphenous catheters are contraindicated in some cases of obstructive/distributive shock, such as GDV, as venous blood flow is compromised from occlusion of the caudal vena cava. Intravenous isotonic crystalloids are the mainstay fluid type for treating these shock states, as they have the most similar composition to the patient’s extracellular fluid compartment. Crystalloid solutions include 0.9% NaCl, Lactated Ringer’s (LRS), Normosol-R and Plasmalyte-A. The shock volume of crystalloid solutions is equal to an animal’s blood volume, and varies slightly depending on the reference source and species. In canines, the shock dose of IV crystalloids is 60 to 90ml/kg.1 In felines, the shock dose of IV crystalloids is 45 to 60ml/kg1. When delivering crystalloids, start with aliquots, such as 1/4 or 1/2 the shock dose, and then reassess the patient. For instance, take a 10kg dog and calculate the shock dose as 90ml/kg. The dog’s full shock dose equals 900mls; to calculate the shock dose aliquot, 900ml is divided by either 2, 4, or 8 (1/2, 1/4, 1/8), which provides the starting aliquot volume. Ideally, IV crystalloids should be administered rapidly over 10-15 minutes. It is often necessary to implement a pressure bag (figure 1) rather than the typical fluid pump. It is also important that the gauge

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on the pressure bag is correct (figure 2). As mentioned earlier, assessment of perfusion parameters and resuscitation endpoints (i.e. heart rate, blood pressure) should be used to guide fluid therapy. Synthetic colloids are also a fluid option during shock resuscitation. Colloid solutions contain large molecules suspended in crystalloid solutions that help maintain intravascular volume because they do not cross the blood vessel barrier as readily as crystalloids. Because molecules in colloids are bigger, they tend to remain within the intravascular space longer, thus better sustaining intravascular volume. The most commonly available synthetic colloids are derivatives of hydroxyethyl starches.1 These solutions include Hetastarch, Tetrastarch, Pentastarch, and Vetstarch. Synthetic colloids can be given as a bolus at 5-10ml/kg IV.1 They can also be used as a CRI so long as the dose doesn’t exceed 20ml/kg within 24 hours.1 In recent years, there has been controversy and debate about the use of synthetic colloids in fluid resuscitation. There has been more recent research and evidence in the human field about the adverse effects of synthetic colloid use. The main concerns of colloid use in human medicine is they may cause acute kidney injury and coagulation derangements. While there is currently no veterinary evidence regarding the adverse effects of colloid use, many clinicians are giving more patient consideration prior to implementing colloid use. The use of hypertonic solutions can also be life-saving in the emergency setting. Hypertonic saline is an excellent choice for rapid, small-volume resuscitation.1 The most commonly used hypertonic solution is 7-7.5% hypertonic saline (figure 3). Hypertonic saline is dosed at 3-5ml/ kg and given IV over 10-15 minutes.1, 2 Although short-lived (typically 30 minutes), the transient cardiovascular effects of administration may provide enough time for other therapies, such as crystalloids, to take full effect.1 Use of hypertonic saline is also desirable as you can deliver a much smaller volume to obtain the wanted restoration of intravascular volume effect. Hypertonic saline is often and ideally given in combination with isotonic crystalloids.

Figure 1: A pressure bag is used to rapidly deliver IV crystalloid solutions

Figure 2: A close-up showing the pressure bag being properly inflated to 300mmHg

Figure 3: A bottle of 7.2% hypertonic saline solution used for small volume, rapid intravascular expansion.

In the case of hypovolemic shock from severe hemorrhage, blood component therapy is often used in addition to IV crystalloid resuscitation (figure 4). The dose of packed red blood cells (pRBCs) and fresh frozen plasma (FFP) is 10-20ml/kg, and the dose of fresh whole blood is 20-30ml/kg.1 Giving pRBCs increases oxygen content and giving FFP addresses coagulopathies. Ideally, blood products are administered slowly, through a filter, over 1-4 hours to be able to monitor for signs of a transfusion reaction and to prevent volume overload from rapid infusion.1 However, in severe cases of hemorrhage, blood products can be given more rapidly as a bolus. The term hypotensive resuscitation has surfaced over recent years as an alternative resuscitation end point in traumatic shock patients with active hemorrhage (i.e. severe cases of hypovolemia from severe blood loss). This is a more conservative resuscitation strategy in which fluids are given until there is a restoration of lower-than-normal systolic blood pressure (i.e. 80 to 90mmHg).1 The idea behind this therapy is that when there is active bleeding, overuse of fluid resuscitation can dislodge formed clots.1 In these cases, a lower-than-normal blood pressure is more tolerated and accepted because there is control of hemorrhage, reduced risk of rebleeding, and preservation of blood flow to vital organs.1 It should be noted that this therapy is only indicated as a temporary measure between stabilization and gaining hemostatic control.1 Patients who are nonresponsive to shock doses of fluid resuscitation may require additional pharmacologic intervention. Other agents that can be used include vasopressors (norepinephrine, vasopressin), catecholamines (epinephrine), and sympathomimetics (dopamine, dobutamine). These agents work on receptors throughout the body to promote arterioconstriction and vasoconstriction (increasing blood pressure and heart rate), as well as improved heart contractility.

Cardiogenic Shock Treatment

The goal of treating the cardiogenic shock state is to improve oxygenation and restore adequate tissue perfusion. Treatment of cardiogenic shock

VETERINARY NURSING EDUCATION differs from the other types of shock, and these patients are more susceptible to rapid decompensation. Providing supplemental oxygen therapy is of the utmost priority. Oxygen can be delivered by flow-by face mask during initial assessment, physical exam, and stabilization measures. Oxygen therapy can continue supportively through either nasal cannulas or an oxygen cage delivery system. It is also very important to limit stress as much as possible in the cardiogenic shock patient. These animals can very easily decompensate; therefore, utilization of low-stress and minimal handling techniques should be performed. In these cases, stabilization and treatment often has to be performed in steps. First provide oxygen, then give sedation, then attempt venous access, then obtain diagnostics, then set up drug therapies. Trying to do everything the doctor orders at once can be overwhelming and can put the patient over the edge if attempted without allowing for breaks. Obtaining venous access is also important; however, unlike the other shock states, a smaller gauge IV catheter is more acceptable and better tolerated in these patients. Restraint for placing an IV catheter can be stressful, and itâ&#x20AC;&#x2122;s not as important to get the biggest gauge possible, as these patients will be receiving little to no IV fluids and small volumes of drugs. The mainstay medication used to treat cardiogenic shock is furosemide. Furosemide is a loop diuretic that exerts its effects on the loop of Henle within the nephron. Furosemide increases urine production by increasing renal excretion of water and electrolytes; in doing so, it reduces intravascular volume and venous pressures. Furosemide is most commonly used to treat congestive heart failure, which is one of the most common causes of cardiogenic shock.2 Furosemide can be given at a dose of 2-4mg/kg IV or IM, but can be better used as a constant rate infusion (CRI) during a shock episode.1 Setting up a furosemide CRI on a syringe pump typically starting at 0.5-2mg/kg/hr allows

Figure 4: Units of pRBCâ&#x20AC;&#x2122;s used to treat hypovolemic shock due to severe hemorrhage. for easier titration of the drug based on the patientâ&#x20AC;&#x2122;s needs and response. It is also important to remember to treat the underlying cause attributing to the cardiogenic shock state. Other pharmacologic intervention is most likely warranted depending on whatever heart condition is also present.

Nursing Care

Patients in shock present in an unstable condition, and the importance of the role of the veterinary nurse cannot be overstated. Dedicated nursing care and close monitoring are essential during the stabilization and hospitalization periods of a shock patient. Monitoring often involves one-on-one care for at least the first hour from time of presentation. During stabilization therapies, it is primarily the veterinary nurse assessing the patient and recording vital signs. A full set of vital signs should initially be taken every 5-10 minutes. Focus should be around the six perfusion parameters (mentation, heart rate, pulse quality, mucous membrane color, CRT and extremity temperature), but should also include the use of blood pressure measurement and ECG monitoring. As the patient becomes less critical, vital sign recordings, blood pressure and/or ECG monitoring can decrease in frequency to every one to four hours. There are also some special considerations to take into account depending on the type of shock a patient is experiencing. In the case of severe hemorrhage, administering a blood transfusion would

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VETERINARY NURSING EDUCATION require additional frequent monitoring to ensure the blood product is given safely and to observe for signs of an adverse reaction. In the case of severe GI losses, maintaining patient cleanliness as well as quantifying losses to be replaced will be necessary. In the case where vasopressor agents are used, more diligent monitoring of heart rate and blood pressure is required as these drugs can rapidly and drastically affect these parameters. In the case of congestive heart failure, monitoring of respiratory parameters (respiratory rate, respiratory effort, pulse oximetry) will also be essential in addition to the above-mentioned perfusion parameters.

Conclusion

Early recognition and prompt emergency therapy is essential in the successful outcome of a patient in shock. It is also important to serially examine and reevaluate perfusion parameters in shock patients and to determine end points of resuscitation.

References

1. Silverstein, D. C., & Hopper, K. (2015). Small animal critical care medicine. St. Louis, MO: Elsevier. 2. Battaglia, A. M., & Steele, A. M. (2016). Small animal emergency and critical care for veterinary technicians. St. Louis: Elsevier.

Article Questions 1. What is shock? a. A state of hypotension b. Inadequate cellular energy production c. Adequate oxygen status d. A state of confusion based on external events 2. Which is the following is not a stage of shock? a. Early compensatory b. Compensatory c. Early decompensatory d. Late decompensatory

5. Creedon, J. M., & Davis, H. (2012). Advanced monitoring and procedures for small animal emergency and critical care. Oxford: Wiley-Blackwell.

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a. Hypovolemic b. Distributive c. Cardiogenic d. Both a and b 5. Which of the following is contraindicated as a therapy for cardiogenic shock? a. Oxygen b. IV fluids c. Furosemide d. Low stress/handling

3. Which of the following is one of the six perfusion parameters? a. Lactate b. Blood pressure c. Heart rate d. Nose temperature

3. Ettinger, S. J., & Feldman, E. C. (2010). Textbook of veterinary internal medicine (7th ed., Vol. 1). St. Louis (Mo.): Saunders Elsevier. 4. Porter, A. E., Rozanski, E. A., Sharp, C. R., Dixon, K. L., Price, L. L., & Shaw, S. P. (2013). Evaluation of the shock index in dogs presenting as emergencies. Journal of Veterinary Emergency and Critical Care. doi:10.1111/ vec.12076

4. Intravenous fluids are the mainstay treatment in which shock state(s)?

CONTINUING EDUCATION

QUIZ ONLINE visit VetMedTeam.com and log in with your Vet Med Team Profile.

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Courtney Waxman, CVT Courtney is an Arizona native who found her passion in emergency and critical care medicine after completing an internship during her technician schooling. She graduated in 2008 with her AAS in Veterinary Technology/Animal Health and obtained her CVT in 2009. Courtney has spent the past 10 years working in emergency medicine, and currently works at VetMed Emergency and Specialty Hospital in Phoenix. She has presented technician case reports at the ACVIM Forum, IVECCS and NAVC conferences. She also lectures locally to referring veterinary practices, veterinary technology students and the public on topics relating to emergency medicine. Courtney is pursuing becoming a Veterinary Technician Specialist in Emergency and Critical Care. Her special interests include mechanical ventilation, anesthesia, environmental hazards and one-on-one case management. Off duty, she enjoys world travel with her husband, reading, yoga, and spoiling her two dogs, Biggs and Ollie.

vetlexicon highlights Aug/Sep 2017

Tracheal rupture repair Tracheal rupture is an infrequent complication of traumatic injury in the dog. This new topic has been accompanied by 5 new images. This new topic has been written by Zoe Halfacree MA VetMB CertVDI CertSAS DipECVS MRCVS

canis

To view the full article visit www.vetstream.com/treat/canis and search for ‘tracheal rupture’

Trachea: cervical bite wounds © Zoe Halfacree

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felis

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Sebaceous adenitis Exfoliative scaling skin disease is occasionally seen in the rabbit. It is usually non-pruritic unless a secondary pyoderma is present. This topic has been updated by Nathalie Wissink-Argilaga CertAVP(ZM) DZM(Reptilian) MRCVS

lapis

To view the full article visit www.vetstream.com/treat/lapis and search for ‘sebaceous adenitis’

Cheyletiella spp: coat scaling © David Scarff

Nasal discharge Nasal discharge in guinea pigs has multiple etiologies, including infectious or non-infectious; the most common being bacterial infection. The primary sign is serous or mucopululent nasal discharge, but there may also be concurrent ocular discharge.

exotis

This topic has been written by Cathy Johnson-Delaney DVM To view the full article visit www.vetstream.com/treat/exotis search for ‘nasal discharge’

Nasal discharge

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Breeding assessment Horses are classically described as being ‘long day seasonal breeders’. Most mares are acyclical during short days (the winter, non-breeding season), and cycle regularly during long days (the summer, breeding season).

equis

This new topic has been written by Madeleine Campbell BVetMed(Hons) MA(Oxon) MA (Keele) PhD DipECAR DipECAWBM (AWSEL) MRCVS To view the full article visit www.vetstream.com/treat/equis and search for ‘breeding assessment’ NAVTA have partnered with Vetstream to offer Vetlexicon at highly preferential prices for NAVTA members. As a member of NAVTA you are entitled to a no obligation FREE 30 days trial to the Vetstream Vetlexicon services, comprising of Canis, Felis, Lapis and Equis. All you need to do is register on https://www.vetstream.com/register/NAVTA30 and you will then have 30 days access to more than 19,000 text articles, images, tables etc from more than 900 of the world’s leaving clinicians.

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As a NAVTA member, you are also eligible for a discount off the subscription price of any of the services. We will contact you during your trial to give you further details. Vetstream Ltd, Three Hills Farm, Bartlow, Cambridge CB21 4EN, UK. Tel: +44(0)1223 895818 Email: enquiries@vetstream.com

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Patients can be made more comfortable by having a few stuffed animals brought into their hospital suite.

CREATURE

COMFORTS Robyn Baillif, RVT, VTS (ECC)

Utilizing Maslowâ&#x20AC;&#x2122;s Hierarchy of Needs to guide the little things we do to make a positive difference during patient hospitalization. This program was reviewed and approved by the AAVSB RACE program for 1 hour of continuing education in jurisdictions which recognize AAVSB RACE approval. Please contact the AAVSB RACE program if you have any comments/concerns regarding this programâ&#x20AC;&#x2122;s validity or relevancy to the veterinary profession.

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Learning Objective Upon completion of this article, participants will be able to describe the subtle things veterinary technicians and assistants can do to help patients feel comfortable and safe during their hospitalization, therefore contributing to better patient outcomes.

It is the responsibility of technicians and assistants working with emergent and critical patients to know what is going on medically and physiologically. There are many resources available to help nurse intensive and critical care patients back to health. Kirby’s Rule of 201 can guide the nursing care, ensuring that the highest standard is being practiced, and knowing when to alert the veterinarian if the patient’s condition changes for better or worse. In addition to being aware of what treatments patients need and why they need them, veterinary technicians and assistants should also be acutely aware of the patient’s mental and emotional well-being. When I was in tech school years ago, I was told that we should never anthropomorphize; that it was inappropriate to assign human mental and emotional states to an animal. However, I believe that by anthropomorphizing we are better able to provide thorough nursing care to our patients and hopefully contribute to better patient outcomes. The methods throughout this article will help veterinary care providers improve patients’ emotional and mental health while they are hospitalized. Not many studies are currently available that show the positive effects environmental conditions have on veterinary patients. A lot of the studies that do exist are geared toward humans because they can be asked how certain conditions affect their mood and mental state. However, some studies can be applied to the nonverbal veterinary patients, as they focus on the physiological responses to stress and anxiety. From a mental and emotional viewpoint, one can look to Maslow’s Hierarchy of Needs2 to help prioritize patient care goals that fall outside of the treatment plan implemented by the veterinarian in charge of the case. Maslow’s Hierarchy pyramid has five tiers and much like the food pyramid, the largest and bottom tier houses the most vital needs of a living being. The fourth and fifth tiers are applicable only to the type of society for humans and are therefore not included in this article, but the lower three tiers can be applied to patient needs.The first tier, physiological needs, must be met before moving to the second tier, safety and security. The first tier includes breathing, food, water, shelter,

VETERINARY NURSING EDUCATION and sleep. The nursing plan should already include making sure the needs of breathing, food, water, and shelter are met—but what steps can be taken to make sure patients get enough sleep? Is it possible to expand on shelter by making their home away from home more comfortable?

Circadian Rhythm and Environmental Noise Humans, animals, plants, and other living organisms have a natural rhythm to their bodies called the circadian rhythm. This rhythm helps dictate when they sleep, wake, and eat, and it can be largely affected by the environment surrounding them. Disruptions of the circadian rhythm can lead to changes in body functions such as cellular metabolism and hormone regulation, as well as affecting the immune system and the brain’s cognitive function. Human studies have shown that sleep quality in an intensive care unit (ICU) setting was significantly worse than the quality of sleep in a single room or at home.3 Of the noises within the ICU setting, the study found that alarms and staff conversation contributed most to sleep disruption. Another study indicated that along with environmental noise, patient

sleep is greatly disturbed by interruptions caused by human interventions and diagnostic testing.4 There are a few ways to help prevent disruptions within the veterinary ICU setting. During the day, it can be hard to limit noise levels because there is often a lot of activity occurring within the ICU and throughout the hospital – which can be said of many nights as well. Employing situational awareness can go a long way to decreasing the amount we contribute to disrupting our patients’ sleep. Place signs on doors leading into the ICU to indicate if there is a sound sensitive patient or if there are other special patient considerations to take before entering the ward. This can help people in other departments know when to keep sound volumes low. Scheduling invasive treatments to be done at the same treatment time so the patient has more opportunity to sleep between disruptions is helpful, as well as remembering to keep volume and lights down at night to keep their circadian rhythm in sync. By ensuring patients get rest during their stay, veterinary healthcare providers are contributing to an improvement in their outcome and their overall cellular, metabolic, and mental health.

A patient in supplemental oxygen had a hard time resting due to constant activity right outside the cage. We provided a perch, a curtain to hide behind that still allowed us to observe our patient, and a box to sit in.

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

VETERINARY NURSING EDUCATION

The contribution of music to environmental enrichment within the ICU and other patient care areas of the hospital has become controversial. Much as noise levels can interfere with a patient’s sleeping habits, specific music can have the opposite affect and help reduce stress and increase patient wellness.7

A music player can be added for enrichment, a pillow can be provided to prop the patients head, and carpeting can be provided for stability to help the patient get up and walk outside of the cage.

Environmental Enrichment – Natural Lighting, Stimuli, Fresh Air, and Music

stimulation than what they get inside a cage or run.

What exactly is an enriched environment? It is an environment that provides social interactions and items that encourage sensory and motor activity.5 Since veterinary healthcare team members are the patient’s primary source of social interaction during their hospitalization, it is important to take their disposition, temperament, and mood into consideration. This is where anthropomorphism can be employed. Do they seem depressed? Are they seeking more or less human interaction? Has the patient been in the hospital for a couple of days with limited access outdoors? There are an increasing number of studies in human medicine that have shown providing natural light and stimuli (visual, olfactory, and auditory) have contributed to patients having quicker recoveries and requiring less pain medication during their hospital stay.6 Exposure to sun and fresh air can also contribute to overall patient wellbeing and mental health – largely because they are provided with something that would be part of their normal routine were they not ill, as well as providing different sensory

Not all veterinary hospitals have windows that provide natural light and scenery for ICU and treatment areas, and it is not always an easy task to get a large, recumbent animal outside for some fresh air and sunshine. When time and staffing allow, transporting a large patient on a gurney and sitting with him or her outside for even a few minutes can help improve their mood and mentation. If he or she has been inappetent, this is also a good time to offer food away from the distractions of the hospital, because he/she may be more inclined to eat in a naturally enriched environment. If the owner is visiting, set up a “picnic” area outside so they can sit with their pet and try to offer them food. If canine patients can walk without sling assistance and are stable enough to be off IV fluids for 10-15 minutes, allow them time to “smell the flowers” on their walk – for them exploring all the scents can be the best part of going on a walk. A slightly longer walk is also a wonderful way to allow owners some one-on-one time with their pet.

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Although more research needs to be done, one study in a shelter environment concluded that classical music allowed dogs to spend more of their time resting, and also resulted in a significantly lower level of barking.8 There are many CDs available composed of music that has been shown to help ease anxiety in canine and feline patients, as well as music players with preloaded SD cards that can be placed on the patients’ cage door to provide comfort if they are prone to anxiety.

Feline Specific Environmental Enrichment The AAFP (American Association of Feline Practitioners) and ISFM (International Society of Feline Medicine) Feline Environmental Needs Guidelines9 outline ways to ensure cats have an enriched environment in which they can feel safe and thrive. Some of the guidelines can be applied to less critical hospitalized feline patients and help improve patient comfort and well being. • Housing cats in a room separate from dogs to reduce their fear and stress. • Providing a safe place that will still allow team members to monitor them, such as a towel to cover a portion of the cage door or a box to curl up in (not viable for critical patients if it obstructs the ability to constantly monitor and assess them).

• When possible, spread cage contents out so the litter box and food are not sitting right next to each other. • When possible, do not place feline patients directly across from each other. If unavoidable, then cover cage doors and/or maximize the amount of space between patients. • Provide consistency in caregivers when possible. • Use synthetic pheromones to help reduce distress in caged cats.

Physical Benefits of Water Intake

Having dry mucous membranes can contribute to a patients’ level of discomfort. Although their treatment plan will often include nutrition - fed a specific diet at a set frequency, fed via a feeding tube with a constant rate infusion/trickle feeding, or bolus feedings; one must consider those that are on NPO orders and dehydrated. Veterinary technicians and assistants must also consider the tube fed animals that do not take water in by mouth. Intravenous fluid therapy will help compensate for dehydration, but until the patient becomes euhydrated, the uncomfortable dry mouths of the patient must be addressed. Ask the veterinarian if it would be acceptable to periodically moisten the patient’s oral mucous membranes with water. If the veterinarian is concerned about water intake leading to increased nausea, or if the patient has a metabolic derangement that requires very measured water intake, then one can ask for orders to apply liquid glycerin to the oral mucous membranes every four hours to help prevent patient distress from the discomfort of dry and tacky mucous membranes. The second tier of Maslow’s Hierarchy focuses on safety and security, while the third on love and belonging. The components of the second tier include health, employment, property, family (in the sense of safety and security) and social stability; the third encompasses friendship, family (in the sense of love and belonging), and sense of connection. The categories of employment or property cannot be applied to the veterinary patients, however, health,

VETERINARY NURSING EDUCATION safety, sense of family, stability, and friendship while they are hospitalized must be a focus. Implementing the veterinarian’s treatment orders and following Kirby’s Rule of 20 help keep the patient’s physical health going in the right direction. Next up: Maslow’s third tier; safety, family and friendship.

Safety, Family and Friendship

How can veterinary team members help patients with their basic need for family, friendship, and safety, and help maintain their comfort and dignity? How does the team’s interaction with the pet’s family affect their relationship with each other?

Family Matters

A human study recently completed assessed what the most important aspects of ICU palliative care was to the people involved. They found that communication about the patient’s condition, treatment, and prognosis; patient-focused medical decision-making; clinical care of the patient to maintain comfort, dignity, personhood, and privacy; and care of the family were the top four priorities of patients and their families.10 The participants valued maximum family access to the patient and bereavement support for families of patients dying in the ICU. Another study geared toward the potential for more visitors creating a higher potential for sepsis among patients found that despite the higher environmental microbial contamination, having more liberal visiting hours in an ICU setting does not increase that potential, and may instead reduce cardiovascular complications through reduced stress or anxiety (which creates a more favorable hormonal profile).11

When I first started working in emergency medicine, it was common practice to whisk pets away from their owners to begin urgently needed medical interventions in the treatment area of the hospital. There were many times I could see the pet’s eyes searching for their people or anything else familiar. It was done this way because we did not want owners “getting in the way” or “preventing us” from doing what we had to do to stabilize our patient. We also thought we were protecting the owner from seeing things that could potentially make them uncomfortable, like drawing blood, placing IV catheters, or performing CPR. Years later, when I started working at an ‘open hospital’ (pets and owners go everywhere, together, in the hospital), I was intimidated by the potential for owners to scrutinize our every movement and statement, and worried that they may interfere with our abilities to provide nursing care to their pet. After working in an open hospital environment for the past few years, I now would have it no other way.

An ICU technician sits with and comforts a patient during down time. VETERINARY NURSING IN ACTION | AUG/SEPT 2017

VETERINARY NURSING EDUCATION

Despite those exceptions, it seems that pets often feel more secure and safe when they have a member of their pack, their family, with them in an unfamiliar place. By allowing an owner to stay with their pet if they so desire, they are able to make point of care decisions, which allows the team to act quickly in providing the patient with the medical interventions they need. Our patients may also be scared or confused by the change in their condition and environment, and seeing the person or people they trust nearby will help them remain calmer - which can help improve their prognosis in many situations. There are always those pets whose stress, anxiety, or aggression can be exacerbated by having their owner present. Surprisingly, those owners are often aware of this and will ask to remain in a separate area of the hospital while we stabilize their pet. If the owner does not seem aware of their negative impact on the pet’s behavior, there are ways to diplomatically inform them that they are exacerbating the situation. When it is not possible for a family member to be with their pet, encourage the owner to leave something familiar at the hospital. The AAFP and ISFM Feline Environmental Needs Guidelines encourages providing an item with a familiar scent such as the cat’s own bedding, or clothing that one of their people has worn, to help the cat feel more safe and secure in an unfamiliar environment.9 There are other ways to make patients feel more safe and secure. In addition to thorough nursing rounds that discuss the medical condition, behavioral preferences should be noted while working with the patient. Cage cards should display known patient preferences so that those unfamiliar with the pet can interact with them in a way that causes minimal stress. Noting if a patient responds better to men or women, if they are fearful of people wearing hats, if they have a pre-existing medical condition that requires the use of a harness on walks, if they are timid or fearful when approached from behind, etc. helps avoid putting the patient in situations that will

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cause unnecessary stress or discomfort. Dogs with mobility issues (arthritis, DJD, disc disease, muscle wasting, ataxia, etc.) may feel unsure about their footing on slick surfaces and therefore are too frightened to attempt walking through the hospital. Placing a non-slip surface under their bedding can help keep bedding in place as they get up from a resting position, and placing carpets in front of their kennel will help give them the confidence they need to get up and get moving. Spending down time, rare as it may be, with patients is another way to help make them feel safe. They will begin to learn that you are someone who provides comfort and company instead of associating you only as the person invading their personal space to take their temperature, administer medications, or draw their blood. Just sitting in the kennel with them can go a long way in developing trust in the relationship between patient and caregiver. By applying an anthropomorphic view of the patients’ state of mind, veterinary team members can be of great service on a mental and emotional level. Taking these parameters into consideration will help provide patients with the type of environment that contributes to a greater prognosis and outcome. By having familiar sights, scents, sounds, and people near them, patients will likely feel more safe and secure. As is true with humans, our veterinary patients are individuals and what works well for a large group of patients will not always be beneficial to certain individuals. Work closely with your patients, spend time with them and their family member(s), and you will intuitively pick up on the environmental cues that your patient responds most positively to. Ultimately, you will be able to guide their care in a way that not only benefits them medically, but mentally and emotionally as well.

References

1. Kirby’s Rule of 20 is a list of monitoring parameters that should be followed for critically ill patients. 2. Maslow’s Hierarchy of Needs uses a pyramid structure to prioritize physiologic through spiritual needs. The bottom three, and arguably the fourth tier, can easily be attributed to veterinary patients. 3. Jonathan Y. Gabor, Andrew B. Cooper, Shelley A. Crombach, et al. Contribution of the Intensive Care Environment to Sleep Disruption in Mechanically Ventilated Patients and Healthy Subjects. Am J Crit Care Med Vol 167. pp 708-715, 2003. DOI: 10.1164/rccm.2201090 4. Neil S. Freedman, Natalie Kotzer, and Richard J. Schwab. Patient Perception of Sleep Quality and Etiology of Sleep Disruption in the Intensive Care Unit. Am J Respir Crit Care Med Vol 159. pp 1155-1162, 1999 5. Florence R. Fischer, MS; Jean D. Peduzzi, PhD. Functional Recovery in Rats with Chronic Spinal Cord Injuries After Exposure to an Enriched Environment. The Journal of Spinal Cord Medicine Vol. 30, 2007 – Issue 2. pp 147-155 6. Walch JM, Rabin BS, DayR, et al. The Effect of Sunlight on Postoperative Analgesic Use: A Prospective Study of Patients Undergoing Spinal Surgery. Psychosom Med. 2005 Jan-Feb; 67(1): 156-63 7. Narda Robinson, DO, DVM. Music as Medicine: It Doesn’t Have to be Mozart. www.veterinarypracticenews.com. Published January 28, 2014. Accessed May 3, 2017. 8. Well, D. L., et al. The Influence of Auditory Stimulation on the Behavior of Dogs Housed in a Rescue Shelter. Animal Welfare 11 (2002): pp. 385-392 9. 2013 AAFP/ISFM Environmental Needs Guidelines. Journal of Feline Medicine and Surgery (2013) 15, 219-230 10. Judith E. Nelson, MD, JD, Kathleen A. Puntillo, RN, CNS, DNSc, FAAN, Peter J. Pronovost, MD, PhD, FCCM, et al. In their own words: Patients and families define high-quality palliative care in the intensive care unit. Crit Care Med. 2010 Mar; 38(3): 808-818 11. Stefano Fumagalli, Lorenzo Boncinelli, Antonella Lo Nostro, et al. Reduced Cardiocirculatory Complications With Unrestrictive Visiting Policy in an Intensive Care Unit, Results From a Pilot, Randomized Trial. Circulation. 2006; 113:946-952. Published February 20, 2006.

VETERINARY NURSING EDUCATION

Article Questions 1. What should you not do when hospitalizing feline patients?

4. Which of the following does not generally contribute to patient and client care?

a. House them in a quiet area of the hospital

a. Patient comfort

b. Make sure they can interact with other cats

b. ICU environment

c. Keep their litter box and food away from each other within their cage

c. Communication

d. Allow their owner to leave a familiar item with them 2. Which of the following can help reduce patient stress and therefore potentially contribute to a better outcome? a. Adjusting treatment times to minimize disruptions in their sleep b. Reducing the frequency of visits from their owners c. Taking them away from their owners to do treatments

d. Frequent invasive treatments 5. Under what circumstances should you ask an owner to leave while you are working with their pet? a. Anytime you need to do treatments on their pet b. If the patient’s condition changes and the veterinarian needs to reassess them c. If the patient seems more stressed and/or aggressive with the owner present d. As soon as the pet is brought in the hospital for an emergency

d. Playing music at a loud volume to drown out other noises 3. How can you help a dog with joint problems feel more comfortable walking through the hospital? a. Walk them less often b. Put non-slip surfaces under their bedding so it doesn’t slip as they stand up c. Use non-slip surfaces such as carpets on their path to get outside so they don’t slip on the floor d. Both B and C

CONTINUING EDUCATION

QUIZ ONLINE visit VetMedTeam.com and log in with your Vet Med Team Profile.

Robyn Baillif, RVT, VTS(ECC) Robyn currently works full time in a busy ICU at a 24-hour general and emergency practice. In 2016, she was certified as a Veterinary Technician Specialist in Emergency and Critical Care by AVECCT and currently serves on the Exam Committee. She has a passion for critical care nursing and for teaching, training, and mentoring other technicians and assistants to be the best caregivers they can be. In addition to her work in ECC, Robyn enjoys listening to music, reading, archery, and spending time with her husband and two dogs.

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTASTUDY CASE NEWS

LOSING YOUR BREATH... TO A POINT April Bays CVT, VTS (ECC)

A six-year-old M/N German Shorthaired Pointer mix named Hank was on a walk when he encountered a porcupine and was appropriately rejected and quilled. The quilling was severe and quills were deeply embedded in the tissues. The owner pulled many out himself along the neck and ventral thorax. At home Hank remained painful and lame and was brought to the Animal Emergency Center of Central Oregon for evaluation.

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Upon arrival he was tachycardic (HR: 148), eupneic, and normothermic. Hank was holding his left front leg somewhat abducted and was painful on manipulation of the limb with extension/flexion. All lung fields ausculted normally. He was given 0.2mg/kg hydromorphone IV for pain. Upon palpation of the ventral thorax, several buried quill ends were felt. Two small quills were successfully excised, but several quills buried deep in the tissue around the

pectoral muscles were unable to be localized. The DVM consulted with the owner, explained the risk of migration into thoracic structures, and presented the options of medical management or surgical exploration. Hank's owner chose to rest Hank and observe him at home. He was prescribed tramadol, carprofen and cephalexin. The following morning, more emerging quills in the pectoral and axillary spaces

NAVTA CASE STUDY NEWS

With Hankâ&#x20AC;&#x2122;s chest tube in place, April Bays, his veterinary technician, aspirates bloody fluid from the chest cavity.

were noticed by the owner and subsequently removed by his rDVM under sedation. According to the owner, two incisions were made, from which several quills were removed. Hank was discharged with gabapentin. That evening Hank was unable to get comfortable and had an elevated respiratory rate. He returned to the ER. The initial presentation to the Animal Emergency Center found Hank tachycardic (HR: 150bpm), tachypneic (RR: 68bpm), and anxious, with tacky mucous membranes, a CRT<2 sec, and normal synchronous pulses. While walking, he was unwilling to go more than a few steps, shifting his weight from thoracic limbs with a hunched back. Auscultation revealed slightly muffled heart sounds and reduced lung sounds ventrally. Triage included IVC placement, crystalloids at twice maintenance and hydromorphone administration, which was later exchanged for a fentanyl CRI at 4mcg/kg/hr. Thoracic radiographs revealed an interstitial pattern with a severe pneumothorax, suspect secondary to traumatic porcupine quill injury. A full blood panel revealed a slight neutrophilia, with chemistry and electrolytes WNL. Supplemental oxygen was provided. With a local block, a thoracocentesis was performed, which removed 1L of air from right side and 2.5L from the left. Later, a second thoracocentesis removed more than 3 liters from the pleural space in total, and the decision was made to place

Veterinary Assistant Stephanie Brooks runs a CT on Hank.

a chest tube. The chest tube was attached to an active suction unit and his respiratory status improved shortly after placement. His fentanyl CRI was increased to 6mcg/ kg/hr and his tachypnea (40-50bpm) corrected to 18bpm. Hank remained stable throughout the night and following day. He was maintained on fluid and oxygen therapy, his fentanyl CRI, bupivicaine infusions via chest tube for improved analgesia, antibiotics, and an antiemetic. Active suction was continued via a Thoravac unit.

A surgeon was consulted, who requested a CT. The CT performed that day revealed alveolar disease inappropriate for a patient with a chest tube. Furthermore, the patient was manually ventilated during CT, which should have re-expanded the lung, but the lung was not appropriately expanded. Therefore, concurrent abscess or necrosis was likely present, but no quills were identified. An exploratory thoracotomy was recommended and pursued for possible lung lobectomy.

aspect of the mediastinum, and thoracic inlet, and one from mid-sternum. No lung tissue required resection. Postoperatively, Hank recovered well without oxygen therapy, though he was still on the active suction unit. As he became increasingly alert, ptyalism and discomfort were noted when Hank attempted to swallow. The neck muscles intermittently contracted and he seemed extremely uncomfortable. A sedated oral exam revealed muscle spasms on palpation, an intact gag reflex, but no foreign body. Following the exam, he developed severe ptyalism with blood flecks. After changing his recumbency, the patient became acutely dyspneic, SpO2 dropped, and a hemothorax was discovered. Hank was quickly placed on a ventilator as complications continued, his HR and ECG remained erratic, and cyanosis developed. Upon investigation via ultrasound, the DVM found a multicavitated structure at the base of the heart within the pericardium with fibrin strands. The DVM consulted with the owners about her concern for a migrating quill traumatizing the heart. After long consideration, the owners chose to humanely euthanize. A post mortem necropsy was not performed.

The next day the surgeon successfully removed seven quills from the thoracic cavity; four were removed from the left cranial lobe, seven from the cranio-ventral VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTASTUDY CASE NEWS

Lily. Photo courtesy of Debbie Russell

HYPERNATREMIA FROM ACCIDENTAL INGESTION

OF A SCIENCE PROJECT Courtney Waxman, AAS, BAS, CVT

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CASE STUDY SIGNALMENT/HISTORY “Lily” is a 7 year old Golden Retriever (FS), weighing 31.3kg. She ingested a mixture of ½ cup salt, ½ cup flour, ½ cup decaffeinated coffee and 1 cup of sand around 9:30pm. The mixture was part of the owner’s child’s science project for school. The owner was confident about the time of ingestion as Lily was crated overnight. In the morning, the owner awoke to several piles of vomit within the crate and reported Lily having a staggering gait and being “shaky”.

Serum Sodium Levels Reference range: 145-152mmol/L 90 min post entry

6 hours post entry

12 hours post entry

18 hours post entry

191.8 mmol/L

182.2 mmol/L

173.3 mmol/L

161.9 mmol/L

Table 1: The progression of Lily's serum sodium levels over the first 24 hours of hospitalization. The drastic decrease in serum sodium levels were tolerated because of the acute nature of her hypernatremia.

INITIAL ASSESSMENT

On presentation, (10 hours after suspect ingestion), Lily was severely disoriented and delirious. She was hypothermic at 96.7oF, bradycardic at 80bpm, and eupneic at 40bpm. Her mucous membranes were pink and tacky with a CRT less than two seconds. Auscultation revealed normal heart rate/rhythm with no murmur appreciated. Her lungs ausculted clearly in all fields. An 18g IV cephalic catheter was placed and blood was collected for a venous blood gas (VBG). Doppler BP was obtained with a systolic reading of 90mmHg. A 15ml/kg bolus of IV crystalloids was given. The initial VBG revealed a severe hypernatremia, with sodium (Na+) of 190mmol/L (145-152mmol/L). PCV was 55% (37-50%) and TP was 9.0g/dL (4.8-7.6g/dL).

NURSING CARE

Over the first 24 hours of hospitalization, Lily’s sodium was measured four additional times (Table 1). Her vital signs normalized within four hours of admittance. Within eight hours, all lab work abnormalities (with the exception of Na+) had resolved and she was drinking an average of 100mls water every hour. Mentation was assessed using the modified Glasgow coma scale (MGCS): the patient was initially 14 and

progressively improved to 17 throughout her hospitalization period (Table 2). Within 36 hours, Lily was ambulating well and had normal mentation. My involvement in this case started shortly after presentation and through discharge. Nursing care I provided centered on critical monitoring of mentation, q2-4h vital signs, serial VBG analysis and interpretation, maintenance of triple lumen catheter, and ensuring access to free choice water. Additionally, I needed a general knowledge of the different types of hypernatremia (acute versus chronic), understanding the physiological processes of both, and what the different treatment and management concerns are.

FINAL OUTCOME

Lily was discharged with a normal sodium of 148.5mmol/L (145-152mmol/L) after 48 hours in the ICU. Three days after discharge, her sodium was within normal range as assessed at her regular veterinarian.

DISCUSSION

In dogs, hypernatremia is defined as a serum sodium level of greater than 155mmol/L (145-152mmol/L), with clinical signs being observed at greater than

170mmol/L. Increased sodium levels can result in serious clinical consequences, including other electrolyte abnormalities, cerebral dehydration, cerebral edema, and ultimately death. The most vulnerable body system affected by changes in sodium levels is the central nervous system, specifically the brain. The brain cell response to hypernatremia is critical; as sodium moves out of brain cells and into the intravascular space, it leaves the brain cells dehydrated and at risk for hemorrhage and lysis. It is important to differentiate chronic hypernatremia from acute hypernatremia, as this changes how a case is managed. Chronic hypernatremia is generally accepted as a rise in sodium over more than 24 hours, whereas acute hypernatremia is a rise in sodium over 12-24 hours. With chronic hypernatremia, sodium levels rise more gradually, giving the brain time to adapt to sodium shifts. The brain does this by creating idiogenic osmoles intracellularly, which act as “sodium substitutes” and prevent intracellular dehydration of the brain. Chronic hypernatremia needs to be treated with a more conscientious selection of sodium-containing crystalloids, because rapid, drastic changes in serum sodium levels could cause cerebral edema. With acute hypernatremia, sodium

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

CASE STUDY levels rise very acutely and rapidly, and therefore the brain has no time to develop these idiogenic osmoles. As such, acute hypernatremia can be treated more loosely (meaning any sodium-containing crystalloid is acceptable so long as it has a lower sodium content than the blood), as the brain will tolerate a more rapid decline of serum sodium levels. Regardless of the

type of hypernatremia, prompt and aggressive medical treatment is required to avoid irreversible CNS injury. This case was interesting in that the animal became an extreme example of the consequences of withholding water and became instructive to the staff about the importance of providing water to patients

when it is not contraindicated. This lesson can also be applied to client education. It is important to provide water, especially when crating animals, in order to help animals maintain their physiologic water balance, preventing dehydration and other deleterious effects of water deprivation.

Modified Glasgow Coma Scale

Motor Activity

Brainstem Reflexes

Level of Consciousness

Normal gait, normal spinal reflexes

Hemiparesis, tetraparesis, or decerebrate rigidity

Recumbent, intermittent extensor rigidity

Recumbent, constant extensor rigidity

Recumbent, constant extensor rigidity with opisthotonus

Recumbent, hypotonia of muscles, depressed or absent reflexes

Normal PLR and oculocephalic reflexes

Slow PLR and normal to reduced oculocephalic reflexes

Bilateral unresponsive miosis with normal to reduced oculocephalic reflexes

Pinpoint pupils with reduced to absent oculocephalic reflexes

Unilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes

Bilateral, unresponsive mydriasis with reduced to absent oculocephalic reflexes

Occasional periods of alertness and responsive to environment

Depression or delirium, capable of responding but response may be inappropriate

Semicomatose, responsive to visual stimuli

Semicomatose, responsive to auditory stimuli

Semicomatose, responsive only to repeated noxious stimuli

Comatose, unresponsive to repeated noxious stimuli

MGCS Score

SCORE

3-8

grave

9-14

gaurded

15-18

grave

Table 2: Depiction of the Modified Glasgow Coma Scale (MGCS) scoring system. The MGCS is an objective way to assess dogs suffering from traumatic brain injury. The score is a useful way to monitor progression of neurological status and assess overall prognosis.

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CASE STUDY

PROVEN REDUCTION IN KEY ORAL HEALTH INDICATORS1*

HALITOSIS

PLAQUE

CALCULUS

53% 42% 54%

Block plaque, calculus, and halitosis with the science of prevention OraVet® Dental Hygiene Chews combat plaque, calculus, and halitosis where they start—bacterial biofilms. The mechanism of action is simple but effective: Each daily chew releases delmopinol hydrochloride to create a barrier that prevents bacterial attachment.2,3 When bacteria can’t attach, they can’t produce plaque biofilms or the volatile sulfur compounds of halitosis. And the scrubbing action of the chew works in parallel to effectively remove plaque and calculus.

Science You Can Believe In

For more information, contact your sales representative or visit OraVet.com

• Novel mechanism of action

Delmopinol • Delmopinol has been extensively tested in human and animal trials • Proven technology originally developed for a human oral rinse OraVet Dental Hygiene Chews • Efficacy demonstrated in multiple canine trials • Exceptional halitosis control1 • Highly palatable1

*Compared with dry diet alone. References: 1. Data on file. 2. Steinberg D, Beeman D, Bowen W. The effect of delmopinol on glucosyltransferase adsorbed on to saliva-coated hydroxyapatite. Archs Oral Biol. 1992;37:33-38. 3. Vassilakos N, Arnebrant T, Rundegren J. In vitro interactions of delmopinol hydrochloride with salivary films adsorbed at solid/liquid interfaces. Caries Res. 1993;27:176-182.

®ORAVET and SERIOUS ORAL CARE MADE SIMPLE are registered trademarks of Merial. All other trademarks are the property of their respective owners. Merial is now part of Boehringer Ingelheim. ©2017 Merial, Inc. Duluth, GA. All rights reserved. OVC15TRADEAD-R (07/17).

• Available through veterinarians

CASE STUDY

AN ETHICAL

DILEMMA

Tammy Y. McCarty, LVT, CVT, VTS(ECC)

Junior stopped breathing due to laryngeal swelling he developed 8 hours after surgery. I placed an endotracheal tube to establish an airway and he was able to breathe on his own. Junior had a do not resuscitate (DNR) code status. Should I have intubated him? I believe in his case I should have, but others did not think so. Therefore, I am proposing a broader defined resuscitation code status protocol to be used in veterinary medicine. Junior was an 11 year old, MN, Labrador Retriever, who weighed 48kg. Junior was diagnosed with a squamous cell carcinoma in his left nare. He had staging that showed no metastasis and a computed tomography scan that revealed a nasal planectomy would be curative. After an extensive consultation, Junior’s owners decided to go forward with surgery. The surgery was uneventful. During recovery he suffered from periods of anxiety that were managed with acepromazine, trazodone and adjusting his morphine, lidocaine and ketamine continuous rate infusion (CRI). That evening his respiratory rate and effort increased. He developed stridorous airway noise which is a high pitched sound associated with disease of the larynx or trachea . His body temperature rose to 105o Fahrenheit. While I was discussing a treatment plan with the doctor on duty, he stretched and stopped breathing. I intubated him. I could not see his larynx due to significant swelling and had to intubate him by digital palpation. He began to breathe on his own. He was administered dexamethasone SP for swelling, put on a dexmedetomidine CRI for sedation and placed in our oxygen cage for oxygen and cooling measures. He stabilized quickly. 56

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What went wrong?

Inflammation led to an upper airway dysfunction similar to brachycephalic syndrome. When he would breathe, he had to overcome the reduction in the diameter of his airway, which required a lot of energy. This turbulent airflow caused further edema leading to soft tissue that collapsed on itself during the force of breathing, causing the airway obstruction. A concern with airway obstruction is hyperthermia. Respiration (which he was not able to do effectively) is the primary method of thermal regulation in dogs. Large breeds, obesity, and brachycephalics are prone to inadequate heat dissipation1. This led to increased oxygen demands. It takes 3% of the oxygen taken in during inspiration to fuel the muscles responsible for inhalation. In respiratory distress, it increases to 30%, leading to respiratory muscle fatigue and ultimately failure. He needed time, an anti-inflammatory, sedation, a cool environment and oxygen. Junior, a DNR that had needed to be intubated, was discharged from the hospital and lived for the next 3 years. What do we do if a DNR is overdosed or has an allergic reaction to a medication, or is having a post operative complication?

Current Code Statuses

• DNR – Do Not Resuscitate is an order to withhold cardiopulmonary resuscitation in respect of the wishes of the owner in case their pet’s heart was to stop or it was to stop breathing .

Figure 1: Junior, before his surgery.

CASE STUDY • CPR- Cardiopulmonary Resuscitation includes basic life support and advanced cardiac life support. These codes are straight forward but do not address all of the owner’s wishes. An improved code status protocol that I am proposing is to eliminate the term DNR. Do not resuscitate focuses on what we are not doing for patients. Allow Natural Death (AND) is a term used in human code status protocols. This focuses on what we are doing for patients; we are allowing them a natural death. The following symbols and letters used in conjunction with CPR and AND provide us greater understanding of the wishes of the owner.

CPR

• O allows open chest CPR • A allows advanced cardiac life support We should encourage pet owners to have advanced directives and hospitals to have them on file so the owner’s wishes are known before an emergency happens. Veterinary protocols are always evolving because of patients like Junior. This new protocol that I am proposing gives clarity to our roles whether we are saving a life or allowing a pet to die a natural death with dignity.

1. Costello, Merilee F. “Upper Airway Disease” Small Animal Critical Care Medicine. Ed Deborah C. Silverstein and Kate Hopper. Saunders, 2009

AND

• - do not euthanize

3. Wikipedia. Do Not Resuscitate. https://en.wikipedia. org/wiki/Do_not_resuscitate. Modified 14 March 2017. Accessed August 2016

• A allows CPR only if an allergic reaction or anesthesia is the cause • D allows CPR at the Doctors discretion. It was a recurring theme during my interviews that owners want to trust the doctor to do what is best for their pet.

COMPRESSIONS

• • • • • •

BREATHING

Figure 2: Junior, three years after

4. Fletcher D, Boller M. Recover Inititiative. ACVECC RECOVER www.acvecc-recover.org. Accessed July 10, 2017. 5. Joseph L Breault, MD. The Ochsner Journal. www.ncbi. nlm.nih.gov/pmc/articles/PMC3241061. Winter 2011; 11(4): 302–306. Accessed August 2016

Lateral recumbancy or ventral for barrel shaped dogs 120 per minute (regardless of size) depth of 1/3 to 1/2 chest allow full recoil of chest cardiac pump(cats, small or keel chested dogs)vs thoracic pump rotate compressor every 2 minutes to reduce fatigue

• Establish an airway: intubate/tracheosostomy • mouth to snout

AND +

euthansia

NO euthanasia

CPR O

open chest

advanced life support

AIRWAY

left nare.

References

2. Hackett, Timothy B. “Tachypnea and Hypoxemia.” Small Animal Critical Care Medicine. Ed Deborah C. Silverstein and Kate Hopper. Saunders, 2009

• + allows euthanasia to alleviate any suffering that may occur with a natural death

Figure 2: Squamous cell carcinoma visible in Junior’s

CPR if cause is allergic reaction or anesthesia related

• Intubated: 10 breaths per minute simultaneoulsy with compressions • mouth to snout: 2 breaths rotate with 30 chest compressions

CPR at Doctors discretion

Please visit www.veccs.org/recover-cpr or www.acvecc-recover.org for in-depth RECOVER Initiative CPR guidelines. VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA

Submit Your Case Report Today!

Technician Case Report Presentations At the 2018 WVC Conference

Had an interesting case recently that you’d like to share? Wondering if you would enjoy public speaking? Or want to begin lecturing? Submit a case report for consideration using the guidelines listed below. If your case is selected you will present your case to an audience of your fellow technicians and a panel of judges. The judges will offer invaluable oral critiques of all presentations! There’s no better way to improve your lecturing skills! Technicians selected to present case reports will receive a complementary conference registration.

Case Report Presentations Guidelines • Credentialed veterinary technicians, with limited lecturing experience, are eligible.

Authors of selected cases will present their case report at the March 2018 WVC Conference.

• Cases from any veterinary discipline may be submitted for consideration.

Presentations should follow a format similar to the written case report submitted.

• Authors of all case report must have

15 minutes will be allowed for each presentation with an additional 5 minutes allotted for questions from the audience and judges. followed by a constructive oral critique from each of the judges. What an awesome learning opportunity!

• a licensed DVM or VTS to determine the initial quality of the case report being submitted. Case report submissions should be 1 to 2 pages in length and be constructed as follows: 1. Title 2. Introduction 3. Signalment 4. Presenting complaint 5. Initial assessment 7. Treatment plan including your role in patient care 8. Key nursing care points 9. Final Outcome 10. Conclusion

An award will be given for the overall best presentation. Criteria for evaluation of the case reports presented will include: • Presentation quality • Case quality • Ability to present the case within the allowed timeframe • Ability to answer questions

SUBMISSION DEADLINE NOVEMBER 1, 2017

CASE REPORT SUBMISSIONS ARE NOW BEING ACCEPTED. Please email your submission to:

navtacasereports@gmail.com, include your name, address, phone number and email address.

SPACE IS LIMITED SUBMIT YOUR CASE TODAY!

NAVTA NEWS

THROUGH THE EYES OF

VETERINARY TECHNICIAN

LEADERS

Amanda Blankenship, LVT takes a few moments out of her day to interview some of the prominent veterinary technician leaders that are taking strides every day to make a difference in a life—whether that be a patient, a fellow technician, or association. These leaders are passionate about Veterinary Technology/Nursing; read on as Amanda explores what drives them to do their best every day. teaching clinics. There is an elevated level of respect for RVTs that, I’m sad to say, didn’t exist with much of the aging generation of veterinarians.

Nicki Castanga, RVT Current President of the Maryland Veterinary Technician Association and Research Specialist II at Johns Hopkins University in Baltimore, MD.

Where do you see the veterinary technician profession going in the future? What are some things you would like to see happen? “I’m still in awe of how far our profession has come from 25 years ago! I am starting to see general practices in Maryland employ RVTs where 10+ years ago that was a “fluke” to see an RVT outside of specialty medicine, industry, teaching, etc. I think we are heading in the direction of every practice employing RVTs, especially with this new generation of veterinarians who are guided and taught by many RVTs now working in university

I would love to see us go to a single, national credential and for us to secure our title of veterinary technician or nurse. It is long overdue and we work so hard through schooling and testing for that title. I’d love to see every practice use RVTs to their fullest potential. We can do everything but diagnose, surgery, and prescribe in Maryland. If every practice uses their RVTs up to this level, then I think it will pay off financially for the practice and build a stronger relationship with clients”.

What do you find to be the biggest challenge within your state association? “We incorporated MDVTA in MD this past December and began our charter membership year at the beginning of this month. Our #1 challenge is our budget at this stage. We were so fortunate to have had two practices sponsor us and give us some startup funds, thanks to the work of two of our board members. This allowed us to afford the cost of applying for 501(c)(6) status with the IRS, and allowed us to mail announcement letters to every practice in the state along with a copy of our application form. This also allowed us to order a banner to use during trade shows and public outreach events, and order other pertinent printable items with our logo. Prior to this, many of us charter board members were paying out of pocket with our own money for things like renting

a post office box, paying for the articles of incorporation fees to file with the state of MD, previous printable items, etc. Another challenge is the mentality we’ve already encountered of the “wait and see if they are successful” by both veterinarians and technicians.

In addition, the other challenge is building up our membership base (and hopefully retaining those members) and rallying members to actively get involved with association projects, committees, etc. I would love to have any tips or advice from other state associations on being successful in this area!

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA NAVTA NEWS

2018 CALL FOR

NOMINATIONS WE’RE EAGER TO

Call for:

HEAR FROM

YOU!

• SCNATVA of the year • ADVISOR of the year • VETERINARY TECHNICIAN of the year Make your voice heard! Let us know who you think should be recognized.

Nominations are due Oct. 1, 2017

For more information visit:

www.navta.net 60

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NAVTA NEWS

MISSION RABIES

Brief Media Concludes Second Vaccine Drive in Malawi with Mission 34 078 137 635 80 Rabies Publisher of Veterinary Team Brief, Brief Media has partnered with Mission Rabies (missionrabies.com) for a second year to help conduct the Mega Vaccine Drive in Malawi, Africa, a country notorious for its high incidence of child rabies deaths. Via annual vaccine drives, Mission Rabies aims to save human and animal lives by vaccinating at least 70% of the canine population in rabies-endemic areas—such as Malawi—to eliminate rabies at the source.

VACCINATED

EDUCATED

WALKED APPROXIMATELY

DOGS (EXCEEDING THE GOAL OF 30 000)

CHILDREN ABOUT RABIES AT 53 SCHOOLS

MILES (130 KILOMETERS)

Twelve Brief Media participants—including 10 volunteers— took part in a 2-week block of the 4-week vaccine drive. While in Malawi, they held rabies vaccination clinics, educated the public about the dangers of rabies, and traveled door-to-door to deliver rabies vaccinations. Brief Media volunteers were sponsored by Merial, now part of Boehringer Ingelheim. n See more photos and read a personal account of the team’s experience in Malawi at cliniciansbrief.com/mission-rabies

Originally published in Veterinary Team Brief VETERINARY NURSING IN ACTION | AUG/SEPT 2017

NAVTA BENEFITS As a NAVTA member you receive: • The NAVTA Journal and NAVTA e-newsletter

• 20% discount from PetPlan Pet Insurance

• 20% membership discount if you are a specialist or member of your state association

• Discounts with Embrace Pet Insurance

• 10% discount on VetMedTeam.com courses!

• Complimentary membership with VetCheck—the amazingly simply veterinary communications software!

• 10% off Puppy Start Right for Instructors Course, hosted by the Karen Pryor Academy

• 50% discount on annual memberships with TrustedHousesitters

• 5% discount on Disability Insurance through VetInsure

• Access to NAVTA Social Link— allowing networking and engagement with other members!

• 20% discount on Vetlexicon, the worlds largest online clinical reference source, provided by Vetstream. In addition, NAVTA members can receive a free, 30 day trial! • 20% off FearFree Certiﬁcation

• $5 off David Liss offerings

• Access the NAVTA Career Center— allowing you to post resumes and look for jobs across the nation! • Watch for more EXCITING opportunities and beneﬁts to come in 2017!

PROFESSIONAL PULSE

INTERESTED IN PURSUING A

SPECIALTY IN BEHAVIOR? Your Path to Helping More Patients Starts Here

Although most people who have experienced such a trauma wouldn’t ever want to go near a dog again, Tara instead used it as a driving force behind her career. “I wanted to know why he did it,” she says. “That was the question that fueled my passion for behavior.” She first had to work through her fear of dogs, which took a few years, but she now donates her time to educate people of all ages about animal safety to try to prevent anything like that from happening to someone else. Rather than avoiding animals after her traumatic experience, Tara used the attack as motivation to learn all she could about animal behavior.

Advocating for Pets With Behavioral Issues When Tara Fisher was 11 years old, she suffered an incident that would have turned many people away from a career working closely with animals. Instead, the experience only made her want to help pets—and the people who love them—even more. Tara sat on the back porch eating a snack each day after school, often with her dog Benny by her side. One day, she was outside sitting by herself when she dropped part of her snack. As she reached for it, Benny appeared out of nowhere and bit her hand. Two weeks later, the dog severely attacked her, “He bit me repeatedly and severed my upper lip in half from the nose down. He released and then came back attacking the right side of my face, and then my right hand. I was rushed into surgery and the next thing I remember is waking up to a face I didn’t recognize with over 155 stitches.” Tara’s first question was, “What happened to Benny?” Her parents had had the dog euthanized, which devastated her. Her family was stunned by the reaction; but Tara believed something had to be really wrong with Benny for him to do something like that. “I truly didn’t blame him”.

Today, Tara works as a Registered Veterinary Technician (RVT) at Tipp City Veterinary Hospital in Tipp City, Ohio, specializing in behavior modification and obedience training. Not only is she a Certified Professional Dog Trainer-Knowledge Assessed (CPDT-KA), a Fear Free Certified professional, and a Canine Good Citizen evaluator for the American Kennel Club, she has been accepted into the Karen Pryor Academy (KPA) Dog Trainer Professional program and was recently awarded the Faith Scholarship. She has also been working toward her Veterinary Technician Specialist (VTS) credential in behavior. At the practice, Tara is the technician everyone turns to for in-home and in-clinic consults for behavior modification. She's there to encourage owners to get their pets the help they need and to do whatever it takes to make their vet visit a positive one. She says that including behavior when talking with owners doesn’t have to be overwhelming or overly complicated. She prefers a more subtle and relatable approach, such as handing clients a checklist to fill out, rather than asking pointed questions. “It’s up to the owner to move forward,” she says, “because he or she has to be ready and willing to make the changes. Modifying behavior takes time and dedication.”

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

PROFESSIONAL PULSE

Alleviating Signs of Noise Aversion

As the practice’s behavior champion, Tara identifies patients that might have noise aversion (fear and anxiety associated with noise). If untreated, noise aversion can progress to the point where the dog can damage property, try to escape, or self-traumatize. Many owners unfortunately think this is normal behavior or fail to realize the physiological and emotional toll that their dog is going through. Some owners may feel responsible for their dog having the condition. Once a veterinarian has made a diagnosis, Tara helps educate clients about noise aversion. She says that there’s a fine line between offending someone and asserting yourself in a way that can help the pet. During a recent client interaction, Tara recalls, “I could tell that if I pushed, the client would walk away. So I said, ‘Here’s some information. If you’re interested, there are some things we can do to help make your dog calmer and more comfortable during a storm.’ He called back the next week.”

Getting Started in Behavior

You don’t need to have experienced a life-altering event to become a Veterinary Technician Specialist in Behavior. NAVTA has partnered with Zoetis to develop and produce two new continuing education (CE) courses for veterinary technicians 64

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who are interested in learning more about noise aversion in dogs. These courses, Noise Aversion 101 and Noise Aversion: The Veterinary Nurse’s Role, will provide information about triggers and signs of noise aversion so participants can help identify and suggest earlier intervention in patients that may be suffering from this serious medical condition. Zoetis has also created several easy-to-use tools for clinic staff, including a checklist to help initiate the noise aversion conversation with pet owners and a discussion guide to walk you through the follow-up conversation. The goal behind these new CE courses and tools is to help veterinary technicians initiate and feel more confident during noise aversion conversations with clients. So whether you’re interested in looking into behavior as a specialty or just want to learn how to help more patients, we’re happy to bring you some great options to advance your skills and knowledge.

Visit www.ce.navta.net to sign up for the CE courses and download the toolbox.

PROFESSIONAL PULSE

noise aversion MODULE 01

MODULE

101

with Julie Shaw, KPA-CTP, RVT, VTS (Behavior)

Breaking the Sound Barrier: How You Can Play a Crucial Role in Helping Dogs With Noise Aversion At least one-third of dogs in the United States suffer from noise aversion,1 and 40% of those dogs do not receive any treatment.2 “Veterinary technicians are playing a crucial role in correcting that situation,” says Sharon L. Campbell, DVM, MS, DACVIM, Medical Lead for Analgesia, Sedation, and Anesthesia in the Veterinary Specialty Operations division at Zoetis. “I’ve always considered technicians to be the backbone of a well-functioning practice, and that’s most evident when it comes to behavioral issues.”

Canine noise aversion is an animal welfare issue that impacts the human-animal bond. Many of the previous treatment options have a limited effect or are ineffective. Dr. Campbell says SILEO® (dexmedetomidine oromucosal gel), as the only FDA approved treatment for noise aversion, fills that void. For dogs suffering from noise aversion, SILEO reduces the dog’s distress and, subsequently, the pet owner’s stress, helping to preserve that bond. Dr. Campbell points out that veterinary technicians are often in charge of getting an initial history and taking patient observations, which is why technicians are in a perfect position to identify dogs

with noise aversion and may require treatment. Tara agrees. When Zoetis introduced SILEO, she saw this unique medication as a way to relieve the signs of noise aversion in these dogs and help them become more well-rounded and happy. SILEO is calming without sedating, so the dog remains fully functional and able to interact normally with the family. “By initiating and monitoring treatment, technicians can help dogs with noise aversion have a better quality of life,” Dr. Campbell says. “They are helping pet owners that might not have realized their dog was suffering or who thought they would have to live with this condition. They are restoring the human-animal bond, preventing relinquishment or euthanasia and, in the process, are gaining pet owners’ appreciation, trust, and loyalty to the practice.”

References

1. FR Market Research—Noise Aversion; N=472 dog owners, N=454 general practitioners, February 2016. 2. Based on an online survey conducted by Harris Poll on behalf of Zoetis in November 2013 among 784 dog owners.

Next Steps

Tara says the process of pursuing her VTS in behavior has been challenging but rewarding. For technicians who are thinking about specializing in behavior medicine, she admits that it’s easy to get overwhelmed by all the work required. “There’s no one telling you what to do, so self-motivation and initiative is an important trait to be successful in this field. Tara suggests joining the Society of Veterinary Behavior Technicians (SVBT) for support and community feedback. In addition, she attends behavior seminars and conferences for continuing education each year. “Don’t be afraid to ask questions. No matter how much knowledge we have, there is always something new to learn.” A VTS in behavior is not required to be a leader in the clinic. With enough passion, and initiative to learn, technicians have the ability to make a difference in pets’ and pet parents’ lives.

VETERINARY NURSING IN ACTION | AUG/SEPT 2017

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