SPRING 2019 Volume 2, Number 2 todaysveterinarynurse.com

22 PRACTICE SKILLS WITH SIMULATED TRAINING

26 WHAT NURSES NEED TO KNOW ABOUT ILLICIT DRUGS

78 MAKING A DIFFERENCE: VOLUNTEERING ON RESERVATIONS An Official Journal of the NAVC

Leading Change, Advancing Health Redefine and Promote the Profession P 8 for Geriatric Patients P 38 Guide to Managing Toxin Ingestion P 58

SPRING 2019 VOLUME 2, NUMBER 2

An Official Journal of the NAVC● todaysveterinarynurse.com

An official journal of the Laura C.S. Walker Editor in Chief Chief Media & Sales Officer Kara M. Burns Chris Kelly Group Publisher MS, MEd, LVT, VTS (Nutrition), Jackie D’Antonio Vice President, Media VTS-H (Internal , Strategy & Operations An official journal of the North Dentistry) Meghan R. Golden Vice President, American Veterinary Community, [email protected] Today’s Veterinary Nurse is the Partnerships & International Relations trusted source for peer-reviewed clinical information in small animal EDITORIAL veterinary medicine. Our goal is to Editorial Advisory Board enhance knowledge and encourage Patricia Wuest Editorial Director confidence, inspiring the highest Brenda K. Feller, Elizabeth Fleener Art Director quality of veterinary care. As an NAVC LVT, CVT, VTS (Anesthesia) Michelle Doster Production Editor publication, our audience has access Animal Specialty Hospital of to world-class continuing professional Florida, Naples, Florida development developed for the global SALES veterinary health care community. Doreen Carpenter Associate Publisher Subscriptions (only): 630.739.0900, Jeanne R. Perrone, Allyson Archambault CDS/Today’s Veterinary Nurse Senior Account Executive 440 Quadrangle Drive, Suite E, Bolingbrook, CVT, VTS (Dentistry) IL 60440. Email subscription form to VT Dental Training, Chelsea Elbert Senior Account Executive [email protected] or fax to Plant City, Florida 630.739.9700 Paige Ellington Account Executive Free subscriptions only to qualifying Mary Hannah Sperry Campaign Manager subscribers.* For a new subscription, confirmation, or renewal, please visit Heidi Reuss-Lamky, LVT, VTS Angelina Varagona Campaign Manager todaysveterinarynurse.com to fill out an online form. For updates, please include your (Anesthesia and Analgesia, ) subscription ID from label. To have a form Oakland Veterinary Referral Services, CIRCULATION emailed or faxed to you, please contact us at Bloomfield Hills, Michigan Mark Rosen NPS Media Group our 800 number or email above and provide email or fax number. Change Name/Address or Cancel: NAVC Board of Directors Please use online form at Kathi L. Smith, todaysveterinarynurse.com President or contact us by phone, fax, or email RVT, VTS (Oncology) Cheryl Good, DVM Portland Veterinary Specialists [email protected]. Please provide Immediate Past President the ID number (directly above your name Portland, Maine on label) for positive identification. If the ID K. Leann Kuebelbeck, DVM, DACVS number is not available or legible, provide President-Elect name and address as it appears on the label Paige Allen, MS, RVT to allow identification of the subscription. Kenichiro Yagi, Vice President *Qualifying Subscribers: veterinary nurses, veterinary technicians, veterinary assistants, MS, RVT, VTS (ECC, SAIM) Harold Davis, Jr, BA, RVT, VTS (Emergency veterinary technician students, and other Adobe Animal Hospital & Critical Care) (Anesthesia & Analgesia) members of the veterinary health care team San Jose, California Treasurer in the United States. Eastern States Veterinary Association, Inc (NAVC) reserves the right to Laurel Kaddatz, DVM determine eligibility for a free subscription. Directors WARRANTIES, LIMITATIONS. Except as expressly Ann Wortinger, BIS, LVT, Sally Haddock, DVM set forth herein, Eastern States Veterinary VTS (ECC, SAIM, Nutrition) Association, Inc (NAVC) makes no warranties Karen Kline, DVM, MS, DACVIM whatsoever, express, implied, or statutory. NAVC 4 Cats Consulting (Neurology), CVA specifically disclaims any implied warranty of Belleville, Michigan merchantability or fitness for a particular purpose. Bob Lester, DVM In no event will NAVC be liable to you or any third Mark Russak, DVM party for any indirect, punitive, special, incidental, or consequential damages (including loss of profits, use, data, or other economic advantage), however it arises, even if NAVC has previously been advised of the possibility of such damage. All rights reserved. No part of this publication may be reproduced in any form without written permission from the publisher. Entire contents ©2018 Eastern States Veterinary Association, Inc (NAVC). SPRING 2019

EDITOR’S LETTER 5 Honoring the Best Kara M. Burns, MS, MEd, LVT, VTS (Nutrition), VTS-H (Internal Medicine, 8 NAVTA CORNER Dentistry), Editor in Chief, 56 ADVERTISER INDEX Director of Veterinary Nursing

26 VITAL SIGNS

TRENDS IN VETERINARY NURSING Illicit Drugs: What Veterinary Nurses Need to Know Erin Freed, CVT, BAS, ASPCA Animal Poison Control Center, Urbana, IL The exposure of animals to marijuana, amphetamines, cocaine, heroin, and hallucinogenic mushrooms as the result of inadvertent or intentional action can result in serious consequences. Veterinary nurses play a critical role in educating clients about the dangers.

NUTRITION NOTES 14 Behind the Hype: Prebiotics and Probiotics for Dogs and Cats Ann Wortinger, BIS, LVT, VTS (ECC, SAIM, Nutrition), FFCP, 4 Cats Consulting, Belleville, MI

EXAM ROOM FROM THE FIELD 22 Simulation Training: 34 The Importance Just Like the Real Thing of Veterinary Maggie Monza, LVT, Oradell Technicians Animal Hospital, Paramus, NJ Abbie Hathaway, CVT, Program Harriet Terodemos, MS, CVT, Bergen Manager, Veterinary Technician Community College, Paramus, NJ Training, Banfield Pet Hospital

Today’s Veterinary Nurse (ISSN 2575-8365 print and ISSN 2575-8373 online) does not, by publication of ads, express endorsement or verify the accuracy and effectiveness of the products and claims contained therein. The publisher, Eastern States Veterinary Association, Inc (NAVC), disclaims any liability for any damages resulting from the use of any product advertised herein and suggests that readers fully investigate the products and claims prior to purchasing. The opinions stated in this publication are those of the respective authors and do not necessarily represent the opinions of the NAVC nor its Editorial Advisory Board. NAVC does not guarantee nor make any other representation that the material contained in articles herein is valid, reliable, or accurate; nor does the NAVC assume any responsibility for injury or death arising from any use, or misuse, of same. There is no implication that the material published herein represents the best or only procedure for a particular condition. It is the responsibility of the reader to verify the accuracy and applicability of any information presented and to adapt as new data becomes publicly available. Today’s Veterinary Nurse (ISSN 2575-8365; print version) is published quarterly (Spring, Summer, Fall, Winter; 4x per year) by NAVC, 622 E Washington St, Suite 300, Orlando, FL 32801. Periodicals postage paid at Orlando, FL 32801 and additional mailing offices. POSTMASTER: Send address corrections to CDS/Today’s Veterinary Nurse, 440 Quadrangle Drive, Ste E, Bolingbrook, IL 60440.

To read this issue online, visit 2 • SPRING 2019 • todaysveterinarynurse.com todaysveterinarynurse.com Reliable Solutions for Veterinarians

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CONTINUING EDUCATION Anesthesia for Geriatric Patients Trish Farry, CVN, AVN, VTS (ECC, Anesthesia and Analgesia), TAA GCHEd, School of Veterinary Science at The University of Queensland, Australia Wendy Goodwin, BVSc, PhD, FANZCVS (Veterinary Anesthesia, Critical Care), School of Veterinary Science at The University of Queensland, Australia The anesthetic plan for a geriatric dog or cat should be tailored to the individual patient. It should take into account the results of a thorough physical examination and medical history, as well as incorporate surgical or procedural planning; anesthesia technique, including support and emergency drugs; physiologic ; and anesthesia recovery.

CASE REPORT: CANINE TOXICOLOGY PRACTICE 52 DIGIT OSTEOSARCOMA 58 Guide to 66 MANAGEMENT An Uncommon Managing Toxin Happy Visits and Malignancy Results Ingestion Victory Visits: Helping in a Dog’s Toe Courtney Waxman, Patients Be Fear Free℠ BAS, CVT, RVT, VTS Amputation (ECC), Monique Feyrecilde, BA, LVT, VTS (Behavior), Teaching Stephani Hrabnicky, LVT, Purdue University, West Lafayette, IN Animals, Mercer Island Veterinary BluePearl Veterinary Partners, Clinic, Mercer Island, WA Southfield, MI

78 EXTRA MILE

WHAT MOVES YOU Changing Animal Welfare on Native Reservations Erin A. Spencer, MEd, CVT, VTS (ECC), Assistant Professor, University of Massachusetts Amherst Rural Area Veterinary Services (RAVS) is a service program that provides free veterinary care to underserved, remote communities located in Native American reservations throughout the western United States. It is an experience that just might change your life.

ON THE COVER CAREER CHALLENGES FINAL THOUGHTS The care provided 74 You’ve Been 82 Burnout in by veterinary nurses can Promoted! Veterinary make a dramatic Now What? Nursing difference in a Heather Prendergast, RVT, Emily Fullerton, RVT, VTS patient’s health CVPM, SPHR, Education (Oncology), and well- Development Specialist, Salt Lake City, UT being. Photo: Patterson Veterinary, shutterstock.com/ Las Cruces, NM Anna Hoychuk

To read this issue online, visit 4 • SPRING 2019 • todaysveterinarynurse.com todaysveterinarynurse.com I’d love to hear from you! Write me at [email protected]. EDITOR’S LETTER

Honoring the Best

hat does leadership look like in a veterinary healthcare setting? I believe that every individual on the team has the potential to be a leader, and on the best teams, every individual is a leader. When you are part of a team, leadership can be defined as hWelping one another to be best. Helping one another strengthens the entire hospital. Stronger hospitals provide better-quality medicine. Every one of us, at some point in our careers, has had help from a “leader”—a teacher, a parent, a coach, a friend, maybe even a random stranger. This guidance is empowering and helps mold us into stronger, more confident individuals, who, in turn, strive Kara M. Burns, to make a difference in someone else’s life. MS, MEd, LVT, VTS (Nutrition), VTS-H (Internal Medicine, Dentistry) The late Dr. Earl H. Rippie, Jr., a former president and secretary-treasurer of Editor in Chief the NAVC, recognized the value veterinary nurses bring to the healthcare team and the significant contributions they make in promoting the well-being of I believe that every animals. In his memory, the NAVC established the Dr. Earl H. Rippie ‘‘individual on the team Veterinary Nurse Leadership Scholarship, which recognizes veterinary nurses who have demonstrated leadership abilities and have made a positive impact on has the potential to be a the growth of the profession or in their practice (for details on applying, visit leader, and on the best navc.com/vmx/scholarships/veterinary-nurse-leadership-scholarship). teams, every individual is a leader.’’ This year’s recipients—recognized during VMX 2019—truly are leaders:

Janet Murray Perth, Western Australia

After growing up on a New Zealand dairy farm, it was a natural fit for Janet to begin her career in 1996 as a veterinary nurse. Janet studied and served in London and Ireland for several years, and in 2012, she moved to Perth, Australia. After a brief stint in a sales role, Janet became a lecturer for Certificate IV veterinary nursing at South Metropolitan TAFE, in Bentley, Western Australia.

“I am so excited to have received the Dr. Earl H. Rippie Veterinary Nurse Leadership Scholarship,” Janet says. “It quantifies everything I have done to date within the veterinary industry and validates my position as a leader within the community. This scholarship epitomizes the leader whose name is given to the award. It is amazing supporters of veterinary nurses like that of the late Dr. Rippie who recognize our important position within the industry. I am humbled to be the recipient of this international award and hope that I can continue to influence veterinary nurses to strive to be the best they can be. I am still only scratching the surface of what it is to be a veterinary nurse.”

todaysveterinarynurse.com • SPRING 2019 • 5 I’d love to hear from you! Write me at [email protected]. EDITOR’S LETTER Advantage Multi® for Dogs and for Cats (imidacloprid + moxidectin) BRIEF SUMMARY: Before using Advantage Multi ® for Dogs (imidacloprid+moxidectin) or Advantage Multi ® for Cats (imidacloprid +moxidectin), please consult the product insert, a summary of which follows: CAUTION: Federal (U.S.A.) Law restricts this drug to use by or on the order of a licensed veterinarian. Janet is president of the Veterinary Nurses Council of Australia, was one Advantage Multi for Dogs: WARNING of the first veterinary nurses invited to sit on the Australian Veterinary • DO NOT ADMINISTER ThIS pRODUCT ORAllY. • For the first 30 minutes after application ensure that dogs cannot lick the product from application sites on themselves Association’s Veterinary Business Group, and is editor of the Australian or other treated animals. • Children should not come in contact with the application Veterinary Nursing Journal. sites for two (2) hours after application. (See Contraindications, Warnings, human Warnings, and Adverse Reactions for more information.) INDICATIONS: Advantage Multi for Dogs is indicated for the prevention of heartworm disease caused by Dirofilaria immitisand the treatment of Dirofilaria immitiscirculating microfilariae in heartworm-positive Kari Griffith, LVT, VTS (Dentistry) dogs. Advantage Multi for Dogs kills adult fleas and is indicated for the treatment of flea infestations(Ctenocephalides felis). Advantage Multi for Dogs is indicated for the treatment and control of sarcoptic Everett, Washington mange caused by Sarcoptes scabiei var.canis. Advantage Multi for Dogs is also indicated for the treatment and control of the following intestinal parasites species: Hookworms (Ancylostoma caninum) (Uncinaria stenocephala), Roundworms (Toxocara canis) (Toxascaris leonina) and Whipworms (Trichuris vulpis). Kari has worked in the veterinary field since 1984. In Advantage Multi for Cats is indicated for the prevention of heartworm disease caused by Dirofilaria immitis. Advantage Multi 1992, she became a licensed veterinary technician in for Cats kills adult fleas(Ctenocephalides felis) and is indicated for the treatment of flea infestations.Advantage Multi for Cats is also indicated for the treatment and control of ear mite (Otodectes Washington state. In 2013, Kari earned her credentials as cynotis) infestations and the intestinal parasites species Hookworm (Ancylostoma tubaeforme) and Roundworm (Toxocara cati). Ferrets: Advantage Multi for Cats is indicated for the prevention a veterinary technician specialist (Dentistry) from the Academy of of heartworm disease in ferrets caused by Dirofilaria immitis. Advantage Multi for Cats kills adult fleas (Ctenocephalides felis) and Veterinary Dental Technicians, only the third person in Washington to is indicated for the treatment of flea infestations in ferrets. CONTRAINDICATIONS: Do not administer this product orally. (See WARNINGS). Do not use the Dog product (containing 2.5% successfully complete the training and earn the designation. Kari also moxidectin) on Cats. WARNINGS: helped develop a healthcare and first-aid training program for police Advantage Multi for Dogs: For the first 30 minutes after application: Ensure that dogs cannot lick the product from application sites on themselves or other treated dogs, and separate treated dogs from departments and K9 handlers in Washington’s Puget Sound area, and one another and from other pets to reduce the risk of accidental ingestion. Ingestion of this product by dogs may cause serious she has spoken at many canine training seminars. adverse reactions including depression, salivation, dilated pupils, incoordination, panting, and generalized muscle tremors. In avermectin sensitive dogsa, the signs may be more severe and may include coma and deathb. a Some dogs are more sensitive to avermectins due to a mutation “It truly never occurred to me that I would be one of the recipients of in the MDR1 gene. Dogs with this mutation may develop signs of severe avermectin toxicity if they ingest this product. The most common breeds associated with this mutation include Collies and the Rippie scholarship,” says Kari. “I have always been passionate about Collie crosses. b Although there is no specific antagonist for avermectin toxicity, sharing my knowledge with others. If I can just share one tidbit with even severely affected dogs have completely recovered from avermectin toxicity with intensive veterinary supportive care. Advantage Multi for Cats: Do not use on sick, debilitated, or someone about their pet, improve pets’ health, or educate at least one underweight cats. Do not use on cats less than 9 weeks of age or less than 2 lbs. body weight. Do not use on sick or debilitated ferrets. person in the veterinary field, then I feel I’ve accomplished what I set hUMAN WARNINGS: Not for human use. Keep out of the reach of children. Dogs: Children should not come in contact with the application sites for two (2) hours after application. Cats: out to do as a veterinary technician. I believe we are never too old to Children should not come in contact with the application site for 30 minutes after application. learn and we need to constantly test our brains. I am forever grateful for Causes eye irritation. Harmful if swallowed. Do not get in eyes or on clothing. Avoid contact with skin. Wash hands thoroughly with soap and warm water after handling. If contact with eyes occurs, this amazing opportunity and I was very excited about attending VMX hold eyelids open and flush with copious amounts of water for 15 minutes. If eye irritation develops or persists, contact a physician. If and to begin sharing.” swallowed, call poison control center or physician immediately for treatment advice. Have person sip a glass of water if able to swallow. Do not induce vomiting unless told to do so by the poison control center or physician. People with known hypersensitivity to benzyl alcohol, imidacloprid, or moxidectin should administer the product with caution. In case of allergic reaction, contact a physician. If contact with skin or clothing occurs, take off contaminated clothing. Wash skin immediately with plenty of soap and water. Call a poison Julie Ann Nettifee, RVT, BS, VTS (Neurology) control center or physician for treatment advice. The Safety Data Sheet (SDS) provides additional occupational safety information. For a copy of the Safety Data Sheet (SDS) or to report adverse Apex, North Carolina reactions call Bayer Veterinary Services at 1-800-422-9874. For consumer questions call 1-800-255-6826. pRECAUTIONS: Do not dispense dose applicator tubes without complete safety and administration information. Use with caution in sick, debilitated or underweight animals. The safety of Advantage “It is difficult to fully put into words all of the impacts Multi for Dogs has not been established in breeding, pregnant, or lactating dogs. The safe use of Advantage Multi for Dogs has not that this opportunity has in store for both myself and the been established in puppies and dogs less than 7 weeks of age or less than 3 lbs. body weight. Advantage Multi for Dogs has not been evaluated in heartworm-positive dogs with Class 4 profession,” says Julie. “Although I did not know Dr. heartworm disease. Cats may experience hypersalivation, tremors, vomiting and Rippie personally, his support of veterinary nurses demonstrates his decreased appetite if Advantage Multi for Cats is inadvertently administered orally or through grooming/licking of the application site. The safety of Advantage Multi for Cats has not been established compassion, love, encouragement, joy, and recognition of us all. I only in breeding, pregnant, or lactating cats. The effectiveness of Advantage Multi for Cats against heartworm infections (D. immitis) after bathing has not been evaluated in cats. Use of this product in hope that through this scholarship that I too can be a part of continued geriatric cats with subclinical conditions has not been adequately studied. Ferrets: The safety of Advantage Multi for Cats has not been advancement for the profession and help to continue his legacy of care established in breeding, pregnant, and lactating ferrets. Treatment of ferrets weighing less than 2.0 lbs. (0.9kg) should be based on a risk- benefit assessment. The effectiveness ofAdvantage Multi for Cats toward his patients and their caregivers.” in ferrets weighing over 4.4 lbs. (2.0 kg) has not been established. ADVERSE REACTIONS: heartworm Negative Dogs: The most common adverse reactions observed during field studies were pruritus, residue, medicinal odor, lethargy, inappetence and hyperactivity. heartworm positive Dogs: The most common For more than 20 years, Julie has been on the staff at North Carolina adverse reactions observed during field studies were cough, lethargy, vomiting, diarrhea (including hemorrhagic), and inappetence. State University College of Veterinary Medicine. She currently supports Cats: The most common adverse reactions observed during field studies were lethargy, behavioral changes, discomfort, hypersalivation, polydipsia and coughing and gagging. Ferrets: The clinical research in neurology and nutrition, teaches, and conducts most common adverse reactions observed during field studies were pruritus/scratching, scabbing, redness, wounds and inflammation at outreach. Julie trained at the University of Minnesota, Waseca, and the the treatment site; lethargy; and chemical odor. For a copy of the Safety Data Sheet (SDS) or to report adverse reactions call Bayer Veterinary Services at 1-800-422-9874. For University of Wisconsin, Madison. She has experience in public consumer questions call 1-800-255-6826. Advantage Multi is protected by one or more of the following U.S. relations, technical writing, and grant research and writing for North patents: 6,232,328 and 6,001,858. NADA 141-251,141-254 Approved by FDA V-03/2016 Carolina State. She has presented locally, nationally, and internationally, © 2015 Bayer Bayer, the Bayer Cross, Advantage Multi TVN are registered trademarks of Bayer. and she has authored numerous articles on veterinary nursing. Made in Germany.

6 • SPRING 2019 • todaysveterinarynurse.com *Treats and controls roundworms, hookworms and whipworms in dogs and roundworms and hookworms in cats. CAUTION: Advantage Multi® is only available from a licensed veterinarian. Dogs: WARNING: DO NOT ADMINISTER THIS PRODUCT ORALLY. For the first 30 minutes after application, ensure that dogs cannot lick the product from application sites on themselves or other treated animals. Children should not come in contact with the application sites for two (2) hours after application. (See Contraindications, Warnings, Human Warnings and Adverse Reactions for more information.) Cats: Do not use on sick, debilitated, or underweight cats. Avoid oral ingestion. © 2019 Bayer, Shawnee Mission, KS 66201. Bayer, the Bayer Cross and Advantage Multi are registered trademarks of Bayer. AM19567 NAVTA CORNER • A word from the National Association of Veterinary Technicians in America

Be a Force for Change: “Show Up”

hat an exciting time for the veterinary nursing and technology profession—never before has the veterinary field been so focused on improving the sustainability of a career in veterinary nursing. The significant attrition rate of the mWembers of our profession has been widely recognized, and many collaborative efforts are being made to make improvements.

The question is: “Where are you in all of these conversations?”

Heather Prendergast, RVT, CVPM, SHPH Where Are You? Co-Chair With social media and the internet being the places many individuals choose The Veterinary Nurse Initiative when asking questions, discussing issues, or venting their frustrations, you can find an abundance of discussions, ideas, and opinions. Common questions about the profession and the veterinary nurse’s role in it often fuel passionate discussions that revolve around wages, credentialing standards, credential title, utilization, education, wellness, practice culture, and others.

The question of where you are in all of these conversations is not whether you have participated in these discussions. The question is whether you “show up” to have a productive discussion with someone who can directly make a difference: the toxic coworker, the veterinarians at your practice, the practice manager, state association leaders, national association leaders. Have you Kenichiro Yagi, MS, RVT, offered your thoughts and made efforts to initiate change—together? VTS (ECC, SAIM) Co-Chair The Veterinary Nurse Initiative Dr. Andy Roark recently wrote an article on venting that distills the factors that cause venting to become a habit that can cause a “perceived lack of control” and “an embrace of victimhood.”1 “The problem is that venting isn’t like lancing an abscess,” Roark writes. “It’s like starting a bonfire in a forest.” Of course, not all venting is harmful, and we often need support from others to move in a positive direction. Dr. Roark also posits it can cause individuals to seek validation of their position and distract them from improving things in their lives that they can control.1

With this in mind, how do we move toward positive change?

Be a Force for Change Are you currently upset by something at work or in the profession at large that has you venting to coworkers, friends, or family members? The key is to utilize

1 Roark A. Need to Vent? Are You Sure? Dr. Andy Roark website. drandyroark.com/need-to-vent-are-you-sure. Accessed December 21, 2018.

8 • SPRING 2019 • todaysveterinarynurse.com

NAVTA CORNER • A word from the National Association of Veterinary Technicians in America

that energy to make changes in the areas you have control over. Changes in your own actions are easier to accomplish since it involves only one person— you. But how do you help change the behavior of a group of people, the veterinary field, or people who aren’t even in the field? This is where it becomes a bit more difficult. The answer, however, is simple: “Show up.”

The executive board of NAVTA and many other individuals invested in the profession serve on committees, collaborating to create positive change in the profession.2 They become conduits for discussions and provide input into other groups thatof people who may have the ability to effect positive change for the Being a member of profession. These individuals are elected to executive boards or appointed to ‘‘NAVTA and your state serve on committees, having varied backgrounds from within the field; they devote countless hours advocating for the profession. Your input can help shape association will give you and refine the dialogue. a voice in the current issues of the profession. Closer to home, state veterinary technician associations advocate for the Offering your help, profession. These associations are connected to NAVTA through the National however small, will add District Representative System (NDRS). A proposal for the NDRS was submitted by Anna Santos, an RVT in Georgia, which aimed to refine the to the capabilities of the communication between NAVTA and the states—and it has become reality.3 associations and help The system now functions to provide regular communication and has become a you become a part of welcome addition to the NAVTA Veterinary Technician Leadership Summits the solution. held twice a year to discuss national and state issues.4 Being a member of ’’ NAVTA and your state association will give you a voice in the current issues of the profession. Offering your help, however small, will add to the capabilities of the associations and help you become a part of the solution.

Move Forward If joining an association and advocating for the profession is not what you are interested in, consider becoming involved in other initiatives. If you are interested in promoting better knowledge in veterinary nursing, for example, work with a group of people who promote better education or look for an association focused on a specialty area. If you’re passionate about changing how veterinary practices are run, then work with a group of individuals centered on that goal, such as the Veterinary Hospital Managers Association (vhma.org). Or start in the workplace: perhaps you can improve your own practice by having productive conversations and finding solutions.

We all stand on the shoulders of those who have advocated for the profession. It is with a great sense of gratitude that we now do the same for the future generations. Don’t let venting be the only step you take. Move forward in a positive way to create change in the profession. The future of the profession is in our hands, and there has been no better time than now to act. So, we leave you with the question we began with: Are you showing up? TVN

2 National Association of Veterinary Technicians in America. NAVTA website. navta.net/page/leadership. Accessed December 21, 2018. 3 National Association of Veterinary Technicians in America. NAVTA website. navta.net/page/DistrictRep. Accessed December 21, 2018. 4 National Association of Veterinary Technicians in America. NAVTA website. navta.net/page/SummitsandSymposia. Accessed December 21, 2018.

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NUTRITION NOTES — Behind the Hype: Prebiotics and Probiotics for Dogs and Cats — 14

EXAM ROOM — Simulation Training: Just Like the Real Thing — 22

TRENDS IN VETERINARY NURSING — Illicit Drugs: What Veterinary Nurses Need to Know — 26

FROM THE FIELD — The Importance of Veterinary Technicians — 34 shutterstock.com/Bsmikeymikey1

NUTRITION NOTES • PEER REVIEWED

PROBIOTICS SYNBIOTICS

PREBIOTICS

MEET THE AUTHOR

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

A 1983 graduate of Michigan Behind the Hype: State University, Ann received her specialty certification in Emergency/Critical Care in Prebiotics and Probiotics 2000. In 2008 she was certified in Small Animal for Dogs and Cats Internal Medicine and in 2013, she earned her third specialty certification in Nutrition. Ann has worked in general, verywhere we look these days we find emergency, and specialty products that include probiotics, prebiotics, or both. practices and education. She is currently an instructor for EThese can be in the form of supplements, known as Ashworth College’s veterinary technician program. She is on nutraceuticals, or over-the-counter foods and therapeutic diets. the executive board for the According to the hype, these products can improve the immune VTS (Nutrition). Ann has written more than 50 system and gastrointestinal (GI) function while performing a published articles in various number of other tasks just short of emptying the litter box. professional magazines, as well as coauthored the book Nutrition and Disease Management for Veterinary Technicians and Nurses.

14 • SPRING 2019 • todaysveterinarynurse.com PEER REVIEWED • NUTRITION NOTES

The Food and Agriculture Organization of the United This defense involves the coordination of 3 different Nations and the World Health Organization define systems within the intestines: probiotics as “living microorganisms which when ● Resident intestinal microflora, which provides an administered in adequate amounts confer a health environment that favors the growth and functioning benefit on the host”1 and prebiotics as “nondigestible of beneficial bacteria food ingredients that selectively stimulate the growth ● Intestinal mucosa, which provides a barrier against and activities of specific bacteria in the gastrointestinal pathogenic bacteria tract and exert beneficial effects on the host.”2 A ● Gut-associated lymphoid tissue (GALT)6 synbiotic is a balanced combination of prebiotics and probiotics used together.3,4 (FIGURE 1) The US Food It would be difficult for us to affect the intestinal and Drug Administration defines nutraceuticals as mucosa or the GALT, but we can help to modulate the “nondrug substances produced in a purified or intestinal microflora to improve the environment the extracted form and administered orally to provide bacteria are living in, which may have a positive impact agents required for normal body structure and function on the dog or cat. Substantial research is looking at with the intent of improving health and wellbeing.”5 how enteral nutrition can help improve both the GALT and the intestinal mucosa barrier. The hope is that we As we can see by these definitions, we are talking about will see the benefits of that research in the next few bacteria or substances that benefit bacteria in the years. Currently, prebiotics and probiotics are being intestinal tract. Millions of bacteria normally reside in used to help with this modulation of the GALT.4 the small and large intestines of normal, healthy animals; we call this population the microflora. These Efforts to maintain a healthy microflora in the GI tract bacteria help digest food, maintain intestinal mucosal or rebalance the gut microbes after a disruption have integrity, participate in metabolism, and stimulate focused on dietary manipulation; helminth therapy; systemic immune function.6 fecal microbiota transplantation; prebiotic, probiotic, and synbiotic use; and antibiotics.3 Probiotics can also Because nutraceuticals are not pharmaceuticals, help to control diarrhea caused by bacterial overgrowth regulatory scrutiny over the sale of these items is or parasitic infection via competitive exclusion, minimal. Thus, it can be challenging to find products that not only do what their manufacturers say they do but also contain viable bacteria in the types and amounts specified on the label.7 Not all commercially available products provide the same level of usefulness, Prebiotics so it is important to understand what products, Food for bacteria Probiotics Synbiotics Live bacteria especially probiotics, have actually been evaluated in Serve as food dogs and cats. Not all bacteria provide the same for intestinal Combination bacteria and of a probiotic Used to benefits with all species, nor are all products tested and produce energy and a help adjust evaluated to the same extent. for intestinal cells prebiotic intestinal bacterial population Plant fibers Available as that can be easily supplements added to pet Difficult to GOOD BUGS, BAD BUGS add to foods foods or given Not added to The intestines are the largest component of the as supplements foods immune system in the body, making up approximately Available as supplements 70% of the total system. The mucosal barrier in the intestines helps to block the entrance of most pathogenic bacteria into the body while allowing the entrance of permeable nutrients.6 Because most pathogens enter the body through the mouth and then the intestinal tract, these intestinal defenses must be working optimally to cope with the onslaught of foreign substances and pathogens to which the intestines are constantly exposed.6 FIGURE 1. What’s in a name? An at-a-glance guide to the difference between prebiotics, probiotics, and synbiotics. shutterstock.com/Alexander_P. Opposite: shutterstock.com/Susan Schmitz; Bacteria: shutterstock.com/Venomous Vector shutterstock.com/Venomous Schmitz; Bacteria: shutterstock.com/Susan Opposite: shutterstock.com/Alexander_P.

todaysveterinarynurse.com • SPRING 2019 • 15 NUTRITION NOTES • PEER REVIEWED

competition for nutrients and binding sites, and an down into FOS by intestinal bacteria to provide both increase in specific and nonspecific immune response.6 FOS and inulin. Inulin can be found in Jerusalem artichokes, jicama, and chicory root. Antibiotics are seen as a significant destroyer of the normal GI flora and can negatively affect function. These 2 fibers are considered minimally digestible Although antibiotics are usually prescribed for a because of the β bond–based connections of the specific reason, they are not necessarily bacteria- or fructose molecules. Dogs and cats lack the intestinal site-specific; instead, they destroy or kill any bacteria enzyme needed to break down the β bond; instead, that fall within its spectrum, regardless of whether the they usually break down α saccharide bonds. The bacteria are beneficial or pathogenic.3 resident bacteria in these animals can break the β bond, producing short-chain fatty acids (SCFAs). The most If an antibiotic is prescribed orally for pneumonia, it common SCFAs are acetate, propionate, and butyrate.4 still must pass through the intestines and will exert its antibacterial effect on that site, as well as on the lungs, Plants do not have only 1 type of carbohydrate in where the actual infection is occurring. Antibiotics used them; some may contain both FOS and inulin in as growth promoters can exert an even larger effect on varying amounts, whereas others may contain neither. the microflora than do those used intermittently.3 Just adding fiber to the diet may or may not provide prebiotic effects. That benefit depends on the types of fibers found in the product.4

The SCFAs produced by the breaking of the β bond No studies have shown that through bacterial fermentation are an energy source for supplementing pet diets with the colonocytes, lower the colonic pH, and stimulate sodium and water absorption.2 One SCFA in particular, yogurt or other fermented food butyrate or butyric acid, is a primary source of energy products, such as kimchee, for colonocytes but may also directly enhance cell proliferation of normal cells while suppressing benefits the pets themselves. proliferation of transformed cells. Because both oligofructose and inulin are fibers, their addition to the diet can also have negative side effects. When used at higher levels, both FOS and inulin reduce fecal protein digestibility.2 PREBIOTICS AND GUT HEALTH Prebiotics are usually considered to be a type of Studies have shown addition of FOS and fructose-based carbohydrate called oligosaccharides. By definition, inulins to the diet has generally positive effects on gut however, noncarbohydrates can be classified as microflora and host health, as evaluated through gut prebiotics. The ones used most frequently are classified integrity and bacterial colonization, and on animal as soluble fibers. These were first identified as a performance, as evaluated through digestion, body functional food in 1995 by Marcel Roberfroid. In weight gain, and feed efficiency.9 2007, Roberfroid clarified that only 2 classes of fructooligosaccharides (FOS) fully meet the definition of a prebiotic: oligofructose and inulin.8 PROBIOTICS AND GUT HEALTH Probiotics present an appealing approach to treatment Oligofructose is a 2-8–chain fructose-based saccharide and prevention of many conditions because of their molecule that undergoes fermentation fairly quickly in potential to be effective and safe and to result in the colon, providing nourishment to the bacteria in decreased use of antibiotics in veterinary medicine.10 that area. Examples of FOS sources include soybeans, Rather than encouraging the growth of beneficial oats, beets, and tomatoes. bacteria and suppressing the growth of pathogenic bacteria, probiotics actually introduce these beneficial Inulin is a longer 9-64–chain fructose-based saccharide bacteria into the environment. Current knowledge that tends to be fermented more slowly, benefiting suggests that the best use for these products is bacteria farther down the colon. It can also be broken treatment of GI disease, such as diarrhea and other GI

16 • SPRING 2019 • todaysveterinarynurse.com PEER REVIEWED • NUTRITION NOTES

abnormalities, potentially including inflammatory demonstrate that routinely adding probiotics to the bowel disease.10 diet improves overall wellness in otherwise healthy animals.10 Studies in different animal species have often demonstrated bacterial strain-specific results. Thus, The primary bacterial populations included in unless you use the exact product on the same species probiotics that do benefit the cat and dog are lactic acid used in the study, at the exact same dose and delivery bacteria, especially lactobacilli, bifidobacteria, and method, your results will likely not be the same as enterococci (TABLE 1). These bacteria use fermentation those the researchers showed.10 to transform some sugars into organic acids, particularly lactic and acetic acids. These acids lower To function as a probiotic, the bacteria must be able to: the pH in the intestinal tract and inhibit the growth of ● Survive the acid and bile found in the GI tract pathogenic bacteria.6 ● Adhere to the intestinal cells or transiently colonize various areas within the GI tract Probiotics can benefit the intestinal microflora in many ● Exclude or reduce pathogenic bacterial adherence ways. They can increase the fecal count of good bacteria ● Produce acids, hydrogen peroxide, and/or while decreasing the numbers of pathogenic bacteria. bacteriocins that antagonize the growth of pathogens Some probiotics minimize adherence to the intestinal ● Coaggregate to help achieve normal balanced epithelial cells and establishment of pathogenic microflora population bacterial populations.6 ● Be safe, noninvasive, noncarcinogenic, and nonpathogenic6 Probiotics can produce various antimicrobial metabolites, known as bacteriocins, that can also The GI tract of a newborn is initially sterile but is enhance functionality of the epithelial barrier and help colonized with bacteria within hours of birth. These modulate the mucosal immune response.3 Compared bacteria find their individual niches within the with the large intestine, the small intestine has poor intestinal tract and reach a state of equilibrium. Once microflora colonization and limited barrier protection this neonatal “grace period” ends, however, introducing against pathogens. Therefore, probiotics can exert an bacteria is substantially more difficult because of gastric important beneficial effect in the small intestines.3,5 acidity and the introduction of bile acids to the chyme The recommendation is to rely on a product for which leaving the stomach.6 research supports both the product and the manufacturer’s claims. The most extensively researched No studies have shown that supplementing pet diets probiotic available in veterinary medicine is FortiFlora™ with yogurt or other fermented food products, such as (purina.com).3 kimchee, benefits the pets themselves. The bacteria found in these products are limited in amount and type and may not be the kind that benefit the health issue SYNBIOTICS AND GUT HEALTH being addressed.1,10 Research has also failed to Synbiotics are a balanced combination of probiotics

TABLE 1 Gut Bacteria: What’s Good and What’s Bad

BENEFICIAL PATHOGENIC

Lactobacilli Pseudomonas aeruginosa

Eubacteria Proteus species

Bifidobacterium Staphylococci

Enterococci Clostridia

Streptococcus Saccharomyces

Pediococcus Veillonella

Leuconostoc

Bacillus

Escherichia coli

todaysveterinarynurse.com • SPRING 2019 • 17 NUTRITION NOTES • PEER REVIEWED

and prebiotics and may be advantageous for treatment contents, can help in evaluating a diet. When in doubt, of various GI diseases. The prebiotic portion may contact the manufacturer for further information. improve the conditions in the GI tract, enabling the probiotics to maximize survival, and may increase Unlike use of prebiotics, use of probiotics is more of a proliferation and adherence of the beneficial bacteria.4 transient process based on need rather than a long-term Prebiotics may enhance or potentiate the benefits of the process. Ideally, the body will supply the bacterial probiotics found in these products. population to support the best intestinal health. But when this doesn’t occur, or when challenges that could You need to consider if the bacterial portion of the affect intestinal health are expected, probiotics can be product is still viable and as stated on the label. easily added to the diet to help support the bacterial Benefits can also be obtained by using 2 separate populations there. No detrimental effects have been products, given at the same time, as with using a seen with long-term prebiotic or probiotic use in probiotic in a food that has been supplemented with a animals, unlike with the use of long-term antibiotics.4 prebiotic fiber.4 When evaluating prebiotic or probiotic products, ensure that research supports the claims given, that the TRUTH IN LABELING: LOOK products contain the stated levels of additives, and that BEYOND THE CLAIMS the products promote normal intestinal microflora. A One of the biggest challenges for manufacturers of review of probiotics in commercial dog and cat foods probiotic products is survivability of the bacteria. Most by Weese and Arroyo demonstrated that few products commercially available products suffer tremendous loss meet these guidelines.1 Alternately, evaluation in a of activity during storage. After 5 to 6 months of controlled clinical setting can provide firsthand storage, almost no live organisms are present. Bacteria knowledge of the effectiveness of the products used. By that are present still must survive the gastric pH and applying this strategy, you can ensure that you are duodenal bile acids before they can colonize the small providing the best product to support a happy, healthy intestines. To address these concerns, some intestinal tract with a hard-working population of manufacturers have developed microencapsulation to beneficial bacteria. TVN protect the bacteria, while others provide a variety of bacterial species to cover more bases.6 References A study by Weese and Martin, at the University of 1. Weese JS, Arroyo L. Bacteriological evaluation of dog and cat diets Guelph in Ontario, Canada, compared the actual that claim to contain probiotics. Can Vet J. 2003;44(3):212-216. 2. Pan XD, Chen FQ, Wu TX, Tang HG, Zhao ZY. Prebiotic oligosaccharides product contents vs label statements for a variety of change the concentrations of short-chain fatty acids and the microbial commercially available probiotics.7 Of the 25 products population of mouse bowel. J Zhejiang Univ Sci B 2009;10(4):258-263. 3. Marks S. Probiotics—not just for people anymore. Proceedings of the evaluated, only 2 had acceptable correspondence 2017 Western Veterinary Conference, Las Vegas, Nevada. between actual production of bacteria classes and what 4. Steiner JM. Understanding the benefits of prebiotics. dvm 360. July 1, was stated on the label. All products were evaluated 2009. veterinarycalendar.dvm360.com/veterinary-team-understanding- benefits-prebiotics-sponsored-iams. Accessed November 6, 2018. 7 before their expiration dates. Prostora™ (produced at 5. Lerman A, Lockwood B. Nutraceuticals in veterinary medicine. Pharm J the time by the Iams Company) and FortiFlora™ were 2007;278:51. the top performers. Prostora™ was discontinued after 6. Kelly M. The role of probiotics in GI tract health. Nestle Purina PetCare Company. purinaproplanvets.com/media/1181/role_of_probiotics.pdf Royal Canin acquired Iams. FortiFlora™ is still 2006. available. 7. Weese JS, Martin H. Assessment of commercial probiotic bacterial contents and label accuracy. Can Vet J. 2011;52(1):43-46. 8. Roberfroid M. Prebiotics: the concept revisited. J Nutrit 2007;137(3 Suppl 2):830S. CONCLUSION 9. Verdonk JM, Shim SB, van Leeuwen P, Verstegan MW. Application of inulin-type fructans in animal feed and pet food. Br J Nutrit Because prebiotics are used as both a source of 2005;93(Suppl 1):s125-s138. nutrition for the colonocytes and a fiber source for the 10. Heinz CR. Good bugs/bad bugs: the confusing world of probiotic animal, inclusion in the diet is fairly easy. The supplements. Pet Foodology. vetnutrition.tufts.edu/2017/06/probiotics. Accessed November 6, 2018. ingredient panel should list the fiber source but may not state whether it is a source of FOS or inulin. Increasing your familiarity with the different fiber sources used, and their relative FOS and inulin

18 • SPRING 2019 • todaysveterinarynurse.com PEER REVIEWED • NUTRITION NOTES Worry Less About a Mess

why mycequin™? Mycequin™ is a targeted probiotic containing NMXAAD™, a proprietary blend of Saccharomyces boulardii, a type of yeast, and beta-glucan to support intestinal health.

CONTAINS 10 BILLION CFUs* OF SACCHAROMYCES BOULARDII

UNLIKE BACTERIA-BASED PROBIOTICS, YEAST-BASED PROBIOTICS ARE NOT AFFECTED BY ANTIBIOTICS

CONTAINS BETA-GLUCAN TO SUPPORT IMMUNE FUNCTION

TASTY CHEWABLE TABLETS FOR DOGS

VETERINARY EXCLUSIVE PACKAGING - NOT AVAILABLE ONLINE

NEW! 010.1398.00

*Colony Forming Units Available from all authorized veterinary producttodaysveterinarynurse.com distributors. • SPRING 2019 • 19

PEER REVIEWED • NUTRITION NOTES Dogs take enough risks on their own. Count on RECOMBITEK® 4 Lepto Combos for comprehensive leptospirosis protection in its purest form.1

Protect your patients from the rising threat of leptospirosis with the nonadjuvanted vaccine that offers four-way protection against disease and shedding.* Available in DAP and DAPP combinations!

The only vaccine that prevents Prevents your patients The only bacterin to leptospirosis caused by Leptospira from shedding bacteria provide a 15-month canicola, L. grippotyphosa, into the environment duration of immunity** L. icterohaemorrhagiae, and aids after exposure* in the prevention of L. pomona.

1 Nobivac: A portfolio of advanced vaccines for the well-being of canine family members [brochure]. Summit, NJ: Merck Animal Health; 2013. MAH-VC-851. * Indicated for the prevention of leptospirosis and leptospiruria caused by L. canicola, L. grippotyphosa and L. icterohaemorrhagiae and as an aid in the prevention of leptospirosis and leptospiruria caused by L. pomona. ** L. grippotyphosa Merial is now part of Boehringer Ingelheim. RECOMBITEK® is a registered trademark of Merial. ©2018 Merial, Inc., Duluth, GA. All rights reserved. VAC16TRADEADS2 (01/18). todaysveterinarynurse.com • SPRING 2019 • 21 EXAM ROOM

HANDS-ON TRAINING Veterinary nurses develop skills with simulation training.

MEET THE AUTHOR

Maggie Monza, LVT Oradell Animal Hospital, Paramus, NJ

Maggie has a bachelor’s degree in veterinary technology and is a Licensed Veterinary Technician. She is an active member of the Association of Veterinary Technician Educators (AVTE) and National Association of Veterinary Technicians in America (NAVTA). She serves on the education committee of New Jersey Veterinary Technicians and Assistants (NJVTA). She works at Oradell Animal Hospital and is an adjunct professor at Bergen Community College.

MEET THE Simulation AUTHOR

Training: Just Like Harriet Terodemos, MS, CVT Bergen Community College the Real Thing Paramus, NJ Harriet has a master’s degree in biology from Montclair ecause veterinary nurses often explain State University and a bachelor’s degree in animal the diagnostic plan for companion animals (and science from Purdue even perform some), they need to understand the University. She received her B associate’s degree in diagnostic procedure being performed, as well as the normal veterinary technology from San Juan College. She has diagnostic values and reference ranges that pertain to the been an instructor with the procedure. While this can create anxiety, simulation training veterinary technology program at Bergen can help veterinary nurses develop the skills and confidence Community College for 17 years. She is an active to explain and perform certain clinical procedures. member of the New Jersey Veterinary Technicians and Assistants (NJVTA). Photo courtesy Kenichiro Yagi and the Cornell and the Cornell Yagi Kenichiro courtesy Photo Medicine of Veterinary College

22 • SPRING 2019 • todaysveterinarynurse.com EXAM ROOM

Even after graduation, however, veterinary nurses can practice their skills via simulation in the veterinary practice. Simulation is not just for the new graduate— High-fidelity simulations use it also benefits seasoned veterinary nurses, who must computerized mannequins,2 continually hone their skills. These simulations can also whereas low-fidelity simulations be useful in training staff members. You may already be using simulations in your practice now. For example, use role-play, noncomputerized your clinic may require monthly crash drills or mannequins, or task trainers.2 scavenger hunts for important items. But how do you incorporate simulation into your clinic when you need to gain more dexterity in such procedures as obtaining intraocular pressure (IOP) or cystocentesis? We’ll get to that, but first, let’s discuss what is meant by simulation. Step by Step 1. Calibrate the tonometer according to the Through simulation, conditions are created or manufacturer’s directions. Always use a sterile tip replicated to resemble real-life situations.1 It is a cover for each patient.3 learning modality in which the practitioner or student 2. Mimic applying a topical anesthetic to the eye practices a procedure on a mannequin. Some (grape).3 mannequins can be purchased, but you can also create 3. Using very light taps, make contact with the cornea your own. High-fidelity simulations use computerized (grape).3 mannequins,2 whereas low-fidelity simulations use 4. Record the average reading. Depending on the role-play, noncomputerized mannequins, or task model used, you may have to record the average of 3 trainers.2 You can create your own mannequin using readings.3 Newer models do this automatically. everyday craft items and stuffed animals. All veterinary nurses should be familiar with the normal IOP range for cats and dogs: 10 to 25 mm Hg.4 SIMULATED PRACTICE: OBTAINING IOP To practice obtaining IOP via simulation requires SIMULATED PRACTICE: OBTAINING nothing more than a stuffed animal, grapes, and the URINE VIA CYSTOCENTESIS regular supplies necessary for this procedure, such as a Another type of simulation entails using a stuffed tonometer and anesthetic eye drops (FIGURE 1). animal to teach the proper protocol for obtaining urine via cystocentesis. Cystocentesis is frequently used to To create your mannequin, replace the eyes on the obtain a sterile urine sample from the patient’s bladder. stuffed animal with grapes (FIGURE 2). Once this is The veterinary nurse uses his or her palpation skills to done, anyone can begin practicing the procedure. isolate the bladder.

FIGURE 1. Materials needed for simulated IOP measurement. FIGURE 2. Simulated measurement of IOP.

todaysveterinarynurse.com • SPRING 2019 • 23 EXAM ROOM

add a drop of yellow food coloring to the water to mimic the look of a urine sample. A follow-up simulation may 7. Release the plunger and withdraw the needle.5 include a mock conversation between the veterinary nurse Complications and facilitator (who acts as All veterinary nurses should be familiar with the the client). complications that can occur during this procedure, including urine leak resulting in a uroabdomen, bowel puncture or laceration, and puncture or laceration of the vena cava.6 This is yet another reason that creating these simulations is a valuable teaching tool: It allows All that’s needed for this exercise is a stuffed animal, new veterinary nurses to get comfortable in these alcohol, a water balloon, and the appropriate-size situations before working with live patients. syringe and needle for the patient and bladder size (for the exercise shown in FIGURE 3, we are using a 3-mL syringe and a 22- to 25-gauge needle).5,6 The needle EDUCATIONAL FOLLOW-UP should be 0.75 to 1.5 inches long, depending on the A debriefing should follow any simulated training with size of the patient and bladder.5,6 a mannequin. This debriefing should be led by a facilitator who guides and supports participants toward To create the mannequin, replace the stuffing with a understanding and achieving objectives.1,2 The water balloon (FIGURE 3). You’re now ready to start facilitator can be a veterinarian or a veterinary nurse practicing the procedure. who is well trained in the procedure being practiced.

A follow-up simulation may include a mock Step by Step conversation between the veterinary nurse and 1. Restrain the “patient” in dorsal recumbency. We are facilitator (who acts as the client). For the IOP using a cat mannequin in this scenario; restraint in procedure, the veterinary nurse should be able to lateral recumbency is also acceptable. educate the client regarding the procedure itself, 2. Palpate the urinary bladder (water balloon).5 normal ranges, the importance of follow-up visits, and 3. Swab the area over the caudal abdomen with alcohol.5 with which the patient may be discharged. 4. Isolate the urinary bladder (water balloon) between For cystocentesis, the veterinary nurse should be able to the fingers of the nondominant hand.4 explain the importance of obtaining a sterile urine 5. Insert the needle at a 45-degree angle without sample. Such simulated conversations teach veterinary applying negative pressure.5 nurses the appropriate communication required for a 6. Withdraw urine (water) from the bladder.4,5 You can successful client education experience and reinforce their skill set, education, and abilities. TVN

References

1. INACSL Standards Committee. INACSL standards of best practice: simulation glossary. Clin Simulat Nurs 2016;12(S):S39-S47. 2. Aebersold M, Tschannen D. Simulation in nursing practice: the impact on patient care. Online J Issues Nurs 2013;18. Manuscript 6. 3. Herring N. Proper intraocular pressure measurement. Clinicians Brief 2017;Jan/Feb:3, 7-9. 4. Collins BK. 6 eye errors you’re probably overlooking. DVM360. March 13, 2017. veterinarymedicine.dvm360.com/6-eye-errors-you-re-probably- overlooking. Last accessed December 8, 2018. 5. Rizzi TE. Urinalysis in companion animals part 1: collection, sample handling, & initial evaluation. Todays Vet Pract 2014;Mar/Apr:64-68. 6. Poulin RV. Using cystocentesis to obtain sterile urine samples. Clinicians Brief 2017;Nov/Dec:52-55.

FIGURE 3. Simulated cystocentesis.

24 • SPRING 2019 • todaysveterinarynurse.com SPONSORED CONTENT

Let’s Work Together to Protect More Dogs by 2020

You know how important it is to protect your patients It’s not a challenge to be taken lightly, and Boehringer from heartworm disease, but do your clients? You’ve Ingelheim understands that the effort needs support. At made recommendations, as you do at all visits as their HeartgardClinic.com, nurses can find valuable front line of communication on how to best protect education materials for clinic staff as well as clinic their pets. Surely they follow those recommendations— tracking tools to support your Heartworm 2020 efforts. they get their regular check ups and you help facilitate their prescription refills, right? They were listening. And if helping more patients avoid an easily Weren’t they? preventable disease isn’t enough, the Heartworm 2020 initiative includes a contest for participating clinics. Sadly, compliance for heartworm disease prevention Get new dogs protected, track them on your specifically isn’t what it used to be. According to recent downloadable tracking poster, and once it’s completed, data from the American Heartworm Society, incidence take a photo and upload it at HeartgardClinic.com. It’s rates of heartworm disease are increasing across the that easy, and you have the chance to win monthly United States. In fact, there has been as much as a 21% prize giveaways including an iRobot Roomba, an Arlo increase in positive heartworm disease tests per clinic Pro 2 4-camera indoor/outdoor camera system, a when comparing 2013 incidence rates to 2016 rates Whirlpool Washer/Dryer set and much more. from the surveys.

So what can nurses and technicians do? Firstly, Make sure your clients truly understand communication is always key. Make sure your clients the importance of prevention, through truly understand the importance of prevention, through all effective methods, and the potentially all effective methods, and the potentially deadly consequences—even if it seems obvious. deadly consequences—even if it Boehringer Ingelheim, the maker of HEARTGARD® seems obvious. Plus (ivermectin/pyrantel), has also launched an initiative to help more dogs receive the protection they need. The Heartworm 2020 campaign is challenging veterinary clinics to get 20 new dogs on heartworm disease prevention by January 1, 2020. If each clinic does its part, this effort will add up to 583,240 more dogs on heartworm disease prevention by the year 2020.

Important Safety Information: HEARTGARD Plus 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 see full prescribing information or visit www.HEARTGARD.com. TRENDS IN VETERINARY NURSING

CAN WE TALK? Although pet owners may be reluctant to talk about illicit drugs, veterinary nurses should discuss poison prevention with owners.

MEET THE AUTHOR

Erin Freed, CVT, BAS ASPCA Animal Poison Control Center, Urbana, IL

This article is brought to you in partnership between Today’s Veterinary Nurse and the ASPCA A Certified Veterinary Animal Poison Control Center (APCC) (aspcapro. Technician, Erin has been in org/poison). If a patient requires emergency care the veterinary field since for poisoning, call the APCC at 888-426-4435. 2000. In 2006, she joined the ASPCA Animal Poison Control Center (APCC), and in 2017, she was named APCC’s Veterinary Team Engagement Coordinator. She Illicit Drugs: What earned an associate’s degree in Applied Science in Veterinary Technology from Veterinary Nurses Parkland Community College in 2005 and a bachelor’s degree in Applied Science in Veterinary Hospital Need to Know Management from St. Petersburg College in 2016. Her interests include toxicology, but her passion is ccording to the ASPCA Animal Poison participating in educational Control Center (APCC) AnTox database, marijuana, opportunities and sharing knowledge with veterinary Aamphetamines, cocaine, heroin, and hallucinogenic staff and clients. Erin is widely mushrooms are five of the most common illicit drugs published, including a chapter on the renal system for Small 1 Animal Toxicology Essentials. companion animals and working police dogs are exposed to. shutterstock.com/JuNiArt. iryna. Opposite: shutterstock.com/avitskaya

26 • SPRING 2019 • todaysveterinarynurse.com TRENDS IN VETERINARY NURSING

Illicit drugs are substances that have been declared illegal to possess, use, or distribute without authorization under federal and/or state laws. This article discusses the importance of the veterinary nurses’ role in pet poisoning cases involving illicit drugs and provides a brief overview of clinical signs, decontamination, and management of patients exposed to illicit drugs.

One of the most critical roles veterinary nurses play is knowing how to obtain an accurate history from clients. Obtaining an accurate history can be challenging for several reasons. Clients may be reluctant to share information for fear of being reported to the authorities or having their pet taken away, clients may be intoxicated with the same illicit drug their pet was exposed to, and some clients may not be aware their pet was exposed to an illicit MARIJUANA substance. Veterinary nurses should reassure clients the Marijuana is a psychoactive drug and used for information shared is confidential and the focus is to recreational and medicinal purposes. Marijuana is the provide the best possible care for the pet. For more dried leaves and flowers of the Cannabis sativa and information on how to obtain a pet poison history, C. indica. It is a Schedule I drug under the Controlled please reference todaysveterinarynurse.com/articles/ Substances Act and it goes by several names: “pot,” how-to-take-a-toxin-exposure-history. “Mary Jane,” “weed,” “kief,” “ganja,” “THC,” “grass,” “reefer,” or “honey oil”.3-6 Marijuana is still the number Decontamination is similar with all 5 illicit drugs. On 1 drug of abuse, even though it has been approved for average, most of these illicit drugs will produce signs medicinal and recreational use in a little more than half within 15 to 30 minutes, but this can depend on the the United States.3,4 Marijuana contains over 100 form of drug and the route of exposure. Unfortunately, identified cannabinoids, but the main cannabinoid this leaves a short time frame for successful responsible for its psychological effects is delta decontamination. Another role of a veterinary nurse is 9-tetrahydrocannabinol, commonly referred to as knowing the benefits and risks associated with THC.2,5,6 THC concentrations vary depending on the decontamination. Decontamination should be form of the plant used. The dried flowers from the performed only in asymptomatic or stabilized patients. female plant may contain 1% to 8% THC, but some of Decontamination can include removing the pet from the newer commercial strains can contain up to 20% the source, inducing emesis, administrating activated THC.2,3 Hashish can contain 10% to 20%; hash oil can charcoal (AC), and bathing drug residue from the pet’s contain 20% to 50%, waxes and shatters can contain fur. Emesis induction may be unsuccessful in patients up to 70%, and dabs can contain over 90% THC.2,5,7 that ingest marijuana due to its strong anti-emetic properties.1,2 AC will bind to all five of these illicit Marijuana is generally inhaled (smoking of the dried drugs but must be administered with caution. An flowers from the female plant or vaping oils), ingested anti-emetic should be administered prior to giving AC (eating edibles; drinking teas, tonics, or elixirs), and to help prevent the risk of aspiration pneumonia, and applied (topical oils, creams, balms, and patches). sodium levels should be monitored because AC poses a Ingestion and inhaling secondhand smoke are common risk for hypernatremia.1 For more information on how causes for animal exposures. to decontaminate the poisoned patient, and the benefits and risks associated with decontamination, Animals generally develop signs within 30 to 60 please see: todaysveterinarynurse.com/articles/ minutes after exposure and signs can last up to 72 oral-decontamination-in-dogs-and-cats/ and hours.2-5 Most dogs present as lethargic, ataxic, and todaysveterinarynurse.com/articles/dermal-ocular- dribbling urine.1 Other common signs reported include and-inhalation-decontamination-in-dogs-and-cats. gastrointestinal (GI) signs, such as vomiting, diarrhea, and hypersalivation; central nervous system (CNS)

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signs, such as depression, vocalizing, and hyperesthesia; agitated, or having seizures.2-7 Marijuana has a wide and cardiovascular (CV) signs, such as bradycardia or margin of safety and deaths are rarely reported.1-3 tachycardia.1,5,6 Other reported signs include mydriasis Prognosis is excellent to good with proper monitoring and hypothermia.1,5,6 Tremors, seizures, and coma have and treatment.1,5,6 been reported but are rare.1,4,5 Management of marijuana toxicosis is based on symptomatic and Cannabidiol (CBD) is another cannabinoid found in supportive care. Veterinary nursing care can include the cannabis sativa plant, but it does not produce the monitoring for CNS signs and vitals (heart rate, blood psychoactive effects like THC.7 CBD can be derived pressure, body temperature); thermoregulation (IV from the marijuana (female) or hemp (male) plants fluids, warming blankets, and rotating the patient’s containing less than 0.3% THC on a dry weight basis.8 body position every 4 hours); keeping the pet dry if If a plant contains more than 0.3% THC, the federal urinary incontinent; confining to reduce injury; and government considers it a marijuana plant. In reducing stimuli (keeping patients in a dark, quiet area December 2018, the Agriculture Improvement Act of of the hospital to reduce further agitation, e.g., 2018 was signed, removing hemp from the Controlled hyperesthetic patients). and Substances Act.8 This means hemp will no longer be an supplementation can include IV fluids; anti-emetics illegal substance under federal law. Most over-the- (e.g., maropitant or ondansetron) to control vomiting; counter (OTC) CBD products are made from hemp, establishing an airway (intubation) and providing and some sources claim CBD can be used to treat oxygen for respiratory depression; atropine for seizures, nausea, stress, anxiety, arthritis, back pain, and bradycardia; methocarbamol for tremors; and signs of cancer in pets. A study on the safety and administering diazepam if the patient is hyperesthetic, efficacy of cannabidiol in dogs with osteoarthritis was published in July 2018.9 According to the results, 2 mg/kg of CBD oil helped increase comfort and activity in dogs.9 No side effects were reported by owners; AMPHETAMINES however, during the CBD treatment, an increase in Common clinical CNS signs include hyperactivity, restlessness, agitation, anxiety, ataxia, circling, head bobbing, apprehension, alkaline phosphatase (ALP) was noted on serum and tremors.11,14 Common CV signs include hypertension (often chemistries.9 in conjunction with reflex bradycardia), tachycardia, and tachyarrhythmias.11 Other clinical signs reported are mydriasis, hyperthermia, serotonin syndrome, and metabolic acidosis.1,6,11,12,14 For a drug to be beneficial, a patient must receive an Some animals, especially cats, appear hypervigilant and tend to sit appropriate dosage, and here lies the concern with and stare.1 Lethargy, depression, and coma have been reported later during intoxication.3,11 Seizures, rhabdomyolysis, and disseminated OTC CBD products. The Food and Drug intravascular coagulation are rare.1,6,11,12 Administration (FDA) does not regulate the products, and the CBD content may not match up with the label. In 2015, the FDA tested various OTC CBD-containing products, including products marketed for pets.10 Some of the products tested did not contain the level of CBD claimed on the label, some products contained no CBD whatsoever, and some products contained THC.10

There are risks involved when giving pets unregulated OTC CBD products. If the product contains little to no CBD, the pet will not reap the desired benefits. If the product contains more THC than what is allowed, the pet is at risk for developing signs of a THC toxicity. The ASPCA APCC has had reports of pets developing THC signs after ingesting CBD products.1

Although these products have not been approved for veterinary use, veterinarians are recommending CBD products to pet owners. Unfortunately, not enough information is known about CBD and its side effects in

pets. It is important for veterinary nurses to know the shutterstock.com/Couperfield

28 • SPRING 2019 • todaysveterinarynurse.com TRENDS IN VETERINARY NURSING

possible risks and side effects associated with the use of does not respond, a beta blocker (e.g., propranolol or CBD products, share this information with clients, and atenolol) is recommended for tachyarrhythmias and inform clients what to do if a THC toxicity is esmolol if the pet is hypertensive.1 Cyproheptadine is a suspected. serotonin antagonist and can be used for the treatment of serotonin syndrome signs.1,14 Methocarbamol can be used for tremors and can be used to AMPHETAMINES manage seizures.11 Gas anesthesia can be used, but Amphetamines are stimulants and 2 common illicit benzodiazepines (e.g., diazepam) are not typically amphetamines produced in illegal street laboratories are recommended due to the risk of paradoxical methamphetamine and 3-4 excitation.1,11 Ammonium chloride and ascorbic acid methylenedioxymethamphetamine (MDMA).6,11,12 have been shown to enhance the elimination of Methamphetamine is a Schedule II drug and is also amphetamines and should not be implemented if the known as “meth,” “speed,” “crystal,” “crank,” and acid-base status cannot be monitored, or if the patient “ice.”6,13 Meth is generally smoked, snorted, injected, or has rhabdomyolysis or myoglobinuria.3,6,11-13 Prognosis taken orally and it comes in crystallized chunks or for amphetamines is generally good, but it depends on powder.6,13 MDMA is a club drug commonly referred the length and severity of signs.11 Development of to as “ecstasy,” “X,” “molly,” “adam,” “roll,” and “e.”3,6,13 seizures, cardiac failure, and DIC poses the highest It is a Schedule II drug and generally comes in powder risks. Renal failure can result from myoglobinuria and form, capsules, and a variety of colored tablets that are acidosis.6,12 imprinted with a character symbol.3,14 Ingestion, inhalation, and dermal are the common routes for animal exposures. COCAINE Cocaine is a stimulant alkaloid that is derived from the Clinical signs can develop within 30 minutes to 2 hours leaves of the coca plant (Erythroxylon coca).12,15,16 after exposure and can last up to 24 to 72 hours.6,11 Cocaine is a Schedule II drug and common names Common clinical CNS signs include hyperactivity, include “crack,” “rock,” “bernies,” “ice,” and “flake” for restlessness, agitation, anxiety, ataxia, circling, head the rock form or “coke,” snow,” “star dust,” “leaf,” bobbing, apprehension, and tremors.11,14 Common CV “blow,” and “nose candy” for the powdered form.6,15,17 signs include hypertension (often in conjunction with Cocaine is often cut with caffeine, lidocaine, reflex bradycardia), tachycardia, and amphetamines, benzocaine, diltiazem, and levamisole tachyarrhythmias.11 Other clinical signs reported are and generally is snorted, injected, or taken orally.12,15,17 mydriasis, hyperthermia, serotonin syndrome, and Ingestion, inhalation, and dermal are the common metabolic acidosis.1,6,11,12,14 Some animals, especially routes for animal exposures. cats, appear hypervigilant and tend to sit and stare.1 Lethargy, depression, and coma have been reported Signs can develop in as little as 30 minutes, and later during intoxication.3,11 Seizures, rhabdomyolysis, although the exact duration of signs is unknown, most and disseminated intravascular coagulation (DIC) are pets are hospitalized for approximately 10 to 30 rare.1,6,11,12 Management of amphetamines toxicosis is hours.1,6,15,17 Common signs reported are GI upset, such based on symptomatic and supportive care. Veterinary as vomiting and hypersalivation; CNS signs, such as nursing care should include monitoring vitals vocalization altered mentation, hyperactivity, mydriasis, (including an electrocardiography [ECG]), watching ataxia, tremors, and seizures; and CV signs, such as for myoglobinuria (renal values and urine color), tachycardia, tachypnea, and hypertension.6,12,17 reducing stimuli, and thermoregulation (e.g., IV fluids, Stimulatory signs can be followed by depression in cooling towels, or fans).1,6,11 Medication and some cases.3 Other conditions reported are supplementation can include IV fluids to maintain hyperthermia and metabolic acidosis.6,12,17 Management hydration and body temperature, protect the kidneys, of cocaine toxicosis is based on symptomatic and and enhance renal excretion of amphetamines; anti- supportive care. Veterinary nursing care can include emetics; and phenothiazine tranquilizers (e.g., monitoring of the vitals including ECG, acepromazine or chlorpromazine) for the treatment of thermoregulation, reducing stimuli to avoid further agitation and hyperthermia and to regulate blood CNS stimulation, and respiratory support by providing pressure.1,11 Acepromazine should be considered first if a clear airway and ventilation.3 Management and the pet is tachycardic or hypertensive.1,11 If the patient supplementation can include IV fluids to maintain

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renal blood flow; anti-emetics; acepromazine or Management of heroin toxicosis is based on chlorpromazine to manage hyperactivity and to help symptomatic and supportive care. Veterinary nursing reduce hyperthermia; a beta blocker (e.g., propranolol) care can include monitoring vitals and to correct tachyarrhythmias; methocarbamol for thermoregulation. Management and supplementation tremors; diazepam or for the treatment of can include IV fluids; anti-emetics; naloxone, the tremors and seizures; barbiturates for refractory recommended reversal agent that can be used to seizures; cyproheptadine for serotonin syndrome signs; manage CNS depression, seizures, and respiratory and sodium bicarbonate if the patient is acidotic and depression; atropine for bradycardia; and lidocaine for only if the acid-base status can be monitored.1,6,16,17 arrhythmias.1,6,19 If seizures cannot be corrected with Cocaine has some lipid solubility and lipid emulsion naloxone, diazepam can be administered.1 However, therapy (intralipids) may be helpful.1,17 The prognosis exercise caution when using diazepam as it may cause is good with treatment.1,17 further respiratory depression.1 If respiratory depression cannot be managed with naloxone, intubation, oxygen or positive pressure ventilation can be implemented.1,6,19 HEROIN Prognosis is excellent if naloxone is used to reverse the Heroin (diacetylmorphine) is a semi-synthetic signs19 and good if the respiratory and CV systems can drug synthesized from , a derivative of the be maintained.1,16 Prognosis is guarded for patients that opium poppy plant, Papaver somniferum.6,18,19 develop seizures.1 act centrally to elevate the pain threshold and to alter the psychological response to pain. Heroin is a Schedule I drug and common street names include HALLUCINOGENIC MUSHROOMS “lady,” “white girl,” “black tar,” “smack,” “H,” “horse,” Hallucinogenic mushrooms are a genus of mushrooms or “brown sugar.”19 Heroin is generally injected, known as Psilocybe and contain hallucinogenic alkaloids smoked, snorted, used as a suppository, or ingested and called psilocybin and psilocin.3,20 These hallucinogenic can be cut with other prescription opioids, sugar, properties stimulate the serotonin receptors in the starch, strychnine, and levamisole.6,18,19 Ingestion, CNS.3,6,16,20 The mushrooms grow naturally in the inhalation, and dermal are the common routes for environment on manure, rotting wood, or mulch and animal exposures. common street names include “magic mushrooms,” “caps,” and “shrooms.”20 Hallucinogenic mushrooms Signs usually develop within minutes and can last up to are a Schedule I drug and are commonly ingested plain, 12 to 24 hours. Commonly reported signs are GI upset, in foods (stews or omelets), or in beverages (teas or such as vomiting or constipation; CNS depression, milkshakes) to disguise the bitter taste.16,21 Ingestion is such as altered mentation, sedation, ataxia, seizures and the common route for animal exposures. coma; CV signs, such as bradycardia, hypotension, and arrhythmias; and respiratory depression.1,19 Other signs Signs can develop as soon as 30 minutes to 3 hours and reported are hypothermia and miosis or mydriasis.1,19 most animals recover within 12 hours.6,20,21 Common Agitation vocalization and excitation have also been signs include GI upset, such as vomiting and diarrhea; reported, especially in cats.6,19 CNS signs, such as mental and behavioral changes, agitation, vocalization, and seizures; and CV signs, such as tachycardia.1,6,20,21 Hyperthermia, mydriasis, and 1,6,20,21 FUNGUS AMONG US. nystagmus have also been reported. Hallucinogenic mushrooms contain various psychedelic compounds, including psilocybin and psilocin. Management of hallucinogenic mushroom toxicosis is based on symptomatic and supportive care. Veterinary nursing care includes monitoring vitals and monitoring for the development of self-mutilation or other bizarre physical behaviors, thermoregulation, confining pet to prevent injury, and reducing stimuli. Medications and supplementation can include IV fluids, anti-emetics, cyproheptadine for serotonin syndrome signs, and diazepam or barbiturates for the management of seizures.16,20,22

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3. Bischoff K. Toxicity of drugs of abuse. In: Gupta RC ed. Veterinary Prognosis is good, and most animals recover with Toxicology Basic and Clinical Principles. 3rd ed. Academic Press; proper monitoring and symptomatic care.6,20 2018:385-408. 4. Delgado J. Marijuana. In: Yip L, Bruno M, Stephen WB, et al. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia: Saunders; 2007:747-754. DRUG SCREEN 5. Donaldson CW. Marijuana exposure in animals. Vet Med 2002;6:437- 439. If an illicit drug is suspected, but not known, an OTC 6. Volmer PA. Recreational Drugs. In: Peterson ME, Talcott ME, eds. Small urine drug screen can be performed. OTC drug screens Animal Toxicology. 3rd ed. Saunders/Elsevier; 2013:309-334. may be purchased at most local drug stores and most 7. Brutlag A, Hommerding H. Toxicology of marijuana, synthetic cannabinoids, and cannabidiol in dogs and cats. In: Hooser SB and drug screens will detect 4 of the 5 discussed drugs, Khan SA, eds. Veterinary Clinics Small Animals: Common Toxicologic Issues in Small Animals: An Update. (Volume 48-6). Elsevier; excluding hallucinogenic mushrooms. If hallucinogenic 2018:1087-1102. mushrooms are suspected, a urine sample can be sent to 8. FDA and Marijuana: Questions and Answers. U.S. Food and Drug select veterinary diagnostic laboratories.20 However, due Administration. fda.gov/newsevents/publichealthfocus/ucm421168. htm. Accessed January 14, 2019 to the short time frame of clinical signs, most animals 9. Gamble LJ, Boesch JM, Frye CW, et al. Pharmacokinetics, safety, and will recover before the lab results are confirmed. clinical efficacy of cannabidiol treatment in osteoarthritic dogs. Front Vet Sci 2018;5:165. 10. Warning Letters and Test Results for Cannabidiol-Related For the screening to be as accurate as possible, most Products. U.S. Food and Drug Administration. fda.gov/newsevents/ patients will need adequate time for the drug to be publichealthfocus/ucm484109.htm. Accessed January 14, 2019 11. Stern L, Schell M. Management of attention-deficit disorder and absorbed, distributed, metabolized, and excreted attention-deficit/hyperactivity disorder drug intoxication in dogs and (ADME) in the urine. False negatives may occur with cats: an update. In: Hooser SB, Khan SA, eds. Veterinary Clinics Small Animals: Common Toxicologic Issues in Small Animals: An Update marijuana because OTC urine drug screens are (Volume 48-6). Elsevier; 2018:959-968. calibrated to detect certain human metabolites in the 12. Osweiler GD. Over-the-counter drugs and illicit drugs of abuse. In: Toxicology, The National Veterinary Medical Series. Media, PA: Williams urine, and dogs can produce different metabolites that and Wilkins; 1996:303-316. 1,6 the screen will not detect. Some medications can 13. Albertson, TE, Kenyon NJ, Morrissey B. Amphetamines and derivatives. cause false positives (e.g., naproxen, ibuprofen, and In: Yip L, Bruno M, Stephen WB, et al. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. 4th ed. proton pump inhibitors can cause false THC positives; Philadelphia: Saunders/Elsevier; 2007:781-792. antidepressants, such as bupropion and fluoxetine or 14. Klatt CA. Methamphetamine. In: Hovda LR, Brutlag AG, Poppenga RH, Peterson KL, eds. Blackwell’s Five-Minute Veterinary Consult phenylpropanolamine can cause amphetamine/ Clinical Companion: Small Animal Toxicology. 2nd ed. Ames, IA: Wiley- methamphetamines positives; diphenhydramine, Blackwell; 2016:271-277. ciprofloxacin, and quetiapine can cause opioid positives). 15. Albertson TE, Chan A, Tharratt, RS. Cocaine. In: Yip L, Bruno M, Stephen WB, et al. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia: Saunders/Elsevier; 2007:755-772. 16. Beasley, VR, Dorman DC, Fikes JD, Diana SG, Woshner V. A Systems Affected Approach to Veterinary Toxicology. Urbana, Ill.: University of CONCLUSION Illinois; 1999:133-136; 243-248; 226-227. Another important role of the veterinary nurse is to be 17. Bischoff K. Cocaine. In: Hovda LR, Brutlag AG, Poppenga RH, Peterson aware that “street drugs” are not pure and can be KL, eds. Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology. 2nd ed. Ames, IA: Wiley-Blackwell; tainted with other illicit substances and can be 2016:253-258. combined with toxic foods such as chocolate, xylitol, or 18. Yip L, Megarbane B, Borron SW. Opioids. In: Yip L, Bruno M, Stephen WB, et al. Haddad and Winchester’s Clinical Management of Poisoning and espresso beans. In these cases, the signs may not always Drug Overdose. 4th ed. Philadelphia: Saunders/Elsevier; 2007:635-658. be consistent with certain substances. When in doubt, 19. Hovda LR. Opiates and Opioids (Illicit). In: Hovda LR, Brutlag AG, Poppenga RH, and Peterson KL, eds. Blackwell’s Five-Minute stabilize the animal and treat the patient’s signs. Veterinary Consult Clinical Companion: Small Animal Toxicology. 2nd Prevention is key to pet poisons. Although pet owners ed. Ames, IA: Wiley-Blackwell; 2016:286-294. may be reluctant to talk about illicit drugs, veterinary 20. Puschner B, Wegenast C. Diagnosis and treatment of hepatotoxic, neurotoxic, gastroenterological, nephrotoxic, and muscarinic nurses should discuss poison prevention with owners, mushrooms. In: Hooser SB Khan SA, eds. Veterinary Clinics Small such as avoiding access to illegal substances, keeping the Animals: Common Toxicologic Issues in Small Animals: An Update. TVN (Volume 48-6). Elsevier; 2018:1053-1067. pet away from parties, and muzzling police dogs. 21. Brent J, Palmer RB. Mushrooms. In: Yip L, Bruno M, Stephen WB, et al. Haddad and Winchester’s Clinical Management of Poisoning and Drug Overdose. 4th ed. Philadelphia: Saunders/Elsevier; 2007:455-472. 22. Hovda LR. Miscellaneous Hallucinogens and dissociative agents. In: References Hovda LR, Brutlag AG, Poppenga RH, Peterson KL, eds. Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal 1. ASPCA Animal Poison Control Center Case AnTox Database: Toxicology. 2nd ed. Ames, Iowa: Wiley-Blackwell; 2016:278-283. Unpublished data. 2019. 2. Sioris K. Marijuana. In: Hovda LR, Brutlag AG, Poppenga RH, and Peterson KL, eds. Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Toxicology. 2nd ed. Ames, IA: Wiley- Blackwell: 2016:278-283.

todaysveterinarynurse.com • SPRING 2019 • 31 Pet owners already have a lot to remember. Give them one less thing to forget. Only BRAVECTO® delivers up to 12 weeks* of flea & tick protection with one topical dose

Fewer doses = fewer potential gaps in protection = less stress for cats, pet owners, staff.1

Ask your Merck Animal Health Rep about BRAVECTO or Visit Bravectovets.com *BRAVECTO kills fleas and prevents flea infestations for 12 weeks. BRAVECTO Topical Solution for Cats kills ticks (black-legged tick) for 12 weeks and American dog ticks for 8 weeks. 1BRAVECTO Topical Solution for Cats [prescribing information]. Madison, NJ: Merck Animal Health; 2016. IMPORTANT SAFETY INFORMATION: BRAVECTO Topical Solution for Cats: The most common adverse reactions recorded in clinical trials were vomiting, itching, diarrhea, hair loss, decreased appetite, lethargy, and scabs/ ulcerated lesions. BRAVECTO has not been shown to be effective for 12-weeks’ duration in kittens less than 6 months of age. BRAVECTO is not effective against American dog ticks beyond 8 weeks of dosing. For topical use only. Avoid oral ingestion. The safety of BRAVECTO has not been established in breeding, pregnant and lactating cats. Use with caution in cats with a history of neurologic abnormalities. Neurologic abnormalities have been reported in cats receiving BRAVECTO, even in cats without a history of neurologic abnormalities. See full Prescribing Information on page 33.XX. Copyright © 2018 Intervet Inc., d/b/a Merck Animal Health, a subsidiary of Merck & Co. Inc. All rights reserved. US/BRVT/0318/0005 Protect your patients from fleas & ticks for up to 12 weeks* with BRAVECTO®

Feature: Feature: Feature: One dose provides up to 12 Available in a chew Available by weeks* of extended protection or topical solution prescription only against fleas & ticks. for dogs, or topical Benefit: solution for cats Benefit: Good for patients, Fewer treatments per year make Benefit: compliance and pet owner adherence easier. Easy to administer your practice

*BRAVECTO kills fleas and prevents flea infestations. BRAVECTO Chew and BRAVECTO Topical for Dogs kills ticks (black-legged tick, American dog tick, and brown dog tick) for 12 weeks and also kills lone star ticks for 8 weeks. BRAVECTO Topical for Cats kills ticks (black-legged tick) for 12 weeks and American dog ticks for 8 weeks.

IMPORTANT SAFETY INFORMATION: BRAVECTO has not been shown to be effective for 12-weeks’ duration in puppies or kittens less than 6 months of age. BRAVECTO Chew: The most common adverse reactions recorded in clinical trials were vomiting, decreased appetite, diarrhea, lethargy, polydipsia, and flatulence. BRAVECTO is not effective against lone star ticks beyond 8 weeks of dosing. BRAVECTO Topical for Dogs: The most common adverse reactions recorded in clinical trials were vomiting, hair loss, diarrhea, lethargy, decreased appetite, and moist dermatitis/rash. BRAVECTO is not effective against lone star ticks beyond 8 weeks of dosing. For topical use only. Avoid oral ingestion. Use caution in dogs with a history of seizures. Seizures have been reported in dogs receiving fluralaner, even in dogs without a history of seizures. BRAVECTO Topical for Cats: The most common adverse reactions recorded in clinical trials were vomiting, itching, diarrhea, hair loss, decreased appetite, lethargy, and scabs/ulcerated lesions. BRAVECTO is not effective against American dog ticks beyond 8 weeks of dosing. For topical use only. Avoid oral ingestion. The safety of BRAVECTO has not been established in breeding, pregnant and lactating cats. Use with caution in cats with a history of neurologic abnormalities. Neurologic abnormalities have been reported in cats receiving BRAVECTO, even in cats without a history of neurologic abnormalities.

See Prescribing Information on following XX page.

Copyright © 2019 Intervet Inc., d/b/a Merck Animal Health, a subsidiary of Merck & Co., Inc. All rights reserved. US/BRV/0119/0002 Fewer doses help improve adherence

More convenient Fewer potential gaps Available by for pet owners in protection1-4 prescription only Four doses of BRAVECTO Fewer doses per year also Administer the first dose in provide nearly a full year of flea means less chance of pet your clinic and rest assured and tick protection instead of owners forgetting and your patient is protected for having to treat 12 times with a missing one. up to 12 weeks.* monthly product.

1BRAVECTO Chew for Dogs [prescribing information]. Madison, NJ: Merck Animal Health; 2014. 2BRAVECTO Topical Solution for Dogs [prescribing information]. Madison, NJ: Merck Animal Health; 2016. 3BRAVECTO Topical Solution for Cats [prescribing information]. Madison, NJ: Merck Animal Health; 2016. 4Rohdich N, et al. Parasites & Vectors. 2014;7:83.

* BRAVECTO kills fleas and prevents flea infestations.BRAVECTO Chew and BRAVECTO Topical for Dogs kills ticks (black-legged tick, American dog tick, and brown dog tick) for 12 weeks and also kills lone star ticks for 8 weeks. BRAVECTO Topical for Cats kills ticks (black-legged tick) for 12 weeks and American dog ticks for 8 weeks. BRAVECTO at Bravectovets.com

Start an Effective Team to Pet Owner Conversation If engaging in an initial discussion, start with: Ms. Jones, we need to think about year-round flea and tick protection. We have a solution your pet will love and it will be easy for you to remember.

STATE THE SOLUTION MAKE YOUR RECOMMENDATION Bravecto will provide your pet with 12-week* Mrs. Jones, I believe that Bravecto will provide your pet with the protection against fleas and ticks. flea and tick protection they need. Do you have any questions? Adverse Reactions: In a well-controlled U.S. field study, which included a total of 161 households and 311 treated cats (224 with fluralaner and 87 with a topical active control), there were no serious adverse reactions. Percentage of Cats with Adverse Reactions (AR) in the Field Study Adverse Reaction Bravecto Group: Control Group: (AR) Percent of Cats with the AR Percent of Cats with the (fluralaner topical solution) for Cats During the 105-Day Study AR During the 84-Day (n=224 cats) Study (n=87 cats) Caution: Vomiting 7.6% 6.9% Federal (USA) law restricts this drug to use by or on the order of a licensed veterinarian. Pruritus 5.4% 11.5% Description: Diarrhea 4.9% 1.1% Each tube is formulated to provide a minimum dose of 18.2 mg/lb (40 mg/kg) body weight. Each milliliter contains 280 mg of fluralaner. Alopecia 4.9% 4.6% The chemical name of fluralaner is (±)-4-[5-(3,5-dichlorophenyl)-5-(trifluoromethyl)-4,5- Decreased Appetite 3.6% 0.0% dihydroisoxazol-3-yl]-2-methyl-N-[2-oxo-2-(2,2,2-trifluoroethylamino)ethyl]benzamide. Inactive Lethargy 3.1% 2.3% ingredients: dimethylacetamide, glycofurol, diethyltoluamide, acetone Scabs/Ulcerated Lesions 2.2% 3.4% Indications: Bravecto kills adult fleas and is indicated for the treatment and prevention of flea infestations In the field study, two cats treated with fluralaner topical solution experienced ataxia. One cat (Ctenocephalides felis) and the treatment and control of Ixodes scapularis (black-legged tick) became ataxic with a right head tilt 34 days after the first dose. The cat improved within one week infestations for 12 weeks in cats and kittens 6 months of age and older, and weighing 2.6 pounds of starting antibiotics. The ataxia and right head tilt, along with lateral recumbency, reoccurred or greater. 82 days after administration of the first dose. The cat recovered with antibiotics and was redosed with fluralaner topical solution 92 days after administration of the first dose, with no further Bravecto is also indicated for the treatment and control of Dermacentor variabilis (American dog abnormalities during the study. A second cat became ataxic 15 days after receiving its first dose tick) infestations for 8 weeks in cats and kittens 6 months of age and older, and weighing 2.6 pounds and recovered the next day. The cat was redosed with fluralaner topical solution 82 days after or greater. administration of the first dose, with no further abnormalities during the study. Dosage and Administration: In a European field study, two cats from the same household experienced tremors, lethargy, and Bravecto should be administered topically as a single dose every 12 weeks according to the anorexia within one day of administration. The signs resolved in both cats within 48-72 hours. Dosage Schedule below to provide a minimum dose of 18.2 mg/lb (40 mg/kg) body weight. In a European field study, there were three reports of facial dermatitis in humans after close contact Bravecto may be administered every 8 weeks in case of potential exposure to Dermacentor variabilis with the application site which occurred within 4 days of application. ticks (see Effectiveness). For technical assistance or to report a suspected adverse drug reaction, or to obtain a copy of the Dosage Schedule: Safety Data Sheet (SDS), contact Merck Animal Health at 1-800-224-5318. Additional information Body Weight Ranges (lb) Fluralaner content Tubes can be found at www.bravecto.com. For additional information about adverse drug experience (mg/tube) Administered reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/ 2.6 – 6.2 112.5 One AnimalVeterinary/SafetyHealth. >6.2 – 13.8 250 One Clinical Pharmacology: >13.8 – 27.5* 500 One Peak fluralaner concentrations are achieved between 7 and 21 days following topical administration and the elimination half-life ranges between 11 and 13 days. * Cats over 27.5 lb should be administered the appropriate combination of tubes. Mode of Action: Step 1: Immediately before use, open the pouch and remove the tube. Hold the tube at the crimped Fluralaner is for systemic use and belongs to the class of isoxazoline-substituted benzamide end with the cap in an upright position (tip up). The cap should be rotated clockwise or counter derivatives. Fluralaner is an inhibitor of the arthropod nervous system. The mode of action of clockwise one full turn. The cap is designed to stay on the tube for dosing and should not be fluralaner is the antagonism of the ligand-gated chloride channels (gamma-aminobutyric acid removed. The tube is open and ready for application when a breaking of the seal is felt. (GABA)-receptor and glutamate-receptor). Effectiveness: In a well-controlled European laboratory study, Bravecto killed 100% of fleas 8 hours after treatment and reduced the number of live fleas on cats by > 98% within 12 hours after treatment or post-infestation for 12 weeks. In well-controlled laboratory studies, Bravecto demonstrated > 94% effectiveness against Ixodes scapularis 48 hours post- infestation for 12 weeks. Bravecto demonstrated > 98% effectiveness against Dermacentor variabilis 48 hours post-infestation for 8 weeks, but failed to demonstrate ≥ 90% effectiveness beyond 8 weeks. In a well-controlled U.S. field study, a single dose of Bravecto reduced fleas by ≥99% for 12 weeks. Cats with signs of flea allergy dermatitis showed improvement in erythema, alopecia, papules, Step 2: The cat should be standing or lying with its back horizontal during application. Part the scales, crusts, and excoriation as a direct result of eliminating flea infestations. fur at the administration site. Place the tube tip vertically against the skin at the base of the skull of the cat. Animal Safety: Margin of Safety Study: In a margin of safety study, Bravecto was administered topically to 11- to Step 3: Squeeze the tube and gently apply the entire contents of 13-week (mean age 12 weeks)-old-kittens at 1, 3, and 5X the maximum labeled dose of 93 mg/kg Bravecto directly to the skin at the base of the skull of the cat. Avoid at three, 8-week intervals (8 cats per group). The cats in the control group (0X) were treated with applying an excessive amount of solution that could cause some mineral oil. of the solution to run and drip off of the cat. If a second spot is needed to avoid run off, then apply the second spot slightly behind There were no clinically-relevant, treatment-related effects on physical examination, body weights, the first spot. food consumption, clinical pathology (hematology, clinical chemistries, coagulation tests, and urinalysis), gross pathology, histopathology, or organ weights. Cosmetic changes at the application site included matting/clumping/spiking of hair, wetness, or a greasy appearance. Oral Safety Study: In a safety study, one dose of Bravecto topical solution was administered orally to 6- to 7-month-old- kittens at 1X the maximum labeled dose of 93 mg/kg. The kittens in the control Treatment with Bravecto may begin at any time of the year and can continue year round without group (0X) were administered saline orally. There were no clinically-relevant, treatment-related interruption. effects on physical examination, body weights, food consumption, clinical pathology (hematology, Contraindications: clinical chemistries, coagulation tests, and urinalysis), gross pathology, histopathology, or organ There are no known contraindications for the use of the product. weights. All treated kittens experienced salivation and four of six experienced coughing immediately after administration. One treated kitten experienced vomiting 2 hours after administration. WARNINGS Human Warnings: In a well-controlled field study Bravecto was used concurrently with other medications, such as Not for human use. Keep this and all drugs out of the reach of children. vaccines, anthelmintics, antibiotics, steroids and sedatives. No adverse reactions were observed from the concurrent use of Bravecto with other medications. Do not contact or allow children to contact the application site until dry. Storage Conditions: Keep the product in the original packaging until use in order to prevent children from getting direct Do not store above 77°F (25°C). Store in the original package in order to protect from moisture. The access to the product. Do not eat, drink or smoke while handling the product. Avoid contact with pouch should only be opened immediately prior to use. skin and eyes. If contact with eyes occurs, then flush eyes slowly and gently with water. Wash hands and contacted skin thoroughly with soap and water immediately after use of the product. How Supplied: Bravecto is available in three strengths for use in cats (112.5, 250, and 500 mg fluralaner per tube). The product is highly flammable. Keep away from heat, sparks, open flame or other sources of ignition. Each tube is packaged individually in a pouch. Product may be supplied in 1 or 2 tubes per carton. Precautions: For topical use only. Avoid oral ingestion. (see Animal Safety). NADA 141-459, Approved by FDA Distributed by: Use with caution in cats with a history of neurologic abnormalities. Neurologic abnormalities have Intervet Inc (d/b/a Merck Animal Health), Madison, NJ 07940 been reported in cats receiving Bravecto, even in cats without a history of neurologic abnormalities (see Adverse Reactions). Made in the USA. Bravecto has not been shown to be effective for 12-weeks duration in kittens less than 6 months Copyright © 2016 Intervet Inc, a subsidiary of Merck & Company Inc. of age. Bravecto is not effective against Dermacentor variabilis ticks beyond 8 weeks after dosing All rights reserved (see Effectiveness). 159363 R3 017392 The safety of Bravecto has not been established in breeding, pregnant and lactating cats. Rev. 09/16 FROM THE FIELD

GET INVOLVED Supporting the Veterinary Nurse Initiative will drive change to help veterinary technicians build a lifelong career around their passions.

MEET THE AUTHOR

Abbie Hathaway, CVT, Program Manager, Veterinary Technician Training, Banfield Pet Hospital From the Field shares insights from Banfield Pet Hospital veterinary team members. Drawing from the nationwide practice’s extensive research, as well as findings from its electronic veterinary medical records database and more than 8 million annual pet visits, this column is intended to explore topics and spark conversations relevant to veterinary Abbie’s career in veterinary practices that ultimately help create a better world for pets. medicine began nearly 12 years ago, following her undergraduate studies at the University of Southern California. After gaining experience in retail The Importance management, Abbie started as a veterinary assistant, then earned her veterinary technician credentials, and of Veterinary evolved her leadership skills as a practice manager. In her current role as Program Technicians Manager of Veterinary Technician Training, Abbie supports current and aspiring veterinary technicians across ey ingredients of delivering the best patient Banfield Pet Hospital’s more outcomes are a high standard of care and a team of than 1000 hospitals nationwide to help create K dedicated, engaged, and skilled veterinary professionals. healthy workplace environments and enable lifelong careers. shutterstock.com/goodluz

34 • SPRING 2019 • todaysveterinarynurse.com FROM THE FIELD

Banfield recognizes the important role veterinary In the past year, we have put significant efforts into not technicians play as a part of the provider team and only all Banfield associates but also the health and believes that by respecting and empowering veterinary wellbeing of the veterinary technician population. In technicians, we all benefit: clients tend to be more addition to increasing hourly pay and continuing engaged and well-informed, and the health and education funding for all Banfield veterinary technicians wellbeing of their pets may also benefit as a result. in 2018, we are partnering with educational institutions to create pathways for additional development. Although the veterinary industry agrees veterinary technicians are of incredible value, we can’t seem to What motivated these efforts? It’s simple: our agree on what that looks like in day-to-day practice. dedication for driving change is the opportunity we see This is further complicated by the variance in state to help veterinary technicians build a lifelong career practice acts. Many states lack a defined scope of around their passions. I have had many goosebumps- practice, title protection, or title reciprocity for inducing moments listening to our technicians share credentialed veterinary technicians. It is frustrating to how we have helped them engage with their work and hear from people who have been credentialed veterinary how they feel their skills and education are being fully technicians for years and who lose their title when utilized for the betterment of their team and the quality moving to a new state because of this variability. of care their patients receive.

REDEFINING WHAT IT MEANS TO BE A VETERINARY TECHNICIAN For these reasons and many more, Banfield is a proud One of the most impactful supporter of the Veterinary Nurse Initiative (VNI), an things you can do is get industry-wide initiative that aims to unite the profession under a single title, set of credentialing involved and be a part of the requirements, and scope of practice. conversations that are happening in your hospital and This effort aims to positively impact veterinary medicine in various ways, including redefining and local veterinary community. standardizing the role of veterinary technicians with a new title: Registered Veterinary Nurse (RVN). Such a change could have the potential to help clients better understand our role—and underscore the skills and training we bring to the hospital team and the pets we EMPOWERING VETERINARY care for, day in and day out. At Banfield, we support TECHNICIANS: the VNI, including efforts to redefine veterinary Engagement, Utilization, technicians as “veterinary nurses.” and Recognition How can you drive similar efforts to help empower veterinary technicians? One of the most impactful SUPPORTING things you can do is to get involved and be a part of the VETERINARY TECHNICIANS: conversations that are happening in your hospital and Rewarding Value with Value local veterinary community. Whether it’s helping the Veterinary technician involvement in the profession is people you work with better understand the veterinary key. We have all heard about the problems veterinarians technician role, becoming familiar with your state’s face, from veterinary student debt, to compassion practice acts and educating your hospital on them, or fatigue, to suicide. Tragically, veterinary technicians representing the needs of veterinary technicians at your also suffer from the same struggles—a reality that is state’s veterinary board, we all have the ability to critical and deserves both immediate attention and become advocates for the engagement, utilization, and swift action. The industry must work together to create recognition of veterinary technicians. It’s about being an environment that enables technicians to pursue a able to operate at the top of our license, and using our lifelong career in veterinary medicine without the skills and education for the betterment of veterinary burden of educational debt and related stress. medicine. TVN

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Features

CONTINUING EDUCATION — Anesthesia for Geriatric Patients — 38

CASE REPORT: CANINE DIGIT OSTEOSARCOMA — An Uncommon Malignancy Results in a Dog’s Toe Amputation — 52

TOXICOLOGY — Guide to Managing Toxin Ingestion — 58

PRACTICE MANAGEMENT — Happy Visits and Victory Visits: Helping Patients Be Fear Free℠ — 66 shutterstock.com/Liliya Frolova shutterstock.com/Liliya CCONTINUINGONTINUING EDUCATIONEDUCATION • PPEEREER REVIEWEDREVIEWED shutterstock.com/David Herraez Calzada Herraez shutterstock.com/David

IN SAFE HANDS Safely dealing with a geriatric patient requires the veterinary nurse to approach the case well informed and aware of potential complications.

3388 • SSPRINGPRING 22019019 • ttodaysveterinarynurse.comodaysveterinarynursTeO.coXmICOLOGY TALK PEER REVIEWED • CONTINUING EDUCATION

CONTINUING EDUCATION

MEET THE AUTHOR ANESTHESIA

Trish Farry, CVN, AVN, Anesthesia for VTS (ECC, Anesthesia and Analgesia), TAA GCHEd, School of Veterinary Science at The University of Geriatric Patients Queensland, Australia

Trish is a lecturer and clinical instructor in anesthesia at The ngoing developments and innovations University of Queensland. Her areas of teaching include in veterinary medicine have resulted in pets living emergency medicine, longer, and the number of older patients requiring anesthesia, analgesia, and O clinical practices for sedation and general anesthesia for various interventions has undergraduate veterinary and veterinary technology subsequently increased. A geriatric patient is often defined students. Trish is on the as one that has reached 75% of its average life expectancy; Board of Directors for the Veterinary Nurses Council of therefore, the exact age depends on breed and species.1 Australia (VNCA) and is Past President of the Academy of Veterinary Emergency and Critical Care Technicians and Geriatric patients may appear “healthy” for their age, Nurses (AVECCTN). but they often have multiple underlying organ dysfunctions that, when challenged by general anesthesia, can result in a cascade of detrimental events. Although age itself is not a disease, age-related physiologic changes must be evaluated for each patient to ensure that the most appropriate sedation and/or MEET THE anesthesia plan is created. AUTHOR

PATIENT ASSESSMENT Wendy Goodwin, BVSc, AND THE ANESTHETIC PLAN PhD, FANZCVS (Veterinary In dogs and cats, increasing age, independent of patient Anesthesia, Critical Care), School of Veterinary physical status, is associated with an increased risk of Science at The University of anesthetic-related death.2 The exact reasons for this are Queensland, Australia not known, but in humans, an anesthetic plan that includes the identification of specific age-related Wendy works at the comorbidities and geriatric syndromes and the University of Queensland’s provision of appropriate preoperative intervention has School of Veterinary Science been shown to improve postoperative outcomes.3 as a clinical anesthetist, lecturer, and researcher in the areas of anesthesia, analgesia, The anesthetic plan for a geriatric dog or cat should be and critical care. tailored to the individual patient. Obtaining a

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thorough physical examination and detailed medical cardiovascular system of dogs and cats are limited; history is essential to allow for preoperative however, it is generally accepted that age-related optimization and to anticipate and prepare for patient- changes exist and result in a decrease in functional related problems. Additionally, the plan should cardiac reserve that renders that patient less able to incorporate surgical or procedural planning; anesthesia respond to cardiac stress. Geriatric humans exposed to technique, including support and emergency drugs; surgical stress have significantly lower cardiac index, physiologic monitoring; and anesthesia recovery. heart rate, and oxygen delivery,8 and it seems likely that the same is true in geriatric dogs and cats. Common In people, specific geriatric syndromes are well age-related physiologic alterations contributing to the recognized and functional assessment tools are available lack of functional cardiac reserve include decreased to aid in perioperative planning. No such tools are baroreceptor activity; changes in cardiac output, available for veterinary patients; however, the contractility, blood volume, and blood pressure; and a preanesthetic evaluation should focus on geriatric- diminished ability to respond to hypotension. specific domains, including consideration of geriatric physiologic changes and common age-related For the most part, these age-related changes in the comorbidities. For example, the following American cardiovascular system are primarily due to changes in Society of Anesthesiologists (ASA) subclassification of connective tissue.9 Older patients often have less the geriatric population has been proposed:4,5 compliant vessels, myocardial hypertrophy, fibrosis, and ● Class 1 or ASA status II: Healthy geriatric patient valvular disease. Additionally, changes in the with minor changes in organ function conduction system may make older patients more ● Class 2 or ASA status III: Geriatric patient with susceptible to arrhythmias. Cardiac disease is common subclinical organ dysfunction, defined as decreased in geriatric dogs and cats and may further reduce the function of at least one organ (heart, liver, kidney) cardiac reserve in these patients. Common diseases ● Class 3 or ASA status IV, V: Geriatric patient with affecting the heart in older dogs include valvular heart an obvious disease, defined as severe clinical organ diseases, dilated cardiomyopathy, pericardial diseases, (e.g., heart, endocrine, kidney) dysfunction or arrhythmias, and systemic hypertension.4 In cats older neoplasia than 6 years, the most common cardiac disease is Comorbidities may be the reason the patient presents hypertrophic cardiomyopathy.7 for anesthesia or may be unrelated (e.g., geriatric cat with renal failure requiring anesthesia for a dental procedure). Regardless, the perianesthetic management Perianesthetic Considerations of overt disease processes should be considered in As older patients have an increased incidence of cardiac conjunction with the normal geriatric physiologic comorbidities, a thorough history and physical considerations when developing the anesthetic plan. examination are essential, and further diagnostic tests, including thoracic radiographs, hematologic testing, electrocardiography, and echocardiology, may be GERIATRIC PHYSIOLOGIC indicated. Patients that are receiving cardiac CONSIDERATIONS medications generally should continue to receive them The process of aging is complex and multifactorial, and on the day of surgery, although care with drugs that detailed reviews of the functional and physiologic may potentiate hypotension (e.g., beta blockers) is changes associated with aging in dogs and cats are advised. Preexisting cardiac arrhythmias should be available elsewhere.6,7 Put simply, aging affects the evaluated preoperatively and treated if necessary. physiology of every major organ system, resulting in a seemingly healthy older patient having a diminished Additionally, certain anesthetic drugs should be avoided ability to handle physiologic stress. Major age-related with some types of cardiac disease; for example, higher changes that have implications regarding the doses of are contraindicated in patients with perianesthetic management of geriatric dogs and cats hypertrophic cardiomyopathy.10 are addressed below. Attenuating anesthesia-induced cardiovascular depression and hypotension is of the utmost Cardiovascular System importance. Careful monitoring of the cardiovascular Studies evaluating the effects of aging on the system throughout the entire anesthetic period and the

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ability to immediately respond to detrimental changes are essential in avoiding or reducing cardiovascular depression and resulting hypotension. Fluid therapy Preoxygenation with 100% oxygen should be prescribed on an individual basis and the before induction of anesthesia is patient’s response to fluid therapy continuously essential, as increasing the oxygen monitored, as many geriatric patients with preexisting heart disease are prone to fluid overload. fraction in the lungs helps prevent hypoxemia during induction Respiratory System and intubation. In people, the risk of preanesthetic respiratory complications is significantly increased in older patients.11 Age-related changes to the respiratory system include alterations in mechanical properties (e.g., reduced lung elasticity, chest wall compliance, and than 8 hours). Water should be withheld only for a respiratory muscle strength resulting in decreased vital short period of time to minimize dehydration. capacity), reduction of arterial oxyhemoglobin saturation, and an impaired response to hypoxemia and The liver experiences significant age-related changes, hypercapnia.11 Older patients have lower tidal volumes such as a reduction in volume and blood flow and a and higher respiratory rates than younger patients.9 decline in phase 1 drug metabolizing activity.3,9 These changes vary between animals but may result in delayed Consequently, older patients have a decreased drug metabolism and prolonged duration of action of respiratory reserve and are highly susceptible to hypoxia some anesthetic medications that undergo hepatic and hypercapnia in the perianesthetic period. metabolism. Complications in recovery from anesthesia are of particular concern. Perianesthetic Considerations Owing to the increased risk of regurgitation and Perianesthetic Considerations aspiration, appropriate risk management strategies, Preoxygenation with 100% oxygen before induction of such as administering gastric protectants, ensuring the anesthesia is essential, as increasing the oxygen fraction airway is secure, and suctioning the esophagus before in the lungs helps prevent hypoxemia during induction extubation, should be considered. Patients with and intubation. Care should be taken not to further preexisting hepatic disease may require further workup, stress dyspneic patients. The facilities and technical including preanesthesia albumin levels, liver function skills to secure an airway and ventilate are a prerequisite tests, and coagulation studies, to establish functional to general anesthesia in geriatric patients. Monitoring, baselines. Patients may be prone to hypoglycemia, and including pulse oximetry, capnography, and possibly blood glucose should be monitored and dextrose respiratory blood gas analysis, should continue into the supplementation administered if required. Anesthetic anesthetic recovery period and supportive therapy (e.g., and analgesic drugs that primarily undergo hepatic oxygen supplementation) should be continued as metabolism should be used with caution with indicated. appropriate dosing adjustments.3

Gastrointestinal System Renal and Endocrine Systems Geriatric patients have reduced esophageal motility and Renal function declines gradually with age; however, it gastric acid secretion and a delayed gastric emptying is worth noting that studies in dogs suggest that time, all of which place them at a higher risk for age-related nephron loss of up to 75% may occur aspiration during anesthetic induction and in the before clinical or routine biochemical changes postoperative period.9 Fasting is recommended for indicative of renal disease are seen.6,12 In cats, chronic patients undergoing elective general anesthesia, but in kidney disease is relatively common, with the reported older patients, to minimize the risk of hypoglycemia, it prevalence in cats aged 12 to 20 years ranging from should be kept to a minimum (generally not longer 28% to 81%.13,14 Age-related renal changes reported in

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humans include diminished renal blood flow, changes anesthetizing geriatric dogs and cats include an impaired in autoregulation, and renal tubular dysfunction, which ability to thermoregulate and diminished sensory may lead to fluid and electrolyte abnormalities.3 functions (e.g., smell, hearing, vision).

Increasing age is also associated with a decline in Changes in the peripheral nervous system in aged endocrine function secondary to a decrease in hormone animals typically result in patients being more sensitive production and tissue responsiveness.3 Common to the effects of local anesthetics and neuromuscular endocrine disorders of geriatric dogs and cats include blocking drugs.18 hyperadrenocorticism, diabetes mellitus, and hypothyroidism; further discussion of the anesthetic management of patients with endocrine disease is Perianesthetic Considerations available elsewhere.15 Age-related changes in the neurologic system (central and peripheral) result in a reduced dose requirement for anesthetic, analgesic, and neuromuscular blocking Perianesthetic Considerations drugs to produce the desired effect. Geriatric dogs and Older patients will have some degree of renal cats are more at risk than younger animals of insufficiency resulting in reduced renal reserve capacity experiencing cognitive and behavioural disorders, such and may be at an increased risk of perioperative acute as delirium and anxiety, in the postoperative period. kidney injury compared with younger patients. During the perioperative period, monitoring and maintenance Hypothermia can lead to cardiac arrhythmias, delayed of adequate blood pressure and renal perfusion are healing, a decrease in anesthetic requirements, increased essential. Baseline blood pressure and electrolyte infection rates, and metabolic acidosis. Hypothermia measurement and renal function tests are may also prolong and potentiate the effects of sedative recommended. Fluid and electrolyte abnormalities and anesthetic agents. should be corrected before surgery, and patients with uremia have been shown to benefit from preanesthetic fluid therapy.16

Intraoperative fluid therapy should be tailored to the individual patient, with specific fluid types and rates varying depending on patient presentation and response. Similarly, vasopressors and inotropes should be available to improve cardiac output, although exact indications for use will depend on the patient.

Central and Peripheral Nervous Systems As the brain ages, its structure and function change, including a loss of brain volume (e.g., neuronal cell loss), increased permeability of the blood–brain barrier, and a decrease in cerebral metabolic rate. Neurotransmitters, such as dopamine and serotonin, also tend to decline. In dogs, an age-related cognitive and behavioral decline is well documented.17 Combined, these changes in the neurologic system may predispose geriatric patients to postoperative cognitive complications. In people, disorders such as postoperative delirium (acute) and postoperative cognitive dysfunction 3 (chronic) are well recognized; although not well defined FIGURE 1. An emaciated geriatric cat. This patient will have in veterinary patients, such disorders most likely occur. difficulty thermoregulating under anesthesia because of its body condition. Additional changes that should be considered when

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Musculoskeletal System In people, sarcopenia is a geriatric syndrome defined as a progressive and generalized loss of skeletal muscle Box 1 Balanced Anesthesia and Analgesia mass and strength in the absence of disease (FIGURE 1), A balanced, multimodal anesthesia and analgesia plan using regional blocks and/or systemic analgesics (e.g., opioids, and it has been identified as an independent predictor ketamine) will help reduce the amount of maintenance of mortality and morbidity.19 A similar decline in anesthetic agent required. The concept of balanced anesthesia, introduced by John Lundy in 1926, combines musculoskeletal function is observed in dogs and cats, premedication, regional anesthesia, and general anesthesia and recent research suggests that the pathophysiology to obtain analgesia using a balance of drugs and techniques. in dogs may be similar to that observed in people.20 An The idea is to reduce overall drug doses and minimize dose- dependent side effects while retaining desirable analgesic age-related decrease in lean body mass has been effects. The exact technique and drug combination depend associated with a shortened lifespan in cats7 and dogs.21 on the patient and surgery to be performed, but in general, techniques are very useful in older patients. While older dogs and cats are more likely to be As patients can be sensitive to the effects of local anesthetic underweight than younger animals, aging is also agents, care should be taken when calculating doses to avoid associated with an increase in adipose tissue and an potential toxicosis. increase in fat:lean ratio may negatively affect longevity. Extremes in weight have been associated with an increased risk of perianesthetic death in dogs and cats.2

Osteoarthritis and degenerative joint disease are blood flow and a reduction in phase 1 reactions. Older common in older dogs and cats, and these patients are patients may also have greater drug sensitivity; for often receiving nonsteroidal anti-inflammatory drugs example, age-related changes in the central nervous (NSAIDs). system may lead to potentiation of the central nervous system depressive effects of many anesthetics.

Perianesthetic Considerations Consequently, drug dose adjustments and the selection Patients that have obvious muscle wasting or are obese of drugs with different routes of elimination and/or may be at an increased risk of perioperative metabolism may be required to reduce the risk of complications. Changes in body composition and overdose and toxicosis. If possible, short-acting, concurrent NSAID use should be considered when reversible drugs should be chosen, and judicious dosing choosing anesthetic and analgesic drugs and dosages. and titration of drugs is advisable until the desired For example, maintenance of adequate blood pressure effect is achieved. It is much easier to administer and renal perfusion during anesthesia is important to additional drug than to manage the effects of an prevent renal injury in patients concurrently receiving overdose. NSAIDs. No single anesthetic technique is suitable for all geriatric patients. A balanced anesthetic technique PHARMACOLOGY should be chosen that is individualized to the patient Normal age-related changes in physiology and and considers the patient’s current physiologic state, subclinical organ dysfunction or coexisting disease may likely perianesthetic complications, and surgical or lead to alterations in pharmacokinetics and procedural goals (BOX 1). pharmacodynamics in geriatric patients. Older animals typically have decreased muscle mass, increased adipose tissue, and a reduction in body water. As a result, Premedication lipophilic drugs (e.g., many drugs used for anesthesia Opioids, phenothiazines, benzodiazepines, and alpha-2 and analgesia) will have a larger volume of distribution adrenergic agonists are commonly used for the sedation and potentially longer duration of action.22 of geriatric patients. These drugs can be used independently or in combination. Changes in renal function may result in decreased clearance of drugs eliminated via renal mechanisms and increased sensitivity to drugs with the potential for Opioids renal damage. Additionally, drug metabolism in older Opioids provide analgesia and sedation in geriatric patients is usually decreased due to reduced hepatic patients, with pure µ agonists (morphine, meperidine,

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, oxymorphone, hydromorphone, and Alpha-2 adrenergic agonists methadone) providing better analgesia than the partial Alpha-2 adrenergic agonists, such as medetomidine and µ agonist (buprenorphine) and the κ agonist/µ partial dexmedetomidine, provide effective sedation and agonists (butorphanol, nalbuphine).23 Administration analgesia; however, they should also be used with of opioids can result in respiratory depression, and caution in geriatric patients based on their effects on oxygen supplementation should always be available. the cardiovascular system (reduced cardiac output, Opioids cause minimal direct cardiovascular depression bradyarrhythmias). This class of drug also requires but may result in bradycardia that is responsive to extensive hepatic metabolism, and prolonged and more anticholinergics. profound effects are expected in patients with reduced hepatic function.24 Some opioids have a relatively short duration of action, which may be beneficial in geriatric patients. Perioperative use of opioids contributes to a balanced Anticholinergics anesthetic technique and, depending on the timing of The anticholinergic drugs atropine and glycopyrrolate administration, decreases the dose of induction and are used predominantly to treat sinus maintenance anesthetic agents required. bradyarrhythmias. Anticholinergics should be used judiciously in geriatric patients because sinus Opioids require hepatic metabolism and should be used tachycardia increases the myocardial oxygen demand judiciously in patients with severe hepatic disease. A and can result in myocardial hypoxia and arrhythmias. decrease in the dose or frequency of administration may be warranted. If adverse effects are seen with the Sinus tachycardia is poorly tolerated in geriatric administration of opioids, an opioid antagonist such as patients with preexisting cardiac disease and may naloxone can be administered. precipitate acute myocardial failure. Anticholinergic drugs should not be used routinely, but as necessary, when bradycardia is exacerbating hypotension. Benzodiazepines Glycopyrrolate may be a better choice in geriatric Benzodiazepines (diazepam, midazolam) can be used patients because it has fewer adverse effects. For for tranquilization of geriatric patients and are example, it does not cross the blood–brain barrier, thus commonly combined with an opioid for premedication. central nervous system effects are avoided. They cause minimal cardiovascular and dose-related respiratory depressant effects and have a relatively short duration of action (particularly midazolam); however, Induction of Anesthesia some patients may become dysphoric and confused Induction of general anesthesia can be achieved by after administration. using injectable or agents. Commonly used injectable agents are ketamine/ Benzodiazepines are metabolized by the liver, and a benzodiazepines, , , , and prolonged duration of action may be seen in patients (outside the United States) thiopentone. with hepatic disease. Flumazenil, a benzodiazepine antagonist, can be used as a reversal agent if necessary. Increased circulation time may cause a delayed response to drug administration. Adequate sedation and careful drug titration assist in reducing the total dose of Acepromazine injectable induction drug required. All induction agents Acepromazine is a phenothiazine with antiemetic, can cause significant respiratory depression. anxiolytic, and antiarrhythmic properties, but it should Preoxygenation with 100% oxygen is essential. be used with caution in geriatric patients. Hypotension and hypothermia due to peripheral vasodilation are Of all the induction agents, only ketamine provides often observed after administration. analgesia, so appropriate analgesic drugs should be used concurrently as indicated. Acepromazine is metabolized by the liver, is not reversible, and has a long duration of action. Blood pressure monitoring and volume support are indicated Propofol if acepromazine is administered to a geriatric patient. Propofol is an injectable anesthetic agent that is rapidly

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cleared from the body; some extrahepatic metabolism preexisting cardiac disease, as after induction of may occur. Propofol can cause dose-dependent anesthesia it results in good cardiovascular stability with cardiovascular and respiratory depression and should be minimal changes to heart rate and arterial blood administered slowly until the desired effect is achieved. pressure. Like propofol, it may cause dose-dependent Propofol can cause direct myocardial depression and respiratory depression and is best titrated to effect. vasodilation, which may result in arterial hypotension. Recovery from this drug is usually rapid and smooth. Etomidate may inhibit adrenocortical function and so should be used with caution in patients with impaired adrenocortical function (e.g., patients with Addison’s Etomidate disease). In unsedated patients, retching, vomiting, and Etomidate is a hypnotic induction agent characterized excitation in the early recovery period have been by a rapid onset of action and rapid recovery. noted.25 Etomidate is an excellent drug choice for patients with

TABLE 1 Suggested Drug Doses for Geriatric Small Animals

DRUG DOSAGE (MG/KG)a COMMENTS

ANTICHOLINERGICS

• Anesthetic adjuvant Atropine 0.02–0.04 SC, IM, IV • Treatment of bradycardia

Glycopyrrolate 0.01–0.02 SC, IM, IV

BENZODIAZEPINES AND TRANQUILIZERS

• SC uptake unreliable Diazepam 0.1–0.4 IV, IM • More effective when used in conjunction with an opioid

• More effective when used in conjunction with an Midazolam 0.1–0.3 SC, IM, IV opioid • Shorter duration of action than diazepam

• Benzodiazepine antagonist Flumazenil 0.1 IV • Short duration of action

Acepromazine 0.025–0.05 SC, IM, IV • Use with caution

OPIOIDS (USE LOWER-END DOSES IN CATS)

Methadone 0.05–0.3 SC, IM, IV • Good analgesia

• Good analgesia Morphine 0.05–0.3 SC, IM • Vomiting may occur

• Slow onset of action Buprenorphine 0.005–0.02 SC, IM, IV • SC route not recommended in cats27

Fentanyl 0.005–0.01 IV • Short acting

• Mild pain only Butorphanol 0.1–0.3 SC, IM, IV • May provide good sedation

Hydromorphone 0.03–0.1 SC, IM, IV • Good analgesia

Oxymorphone 0.03–0.07 SC, IM, IV • Good analgesia

• Opioid antagonist Naloxone 0.01–0.04 IV • All analgesia reversed • Short duration of action

INDUCTION AGENTSb

Propofol 2–6 IV • Hypotension and apnea common

Ketamine/diazepam 0.15–0.3/1.5–3 IV

Etomidate 1–3 IV

Alfaxalone 1–2 IV

a Extrapolated from healthy adult doses. Combining drug groups provides balanced premedication. b Induction dose rates are for premedicated patients and should be titrated slowly to effect.

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Ketamine Barbiturates Ketamine is a dissociative anesthetic agent. Anesthesia Barbiturates cause significant cardiovascular and with ketamine is characterized by good cardiovascular respiratory depression. They are also arrhythmogenic stability; increased cardiac output and tachycardia may and best avoided in geriatric patients. result from stimulation of the sympathetic nervous system. Tachycardia increases myocardial oxygen TABLE 1 summarizes drug dosages for geriatric patients. demand, which may result in myocardial hypoxia and subsequent cardiac failure in a compromised patient (e.g., one with hypertrophic cardiomyopathy). Seizures, Maintenance of Anesthesia muscular tremors, and vomiting have been observed General anesthesia is commonly maintained with with the use of ketamine as a sole anesthetic agent. It is inhalational anesthetic agents. All inhalational agents often combined with a muscle relaxant, such as produce some dose-dependent cardiovascular and midazolam, to minimize these undesirable effects. respiratory depression. , , and are all appropriate choices for geriatric patients. These agents require minimal hepatic Alfaxalone metabolism and renal elimination. Alfaxalone in cyclodextrin is a steroidal anesthetic agent that is commercially available in preserved and The minimum alveolar concentration of inhalational unpreserved formulations. Alfaxalone acts rapidly and agents is reduced in geriatric patients, resulting in a results in good muscle relaxation and cardiovascular decrease in inhalant anesthetic requirements. Lung stability with minimal respiratory depression observed changes (pulmonary fibrosis) and hypoventilation in at clinical dose rates.26 It is noncumulative and rapidly these patients may lower the levels of inhalant reaching metabolized by the liver. Recovery in premedicated the brain and thereby prolong the time needed to reach animals is usually smooth and uneventful. a stable anesthetic plane.

ANESTHETIC MONITORING AND EQUIPMENT Minimum monitoring for an anesthetized geriatric patient should include pulse oximetry, capnography, noninvasive blood pressure, ECG, and temperature. Additional monitoring as indicated by individual patient requirements may include invasive blood pressure, central venous pressure, blood gases, blood glucose, and urine output (FIGURE 2).

Each patient should have intravenous access, although care should be taken not to stress the patient during restraint for placement. Use of local anesthetic (e.g., EMLA® cream) may improve patient comfort and aid in placing the catheter. Geriatric patients should receive perianesthetic fluid support, but overzealous fluid administration may precipitate congestive heart failure or pulmonary edema, particularly in cats or patients with underlying cardiac disease. As patients are prone to hypothermia, appropriate perioperative warming, such as heated intravenous fluids, breathing circuits, and convective air warmers, should be used.

Geriatric patients have decreased organ reserve, and appropriate supportive drugs and equipment should be FIGURE 2. Monitoring a geriatric dog during anesthesia. readily available. Doses for cardiovascular support and

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emergency drugs should be calculated and the drugs CONCLUSION drawn up in syringes and prepared if possible. Safely dealing with a geriatric patient requires the Respiratory support equipment, including endotracheal veterinary nurse to approach the case well informed tubes, oxygen, and equipment for assisted ventilation and aware of potential complications. The importance (e.g., breathing system, rebreathing bag, manometer, of a thorough history and workup cannot be mechanical ventilator) should be prepared and checked. overemphasized for these patients. Drug doses should be reduced, slower response times may be seen, and drugs that have long durations of action are best RECOVERY FROM ANESTHESIA avoided. The anesthetist needs to be vigilant and Continued physiologic monitoring and planning for prepared to respond to a variety of situations. An the recovery phase of anesthesia is essential for geriatric understanding of the physiologic and anatomic patients. Care must be taken to maintain body differences in the geriatric patient will ensure that the temperature, as shivering significantly increases oxygen anesthetist is well prepared for the successful consumption and may lead to hypoxia. Supplemental management of these often complex, challenging, and oxygen may be required until the patient is able to difficult cases. TVN maintain adequate oxygenation on room air. Intravenous fluid therapy should be maintained until This article has been updated, edited and reprinted with the animal has adequate intake of food and water and is permission of John Wiley & Sons, Inc. From: Anesthesia hemodynamically stable. for Veterinary Technicians, Ed. Bryant 2010©

Appropriate analgesia should be continued in the recovery period. Anesthetists should be prepared for postoperative delirium in geriatric patients, and sedatives such as acepromazine, medetomidine, Geriatric patients with minimal dexmedetomidine, and opioids should be readily available. Distinguishing between pain and delirium in body fat and decreased muscle older patients can often be challenging; however, if in mass often have bony doubt, pain relief should always be provided. Geriatric prominences (hips, hocks, animals often require extra attention and respond well to regular positive interactions with staff. elbows, sternum) that may be susceptible to the formation of Hospitalization should be kept to a minimum because decubital ulcers if not padded these patients often do better at home with their 28 owners. Appropriate nutrition must be instigated as and protected appropriately. soon as feasible in the recovery period. Each patient should have an individual diet plan based on its current disease status and metabolic requirements.

Comfortable bedding and diligent nursing care should References always be provided. Special care needs to be taken with 1. Goldston R. Introduction and overview of . In: Goldston R, Hoskins J, eds. Geriatrics and Gerontology of the Dog and Cat. providing support with the positioning of the Philadelphia, PA: WB Saunders; 1995. recumbent or anesthetized patient. Extra padding and 2. Brodbelt D. Perioperative mortality in small animal anaesthesia. Vet J support for arthritic joints should be provided when 2009;182(2):152-161. 3. Dalton A, Zafirova Z. Preoperative management of the geriatric positioning these patients on the surgery table. patient: frailty and cognitive impairment assessment. Anesthesiol Clin Geriatric patients with minimal body fat and decreased 2018;36(4):599-614. muscle mass often have bony prominences (hips, hocks, 4. da Cunha AF. Neonatal, pediatric, and geriatric concerns. In: Snyder LBC, Johnson RA, eds. Canine and Feline Anesthesia and Co-Existing elbows, sternum) that may be susceptible to the Disease. Singapore: John Wiley & Sons Inc.; 2015:310-319. formation of decubital ulcers if not padded and 5. Kukanich B. Geriatric veterinary pharmacology. Vet Clin North Am protected appropriately.28 Small Anim Pract 2012;42(4):631-642, v. 6. Bellows J, Colitz CM, Daristotle L, et al. Common physical and functional changes associated with aging in dogs. JAVMA 2015;246(1):67-75.

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7. Bellows J, Center S, Daristotle L, et al. Aging in cats: common physical 19. Malafarina V, Uriz-Otano F, Iniesta R, et al. Sarcopenia in the and functional changes. J Feline Med Surg 2016;18(7):533-550. elderly: diagnosis, physiopathology and treatment. Maturitas 8. Belzberg H, Wo CC, Demetriades D, et al. Effects of age and obesity 2012;71(2):109-114. on hemodynamics, tissue oxygenation, and outcome after trauma. J 20. Pagano TB, Wojcik S, Costagloila A, et al. Age related skeletal Trauma 2007;62(5):1192-1200. muscle atrophy and upregulation of autophagy in dogs. Vet J 9. Alvis BD, Hughes CG. Physiology considerations in geriatric patients. 2015;206(1):54-60. Anesthesiol Clin 2015;33(3):447-456. 21. Adams VJ, Watson P, Carmichael S, et al. Exceptional longevity and 10. Bednarski R, Grimm K, Harvey R, et al. AAHA anesthesia guidelines for potential determinants of successful ageing in a cohort of 39 Labrador dogs and cats. JAAHA 2011;47(6):377-385. retrievers: results of a prospective longitudinal study. Acta Vet Scand 2016;58(1):29. 11. Sprung J, Gajic O, Warner DO. Review article: age related alterations in respiratory function—anesthetic considerations. Can J Anaesth 22. Lin HS, McBride RL, Hubbard RE. Frailty and anesthesia—risks during 2006;53(12):1244-1257. and post-surgery. Local Reg Anesth 2018;11:61-73. 12. Kaufman GM. Renal-function in the geriatric dog. Compend Contin 23. Epstein M, Rodan I, Griffenhagen G, et al. 2015 AAHA/AAFP pain Educ Pract Vet 1984;6(12):1087-1094. management guidelines for dogs and cats. JAAHA 2015;51(2):67-84. 13. Bartlett PC, Van Buren JW, Neterer M, et al. Disease surveillance and 24. Smith S, Scarth E, Sasada M. Drugs in Anaesthesia and Intensive Care. referral bias in the veterinary medical database. Prev Vet Med 2010;94 4th ed. Oxford, UK: Oxford University Press; 2011:390. (3-4):264-271. 25. Carpenter RE, Pettifer GR, Tranquilli WJ. Anesthesia for geriatric 14. Marino CL, Lascelles BD, Vaden SL, et al. Prevalence and classification patients. Vet Clin North Am Small Anim Pract 2005;35(3):571-580. of chronic kidney disease in cats randomly selected from four age 26. Keates H, Whittem T. Effect of intravenous dose escalation with groups and in cats recruited for degenerative joint disease studies. J alfaxalone and propofol on occurrence of apnoea in the dog. Res Vet Feline Med Surg 2014;16(6):465-472. Sci 2012;93(2):904-906. 15. Fischer BL. Endocrine disease. In: Snyder LBC, Johnson RA, eds. 27. Giordano T, Steagall PV, Ferreira TH, et al. Postoperative analgesic Canine and Feline Anesthesia and Co-Existing Disease. Singapore: effects of intravenous, intramuscular, subcutaneous or oral John Wiley & Sons Inc.; 2015:151-174. transmucosal buprenorphine administered to cats undergoing 16. Davis H, Jensen T, Johnson A, et al. 2013 AAHA/AAFP fluid ovariohysterectomy. Vet Anaesth Analg 2010;37(4):357-366. therapy guidelines for dogs and cats. JAAHA 2013;49(3):149-159. 28. Amalsadvala T, Swaim SF. Management of hard-to-heal wounds. Vet 17. Chapagain D, Range F, Huber L, et al. Cognitive aging in dogs. Clin North Am Small Anim Pract 2006;36(4):693-711. Gerontology 2018;64(2):165-171. 18. Doshi A, Cabeza R, Berger M. Geriatric anesthesia: age-dependent changes in the central and peripheral nervous systems. In: Reves JG, Barnett SR, McSwain J, et al, eds. Geriatric . Switzerland: Springer International Publishing; 2018:145-160.

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CONTINUING EDUCATION Anesthesia for Geriatric Patients

The article you have read has been LEARNING OBJECTIVES submitted for RACE approval for 1 Upon completion of this article, the reader should be able to: hour of continuing education • Describe the risks associated with administration of anesthetic agents to a credit and will be opened for geriatric patient. enrollment when approval has been • Understand basic physiology and pharmacology as related to a geriatric received. To receive credit, take the anesthesia patient. approved test online for free at • Understand the importance of developing an anesthesia plan for every patient. vetfolio.com/journal-ce. Free registration on VetFolio.com is TOPIC OVERVIEW required. Questions and answers This article will provide veterinary nurses with the information they need to safely online may differ from those below. anesthetize geriatric patients, from surgical planning to anesthesia recovery. Tests are valid for 2 years from the date of approval.

1. A geriatric patient can be defined as one that has 7. Neurologic system changes that may predispose reached ____ of its life expectancy. geriatric patients to postoperative cognitive a. 50% complications include: b. 60% a. Increased permeability of the blood–brain c. 75% barrier d. 85% b. Neuronal cell loss c. Decreased cerebral metabolic rate 2. Age-related cardiovascular system changes in d. Increased levels of neurotransmitters (e.g., geriatric patients may include all of the following dopamine, serotonin) except: a. Alterations in heart rhythm 8. ______is one of the most common effects b. Diminished ability to respond to hypotension seen with the administration of acepromazine as c. Myocardial hypertrophy and fibrosis part of an anesthesia protocol. d. Increased baroreceptor activity a. Peripheral vasodilation b. Peripheral vasoconstriction 3. Age-related respiratory system changes in geriatric c. Tachycardia patients may include all of the following except: d. Bradycardia a. Impaired response to hypoxemia and hypercapnia 9. Preoxygenating a patient immediately before b. Decreased lung elasticity induction: c. Lower tidal volumes a. Increases the oxygen fraction in the lungs d. Increased chest wall compliance b. Increases uptake of the anesthetic induction agent 4. Anticholinergics are administered to veterinary c. Decreases uptake of the anesthetic induction patients to: agent a. Decrease the heart rate d. Causes respiratory depression b. Treat sinus bradyarrhythmia c. Treat sinus tachyarrhythmia 10. Which of the following regarding balanced d. Decrease the heart rate and respiratory anesthesia in geriatric patients is incorrect? secretions a. Balanced anesthesia techniques should be tailored to the individual patient. 5. Which drug does not cross the blood–brain barrier? b. Balanced anesthesia combines premedication, a. Glycopyrrolate regional anesthesia, and general anesthesia to b. Alfaxalone obtain analgesia using a selection of drugs and c. Propofol techniques. d. Atropine c. Balanced anesthesia is intended to reduce overall drug doses and minimize dose- 6. Hypothermia in an anesthetized patient may lead dependent side effects and analgesic effects. to all of the following except: d. A balanced, multimodal anesthesia and a. Cardiac arrhythmia analgesia plan using regional blocks and/or b. Delayed wound healing systemic analgesics helps reduce the amount of c. Increase in anesthetic requirements maintenance anesthetic agent required. d. Increase in infection rate

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UNUSUAL CASE Canine digits are amputated for reasons ranging from osteomyelitis to melanoma. This

case was the author's shutterstock.com/Eudyptula first experience with a diagnosis of digit osteosarcoma.

Who Will Win the Grand Prize? A panel of judges selected by the NAVC, Today’s Veterinary Nurse editors, and Zoetis® will choose 4 finalists whose case reports will be published in Today’s Veterinary Nurse during 2019. The judges will select the Grand Prize winner from among the 4 finalists, who are “competing” to win a trip to VMX 2020, including registration, hotel, and airfare.

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CASE REPORT: CANINE DIGIT OSTEOSARCOMA An Uncommon Malignancy Results in a Dog’s Toe Amputation

everal disease processes can affect

MEET THE an animal’s digits. Those that require surgical AUTHOR Sintervention include severe fractures, infection (e.g., osteomyelitis), benign masses, and malignant processes

Stephani Hrabnicky, LVT of the bone and/or surrounding soft tissue. Over the BluePearl Veterinary Partners past year, the surgery department of BluePearl Veterinary Southfield, MI Partners in Southfield, Michigan, has seen cases involving each of these ailments. One case proved to be particularly Stephani obtained her license in 2013 after earning a interesting, as it involved an uncommon malignant bachelor’s of science degree in veterinary technology from process of the affected digit: osteosarcoma (OSA). Michigan State University. She got her start in general practice, but has spent the HISTORY AND PRESENTATION past 3 years dedicated to the busy surgery department of Bella, a 9-year-old, female, spayed pit bull, initially BluePearl Veterinary Partners presented to the oncology department with swelling in Southfield, Michigan, where associated with the second digit of the right forelimb. she is currently the primary She had an approximately 1-year history of intermittent nurse for her surgeon. When not in the operating room, lameness of the right forelimb with localized bleeding she can be found planning for and tissue exposure of the second digit. a future VTS in anesthesia and analgesia. INITIAL ASSESSMENT On presentation, Bella was found to be bright, alert, and responsive. The base of the affected toenail was actively bleeding. On physical examination, the only significant findings were a firm, 2.5 × 2 cm tumor associated with the second digit on the right forelimb (FIGURES 1 AND 2) and a grade III/VI heart murmur. A cardiology consultation was recommended to better assess the heart murmur before any future anesthetic events. Thoracic radiographs were recommended to

todaysveterinarynurse.com • SPRING 2019 • 53 FEATURES • PEER REVIEWED

assess for metastatic disease as well as to evaluate the chose to return with Bella for a cardiology evaluation to cardiac silhouette and major vessels in light of the heart address her heart murmur. At physical examination, the murmur. The owners agreed to the radiographs, which only significant findings were, again, a grade III/VI were obtained at the initial appointment. Official review heart murmur and swelling associated with the second of the radiographs revealed age-related pulmonary digit of her right front foot. The size and appearance of changes, with no obvious signs of metastatic disease. The the swelling appeared to be consistent with her initial cardiology consultation was planned for a future date. presentation.

Given the length of time that Bella had been A full cardiology examination was completed, including experiencing issues with her digit, along with financial an echocardiogram, to assess the structure and function concerns on the part of the owners, digit amputation of Bella’s heart. Chronic degenerative valve disease with was recommended with no further diagnostic tests (i.e., mild to moderate mitral regurgitation was diagnosed. No fine-needle aspiration and digit radiography). Several cardiac remodeling was present. One singular ventricular possible tumor types were discussed with the owners premature contraction was noted during the before surgery, including squamous cell carcinoma echocardiogram but was not repeatable. Regular recheck (SCC) and melanoma. These two types account for examinations were recommended every 6 to 8 months to most malignant processes affecting the digits, with assess potential progression of the cardiac disease, but no SCC diagnosed in 50% of cases and melanoma in medications were deemed necessary at that time. Bella 16%.1 Digit OSA is much less common and was not was cleared for a normal anesthetic protocol by the discussed in depth with the owners. It was listed along cardiology department, with the only recommendation with mast cell tumor as a diagnostic differential for the being a reduced intraoperative fluid rate. mass, pending histopathology results. A surgical consultation was performed on the same day to discuss options for the digit mass. In agreement with PREOPERATIVE TESTING the oncology department, surgical amputation of the Seven weeks after the initial presentation, the owners affected digit was recommended, with potential

FIGURE 1. Palmar aspect of affected forepaw. Swelling of digit 2 and abnormalities of the corresponding nail can be seen. FIGURE 2. Lateral aspect of affected forepaw.

54 • SPRING 2019 • todaysveterinarynurse.com PEER REVIEWED • FEATURES

follow-up with oncology department based on given by injection every 3 weeks for 6 treatments total.2 histopathology results. The owners agreed to surgery As of this report, no further follow-ups have been and scheduled Bella’s procedure for the following week. scheduled at BluePearl past the 1-week recheck with the surgery department.

SURGERY AND DIAGNOSIS Based on the medial location of the second digit, Bella was placed in right lateral recumbency for surgery to provide the surgeons with better access to the area. At the time of diagnosis with Sterile vet wrap was used as a tourniquet to decrease intraoperative hemorrhage. The digit was disarticulated traditional OSA, about 90% of at the metacarpal-phalangeal junction, and additional cases have micrometastatic metacarpal bone was removed with rongeurs before disease; only 15% have gross closure. This bone removal not only achieved better 5 cosmetic results but also decreased the risk of pressure metastatic disease. sores developing during Bella’s recovery, as a bandage was planned as part of her aftercare. Nocita® (nocita. aratana.com) (bupivacaine liposome injection) was administered intraoperatively around the incision in multiple layers for immediate postoperative pain DISCUSSION management that would last for 72 hours after In the traditional presentation, OSA accounts for about administration. The amputated digit was preserved in 85% of primary bone tumors in dogs and is typically 10% neutral, buffered formalin and submitted for highly malignant.3 If possible, surgery is recommended histopathology through Colorado State University. to remove the primary tumor. As most tumors are found in appendicular locations—most commonly the A soft, padded bandage and splint were placed on the proximal humerus and distal radius4—this is typically right forelimb for compression and protection of the achieved by amputation. Follow-up chemotherapy is surgery site, and Bella was recovered quietly without then recommended to prevent or delay the onset of incident. She was hospitalized overnight with malignant spread of disease, which commonly occurs to intermittent injections of hydromorphone for analgesia. the lungs and lymph nodes. Median survival after At discharge the following morning, instructions were diagnosis for appendicular OSA is about 4 to 5 months given to the owners for 2 weeks of activity restriction after amputation of the limb alone. Survival time is and bandage care. Bella was discharged with oral prolonged to about 1 year with the addition of cefpodoxime and carprofen. chemotherapy following surgery.5

A final histopathology report, received 13 days after Bella presented a unique case, as her development of surgery, revealed OSA of the digit that appeared to be OSA did not fit the traditional presentation. Although contained solely in the third phalanx and was the digit is an uncommon location for OSA, it is completely removed. generally thought to be more favorable in terms of prognosis. One study that looked at a small population of dogs with digit OSA (n = 9) concluded that OSA FOLLOW-UP accounts for approximately 6% of digit tumor cases, Bella presented to the surgery department 1 week after with a median survival time of 466 days (1.5 years).6 surgery for a bandage change. The owner reported that Chemotherapy after surgery did not seem to have an she was doing well and had no concerns. As the second effect on survival time compared with surgery alone. digit is a non-weight-bearing toe, Bella easily overcame Additional studies focusing specifically on digit OSA its loss. The following week, her primary veterinarian presentation and the long-term implications of performed final bandage removal and suture removal. treatment and prognosis are not readily available. The owners were contacted by the oncologist and encouraged to follow up with the oncology department At initial presentation, Bella showed no signs of to begin chemotherapy treatment. The recommended metastatic disease. When dealing with any mass that agent of choice for treatment of OSA is carboplatin has the potential to be neoplastic, it is important to

todaysveterinarynurse.com • SPRING 2019 • 55 FEATURES • PEER REVIEWED Ad Index

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doing very well since surgery with no signs of lameness EXELINT International in the operated leg. exelint.com Needles/Syringes ...... 9 During my time in the surgery department, we have Merck bravectovets.com amputated digits for reasons ranging from osteomyelitis BRAVECTO ...... 32, 33

to benign masses to SCC and melanoma. Bella’s case NAVC was my first experience with a diagnosis of digit OSA. vetfolio.com Follow-up involving regular, thorough physical Vetfolio ...... 20 examination, thoracic radiography, and abdominal NAVC navc com/certifications. ultrasonography is needed to assess her progress and Certifications ...... 50,. 51 TVN potential for disease spread. NAVC bookstore.navc.com Bookstore ...... 72. References NAVC veterinaryresourcelibrary.com 1. Henry CJ, Brewer WG, Whitley EM, et al. Canine digital tumors: a Business Resource Library ...... 80 veterinary cooperative oncology group retrospective study of 64 dogs. J Vet Intern Med 2005;19:720-724. Nutramax 2. Selmic LE, Burton JH, Thamm DH, et al. Comparison of carboplatin nutramaxlabs.com and doxorubicin-based chemotherapy protocols in 470 dogs after Proviable Forte ...... Inside. back cover amputation for treatment of appendicular osteosarcoma. J Vet Intern Nutramax Med 2014;28:554-563. nutramaxlabs.com 3. Walter CU, Dernell WS, LaRue SE, et al. Curative-intent radiation therapy Mycequin ...... 19 as a treatment modality for appendicular and axial osteosarcoma: a preliminary retrospective evaluation of 14 dogs with the disease. Vet Penn Foster Comp Oncol 2005;3(1):1-7. pennfoster.edu/tvn 4. Goldschmidt MH, Thrall DE. Malignant bone tumors in the dog. Practice Management Certificate ...... 76 In: Newton CN, Nunamaker DM, eds. Textbook of Small Animal Orthopaedics. Philadelphia, PA: Lippincott Williams & Wilkins; 1985:74. Royal Canin royalcanin.com/multifunction 5. Coomer A, Farese J, Milner R, et al. Radiation therapy for canine Multifunction ...... 13 appendicular osteosarcoma. Vet Comp Oncol 2009;7(1):15-27. 6. Gamblin RM, Straw RC, Powers BE, et al. Primary osteosarcoma distal to Sarstedt the antebrachiocarpal and tarsocrural joints in nine dogs (1980-1992). sarstedt.com JAAHA 1995;31(1):86-91. Collection Solutions ...... 48 Terumo terumomedical.com Recommended Reading SurGuard 3 ...... Inside. front cover ƒ Liptak JM, Dernell WS, Rizzo SA, et al. Partial foot amputation in 11 dogs. Vetstream JAAHA 2005;41(1):47-55. vetstream.com/tvn Vetlexicon ...... 77. ƒ Marino DJ, Matthiesen DT, Stefanacci JD, et al. Evaluation of dogs with digit masses: 117 cases (1981-1991). JAAHA 1995;207:726-732. Zoetis zoetisus.com Diagnostics ...... 57.

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GARDEN VARIETY POISONS. Finding a chewed-on lily plant or pieces of plant, such as lily of the valley (Convalaria majalis), in the vomit allows for a definitive diagnosis. shutterstock.com/Timolina

58 • SPRING 2019 • todaysveterinarynurse.com PEER REVIEWED • FEATURES

TOXICOLOGY Guide to Managing Toxin Ingestion

oxin ingestion is a near-everyday

MEET THE occurrence in veterinary practice. Companion AUTHOR Tanimals are susceptible to several potentially life-threatening toxicants, ranging from human food

Courtney Waxman, BAS, and medication to animal medication, common plants, CVT, RVT, VTS (ECC) illicit drugs, routine household products, and more. Purdue University, West Lafayette, IN

While there are many types of toxins and routes of Courtney is an Arizona native contamination, this article focuses on general guidelines who found her passion in emergency and critical care for management of cases of toxin ingestion, in which medicine after completing an veterinary nurses play an important role. The clinical internship during her approach to these cases involves patient history, patient technician schooling. She assessment, decontamination, diagnostics, treatment, attended Mesa Community College and obtained her and nursing care. Certified Veterinary Technician credential for Arizona in 2008 and her PATIENT HISTORY Registered Veterinary Technician credential for Obtaining a thorough patient history is the first Indiana in 2018. In 2017, priority in toxicosis cases. Usually, a veterinary nurse Courtney earned her goes through this process with the pet owner. It often Veterinary Technician starts over the phone, with the owner calling with Specialty certification in emergency and critical care. concerns about an ingested substance (BOX 1). Currently, she works as an Obtaining some parts of the history can be challenging, instructor for Purdue as pets often ingest toxins unseen, and the onset of University’s Veterinary clinical signs may be delayed after ingestion. However, Nursing Program and as a relief technician in the the information collected during the history is Veterinary Teaching Hospital necessary for further recommendations about emergency and intensive care decontamination, diagnostics, and treatment. unit services. With any potential toxin exposure, it is generally recommended for the pet to be seen by a veterinary

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BOX 1

Toxicosis Patient History Questions

● How much does your pet weigh? ● What is the active ingredient ● Is your pet showing any ● What is the name of the toxin? of the toxin? signs/symptoms? ● If the toxin is a medicine: ● How much do you think your pet ● If so, how long have you ingested? noticed the signs/symptoms? ● What is the strength? ● How much could your pet ● What is the generic name? ● How old is your pet? have ingested? ● Is it a special formulation (worst-case scenario) ● Does your pet have any (e.g., extended release)? underlying health issues? ● How long ago (or what general time frame) did your pet ingest ● Is your pet currently on any the toxin? medications?

professional. If possible, the pet owner should be systems (cardiovascular, respiratory, neurologic), as advised to bring any bottles/labels/packaging of the toxicants have differing physiologic effects on these toxicant with them to better aid the veterinary team. (TABLE 1).1 Physiologic effects on renal and hepatic It can also be helpful to consult a veterinary systems are better assessed diagnostically. toxicologist (BOX 2). Gastrointestinal (GI) symptoms (nausea/vomiting, diarrhea, inappetence) are prominent in many cases of toxin ingestion. PATIENT ASSESSMENT Regardless of the type of hospital setting, toxicosis cases Because clinical signs of toxin ingestion can be are unplanned and usually present on a walk-in basis. A immediate (minutes to hours) or delayed (days to veterinary nurse should assess the patient as soon as weeks) patient status on presentation will vary. possible to obtain a baseline set of vital parameters (BOX 3). The evaluation should focus on the major DECONTAMINATION Decontamination is the process of removal or neutralization of dangerous/poisonous substances from a patient.2 When the toxin is ingested, the goals BOX 2 Toxicology and Poison Control Resources of decontamination are to inhibit toxin absorption and promote excretion and/or elimination.3 Generally The two primary veterinary toxicology resources, the ASPCA Animal Poison Control Center and the Pet Poison Helpline, speaking, to be most successful, safe, and beneficial employ toxicologists who have database information for the patient, decontamination should take regarding specific toxins. Their insight can often be critical 3 to the successful management of toxicosis. These services place within 1 to 2 hours of toxin ingestion. The also assign each case a number that can be referenced most common gastric decontamination methods repeatedly as the patient’s status changes. Additionally, they include emesis induction, gastric lavage, activated can be called by pet owners (before arrival) and veterinary 1-3 professionals (at patient presentation). charcoal administration, and colonic enema.

ASPCA Animal Poison Control Center ● 888-426-4435 ● $65 consultation fee (waived with HomeAgain® microchip) Emesis Induction ● Available 24 hours/day, 365 days/year Inducing emesis is indicated if toxin ingestion has been

Pet Poison Helpline recent (within 1 to 2 hours); if the ingested toxin is ● 855-213-6680 known to stay in the stomach for prolonged periods ● $59 consultation fee (e.g., grapes, chocolate), even if time of ingestion is ● Available 24 hours/day, 365 days/year unknown; and if the patient is asymptomatic.3 Emesis induction is contraindicated in patients that are symptomatic, have airway disease, have an altered

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BOX 3

Baseline Patient Parameters

● Weight (in kg) ● Mentation ● Heart rate ● Pulse rate and quality ● Respiratory rate ● Respiratory effort ● Mucous membrane color ● Capillary refill time ● Blood pressure FIGURE 1. Emesis induction in a dog that ingested rodenticide.

mentation, have already been vomiting, or have recommended (TABLE 2). Both of these drugs are also ingested a corrosive/caustic agent.1-3 centrally acting emetics that exert their effects on alpha receptors in the CRTZ. Successful emesis induction typically results in expulsion of 40% to 60% of gastric contents Another, less desirable option for inducing emesis is (FIGURE 1).1 The most common drug used to induce oral administration of 3% hydrogen peroxide. emesis in dogs is apomorphine (TABLE 2). Hydrogen peroxide works by locally irritating the Apomorphine is a centrally acting emetic that exerts its gastric mucosa to stimulate the vomiting reflex. It was effects on dopamine receptors in the chemoreceptor previously thought that hydrogen peroxide had trigger zone (CRTZ; the brain’s vomiting center).4 minimal harmful effects; however, a recent study Apomorphine is not labeled for use in cats and is showed it to be associated with esophageal lesions and therefore contraindicated in this species.1,4 To induce increased risk of gastric irritation/ulcers.5 Therefore, vomiting in cats, xylazine or dexmedetomidine is hydrogen peroxide should be used with caution.

TABLE 1 Potential Physiologic Effects of Toxicosis on the Major Body Systems

CARDIOVASCULAR CHANGES RESPIRATORY CHANGES NEUROLOGIC CHANGES

• Heart rate • Respiratory rate • Mentation/level of consciousness • Tachycardia • Tachypnea • Alert • Bradycardia • Bradypnea • Obtunded • Stuporous • Heart rhythm • Respiratory effort • Comatose • Atrial arrhythymias • Increased effort • Ventricular arrhythymias • Dyspnea • Gait • Ataxia • Pulse quality • Oxygenation status • Weakness • Synchronous pulses • Hypoxia • Paraparesis • Asynchronous pulses • Hypoxemia • Paraplegia • Stronger than normal pulses • Weaker than normal pulses • Ventilation status • Proprioception • Hyperventilation • Absent reflexes • Blood pressure • Hypoventilation • Hyporeflexia • Hypotension • Hyperreflexia • Hypertension

• Mucous membrane color/ capillary refill time • Injected/rapid (vasodilation) • Pale/prolonged (vasoconstriction)

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TABLE 2 Emesis Induction Agents APOMORPHINEa XYLAZINEb DEMEDETOMIDINEc

• Injectable • Injectable • Injectable • 0.02 mg/kg SC • 0.44 mg/kg IM • 7 mcg/kg IM • 0.03 mg/kg IV • 3.5 mcg/kg IV • 0.04 mg/kg IM

• Tablet • 6.25 mg conjunctivallyd

a Contraindicated in cats. b Reversible with yohimbine. c Reversible with atipamezole. d Need to rinse eye thoroughly with sterile saline after use.

Ideally, pet owners should be advised to come to the Activated Charcoal Administration hospital for emesis induction using approved drugs AC is administered orally following emesis induction under veterinary supervision. After successful emesis, and if indicated. AC particles have a large surface area, the vomitus should be collected and inspected for the and AC acts as an adsorbent by binding toxins to help presence of the toxicant. reduce systemic absorption from the GI tract.1 Some formulations of AC include a cathartic (sorbitol) to increase GI motility, decrease absorption, and promote Gastric Lavage elimination through the GI tract.1 Gastric lavage is a more advanced method of removing gastric contents. It is indicated for cases of severe The recommended dosing of AC with sorbitol is a intoxication (large volume of toxin), toxins with a single dose (1–5 g/kg PO).3 Repeated doses of AC narrow margin of safety (e.g., strychnine, baclofen), without sorbitol (1–2 g/kg PO q6h to q4h) can be patients at higher risk for aspiration (i.e., altered level administered in cases of toxins that undergo of consciousness), or when emesis is contraindicated.2,3 enterohepatic recirculation or delayed distribution.3 If multiple doses of AC are to be administered, it is The procedure for gastric lavage involves general important to obtain a baseline sodium level, check the anesthesia with the patient in lateral recumbency, patient’s electrolyte levels every 4 to 12 hours, and passing of an orogastric tube, and using room- ensure that the patient stays well hydrated to minimize temperature water to lavage and empty gastric contents the risk for life-threatening electrolyte imbalances.1 (FIGURE 2).2 If activated charcoal (AC) is indicated, it can be administered via the orogastric tube once the AC is contraindicated in patients that present in the lavage cycles are complete. late stages of toxicosis, are symptomatic, have altered mentation, have a diminished gag reflex or airway disease, or have ingested toxins that do not readily bind to AC (i.e., xylitol, glycol).1,3

Colonic Enema Colonic enemas are indicated in patients that have ingested large amounts of a toxin or may be experiencing a delay in onset of clinical signs, or when elimination of toxicants from the lower GI tract is indicated. The technique involves lubricating and passing a red rubber catheter through the rectum to the level of the transcending colon (midabdomen).2 Warm water and additional lubricant are used to irrigate the colon and expel toxin remnants (FIGURE 3).

FIGURE 2. Gastric lavage in a dog that ingested baclofen.

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FIGURE 3. Colonic enema in a dog that ingested sago FIGURE 4. Example of a commercially available urine drug palm. screen test.

DIAGNOSTICS species. This is especially important as the number of When it comes to toxicosis, the diagnostic workup is reported cases of tetrahydrocannabinol (THC) relatively minimal (usually in-house laboratory work), ingestion/toxicosis continues to rise. A 2012 study as more focus is directed toward decontamination and reported on the use of UDSTs for the detection of treatment. THC and found that dogs do not produce the same metabolites as humans, meaning the UDST for THC is A minimum database (MDB) should be obtained for not accurate in dogs.6 patients presenting for toxicosis. The MDB can vary but in general could include packed cell volume/total protein, blood glucose, blood urea nitrogen, TREATMENT electrolytes, and/or urine specific gravity. The ingested Toxicosis patients often need to be hospitalized for toxin will also guide what laboratory work is most anywhere from several hours to several days, depending indicated (e.g., serial blood glucose monitoring for on the toxin and severity of clinical signs. Once xylitol, clotting times for anticoagulant rodenticide, decontamination procedures have been performed, urine sediment for ethylene glycol). treatment should focus on providing supportive care.

Urine drug screen tests (UDSTs) are available for cases Venous access is vital to ensure patent delivery of fluid in which ingestion of an illicit substance is suspected therapy and medications. Crystalloid fluids help (FIGURE 4). UDSTs use an immunoassay that indicates promote diuresis and toxicant excretion. Maintenance a positive result with a dye color change, meaning that fluid requirements are 40 to 60 mL/kg/day, and fluid the metabolite of the drug being tested for is present in rates can vary from 1.5 to 4 times maintenance the urine. However, UDSTs are meant for human use; requirements, depending on the toxin. no over-the-counter test is validated for veterinary

TABLE 3 Toxins With Antidotes TOXIN ANTIDOTE Acetaminophen N-Acetylcysteine Ethylene glycol Fomepizole (4-methylpyrazole, 4-MP) Ethanol

Anticoagulant rodenticide Vitamin K1 Cholecalciferol rodenticide Calcitonin Organophosphate insecticide Pralidoxime chloride (2-PAM) Oleander Digoxin Benzodiazepines Flumazenil Opioids Naloxone

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BOX 4 most popular theory on how ILE works is known as the lipid-sink effect, which suggests that ILE Intralipid Emulsion Use for Toxicosis expands the intravascular lipid compartment and sequesters lipophilic toxins, thus lowering the 3,7,8 ● Indicated for toxicosis caused by a concentration of available toxin. This prevents lipophilic drug further tissue exposure until the toxin is excreted. ● Local anesthetics ● Ivermectin ● Baclofen ● Pyrethrins NURSING CARE ● Permethrins Monitoring involves diligent assessment and care over ● Calcium-channel blockers the duration of hospitalization. Patients exposed to ● Beta blockers toxins can present with a wide variety of signs and ● Antidepressants ● Synthetic cannbinoids physiologic effects. Toxicosis cases can be complex ● 20% Intralipid emulsion dosing because multiple body systems are often involved. ● Initial bolus: 1.5 to 4 mL/kg IV Diligent assessment, close monitoring, attentive nursing ● Constant rate infusion: 0.25 mL/kg/min care, and stabilization of the patient are essential. The IV over 30 to 60 min level of nursing care ranges from outpatient supportive ● Additional intermittent boluses: 1.5 mL/kg IV q6h to q4h for the first 24 care to multiple days in the hospital. hours in hospital ● Administration/handling/storage Assessment and monitoring can include recording vital ● Maintain strict aseptic technique signs and assisting the veterinarian with treatment. ● Use dedicated catheter (peripheral or Some poisoning cases may require additional central) ● Store unused portion in refrigerator monitoring (TABLE 4). Monitoring should also include ● Discard solution after 24 hours assessment of discomfort, using a pain scoring system, ● Adverse effects and providing analgesia as needed. ● Fat overload syndrome ● Hypertriglyceridemia ● Lipemia CONCLUSION It can be challenging to recognize, intervene in, and provide treatment and care for toxicosis cases, but also very rewarding. The role of veterinary nurses in these Using pharmacologic agents to support the GI system is cases cannot be overstated. From initial patient history generally accepted, as the GI tract is commonly affected. and assessment to decontamination and overall nursing While most toxicants do not have an antidote, some do care, veterinary nurses are involved in the entirety of a (TABLE 3). Additional pharmacologic support should case. Being familiar with general guidelines of how to be provided based on specific signs of individual toxins. approach a toxicosis patient and the specific toxins commonly seen in practice is fundamental to successful Another treatment option is intralipid emulsion patient outcomes. TVN (ILE) administration. ILE was first considered as an antidotal therapy for lipophilic (fat-soluble) To see the references for this article, please drug toxicosis in a 2011 study (BOX 4).1,5,7,8 The visit todaysveterinarynurse.com.

TABLE 4 Potential Monitoring Needs for Toxicosis Patients COMPROMISED SYSTEM MONITORING METHOD TOXIN EXAMPLES

Cardiovascular ECG Chocolate, oleander

Neurologic Modified Glasgow Coma Scale (mental status) Bromethalin rodenticide, anxiety medications

Respiratory Pulse oximetry or blood gases Baclofen, acetaminophen

Hematologic Clotting times Anticoagulant rodenticide

Renal Evaluation of urine output and renal parameters NSAIDs, ethylene glycol

ECG = electrocardiography; NSAID = nonsteroidal anti-inflammatory drug.

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FEATURES • PEER REVIEWED HAPPY TOGETHER When the veterinary team protects the emotional health of a patient, they decrease the animal’s fear, anxiety, and stress. shutterstock.com/ShutterDivision

66 • SPRING 2019 • todaysveterinarynurse.comTOXICOLOGY TALK PEER REVIEWED • FEATURES

PRACTICE MANAGEMENT Happy Visits and Victory Visits: Helping Patients Be Fear Free℠

xperiencing unpleasant stimuli associated

MEET THE with veterinary visits can classically condition patients AUTHOR Eto have a stress response.1 The physiologic effects of fear, anxiety, and stress (FAS) can, in turn, compromise physical BOX 1 Monique Feyrecilde, BA, welfare, examination findings, and test results ( ). LVT, VTS (Behavior) Teaching Animals Mercer Island Veterinary Clinic, Mercer Island, Protecting the emotional welfare of pets and people Washington while providing excellent medical care to help restore physical health, prevent animal disease, and prevent suffering is the foundation of Fear Free veterinary care Monique is a Veterinary BOX 2 Technician Specialist in ( ). As part of this goal, Happy Visits and Victory behavior, working full time in Visits can be great aids in empowering pets and medical small animal practice near teams to work together in an emotionally safe and even Seattle, Washington. Monique enjoyable place for patients and clients.2 strives to provide pragmatic solutions based on her extensive practical experience to groups of every size, from individual clients and clinics BOX 1 to the largest of veterinary conferences. When strangers Physiologic Effects of FAS2 ask what she does, Monique answers, “I teach veterinary professionals how to fulfill their love of animals by ● Increased respiratory rate empowering them to be kind ● Increased heart rate to patients.” In addition to ● Increased blood pressure writing for online courses, ● Increased cortisol levels magazines, and journals, ● Blood glucose, stress leukograms Monique released her first book, Cooperative Veterinary ● Delayed wound healing Care, in April 2018. ● Stress colitis ● Stress-induced feline idiopathic cystitis

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INVITING PETS TO ENJOY THE VETERINARY EXPERIENCE BOX 2 Fear Free Resources Setting the stage for successful visits—whether medical, Fear Free care incorporates several principles, including use Happy, or Victory—begins with some basic measures of the Fear Anxiety and Stress Scale, Gentle Control, Touch Gradient, and Considerate Approach. More information throughout the practice. about these practices and how to implement them in practice is available at fearfreepets.com. Preparing the Environment Every patient area should be prepared with the goal of increasing comfort and decreasing FAS (BOX 3). Some suggestions include: BOX 3 ● Provide nonslip surfaces for patients on the scale, along walking paths, and in all examination and Ideas for Creating a Fear Free Environment treatment areas. ● Keep wonderful treats on hand near the entrance and the scale and in every examination and treatment area. Surface treatments ● Have tools to dispense food, mats, and regular pet ● Yoga mats dishes in all examination rooms and treatment areas. ● Rubber backed mats and rugs ● ● Anti-fatigue mats Use pheromones throughout the hospital to help ● Pet Vet mats improve feelings of patient wellbeing. ● Table covers ● Play music demonstrated to calm pets, to contribute ● Stat-Mats to a relaxing “spaw” atmosphere. ● Towels and blankets

Area treatments ● Pheromones Preparing the Team ● Acoustic therapy ● Dimmable lights Every team member who interacts with patients should have the skills to evaluate body language for signs of Treats FAS and know how to modulate their interaction to ● Nut butters stay within the comfort level of the individual patient. ● Cheeses (e.g., squeeze cheese, cream cheese) ● Canned pet diets Team members must also be able to coach pet owners ● Hot dogs in cooperative patient movement methods, such as ● Braunschweiger/pates keeping leashes loose and offering food lures or treat ● Baby food ● Broth trails to encourage patients onto scales and into ● Pureed specialty foods examination rooms. Team members should also be able ● Commercially made treats (moist, semi- to help clients understand the signs of FAS and how to moist, crunchy, flakes) respond if a patient’s FAS level is increasing. Food dispensers ● Pretzel rods ● Cooking spoons ● Paper plates and bowls Assessing the Patient ● Pet bowls Every patient interaction should be conducted in a way ● Textured silicone mats that is mindful of both physical and emotional welfare. ● Water bowl A patient’s emotional welfare can be judged, at least in Toys part, by assessment of body language and interactions ● Food dispensing toys to determine its FAS score (TABLE 1). Patients with low ● Other toys (ball, tug) levels of FAS interact readily with team members, show Training tools few signs of stress, and accept preferred items, such as ● Clicker treats, toys, and tactile interactions. As FAS increases, ● Mat the frequency and intensity of stress signals increase ● Platform ● Targets (BOX 4). ● Basket muzzles To avoid compromising emotional welfare, the goal should always be to maintain a low FAS score. Signs of

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increasing FAS mean that team members need to slow Over repeated visits, patients that previously displayed down and work at the patient’s pace. If a patient begins low levels of FAS may show increases in FAS. to show increased stress during a visit, team members Preventive steps, such as Happy Visits, are appropriate should immediately pause and return to the last area or for patients with low FAS as a maintenance strategy for interaction at which FAS was low or absent. Once the a good comfort level. Patients displaying moderate or pet is calm, make a new plan for careful reintroduction high FAS require intervention, such as Victory Visits, of the next step before trying again. for FAS reduction. Taking steps to prevent escalation and reduce FAS leads to a decrease in defensive aggression by patients, improving not only patient TABLE 1 The Spectrum of Fear, welfare but also safety for the veterinary team. Anxiety & Stress

RED: SEVERE SIGNS - FIGHT/AGGRESSION (FAS 5)

• Stop treatment and triage wants and needs HAPPY VISITS • Only needs should be pursued, all else postponed Nonmedical Happy Visits (also called Fun Visits) are • Medical treatment of FAS Behavior Modification and Cooperative Veterinary Care Training should be designed to strengthen a patient’s positive experience. recommended Happy Visits can be used to maintain a positive • Victory Visits with a team member trained in emotional connection with the veterinary clinic or to advanced techniques attempt to reverse very mild fear of the veterinary • Referral and/or collaboration often indicated setting. Patients with FAS scores of 0 to 2 are often RED: SEVERE SIGNS - FLIGHT/FREEZE/FRET (FAS 4) appropriate candidates for Happy Visits (FIGURE 1).

• Stop treatment and triage wants and needs • Only needs should be pursued, all else postponed Preparing the client is key to a successful Happy Visit. • Medical treatment of FAS Clients should be encouraged to schedule Happy Visits • Behavior Modification and Cooperative Veterinary Care when their pet is hungry (to make treats given at the Training should be recommended • Victory Visits with a team member trained in advanced techniques • Referral and/or collaboration often indicated

YELLOW: MODERATE SIGNS (FAS 3) BOX 4

• Pause and assess the plan Signs of FAS2 • Triage wants and needs, consider medical treatment of FAS • Victory Visits are recommended to reverse FAS Low FAS (Score 1) YELLOW: MODERATE SIGNS (FAS 2) ● Lip licking ● Yawning • Pause and assess the plan ● Panting • Proceed with caution ● Pupillary dilation • Victory Visits are recommended to reverse FAS ● Looking away from team members ● Attention seeking GREEN: MILD/SUBTLE SIGNS (FAS 1) Moderate FAS (Score 2-3) • Proceed with treatment Signs of low FAS, plus: • Happy Visits are suggested to maintain low FAS ● Taking treats roughly when previously gentle ● Moving away from team members GREEN: ALERT/EXCITED/ANXIOUS? (FAS 0-1) ● Showing the whites of the eye (if not normal for breed) • Proceed with treatment ● Crouching • Happy Visits are suggested to maintain low FAS ● Hiding ● Dilated pupils GREEN: PERKED/INTERESTED/ANXIOUS? (FAS 0-1) ● Rapid panting

• Proceed with treatment High FAS (Score 4-5) • Happy Visits are suggested to maintain low FAS Signs of low and moderate FAS, plus: ● Efforts to escape and avoid GREEN: RELAXED (FAS 0) ● Defensive displays (e.g., growling, snarling, barking, lunging, snapping, biting) • Proceed with treatment • Happy Visits may be appropriate to maintain low FAS Table 1 content copyright Fear Free. Fear copyright 1 content Table

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FIGURE 2. A puppy receives treats during a Victory Visit.

FIGURE 1. A patient relaxes in an examination room during a Happy Visit. enter the veterinary clinic, or display signs of moderate to high FAS should be scheduled for Victory Visits or other behavioral intervention rather than Happy Visits. clinic even more desirable) as well as to bring a generous supply of the pet’s favorite treats, a favorite toy, and a preferred bed or mat, if appropriate. Clients VICTORY VISITS should expect to guide themselves through the visit to Victory Visits are a tool to assist patients that are some extent and be willing to spend a few minutes experiencing higher FAS, especially pets stressed by building a positive emotional connection with coming specific activities (e.g., physical examination, vaccination, to the clinic—for themselves, as well as their pets! blood collection). Victory Visits are generally appropriate for patients with FAS 2 and greater. Victory Visits are A Happy Visit might look something like this: also useful for clients who are highly motivated to ● Client arrives with pet and gives the pet treats minimize the use of manual restraint and wish to teach while in the parking lot and while walking their pets to be active participants in their own through the front door. husbandry and medical care. During Victory Visits, the ● Client walks pet through the lobby and an examination veterinary team (or a qualified trainer, if no one on the room, pausing several times for “treat parties.” veterinary team has the necessary skills) uses techniques ● Pet is allowed to investigate and become familiar with the scale and is given treats for weigh-in. ● Pet receives treats from team members if timing allows.

Happy Visits are generally free of charge for the client, but they bond the client to the practice. Increased face time with the team, increased time spent in the veterinary clinic, and normalizing frequent contact with the veterinary hospital are all side benefits of Happy Visits that can boost revenue over time.

Because Happy Visits can involve spending time in the lobby or examination rooms, scheduling them can help prevent “traffic jams.”

Happy Visits are not appropriate for every patient. Patients that require pre-visit prescriptions to visit the FIGURE 3. In this Victory Visit, the patient is rehearsing a chin rest behavior while the veterinarian auscults.

hospital, experience travel distress, are reluctant to (2). Monique Feyrecilde Opposite: Monique Feyrecilde. Becker; left: Mikkel From

70 • SPRING 2019 • todaysveterinarynurse.com PEER REVIEWED • FEATURES

such as desensitization, classic counterconditioning, For immediate medical needs, high FAS patients should and operant conditioning or counterconditioning to be sedated not only to facilitate care but also to avoid teach the patient how to participate in veterinary care. creating long-term emotional scars that are sometimes Victory Visits may also include medical intervention for unrecoverable. Over the long term, these patients need FAS and advanced training techniques (e.g., restraint- a combination of pharmaceutical intervention to treat free Cooperative Veterinary Care3). FAS; a more advanced behavior modification and training plan that includes desensitization and classic Victory Visits are a step beyond Happy Visits. Happy and operant counterconditioning; and specific skill Visits help pets learn to anticipate fun and treats in the training to expedite future visits. While veterinarians veterinary hospital, while Victory Visits, which are held will be responsible for choosing appropriate short- at a scheduled appointment time, prepare pets for acting anxiolytic supplements and medications, it is specific procedures. worth noting that the use of acepromazine as a single agent for fearful and especially defensively aggressive An early Victory Visit might include: patients is contraindicated. ● Patient comes into an examination room. ● Patient moves onto a mat or the examination table. ● Patient’s most trusted veterinary team member MAKING THE INVESTMENT performs a mock physical examination or short Victory Visits and Happy Visits are an investment in examination segments (FIGURE 2). long-term patient comfort and medical care, and the ● Patient practices targeting or gains familiarity with whole team needs to be committed to the process for equipment such as stethoscope, otoscope, syringes, them to be successful. From the beginning, client and swabs.

As the patient and team become more proficient, A Victory Visits might include: ● Patient moves into the examination room and the examination area. ● Patient’s most trusted veterinary team member performs a physical examination (FIGURE 3). ● A novel team member(s) performs a mock examination or small examination segments (“transfer of skills”). ● Patient’s most trusted veterinary team member uses equipment (e.g., stethoscope, otoscope, syringes) to touch the patient and gradually to simulate their actual use. ● Patient learns specific trained behaviors to facilitate restraint-free care (e.g., physical examination, B venipuncture) (FIGURE 4).

WHEN HAPPY VISITS AND VICTORY VISITS ARE NOT ENOUGH Some patients have a high level of FAS (score of 4 or 5) and need more help than Happy Visits and Victory Visits alone can provide. Because treating FAS is crucial to restore physical welfare as well as emotional welfare, a total healthcare plan must be made for intervention for these patients. Often, patients that show high FAS for handling have comorbid behavioral diagnoses and FIGURE 4. (A) A patient learning voluntary lateral benefit from behavior consultation. recumbency to facilitate cooperative radiographs. (B) A Victory Visit practicing nail scratch board training.

todaysveterinarynurse.com • SPRING 2019 • 71 communication needs to be constructive to set clients and teams up for success. For example, avoid labeling the pet as mean, uncooperative, bad, difficult, or fractious. Objective descriptions of experiences and the goals of treatment are more appropriate talking points.

An opening conversation might sound like: “Mrs. Smith, I can see that Fluffy is moving away from me. When she sees my syringe, she looks away and her body language changes completely. Clearly Fluffy is really clever and has connected the idea that this syringe means something she doesn’t enjoy happens next. I think we should pause this visit for now, and sign you up for some Victory Visits. During those visits, I will teach Fluffy that injections are nothing to fear, and how to happily accept them. We can then vaccinate her without causing unnecessary stress.”

Victory Visits require a time investment and special skills on the part of the veterinary team. However, they are also an investment in the practice. It is appropriate to charge for Victory Visits, and clients will pay for them if they understand the value.

CONCLUSION In one survey, up to 38% of clients said they feel considerable stress just thinking about bringing a pet to the veterinarian.4 More than half perceived that their pets experience significant stress within the veterinary environment. Committing to protecting the emotional and physical health of patients requires the team to devise medical as well as behavior modification strategies to decrease FAS. Happy Visits are easy for any team to start at any time, while Victory Visits require a bit more knowledge and experience to implement. For patients with FAS scores of 4 and 5, medical management is an easy first step, and providing more advanced training visits, either with the clinic’s own team or on a referral basis, is indicated. Try these techniques and watch patients relax and begin to participate more willingly in their own care. TVN

References

1. Fear Free Certification Courses. 2016-present. http://www.fearfreepets.com. 2. Shaw J, Martin D. Canine and Feline Behavior for Veterinary Technicians and Nurses. Wiley Blackwell; 2014. 3. Howell A, Feyrecilde M. Cooperative Veterinary Care. Wiley Blackwell; 2018. 4. Volk JO, Thomas JG, Colleran EJ, et al. Executive summary of phase 3 of the Bayer veterinary care usage study. JAVMA 2014;244(7):799-802. Extra Mile

CAREER CHALLENGES — You’ve Been Promoted! Now What? — 74

WHAT MOVES YOU — Changing Animal Welfare on Native Reservations — 78

FINAL THOUGHTS — Burnout in Veterinary Nursing — 82 shutterstock.com/Lorenzooooo CAREER CHALLENGES

THE ROAD TO SUCCESS An effective leader—with crucial support from his or her team—paves a path built on mutual respect. MEET THE AUTHOR

Heather Prendergast, RVT, You’ve Been CVPM, SPHR, Education Development Specialist, Patterson Veterinary, Promoted! Las Cruces, New Mexico

Now What? Heather has spent over 25 years in small animal practice, teaches veterinary technology and assistance common scenario that occurs in practices programs, and is the author throughout the United States is the advancement of of Front Office Management for the Veterinary Team. She A a long-time team member into a leadership role. Of lectures, has written several articles, and participated in course this seems absolutely logical; internal team members published roundtable are familiar with the practice’s policies and procedures. This discussions. Currently, Heather is an Educational person probably possesses many of the skills needed to excel Development Specialist with in a leadership role. However, the one attribute he or she may Patterson Veterinary. not have is the ability to overcome the resistance of colleagues who either applied for the same position or lack confidence

in the newly promoted manager’s ability to lead the team. Calzada Herraez shutterstock.com/David

74 • SPRING 2019 • todaysveterinarynurse.com CAREER CHALLENGES

Congratulations if you have recently been promoted into a managerial or leadership role! It’s crucial to convey to your team that a leader cannot succeed without his or The mission, vision, and her team and that a successful team needs a leader to values (MVVs) of a hospital or help provide the vision to achieve goals. Every practice are core competencies organization should have a mission, vision, and values statement that helps provide guidance to the entire team. that must be integrated into When every team member accepts and supports the every practice. mission and vision, the road to a positive work environment is paved with respect for one another. That road comes with speed bumps—all of which can be overcome with superior leadership, respect, integrity, and enthusiasm. model the characteristics, behaviors, and actions that he Step 1: Craft a Mission, Vision, and or she wants the team to demonstrate day in and day Values Statement out. By being a role model, leaders compel individuals The mission, vision, and values (MVVs) of a hospital to support the mission, value, and goals of the leader. or practice are core competencies that must be integrated into every practice. MVVs set the structure, Step 3: Delegate to Others establishing a positive culture and goals that help define Newly elevated leaders soon realize there are many team member expectations. Without these, team responsibilities that come with the promotion. Too members have no direction; they simply show up to often, newly appointed leaders feel that if they delegate, work and complete the tasks assigned to them. Owners it will signal weakness or the inability to handle the make it day to day, with no clear light at the end of the job. But the truth is that effective leadership includes tunnel, and managers struggle to implement successful delegating and empowering team members to aid in the goals and policies to increase value in the hospital. completion of tasks and end goals. Respect the talents and contributions of your team members and give Ask the team to help establish the MVVs. Of course, them responsibilities that match their skill sets. For the owner’s viewpoint is critical, but so is the team’s. If successful delegation, establish SMART goals (specific, team members are invested in creating the MVVs, they measurable, attainable, realistic, time bound) for them. will hold themselves accountable in upholding them. The criteria for these goals are outlined in BOX 1. This is an imperative first step for a new leader who will be managing an existing team.

Step 2: Provide Inspired Leadership BOX 1 Successful leaders are influencers; they spur team What Does SMART Mean? members into action and motivate them to be the best that they can be. They guide their teams by employing The criteria for SMART goals can be used clear communication and creating an environment that to guide a manager in setting objectives facilitates and encourages teamwork. for employees. The SMART acronym has come to mean different things to different organizations (as shown below), but Communication is a two-way street. Exceptional whatever term you use, these criteria can leaders establish workplace environments where team help you establish clear, attainable goals for each team member: members are empowered to communicate openly, voice ● Specific: Simple, Sensible, or Significant their concerns, and make changes where necessary. ● Measurable: Meaningful or Motivating Leaders invite creative thinking from team members ● and integrate this creative thinking into daily Attainable: Achievable or Agreed conversations. Creative thinking facilitates productive, ● Realistic: Reasonable, Relevant, or Results-based problem-solving team members who are not afraid to ● Time bound: Time-based, Time-limited, think—and act—outside the box. Time/cost-limited, Timely, or Time- sensitive Leadership must also be demonstrated daily through one’s character, behavior, and actions. A leader must

todaysveterinarynurse.com • SPRING 2019 • 75 CAREER CHALLENGES

implement it. They can be accountable for any new team member assigned to them. When a team member returns from a continuing education Also implement yearly education requirements for team course, work with him or her to members, which sparks passion and excitement. Allow team members to implement what they have learned. incorporate the new procedure When a team member returns from a continuing into the practice. education course, work with him or her to incorporate the new procedure into the practice.

Step 5: Leverage the Passion of the Team Every support team member drives passive income Step 4: Provide Training and Continuing Education (DVMs drive active income), so ensure each team Every team member requires training in the veterinary member is completing the tasks they have the practice. This starts the first day of employment and capabilities to contribute. When a team member seems continues through the last day. High-quality training disengaged, take the time to have a conversation to takes time and must be achieved in phases; each phase determine a course of action that will reignite his or her is successfully completed before the next phase starts. passion. Leveraging team members drives income, client retention, and team member respect. Phase training is crucial for new employees to ensure their success and to avoid creating potholes in the road Step 6: Recognize Team Contributions that is being paved. Team members can help create a Team members are energized when they receive phase training program and should be asked to help recognition, so be sure to recognize a team member for his or her contributions when it is warranted. While it’s also necessary to correct mistakes that are made, don’t let this be the only communication they hear from you. Take the time to applaud excellent work.

Online • Self-paced • Affordable PUTTING IT ALL TOGETHER A team is a simple concept: a group of individuals with Veterinary Practice different skills and attributes that contribute to the positive culture of the practice. Effective leaders build Management Certificate teams that allow the business to succeed at all levels, Learn the skills to help you manage and grow a veterinary practice. including providing excellent patient and client care, maintaining a friendly and cohesive work environment,  NATIONALLY ACCREDITED and maintaining a profit for the practice.  PREPARE FOR CVPM CERTIFICATION Respect does not happen overnight, nor does it come with a position title. An outstanding leader earns respect by providing clear, mission-guided goals, modeling expected behavior, utilizing others’ talents and skills effectively, recognizing contributions, exhibiting patience, and even making mistakes (and taking responsibility for them). Only then will you be an effective, influential leader who has earned the respect of your team. TVN

680GA Reference

Call Today! 888.427.1700 Ext: 1010 1. Prendergast H. Front Office Management for the Veterinary Team, 3rd OR VISIT US AT PENNFOSTER.EDU/TVN ed. St. Louis, MO: Elsevier, 2019. Enter AEWS39V to enroll online Penn Foster College, Administrative Office 14300 N. Northsight Blvd., Scottsdale, AZ 85260

WHAT MOVES YOU

FIELD DAY RAVS staff and volunteers at a field clinic on South Dakota’s Cheyenne River Sioux Reservation in 2018. The team provided high-quality spay/neuter and wellness care for 565 animals.

MEET THE AUTHOR

Erin A. Spencer, MEd, CVT, VTS (ECC) Assistant Professor, University of Massachusetts Amherst

Erin has a degree in veterinary technology (2001) Changing Animal and a master’s degree in education (2015). She earned her veterinary technician specialty in emergency and Welfare on Native critical care in 2011. In 2009, Erin began volunteering with the Rural Area Veterinary Reservations Services program; in 2012, she accepted a full-time role. Erin spends 4 weeks each summer participating in field clinics on n 2004, I felt the first pangs of burnout. I took a Native reservations in western states. Currently an assistant break from being a veterinary nurse, transitioning to the front professor at the University of Idesk and going back to school to finish my bachelor’s degree Massachusetts Veterinary Technology program, Erin is in history. I thought I was done, but staying in the field during past president of the that time allowed me to reevaluate my career goals and I ended Massachusetts Veterinary Technician Association and up returning to my work as a veterinary nurse after graduation. the current president of National Association of Veterinary Technicians in America (NAVTA). Daniel Heddon/The HSUS Daniel Heddon/The

78 • SPRING 2019 • todaysveterinarynurse.com WHAT MOVES YOU

I kept the burnout at arm’s length by taking on new, veterinary students in surgery. Veterinarians and challenging roles in the hospital. By 2008, I was an veterinary nurses assist students with physical exams assistant supervisor in the emergency department, but I and vaccination administration. Veterinary nurses are was slowly heading back to being physically, emotionally, the primary anesthesia team and work with students on and mentally exhausted at work. This concerned everything from IV catheter placement to me—this was no longer just a job; it was my career. troubleshooting anesthetic complications.

Then it all changed. One night, I overheard a veterinarian telling a fellow veterinary nurse about a field clinic she had just returned from. I asked a few questions and within a couple weeks I was placed on Working in underserved the roster for a trip with Rural Area Veterinary Services communities gave me a new (RAVS). In the summer of 2009, I flew out to North Dakota to meet 50 strangers. Somehow, we were all perspective on my life and, going to run a veterinary clinic out of a gym for a week. more importantly, the human- It was a trip that changed my life. animal bond.

WHAT IS RAVS? RAVS is a combination of things. First and foremost, it is a service program that provides free veterinary care to underserved, remote communities located in Native Prior to joining RAVS, I had done some lecturing and American reservations throughout the western United training in my hospital and liked it, but it was RAVS States. The program also has a teaching component. that made me realize this was my passion. Watching a Each clinic has veterinary and veterinary technology student place their first IV catheter or correctly assess students who are able to practice their skills under the their patient for the first time gave me a rush that made guidance of staff and volunteer veterinarians and me remember how much I love veterinary medicine. It veterinary nurses. is immensely satisfying to watch a student—who on their first day at a RAVS clinic was on the verge of tears Finally, as a veterinary nurse, I found RAVS to be an and barely able to assess vital signs, never mind record example of how veterinary nurses can be utilized to them accurately—develop confidence and skills as an their fullest extent. On my first trip, I was given the anesthetist. Education became my passion. I went on to role of “walking the line.” This basically means I earn a Master’s in Education and changed jobs to teach oversaw the student anesthetists at each of five surgery in a veterinary technology program. tables. I was given the protocols that had been set by the staff veterinary team and then was allowed to draw upon my knowledge and skill set to make decisions PURPOSE-DRIVEN PASSION within those protocols to address anesthetic issues that ELEVATES YOU arose. Though I was utilized at the hospital where I Education wasn’t the only thing I discovered, though. worked, the veterinary team at the RAVS clinic trusted Until participating in a RAVS clinic, I had always my skill set at a whole new level. Since that first trip, I worked in private practice—primarily in emergency have witnessed countless veterinary nurse and assistant medicine—in an area where most clients could at least volunteers have eye-opening and life-changing afford some treatment for their pets. Working in experiences just as I did. This is a major reason I underserved communities gave me a new perspective continue to work at RAVS clinics and to encourage on my life and, more importantly, the human-animal veterinary nurses to join a RAVS trip. bond. Further, I learned that I really like working with the people! The community members are so appreciative that we give their animals much-needed IDENTIFY YOUR PASSION care. Over time, I made a slow transition from a A major responsibility of a professional volunteer or veterinary nurse who was solely focused on the patient staff member on a RAVS trip is to educate the students with little patience for animals’ owners to someone who who join us. Veterinarians work one on one with embraced the human-animal bond as crucial to treating

todaysveterinarynurse.com • SPRING 2019 • 79 WHAT MOVES YOU

LEAD THE FIELD. RAVS clinics allow practitioners to share their skills and knowledge with students. the patient and who adopted an empathetic approach to upset and angry clients. This change in attitude has kept compassion fatigue out of my narrative. When I feel that sort of emotional distress creeping into my life, I have a new outlook that helps me get past it.

PURPOSE-DRIVEN PASSION PROVIDES ENERGY AND STRENGTH Though there are still times in my career, whether working relief in practice or with students in the veterinary technology program, when I hit a rough patch. The things I have learned about myself and others through RAVS lift and sustain me. When I’d begin to feel emotionally, physically, and mentally drained, my RAVS trips always rejuvenated me.

Of course, eventually I needed more than the trips, and luckily, I was able to let my passion for education carry me into my new role as an instructor in the veterinary technology program and also become a member of the RAVS staff.

I continue to find purpose and strength from the passion RAVS ignited in me 10 years ago. How can you find your passion? Start by identifying things that interest you and then pursue them. You won’t regret it!

If you think volunteering at a RAVS clinic might help you identify your passion, visit the website:

ruralareavet.org. TVN HSUS Shea Michelle/The

FINAL THOUGHTS

WHAT IS BURNOUT? It’s a state of emotional, physical, and mental exhaustion caused by excessive and prolonged stress—here’s how to overcome it.

MEET THE AUTHOR

Emily Fullerton, RVT, VTS (Oncology) Salt Lake City, UT

Emily obtained her associate’s Burnout in degree from Vet Tech Institute in December 2008, leading her to her registered Veterinary Nursing veterinary technician license in January 2009. She moved to Maryland where she found her place in hen I started working as a veterinary veterinary medicine—medical oncology. With her passion nurse in 2008, the hours were not great. In for helping animals and fact, they were horrible. I was working Friday, support from her coworkers, W she achieved Veterinary Saturday, and Sunday overnights, 12 to 13 hours at a time, Technician Specialist certification in oncology at a very busy ER private practice. Those hours were rough, in 2014. even for a 20-year-old. The pay was enough for me to get Emily is currently working at Advanced Veterinary Care, by, but I always jumped at the chance to get overtime pay. a small animal specialty and A few months in, I decided to get a second job, working level 1 trauma center, located in Salt Lake City, Utah. She daylight hours at a general practice. I would come home has a love for food and wine, exploring her new outdoor from work, sleep for 2 to 3 hours, and then get up and go to surroundings in Utah, and the day practice. I was busy, but I loved what I was doing. spending time with her loved ones and pets. shutterstock.com/gpointstudio

82 • SPRING 2019 • todaysveterinarynurse.com FINAL THOUGHTS

Fast forward 10 years, and I am still working as a What can we do as members of this profession to veterinary nurse, but now in a medical oncology decrease the incidence of burnout experienced by department. I had gone as far as a veterinary nurse can licensed veterinary nurses? I think it starts with without further schooling, obtaining my VTS in employers. The NAVTA study showed that the majority oncology in 2014. I was always the type of worker who of responders (44%) earn a salary of $15 to $20 per gave it my all. I was in before anyone else in the hour.2 Even the best-paid veterinary nurses in this study department, and I was usually the last to leave. ($20/hr) are only bringing home about $28,000 annually (40 hours/week, 50 weeks, 30% taxes).2 To In August 2018, I quit my job for a cross-country move put that number into perspective for you, the national and took a month off before joining a new hospital. In poverty level, for a family of four, is $25,000.3 that month off, something happened. I realized how detached I had become at my previous job. I had lost sympathy for the animals and empathy for the owners. In fact, I remember one day at my previous job, a coworker was trying to explain that some clients in the lobby were very late for their consult, but still really Symptoms of burnout can vary wanted to be seen. She tried to pull on my heartstrings from person to person and can (as we all do in veterinary medicine) by saying, “They occur throughout multiple stages are upset; their cat has cancer!” of a veterinary nurse’s career, My response has stuck with me for years. “They all making it difficult to identify. have cancer!” I shouted.

I should have realized at that time what I had become—a robot. A robot who was very good at her job, but who was missing the warm “fuzzies” that she used to get when she started as a veterinary nurse. Now, The first step for employers is to respect and recognize at my new job, I find myself being much more the value of their licensed veterinary nurses and to pay compassionate, patient, and even-keeled when dealing them accordingly. In addition, employers can help by with patients and clients. I have found my old self taking care of their employees’ well-being. Veterinary again, the person who got into a veterinary nursing nurses should be encouraged to use their earned career to help animals and people. The one who has a vacation time, and should receive regular lunch breaks drive to learn and improve every day. I now know what at appropriate times. And while there are many burnout is like for me. I am not alone. veterinary nurses who will jump at the chance for overtime hours, employers should limit the amount of According to an article published in the Annual Review overtime hours, so that employees are ensured of of Psychology, “Burnout is a prolonged response to maintaining a work-life balance. chronic emotional and interpersonal stressors on the job.”1 Veterinary professionals (doctors, nurses, and Symptoms of burnout can vary from person to person administrative staff) are exposed to raw emotions day and can occur throughout multiple stages of a in and day out. On top of witnessing the suffering of veterinary nurse’s career, making it difficult to identify. patients and the grief of clients, we have other stressors Those who suffer from burnout may experience trouble in our profession that contribute to burnout. A sleeping, retraction from interaction with loved ones, demographic study, conducted by the National anger (at work and outside of work), and weight gain.4 Association of Veterinary Technicians in America They may also find their work to be frustrating and (NAVTA) in 2016, confirmed that the number 1 develop negative attitudes toward the workplace and reason why veterinary nurses leave the field is coworkers.5 They may develop new or worsening insufficient pay. This is followed by “lack of respect compulsive behaviors, which may include both healthy from the employer (20%), burnout (14%), lack of and unhealthy practices (exercising, dieting, smoking, benefits, childcare difficulties, lack of respect for the and alcoholic beverage consumption).4 Losing patience profession and compassion fatigue.”2 with our clients and/or patients is one of the red flags of burnout.4

todaysveterinarynurse.com • SPRING 2019 • 83 FINAL THOUGHTS

The American Veterinary Medical Association (AVMA) Group Health and Life Insurance Trust compared chewables airline preflight safety briefings to burnout in veterinary medicine; in order to help others, we must 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 first help ourselves.6 Burnout prevention does not only 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). fall on the shoulders of employers. We need to look out 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 for ourselves and our colleagues. 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:

Color Coding 0n Dog Chewables Ivermectin Pyrantel Foil Backing KEEP BURNOUT AT BAY Weight Per Month Content Content and Carton Up to 25 lb 1 68 mcg 57 mg Blue The AVMA article recommends taking care of yourself 26 to 50 lb 1 136 mcg 114 mg Green as the number 1 thing to avoid burnout. Exercising, 51 to 100 lb 1 272 mcg 227 mg Brown eating right, and making yourself a priority are key HEARTGARD Plus is recommended for dogs 6 weeks of age and older. steps to take. Enjoying your time off and spending it 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 with friends and loved ones will help you reset. 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 Along with fun and play, people in caregiving jobs also 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 3 need a relaxation technique. Relaxation techniques 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. don’t have to be the same for everyone. Some HEARTGARD Plus should be given at monthly intervals during the period of the year when mosquitoes (vectors), individuals might find reading works for them, whereas 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 others enjoy yoga, or a day at the spa. 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. Try to be positive and encouraging in the workplace, 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 and not negative and demoralizing. The power of 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. positive thinking, along with the ability to perceive and 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 celebrate positive outcomes, are highly correlated with taken to prevent reinfection with intestinal parasites. lower levels of compassion fatigue and higher levels of EFFICACY: HEARTGARD Plus Chewables, given orally using the recommended dose and regimen, are effective against 7 the tissue larval stage of D.immitis for a month (30 days) after infection and, as a result, prevent the development satisfaction. 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 The last recommendation for combatting burnout is: 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 do not be ashamed to talk about it. Hospital managers HEARTGARD Plus which is not effective against adult D. immitis. Infected dogs must be treated to remove adult and supervisors are busy people; they may not pick up 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, on the signs you are exhibiting. Talk to them about an 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 action plan to get you back to feeling the warm fuzzies ivermectin alone after treatment of some dogs that have circulating microfilariae. again, and less like a robot. TVN 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. References 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 1. Maslach CH, Schaufeli WB, Leiter MP. Job burnout. Ann Rev Psych following the use of HEARTGARD: Depression/lethargy, vomiting, anorexia, diarrhea, mydriasis, ataxia, staggering, 2001;52(1):397–422. convulsions and hypersalivation. 2. National Association of Veterinary Technicians in America. NAVTA SAFETY: HEARTGARD Plus has been shown to be bioequivalent to HEARTGARD, with respect to the bioavailability 2016 Demographic Survey. NAVTA.net.cdn.ymaws.com/www.navta.net/ 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 resource/resmgr/docs/2016_demographic_results.pdf. ivermectin administered at elevated dose levels (more than 16 times the target use level) than dogs of other breeds. 3. U.S. Department of Health and Human Services. U.S. Federal Poverty 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 Guidelines Used to Determine Financial Eligibility for Certain Federal 10 times the recommended dose (60 mcg/kg) in sensitive Collies. Results of these trials and bioequivalency studies, Programs. 13 Jan 2018. https://aspe.hhs.gov/poverty-guidelines. support the safety of HEARTGARD products in dogs, including Collies, when used as recommended. 4. DVM 360 Staff. Recognizing the warning signs of burnout. DVM360.com. HEARTGARD Plus has shown a wide margin of safety at the recommended dose level in dogs, including pregnant 1 Oct. 2005. veterinarycalendar.dvm360.com/recognizing-warning-signs- or breeding bitches, stud dogs and puppies aged 6 or more weeks. In clinical trials, many commonly used flea burnout. collars, dips, shampoos, anthelmintics, antibiotics, vaccines and steroid preparations have been administered with HEARTGARD Plus in a heartworm disease prevention program. 5. Scheidegger J. Burnout, compassion fatigue, depression—what’s the In one trial, where some pups had parvovirus, there was a marginal reduction in efficacy against intestinal nematodes, difference? DVM360.com. 1 May 2015. veterinarynews.dvm360.com/ possibly due to a change in intestinal transit time. burnout-compassion-fatigue-depression-what-s-difference. HOW SUPPLIED: HEARTGARD Plus is available in three dosage strengths (See DOSAGE section) for dogs of different 6. AVMA Group Health and Life Insurance Trust. Managing Stress and weights. Each strength comes in convenient cartons of 6 and 12 chewables. Avoiding Burnout. Avma.org. 1 Aug. 2004. avma.org/News/JAVMANews/ For customer service, please contact Merial at 1-888-637-4251. Pages/040815k.aspx. 7. Figley C, Roop R. Compassion Fatigue in the Animal Care Community. Washington, D.C.: Humane Society Press, 2006. ®HEARTGARD and the Dog & Hand logo are registered trademarks of Merial. ©2015 Merial, Inc., Duluth, GA. All rights reserved.

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1 Freedom of Information: 2 Data on file at 3 Data on file at NADA140-971 (January Boehringer Ingelheim. Boehringer Ingelheim. 15, 1993). IMPORTANT SAFETY INFORMATION: HEARTGARD® Plus (ivermectin/pyrantel) is HEARTGARD® and the Dog & Hand logo® are well tolerated. All dogs should be tested for heartworm infection before starting registered trademarks of Boehringer Ingelheim a preventive program. Following the use of HEARTGARD Plus, digestive and Animal Health USA Inc. ©2019 Boehringer Ingelheim Animal Health USA, Inc., Duluth, GA. neurological side effects have rarely been reported. For more information, please All rights reserved. PET-1309-HGD0319. see full prescribing information or visit www.HEARTGARD.com.