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NAVC Conference 2017

June 2017

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Potential Long-Acting Local Anesthetic

Local anesthetics can effectively prevent the transduction and transmission of pain and may be the only way to completely block perioperative pain. Methods of providing local anesthesia include wound or tissue infiltration, regional nerve blocks, neuraxial analgesia (eg, intrathecal, epidural), and placement of soaker catheters. The short duration of action of available formulations of local anesthetics is the significant limiting factor. Fenestrated wound catheters with intermittent local anesthetic administration can extend the duration of analgesia of local anesthetics but are only useful in hospitalized patients. 

The FDA recently approved a bupivacaine liposomal injectable suspension that is estimated to be efficacious for 72 hours post- intraoperative tissue infiltration following cruciate surgery in dogs. Liposomes are microscopic structures composed of lipid bilayers, which gradually break down to release their contents over 96 hours. A moving-needle technique is used to inject the solution into all tissue layers in the surgical field. Bupivacaine is gradually released into local tissues and then into systemic circulation. 

The author concluded that this product may be an effective and beneficial tool for post-operative pain management.—Lascelles BDX 

The research referenced includes a study funded by Aratana Therapeutics.

Adding Exotics to Your Practice

Exotic animals (eg, birds, small mammals, reptiles, amphibians) now comprise approximately 20% of the companion animal market. Adding exotic animal care to a practice can present challenges for both hospital setup and marketing. 

The challenge begins with appropriate scheduling. Exotic patients tend to require fewer wellness appointments and more illness visits but a high percentage of emergency visits. Most sick exotic patients should be seen the same day, and schedules must accommodate this. Furthermore, exotic appointments tend to take longer, with significant time spent on client questions and husbandry education. 

Hospital design should address the unique needs of exotic pets. Examination rooms should be escape proof, and treatment areas should block views of predator species. Special equipment needed may include pediatric stethoscopes, ball-tipped feeding needles, small-gauge catheters and endotracheal tubes, gram scales, perches, heating elements, and syringe pumps. Many medications used in exotic species are common to small animal pharmacies, but these medications often must be compounded into oral suspensions. 

Retaining a client base is another challenge. With the shorter lifespans and higher death rates of exotic animal patients, a constant stream of new clientele is needed. 

The authors stressed the importance of marketing to the target audience through sponsorship and exhibitions at local exotics events and clubs. The most important source of clients is other veterinarians; therefore, cultivating relationships with local practitioners is essential.—Johnson DH, Wilkinson SL

Engage Clients in At-Home Care of Pets with Heart Disease

For pets with cardiac disease, veterinarians should partner with their clients and use at-home monitoring tools to optimize care. 

Devices and smartphone apps can assist in diagnosing and monitoring cardiac disease. Video can be obtained of breathing, cough, and collapse—some of which can be difficult to describe. There are apps that can aid in logging heart and respiratory rates. Some apps are linked directly to a pet’s collar and transmit the data to clinicians, who can monitor trends. This data could mean quicker reaction times on the clinician’s part if treatment needs to be altered or if a recheck is deemed necessary. 

Routine examinations should be scheduled to re-evaluate the patient and the treatment regime and to continually educate the owner about the pet’s condition and how to assess it. Depending on stage, restricted-sodium diets may be recommended; omega-3 fatty acid supplements may also be beneficial. Activity usually needs to be monitored and animals allowed to self-regulate; however, strict restriction may be necessary to prevent clinical signs in some advanced cases of cardiac failure.—Saunders AB

Increased Liver Enzymes in Dogs

Liver enzyme elevation is commonly seen on blood work. Interpreting these results can be challenging, as increases in these values can be caused by primary hepatobiliary disease or can be secondary to extrahepatic disease. The liver is also susceptible to injury from a variety of drugs, toxins, other diseases, and ischemia. In addition, elevations can occur because of benign processes. 

Clinician's Brief

In general, alanine aminotransferase (ALT) elevations tend to be relatively liver specific as compared with alkaline phosphatase (ALP) elevations, which can have hepatic, bone, and steroid-induced isoenzymes. Increases in aspartate aminotransferase (AST) generally parallel those in ALT; however, muscle disease can also increase serum AST activity. Elevations in both ALP, when hepatic in origin, and gamma glutamyltransferase tend to be relatively sensitive markers for cholestasis. 

Signalment and clinical signs can help guide a differential list. Puppies are more likely than older dogs to have congenital portosystemic shunts and certain infectious causes of liver disease; neoplasia and chronic hepatitis are more common in older pets. Further diagnostic testing (eg, serum ammonia levels, pre- and postprandial bile acid testing, abdominal ultrasonography) are often recommended when hepatobiliary disease is suspected or when liver enzymes are severely or persistently increased. 

Liver biopsy is often required to make a definitive diagnosis of primary hepatic diseases.—Lidbury J

Tricks & Tips for Food Trials

An elimination diet trial is an important aspect of any diagnostic investigation for the nonseasonally pruritic patient. Because many nonprescription diets contain “contamination” ingredients, prescription or home-cooked diets are typically recommended. Taking a comprehensive dietary history is essential to determine what might work best for the pet and the owner. 

Clinician's Brief

It is ideal to feed a protein from a source the pet has not been exposed to in the past and useful to determine the importance of treats and canned food in the pet’s diet so that a diet that includes those options can be found, if needed. Stopping all flavored medications and supplements is essential, as even small amounts of allergen can trigger a reaction. Controlling secondary skin infections and pruritus can help ensure the food trial is as effective as possible. Typically, food trials should last for 8 to 12 weeks; however, if there is no improvement by 8 weeks, further treatment for atopy may be warranted. 

If improvement is noted at the end of the food trial period, the owner may elect to begin adding food or treats one at a time to know what can and cannot be fed. Clear communication with the client regarding what needs to be accomplished in the food trial is essential. Clients know best if their home situation will facilitate the trial. Homes with geriatric humans and multiple cats tend to be highly susceptible to food trial failures.—DeVore TA

Communication Tools to Reduce Medical Errors

Highly effective medical team members anticipate one another’s needs, adjust to changing situations, and have a shared understanding of the care plan. It is estimated that approximately 80% of serious human medical errors occur due to miscommunication. 

Key components of the TeamSTEPPS approach, which was developed to optimize teamwork and prevent errors, are leadership, communication, situation monitoring, and mutual support among healthcare team members. Effective leaders foster a collaborative environment. Communication is essential. 

A brief is a strategy session conducted at the outset of every case. The care plan is introduced and tasks are delegated. A huddle is an ad hoc meeting that occurs when problems arise and a change in the treatment plan is needed. A debrief is conducted at the end of a case and provides opportunities for improvement. Situation monitoring involves constant vigilance by all team members. Shared information should be complete, clear, brief, and timely. The client should be included in communication about the case. Call-outs convey important or critical information in an emergency. A check-back, in which the listener acknowledges a message and repeats back vital information, is an efficient way to minimize errors. 

When patient care is transferred from one team to another, such as at the end of a shift or service transfer, a proper handoff should occur. Components of the handoff include illness severity information, patient summary, action list, and synthesis by receiver. Mutual support and assertive advocacy are critical.—Fletcher DJ

For global readers, a calculator to convert laboratory values, dosages, and other measurements to SI units can be found here.

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