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Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.1 Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.1
TRANSFUSIONS IN PRACTICE
PART1:TREATMENT OF ANEMIA AND BLOOD BANK MANAGEMENT
KRISTIN WELCH,DVM,DACVECC
DVM STAT 24/7 2019Close slides View other slides in this lecture-
Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.2 Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.2
Why Consider Transfusions in Practice?
-Blood typing supplies are inexpensive
-Cross match kits are available
-No special equipment needed to store purchased blood units
-24 hr shipment available through animal blood banks -
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Why Consider Transfusions in Practice?
-In some cases, referral is not possible...
- Too unstable
- Cost constraints
- Location -
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Indications for Transfusion
-Anemia
-Coagulopathy
-Thrombocytopenia / thrombocytopathia
-Hypoproteinemia -
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Most Common Indication for Transfusion
-Anemia
1. Acute blood loss
2. IMHA
3. Chronic anemia -
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Acute Blood Loss Anemia
-Healthy animals can tolerate <= 20% loss of blood volume
-Peracute blood loss may have normal PCV for hours...only indication is low TS
-Many animals will have normalization of organ perfusion with crystalloids alone -
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Increased Destruction
-Hemolytic anemias
-pRBC are lifesaving
-No evidence that blood adds "fuel to the fire"
-No evidence that transfused cells are destroyed more rapidly than patient's cells -
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Decreased Production
-Bone Marrow Directed Anemia
- Destruction of RBC precursors in the marrow
- Pure red cell aplasia
- Erythroid maturation arrest
- Bone marrow directed IMHA
-Slow drop in PCV associated with a subtle onset of clinical signs
-Transfused RBC have near normal RBC lifespan
- 110 days in dogs
- 70 days in cats -
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Chronic Nonregenerative Anemia
-Case by case basis
-Much lower PCV may be tolerated without evidence of hypoxemia
-If anesthetic or surgical event anticipated, transfusion may be required -
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When to Consider Transfusion?
-Continued blood loss
-Evidence of hypoxemia
- Markers to look for?
-Planned anesthetic procedure (PCV < 20-25%)
Tachycardia Tachypnea increases Lactate -
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Possible Side Effects
-Infectious disease transmission -Fatal hemolytic transfusion reactions
-Transfusion related lung injury (TRALI) -Transfusion related circulatory overload (TACO) -Transfusion related immunomodulation (TRIM) -
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TRALI
-ARDS occurring <4-6 hrs after transfusion
- Dyspnea - Hypoxemia
- PaO2:FIO2 < 300; SpO2 <90% on room air
- Non cardiogenic pulmonary edema
- Bilateral pulmonary infiltrates
- No evidence of left atrial hypertension (ie. not volume overload!)
-Incidence as high as 0.08%
-#1 cause of transfusion related mortality in people -
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TACO-Transfusion Associated Circulatory Overload
-Volume of blood infused causes acute hypervolemia and cardiogenic pulmonary edema -
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TRIM-Transfusion Related Immunomodulation
-Transfusions are immunosuppressive and pro- inflammatory
- HLA proteins and immunologically active donor WBCs
--> immunosuppression
- Cellular factors from deteriorating donor WBC -->
endothelial cell and neutrophil activation
- increased incidence of infection in transfused ICU patients
- Transfused transplant patients have improved outcome -
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Evidence Against Liberal Transfusions
-Increased risk of:
- Infection
- Earlier reoccurrence of malignancy
- Myocardial infarction
- Stroke
- Organ failure
- Death
CRIT study.CCM 2003
TRICC study.CCM 1999 -
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Fact or Fiction?
-Do transfusion triggers exist?
- PCV
- Lactate
- Membranes, CRT, HR, BP -
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Options
-Packed red blood cells
-Fresh whole blood
-Stored whole blood -
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Packed Red Blood Cells
-Benefits:
- Specific component therapy for anemia - Readily available
- National blood banks
- In house blood bank
-Downsides:
- Only provides RBCs... -
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Fresh Whole Blood
-Benefits:
- Provides healthy platelets
- Provides coagulation factors
- Improved survival in human trauma victims over stored whole blood
-Downsides:
- Possible increased risk of disease transmission
- Possible increased risk of transfusion reactions
- Not available for purchase from animal blood banks
- Large volume -
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Stored Whole Blood
-Benefits:
- Can be stored at 4°C for <= 35 days - Improved hemostasis over component therapy
-Downsides:
- Decreased platelet function within 5 hrs at 4°C
- Decreased factor V and VIII within 12-18 hrs at 4°C -
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Canine Blood Types
->12 DEA groups
-Most important DEA = DEA 1.1
- Acute hemolytic transfusion reaction
-Other reported transfusion reactions
- DEA 4 - Dal antigen in Dalmatians-Dogs do NOT have pre-existing antibodies
-Pregnancy does not cause sensitization -
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-Some dalmations lack an IgG antigen on RBC - Dal antigen
- Readily sensitized to Dal positive blood
- All non-dalmation blood transfusions
- Not detected by typing
- DEA 4 negative dogs can be sensitized
- Most dogs in US are DEA 4+ -
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Canine Blood Typing
-In-house tests
- Rapid Vet-H Canine Cards
- Alvedia Quick Test DEA 1.1
-Reference laboratories
-Animal blood banks -
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Rapid Vet Cards
-Difficult to interpret with severe anemia
-Unable to use in autoagglutination
www.rapidvet.com -
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Alvedia Quick Test
-Reliable with severe anemia
-CAN use with autoagglutination
www.alvediaVET.com -
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What About Autoagglutination?
-Negates any typing using the cards
-Alvedia Quick Test still valid
-Laboratory to wash RBC before typing
- Turnaround time makes this impractical in an emergency setting -
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Feline Blood Types
-AB blood group system
- Type A
- Type B
- Type AB
-Mik antigen
-Cats have naturally occurring alloantibodies
-All feline donors MUST be typed -
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Feline Blood Types
-Siamese are type A
-Most DSH are type A - Geographic variations
-NEVER assume a cat's blood type- type ALL cats
-Type B cats have STRONG anti-A antibodies
- Neonatal isoerythrolysis -Type AB cats should receive A blood -
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Feline Blood Typing
-In-house tests
- Rapid Vet-H Feline Cards
- Miss AB cats
- Autoagglutination
- Alvedia Quick Test A+B
- Rapid Vet-H Gel Test
-Reference laboratories
-Animal blood banks -
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Crossmatching
-Major Crossmatch
- Donor RBC, patient plasma
-Minor Crossmatch
- Donor plasma, patient RBC -
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When to Crossmatch?
-Dogs
- Any dog with a transfusion history
- Transfusion >4 days ago
- Adult dog with unknown history
- Any dog that hemolyzes their 1st transfusion
- Suspicious... -
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When to Crossmatch?
-Cats
- Cats that can't be typed
- Any cat with a previous transfusion history
- More recent recommendations...all cats? -
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-Major Crossmatch compatible feline transfusions
- Increase in PCV was greater with major
crossmatched blood when compared to non- crossmatched transfusions
- Alloantibodies
- Mik antigen -
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-Major Crossmatch compatible feline
transfusions - No significant difference in incidence of transfusion reactions in crossmatched vs. non-crossmatched
- 17% vs. 29% (p=0.16)
- No significant difference in % change in PCV -
Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.35 Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.35
-Non-AB incompatibility was detected in 15% of transfusion naïve cats
- In these transfusion naïve cats, 74% had 1+ incompatibility; 26% had 2-3+ incompatibility
- Mik?
-Febrile transfusion reactions noted more commonly in non-crossmatched vs. crossmatched transfusions
- 10.1% vs. 2.5% (overall in 5%) -
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Crossmatch in Practice?
-In-house
- DMS Laboratories Rapid Vet-H Companion Animal
Crossmatch
- Cursory slide method- Major
- 1 drop donor blood with recipient plasma
- Agglutination? -
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Gel-based Crossmatch
-
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What About Autoagglutination?
-*Autoagglutination precludes in-house crossmatching
- Wash cells 3 x in 0.9% saline
- Send blood to lab for crossmatch with stems from 2-3 type-specific blood units- Send blood to Animal Blood Resources International
- Receive the requested number of crossmatched units -
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Where to obtain blood products?
-Planned Autologous transfusion
- Obtain 1 unit of blood from patient with a planned surgical procedure >4 weeks in advance
- Not practical in MOST cases -
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Where to obtain blood products?
-Autotransfusion
- Immediately transfuse blood from body cavity
hemorrhage < 1 hr old
- Surgical or trauma
- AVOID in malignant hemorrhage, possible infection
- Requires use of a blood administration filter
- Risks -
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Autotransfusion
-1 year FS German Shepherd
- Anticoagulant Rodenticide
- Presents with PCV 20%, TS 3.1 g/dL, tachypnea, muffled lung sounds, pale, tachycardic
- Diagnosed with large volume hemothorax - PT out of range, PTT out of range - Treatment?
- Vitamin K1
- FFP to correct PT/PTT
- Autotransfused 500 ml blood from hemothorax
- Discharged in 36 hours - Normal PT/PTT - PCV 30%, TS 5.2 g/dL -
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Where to obtain blood products?
-In house blood donation
-Blood banks -
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In House Blood Donation
-Requires diligent record keeping, annual infectious disease testing and dedicated equipment for safe blood handling and storage
-Practical in a large emergency or referral practice with a technician and veterinarian dedicated to blood banking
-Feasible on an emergency basis in practice with preplanning -
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Canine Donors
->25 kgs ... donate 450 ml
-No transfusion history
-UTD on vaccines, indoor only
-CBC, chemistry, UA every 6-12 months
-Specific testing:
- Brucella, Babesia, Ehrlichia, Anaplasma, Borrelia, Leishmania
- Regional and breed variations
-PE and PCV/TS prior to every bleeding
- PCV >40% -No more than every 4 weeks -
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Feline Donors
-> 4 kgs ... donate 40 ml
-No transfusion history
-UTD on vaccines, indoor only
-CBC, chemistry, UA every 6-12 months -Echocardiogram or proBNP
-Specific testing:
- HW, FeLV, FIV, Mycoplasma haemofelis
-PE and PCV/TS before every bleeding
- PCV >30% -No more than every 4 weeks -
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Blood Collection
-Sedation
- Avoid acepromazine, dexmedetomidine
- Dogs - butorphanol / benzodiazapine
- Cats - ketamine/valium -
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Blood Collection- Dogs
-Closed collection system
- Containing CPDA
- With or without satellite bags for component separation -
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Blood Collection- Cats
-Commercial closed collection system
-Modified closed collection system
- Butterfly catheter, 30 cc syringe, 3- way stopcock, satellite collection bags -Open collection system
- 30 cc syringes with 19 G butterfly
- 1 ml CPDA or citrate per 9 ml blood -
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Closed Collection System- Cat
-
Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.50 -
Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.51 -
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Obtaining Component Therapy
-Use of closed collection system & satellite bags
-Centrifugation of FWB within 8 hrs
- pRBC
- FFP / platelet rich plasma
- Cryoprecipitate
- Cryoprecipitate poor plasma -
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Blood Product Storage
-What if FFP is thawed for a patient, and the unit is not used?
- Can be refrozen within 2 hrs of thaw and maintains all
factor efficacy
- Frozen plasma
Yaxley PE. Freeze-thaw-cycled FFP. JVECC 20(5) 2010. -
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Blood Product Storage
-What if FFP is thawed for a patient, and the unit is
not used?
- Can be refrozen within 2 hrs of thaw and maintains all
factor efficacy
- Frozen plasma
Yaxley PE. Freeze-thaw-cycled FFP. JVECC 20(5) 2010. -
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-Filter with 170-260 um pores most
common -Removes RBC and platelet aggregates
-Filter with 20 um pores
-Hemo-Nate -
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Administration
-Warming bath for FFP
- 39 C (102.2 F) -
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Does Administration Method Alter RBC Survival?
-
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Administration via Pump - Dog
-Very high proportion of early loss of
transfused RBC at 24 hr post-transfusion
- 4/8 dogs via volumetric pump
- 1/7 dogs via syringe pump
- 0/8 dogs transfused via gravity drip
-Average RBC lifespan 43 days -
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Administration via Pump-Cat
- No decrease in circulating number of RBC with
administration using syringe pump/aggregate filter
- Rate of administration
- RBC MCV - Average RBC lifespan 23 days
- Transfused RBC detectable for 6 weeks -
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Administration
-IV or IO
- Neonates
-0.9% NaCL can be administered concurrently
-Can add warm 0.9% NaCl to pRBC to increase bolus speed in emergencies -
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What's in a Date?
-Age of blood is associated with rate of
transfusion complications
-Rate of transfusion complications 25% (333
transfusion events)
- Fever 12% - Hemolysis 6% -Odds of hemolysis increased significantly for
every additional day of age (OR 1.11) -
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What volume to administer?
-Expected rise in PCV
- Whole blood
- 1% for each 2 ml/kg WB administered
- pRBC
- 1% per 1ml/kg pRBC administered -
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Premedication
-Overall 15% rate of transfusion reactions (TR)
- 53% fever - 18% vomiting - Significantly associated with type of transfusion
- PRBC >>> Plasma - Immune mediated disease more likely to have TR - Premedication did NOT decrease overall TR
- Did decrease allergic reactions -
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Transfusion Monitoring
-Rate is dependent on patient, indication for transfusion, CV status -Monitor for transfusion reactions
-Initial 2-5 ml over 15 minutes
-Entire transfusion volume over 4 hours
-TPR q 5 min for 1st 15 min
-TPR q 15 minutes for 1st hr
-TPR q 1 hr for 4 hours
-PCV/TS 2 hrs after completion of transfusion -
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Acute Transfusion Reactions
-Non hemolytic febrile transfusion reaction
-Hemolytic transfusion reaction
-Infectious transfusion reactions -
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Non Hemolytic Febrile Transfusion Reaction
-Most common transfusion reaction identified
-Occurs within minutes to hours of receiving transfusion
-Usually mild and self limiting
-Likely due to leukocytes and cytokines
- Leukoreduced RBC reduce incidence of febrile
transfusion reactions but not common practice in the US -
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Hemolytic Transfusion Reaction
-Due to donor-recipient incompatibility
- Minimized by blood typing all recipients
- If indicated, major and minor crossmatching will indicate incompatibility prior to transfusion
-Due to previous sensitization
- Knowing past transfusion history is critical - Antibodies form in 4-5 days from 1st transfusion -->
crossmatch required with all subsequent transfusions -
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Hemolytic Transfusion Reaction
-Due to donor-recipient incompatibility
1. Canine patient with past transfusion history that was not
crossmatched
2. Any cat that was not blood typed before transfusion
3. Cat receiving type-specific blood that has Mik-antigen incompatibility
-As little as 1 ml of incompatible blood can potentially
cause fatal hemolytic transfusion reaction
- Blood typing is critical, especially in cats
- Type B cats have strong anti-A antibodies
- Incompatible transfusion is fatal -
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Infectious Transfusion Reactions
-Contaminated blood units
- Out of date
- Incorrect storage temperature
- Non sterile collection technique
- Blood bag sterility compromised
-Donor with infectious disease
- Incomplete donor infectious disease testing
- Not receiving heartworm prevention monthly
- Not up to date on vaccinations -
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Recognizing Transfusion Reactions
-Febrile Non-hemolytic transfusion reactions
- Signs
- Fever
- Vomiting
- Urticaria
- Pruritis
- Most commonly respond to slowing the transfusion rate
- May require diphenhydramine, less commonly steroids -
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a picture of a dog laying down
-
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Action Step
Febrile Non-hemolytic transfusion reactions
- Slow rate of transfusion
- If temperature normalizes or stabilizes then can continue transfusion
- If temperature continues to rise, stop transfusion temporarily
- If temperature stabilizes, continue transfusion at a slower rate
- If temperature continues to rise, STOP transfusion and submit blood for a bacterial culture and gram stained blood smear to rule out bacterial contamination -
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Action Step
Non-hemolytic transfusion reactions
- Vomiting, urticaria, pruritis
- Slow rate of transfusion
- Administer 1-4 mg/kg diphenhydramine IM/SQ
- If clinical signs resolve, continue transfusion at current rate
- If clinical signs continue, try slowing transfusion even further - If signs resolve, continue transfusion
- If signs continue, consider repeating diphenhyrdamine or administering corticosteroids - No data to support use of steroids to treat non hemolytic transfusion reactions -
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Recognizing Transfusion Reactions
-Acute hemolytic transfusion reaction
- Tachycardia
- Collapse
- Vomiting
- Pyrexia
- Hypotension
- Hemoglobinemia, hemoglobinuria -
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Action Step
Acute hemolytic transfusion reaction
- Stop the transfusion immediately
- Submit blood (pre-transfusion) from recipient and blood from donor bag to reference lab or complete in house testing to confirm type/ crossmatch
- Monitor recipient closely with serial PCVs as hemolysis can be severe
- Perform new blood type and crossmatch before another transfusion is administered -
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Recognizing Transfusion Reactions
-Delayed hemolytic transfusion reaction
- Extravascular hemolysis occurring 3-21 days after
transfusion
- Drop in PCV sooner than expected
- New hyperbilirubinemia
- New hyperbilirubinuria
-Usually no specific treatment required -
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How long will the transfusion last?
-RBC lifespan
- 110 days in dogs - 70 days in cats
-Factors that shorten the RBC lifespan
- Hemolysis
- IMHA
- Transfusion related hemolysis
- Bleeding -
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Resources for Transfusion Medicine
-
Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.79
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Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.1 Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.1
ASSESSING PAIN IN CATS AND DOGS (HOW PAIN AFFECTS BEHAVIOR)
Mary Ellen Goldberg LVT, SRA, CCRVN, CVPP, NTS-lab animal medicine (research anesthesia) and VTS-physical rehabilitation
VetScopo 2019Close slides View other slides in this lecture-
Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.2 Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.2
IVAPM
Your Ultimate Resource For Animal Pain Management -
Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.3 Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.3
Woolf, CJ. Pain: Moving from Symptom Control toward Mechanism-Specific Pharmacologic Management, Ann Intern Med. 2004;140:4451-451
Pain is:
-Multidimensional sensory experience
-Unpleasant
-Hurting and soreness – varies
-Intensity (mild, moderate, or severe)
-Quality (sharp, burning, or dull)
-Duration (transient, intermittent, or persistent)
-Referral (superficial or deep, localized or diffuse) -
Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.4 Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.4
Composition of Pain
-Cognitive
-Emotional
-Suffering
-Avoidance motor reflexes
-Autonomic output alterations
- “Demands all our attention”
Woolf, 2004 -
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Categories of Pain
-
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Types of Pain
-Acute – serves a protective role by enabling healing and tissue repair and usually is considered to end within 3months. Muir WW and Woolf CJ. Mechanisms of pain and their therapeutic implications, JAVMA, 2001, 219(10):1346-1356-Chronic – induces biochemical and phenotypic changes in the nervous system that escalate and alter sensory inputs, resulting in physiologic, metabolic, and immunologic alterations that threaten homeostasis and contribute to illness and death.Maier SF, Watkings LR. Cytokines for psychologists: implications of bidirectional immune- to- brain communication for understanding behavior, mood, and cognition. Psychol Rev 1988;105: 83-107
-Neuropathic – is a maladaptive phenomenon caused by pathologic neuroplasticity and can become a disease of the neurologic system by persisting beyond resolution of an inciting cause. Von Hehn CA, Baron R, Woolf CJ. Deconstructing the neuropathic pain phenotype to reveal neural mechanisms. Neuron, 2012 73:638-52.
-
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Pain Types
-Acute GI pain
-Chronic OA pain
-Neuropathic post onychectomy pain -
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Some detrimental effects associated with inadequate pain management (Orskov, 2010)
Altered Mentation
Reduced Appetite
Reduced Immune Function
Prolonged Recumbency
Altered Physiological Parameters
Unnecessary suffering
e.g. anxiety, dullness, aggression
weight loss and tissue breakdown for energy
e.g. Cortisol: tissue breakdown and delayed wound healing
increased risk of wound infections
ischemia, vascular thrombosis, urinary / fecal retention
e.g. lick granulomas
interference with patient assessment
e.g. animal welfareOrskov T. Pain Assessment in Cats and Dogs, Irish veterinary journal, 2010, 63(6):362-364
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World Small Animal Veterinary Association (WSAVA) Tenets of Pain Assessment and Recognition (Mathews, Kronen, Lascelles et al, 2014)
-Pain assessment should accompany every patient assessment
-Treat predictable pain – pain associated with surgery is 100 predictable
-Pain assessment is key to determining the degree and duration of pain treatment but should not replace the adage of treating predictable pain
-Perioperative pain extends beyond 24 hours and should be managed accordingly
-Practice preventive (preemptive) pain management – initiate appropriate treatment before a procedure to prevent the onset of pain, and continue this to prevent occurrence of pain for the duration of time commonly recommended for the problem or which the patient requires
-Response to appropriate treatment is the gold standard to measure the presence and degree of pain. -
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PAIN ASSESSMENT SHOULD BE A ROUTINE COMPONENT OF EVERY PHYSICAL EXAMINATION
Pain Assessment
-Pain assessment is the “fourth vital sign”
-Pain scoring tools
Acute ? Chronic
Canine ? Feline -
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Behavioral Keys
1. Maintenance of normal behaviors
2. Loss of normal behaviors
3. Development of newbehaviors -
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Pain vs Dysphoria
Reversal of opioid
0.01 mg/kg naloxone IV
0.1 mg/kg butorphanol IV
dexmedetomidine (0.5-2mcg/kg)
acepromazine (0.01-0.02mg/kg) -
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Behavioral changes associated with acute pain incats: (Mathews, Kronen, Lascelles et al, 2014)
. Reduced activity
. Loss of appetite
. Quietness
.Hiding
. Hissing and growling (vocalization)
. Excessive licking of a specific area of the body (usually involving surgical wounds)
. Guarding behavior
. Cessation of grooming
. Tail flicking
. Aggression
. Cats in severe pain are usually depressed, immobile and silent. They will appear tense and distant from their environment -
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Appropriate Pain Management
-
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Behavioral Signs of pain in dogs: (Balakrishnan and Benasutti, 2012)
Category
Attitude/Mentation
Body Movement
Facial Expression
Guarding
Posture
Respiratory Pattern
VocalizationScared, submissive appearance; Unwilling to eat or interact with people; Inability to lay down
Constant trembling with / without stimulation and / or handling
Flinching from fingertips lightly brushed over the body
Tense facial muscles with furrowed brows; Lips drawn back; Grimace with unfocused or fearful look in eyes; Dilated pupils; Ears flattened against head
Guarding or biting at a painful area; Tensing abdomen when palpation is attempted; Growling when approached
Back or abdominal pain: hunched up or tense appearance; severe abdominal pain: Prayer position (standing on the hindlimbs, with sternum and forelimbs flat on the floor); May move to back of cage or into corner
Short, Shallow breathing pattern
Crying, whining, whimpering -
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Appropriate Pain Management
-
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Acute Pain Scales for Dogs and Cats that IncorporateBehaviors
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Behaviors of chronic pain in cats (Goldberg, 2017a)
-Decreased grooming
-Reluctance to jump
-Inability or reluctance to climb or descend stairs
-Inability to jump as high before
-Urinating and soiling outside the litter tray
-Increased or decreased sleep
-Avoiding human interaction
-Hiding
-Dislike of being stroked or brushed -
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Chronic Pain in Cats
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Categories for assessment of chronic pain in cats(Goldberg, 2017a) (Mathews et al., 2014)
. General mobility (e.g. ease of movement, fluidity of movement)
. Performing activities (e.g. playing, hunting, jumping, using a litter tray)
. Eating, drinking
. Grooming (e.g. scratching)
. Resting, observing, relaxing (how well these activities can be enjoyed bythe cat)
. Social activities involving people and other pets
. Temperament -
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Chronic Pain in Cats
-
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Feline Chronic or Neuropathic Pain Conditions (Goldberg, 2017a)
. Degenerative joint disease/ osteoarthritis
. Feline orofacial pain syndrome (FOPS)(Goldberg, 2017a) (Heath et al., 2010)
. Post-amputation which includesonychectomy (Goldberg, 2017a)(Mathews, 2008)
. Diabetic neuropathy (Goldberg, 2017a)(Mathews, 2008)
.Feline hyperesthesia syndrome (Goldberg,2017a) (Ciribassi, 2009)
. Feline interstitial cystitis (Goldberg,2017a) (Mathews, 2008)
. Gingivostomatitis (Goldberg, 2017a)(Cannon, 2015)
. Inflammatory bowel disease (IBD) (Mathews, 2008)
. Pancreatitis/pancreatic pain (Mathews,2008)
. Spinal Cord Trauma/ Intervertebral discherniation (Mathews, 2008)
. Pelvic Fractures (Mathews, 2008)
. Trauma: accidental or surgical (Mathews,2008) -
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Feline Neuropathic Pain
Feline Orofacial Pain Syndrome
Feline Hyperesthesia Syndrome -
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Causes of Feline Cancer Pain (Goldberg, 2017a) (Fox, 2014)
1. Is directly produced by the tumor
2.Is due to the various treatment modalities
3. Is related to chronic debility
4. Is due to unrelated, concurrent disease processes
. lymphoma (lymphosarcoma
. alimentary (gastrointestinal)
. cranial mediastinal (chest)
. extranodal
. squamous cell carcinoma
. soft-tissue sarcoma
. feline injection site sarcoma (FISS) -
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Cancers in Cats . Feline Lymphomaand FISS
-
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Behavioral Considerations for Chronic Pain in Dogs
. Increasingly diminished function and mobility that indicate progressive disability
. Diminished exercise tolerance and general activity
. Difficulty standing, walking, taking stairs, jumping or getting up
. Decreased grooming
. Changes in urination or defecation habits -
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Chronic Pain in Dogs
-
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Positive behaviors reduced with chronic pain(Goldberg, 2017b) (Hielm-Bjkman et al, 2009)
. Decreased socialization/play with human family
. Decreased socialization/play with other dogs
. Decreased movement (quality and quantity)
. Decreased interest in hygiene/grooming
. Decreased tail wagging
. Hypo-or anorexic
. Decreased curiosity -
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Chronic Pain in Dogs
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Negative behaviors more frequent with chronic pain (Goldberg, 2017b)
-Aggression towards humans and / or other dogs
-More dependent on owner, jealous, “clingy”
-Sleeping more
-Does not come up to greet owner
-Fearful
-Guarding behavior, guards body parts
-Biting painful areas
-Licking painful areas or dorsal aspects or front limbs
-sudden, excessive negative reaction (compulsive behaviour)
-Under – or overactive -
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Chronic Pain in Dogs and Cats
-
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Abnormal posture or movement seen with chronic pain (Goldberg, 2017b)
-Reluctance to move (walk, trot, gallop, jump)
-Inability to turn in one or both directions
-Hind legs tucked under abdomen
-Tail between hind legs
-Ears back
-Restlessness, wandering, circling
-Rigid posture and gait
-Sitting or lying down in the middle or walks
-Head hanging: will not lift or turn head (neck pain)
-Praying position (abdominal pain)
-Decreased weight bearing (limb pain)
-Sitting abnormally (e.g. knee out in stifle pain)
-Trembling or shaking -
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Postures with Chronic Pain in Dogs
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Mental and physiological behavior(Goldberg, 2017b)
. Depressed, sad, and / or anxious demeanor
. Visible white sclera around the iris (not always pain, some breeds show this all the time)
. Panting or tachypnea or tachycardia without exercise -
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Other (Goldberg, 2017b)
. No change in behaviour
. Decreased vocalization and/or quiet whining or whimpering
. Increased vocalization including screaming or howling with breakthrough pain or manipulation of painful area
. Allodynia
. Hyperesthesia or hyperalgesia -
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THE CONTINUUM OF PAIN…
Hypersensitization
Physiologic Pain
Acute Pain
Hyperalgesia
Chronic Pain
Dysthesia
Expanded field
Allodynia
Neuropathic Pain
IASP: “…primary lesion or dysfunction in the nervous system”
Adaptive
Maladaptive -
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Hyperesthesia and Allodynia
Hyperesthesia
-Hyperesthesia is a condition in which someone becomes highly sensitized to sensory stimuli.
Allodynia
-Pain when touch should be nonpainful -
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Hypersensitization in a nutshell
-
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Canine Chronic Neuropathic Pain Conditions (Goldberg, 2017b)
. Degenerative joint disease/osteoarthritis
. Intervertebral Disc Disease (Fingeroth & Thomas,2015)
. Post amputation (Mathews, 2008)
. Ocular Conditions (Fox, 2010)
. Otic Conditions (Fox, 2010)
. Trauma: accidental and surgical (Mathews, 2008) -
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Neuropathic Pain in Dogs
Chronic otitis externa
Amputation
Osteoarthritis -
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Neuropathic Pain from Glaucoma
-
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Tumors associated with pain (Goldberg,2017b) (Lucroy, 2013)
-Primary bone tumors such as osteosarcoma, fibrosarcoma. Chondrosarcoma or hemangiosarcoma
-Tumors metastatic to bone. Such as prostate carcinoma or mammary carcinoma
-Multiple myeloma
-CNS tumors, particularly spinal tumors.
-Inflammatory mammary carcinoma. Although large mammary tumors may also be painful
-Lower urinary tract rumors and those involving the prostate may be painful
-Oral tumors, especially if invasive bone
-Invasive cutaneous tumors
-Intra-abdominal tumors. Particularly if placing traction on the root of the mesentery. Causing
-Complete or partial obstruction of the intestinal tract or resulting in distension of the capsule of solid organs. -
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Canine Osteosarcoma
-
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Multifactorial clinical measurement instruments for chronic pain for Dogs and Cats that Incorporate Behaviors (Epstein et al, 2015)
. Helsinki Chronic Pain Index (HCPI)
. Canine Brief Pain Inventory (CBPI)
. Cincinnati Orthopedic Disability Index (CODI)
. Health-Related Quality of Life (HRQL)
. Liverpool Osteoarthritis in Dogs (LOAD)
. Feline Musculoskeletal Pain Index (FMPI) -
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CBPI and CODI Scales
-
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HRQL and LOAD Scales
-
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Veterinary Nurses Must Be:
. Experts on assessing any pain
. Primary advocate for our patients
. Educate owners
. Employ stress free handling techniques -
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Listen to Me .
THANK YOU -
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"VETSCOPE
THANK YOU
"
-
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Peritoneal Tumor Resection (Hepatocellular Carcinoma) - P.1 Peritoneal Tumor Resection (Hepatocellular Carcinoma) - P.1
Dr. George Ohta
President of Inuyama Animal General Medical Center
He has conducted more than 30,000 surgeries in his career, covering a broad range of surgeries including soft tissue surgeries, orthopedics, neurosurgery, etc.Close slides View other slides in this lecture-
Peritoneal Tumor Resection (Hepatocellular Carcinoma) - P.2 Peritoneal Tumor Resection (Hepatocellular Carcinoma) - P.2
Steps
1. Incise the affected area
2. Excision of the tumor metastasis organ (Spleen)
3. Confirmation of tumor adhesion site
4. Detachment and removal of the tumor
5. Suture the wound -
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Step 1
Incise the affected area -
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Step 2
Excision of tumor metastasis organ (Spleen) -
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Step 3
Confirmation of tumor adhesion site -
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Step 4
Detachment and removal of the tumor -
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Step 5
Suture the wound
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NSAIDs: What We Do Know - P.1 NSAIDs: What We Do Know - P.1
NSAIDs: What We Do Know
Matt Brunke, DVM, CCRP, CVPP, CVA
Diplomate, American College of Veterinary Sports Medicine and RehabilitationClose slides View other slides in this lecture-
NSAIDs: What We Do Know - P.2 NSAIDs: What We Do Know - P.2
A little about me..... I like to keep busy
-
NSAIDs: What We Do Know - P.3 NSAIDs: What We Do Know - P.3
Who
-Use NSAIDs in their practice?
-Dogs?
-Cats?
-Other?
-Themselves? -
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NSAID
-Non Steroidal Anti Inflammatory Drug
-Historically for mild, chronic pain
-Humans – classically associated with GI side fx
-Hippocrates showed medical benefits of willow bark
-1971 – Aspirin proposed mechanism of action realized -
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What's special about them?
-Potent anti-inflammatory
-End result similar to steroids
-Prostaglandin production decreased
-Central and peripheral effects
-Analgesic
-Antipyretic
-Non-dependence
-Devoid of opioid side fx -
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Generalizations of NSAIDs
-Rapidly absorbed by the GI
-Highly protein bound
-Weak acids – accumulate in inflamed tissue
-Metabolized in the liver +/- enterohepatic cycling
-Half lives vary from 2-72 hours
-Effects differ in half life and route of admin -
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Where’s the action?
ARACHIDONIC ACID
Lipooxygenase
Leukotrienes
Bronchospasm Inflammation
COX-1
Prostaglandin
Gastric Protection uterine contraction,renal function
Throbocanes
Platelet Aggregation
Tissue damage
COX-2
prostaglandins
Pain inflam mation,renal function -
NSAIDs: What We Do Know - P.8 NSAIDs: What We Do Know - P.8
Mechanisms of Action
-Decreasing production of prostaglandin
-Cyclooxygenase (COX) inhibition
-Neutrophil inhibition
-Glycosaminoglycan synthesis exacerbation
-Metalloproteinase inhibition
-CNS/spinal modulation
-Excitable membranes
-Cell metabolism
-Messenger systems -
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Pain Pathway
-
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Who benefits?
-Orthopedic procedures
-Soft tissue biopsy
-Bone marrow aspirate
-Joint taps
-OVH
-Dental
-Otic/Ophthalmalogic procedures
-OA/DJD
-Polyarthritis
-Cystitis
-Otitis/Uveitis
-Dermatologic disease
-Meningitis
-Bite Wounds
-HOD/panosteitis -
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COX
-Cyclooxygenase – prostaglandin synthase
-Its job is to place oxygen into arachidonic acid
-Metabolizes AA
-It produces mediators of function AND pathology
-Thromboxanes, prostacyclin, prostaglandins E2, F2, D2 -
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COX has (at least) 2 isoforms
COX-1 (good?)
-Constitutive
-Platelets
-Kidneys
-Stomach
-Repro tract
-Maintains homeostasis
-Renal blood flow
-Gastric secretion
mucus COX-2 (bad?)
-Inducible
-Fibroblasts
-Endothelial cells
-Chondrocytes
-Macrophages
-Constitutive
-CNS
-Kidneys
-Main inflammation mediator and of pain -
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COX-3???
-Simmons D, et. Al. Proc Nat Acad Sci 2002
-“COX-1 variant or isoform expressed in high amounts in brain and heart”
-Acetaminophen
-Poorly inhibits COX-1 and COX-2
-Greatly inhibits COX-3
-Partial COX-1 or PCOX-1 proteins abundant in canine brain -
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How did isoforms influence the industry
-If COX-2 is the enzyme that mediates bad things.........
-Suppressing it alone and sparing COX-1 would limit side effects of
-GI ulcers
-Platelet inhibition
-Renal perfusion -
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Classes of NSAID
-Nonselective
-Inhibit both COX-1 and COX-2
-Aspirin, flunixin
-Preferential
-Inhibit COX-1 and COX-2, but less COX-1
-Carprofen, meloxicam
-Selective
-Inhibit COX-2 only
-Deracoxib, firocoxib -
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Because enzymes don't read books
-COX-2 can be good in some tissues
-Damaged gastric epithelium
-Hypovolemic and developing renal tissues
-Brain
-Endometrium
-Although COX-2 is mainly “bad” it may also modulate (help decrease) inflammation long term -
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Ratio problems; COX-2: COX-1
-Selectivity of a particular NSAID for one isoform or the other is expressed as a ratio.
-The higher the ratio, the less SPARING to COX- 1. -
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COX-2 to COX-1
-
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Great! That solved it.
-
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Nope! There is a problem with COX ratios
-Assays were done in vitro, not in vivo
-Recombinant enzymes or whole cell cultures?
-Selectivity for isoform may be lost at greater concentrations (clinical concentration) of drug
-Individual isoform variability
-Length of study
-Species differences -
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So things are not as simple as we would like them. Why?
-Genetic expression of isoform differs from individual to individual
-Enzymes which metabolize NSAIDs differ from one individual to another
-At clinically effective doses, some NSAIDs lose their preference for one COX isoform -
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NSAIDs Inhibit Both Inflammation and Pain
-
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Do the Risks Outweigh the Benefits?
- Benefits and risk of any medication is assessed on a case by case basis
- Understanding the different types of adverse events:
- Allows veterinarians to minimize the risk
- Better communicate the actual risks to pet owner
- Appropriate patient selection is key to maximize the benefits of NSAID use
Benefit
Risk
For the Vast Majority of Canine Patients, the Benefits Outweigh the Risks -
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Adverse Reactions for All Drugs Fall into Two Major Categories
Inducible Idiosyncratic
Reactions Are Dose-related
Reactions Are Attributable to the Mechanism of Action of the Drug
Predictable
Examples: Antineoplastic Drugs - Neutropenia NSAIDs - GI Signs
Not Dose-related
Not Attributable to the Mechanism of Action of the Drug
Unpredictable and Rare; Maybe Serious
Examples: Penicillins - Anaphylaxis NSAIDs - Hepatic Toxicity -
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The Risk of an Adverse Reaction is Greatest Early in Treatment
- The most common seen with NSAIDs are inducible, and include GI irritation
- Typically occur early in treatment
- Idiosyncratic reactions occur infrequently (<1 in 10,000)
- Idiosyncratic reactions are most likely to occur in the first 90 days of treatment
- Although individual response may vary, benefits of NSAID use outweigh the risks or the majority of dogs
Appropriate Patient Selection and Monitoring During Treatment Can Minimize the Potential for Adverse Events
1.Wolf MM et al. NEJM, 340:1888-1899; 1999. 2.Autefage et al. Revue Méd. Vét, 158:119-127; 2007. 3.Innes J et al. Vet Rec 166:226-230; 2010. 4.Lee WM. NEJM, 349:474-448; 2003. -
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FDA NSAID Class Language on “Lowest Effective Dose”
- The Label Language: Lowest effective dose for the shortest duration consistent with individual response
- Duration of treatment should be determined by the patient’s response
- Start at lowest FDA Label Dose; some NSAIDs have dose range
- If considering a reduction in dose monitor to ensure that the lower dose is effective
- For idiosyncratic reactions, reducing the dose does not decrease the risk
- Addressing other issues? – Obesity, chondroprotection?
- Decision for dose and duration of treatment is based on patient and Benefit/Risk analysis -
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Treating with NSAID on a Patient by Patient Basis
Benefits Risks
Pain Relief GI Signs
Relief of Inflammation Renal Disease
Return to Function Hepatic Disease
Re-establish Human-Animal Bond Other Less Commonly Reported Signs
- Frequency is low for most adverse events and resolve with discontinuation and/or supportive treatment
- With appropriate patient selection and monitoring can maximize the benefits and minimize the risks -
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Adverse Effects of NSAIDs
- Gastrointestinal
- Renal
- Platelet function
- Respiratory
- Miscellaneous
- Repro
- CNS
- Cardiac -
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GI
- Related to inhibition of COX-1
- COX-1 regulates numerous functions
- Motility
- Mucosal blood blow
- Prostaglandin cytoprotection
- When a GI ulcer forms
- COX-2 needed for repair
- Even COX-2 inhibitors will delay healing -
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GI Side Effects – Clinical Importance
- Patients with overt GI upset should not be given NSAIDs
- Stressed?
- Cushing’s?
- In patients with pre-existing GI ulcers, NSAIDs, (especially COX-2 selective) should not be used
- Perfusion and oxygen tension should be considered -
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What about NSAIDs in pancreatitis?
- Bang UC, et al. World J Gastroenterolo. 2008 May 21;14(19):2968-76. Pharmacological approach to acute pancreatitis
- “The NSAID indomethacin and diclofenac have in randomized studies showed potential as prophylaxis again pancreatitis”
- Otsuka, T. et al. J Gastroenterol. 2012 Aug;47(8):912-7. Low dose rectal diclofenac for prevention of post-endoscopic retrograde cholangiopancreatography pancreatitis: a randomized controlled trial.
- “Pain was significantly more frequent in the control group than in the diclofenac group (37.7 vs. 7.8%). There was no adverse effects related to diclofenac. Low dose rectal diclofenac can prevent PEP” -
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But if we need to use NSAID, what protects the GI best?
- Tolbert K, Bissett S, King A, et al. Efficacy of oral famotidine and 2 omeprazole formulations for the control of intragastric pH in DOGS. J Vet Intern Med 2011;25;47-54.
- “Co administration of misoprostol 3mcg/kg PO q8-12h or based on a combination of canine antacid efficacy and human recommendation data – omeprazole approximately 2mg/kg PO daily, q24h or divided. -
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And even more info
- Bersenas AME, Mathew KA, Allen DG, et al. Effects of ranitidine, famotidine, pantoprazole, and omeprazole on intragastric pH in dogs. Am J Vet Res, 2005, 66:425-31.
- “Compared to standard or high dose H2RAs, PPIs (proton pump inhibitors) appear superior at acid reduction in dogs." -
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Great, until we add tramadol?
- Hill T, Blikslager A. Co-Administration of NSAIDs and Tramadol Decreases Gastric Mucosal Barrier Function. ACVIM 2011
- Recovery of gastric barrier function after acid injury was inhibited by co-administration of tramadol and indomethacin but not by tramadol or indomethacin alone.
- Torring ML, et al. Perforated peptic ulcer and short-term mortality among tramadol users. Br J Clin Pharmcol. 2008 Apr;65(4):565-72
- “Among patients hospitalized for perforated peptic ulcer, tramadol appears to increase mortality at a level comparable to NSAIDs.” -
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Some of that info gave me an ulcer...
-
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So let’s move on to renal adverse effects
- Related to inhibition of COX-1 and COX-2
- COX-2 necessary for renal development
- Basal kidney function doesn’t depend on COX or its prostaglandin production
- But....during hypovolemia or hypotension
- COX-1 maintains blood flow
- COX-2 mediates renin release and tubular function -
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Perioperative NSAID use
- Crandell DE et al. Effect of meloxicam and carprofen on renal function when administered to healthy dogs prior to anesthesia and painful stimulation. Am J Vet Res. October 2004;65(10):1384-90.
- “When administered 1 hour before onset of anesthesia and painful electrical stimulation, meloxicam or carprofen did not cause clinically important alteration of renal function in young healthy dogs. -
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More evidence for perioperative NSAID
- Goodman LA, et al. Effects of meloxicam on plasma iohexol clearance as a marker of glomerular filtration rate in conscious healthy cats. Am J Vet Res. July 2009;70(7):826-30.
- “Short term meloxicam administration did not measurable alter the glomerular filtration rate as assessed via plasma clearance of iohexol.” -
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Yet more evidence
- Hellyer P et al. AAHA/AAFP pain management guidelines for dogs and cats. JAAHA 2007;43:235-48.
- “Before an elective surgery, use an opioid that also reduces the anesthetic requirement. Before or during surgery, use a local anesthetic at the incision to block the transmission of noxious stimuli. During anesthetic recovery, use an NSAID to decrease the inflammation from the surgical trauma." -
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My own rules for perioperative NSAIDs
- Avoid NSAIDs in patients with
- Clinical ARF
- Failure vs. chronic disease
- Severe dehydration
- Hypovolemia
- Hypotension
- Hemorrhage
- Cats
- Intraop
- Postop if not ASA I -
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More of my own rules
- ASA I and II patients: NSAID likely fine without fluids or support in elective short procedures; administer pre or intra
- ASA III: Provide fluid support and BP monitoring to patients, admin post-op
- ASA IV: Weigh pros/cons
- ASA V: I don’t use them in the immediate perioperative period -
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Platelet function and NSAIDs
- Aggregation of platelets is dependent on thromboxane A2
- Which is produced by COX-1
- Problems related to NSAIDs inhibiting COX-1 - no platelet aggregation
- Aspirin irreversibly inhibits COX-1
- COX-2 inhibitors (selective and preferential) preserve platelet function -
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Better safe than sorry
- Mullins KB et al. Effects of carprofen, meloxicam, and deracoxib on platelet function in dogs. Vet Anes/Anal 2012 39(2) 206-17.
- “Individual assessment of platelet FUNCTION is advised when administering these drugs prior to surgery, particularly in the presence of other risk factors for bleeding.”
- Pt/Ptt, BMBT -
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Other NSAID side effects
- COX inhibition can cause bronchospasm
- COX-2 inhibition can result in increase neuron activity in seizure patients
- Human studies: risk of thrombosis in patients with pre-existing disease increases with COX-2 inhibition
- Chronic blockade of COX-1 and COX-2 may aggravate hypertension in humans
- COX-2 in repro
- Prolonged labor
- Decrease myometrial contraction
- Decreased embryo implantation -
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NSAIDs as chemotherapeutics
- Bommer NX, et al. Clinical features, survival times and COX-2 expression in cats with transitional cell carcinoma of the urinary bladder treated with meloxicam. J Feline Med Surg August 2012;14(8):527-33.
- “Ten of the cats showed clinical improvement (reduction of hematuria and or dysuria) with a mean survival time of 311 days (range 10-1064)." -
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Chemo
- Bulman-Fleming JC et al. Evaluation of adverse events in cats receiving long-term piroxicam therapy for various neoplasms. J Feline Med Surg April 2010;12(4):262-8.
- “Piroxicam administration was not significantly associated with hematologic, renal or hepatic toxicities. Adverse effects were not correlated with dosage. Adverse events were reported in 29% of cats, and were greatly mild or transient.” -
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Chemo
- McMillian SK, et al. Antitumor effects of deracoxib treatment in 26 dogs with transitional cell carcinoma of the urinary bladder. JAVMA October 2011;239(8):1084-9.
- “Of 24 dogs for which tumor response was assessed, 4 had partial remission, 17 had stable disease, 3 had progressive disease. (17/71/13%)” -
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NSAID long term safety - canine
- Innes JF, et al. Review of the safety and efficacy of long-term NSAID use in the treatment of canine osteoarthritis. Vet Rec Feb 2010;166(8):226-30.
- “The balance of evidence for the efficacy of NSAIDs supports longer-term use of these agents for increased clinical effect. There is no indication in the literature that such an approach is associated with a reduction in safety, although robust data on the safety of long-term NSAID use is lacking in large numbers in dogs.” -
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Cats and NSAIDs
- Most NSAIDs are metabolized via glucuronidation
- Cats deficient in glucuronyl transferase enzymes
- Toxic metabolites increase rapidly with repeat dosing of certain NSAIDs
- Subclinical renal impairment likely in this species
- Operative monitoring of perfusion is very tough, hence most operative problems common, let alone those with NSAIDs
- Acetaminophen toxicity
- Impaired gluconate conjugation
- Toxic metabolites overwhelm glutathione reductase -
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Cats and NSAIDs
- Carprofen - UK
- Ketoprofen – inj only
- Meloxicam – inj yes, BLACK BOX oral
- Piroxicam
- Robenacoxib (Onsior)
- 3 days in USA
- 6 days in Europe -
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Long term robenacoxib in cats
-
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Safety of NSAIDs in cats
- Girauder JM, et al. Evaluation of orally administered robenacoxib versus ketoprofen for treatment of acute pain and inflammation associated with musculoskeletal disorders in cats. Am J Vet Res July 2010;71(7):710-9.
- “Safety was assess by monitoring adverse events, clinical signs, and hematologic and plasma biochemical variables (before and after treatment). Results: no significant differences were detected among the 3 treatment groups for any primary or secondary efficacy endpoints or for tolerability variables.” -
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One more
- Gowan RA, et al. Retrospective case-control study of the effects of long- term dosing with meloxicam on renal function in aged cats with degenerative joint disease. J Feline Med Surg October 2011;13(10):752-61.
- “There was no difference in sequential serum creatinine concentration or USG measurements between the non-renal group treated with meloxicam compared to control cats not treated with meloxicam. - There was less progression of renal disease in the renal group treated with meloxicam compared to the age and IRIS matched cats with CKD not given meloxicam. - These results suggest that a long term maintenance dose of 0.02/mg/kg of meloxicam can be safely administered to cats older than 7 years even if they have CKD." -
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Contraindications – Cats and Dogs
Avoid in
- ARF
- Dehydration, hypovolemia, hemorrhage
- Liver failure
- Hypoalbuminemia
- Hypocoagulopathy
- Suspected or overt ulcerative GI dz
- Coagulopathy
Decrease interval dose or increase dosing - Impaired liver function
- Clinical renal disease
- Myocarditis patients
- Asthmatic patient -
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Minimizing the Risk: Patient Selection
- All dogs should undergo a thorough history and physical examination before initiating NSAID therapy
- Appropriate hematological and serum baseline data is recommended prior to and periodically during administration
- Avoid in dogs with a history of renal disease
- NSAIDs are not recommended for dogs with bleeding disorder
- Dogs that have adverse reactions from other NSAIDs, may have adverse reactions with other NSAIDs
- Dogs at greatest risk
- Dehydrated or on concomitant diuretic therapy
- Dogs with renal failure, cardiovascular and or hepatic dysfunction
1. Deramaxx Package insert, NADA # 141-203, 2008 Novartis Animal Health.
2. Etodolac Package insert, NADA 141-108, 2008 Fort Dodge.
3. Metacam Package Insert, NADA 141- 213, 2010, Boehringer Ingelheim Vetmedica, Inc.
4. Previcox package insert NADA 141-230, 2010,
5. Rimadyl Package insert, NADA 141- 111, 2007 Pfizer Animal Health,
6. http://www.fda.gov/AnimalVeterinary/SafetyHeal th/ ProductSafetyInformation/ucm055434.htm, FDA Website. Merial. -
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Minimizing the Risk: Concurrent Medications
- Concomitant use of NSAIDs with other anti-inflammatory drugs such as corticosteroids and other NSAIDs should be avoided
- Pet owners may not disclose that they are treating dogs with aspirin
- 7% veterinarians recommend aspirin to treat canine osteoarthritis7
- 28% of pet owner indicated that they use aspirin to treat their dogs osteoarthritis7
- Studies to determine the activity of NSAIDs when administered concomitantly with other protein-bound or similarly metabolized drugs have not been conducted
- Drug compatibility should be monitored closely in patients requiring cardiac, anticonvulsant and behavioral medications1. Deramaxx Package insert, NADA # 141-203, 2008 Novartis Animal Health.
2. Etodolac Package insert, NADA 141- 108, 2008 Fort Dodge.
3. Metacam Package Insert, NADA 141- 213, 2010, Boehringer Ingelheim
5. Rimadyl Package insert, NADA 141- 111, 2007 Pfizer Animal Health,
6. http://www.fda.gov/AnimalVeterinary/SafetyHealth/Product SafetyInformation/ucm055434.htm, FDA Website. PAH GMR, Canine OA Compliance Study, April 2011. -
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Minimizing the Risk: Pet Owner Communication
- Always provide a Client Information Sheet with prescription
- Pet owners should be:
- Informed regarding potential adverse events
- Advised to discontinue NSAID therapy if side effects occur and contact their veterinarian
- Store palatable formulations out of reach of dogs, in a secured location. Severe adverse reactions may occur if large quantities of tablets are ingested
- Made aware of the importance of periodic follow-up for
- Safety, Efficacy, Compliance
- Development of unrelated conditions -
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Not recommended when
- Hyperbilirubinemia
- Elevated ALT, AST and GGT
- If any of these are elevated alone or in combination, with or with out signs of hepatic disease
- Albumin decreased – Recommend workup for renal, GI or hepatic dysfunction
- Clotting disorder
- Elevated ALP with clinical signs of liver or Cushing’s disease -
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ALP is elevated, but normal dog
- Could be Benign Nodular Hyperplasia
- Is fairly common in older dogs
- ALP can be 2.5x to >10x normal
- Ultrasound and Bile Acids to rule out other disease
- Additional diagnostic as needed
- Consider NSAIDs if no other underlying disease detected
- Monitor to ensure no further elevation or other abnormalities (within 10–30 days, then periodically)
- Any further increases in hepatic enzymes warrants further evaluations -
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My NSAID Rules
- Use one or two in your clinic. Be comfortable with them.
- Don’t mix NSAID & NSAID. Don’t mix steroid & NSAID.
- It’s not working. Can it handle it alone? Do we need a helper? (gabapentin, amantadine)
- Client handouts, emails and “if vomiting, diarrhea, dark tarry stools STOP med and CALL OFFICE” on EVERY LABEL. -
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More rules
- Use manufacturers dosing. Tapering to “least effective” could bring back windup, and we under diagnose pain already...
- If I have to change NSAID (or to/from pred): washout (5-7 days) bridge (Gabapentin, buprenorphine, Tylenol)
- I stick with brand names. – Product support, reliability.
- Break a tablet in half – is it equally distributed?
- Have a problem? Report it -
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What is GALLIPRANT® (grapiprant tablets)?
- Galliprant is a first-in-class non-cyclooxygenase (COX) inhibiting, non-steroidal anti-inflammatory drug (NSAID) in the piprant class.
- Piprants are a newly recognized drug class, established and defined by the World Health Organization in 2013 as prostaglandin receptor antagonists (PRA).
- Unique mechanism of action by antagonizing the prostaglandin E2 (PGE2) EP4 receptor.
- PGE2 its physiologic effects through binding of four different receptors, EP1, EP2, EP3, and EP4.
- EP4 receptor has been identified as the primary receptor responsible for mediating pain and inflammation associated with osteoarthritis. GALLIPRANT selectively blocks the EP4 receptor, thus blocking PGE2 elicited pain. -
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Aratana - Galliprant®
-
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Key Points to Consider When Choosing an NSAID
- NSAIDs in general are safe and efficacious
- Start treatment using preferred NSAID
- Monitor pet owner – efficacy, compliance safety and - With and outweigh monitoring, appropriate the risk benefits patient for most will selection dogs
- Consider consequences of not treating
Benefit
Risk
- Change in NSAID maybe required based on patient’s response
- One drug maybe more effective than another drug
- One drug may be better tolerated
- Pharmacogenetics may play a role in the variability -
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Contact info
- VOSM - Veterinary Orthopedic & Sports Medicine Group
- drmattbrunke.com
- 10975 Guilford Rd
- Annapolis Junction, MD 20701
- (240)295-4400 (office)
- www.vosm.com
- drbrunke.wordpress.com
-
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Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.1 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.1
Dancing Machine; skillful manipulation of the anesthetic mothership
Kristen Cooley BA, CVT, VTS (Anesthesia/Analgesia
University of Wisconsin School of Veterinary Medicine
Veterinary Anesthesia Support and Training
vastwise@gmail.comClose slides View other slides in this lecture-
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.2 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.2
The design
Anesthetic machines are designed to deliver volatile anesthetic gases in the presence of oxygen -
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Concentrating...
- Why is 100% oxygen necessary?
- Delivery of oxygen based on need
- Reduced tidal volumes - Respiratory depression -
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Following the Yellow Brick Road...
-
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Oxygen
Compressed gas
Pressurization
Two most common sizes
E
700 Liters
H
7000 Liters
Full cylinders
2200 psi of gas -
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Medical Gas Coding
Oxygen - green
Medical Air - Yellow
Vacuum - White
Nitrous Oxide - Blue
Carbon Dioxide - Gray
WAGD - Purple
Instrument Air - Red -
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Following the Yellow Brick Road...
-
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Pressure Regulator
- Tank = HIGH PRESSURE - Pressure regulator = Safe, constant operating pressure
- Regardless of the pressure in the oxygen tank or central system -
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Oxygen Flush Valve
- Vaporizer bypass
- 30-50 L/min!
- Safety 15 L/min
- Handy but dangerous
- Over pressurization is easy -
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CAUTION!
Use with care or not at all when the circuit is connected to the
patient
NEVER use it with a non-rebreathing system
NEVER use when pop-off is closed NEVER use in small patients
Decreases anesthetic concentration in the system and in the patient! -
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Flowmeter
- Adjust O2 flow rate
- L/min
- O2 enters the bottom
- Indicator ball support -
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- A time constant represents the volume of the machine
in relation to the flow of gases - Machine volume (components of breathing system)
- Sodasorb canister ~ 1 L
- Rebreathing bag - depends on size
- Breathing hoses- depends on length and diameter
- Example volume 5 L -
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Time Constant Math
- It takes approximately 3 time constants to see a 95% change in the concentration of gases within the system
3 TC
X 5 L machine at 1 L/min = 15 min (15 min to approach a steady state)
3 TC
X 5 L machine at 2 L/min = 7.5 min (7.5 min to approach a steady state) -
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Example
- You want to go from A to B
- Your flow rate is 1 L/min
- Your volume is 5 L
- You know it will take 3 time constants to go from A to B
- 3TC X 5 L / 1L per min = 15 min
- You are at A and in 15 minutes you will be solidly at B. -
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Example
- You are impatient. 15 minutes is too long.
- What can you do to speed things up?
A. Reduce your volume
B. Increase your flow
C. Change your time constant
D. Use the oxygen flush valve -
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Example
- You want to go from A to B quickly.
- Your flow is now 2 L/min - Your volume is 5 L
- Your time constant is constant at 3...
- 3TC X 5L / 2L per min = 7.5 min!
- Now we are getting somewhere! -
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Time Constants
- Factors affecting changes
- Hypoventilation
- Apnea
- Lack of breathing = lack of gas exchange
- This includes oxygen as well as anesthetic! -
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Caution with high flows
- Monitor closely!
- Increases system flow = increased patient pressure
- Never close pop-off valve when you have higher flows
- High flows waste anesthetic gas, oxygen, and money -
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Back on the road...
-
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Vaporizer
- Converts liquid anesthetic to gas anesthetic
- Precision
- Temperature controlled
- Back pressure compensated -
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Vaporizers
- Agent specific
- Must be calibrated and cleaned regularly!
- Never fill vaporizer with an unspecified anesthetic! -
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Fresh gas outlet/inlet
-
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Fresh gas outlet/inlet
- Exits vaporizer and enters machine
- Non-rebreathing system connection -
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Flutter Discs
- One-way valves
- Circle system
- Inspect daily and clean regularly -
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Manometer
- Pressure of gases
- Manual ventilation
- Pressure in system/patient
- Not to exceed 15-20 cmH2O or 10-14 mmHg -
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Pop-off of APL valve
- Prevents pressure build-up
by allowing gases to escape out to scavenge
The pop-off occlusion valve vents pressure at 2 cm H2O -
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Pop-off or APL valve
- A closed pop-off allows pressure to build within the machine and patient
- This pressure build-up may impede venous return to the heart or cause barotrauma -
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Carbon dioxide absorbent
- Absorbent granules
- Removes CO2 -
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CO2absorber
- Lowers fresh gas flows
- Reduces waste
- Re-breathing of gases
- Lowers overall cost -
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The granules
- Calcium hydroxide or barium hydroxide
- Exothermic reaction
- Must be changed when exhausted
- pH color indicator
- White to lavender or blue - Short lived chemical reaction
- Fresh granules are easily chipped or crumbled
- Saturated granules are hard and brittle -
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Scavenge
- Collects waste gas from breathing system
- Passive disposal
- Non-circulating ventilation systems
- Activated charcoal
- F/air canisters
- Enviro-Pure
- Active disposal
- Central vacuum system
- Personnel safety should be a priority! -
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Anesthetic machine
-
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.33 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.33
Breathing System
- After the common gas outlet
- Anesthetic tubing
- Rebreathing bag
- CO2 absorber
- Scavenge system -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.34 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.34
The Breathing System
- Oxygen and anesthetic gas
- Remove CO2
- Controlled ventilation -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.35 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.35
Breathing Systems
- Circle system
- Patients > 3 kg
- Inspiratory and expiratory valves, sodasorb canister
- O2 flow rate of 40 ml/kg/min
- Non-rebreathing system
- Patients < 3 kg
- O2 flow rates of 180-300 ml/kg/min
- Closed or partially closed system
- Refers to O2 flow rate (not position of pop-off valve)
- Also called low-flow anesthesia
- Flow rates 11-22 ml/kg/min or less than 40 ml/kg/min -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.36 -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.37 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.37
NRB
- Follow the flow of oxygen
Same as circle system up to fresh gas inlet...
Bypasses flutter valves
Bypasses carbon dioxide absorber
High gas flows -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.38 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.38
Non-rebreathing systems
-
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.39 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.39
Breathing Bag/Reservoir Bag
- Reservoir for gases
- Should hold a minimum of 60 ml/kg
- 6 X tidal volume
- (10-20 ml/kg/min)
- Calculate the range
- Pick a size within the range -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.40 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.40
Breathing Bag
- Large breath
- Observe breathing
- Assist breaths -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.41 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.41
Bag Size
- If bag is too large...
- Impairs monitoring
- Machine volume
- Slows changes
- If bag is too small...
- Bag collapse
- Unable to take adequate breath -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.42 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.42
Breathing Hoses
- Transports anesthetic gas
- Diameter hoses;
- 22 mm for larger dogs
- 15 mm for small dogs and cats
- Different lengths -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.43 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.43
Endotracheal Tubes
- One time use only in humans
- Cuffs tend to wear out
- Always check for leaks!
- Make sure cuff inflates
- Discard any leaky tubes
- Place inflated tube into a bowl of water and look for bubbles/leaks -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.44 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.44
Mechanical Dead Space
- Bi-directional flow
- Extra pieces
- CO2 monitor adapter
- Swivel
- Elbow
- Excess pieces should be avoided in small patients
Hose length does not contribute to dead space -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.45 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.45
Best Practice
- Always pressure test the machine before every case and every time a component of the breathing circuit is changed. -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.46 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.46
Machine Troubleshooting
Common areas prone to leaks;
- Around CO2 absorbent canister
- Around valve caps
- Re-breathing bag
- Around any joint that gases pass through
If leaking when connected to patient, check ET tube first, then check machine -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.47 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.47
If you suspect a leak...
- Go through and tighten all joints and connections and hope that you catch the leak
- If the leak remains...
Keep O2 on and spray dilute soapy liquid around all joints in the breathing circuit The gas sneaking out of the system will make bubbles! -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.48 Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.48
Wrapping it all up...
- The anesthesia machine is a dynamic piece of equipment
- Understanding how it works allows you to better serve your patients
- Mindfully choosing breathing systems can improve patient outcomes
- Regular and proper maintenance is important to the machine's longevity -
Dancing Machine: Skillful Manipulation of the Anesthetic Mothership - P.49
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-
Evidence-based CPR: The Recover Guidelines - P.1 Evidence-based CPR: The Recover Guidelines - P.1
EVIDENCE-BASED CPR: THE RECOVER GUIDELINES
Kenichiro Yagi MS, RVT, VTS (ECC, SAIM)Close slides View other slides in this lecture-
Evidence-based CPR: The Recover Guidelines - P.2 Evidence-based CPR: The Recover Guidelines - P.2
Video of a dog receiving CPR
-
Evidence-based CPR: The Recover Guidelines - P.3 Evidence-based CPR: The Recover Guidelines - P.3
CPR being performed at a practice
-
Evidence-based CPR: The Recover Guidelines - P.4 Evidence-based CPR: The Recover Guidelines - P.4
DO IT ALL NOW!!
How much epi?
Hook up the ECG!
Get a tube in!
Do we have an IV yet!? -
Evidence-based CPR: The Recover Guidelines - P.5 Evidence-based CPR: The Recover Guidelines - P.5
How much epi?
What does the ECG show us?
What should we do first? -
Evidence-based CPR: The Recover Guidelines - P.6 Evidence-based CPR: The Recover Guidelines - P.6
RECOVER
Reassessment Campaign on Veterinary Resuscitation -
Evidence-based CPR: The Recover Guidelines - P.7 Evidence-based CPR: The Recover Guidelines - P.7
CRP Algorithm
Unresponsive, Apneic Patient
decreased
Initiate CRP Immediately
Basic Life Support
1 full cycle = 2 minutes
uninterrupted compressions/ventilation
1: Chest Compressions
100-120/min
- Lateral recumbency
- 1/3-1/2 chest width
2: Ventilation
10/min
Intubate in lateral
Simultaneous compressions
or
C:V 30:2
- Interpose compressions
Advanced Life Support
3 Initiate Monitoring
- Electrocardiogram(ECG)
- End Tidal CO2(ETCO2)
->15 mmHg = good compressions
4 Obtain Vascular Access
5 Administer Reversals
-Opioids - Naloxone
-2 agonists - Atipamezole
-Benzodiazepines - Flumazenil
Evaluate Patient Check ECG
Basic Life Support
Change compressor Perform 1 full cycle = 2minutes
Reprinted with permission from Fletcher et al., J Vet Emerg Crit Care,22(S1): S1022-S131, 2012 -
Evidence-based CPR: The Recover Guidelines - P.8 Evidence-based CPR: The Recover Guidelines - P.8
CRP Algorithm
Unresponsive,Apneic Patient
decreased
Initiate CRP Immediately
Basic Life Spport
1 full cycle = 2 minutes
uninterrupted compressions/ventailation
1 Chest Compressions
100-120/min
-Lateral recumbency
-1/3-1/2 chest width
2 Ventailation
10/min
Intubate in lateral
Simultaneous compressions
or
C:V 30:2
-Interpose compressions
Advanced Life Support
3 Initiate Monitoring
-Electrocardiogram(ECG)
-End Tidal CO2(ETCO2)
->15 mmHg = good compressions
4 Obtain Vascular Access
5 Administer Reversals
-Opioids - Nalocone
-2 agonists - Atipamezole
-Benzodiazepines - Flumazenil
decreased
Evaluate Patient Check ECG -->ROSC -->Post-CPA Algorithm
VF / Pulseless VT
Asystole / PEA
-Continue BLS,charge defibrillator
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT,consider
-Amiodarone or Lidocaine
-Epinepherine / Vasopressin every other cycle
-Increase defibrillator dose by 50%
-Low dose Epinephrine and/or Vasopressin
every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10min,consider
-High dose Epinephrine
-Bicarbonate therapy
decreased
Basic Life Support
Change compressor Perform 1 full cycle = 2minutes
Reprinted with permission from Fletcher et al., J Vet Emerg Crit Care,22(S1): S1022-S131,2012 -
Evidence-based CPR: The Recover Guidelines - P.9 Evidence-based CPR: The Recover Guidelines - P.9
Compression Technique
- Start immediately
- Rate: 100-120bpm
- Depth: 1/3-1/2 of chest
- Allow full recoil
- 2 min uninterrupted
- Compression Point -
Evidence-based CPR: The Recover Guidelines - P.10 Evidence-based CPR: The Recover Guidelines - P.10
Round Chested
As wide as deep Highest point of chest Thoracic pump theory
Keel Chested
Deeper than wide Over the heart Cardiac pump theory
Flat Chested
Wider than deep Over the sternum Cardiac pump theory
This is a rare case!! -
Evidence-based CPR: The Recover Guidelines - P.11 Evidence-based CPR: The Recover Guidelines - P.11
Round-Chested Dog
Focus compressions on the widest portion of the chest -
Evidence-based CPR: The Recover Guidelines - P.12 Evidence-based CPR: The Recover Guidelines - P.12
Narrow-Chested Dog
Focus compressions over the heart -
Evidence-based CPR: The Recover Guidelines - P.13 Evidence-based CPR: The Recover Guidelines - P.13
Video of Bulldog try turnover
-
Evidence-based CPR: The Recover Guidelines - P.14 Evidence-based CPR: The Recover Guidelines - P.14
Chest Compressions
- Recumbency
- No significant difference
- Physical Tips
- Hand over hand
- Shoulder over hands
- Lock Elbows, use back -
Evidence-based CPR: The Recover Guidelines - P.15 Evidence-based CPR: The Recover Guidelines - P.15
Demonstration of how to keep your arms while performing CPR
-
Evidence-based CPR: The Recover Guidelines - P.16 Evidence-based CPR: The Recover Guidelines - P.16
Image of a dummy dog to practice CPR
-
Evidence-based CPR: The Recover Guidelines - P.17 Evidence-based CPR: The Recover Guidelines - P.17
THE ORIGINAL MOVIE SOUNDTRACK
SATURDAY NIGHT FEVER -
Evidence-based CPR: The Recover Guidelines - P.18 Evidence-based CPR: The Recover Guidelines - P.18
OUEEN
Another One Bites the Dust -
Evidence-based CPR: The Recover Guidelines - P.19 Evidence-based CPR: The Recover Guidelines - P.19
100 BPM HITS
ARTIST
ABBA
All American Rejects
Arrested Development
Backstreet Boys
Bangles
Beastie Boys
Beastie Boys
Beastie Boys
Black Crowes
Black Eyed Peas
Bon Jovi
Cyndi Lauper
Diana Ross
Fall Out Boy
Guns N' Roses
Hanson
John
Denver
Justin Timberlake
KT Tunstall
Lily Allen
Linkin Park
Ludacris
Madonna
SONG
Dancing Queen
Gives You Hell
Tennessee
Quit Playing Games (With My Heart)
Walk Like An Egyptian
Body Movin' [Fatboy Slim Remix]
Heart Attack Man
Root Down
Hard To Handle
Hey Mama
Lay Your Hands On Me
Girls Just Want To Have Fun
Ain't No Mountain High Enough
This Ain't A Scene, It's An Arms Race
Paradise City
Mmmbop
Thank God I'm A Country Boy
Rock Your Body
Suddenly I See
LDN
Breaking the Habit
The Potion
Who's That Girl -
Evidence-based CPR: The Recover Guidelines - P.20 Evidence-based CPR: The Recover Guidelines - P.20
Linkin Park
Ludacris
Madonna
Mariah Carey
Marvin Gaye
Michael Jackson
Missy Elliott
Motley Crue
Notorious B.I.G.
Patty Loveless
Paul Oakenfold
Phil Collins
Ricky Martin
Rod Stewart
Shakira
Simon & Garfunkel
Soul II Soul
Stray Cats
Sugar Ray
Tracy Chapman
U2
Breaking the Habit
The Potion
Who's That Girl
Heartbreaker
What's Going On
Man In The Mirror
Work It
Kickstart My Heart
Notorious B.I.G. [Featuring Lil' Kim and Puff Daddy]
Strong Heart
Starry Eyed Surprise
You Can't Hurry Love
Shake Your Bon Bon
You're In My Heart
Hips Don't Lie [Featuring Wyclef Jean]
Cecilia
Back To Life
Rock This Town
Fly
Fast Car
I Still Haven't Found What I'm Looking For
bethebeat.heart.org
2009 American Heart Association, Inc. All rights reserved. Unauthorized use prohibited. -
Evidence-based CPR: The Recover Guidelines - P.21 Evidence-based CPR: The Recover Guidelines - P.21
Participants of a CPR workshop in Japan
-
Evidence-based CPR: The Recover Guidelines - P.22 Evidence-based CPR: The Recover Guidelines - P.22
Video of a CPR workshop in Japan
-
Evidence-based CPR: The Recover Guidelines - P.23 Evidence-based CPR: The Recover Guidelines - P.23
Doraemon - A famous character in Japan
-
Evidence-based CPR: The Recover Guidelines - P.24 Evidence-based CPR: The Recover Guidelines - P.24
Video of a woman performing chest compressions
-
Evidence-based CPR: The Recover Guidelines - P.25 Evidence-based CPR: The Recover Guidelines - P.25
Chest Compressions
- Cycle
- Interruption = Bad
- Less perfusion during pauses
- Blood flow build-up takes time
- Recommendations
- Limit rhythm checks to q2min
- <10 sec pauses
- Switch every 2 minutes -
Evidence-based CPR: The Recover Guidelines - P.26 Evidence-based CPR: The Recover Guidelines - P.26
CRP Algorithm
Unresponsive, Apneic Patient
decreased
Initiate CRP Immediately
Basic Life Support
1 full cycle = 2 minutes
uninterrupted compressions/ventilation
1 Chest Compressions
100-120/min
-Lateral recumbency
-1/3-1/2 chest width
2 Ventilation
10/min
Intubate in lateral
Simultaneous compressions
or
C:V 30:2
-Interpose compressions
Advanced Life Support
3 Initiate Monitoring
-Electrocardiogram(ECG)
-End Tidal CO2(ETCO2)
->15 mmHg = good compressions
4 Obtain Vascular Access
5 Administer Reversals
-Opioids - Naloxone
-2 agonists - Atipamezole
-Benzodiazepines - Flumazenil
decreased
Evaluate Patient Check ECG -->ROSC -->Post-CPA Algorithm
VF / Pulseless VT
Asystole / PEA
-Continue BLS, charge defibrillator
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT, consider
-Amiodarone or Lidocaine
-Epinephrine / Vasopressin every other cycle
-Increase the defibrillator dose by 50%
-Low dose Epinephrine and/or Vasopressin
every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10min,consider
-High dose Epinephrine
-Bicarbonate therapy
decreased
Basic Life Support
Change compressor Perform 1 full cycle = 2minutes
Reprinted with permission from Fletcher et al., J Vet Emerg Crit Care,22(S1): S1022-S131, 2012 -
Evidence-based CPR: The Recover Guidelines - P.27 Evidence-based CPR: The Recover Guidelines - P.27
Ventilation Timing
The "ABCs" of CPR?
Airway
Breathing
Circulation
Prioritize compressions
Do not stop compressions to intubate! -
Evidence-based CPR: The Recover Guidelines - P.28 Evidence-based CPR: The Recover Guidelines - P.28
The Evidence
Requirement Reduced Oxygen
Low oxygen pulmonary uptake
Oxygen Supply without Ventilation
Compression Induced Ventilation
Detrimental Effects
Interrupted chest compressions -
Evidence-based CPR: The Recover Guidelines - P.29 Evidence-based CPR: The Recover Guidelines - P.29
Ventilation Technique
- Single Rescuer/No tube
- Mouth-to-snout
- Close mouth, blow in
- Keep neck straight
- Brisk breaths
- 30:2 ratio
- In veterinary practice
- Intubate
- Ambu-bag / Anesthetic machine -
Evidence-based CPR: The Recover Guidelines - P.30 Evidence-based CPR: The Recover Guidelines - P.30
10 breaths per minute
1s inspiration -
Evidence-based CPR: The Recover Guidelines - P.31 Evidence-based CPR: The Recover Guidelines - P.31
CRP Algorithm
Unresponsive, Apneic Patient
decreased
Initiate CRP Immediately
Basic Life Support
1 full cycle = 2 minutes
uninterrupted compressions/ventilation
1 Chest Compressions
100-120/min
-Lateral recumbency
-1/3-1/2 chest width
2 Ventilation
10/min
Intubate in lateral
Simultaneous compressions
or
C:V 30:2
-Interpose compressions
Advanced Life Support
Monitoring
3 Initiate Monitoring
-Electrocardiogram(ECG)
-End Tidal CO2(ETCO2)
->15 mmHg = good compressions
4 Obtain Vascular Access
5 Administer Reversals
-Opioids - Naloxone
-2 agonists - Atipamezole
-Benzodiazepines - Flumazenil
decreased
Evaluate Patient Check ECG -->ROSC -->Post-CPA Algorithm
VF / Pulseless VT
Asystole / PEA
-Continue BLS, charge defibrillator
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT, consider
-Amiodarone or Lidocaine
-Epinephrine / Vasopressin every other cycle
-Increase the defibrillator dose by 50%
-Low dose Epinephrine and/or Vasopressin
every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10min,consider
-High dose Epinephrine
-Bicarbonate therapy
decreased
Basic Life Support
Change compressor Perform 1 full cycle = 2minutes
Reprinted with permission from Fletcher et al., J Vet Emerg Crit Care,22(S1): S1022-S131,2012 -
Evidence-based CPR: The Recover Guidelines - P.32 Evidence-based CPR: The Recover Guidelines - P.32
Monitoring
- Which of the following is the best measure for effective perfusion in CPR?
A. Palpable pulses
B. EtCO2
C. Doppler
D. ECG
E. Lactate -
Evidence-based CPR: The Recover Guidelines - P.33 Evidence-based CPR: The Recover Guidelines - P.33
Useful Monitors
- ETCO2
- ECG -
Evidence-based CPR: The Recover Guidelines - P.34 Evidence-based CPR: The Recover Guidelines - P.34
Capnography
Ventilation
Perfusion
ETCO2
Blood In
Alveoli
Co2 Out
O2 In
Blood Out -
Evidence-based CPR: The Recover Guidelines - P.35 Evidence-based CPR: The Recover Guidelines - P.35
Capnography
- Confirms Intubation
- Predictor of ROSC
- 15mmHg
- Indicator of ROSC
- Sudden increase -
Evidence-based CPR: The Recover Guidelines - P.36 -
Evidence-based CPR: The Recover Guidelines - P.37 Evidence-based CPR: The Recover Guidelines - P.37
Readings on the monitor
-
Evidence-based CPR: The Recover Guidelines - P.38 Evidence-based CPR: The Recover Guidelines - P.38
Other
- Doppler/Oscillometric
- Pulse palpation
- Venous pulsation
- Pulse Oximetry
- Vasoconstriction
- Motion -
Evidence-based CPR: The Recover Guidelines - P.39 Evidence-based CPR: The Recover Guidelines - P.39
CRP Algorithm
Unresponsive,Apneic Patient
decreased
Initiate CRP Immediately
Basic Life Spport
1 full cycle = 2 minutes
uninterrupted compressions/ventailation
1 Chest Compressions
100-120/min
-Lateral recumbency
-1/3-1/2 chest width
2 Ventailation
10/min
Intubate in lateral
Simultaneous compressions
or
C:V 30:2
-Interpose compressions
Advanced Life Support
3 Initiate Monitoring
-Electrocardiogram(ECG)
-End Tidal CO2(ETCO2)
->15 mmHg = good compressions
4 Obtain Vascular Access
Vascular Access
5 Administer Reversals
Reversals
-Opioids - Naloxone
-2 agonists - Atipamezole
-Benzodiazepines - Flumazenil
decreased
Evaluate Patient Check ECG -->ROSC -->Post-CPA Algorithm
VF / Pulseless VT
Asystole / PEA
-Continue BLS, charge defibrillator
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT, consider
-Amiodarone or Lidocaine
-Epinepherine / Vasopressin every other cycle
-Increase defibrillator dose by 50%
-Low dose Epinephrine and/or Vasopressin
every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10min,consider
-High dose Epinephrine
-Bicarbonate therapy
decreased
Basic Life Support
Change compressor Perform 1 full cycle = 2minutes
Reprinted with permission from Fletcher et al., J Vet Emerg Crit Care,22(S1): S1022-S131,2012 -
Evidence-based CPR: The Recover Guidelines - P.40 Evidence-based CPR: The Recover Guidelines - P.40
Drugs and Venous Access
-
Evidence-based CPR: The Recover Guidelines - P.41 Evidence-based CPR: The Recover Guidelines - P.41
CPR Emergency Drugs and Doses
Weight (kg) 2.5 5 10 15 20 25 30 35 40 45 50
Weight (lb) 5 10 20 30 40 50 60 70 80 90 100
DRUG DOSE ml ml ml ml ml ml ml ml ml ml ml
Arrest
Epi Low (1:1000) 0.01 mg/kg 0.03 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5
Epi High (1:1000) 0.1 mg/kg 0.25 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Vasopressin (20 Umi) 0.8 U/kg 0.1 0.2 0.4 0.6 0.8 1 1.2 1.4 1.6 1.8
Atropine (0.54 mg/m) 0.05 mg/kg 0.25 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Anti - Arrhyth
Amiodarone (50 mg/ml) 5 mg/kg 0.25 0.5 1 1.5 2 2.5 3 3.5 4 4.5
Lidocaine (20 mg/ml) 2-8 mg/kg 0.25 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Reversal
Naloxone (0.4 mgml) 0.04 mg/kg 0.25 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Flumazenil (0.1 mg/m) 0.01 mg/kg 0.25 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5
Atipamezole (5 mg/ml) 50 4g/kg 0.03 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45 0.5Defib monophasic
External Defib (J) 2-10 J/kg 20 30 50 100 200 200 200 300 300 300 360
Internal Defib (w 0.2-1 J/kg 2 3 5 10 20 20 20 30 30 30 50 -
Evidence-based CPR: The Recover Guidelines - P.42 Evidence-based CPR: The Recover Guidelines - P.42
CRP Algorithm
Unresponsive, Apneic Patient
decreased
Initiate CRP Immediately
Basic Life Support
1 full cycle = 2 minutes
uninterrupted compressions/ventilation
1 Chest Compressions
100-120/min
-Lateral recumbency
-1/3-1/2 chest width
2 Ventailation
10/min
Intubate in lateral
Simultaneous compressions
or
C:V 30:2
-Interpose compressions
Advanced Life Support
3 Initiate Monitoring
-Electrocardiogram(ECG)
-End Tidal CO2(ETCO2)
->15 mmHg = good compressions
4 Obtain Vascular Access
5 Administer Reversals
-Opioids - Nalocone
-2 agonists - Atipamezole
-Benzodiazepines - Flumazenil
decreased
Evaluate Patient Check ECG -->ROSC -->Post-CPA Algorithm
VF / Pulseless VT
Asystole / PEA
-Continue BLS, charge defibrillator
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT, consider
-Amiodarone or Lidocaine
-Epinepherine / Vasopressin every other cycle
-Increase the defibrillator dose by 50%
-Low dose Epinephrine and/or Vasopressin
every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10min,consider
-High dose Epinephrine
-Bicarbonate therapy
decreased
Basic Life Support
Change compressor Perform 1 full cycle = 2minutes
Reprinted with permission from Fletcher et al., J Vet Emerg Crit Care,22(S1): S1022-S131,2012
Reversal
Naloxone(0.4mg/ml) 0.04mg/kg
Flumazenil(0.1mg/ml) 0.01mg/kg
Atipamezole(5mg/ml) 50ug/kg -
Evidence-based CPR: The Recover Guidelines - P.43 Evidence-based CPR: The Recover Guidelines - P.43
CRP Algorithm
Unresponsive,Apneic Patient
decreased
Initiate CRP Immediately
Basic Life Support
1 full cycle = 2 minutes
uninterrupted compressions/ventilation
1 Chest Compressions
100-120/min
-Lateral recumbency
-1/3-1/2 chest width
2 Ventailation
10/min
Intubate in lateral
Simultaneous compressions
or
C:V 30:2
-Interpose compressions
Advanced Life Support
3 Initiate Monitoring
-Electrocardiogram(ECG)
-End Tidal CO2(ETCO2)
->15 mmHg = good compressions
4 Obtain Vascular Access
5 Administer Reversals
-Opioids - Naloxone
-2 agonists - Atipamezole
-Benzodiazepines - Flumazenil
decreased
Evaluate Patient Check ECG -->ROSC -->Post-CPA Algorithm
VF / Pulseless VT
Asystole / PEA
-Continue BLS, charge defibrillator
Defib
Anti-arrhythmics
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT, consider
-Amiodarone or Lidocaine
-Epinepherine / Vasopressin every other cycle
-Increase defibrillator dose by 50%
Epi/Atropine
-Low dose Epinephrine and/or Vasopressin
every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10min,consider
-High dose Epinephrine
-Bicarbonate therapy
decreased
Basic Life Support
Change compressor Perform 1 full cycle = 2minutes
Reprinted with permission from Fletcher et al., J Vet Emerg Crit Care,22(S1): S1022-S131,2012 -
Evidence-based CPR: The Recover Guidelines - P.44 Evidence-based CPR: The Recover Guidelines - P.44
Shockable Rhythms
Evaluate Patient Check ECG
Non-shockable Rhythms
VF/Pulseless VT
Asystole/PEA
-Continue BLS,charge defibrillator
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT,consider
-Amiodarone or Lidocaine
-Epinephrine / Vasopressin every other cycle
-Increase defibrillator dose by 50%
-Low dose Epinephrine and/or Vasopressin every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10 min,consider
-High dose Epinephrine
-Bicarbonate therapy -
Evidence-based CPR: The Recover Guidelines - P.45 Evidence-based CPR: The Recover Guidelines - P.45
Simple CPR ECG Algorithm
RECOVER
recoverinitiative.org
Are there consistent, repeating complexes?
YES
Are pulses associated with the complexes?
NO
Rate > 200/min?
NO
PEA NO SHOCK!
YES
Perfusing Rhythm = ROSC
YES
Pulseless VT SHOCK!
NO
Is the ECG a flat line?
YES
Asystole NO SHOCK!
NO
VF SHOCK! -
Evidence-based CPR: The Recover Guidelines - P.46 Evidence-based CPR: The Recover Guidelines - P.46
Simple CPR ECG Algorithm
RECOVER
recoverinitiative.org
Are there consistent, repeating complexes?
YES
Are pulses associated with the complexes?
NO
Rate > 200/min?
NO
PEA NO SHOCK!
YES
Perfusing Rhythm = ROSC
YES
Pulseless VT SHOCK!
NO
Is the ECG a flat line?
YES
Asystole NO SHOCK!
NO
VF SHOCK! -
Evidence-based CPR: The Recover Guidelines - P.47 Evidence-based CPR: The Recover Guidelines - P.47
Simple CPR ECG Algorithm
RECOVER
recoverinitiative.org
Are there consistent, repeating complexes?
YES
Are pulses associated with the complexes?
NO
Rate > 200/min?
NO
PEA NO SHOCK!
YES
Perfusing Rhythm = ROSC
YES
Pulseless VT SHOCK!
NO
Is the ECG a flat line?
YES
Asystole NO SHOCK!
NO
VF SHOCK! -
Evidence-based CPR: The Recover Guidelines - P.48 Evidence-based CPR: The Recover Guidelines - P.48
Simple CPR ECG Algorithm
RECOVER
recoverinitiative.org
Are there consistent, repeating complexes?
YES
Are pulses associated with the complexes?
NO
Rate > 200/min?
NO
PEA NO SHOCK!
YES
Perfusing Rhythm = ROSC
YES
Pulseless VT SHOCK!
NO
Is the ECG a flat line?
YES
Asystole NO SHOCK!
NO
VF SHOCK! -
Evidence-based CPR: The Recover Guidelines - P.49 Evidence-based CPR: The Recover Guidelines - P.49
Simple CPR ECG Algorithm
RECOVER
recoverinitiative.org
Are there consistent, repeating complexes?
YES
Are pulses associated with the complexes?
NO
Rate > 200/min?
NO
PEA NO SHOCK!
YES
Perfusing Rhythm = ROSC
YES
Pulseless VT SHOCK!
NO
Is the ECG a flat line?
YES
Asystole NO SHOCK!
NO
VF SHOCK! -
Evidence-based CPR: The Recover Guidelines - P.50 Evidence-based CPR: The Recover Guidelines - P.50
Shockable Rhythms
Evaluate Patient Check ECG
Non-shockable Rhythms
VF/Pulseless VT
Asystole/PEA
-Continue BLS, charge defibrillator
-Clear and give 1 shock or Precordial Thump if no defibrillator
-With prolonged VF/VT, consider
-Amiodarone or Lidocaine
-Epinephrine / Vasopressin every other cycle
-Increase defibrillator dose by 50%
-Low dose Epinephrine and/or Vasopressin every other BLS cycle
-Consider Atropine every other BLS cycle
-With prolonged CPA > 10 min,consider
-High dose Epinephrine
-Bicarbonate therapy -
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Non-shockable Rhythm
- Asystole (most common)
- Continue compressions
- Pulseless Electrical Activity
- Pulseless, <200 bpm
- Continue compressions
- Drugs -
Evidence-based CPR: The Recover Guidelines - P.52 Evidence-based CPR: The Recover Guidelines - P.52
CPR Drugs
- Epinephrine
- Arterial Vasoconstrictor
- Increased aortic pressure -> Increased CPP
- Low Dose: 0.01mg/kg
- High Dose: 0.1mg/kg
- Vasopressin (0.4-0.8 U/kg)
- Smooth muscle vasoconstrictor
- Alternative to Epinephrine
- Half life longer (10-20 min)
- Atropine(0.05mg/kg)
- Blocks vagus nerve(Parasympathetic)
- Increases HR
- 0.05mg/kg or 1ml/10 lb
If non-shockable rhythm
After the first rhythm diagnosis
Every other cycle -
Evidence-based CPR: The Recover Guidelines - P.53 Evidence-based CPR: The Recover Guidelines - P.53
Shockable Rhythms
- Ventricular Fibrillation
- Coarse vs Fine
- Pulseless Ventricular Tachycardia
- Pulseless, >200 bpm
- Shockable Rhythms
- Defibrillator -
Evidence-based CPR: The Recover Guidelines - P.54 Evidence-based CPR: The Recover Guidelines - P.54
Demonstrating fibrillation
-
Evidence-based CPR: The Recover Guidelines - P.55 Evidence-based CPR: The Recover Guidelines - P.55
Shockable Rhythms
- Ventricular Fibrillation
- Coarse vs Fine
- Pulseless Ventricular Tachycardia
- Pulseless, >200 bpm
- Shockable Rhythms
- Defibrillator
- Mechanical Defib? -
Evidence-based CPR: The Recover Guidelines - P.56 -
Evidence-based CPR: The Recover Guidelines - P.57 Evidence-based CPR: The Recover Guidelines - P.57
Communication
- Clear, direct, communication
- Closed-loop communication
- Situational awareness/cross-monitoring
- Debriefing -
Evidence-based CPR: The Recover Guidelines - P.58 Evidence-based CPR: The Recover Guidelines - P.58
Post Resuscitative Care
- Respiratory Optimization
- Hemodynamic Support
- Neuroprotective therapy
D.J Fletcher et al.
Post-Cardiac Arrest Care Algorithm
ROSC
RESPIRATORY OPTIMIZATION
Spontaneous Breathing?
NO
PaCO2 or EtCO2 +5mm Hg
Dog = 32-43 mm Hg?
Cat = 26-36mm Hg?
No
IPPV
Titrate Suppiemental Oxygen
FiO2 >0.6
SpO2 > 98%
PaO2 > 100 mm Hg
Hyperoxemic
SpO2 > 94-98%
PaO2 > 80-100 mm Hg
Normoxemic
SpO2 < 94%
PaO2 > 80 mm Hg
Hypoxemic
SAP > 200 mm Hg
MAP > 120 mm Hg
Hypertensive
SAP = 100-200 mm Hg
MAP = 80-120 mm Hg
Normotensive
SAP < 100 mm Hg
MAP < 80 mm Hg
Hypotensive
1 Pressor
2 Treat Pain
3 Anti-hypertensive
ScvO2 > 70%?
Lactate < 2.5 mmol/L?
1 Hypovolemia?
YES
IV fluids
2 Vasodilation?
CRT, Injected MM?
Vasopressor
3 Contractility?
YES
Inotrope
4 PCV < 25%?
Transfuse
HEMODYNAMIC OPTIMIZATION
NEUROPROTECTION
ICU
Consider:
-Hypothermia if comatose
-Mannitol / HTS if neuro signs
-Seizure prophylaxis -
Evidence-based CPR: The Recover Guidelines - P.59 Evidence-based CPR: The Recover Guidelines - P.59
RECOVER
Reassessment Campaign on Veterinary Resuscitation -
Evidence-based CPR: The Recover Guidelines - P.60 Evidence-based CPR: The Recover Guidelines - P.60
Has your practice implemented the RECOVER guideline?
-
Evidence-based CPR: The Recover Guidelines - P.61 Evidence-based CPR: The Recover Guidelines - P.61
Adobe Animal Hospital
- 24hr General/Emergency Practice
- 27 Veterinarians
- 90 Technical (50 RVT, 3 VTS)
- Emergency, ICU, Surgery -
Evidence-based CPR: The Recover Guidelines - P.62 Evidence-based CPR: The Recover Guidelines - P.62
Why implement?
- Standardizing of CPR
- No ""Official"" protocol beforehand
- Doctor/Tech/Shift dependent differences
- Helplessness and frustration
- Evidence-based guideline
- Best current practice
-""Smooth"", simplified CPR
- Patient outcome -
Evidence-based CPR: The Recover Guidelines - P.63 Evidence-based CPR: The Recover Guidelines - P.63
Challenges
-Large Scale Training
-24/7 hospital
-Financial investment
-Some pushback -
Evidence-based CPR: The Recover Guidelines - P.64 -
Evidence-based CPR: The Recover Guidelines - P.65 -
Evidence-based CPR: The Recover Guidelines - P.66 -
Evidence-based CPR: The Recover Guidelines - P.67 -
Evidence-based CPR: The Recover Guidelines - P.68 Evidence-based CPR: The Recover Guidelines - P.68
The Result
Number
Average Age
Average Length
ROSC
Discharged
2013-2014
54
8.90yr
11min
13 (24.1%)
2 (3.7%)
2014-2015
28
7.46yr
12.7min
12 (42.9%)
2 (7.1%)
2015-2016
21
8.13yr
6.47min
6 (28.6%)
3 (14.3%)
Total
103
8.35yr
10.5min
31 (30.1%)
7 (6.8%) -
Evidence-based CPR: The Recover Guidelines - P.69 Evidence-based CPR: The Recover Guidelines - P.69
Was it worth it?
- Survival to discharge still low
- ROSC higher
- Gained perspective on performance
- Performance prior unknown -
Evidence-based CPR: The Recover Guidelines - P.70 Evidence-based CPR: The Recover Guidelines - P.70
Other Intangible Gains
- Bring order to the chaos
- Less frustration
- Sense of control
- Happier staff -
Evidence-based CPR: The Recover Guidelines - P.71 Evidence-based CPR: The Recover Guidelines - P.71
"I feel like things are so organized. We have very smooth CPR attempts."
"I can’t remember how we used to do this before the new protocol. It feels so calm going through the compression cycles. "
"We still have our chaotic sessions, but I like how everyone knows what should be happening. The debriefing helps a lot."
"With the new protocol, we are doing the best job possible. Our patients get the best chance." -
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It was totally worth it.
Adobe Animal Hospital
- Better efficiency
- Large scale training
- Better communication
- EBVM awareness
- Better teamwork
- Higher morale
- Better outcome(?) -
Evidence-based CPR: The Recover Guidelines - P.73 Evidence-based CPR: The Recover Guidelines - P.73
ABOUT
HOW CERTIFICATION WORKS
COURSES/EDUCATION
GUIDELINES
RESEARCH
CERTIFICATION RESOURCES
CRP PACKAGE
Basic and Advanced Life Support for Veterinarians
CRP: Basic Life Support Course
CRP: Advanced Life Support Course
www.recoverinitiative.org -
Evidence-based CPR: The Recover Guidelines - P.74 Evidence-based CPR: The Recover Guidelines - P.74
Future Directions
- ACVECC approved certification
- BLS
- ALS
- Certification Training
- Collaborative data collection
- 2020 Guidelines
- Laymen training? -
Evidence-based CPR: The Recover Guidelines - P.75 Evidence-based CPR: The Recover Guidelines - P.75
RECOVER
PET CERTIFIED RESCUER -
Evidence-based CPR: The Recover Guidelines - P.76 Evidence-based CPR: The Recover Guidelines - P.76
Video of CPR being performed on a squirrel
-
Evidence-based CPR: The Recover Guidelines - P.77 Evidence-based CPR: The Recover Guidelines - P.77
Questions?
Saving one dog will not change the world,
but surely for that one dog,
the world will change forever.Kenichiro Yagi, MS, RVT, VTS (ECC, SAIM)
Email: kenyagirvt@gmail.com
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