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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 2019

    Close slides View other 78 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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.3

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.3

      Why Consider Transfusions in Practice?
      -In some cases, referral is not possible...
      - Too unstable
      - Cost constraints
      - Location

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.4

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.4

      Indications for Transfusion
      -Anemia
      -Coagulopathy
      -Thrombocytopenia / thrombocytopathia
      -Hypoproteinemia

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.5

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.5

      Most Common Indication for Transfusion
      -Anemia
      1. Acute blood loss
      2. IMHA
      3. Chronic anemia

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.6

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.6

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.7

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.7

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.8

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.8

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.9

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.9

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.10

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.10

      When to Consider Transfusion?
      -Continued blood loss
      -Evidence of hypoxemia
      - Markers to look for?
      -Planned anesthetic procedure (PCV < 20-25%)
      Tachycardia Tachypnea increases Lactate

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.11

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.11

      Possible Side Effects
      -Infectious disease transmission -Fatal hemolytic transfusion reactions
      -Transfusion related lung injury (TRALI) -Transfusion related circulatory overload (TACO) -Transfusion related immunomodulation (TRIM)

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.12

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.12

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.13

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.13

      TACO-Transfusion Associated Circulatory Overload
      -Volume of blood infused causes acute hypervolemia and cardiogenic pulmonary edema

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.14

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.14

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.15

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.15

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.16

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.16

      Fact or Fiction?
      -Do transfusion triggers exist?
      - PCV
      - Lactate
      - Membranes, CRT, HR, BP

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.17

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.17

      Options
      -Packed red blood cells
      -Fresh whole blood
      -Stored whole blood

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.18

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.18

      Packed Red Blood Cells
      -Benefits:
      - Specific component therapy for anemia - Readily available
      - National blood banks
      - In house blood bank
      -Downsides:
      - Only provides RBCs...

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.19

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.19

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.20

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.20

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.21

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.21

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.22

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.22

      -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+

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.23

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.23

      Canine Blood Typing
      -In-house tests
      - Rapid Vet-H Canine Cards
      - Alvedia Quick Test DEA 1.1
      -Reference laboratories
      -Animal blood banks

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.24

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.24

      Rapid Vet Cards
      -Difficult to interpret with severe anemia
      -Unable to use in autoagglutination
      www.rapidvet.com

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.25

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.25

      Alvedia Quick Test
      -Reliable with severe anemia
      -CAN use with autoagglutination
      www.alvediaVET.com

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.26

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.26

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.27

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.27

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.28

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.28

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.29

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.29

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.30

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.30

      Crossmatching
      -Major Crossmatch
      - Donor RBC, patient plasma
      -Minor Crossmatch
      - Donor plasma, patient RBC

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.31

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.31

      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...

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.32

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.32

      When to Crossmatch?
      -Cats
      - Cats that can't be typed
      - Any cat with a previous transfusion history
      - More recent recommendations...all cats?

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.33

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.33

      -Major Crossmatch compatible feline transfusions
      - Increase in PCV was greater with major
      crossmatched blood when compared to non- crossmatched transfusions
      - Alloantibodies
      - Mik antigen

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.34

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.34

      -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%)

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.36

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.36

      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?

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.37

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.37

      Gel-based Crossmatch

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.38

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.38

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.39

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.39

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.40

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.40

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.41

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.41

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.42

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.42

      Where to obtain blood products?
      -In house blood donation
      -Blood banks

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.43

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.43

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.44

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.44

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.45

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.45

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.46

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.46

      Blood Collection
      -Sedation
      - Avoid acepromazine, dexmedetomidine
      - Dogs - butorphanol / benzodiazapine
      - Cats - ketamine/valium

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.47

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.47

      Blood Collection- Dogs
      -Closed collection system
      - Containing CPDA
      - With or without satellite bags for component separation

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.48

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.48

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.49

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.49

      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.50

      Blood Collection

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.51

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.51

      Blood Collection

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.52

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.52

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.53

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.53

      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.

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.54

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.54

      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.

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.55

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.55

      -Filter with 170-260 um pores most
      common -Removes RBC and platelet aggregates
      -Filter with 20 um pores
      -Hemo-Nate

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.56

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.56

      Administration
      -Warming bath for FFP
      - 39 C (102.2 F)

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.57

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.57

      Does Administration Method Alter RBC Survival?

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.58

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.58

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.59

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.59

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.60

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.60

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.61

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.61

      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)

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.62

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.62

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.63

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.63

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.64

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.64

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.65

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.65

      Acute Transfusion Reactions
      -Non hemolytic febrile transfusion reaction
      -Hemolytic transfusion reaction
      -Infectious transfusion reactions

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.66

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.66

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.67

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.67

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.68

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.68

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.69

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.69

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.70

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.70

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.71

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.71

      a picture of a dog laying down

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.72

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.72

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.73

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.73

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.74

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.74

      Recognizing Transfusion Reactions
      -Acute hemolytic transfusion reaction
      - Tachycardia
      - Collapse
      - Vomiting
      - Pyrexia
      - Hypotension
      - Hemoglobinemia, hemoglobinuria

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.75

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.75

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.76

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.76

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.77

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.77

      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

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.78

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.78

      Resources for Transfusion Medicine

    • Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.79

      Transfusion in Practice Part 1: Treatment of Anemia and Blood Bank Management - P.79

      DVM STAT 24/7 2019

  • 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 2019

    Close slides View other 49 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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.5

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.5

      Categories of Pain

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.6

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.6

      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.

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.7

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.7

      Pain Types
      -Acute GI pain
      -Chronic OA pain
      -Neuropathic post onychectomy pain

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.8

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.8

      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 welfare

      Orskov T. Pain Assessment in Cats and Dogs, Irish veterinary journal, 2010, 63(6):362-364

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.9

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.9

      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.

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.10

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.10

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.11

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.11

      Behavioral Keys
      1. Maintenance of normal behaviors
      2. Loss of normal behaviors
      3. Development of newbehaviors

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.12

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.12

      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)

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.13

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.13

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.14

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.14

      Appropriate Pain Management

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.15

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.15

      Behavioral Signs of pain in dogs: (Balakrishnan and Benasutti, 2012)
      Category
      Attitude/Mentation
      Body Movement
      Facial Expression
      Guarding
      Posture
      Respiratory Pattern
      Vocalization

      Scared, 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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.16

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.16

      Appropriate Pain Management

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.17

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.17

      Acute Pain Scales for Dogs and Cats that IncorporateBehaviors

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.18

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.18

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.19

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.19

      Chronic Pain in Cats

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.20

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.20

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.21

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.21

      Chronic Pain in Cats

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.22

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.22

      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)

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.23

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.23

      Feline Neuropathic Pain
      Feline Orofacial Pain Syndrome
      Feline Hyperesthesia Syndrome

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.24

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.24

      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)

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.25

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.25

      Cancers in Cats . Feline Lymphomaand FISS

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.26

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.26

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.27

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.27

      Chronic Pain in Dogs

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.28

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.28

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.29

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.29

      Chronic Pain in Dogs

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.30

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.30

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.31

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.31

      Chronic Pain in Dogs and Cats

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.32

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.32

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.33

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.33

      Postures with Chronic Pain in Dogs

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.34

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.34

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.35

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.35

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.36

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.36

      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

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.37

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.37

      Hyperesthesia and Allodynia
      Hyperesthesia
      -Hyperesthesia is a condition in which someone becomes highly sensitized to sensory stimuli.
      Allodynia
      -Pain when touch should be nonpainful

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.38

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.38

      Hypersensitization in a nutshell

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.39

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.39

      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)

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.40

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.40

      Neuropathic Pain in Dogs
      Chronic otitis externa
      Amputation
      Osteoarthritis

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.41

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.41

      Neuropathic Pain from Glaucoma

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.42

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.42

      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.

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.43

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.43

      Canine Osteosarcoma

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.44

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.44

      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)

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.45

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.45

      CBPI and CODI Scales

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.46

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.46

      HRQL and LOAD Scales

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.47

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.47

      FMPI Index

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.48

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.48

      Veterinary Nurses Must Be:
      . Experts on assessing any pain
      . Primary advocate for our patients
      . Educate owners
      . Employ stress free handling techniques

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.49

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.49

      Listen to Me .
      THANK YOU

    • Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.50

      Assessing Pain in Cats and Dogs ( How Pain Affects Behavior ) - P.50

      "VETSCOPE
      THANK YOU
      "

  • 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 Rehabilitation

    Close slides View other 64 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?

    • NSAIDs: What We Do Know - P.4

      NSAIDs: What We Do Know - P.4

      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

    • NSAIDs: What We Do Know - P.5

      NSAIDs: What We Do Know - P.5

      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

    • NSAIDs: What We Do Know - P.6

      NSAIDs: What We Do Know - P.6

      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

    • NSAIDs: What We Do Know - P.7

      NSAIDs: What We Do Know - P.7

      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

    • NSAIDs: What We Do Know - P.9

      NSAIDs: What We Do Know - P.9

      Pain Pathway

    • NSAIDs: What We Do Know - P.10

      NSAIDs: What We Do Know - P.10

      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

    • NSAIDs: What We Do Know - P.11

      NSAIDs: What We Do Know - P.11

      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

    • NSAIDs: What We Do Know - P.12

      NSAIDs: What We Do Know - P.12

      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

    • NSAIDs: What We Do Know - P.13

      NSAIDs: What We Do Know - P.13

      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

    • NSAIDs: What We Do Know - P.14

      NSAIDs: What We Do Know - P.14

      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

    • NSAIDs: What We Do Know - P.15

      NSAIDs: What We Do Know - P.15

      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

    • NSAIDs: What We Do Know - P.16

      NSAIDs: What We Do Know - P.16

      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

    • NSAIDs: What We Do Know - P.17

      NSAIDs: What We Do Know - P.17

      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.

    • NSAIDs: What We Do Know - P.18

      NSAIDs: What We Do Know - P.18

      COX-2 to COX-1

    • NSAIDs: What We Do Know - P.19

      NSAIDs: What We Do Know - P.19

      Great! That solved it.

    • NSAIDs: What We Do Know - P.20

      NSAIDs: What We Do Know - P.20

      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

    • NSAIDs: What We Do Know - P.21

      NSAIDs: What We Do Know - P.21

      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

    • NSAIDs: What We Do Know - P.22

      NSAIDs: What We Do Know - P.22

      NSAIDs Inhibit Both Inflammation and Pain

    • NSAIDs: What We Do Know - P.23

      NSAIDs: What We Do Know - P.23

      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

    • NSAIDs: What We Do Know - P.24

      NSAIDs: What We Do Know - P.24

      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

    • NSAIDs: What We Do Know - P.25

      NSAIDs: What We Do Know - P.25

      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.

    • NSAIDs: What We Do Know - P.26

      NSAIDs: What We Do Know - P.26

      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

    • NSAIDs: What We Do Know - P.27

      NSAIDs: What We Do Know - P.27

      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

    • NSAIDs: What We Do Know - P.28

      NSAIDs: What We Do Know - P.28

      Adverse Effects of NSAIDs
      - Gastrointestinal
      - Renal
      - Platelet function
      - Respiratory
      - Miscellaneous
      - Repro
      - CNS
      - Cardiac

    • NSAIDs: What We Do Know - P.29

      NSAIDs: What We Do Know - P.29

      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

    • NSAIDs: What We Do Know - P.30

      NSAIDs: What We Do Know - P.30

      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

    • NSAIDs: What We Do Know - P.31

      NSAIDs: What We Do Know - P.31

      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”

    • NSAIDs: What We Do Know - P.32

      NSAIDs: What We Do Know - P.32

      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.

    • NSAIDs: What We Do Know - P.33

      NSAIDs: What We Do Know - P.33

      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."

    • NSAIDs: What We Do Know - P.34

      NSAIDs: What We Do Know - P.34

      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.”

    • NSAIDs: What We Do Know - P.35

      NSAIDs: What We Do Know - P.35

      Some of that info gave me an ulcer...

    • NSAIDs: What We Do Know - P.36

      NSAIDs: What We Do Know - P.36

      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

    • NSAIDs: What We Do Know - P.37

      NSAIDs: What We Do Know - P.37

      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.

    • NSAIDs: What We Do Know - P.38

      NSAIDs: What We Do Know - P.38

      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.”

    • NSAIDs: What We Do Know - P.39

      NSAIDs: What We Do Know - P.39

      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."

    • NSAIDs: What We Do Know - P.40

      NSAIDs: What We Do Know - P.40

      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

    • NSAIDs: What We Do Know - P.41

      NSAIDs: What We Do Know - P.41

      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

    • NSAIDs: What We Do Know - P.42

      NSAIDs: What We Do Know - P.42

      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

    • NSAIDs: What We Do Know - P.43

      NSAIDs: What We Do Know - P.43

      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

    • NSAIDs: What We Do Know - P.44

      NSAIDs: What We Do Know - P.44

      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

    • NSAIDs: What We Do Know - P.45

      NSAIDs: What We Do Know - P.45

      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)."

    • NSAIDs: What We Do Know - P.46

      NSAIDs: What We Do Know - P.46

      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.”

    • NSAIDs: What We Do Know - P.47

      NSAIDs: What We Do Know - P.47

      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%)”

    • NSAIDs: What We Do Know - P.48

      NSAIDs: What We Do Know - P.48

      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.”

    • NSAIDs: What We Do Know - P.49

      NSAIDs: What We Do Know - P.49

      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

    • NSAIDs: What We Do Know - P.50

      NSAIDs: What We Do Know - P.50

      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

    • NSAIDs: What We Do Know - P.51

      NSAIDs: What We Do Know - P.51

      Long term robenacoxib in cats

    • NSAIDs: What We Do Know - P.52

      NSAIDs: What We Do Know - P.52

      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.”

    • NSAIDs: What We Do Know - P.53

      NSAIDs: What We Do Know - P.53

      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."

    • NSAIDs: What We Do Know - P.54

      NSAIDs: What We Do Know - P.54

      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

    • NSAIDs: What We Do Know - P.55

      NSAIDs: What We Do Know - P.55

      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.

    • NSAIDs: What We Do Know - P.56

      NSAIDs: What We Do Know - P.56

      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 medications

      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
      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.

    • NSAIDs: What We Do Know - P.57

      NSAIDs: What We Do Know - P.57

      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

    • NSAIDs: What We Do Know - P.58

      NSAIDs: What We Do Know - P.58

      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

    • NSAIDs: What We Do Know - P.59

      NSAIDs: What We Do Know - P.59

      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

    • NSAIDs: What We Do Know - P.60

      NSAIDs: What We Do Know - P.60

      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.

    • NSAIDs: What We Do Know - P.61

      NSAIDs: What We Do Know - P.61

      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

    • NSAIDs: What We Do Know - P.62

      NSAIDs: What We Do Know - P.62

      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.

    • NSAIDs: What We Do Know - P.63

      NSAIDs: What We Do Know - P.63

      Aratana - Galliprant®

    • NSAIDs: What We Do Know - P.64

      NSAIDs: What We Do Know - P.64

      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

    • NSAIDs: What We Do Know - P.65

      NSAIDs: What We Do Know - P.65

      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

  • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.1

    The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.1

    The top ten eye problems seen in Veterinary Practice
    Robin G Stanley, Jane Whitley Matt Sanders, Heather Kaese Animal Eye Care,
    Animal Eye Care, Melbourne

    Close slides View other 44 slides in this lecture
    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.2

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.2

      In this presentation
      - Conjunctivitis
      - Squinting
      - Ocular Discharge
      –Watery
      –Mucky
      - Dry Eye
      - Corneal Ulceration
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.3

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.3

      In this presentation
      - Uveitis
      - Glaucoma
      - Cataracts
      - Prominent Eye
      - Vision Loss
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.4

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.4

      Image
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.5

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.5

      Canine Conjunctivitis
      - Most commonly this is bacterial conjunctivitis
      - Check for a predisposing cause
      – Always do a STT in all cases of conjunctivitis (and
      corneal disease and ocular discharge)
      – Check under the third eyelid and the eyelids
      - Grass seeds
      - Tumours
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.6

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.6

      Canine Conjunctivitis
      - Topical Antibiotics
      – Tricin – triple antibiotics, if red or inflamed Amacin
      – Use TID for 5 days
      – Check then recheck the STT – tear test
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.7

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.7

      Follicular Conjunctivitis
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.8

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.8

      Recurrent Canine Conjunctivitis
      - Usually there is an underlying cause eg dry eye or a FB
      - IF no underlying cause the recurrent cases are usually allergic
      - Topical cortisone drops are indicated
      – Topical cyclosporin/Tacrolimus may help

      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.9

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.9

      Feline Conjunctivitis
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.10

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.10

      Feline Conjunctivitis
      - Usually infectious
      - Oral Doxycycline 5mg/kg BID for 21 days
      - Hylo-Forte – 1 drop BID to TID
      - Most cases settle down well
      - If redness persists then topical NSAIDs may be needed.

      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.11

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.11

      Equine Conjunctivitis
      - Bacterial, viral, fungal
      - Fly Control is very important
      - Foreign bodies
      – Check under the TE – third eyelid and also under the eyelids and the NASOLACRIMAL duct
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.12

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.12

      Image
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.13

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.13

      Unusual Equine Conjunctiva
      - Fat pad prolapse
      – Can cover the eye completely
      – ALWAYS suture closed any conjunctival wounds or after removing the TE- third eyelid
      – https://veteriankey.com/ocular-infections/
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.14

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.14

      Equine Parasitic lesions from Slideshare Dr David Ledbetter
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.15

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.15

      from Slideshare Dr David Ledbetter
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.16

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.16

      from Slideshare Dr David Ledbetter
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.17

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.17

      Canine Conjunctivitis Summary
      - Dogs
      – Most cases are bacterial – should respond quickly to antibiotics
      – Recurrent cases
      - Is it dry eye ? – Always do a STT – Schirmer Tear Test
      - Allergic
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.18

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.18

      Feline Conjunctivitis Summary
      - Cats
      – Usually due to Herpes and or Chlamydia
      – Most cases require a prolonged course of oral doxycycline 5mg/kg BID for 21 days
      – Hyaluronate tears eg Hylo-Forte BID
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.19

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.19

      Squinting
      - Can be caused by
      – Eyelid disease eg entropion, extra eyelashes
      – Corneal Ulceration
      – Ocular pain
      - Uveitis
      - Glaucoma
      – Treat the underlying cause
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.20

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.20

      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.21

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.21

      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.22

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.22

      Managing Ocular Pain
      - Tramadol
      - Gabapentin
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.23

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.23

      Ocular Discharge - watery
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.24

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.24

      Watery Ocular Discharge
      - Do a STT – Schirmer tear test
      – >20 mm wetting suggests irritation that might be
      causing the epiphora
      – Normal STT~ 15 mm suggests decreased nasolacrimal fluroscein passage
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.25

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.25

      Watery Ocular Discharge - epiphora
      - Nasolacrimal fluroscein passage
      – No passage through to the nose indicates its time to flush the tear duct
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.26

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.26

      Mucky Ocular Discharge
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.27

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.27

      Mucky Ocular Discharge
      - Dry eye
      - Dry eye
      - Dry eye
      - Chronic Conjunctivitis
      - Nasolacrimal duct infection
      – Dacryocystitis
      • Foreign bodies
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.28

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.28

      • Do a STT – mm wetting/minute cause
      - If normal think of reduced nasolacrimal drainage
      -If no nasolacrimal fluorescein passage time to flush the tear duct
      – If > 20 think irritation as a
      – If < 15 think dry eye
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.29

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.29

      Equine Ocular Discharge
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.30

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.30

      Dry Eye – keratoconjunctivitis sicca
      - Always do a STT – s¥Schirmer tear test in all cases of conjunctivitis, corneal disease and all cases of ocular disease
      - Dry eye can be the cause or as the result of conjunctivitis
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.31

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.31

      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.32

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.32

      Dry Eye
      - Breed predisposition
      - Best results with treatment when
      – Initial STT > 5mm
      – Been less than 6 months
      - Always do a STT
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.33

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.33

      Dry eye treatment
      - Artificial Tears
      – Preservative free Systane UD or Hylo-Forte
      - Clean the eyes clear of all discharge before applying the active drugs
      – Mucous can stop the active drugs from getting to the lacrimal glands
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.34

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.34

      Dry Eye
      - Artificial Tears
      – 1-2 drops to clean out all the mucous
      - Optimmune – Cyclosporin Ointment
      – Most cases BID
      – Severe cases TID
      - Cortisone ointment if the cornea is healthy enough eg Siguent Hycor
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.35

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.35

      Dry Eye Summary
      - Always do a STT – early treatment gives the best results
      - Optimmune BID, if STT<6 mm use TID
      - Wipe away all the mucous
      – Long term treatment likely
      - Tacrolimus if the response is poor
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.36

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.36

      Corneal Ulceration
      - Always do a STT in all cases of ulcers
      - Look for a cause
      - Biggest concern is infection
      – Stop any topical anti-inflammatories
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.37

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.37

      Corneal Ulceration
      - Look for a cause
      – Dry eye – always do a STT
      - Eyelids
      – Entropion
      – Extra Eyelashes
      – Ectopic Cilia
      – Oversize eyelid openings
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.38

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.38

      Corneal Ulcer Treatment
      - Topical antibiotics
      – Tricin – triple antibiotic
      – Reserve the potent antibiotics eg Ocuflox/Gentamicin for infected corneas
      - Oral Doxycycline 5mg/kg BID
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.39

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.39

      Corneal Ulcer Treatment
      - Oral anti- inflammatories
      – Oral NSAIDs
      - Atropine
      – Use only if the pupil is small
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.40

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.40

      Infected Ulcers
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.41

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.41

      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.42

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.42

      Infected Ulcers - keratomalacia
      - Usually pseudomonas or Streptococcosis
      - Cytology
      - Antibiotics
      – Use frequently
      – every 5 minutes for the first hour then hourly
      – Fluoroquinolone / Chloramphenicol OR
      – Fortified Gentamicin
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.43

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.43

      Infected Ulcers - keratomalacia
      - Oral Doxycycline 5mg/kg
      - Atropine BID
      - Oral NSAIDs
      - Serum drops
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.44

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.44

      Consider Surgery
      - TT – temporary tarsorrhaphy
      - Contact lens
      - TEF – third eyelid flap
      - Conjunctival grafting
      Animal Eye Care

    • The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.45

      The Top 10 Eye Problems seen in Veterinary Practice Pt. 1 - P.45

      Corneal Ulcer Summary
      - Always looks for an underlying cause
      - Always do a STT
      - Antibiotics – topical and oral doxycycline
      - Oral NSAIDs
      Animal Eye Care

  • Initial Vaccination Protocol - P.1

    Initial Vaccination Protocol - P.1

    Initial Vaccination Protocol
    Richard B. Ford, DVM, MS
    North Carolina State University

    Close slides View other 15 slides in this lecture
    • Initial Vaccination Protocol - P.2

      Initial Vaccination Protocol - P.2

      AAHA Canine Vaccination Guidelines

      VACCINATION RECOMMENDATIONS Practice
      RABIES VACCINATION (NEW)
      OVERDUE for VACCINATION (NEW)
      VACCINATION RECOMMENDATIONS Shelter-Housed Dogs
      ANTIBODY TESTING vs VACCINATION (NEW)
      VACCINE STORAGE & HANDLING (NEW)
      LEGAL CONSIDERATIONS
      THERAPEUTIC BIOLOGICS (NEW)
      VACCINE ADVERSE REACTIONS
      VACCINE TYPES
      VACCINE STORAGE & HANDLING (NEW)
      THERAPEUTIC BIOLOGICS (NEW)
      LICENSING of VACCINES
      FREQUENTLY ASKED QUESTIONS
      REFERENCES and Appendices
      LIFESTYLE FACTORS (NEW)

    • Initial Vaccination Protocol - P.3

      Initial Vaccination Protocol - P.3

      Canine Vaccines
      r Distemper B. bronchiseptica-AvL (intranasal)
      Distemper-MLV B. bronchiseptica-killed (parenteral)
      Measles B. bronchiseptica-AvL (oral)
      Parvovirus-MLV Leptospirosis var. canicola
      Parainfluenza Virus-MLV Leptospirosis var. icterohaemorr.
      Adenovirus-2 (CAV-2)-MLV Leptospirosis var. pomona
      Adenovirus-2 (CAV-2)-AvL Leptospirosis var. grippotyphosa
      Adenovirus-2 (CAV-2)-killed r Lyme (OspA)
      Rabies 1-year rcLyme (OspA + C)
      Rabies 3-year Lyme (OspA)-killed
      Coronavirus-MLV Lyme (OspA+C)-killed
      Coronavirus-killed Crotalus atrox
      Canine Influenza (H3N8)-killed Giardia
      Canine Influenza (H3N2)-killed ...and others
      Over 30 antigens ~ 120 vaccines

    • Initial Vaccination Protocol - P.4

      Initial Vaccination Protocol - P.4

      Canine Vaccination Guidelines

      INITIAL CORE SERIES
      MLV or r Distemper
      MLV Parvovirus
      MLV Adenovirus-2
      Rabies
      3-dose series
      Booster within 1 year

      6 weeks
      7 weeks
      8 weeks
      9 weeks
      10 weeks
      11 weeks
      12 weeks
      13 weeks
      14 weeks
      15 weeks
      16 weeks

    • Initial Vaccination Protocol - P.5

      Initial Vaccination Protocol - P.5

      Maternal Antibody Interference “window of susceptibility”

      MLV Vaccines (distemper, parvovirus, adenovirus)
      Recombinant Distemper (rCDV)
      Titer
      ~50% ~15%
      8 wk 12 wk 16 wk 18 to 20 wks

    • Initial Vaccination Protocol - P.6

      Initial Vaccination Protocol - P.6

      Vaccination Recommendations During the COVID19 Pandemic

      CDV-CPV-CAV2
      - Pups between 6 and 20 weeks: 3 to 4 doses, 3-4 weeks apart.
      Emphasis on the last 2 doses in the series.

      - Adult, previously vaccinated > 20 weeks: booster dose can be delayed.

      SEARCH: AAHA interim clinical considerations

    • Initial Vaccination Protocol - P.7

      Initial Vaccination Protocol - P.7

      Feline Vaccination Guidelines

    • Initial Vaccination Protocol - P.8

      Initial Vaccination Protocol - P.8

      Feline CORE Vaccines

      INITIAL SERIES (Kitten)
      MLV Panleukopenia
      MLV Herpesvirus + Calicivirus

      6 weeks
      7 weeks
      8 weeks
      9 weeks
      10 weeks
      11 weeks
      12 weeks
      13 weeks
      14 weeks
      15 weeks
      16 weeks

    • Initial Vaccination Protocol - P.9

      Initial Vaccination Protocol - P.9

      Feline CORE Vaccines

      INITIAL SERIES (Kitten)
      MLV Panleukopenia
      MLV Herpesvirus + Calicivirus
      Recombinant Rabies (1 & 3 Year)

      Killed = Adjuvant

      Feline Leukemia (FeLV) is “Highly Recommended in Kittens”

      6 weeks
      7 weeks
      8 weeks
      9 weeks
      10 weeks
      11 weeks
      12 weeks
      13 weeks
      14 weeks
      15 weeks
      16 weeks

    • Initial Vaccination Protocol - P.10

      Initial Vaccination Protocol - P.10

      Feline Injection-Site Sarcoma

    • Initial Vaccination Protocol - P.11

      Initial Vaccination Protocol - P.11

      Vaccination Recommendations During the COVID19 Pandemic

      FVR-C-P
      Kittens between 6 and 20 weeks: 3 to 4 doses, 3-4 weeks apart.
      Emphasis on the last 2 doses in the series.

      Adult, previously vaccinated > 20 weeks: booster dose can be delayed.

      SEARCH: AAHA interim clinical considerations

    • Initial Vaccination Protocol - P.12

      Initial Vaccination Protocol - P.12

      Why Vaccination FAILS to Immunize

    • Initial Vaccination Protocol - P.13

      Initial Vaccination Protocol - P.13

      Breed Specific Parvovirus Vaccination Failure

      Genetic “Non-Responder”

    • Initial Vaccination Protocol - P.14

      Initial Vaccination Protocol - P.14

      VACCINE STORAGE & HANDLING

      How long after reconstitution...?
      1 hour

    • Initial Vaccination Protocol - P.15

      Initial Vaccination Protocol - P.15

      Same Volume for ALL breeds?

    • Initial Vaccination Protocol - P.16

      Initial Vaccination Protocol - P.16

      THANK YOU...

  • 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 76 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.36

      Video

    • 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

    • Evidence-based CPR: The Recover Guidelines - P.51

      Evidence-based CPR: The Recover Guidelines - P.51

      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.56

      Image

    • 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.64

      Image

    • Evidence-based CPR: The Recover Guidelines - P.65

      Evidence-based CPR: The Recover Guidelines - P.65

      Image

    • Evidence-based CPR: The Recover Guidelines - P.66

      Evidence-based CPR: The Recover Guidelines - P.66

      Image

    • Evidence-based CPR: The Recover Guidelines - P.67

      Evidence-based CPR: The Recover Guidelines - P.67

      Image

    • 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."

    • Evidence-based CPR: The Recover Guidelines - P.72

      Evidence-based CPR: The Recover Guidelines - P.72

      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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