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Symposium Proceedings
Room A
Room C
Brian Cellio, DVM, DACVIM-Neurology
Susan Keil, DVM, DACVO
Ryan Bragg, DVM, DACVECC
Crystal Hoh, DVM, DACVIM
Ralph Millard, DVM, DACVS-SA
Theresa Bradley-Bays, CVA,
DABVP(ECM)
Chris Morrow, DVM,
Heather Gill, DVM
Director, Maple Woods Vet Tech Program
David Weinstein, DVM
Heather Kaese, DVM, DDACVO
Connie Schulte, DPT, CCRP
Jeff Dennis, DVM, DACVIM
Stephanie Pierce, DVM, DACVIM
Kim Gugler, DVM
V
Room B
ROOM A
Use of Patient Signalment in the Diagnosis of Neurologic
Disease
Brian Cellio DVM ACVIM (Neurology)
Felines
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Ischemic Myelopathy (mean age 14 years)
– Clinical Signs:
• Acute, non-painful, and non-progressive cervical lesion resulting in various
degrees of tetraparesis or tetraplegia.
• Cervical ventroflexion
– Diagnosis:
• MRI
– Treatment:
• Supportive
– Prognosis:
• Favorable
Yorkshire Terrier
•
Portosystemic Shunt
•
Atlantoaxial Instability
•
Necrotizing Leukoencephalitis
•
Portosystemic shunt (< 1 year of age)
– Clinical signs:
• Reflective of forebrain disease
• Altered mentation, pacing, visual deficits and seizures
– Diagnosis:
• Transcolonic portal scintigraphy
– Prognosis:
• Fair to good
•
Atlantoaxial Instability (<2 years of age)
– Clinical signs:
• range from mild cervical pain to tetraplegia
– Diagnosis:
• Non-sedated, mildly ventroflexed lateral radiograph
– Treatment:
• Surgical
• Conservative
– Prognosis
•
•
Fair
Necrotizing Leukoencephalitis (1-10 years of age)
– Young, adult females over-represented
– Clinical Signs:
• Seizures are the most common clinical abnormality but signs represent the
distribution of brain lesions
– Diagnosis:
• Spinal tap with CSF analysis
• Advanced imaging
– Treatment:
• Immunosuppression
– Prognosis:
• Grave
Boxer
•
Degenerative Myelopathy
•
Idiopathic Head Tremors
•
Aseptic Meningitis
•
Boxer
•
Degenerative Myelopathy (≥ 8 years of age)
– Clinical signs:
• An insidious onset of a non painful deterioration in rear limb function resulting
in progressive paresis and ataxia
– Diagnosis:
• Genetic testing
– Treatment:
• None
– Prognosis
• Poor
•
Idiopathic Head Tremors (adult onset)
– Clinical Signs:
• A series of repetitive involuntary muscle contractions involving the head and
neck occurring in either a vertical or horizontal direction
– Diagnosis:
• Clinical presentation
– Treatment:
• None needed
– Prognosis:
• Excellent
•
Aseptic Meningitis (< 2 years of age)
– Clinical Signs:
• Arched back with cervical ventroflexion (pain)
• Stiff, stilted gait
– Diagnostics
• Spinal tap with CSF analysis
– Treatment:
• Immunosuppression
– Prognosis:
• Good to excellent
Pug
•
Type II Intervertebral Disc Disease
•
Spinal Arachnoid Cyst
•
Type II Intervertebral Disc Disease (older)
– Clinical Signs:
• Insidious onset of a non painful, slowly progressive ataxia and paresis of the rear
limbs
– Diagnosis:
• MRI
– Treatment:
• Conservative
• Surgical (rare)
– Prognosis
• Fair
•
Spinal Arachnoid Cyst (adult age)
– Clinical signs:
• Insidious onset of a non painful, slowly progressive ataxia and paresis of the rear
limbs
• Urinary and/or fecal incontinence
– Diagnosis:
• MRI
– Treatment:
• Conservative
• Surgical (preferred)
– Prognosis:
•
Good with surgery
•
Secretory Otitis
•
Syringomyelia
•
Secretory Otitis (adult onset)
– Clinical Signs:
• Moderate to sever pain, vestibular and/or facial nerve dysfunction, and hearing
loss
– Diagnosis:
• Otoscopic exam
• Bullae radiographs
• Advanced imaging
– Treatment:
• Ventral bulla osteotomy
• Myringotomy
– Prognosis:
• Excellent
Cavalier King Charles Spaniel
•
Syringomyelia (6 months to 3 years)
– Clinical Signs:
• Air scratching, cervical discomfort, ataxia
– Diagnosis:
• MRI
– Treatment:
• Surgical (uncommon)
• Medical
– Omeprazole
– Prognosis:
• Guarded
Doberman Pinscher
•
Caudal Cervical Myelopathy
•
Idiopathic Head Tremors
•
Doberman Pinscher
•
Caudal Cervical Myelopathy (6-8 yrs old)
– Clinical Signs:
• Cervical pain with varying degrees of ataxia and paresis
– Diagnosis:
• MRI preferred
– Treatment:
Medical
– Prednisone
• Surgical
– Prognosis:
• Fair to good
•
Labrador Retriever
•
Idiopathic Epilepsy
•
Caudal Cervical Myelopathy
•
Idiopathic Head Tremors
•
Geriatric Vestibular Disease
•
Peripheral Nerve Sheath Tumor
•
Labrador Retriever
•
Peripheral Nerve Sheath Tumor (older)
– Clinical signs:
• An insidious onset of progressive forelimb lameness
• Ipsilateral miotic pupil possible
– Diagnosis:
• MRI
– Treatment:
• Amputation
– Prognosis:
• Variable
End
Rational Use of Antacids
Crystal Hoh, DVM, MS, DACVIM
Overland Park, KS
Topics to Cover
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Adverse Effects of Antacids
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Indications for Use
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Proactive Esophageal Reflux Therapy
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Steroid Induced Ulcers
•
Brief Reminder of Drug Mechanism of Action
•
Specific Drugs Used
•
Questions
Adverse Effects Dogs / Cats
•
Drug absorption issues
•
Cytochrome P450 interference
•
Rarely diarrhea or vomiting
•
Shifts in flora – uncertain consequences
•
Likely rebound hyperacidity with chronic use
•
One extra medication, lower compliance
Adverse Effects Humans (PPI)
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Low magnesium causes low calcium
•
Muscle tremors / twitching / weakness
•
Bone fracture
•
Increased risk for bacterial gastroenteritis
•
Increased risk C difficile
•
Chronic use ~1-5 years or more
Adverse Effects Rodent Studies (PPI)
•
Gastric hyperplasia with increased gastric carcinoma risk
Essential Antacid Use
•
Esophagitis
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Esophageal stricture
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Esophageal foreign body
•
Known causes for gastroesophageal reflux
•
Severe GI bleeding (suspected ulcer)
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Melena
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Hematemesis
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Low MCV anemia
Signs of Esophagitis
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Ptyalism
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Neck stretching
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Dysphagia
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Hard swallow
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Cough
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Snorting (nasopharyngeal stricture)
–
Regurgitation
–
Moaning / Discomfort
– Inappetence
Good Idea Antacid Use
•
Abdominal surgeries (rate of reflux up to ~38%-50% in longer procedures as measured by probe
monitoring)
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Prolonged fasting / inappetence
•
Vomiting / regurgitation
•
Acute Renal / Liver disease
•
Pancreatitis
May Help, Lower Priority
•
Chronic renal disease
•
Chronic liver disease
•
Prolonged inappetence
•
Chronic gastrointestinal disease
Proactive Esophageal Reflux Therapy
•
•
Surgical reflux
–
Up to 50% of dogs will have reflux under anesthesia
–
Worse abdominal procedures
–
Antacid with metoclopramide or cisapride
–
At least 50% of esophageal strictures are caused by surgical reflux
Esophagitis can cause regurgitation / loss of appetite / prolonged recovery and hospitalization
Sodium Bicarbonate – Reflux Therapy
•
Suction to remove reflux but not enough
•
Lavage warm water until fluid looks clear
•
Instill sodium bicarbonate 4.2% solution ~20 mls
•
Need well inflated tracheal tube cuff, be certain not in trachea!
•
12 Fr catheter
Steroids and Ulcers
•
Dexamethasone used in models to cause ulcers
•
75% of IVDD dogs develop ulcers
•
None of these can prevent steroid ulcers
–
Omeprazole
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Misoprostol
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Sucralfate
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Cimetidine
Steroid Ulcer Healing
•
Natural healing no treatment 12-14 days
–
Treatments tried
•
Lansoprazole (PPI)
•
Sucralfate
•
Misoprostol
•
Famotidine
•
Seabuckthorn seed oil
Steroid Ulcer Healing
•
•
Dogs 15-25kg
–
Seabuckthorn seed oil 5 mL/dog, q12h
–
Healed the fastest (day 6)
Famotidine 1 mg/kg q12h
–
next fastest (day 7.5)
Human Ulcer Healing Guidelines
•
Duodenal and esophageal pH > 4 for 75% of day
•
pH values > 4 inactivate pepsin and inhibit fibrinolysis
•
Gastric bleeding: hemostasis
–
pH > 6 needed
–
At least 66% of day to heal
Proton
pump
Stomach Acid Production
H2
Acetylcholin
e
Gastrin
Famotidine – Pepcid AC
•
H2 receptor antagonist
•
Can increase pH > 4 for up to 48% of the day
•
1 mg/kg, q12h dosing
•
Gastrin levels returned to baseline by day 14 of treatment
–
May become less effective with chronic use
–
Rare anecdotal hemolysis cats rapid IV (not proven in study)
Ranitidine - Zantac
•
H2 receptor antagonist
•
Prokinetic properties
•
Multiple studies have shown no pH changes over placebo
•
Gastrointestinal emptying time not changed compared to placebo
•
False positive urine protein on Multistix
•
Probably not a good choice in dogs or cats
Cimetidine - Tagamet
•
H2 receptor antagonist
•
Weak inhibitor of cytochrome P450 enzymes
•
Anti-androgenic effects
•
Cannot be substituted for ketoconazole to increase cyclosporine levels
•
No change in esophageal pH during reflux in OHE dogs
•
Dosing needed q6-8h
•
Likely not good choice in dogs
Omeprazole – Prilosec OTC, Gastroguard
•
Proton pump inhibitor (PPI)
•
Inhibits cytochrome P450 enzymes
•
1 mg/kg PO q24h for most conditions is fine
•
Need q12h for severe bleeding ulcers (75% of day pH over 4-6)
•
Cut tablets still effective in cats
Sucralfate - Carafate
•
Gastroprotective drug
•
Needs low pH to form paste and bind ulcers
•
¼-1 gram per animal PO or in slurry q8h
•
Interfere with other medications.
•
Separate from other drugs / food by 2 hours
•
Best given q8h
•
Anecdotally soothing properties for rapid relief
END
Veterinary Technicians
The Next Profit Center
[email protected]
What is profit?
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Profit = Business Success, Job Security, Happiness
Profit = Revenue – (Operating Expenses + Overhead)
Remember when you made a good profit from…
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Vaccines
Dewormers
Flea and Tick Products
Drugs
Food
Spays/Neuters
Lab Tests
Veterinary Economic 2011 Benchmarks:
Expense type
Percentage of total practice revenue
2007
2009
2011
Variable
21.8%
24.5%
25.1%
Fixed
9.0%
8.9%
8.9%
Staff
25.6%
25.3%
24.7%
Facility
8.0%
8.4%
8.8%
Reinvestment
5.9%
4.3%
4.5%
Revenue has increased, but operating expenses have increased more!
2007 AVMA Study:
Table 1—Results of an ordinary least squares regression model to evaluate the effects of staffing on
gross revenue in private veterinary practices in the United States, 2007.
Variable
Gross revenue ($)
No. of full-time
Equivalent veterinarians = 1.73
Full-time–
Equivalent veterinarians
318,545
Credentialed
Veterinary technicians to veterinarians
161,493
Noncredentialed Veterinary technicians
to veterinarians
10,567
Veterinary Technician Utilization
2007 AVMA Study found:
$93,311 increased gross revenue per Credentialed Veterinary Technician added
What is a Technician?
Missouri Veterinary Board Definitions
"Registered veterinary technician", a person who is formally trained for the specific purpose of assisting
a licensed veterinarian with technical services under the appropriate level of supervision as is consistent
with the particular delegated animal health care task
"Unregistered assistant", any individual who is not a registered veterinary technician or licensed
veterinarian and is employed by a licensed veterinarian
Dr. Morrow’s Definition: A Veterinary Technician has…
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a license.
medical knowledge to pass the National Exam.
legal knowledge to pass the State Exam.
I want someone who has something to lose because my license is on the line!
LICENSE = TECHNICIAN
NO LICENSE = ASSISTANT
Any Technician, RVT
Even when they have a license they still have to … EARN MY TRUST!
I would not hire a new Veterinarian and immediately go on vacation.
Why would I expect to do the same with my new RVT?
Step 1
UTILIZE THE TECHNICIANS ENTRY LEVEL SKILLS
Utilize their client communication skills!
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30 minute examination time
– 10 minutes:
 Obtain History
 Establish Visit Plan
 Obtain Client Authorization
 Sample Collection
10 minutes: Veterinary Exam / Consult
10 minutes: Client education on treatment, monitoring, recheck scheduling
Create Technician Appointments
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All of us want to market our hospitals.
Give them their own business cards.
Let them bond with the clients!
Common Error = Clients only bonded with Veterinarian
If clients are only bonded with you, then taking a day off or selling your practice in the future will be
harder.
Schedule Technician Appointments
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Create A Separate Technician Schedule
If you do not have enough room, then take a longer lunch time!
I currently get a 3 hour lunch from 12:00 - 3:00 PM. It works great!
Technician Appointments
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Anal Glands
Nail Trims
Ear Hair Plucking
Ear Cleaning
Shaving Hair Mats
Teeth Brushing
Soft Paws Application
Weight loss – Weigh Ins
Nutrition Counseling
Puppy training
Boarding Admit / Discharge
Fecal Recheck
Radiograph Recheck
Microchip
Urinalysis Recheck
Blood Collection
Medication Screening
Pre-Anesthesia
Follow-up testing
Glucose testing
Suture Removal
SQ fluid administration
Medication administration
Surgery Admit / Discharge
Blood Pressure Rechecks
Bandage Changes
Laser Therapy
Utilize their laboratory skills!
Reduce our outside lab cost, improve turn-around time, get more accurate results, and impress our
clients.
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Fecal Exam: Float, Centrifugation, Cytology
Urine Exam: Urinalysis and Culture
Blood Smears: Hemoparasite identification,
 WBC estimates, RBC estimates, Platelet Estimates
Skin Scrapes
Ear Cytology
Fungal cultures
Technician Appointments
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Increased Production
Happier Employees
Happier Clients
Increased Bonding of Clients to Practice
Increased Revenue
2011 DVM360 article by Karen Felsted, CPA, MS, DVM, CVPM
Step 2
SUPPORT THEM IN BRINGING NEW SERVICES TO YOUR PRACTICE
Allow Technicians to grow and improve!
Most common reason that Veterinary Technicians leave a hospital……they are under utilized and they
feel burned out.
They want to help animals and to be a productive member of the veterinary team.
Like us, they get energized by learning something new and using their new skills.
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Behavior
Nutrition and Weight Loss
Laser Therapy
Stem Cell Therapy
Ultrasound
Rehabilitation
Academies for Veterinary Technicians
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Academy of Veterinary Behavior Technicians
Academy of Veterinary Clinical Pathology Technicians
Academy of Veterinary Technicians in Clinical Practice
Academy of Veterinary Dental Technicians
Academy of Dermatology Veterinary Technicians
Academy of Veterinary Emergency and Critical Care Technicians
Academy of Equine Veterinary Nursing Technicians
Academy of Internal Medicine for Veterinary Technicians
Academy of Veterinary Nutrition Technicians
Academy of Veterinary Surgical Technicians
Academy of Veterinary Zoological Medicine Technicians.
Societies
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Society of Veterinary Behavior Technicians
American Association of Equine Veterinary Technicians
American Association of Rehabilitation Veterinarians and Veterinary Technicians
Association of Zoo Veterinary Technicians
Veterinary Emergency and Critical Care Society
Society of Laboratory Animal Veterinary Technicians
Kansas City
Registered Veterinary Technician
Association
[email protected]
END
Rehabilitation of a Cruciate Deficient Stifle
Connie Schulte, DPT, CCRP
Physical Rehabilitation can Improve:
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Range of motion
Muscle mass
Weight bearing
In dogs with cranial cruciate ligament disease
Conzemius MG, Evans RB, Besancon MF, et al: Effect of surgical technique on limb function after surgery for rupture of the cranial
cruciate ligament in dogs. J Am Vet Med Assoc 2005;226:232-236
Monk ML, Preston CA, McGowan CM: Effects of early intensive postoperative physiotherapy on limb function after tibial plateau
leveling osteotomy in dogs with deficiency of the cranial cruciate ligament.. Am J Vet Res 2006;67:529-536
Marsolais GS, Dvorak G, Conzemius MG: Effects of postoperative rehabilitation on limb function after cranial cruciate ligament
repair in dogs. J Am Vet Med Assoc 2002;220:1325-1350
Johnson JM, Hohn AL, Pijanowski GJ, et al: Rehabilitation of dogs with surgically treated cranial cruciate ligament-deficient stifles
by use of electrical stimulation of muscles. Am J Vet Res 1997;58:1473-1478
Francis DA, Millis DL, Head LL: Bone and lean tissue changes following cranial cruciate ligament transection and stifle
stabilization. J Am Anim Hosp Assoc 2006;42:127-135
WHY do Conservative Management of CCL injury?
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Not all animals are surgical candidates
– Age
– Poor health
– Inadequate state of fitness
– Financial constraints
– Owners’ beliefs
These animals deserve a chance at optimal function as much as those that are surgical
candidates
Characteristics of a Grade One CCL Injury
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Mild effusion at the stifle
Mild discomfort on stress testing
Partial weight bearing
Laurie Edge Hughes BScPT, MAnimSt(Animal Physio),CAFCI, CCRT www.fourleg.com
Cruciate Deficient Canine Stifle
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One incident or daily mechanical wear and degenerative changes
Prevalence in Rottweilers and Staffordshire Terriers
– (Whitehair et al 1993)
Neapolitan Mastiff, Akita, Saint Bernard, Mastiff, Chesapeake Bay Retriever, and Labrador
retriever
– (Duval et al 1999)
Cruciate Deficient Canine Stifle
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Neutered or spayed
– (Whitehair et al 1993)
Weight > 22 kg occurred at a younger age
– (Whitehair et al 1993)
Obesity contributes
– (Johnson & Johnson 1993)
Cruciate Deficient Canine Stifle
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Chronology of degenerative events (Johnson & Johnson 1993)
– Cartilage fibrillation
– Periarticular hypervascularity
– Osteophyte development
– Medial joint swelling
– Periarticular fibrosis (re-stabilization)
– Meniscal injury
– Peak osteophyte formation and synovitis
– Settling synovitis
– Articular cartilage erosion
– Collagen fibril network breakdown
– Slowing of osteophyte formation
Conservative management-Where to start
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Dog on leash for 2-3 months – NO EXCEPTION!
Modalities to encourage circulation to affected stifle – laser, pemf, ultrasound, acupuncture
Joint proprioceptive techniques (joint compressions)
Joint gliding techniques
Strengthening of adjacent musculature
Balancing/Co-coordination
Supplementation
Laurie Edge Hughes BScPT, MAnimSt(Animal Physio),CAFCI, CCRT www.fourleg.com
Protection Phase (0-4 weeks)
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Increase ROM
– PROM
– Tummy rubs
– Square sitting
Protection Phase (0-4 weeks)
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Passive Range of Motion
Increase muscle function using movement synergies and motor learning transfer
– Active sit to elevated surface
– Toe pinching in sidelying
– Leash walking
o Initially only to urinate/defecate
o 3-5 minute leash walks, increase time by 3-5 minutes per week
Weight shifting
Balance board - front
Stand and balance on soft surfaces
3 legged standing
Step ups
Circles or figure 8 (on leash)
Protection Phase
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Underwater treadmill
– High water
– Slow speed
Increase proprioception
– Joint compressions
o Mimics weight bearing
Grade 1-2 joint mobilizations
o Grade 1 – small amplitude rhythmic oscillating mobilization in early range of movement
o Grade 2 – large amplitude rhythmic oscillating mobilization in midrange of movement
Decrease pain and effusion
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Ice
PROM and AROM
Joint compressions/mobilizations
NMES
Modalities
Early strength training (5-8 weeks)
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Full ROM
– PROM, tummy rubs, square sits
Normal gait
– Obstacle walking or trotting
– Steep up hill walking or trotting
Increase motor control and strength (neuromuscular training)
– UWTM
– Swimming
– NMES or manual tapping on quadriceps or gluts with 3 legged standing
– NMES or manual facilitation of hamstrings with sitting
Side step or back stepping over a pole
Stepping up backward
Walking backwards
Any of the above on a soft surface
Hill walking
Stair walking
Load: 50-60% of uninjured limb
– Increase time and duration of above exercises
Phase 3: Intense Strength Training (9-12 weeks)
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Increased strength and motor control
– Continue most challenging exercises from above
– Walk with weight on affected leg (open kinetic chain)
– Trotting up and down hills
– Walking on uneven surfaces
– Recall running between 2 people
Increased Load: 70-80% of uninjured limb
– Increase time and duration of above exercises
– Use a weight pack
Phase 4: Intensive strength training/return to sports
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Increased strength
– Continue most challenging exercises from above
– Destination jumping from a stand (plyometrics)
Increased coordination
– Agility type training
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Increased ability in sport specific activity
– Short distance ball retrieves
– 1-2 pieces of agility equipment
– Short interval of play with other dogs
Load 80% of uninjured leg
– Increase time and duration of above exercises
– Perform above exercises with a weight pack
Post Op Rehabilitation
Rehabilitation following cruciate repair
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Goals:
– Increase ROM
– Increase strength
– Increase weight bearing
– Increase muscle mass
– Prevent compensatory postures
Post op Day 1- Day 10
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Ice stifle 10 minutes 2-3 times per day
PROM 2-3 times per day
Joint compressions
Short leash walks for ‘toileting’ only
Crate confinement
No running, jumping, rough housing
Sling on slippery floors and stairs
Laser or ultrasound to stifle
Electrical muscle stimulation: quadriceps, hamstrings, and gluteals
Check spine and pelvis for joint dysfunction
Post op Week 2
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PROM
Leash walks –> 5 minutes
Laser, Ultrasound, or PEMF
stimulate healing and enhancement of blood flow
Post op week 2
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Exercises
– Weight shifting
– Sit to stand – elevated if needed
– Begin UWTM – 5 minutes
Post op week 3
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Leash walking – 10 minutes
3 legged standing – front only
Elevated front with head turns
UWTM 10 minutes
Post op Week 4
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Leash walking 10-15 minutes
Cavalettis
Walking inclines
3 legged standing – add in unaffected back leg
UWTM 10-15 minutes
Post op Week 5
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Leash walking 15-20 minutes
Side stepping
Backward walking
UWTM 20 minutes
Post op weeks 6-7
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Leash walking 20-25 minutes
Back up onto small step (2-4 inch)
4 inch step overs
UWTM 20 minutes – adjust speed, H2O height
8 weeks post op
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Recheck with surgeon
Radiographs
Determine further ramp to normal activity
Worst Case Scenario:
Is your practice prepared for disaster?
Kim Gugler, DVM
Board Eligible ACVECC
Disasters Happen
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150 Major Disasters Worldwide
– Nepal Earthquake
– Heatwaves in India
– Flooding in India
43 Major Disasters
2 Emergency Declarations
34 Fire Management Assistance
Disasters
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Winter weather/Blizzard
Heavy Rains/Flooding
Levee/Dam break
Tornado
Loss of Electricity
Fire or Burglary
Earthquake
Train Derailment
Chemical Spills
Heatwave/Drought
Infectious Disease
Why Should We Plan?
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Concerns for our practice and staff
– Can we protect our staff?
– Can we pay the bills?
– This is our livelihood
 Community concerns
– The human-animal bond
o PETS Act
– Respect of the community as leaders
o Important for response and recovery phases
– Our knowledge is invaluable
o Recognize zoonotic diseases and potential bioterrorism
Objectives
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Take a deep breathe and don’t panic
Prepare yourself
Understand the essentials of a written plan for your practice
Be familiar with available resources
Prepare Yourself
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Have a plan for your home
Have kits prepared for you and your family
Don’t forget about your own pets
Have a plan for traveling
Home Kit


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Water
Food
Radio
Flashlight
Batteries
Rx Meds List
First Aid Kit
Change of Clothes
Money
Pet Kit
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Water/Food/Bowls
ID tags/Collar/Photo
Proof of vaccination
Carrier/Leash
Medications
Litter
First Aid Kit
Plastic bags
Mobile app
Creating a Clinic Plan


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
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
General Emergency Planning
Security
Fire Prevention
Animal Relocation
Medical and Business Records
Continuity of Business
Insurance and Legal Issues
General Emergency Plan





Determine an Incident Command System
– Chain of command
– Responsibilities list
Identify and address responses to foreseeable emergencies
Identify training, information, and equipment needed
– CPR/First Aid
– Level 1 HAZMAT training
Perform proper housekeeping, maintenance, surveillance
– Safety team
Ensure compliance with state and federal regulations
Security



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


Identification/Key Cards
Reporting Emergencies
Alarm System/Panic Button
Money Drawer
Drop/Time-Lock Safe
Controlled Substances
Training
Fire Prevention






Identify the Hazards
– Potential ignition sources
– Electrical
– Oxygen
– Proper handling, storage, and maintenance
Smoke/Fire Alarms
Extinguishers
Spill Containers
Clearly marked exits
Training
Severe Weather Plan



Emergency Radio
Storm Shelter
Winter Weather
– Employees
– Clinic Closure
– Care of patients/boarders
Evacuation of Staff



Pre-arranged Meeting Place
List of Employees
Method of Contact
– Group text
– E-mail list
– Private Facebook group


Designated alternative shelter and pre-arranged transportation
Copy and Back-up of records
– Client contact list
Transport cages/Leashes
Identification
3 day supply of food and medications
Emergency Drugs and Supplies




Records Back-up

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
Off-site computer back-up
Client/employee phone list
Business insurance papers
Contracts/Payroll Information
Lease/Deed to property
Banking information/Check books
Health insurance papers
Emergency contact list
Controlled drugs/DEA registration
Veterinary licenses
Itemized inventory list
Continuity of Operations







Communications
Alternate power source and fuel
Alternate food and water sources
On-site food and water
On-site medications
Alternate practice location
– Within your local vicinity
Adopt a sister practice
– Outside your vicinity
Clinic Preparation





Records backed-up and stored
Equipment stored/protected
Windows and doors protected
Valuable artwork removed
Retail items stored
Insurance



Current and Comprehensive Business Insurance
– Contents
o Receipts and photographs of inventory
– Interruption of practice
o Extra expenses and Loss of income
o Renting/Leasing equipment and location
– Flood coverage/Water damage
– Debris removal/cleanup
– Comprehensive building replacement
– Civil ordinance coverage
Professional Liability/Extension
Health Insurance/Disability
– Are you covered during drills?
Resources/Organizations

www.fema.gov/disasters/grid/state
– See what disasters have occurred in the past by state
 www.fema.gov/protecting-our-communities
– See what disasters could potentially occur in the future
 www.avma.org/KB/Resources/Reference/disaster/Pages/default.aspx
 www.diastersafety.org
– Free business continuity planning kit
 www.avmaplit.com
– Review business owners policies
 www.osha.gov/SLTC/emergencypreparedness/
– Requires small business to create fire prevention and emergency response plans
END
ROOM B
It’s a Corneal Ulcer: Now What?
My Daily Approach
Susan Keil, DVM, DACVO
Basic “Rules”


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
History
Signalment
Ocular Exam
Treatment / Plan
Types of Canine Ulcers
Types of Feline Ulcers
Patients are too stoic: ulcers hurt!
Patients do rub
Don’t listen to the client, listen to the patient
– Owner will blame cat, groomer, in-law’s dog and tell you it just started
– Patient will show you the story
Basic “Rules”: 3 Canine Ulcers
All types are painful



Simple: heal 1-3 days on their own, any age
Refractory/indolent/Boxer/SCCED: middle/older age, chronic, superficial, not infected
Complicated: infected and/or deep any age, can be superficial hypopyon, steamy cornea, bugeyed patients
Basic “Rules”: One Feline Ulcer


VIRAL / HERPES
– Ulcerative*
– Sequestrum
– Stromal
– Eosinophilic Keratitis
Complicated
Basic “Rules”: Ulcers Hurt



Tramadol
– 2 to 4 mg/kg BID-TID
Oral NSAID
– Rimadyl 2.2 mg/kg BID; 4.4 mg/kg QD
– Deramaxx 1-2 mg/kg QD
Feline
– 81 mg aspirin q 2-3 days
Basic Rules: The Stupid Cone







Use appropriate sized / fitted collar
– some have to be cut back; - warn about doggie door
Some collars do not work: donuts, neck brace
Generates justified revenue
Helps keep out of pond, garden, woods (hope)
Rubbing is bad
– delays healing, increases rate of rupture, infection
Write in record when client declines
Comfy-cone (has rigid inserts): Amazon $27
Basic “Rules”


Diagnosis the ulcer type to help you determine your treatment plan
If improvement is not appropriate, recommend referral
History







Take a thorough, filtered history
Trauma: cat claw = puppies, grass seeds = hunting/hiking, blunt/sharp objects
Acidic/alkalotic: shampoos, cleaning agents
Acute: trauma, chemicals, melting (infected)
Recurring: dry eye, aberrant hair, entropion
Chronic: refractory
Young (< 5 yrs) dogs do not get refractory ulcers
Signalment



o
Boxer: refractory
Puppy: entropion, ectopic cilia, cat claw
Bug-eyed: exposure, dry eye, nasal trichiasis, chronic micro-traumas
Breed related: Yorkie/Pug=congenital dry eye, Shar Pei/Chow/Bulldog=entropion, Shih
Tzu/Boston/Lhasa/Bulldog=stromal keratitis, Bulldog/Cocker/Westie/Frenchie=dry eye
Ocular Exam



Menace:
– assess function
o helps guide tx plan
Dazzle/PLR
– assess function, severity
Schirmer Tear Test
– VERY important
– check other eye: clues!
– repeat after healed
– maybe falsely elevated
Ocular Exam


Fluorescein Stain
nontoxic, excites at 480 nm (blue)
– detects ulcers, extremely hydrophilic
 epithelium very hydrophobic
 dendritic ulcers need blue light to enhance
 binds to exposed stroma; flush well
 tear small piece of strip, put in 3 cc syringe & fill with saline for a few days (then toss!)
 IOP: tonovet, tonopen
– use caution on soft, infected corneas
– change tip / cover if suspect infected
– evaluating reflex keratouveitis
 Use topical anesthesia
 Cytology: dull blade end
– Kimura spatula
– collect from ulcer edge
– use caution
 Culture
– microtip culturette
– collect from within ulcer
– use caution
Administering Topical Meds



Wait 5-10 minutes between medications
– allow first drug to absorb
Thinner before thicker (ointments last)
– doesn’t matter which drop goes first
– specify to client if need drops at different times to maximize therapy (multiple antibiotics)
Delivery volume of one drop 35-50 microliters
– lacrimal lake holds 30 microliters
– one drop is all you need per treatment
Feline Ulcer: Diagnosis

Important: diagnosis of FHV-1 based on the history/signalment/exam, confirming this is not
a complicated ulcer
– stresses: neuter/OHE, moved, baby, fiancé
o older cat – think underlying disease; do general exam and recommend
CBC/Profile/FeLV/FIV/Toxo (note if decline)
– often will not see classic dendritic ulcers, but will get stain uptake: STILL THINK
HERPES
– I do not do cytology/culture and rarely do viral testing
– Suspect 90-95% of all cats have FHV-1
Feline Ulcer Diagnosis



Epiphora, chemosis, blepharospasm, stain positive, +/- dendritic ulcers, blood vessels
No additional tests
Do you elect to treat?
– mild, may elect to run course
– may not start antiviral
o pilling, topical frequency
Feline Ulcer: Treatment


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
No Elizabethan collar
Antiviral!!!
– Oral Famvir: 125 – 250 mg QD – BID for days, weeks, month(s)
– Topical Idoxuridine: 1 gtt 6 times daily x 2 days, then QID for days/wks, then taper
Atropine OINTMENT
– QD-BID, tapering
Terramycin / Erythromycin ointment:
– ¼ inch strip (bead) TID x 3 weeks
o prophylaxis, unlikely bacterial infection
Lubricant: soothing (Genteal, Refresh, Optix)
Recheck: depends on severity / discomfort
– one week average, then may require more
Daily lysine if patient will take (don’t stress)
– Equine VitaFlex (pure lysine) from Farnam (4 pounds)
o Fill 40 dram vial 80% full; dispenser - clear end of monoject 20 gauge needle
Don’t forget the antiviral
Feline Ulcer: Recheck



7-10 days
Have client call if worse / not improving
Refer: sequestrum, stromal keratitis, eosinophilic keratitis, not improved by recheck, getting
worse
Canine Simple Ulcer

Hx / Diagnosis
– sudden
– any signalment
– positive stain
o superficial
o not infected
o not chronic problems
– epiphora
– +/- miosis
– mild to severe pain

Treatment
– broad spectrum topical antibiotic TID x 5 days
o triple antibiotic
– oral NSAID 1-4 days
– lubricant
o OTC (Genteal, Refresh)
– atropine solution
o one in-house dose?
o QD / BID x 1-3 days
– tramadol
Canine Simple Ulcer



Should heal no matter what we do or don’t do in 1-3 days
No(?) Elizabethan collar
Recommend recheck in 2-5 days if not 100% or gets worse at any point
Canine Refractory Ulcer

Hx/Diagnosis
– chronic (1-3+ weeks)
– middle / older age
– Boxer (but any breed)
– undermining + stain
o superficial
o not infected
– mild to severe pain
– +/- miosis
– zero to extreme neovascularization
Refractory Ulcer Treatment





Once diagnosed, needs a diamond burr (grid) keratectomy (80% heal rate)
Changing antibiotics will not increase healing
Do not perform keratectomies on infected ulcers or descemetoceles!
Get into an Elizabethan collar
50% of patients will develop same ulcer in opposite eye within 18 months
Refractory Ulcer Treatment



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

Mydriatic
– reflex keratouveitis
– atropine solution BID x 4 days, then QD UR
Prophy antibiotic
– tobramycin TID UR
Oral NSAID UR
Lubricant (Optix, Genteal, Refresh)
Tramadol
Don’t need serum
Refractory Ulcer Tx/Recheck


Contact lens
– 80% retention
– increases to 95% healing
– do not put on infection
– really want E-collar on
Recheck 2-3 weeks
– if not healed, repeat procedure if painful
– if open/comfortable, give more time
Canine Refractory Ulcer


This ulcer is caused by an epithelial basement membrane (collagen IV) defect
– need to stimulate BM
– have seen ulcers 6 – 12 months chronic (18 mo*)
– painful; changes personality
Do not perform a grid keratectomy on cats
– will generate sequestrum formation
– soft diamond burr may work to debride
Canine Refractory Ulcer


I do not perform cytology / culture on refractory
If you don’t know it is refractory, cytology should be helpful in confirming not infected
Canine Complicated Ulcer






Infected (any depth)
Descemetocele
Bug-eyed patients higher risk
Apply topical anesthetic
– help relax
– sedate if necessary
Does the eye work???
Once diagnosed, recommend referral
Complicated Ulcer Hx/Diagnosis


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

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

Acute, subacute, chronic
Brachycephalics, chronic ocular dz higher risk
Any age
Superficial, mid-stromal, deep stromal stain
Descemetocele center stain negative
Moderate to extreme pain
ADR, anorexia, crying
Miosis, hypopyon, edema/steamy cornea
Zero to significant neovascularization
Complicated Ulcer Diagnosis





Look at opposite eye
– KCS
Look for aberrant hairs
– nasal trichiasis
Can the patient blink?
Corneal cytology
– use caution, may rupture
Corneal culture
Complicated Ulcer Treatment


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Elizabethan collar!!
No ointments
Tramadol: pain control, keeps them quiet
Oral NSAID – Rimadyl
Atropine solution:1 gtt BID – QID
Refer
– medical
– surgical
Complicated Ulcer Treatment




Ofloxacin (or other enrofloxacins)
– 1 gtt 5x daily on odd hours x 2 days, then 4x daily x 3-4 days, then TID for 7-10 days
Cefazolin in Artificial Tears (expires in 10 days)
– 3 mls diluent into 1 gram cefazolin
– pull 1 ml from 15 ml AT bottle
– See ofloxacin (given on even hours) x 10 days
Dilute Betadine solution (1:10): 0.5 mls TID
Serum: 0.2 mls QID until stable
Complicated Ulcer Recheck




24 hours after start therapy
– is pupil dilating?
– is eye more relaxed?
– does cornea stabilizing (less keratomalacia)
– to much structural loss?
Continue with medical therapy?
Is corneal/conjunctival surgery required?
Rechecks then 2 days, 4 days, one week
Canine Complicated Ulcer





No ointments
– difficult application
– do not want petrolatum inside eye
Leave caked debris/nasal trim for later
– trim direct contact
If struggling,  drops
If ruptured, just atropine
Do NOT grid!
Office Hours
Monday, Tuesday, Thursday 7:30 – 5:00
Wednesday 7:30 – 5:45
Friday 8:00 – noon
Emergency services 24/7
END
Does this fracture need surgery?
Fracture assessment, Initial stabilization, and decision
making
Ralph P. Millard, DVM, MS, DACVS-SA
Emergency Management
 #1 RULE: Stabilize Patient. . .Fractures come later
 History & Physical Exam (prioritize)
 Fluids
 Pain meds
 ECG, Pulse Ox, BP
 Blood work
 If wound, cover while stabilizing patient
○ Exception: wound making patient unstable, rarely the case with a fracture
 Thoracic radiographs +/-Abdominal radiographs/US
 THEN. . . once patient completely stable, consider radiographs of fracture
Fracture Assessment/Description
 Facts to Know!
 Bone/bones
 Right/left
 Open or closed
 Location of fracture
○ metaphyseal, physeal, diaphyseal, articular
 Type of fracture
○ transverse, short oblique, long oblique (spiral), comminuted, etc.
 Orientation
○ 3D description based upon distal fragment
○ i.e. cranial/caudal, proximal/distal, medial/lateral
 Acute/chronic
 Orthopedic exam
 Neurologic function (**very important!!)
Open Fractures
•
Unique combination of orthopedic and soft tissue injury
– Infection
– Delayed Union
– Non-Union
Wound Management
•
•
•
•
•
•
•
•
•
•
Confirm patient stable
Classify wound
Copious K-Y (sterile)
Clip wide
Clean surrounding skin
Copious wound lavage
Cut (debride necrotic tissue)
+/- Culture
Cover (bandage) wounds
Rigid external support
Open Fracture Classification
(Gustilo-Anderson, Types 1-3)
Type I: An open fracture with a wound smaller than 1 cm
– Surrounding soft tissues are mildly/moderately contused. Frequently the external
wound is created from the inside out by sharp bone fragments
• Type II: An open fracture with a wound larger than 1 cm without extensive soft tissue
damage, flaps, or avulsions
– The external wound typically is created from the outside in by high energy forces
 Type III: An open fracture with extensive soft tissue damage. Soft tissue avulsion, de-gloving
injury, and bone loss are frequently noted. These include fractures with accompanying
neurovascular injury requiring repair, gunshot injuries, and traumatic partial amputations
 IIIA: Adequate soft tissue coverage despite extensive soft tissue laceration or flaps
 IIIB: Extensive soft tissue loss, periosteal stripping and bone exposure
 IIIC: Associated arterial injury requiring repair
•
Open Fractures: ANTIBIOTICS
Required component of successful outcome
Timing: < 3 hours after injury sig lower infection rate compared to 4 hours or greater
Coverage
– Type I or II: First generation cephalosporin
– Type III: Broader coverage, cephalosporin & fluoroquinolone
– Nosocomial Infections (82%)
–
Open Fracture Treatment
•
•
•
•
•
•
Bone plates, plate rod, interlocking nail and external skeletal fixators
Type I fractures often treated similar to closed
Type III/severely contaminated
– External skeletal fixator
**External coaptation NOT recommended for definitive stabilization.
Open Fracture Outcomes
•

Infection rates
– Type I: 0-2%
– Type II: 2-10%
– Type III: 10-50%
Delayed union/non-union
– Type I: 0-5%
– Type II: 1-14%
– Type III: 2-37%
Temporary Fracture Stabilization
•
•
•
Reduce further injury:
– Soft tissue (neurovascular)
– Musculoskeletal
Attenuate painful stimulus
Prevention of open fracture
Bandage Anatomy
•
•
•
Primary Layer (if wound)
– Adherent
– Non-adherent
Secondary Layer (absorb and support)
– Cast Padding
– Kling
Tertiary Layer (support and protect)
– VetWrap
Temporary Fracture Stabilization
•
•
•
•
Humerus
– Spica or nothing
Radius/Ulna (or distal)
– Modified Robert Jones
Femur
– Spica or nothing
Tibia/Fibula (or distal)
– Modified Robert Jones
Bandage Complications
•
•
•
•
•
•
•
•
•
Moist dermatitis
Skin necrosis / Gangrene
Valgus deformity of the forelimb
Amputation of limb or digits
Death
Closely monitor bandages and digits
– Swelling, warmth, odor, moisture
63% developed soft-tissue injury
– 60% mild, 20% moderate, 20% severe
Can occur at any time frame, no association with duration of cast/splint
Cost of treatment 4-121% cost of original ortho procedure
Fracture Decision Making
•
•
•
•
Biomechanics fracture repair
Cost
Patient Dynamics
Owner Dynamics
Definitive Stabilization Decision-Making





Compression
Tension
Bending
Rotation
Shear
Traumatic Fractures
•
•
•
•
•
•
Activity restriction
Closed Reduction External Coaptation (Splint/Cast)
ORIF (Open reduction and internal fixation)
Closed/Open reduction and rigid external fixation (external skeletal fixator)
Closed reduction internal fixation (ILN, Flouro guided)
MIPO (Minimally Invasive Plate Osteosynthesis)
Definitive Stabilization (External Coaptation)
•
•
•
•
•
Distal to elbow/stifle
Incomplete fractures
Simple minimal/non-displaced
Young*
Financial constraints
– Cost of bandage changes or complications
External Coaptation
•
•
Toy breed
Distal radius/ulna fracture
Metacarpal/tarsal Fractures
•
•
•
•
•
•
More than two metacarpal/tarsal fractures present
Involves both III and IV
Articular
Displaced by > 50%
Involve base of II or V (collaterals)
Large breed or athletic/working
Sacroiliac Luxation
•
Indications for internal fixation
– Pain
– Instability/inability to bear weight
– Compromised pelvic canal or joint alignment
– Contralateral injuries requiring internal fixation
Scapular Fractures
•
•
Unstable extra-articular (neck) fractures and articular fractures are optimally managed with
internal fixation.
Scapular body fractures
– Minimal displacement
– Can have inherent stability
– Can heal rapidly
Summary
•
•
•
Most traumatic fractures require (at least have indication) surgical stabilization
Temporary stabilization is ALWAYS indicated for fractures distal to elbow and stifle.
Coaptation (definitive)
– Distal to elbow or stifle
– Sufficiently stable in coaptation
– Expected to heal quickly (incomplete or minimamaly displaced, young etc)
Thank You
END
Treating Diabetic Ketoacidosis
Heather Gill-Bragg, DVM
Small Animal Internal Medicine, Resident
Insulin Deficiency: Absolute and Relative




Insulin made & secreted by pancreatic β cells.
Deficiency leads to:
– Decreased tissue utilization of glucose, aa, FA
– Accelerated hepatic glycogenolysis and glucogenesis
– Accumulation of glucose in circulation
Absolute: no insulin produced
Relative: inability of insulin to work appropriately
– Main sites: liver, muscle, adipose tissue
Formation of Ketone Bodies



Most impt regulators of ketone body production are:
– FFA availability
– Ketogenic capacity of the liver
FFA are oxidized by liver and used as energy source when glucose deficiency (real or perceived)
is present
FFA turned into ketone bodies:
– Acetoacetate
– β-hydroxybutyrate
– Acetone
Treatment of “Healthy” DKA

Regular insulin (0.1-0.2U/kg/injection) SQ TID until ketonuria and ketonemia resolves (4896hrs)
– Feed 1/3 daily caloric intake at time of each injection
– Adjust based on clinical response and BG measurements
- OR 
Institute intermediate or long-acting insulin and monitor
Treatment of “Healthy” DKA


If patient remains ketotic, concurrent illness at play
Institute more aggressive insulin therapy
Treatment of “Sick” DKA




5 GOALS:
– Restore H2O and electrolyte losses
– Provide adequate amounts of insulin
o Suppress lipolysis, ketogenesis, hepatic gluconeogenesis
Provide dextrose to allow continued insulin use without hypoglycemia
Correct acidosis
Identify precipitating factors
Our goal is NOT to correct abnormalities as fast as possible due to potentially fatal side effects
Correction over 24-48 hours is much more likely to be successful
Goal #1:



Restore Water and Electrolyte Losses
Restore Water Losses
Fluids, fluids, and did I mention Fluids?

1 Line of Therapy





– (Insulin is NOT the 1 line!)
Maintain CO, BP, renal blood flow
Correct electrolyte deficiencies (Na, K)
Dampen K-lowering effect of insulin tx
Lower blood glucose concentration
Minimize intracellular shift of H2O caused by osmolality changes
– Gradual ↑ [Na] while ↓ [BG]
st
st
Restore H2O Losses

Rates of Fluid
– Is shock present? Is cardiac disease present? Urine output?
– Dehydration deficit: Replace over 24 hours
– Maintenance: (30 x BWkg) + 70 = 24hr maintenance
– Losses: GI (weigh potty pads), urine output (urinary catheter)
Monitor. Monitor. Monitor.
Restore Electrolyte Losses
Sodium Deficit





Urinary loss
GI loss
Types of Fluid (by the book)
Serum [Na] < 130mEq/L: 0.9% NaCl
Serum [Na] > 130mEq/L: Plasma-lyte, NSR
(Hypotonic fluids?)
Do NOT replace sodium too rapidly!!!
Central pontine demyelination
Restore Electrolyte Losses
Potassium Deficit




Intra/Extracellular shifts
Urinary loss
GI loss
Decreased intake
*Remember*
Do not exceed 0.5mEq/kg/hr
You absolutely can, and should, supplement up to that rate as needed.
Restore Electrolyte Losses: K+
Serum [K+] (mEq/L)
K+ Supplementation /L of fluids
> 5.0
WAIT
4.0-5.5
20-30mEq
3.5-4.0
30-40mEq
3.0-3.5
40-50mEq
2.5-3.0
50-60mEq
2.0-2.5
60-80mEq
< 2.0
80mEq
Restore Electrolyte Losses
Phosphate deficit




Cellular shifts
Renal loss
GI loss
Treat if [Phos] <1.5mg/dL. Options:
– 0.01-0.03mmol of Phos/kg/hr CRI (Note: Use Ca-free fluids)
o 0.03-0.12mmol/kg/hr in severe cases
– Use KPhos w/ KCl and use at a dosage of 5-10mEq of total K supplement
Restore Electrolyte Losses
Magnesium deficit





Osmotic diuresis, cellular shifts
Refractory hypokalemia or hypocalcemia
Replacement:
o Slow replacement: 0.5-1.0mEq/kg/d CRI
o Fast replacement: 0.3-0.5mEq/kg/d CRI
o Calcium-free fluids
Dose reduce (50-75%) in the azotemic patient
Side effects: Hypocalcemia, hypotension, AV & BB blocks
Restore H2O and Electrolyte Losses


Fluids, Fluids, Fluids
Electrolyte supplementation
– Sodium
– Potassium
– Phosphorus
– (Magnesium)
MONITOR, MONITOR, MONITOR
Goal #2:
Provide Insulin – Resolve Ketosis
Bottom Line:
The only way to reverse ketosis is to use insulin if hypoglycemia occurs, provide dextrose and
continue insulin!
Insulin Therapy
3 Major Techniques



CRI
Hourly IM
Intermittent SQ/IM
Remember….Initiate Fluid Therapy First!!!!
(Usually 2-4 hours of fluid therapy prior to insulin)
CRI of Regular Insulin



Goals:
– SLOWLY decrease BG by ~50mg/dL/hr
Pros:
– Can administer insulin continuously even as BG decreases
Cons:
– Hourly BG checks
– 2 separate lines required:
o Insulin CRI pump
o Crystalloid fluids
CRI of Regular Insulin
Regular insulin added to 250ml bag of 0.9% NaCl
– Dog: 2.2U/kg
– Cat: 1.1U/kg
If Glucose (mg/dl) is:
Fluids
Rate of Insulin CRI (ml/hr)
>250
0.9% NaCl
10
201-250
0.9%NaCl + 2.5% dextrose
7
150-200
0.9% NaCl + 2.5% dextrose
5
100-149
0.9% NaCl + 5% dextrose
5
<100
0.9% NaCl + 5% dextrose
STOP
CRI of Regular Insulin


st
Discard 1 50ml thru CRI line as insulin binds to plastic!
Treatment options moving forward:
– Continue CRI until patient is eating/drinking and switch to intermediate/long-acting
insulin and discharge
– Once BG reaches 250mg/dL -> change to intermittent IM/SQ regular insulin protocol
Hourly IM Technique



Goals:
– SLOWLY decrease BG by ~50mg/dL/hr
Pros:
– Only need one IV line
Cons:
– Hourly BG checks
Hourly IM Technique





Regular insulin in dogs and cats
0.1-0.2U/kg loading dose IM
0.1U/kg IM every 1-2 hours thereafter until BG is appx 250mg/dL
Once BG ~ 250mg/dL, then give:
– Regular insulin q4-6hrs IM - or – Regular insulin q6-8hrs SQ (only if hydration is adequate!)
Maintain BG between 150-300mg/dL
– If BG <250, add dextrose to fluids to maintain BG between 150-300mg/dL
Intermittent IM/SQ Technique



Goals:
– SLOWLY decrease BG by ~50mg/dL/hr
– Maintain BG between 150-300mg/dL
o If BG <250, add dextrose to fluids to maintain BG between 150-300mg/dL
Pro: Less labor-intensive
Con: Decrease in BG can be rapid, risk of hypoglycemia greater
Intermittent IM/SQ Technique



Regular insulin 0.25U/kg IM with subsequent IM injections q4hrs
Once rehydrated, administer regular insulin SQ every 6-8hrs
Insulin dosing (IM and SQ) is adjusted according to hourly BG
Goal #3:

Provide Dextrose as Necessary to Allow Continued Insulin Use Without Hypoglycemia
Goal #4:



Correct Acidosis
FLUIDS
Bicarbonate therapy
– [HCO3] <11mEq/L
– Dose:
o mEq HCO3 = BWkg x 0.2 x (12 – patient [HCO3])
o Administer as CRI over 6 hours. Recheck HCO3
– Complications:
o Exacerbation of hypokalemia
o Tissue anoxia
o Decrease in CSF pH w/ worsening of CSF function
o Alkalosis
Goal #5: Identify Precipitating Factors
ID Precipitating Factors
Don’t forget to manage your concurrent illnesses:






Pancreatitis
Infection
Heart disease
Renal disease
Hepatobiliary disease
Endocrine (HAC, hyperthyroidism, diestrus)
Prognosis
Concurrent illness & client financial constraints often affect outcome more than the metabolic
complications of ketoacidosis (Claus et al, 2010)
Survival of Dogs (hospitalized)


71% (Macintire, 1993)
80% (Hume, et al, 2006)
Survival of Cats






74% (Bruskiewicz et al, 1997)
100% (Marshal et al, 2013)
93% (Claus et al, 2010)
83% (Koenig et al, 2004)
82% (Kley et al, 2002)
69% (Buob et al, 2010)
Take Home Points
 Fluid Therapy is the first line of treatment
 You need insulin to reverse ketotic state
 If hypoglycemic, add dextrose to fluids and continue insulin
 Monitor, Monitor, Monitor
References
th
Canine & Feline Endocrinology, 4 Ed. Feldman & Nelson. Elsevier. 2015.
Claus MA, Silverstein DC, Shofer FS, Mellema MS. Comparison of regular insulin infusion doses in critically ill diabetic cats: 29 cases
(1999-2007). JVECC 2010: 20(5): 509-517.
Cooper RL, Drobatz KJ, Lennon EM, Hess RS. Retrospective evaluation of risk factors and outcome predictors in cats with diabetic
ketoacidosis (1997-2007): 93 cases. JVECC 2015; 25(2): 263-272.
Gallagher BR, Mahony OM, Rozanski EA, Buob S, Freeman LM. A pilot study comparing a protocol using intermittent administration of
glargine and regular insulin to a continuous rate infusion of regular insulin in cats with naturally occurring diabetic ketoacidosis.
JVECC 2015; 25(2): 234-239.
Hume DZ, Drobatz KJ, Hess RS. Outcome of dogs with diabetic ketoacidosis: 127 dogs (1993-2003). JVIM 2006;20:547-555.
References
Marshall RD, Rand JS, Gunew MN, Menrath VH. Intramuscular glargine with or without concurrent subcutaneous administration for
treatment of feline diabetic ketoacidosis. JEVCC 2013; 23(3): 286-290.
Sears KW, Drobatz KJ, Hess RS. Use of lispro insulin for treatment of diabetic ketoacidosis in dogs. JVECC 2012; 22(2): 211-218
th
Textbook of Veterinary Internal Medicine, 7 Ed. Ettinger & Feldman. Saunders Elsevier. 2010.
Walsh ES, Drobatz KJ, Hess RS. Use of intravenous insulin aspart for treatment of naturally occurring diabetic ketoacidosis in dogs.
JVECC 2016; 26(1): 101-107.
END
Cases: Commonly Used Medications of Neurology
David Weinstein, DVM
BluePearl Veterinary Partners, Neurology Service
Recap the management of IVDD
• Activity restriction is the key!!
– 3 weeks
– Medication protocol
– Tapering course of Prednisone and Tramadol
– Unpredictable response
How to Manage A Dog with Epilepsy
• Signalment
– 3 yr old FS Golden Retriever
• History
– 2 month history of grand mal seizures with a total of 4 seizures
• Ictal phase approximately 2 minutes
• Post-ictal phase approximately 30 minutes
– Normal in between seizure episodes
• Neurologic Examination
– Unremarkable
Treatment Options
• First Line Choice of Anti-seizure Medications
– Depending on owners goals
• Phenobarbital
– Check levels after 2 to 3 weeks
• Keppra (Levetiracetam)
– Do not need to check levels
– Second Line Choice of Anti-Seizure Medications
– Add the other medication between Phenobarbital or Keppra
– Treatment Options Continued
• Third Line Choice of Anti-seizure Medications
– Potassium Bromide Level
• Check levels after 3 months
• Fourth Line Choice of Anti-Seizure Medications
– Zonisamide
• Do not usually check levels
• Does oral valium help with maintenance therapy?
– No
How to Manage a Dog with Brain Tumor
• Signalment
– 11 yr old MN German Shepard Dog
• History
– 3 week history of aimlessly pacing around the house
– 1 grand mal seizure
• Ictal phase approximately 3 minutes
• Post-ictal phase approximately 2 hours
– Neurologic Examination
– Mentally inappropriate
– Absent menace OS
– Tendency to circle to the right
– Absent postural reaction in left front and rear limb
Diagnostic & Treatment Options
• Advanced Diagnostics
– MRI
• Ideal testing option
– CT scan
• First Line Choice of Medications
– Keppra
• Quickest Onset
• Lack of sedation
– Prednisone
• Essential for dogs with brain tumors
• Treatment Options Continued
• Second Line Choice of Anti-Seizure Medications
– Phenobarbital
• Other Medication Options
– Increase dose of Prednisone
– Do not usually end up using Zonisamide or Potassium Bromide
• More aggressive treatment options
– Radiation therapy
– Brain Surgery
How to Manage a Dog with Meningoencephalitis of Unknown Etiology
• Signalment
– 3 yr old FS Maltese
• History
– 2 week history of unsteadiness on feet
– Abnormal head position and eye movements
– 2 grand mal seizures
• Ictal phase approximately 1 minute
• Post-ictal phase approximately 3 hours
• Neurologic Examination
– Menace deficit OD
– Right head tilt and vertical nystagmus
– Postural deficits in right front and rear limb
Diagnostic & Treatment Options
• Advanced diagnostics
– MRI/CT scan
– Spinal tap
– First choice of Medications
– Prednisone
• Start with immunosuppressive & slowly taper
• Cornerstone of treatment
– Keppra
• First choice of anti-seizure medication
– Clindamycin
• Use if owner did not pursue advanced diagnostics
Treatment Options
• Additional Immunosuppressive Medications
– Cyclosporine
– Cytosine Arabinoside (Cytosar)
– Procarbazine
– Additional Anti-seizure Medications
– Second Choice
• Phenobarbital
– Do not usually end up adding additional anti-seizure medications
END
Jeff Dennis, DVM, DACVIM
BluePearl Veterinary Partners Internal Medicine Department
Frostbite 2016, Questions and Panel Discussion
Diabetes Mellitus
•
•
How are you monitoring the diabetic cat at home? How aggressive are you with the treatment to induce remission?
How are you monitoring the diabetic dog at home?
Cushing’s Disease
•
•
•
Which test are you using for diagnosis?
When are you treating Cushing’s Dz?
When are you testing a dog with Diabetes mellitus for Cushing’s disease?
Cushing’s Dz and Diabetes Mellitus
•
•
•
How are you treating concurrent DM and Cushing’s?
Pick a corticosteroid: Prednisone, prednisolone, budesonide, dexamethasone, triamcinolone, other
Which do you most commonly use or how do you decide which you are going to use?
END
Managing Anesthetic Complications
Ryan Bragg, DVM, MS DACVECC
BluePearl Veterinary Partners







Plan
o Hypotension
o Hypoxia
o Arrhythmias
o Preparation
o Recognize
o Treatment
Preparation
o Examine your patient
o Review Protocols
o Be prepared
o Educate
Pre Med
o Analgesia!
 Opiods
o Neuroleptic
 Benzodiazapine
 Acepromazine
 Alpha-2 Agonist
o Atropine
o Cerenia
Monitoring
o Monitor patient
o Every 5 minutes – use a timer if one tech
o Blood Pressure
 Doppler – makes me happy
 Oscillemtric
 Arterial line: so much fun
o ECG
o Pulse OX
o ETCO2
o And…
A Kick Butt RVT!
Hypotension –prevention
o Keep your inhaled anesthesia low
 Pre-med
 Multi-modal
o Volume Resuscitate prior to anesthesia
 When is anesthesia in the patient’s best interest?
Hypotension- Recognize
o Begin monitoring BP at induction
o If patient is sick, should know BP Pre induction
 If hypotensive, consider alternative induction agents

 Fentanyl 10mcg/kg
 Use midazolam 0.2-0.5 mg/kg IV
o Action points:
 Systolic below 80
 MAP below 70
Treatment
o Reduce inhalant concentration
o Stop the bleeding
 Recheck PCV intro-op
 Pay attention to the total solids
o Crystalloid bolus x2
 10mls/lb dog
 10mls/kg cat
o Vetstarch Bolus 5-10 mls/kg

Treatment
o Surgical stimulation?
o Vasopressive agents
 Dopamine CRI 5-20mcg/kg/min
 Dobutamine CRI 5-20 mcg/kg/min
o Fentanyl CRI 10-20 mcg/kg/hr
 Will need to ventilate
o Ketamine 10-40 mcg/kg/min
o Shut off inhalant gas can you stop the procedure?
o Suture faster

Hypoxia
o Prevention
 Check machine prior to procedure
 Pre-oxygenate
 Careful anesthetic candidate selection
 Transfusion?

Recognize
o Pulse Ox
 Must have wave form
 Change position
 Gauze is your friend
o Arterial Blood gas
o Anemia?
 They won’t show cyanosis

Treatment
o Check your oxygen tank
o Check your respiratory rate
o Check pop off valve
o Re-intubate
o Auscultate
o Hand Bag
o Inspiratory hold
o Radiographs
 Thoracenteses
o PEEP valves

Arrythmias
o Prevention
 Labwork
 Murmur – Echo
 Analgesia
 Oxygenate

Tachyarrhythmias
o Rate and blood pressure go hand in hand
 Need to know both to evaluate and make decisions
o Think of causes:
 Pain
 Surgical stimuli
 Hypovolemia
 Anticholinergics
 Hypoxia

Try to Address cause
o Volume
o Fentanyl
o Try to be easy with inhalant gas
o Unless wide complex with rates greater than 160, I don’t use antiarrhythmics

Bradyarrythmias
o Causes
 Drugs
 Vagal response
 Potassium
o Treatment
 More atropine 0.02-0.04 mg/kg IV
 Decrease other drugs (i.e. fentanyl)
 No Lidocaine!!!

Other arrhythmias
o Don’t let wide complexes scare you
 Bundle branch blocks not usual
o Lose baseline
 Are they moving or being moved?
o If BP is normal, let it ride
 Doppler
o EMD/PEA: Use your stethoscope!

Recovery
o Highest complication rate
o Just because the tube is out doesn’t mean everything is ok
o Monitor mentation, TPR, BP, PCV/TP
o Respiratory Distress

Tale home points
o Review protocols
o Educate
o If they are sick, keep inhalant low
o Pre-medicate
o Choose your surgical time wisely
o Be Prepared
END
What’s Your Diagnosis?
Theresa Bradley Bays, DVM, CVA, DABVP
(Exotic Companion Mammal)
Belton Animal Clinic and Exotic Care Center

Marlee – Monday History
o 3 Year Old F/S Pot Bellied Pig, 78 lbs
o Bit by Dog 4 days ago
o Placed on Ampicillin 3 days ago
o Ate plastic spoon 3 days ago
o Feet Dragged on street this AM
o Spit up Blood this AM
o Chewing Bubble Gum

Clinical Signs
o Lethargy
o Hot to Touch
o Not Eating well




Clinic Reality
6PM Ate today Limited Staff
Nite Nite, Clavamox and no food overnight
Tuesday
o Brighter
o Cool to touch
o Spoon, Blood

WORK UP
o Anesthesia – Injectable or iso by intubation – small amount of blood on the
thermometer
o Radiographs – Abdo/Chest-serpentine ileus in small itestines – fluid/gas, no spoon
evident
o Venipuncture – Cranial Vena Cava/ Lateral Auricular – normal CBC and chemistries
Recovery
o 11am – BAR and standing
o 2PM BAR, alert and standing
o 3PM Dyspnic, reluctant to stand
o 5PM Severe dyspnea, not eating WTH!
Hold it –
o Marlee – Companion Pig, Changed the laws in KC, News Programs and TV Shows



Owner feels that neck is swollen, what are your rule outs?
o Laryngeal Swelling
o Rodenticide Exposure
o New apartment within 48 hours
o Slum Lord/Dirty
o Storage Unit










6PM Tuesday
o Dex SP Clavamox
o Vitamin K Injection
o Prayers – NO Sleep
Wednesday
o Alive, not eating, less dyspnic, winded with exercise
Wednesday (My plan)
o Minimal handling
o Quiet
o Vit K
o Walks to stimulate
o Benign neglect (prayers)
Wednesday (owners plan)
o Walks to stimulate D/U (hyperfocused)
o Take outside in harness
o Loose from Harness
o Owner tackles pig
o Hurt leg
o 1 & ½ hours dyspnea – worse than before
Thursday
o Improved respiration
o Unable to use leg
o Unwilling to stress for xray
o Eating if syringe/spoon fed
o Limited owner contact
o Benign neglect
o TBB off
o Owner feeds 4 mint oreos
Saturday and Sunday
o TBB off but feeding 4x a day
o No owner contact!
o Prayers/vit K continue
Monday
o Portable xray – no fx!
o No owner contact!
o Prayers/ Vit k continue
Thursday
o Breathing better but still winded with exercise, continue vit K
o Owner happy to get pig home
o Owner happy to get pig home
o Strictly limit activity
o TBBs husband happy pig is finally gone
o Everyone can sleep now
Great Medicine
o Suggest a full work up every time
o If you don’t look, you won’t find
o If you don’t ask, you won’t know!
Get the whole picture
o Xray of severe dental disease of rabbit

Great medicine – whole patient every time – ask and look!

Hedgehog prolapse – don’t be afraid to try!
o Rule outs –
 Gastrointestinal
 Reproductive
 Urinary
END
Leptospirosis:
A Review and What’s New
Stephanie A. Pierce DVM
Diplomate American College of Veterinary Internal Medicine
BluePearl Veterinary Partners
•
•
•
•
Leptospira interrogans sensu lato
Reported in over 150 mammalian species
Over 250 pathogenic serovars
Maintenance hosts
– Dogs (Canicola)
– Rats (Icterohaemorrhagiae)
– Raccoons, skunks, voles, opossums (Grippotyphosa)
– Cattle, pigs (Pomona)
– Pigs (Bratislava)
– Cattle (Hardjo)
– Mice (Ballum)
Canine Pathogenic Serovars
•
Leptospira interrogans
– Icterohaemorrhagiae
– Canicola
– Pomona
– Grippotyphosa
– Bratislava
– Autumnalis
– Ballum
– Bataviae
– Hardjo
– Australis
What’s New???
•
•
Serovars causing infection in dogs
– Used to be Icterohaemorrhagiae and Canicola
– Now Pomona, Grippotyphosa, Autumnalis?, Bratislava?, Hardjo?, Ballum? more likely
Risk Factors
– Contact with slow-moving/stagnant water
– Contact with wild animals
– Rain or flooding
– Warm climate
– Male
– Young
– Large breed
– Outdoor
– Hunting/sporting/herding dogs
What’s New???
•
Lee, H.S., Guptill, L., Johson, A.J. & Moore, G.E. (2014). Signalment Changes in Canine
Leptospirosis between 1970 and 2009. J Vet Intern Med, 28, 294-299.
– In the 2000s, dogs < 15# most likely to be diagnosed with leptospirosis
– Terrier group
– Yorkshire Terriers
– Less likely in dogs < 1 year
What’s New???
•
Lee, H.S. et. al. (2014). Regional and Temporal Variations of Leptospira Seropositivity in Dogs
in the United States, 2000-2010. J Vet Intern Med, 28, 779-788.
– Highest positive rates in October - December in Midwest
– Lowest positive rates in February
– Highest positive rates December and January in South Central
– Lowest positive rates in February
•
•
Transmission
Direct transmission
– Contact of mucous membranes or skin wound/softened skin with urine
– Bite wounds
– Ingestion of infected tissues
– Venereal
– Placental
•
Indirect transmission
– Contact with/ingestion of contaminated soil, water, food, bedding
– Viable in soil weeks to months
•
Incubation Period/Shedding
– Average incubation period 7-10 days (shorter or up to 30 days)
– Large inocula = faster incubation period
– Small incolua = longer incubation period
•
Urinary shedding usually starts 7-10 days after infection
– Shedding occurs for days to months
•
•
•
Pathogenesis
Clinical Signs
Subclinical
– Fever
– Polyuria/polydipsia
– Muscle tenderness
– Reluctance to move
– Dehydration
– Vomiting
– Diarrhea
– Anorexia
– Lethargy
– Abdominal pain
•
Think Leptospirosis If...
– Renal failure
– Hepatic failure
– Respiratory disease
– Acute fever
– Uveitis
– Abortion
– Meningitis?
– Renal failure + Hepatic failure = ALARM! ALARM! ALARM!
What’s New???
– Polyuria/polydipsia
– Isosthenuria/hyposthenuria
– No azotemia
Test for Leptospirosis!!!
•
Clinicopathologic Abnormalities
CBC
Leukocytosis
Neutrophilia +/- left shift
Lymphopenia
Mild non-regenerative anemia
• Severe anemia
– Thrombocytopenia
– Clinicopathologic Abnormalities
–
–
–
–
Urinalysis
Isothenuria
Hyposthenuria
Proteinuria
Glucosuria
Hematuria
Bilirubinuria
Pyuria
– Cylindruria
–
–
–
–
–
–
–
What’s New???
– Azotemia
– Thrombocytopenia
– Glucosuria
THINK LEPTOSPIROSIS!!!
–
Imaging Abnormalities
Chest radiographs
– Mild interstitial pattern, focal to diffuse
– Severe interstitial pattern, focal to diffuse
– Alveolar pattern
– Pleural effusion
What’s New???
Leptospiral Pulmonary Hemorrhage Syndrome
Up to 70% of dogs with Leptospirosis have pulmonary changes
Severe respiratory distress
Severe anemia
Much worse prognosis
– Treatment oxygen
immunosuppressants
–
–
–
–
–
Abdominal ultrasound
Renomegaly
Perirenal fluid accumulation
Increased cortical echogenicity
Pyelectasia
Medullary band of increased echogenicity
Testing: Microscopic Agglutination Test (serology)
Test of choice
Can be negative in 1st week of illness
Acute and convalescent titers needed
Antibiotics blunt response
Cross-reactivity occurs
– Vaccination interferes
–
–
–
–
–
–
–
–
–
–
–
What’s New???
–
Seroconversion only takes 3-5 days
Convalescent titer at 7-14 days
Testing:
Polymerase Chain Reaction
Detects Leptospira DNA
Blood
Urine
Antibiotics will cause false negative
Low organism numbers can cause false negative
Not affected by vaccination
– Can detect chronic carrier state
–
–
–
–
–
–
What’s New???
–
Titers + PCR is best
PCR on blood and urine is best
•
Treatment: Supportive Care
– Jugular catheter
– Urinary catheter
– IV fluids with monitoring “ins and outs”
– Antacids/gastric protectants
– Antiemetics
– Antihypertensives
– Phosphate binders
– Nutritional support
– Blood/plasma
– Vetstarch
Treatment: Antimicrobials
– Doxycycline 5 mg/kg IV or PO BID 14 days
– If vomiting/unable to tolerate oral medications
• Ampicillin 20 mg/kg IV q 6hr
– Follow with doxycycline as above
Treatment: Oliguria/Anuria
Rehydrate!!!!
Monitor “ins and outs”
Furosemide
Mannitol
– Dopamine
–
–
–
–
What’s New???
•
Matthew, K.A. and Monteith, G. (2007). Evaluation of Adding Diltiazem Therapy to Standard
Treatment of Acute Renal Failure Caused by Leptospirosis: 18 dogs (1998-2001). J
Vet Emergency and Critical Care, 17(2), 149-158.
– Diltiazem therapy group
• Rate of reduction of creatinine 1.76 times faster than non-diltiazem group
• May be more likely to have recovery of renal function than non-diltiazem group
•
Treatment: Dialysis/CRRT
Increased survival
Shorter hospitalization
Recommended if
– Anuric/oliguric
– Volume overload
– Hyperkalemia
– BUN > 80 mg/dL
– Uremia not responding to medical management
•
•
•
•
Monitoring in the Hospital
– Chemistry at least every 24 hours
– PCV every 24 hours
– CBC every 48 hours
– Urine output
– Weight
– Respiratory rate
– Lung sounds
– Blood pressure
– Central venous pressure
– Zoonotic Potential
– Transmitted by urine
– Transmitted by other body fluids???
Leptospires in blood and urine before treatment and at least 2-3 days after treatment
•
– If not treated, shed in urine for months
Minimizing Risk
– Killed by UV light, dessication, freezing, routine disinfectants
– Label cages
– Wear gloves, gown, protective eye wear
– Wash hands
– Urinary catheter
– Bathing
– Avoid moving around hospital
– Avoid access to rodents, farm animals, wild animals
What’s New???
ACVIM recommends treatment of other dogs in household
– Vaccination
– Serovars
• Icterohaemorrhagiae, Canicola, Grippotyphosa, Pomona
Vaccination with 2 serovar vaccine not recommended
Prevents disease
Prevents shedding
Protects for at least 12 months
Does not protect against other serogroups
– Partial immunity for other serogroups
–
–
–
–
What’s New???
– No more likely to react to Leptospirosis vaccine than others
– Strongly consider vaccination
– Must receive Leptospirosis vaccination yearly
– Vaccinate dogs that have recovered from leptospirosis
Leptospirosis in Cats???
– Seropositivity possible
– Clinical disease rare
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
References
Arbour, J., Blais, M., Carloto, L., and Sylvestre, D. (2012). Clinical Leptospirosis in Three Cats (2001-2009). J Am An Hos
Assoc, 48 (4), 256-260.
Gautam, R. et. al. (2010). Detection of Antibodies Against Leptospira Serovars via Microscopic Agglutination Tests in Dogs in
the United States, 2000-2007. J Am Vet Med, 237 (3), 293-298.
Greene, C.E. (2012). Infectious Diseases of the Dog and Cat, Fourth Edition.
Kohn, B. et. al. (2010). Pulmonary Abnormalities in Dogs with Leptospirosis. J Vet Intern Med, 24, 1277-1282.
Lee, H.S. et. al. (2014). Regional and Temporal Variations of Leptospira Seropositivity in Dogs in the United States, 20002010. J Vet Intern Med, 28, 779-788.
Lee, H.S., Guptill, L., Johson, A.J. & Moore, G.E. (2014). Signalment Changes in Canine Leptospirosis between 1970 and 2009.
J Vet Intern Med, 28, 294-299.
Martin, L.E.R. et. al. (2014). Vaccine-Associated Leptospira Antibodies in Client-Owned Dogs Leptospira Vaccine Responses in
Dogs Martin et al. J Vet Intern Med, 28, 789-792.
Matthew, K.A. and Monteith, G. (2007). Evaluation of Adding Diltiazem Therapy to Standard Treatment of Acute Renal
Failure Caused by Leptospirosis: 18 dogs (1998-2001). J Vet Emergency and Critical Care, 17(2), 149-158.
Midence, J.N., Leutenegger, C.M., Chandler, A.M., and Goldstein, R.E. (2012). Efects of Recent Leptospira Vaccination on
Whole Blood Real-Time PCR Testing in Healthy Client-Owned Dogs. J Vet Intern Med, 26, 149-152.
References
Miller, M.D., Annis, K.M., Lappin M.R., and Lunn, K.F. (2011). Variability in Results of the Microscopic Agglutination Test in
Dogs with Clinical Leptospirosis and Dogs Vaccinated against Leptospirosis. J Vet Intern Med, 25, 426-432.
Rodriguez, J. et. al. (2014). Serologic and Urinary PCR Survey of Leptospirosis in Healthy Cats and in Cats with Kidney
Disease. J Vet Intern Med, 28, 284-293.
Sykes, J.E. et. al. (2011). 2010 ACVIM Small Animal Consensus Statement on Leptospirosis: Diagnosis, Epidemiology,
Treatment, and Prevention. J Vet Intern Med, 25, 1-13.
Tangeman, L.E. and Littman, M.P. (2013). Clinicopathologic and Atypical Features of Naturally Occurring Leptospirosis in
Dogs: 51 Cases (2000-2010). J Am Vet Med, 243 (9), 1316-1322.
Wellborn, L.V. et. al. (2011). 2011 AAHA Canine Vaccination Guidelines. J Am An Hos Assoc, 47 (5), 1-42.
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