VETgirl Oct 2023 Beat e-Magazine

Discover a treasure trove of information for veterinary professionals in the October edition of VETgirl BEAT eMagazine. Uncover valuable insights from webinars, articles, and recent developments across a range of topics, including Feline Injection Site Sarcoma and Esophageal Obstruction in the Horse. Stay ahead in the world of veterinary medicine and get a sneak peek of this FREE publication now.

/// QUARTERLY BEAT / OCTOBER 2023 BEAT

ISSUE 18 | OCTOBER 2023

EMAGAZINE

Tech Tip New Dashboard FELINE INJECTION SITE SARCOMA (FISS) FROM A DIFFERENT PERSPECTIVE

mind massage recap 26

FOCUSING IN ON

GI MICROBIOME HEALTH

Esophageal Obstruction in the Horse WEBINAR HIGHLIGHTS

5 WAYS TO BE A LEADER

YOUR VETERINARY TEAM WANTS TO FOLLOW

Heatstroke in Dogs 14

VETGIRLONTHERUN.COM

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

Tech Tip NEW DASHBOARD COMING YOUR WAY SOON

Esophageal Obstruction in the Horse

FELINE INJECTION SITE SARCOMA (FISS) FROM A DIFFERENT PERSPECTIVE

Every vaccination counts

Every extra year of FeLV protection matters

FOCUSING IN ON GI MICROBIOME HEALTH

MIND MASSAGE WEBINAR KEY TAKEAWAYS

Nobivac ® Feline 2-FeLV—the ONLY feline leukemia vaccine shown to be effective against viremia for 2 years after vaccination 1

With a 2-year duration of immunity, 1 and a 99% reaction-free safety profile, 2 Nobivac ® Feline 2-FeLV delivers unrivaled confidence and peace of mind.

5 Ways to Be a Leader Your Veterinary Team Wants to Follow

Heatstroke in Dogs

Put confidence into practice with Nobivac ® Feline 2-FeLV.

To learn more, contact your Merck Animal Health sales representative or your distributor representative. Customer Service: 1-800-521-5767 Technical Services: 1-800-224-5318 (Monday–Friday, 9:00AM–6:00PM EST) (Monday–Friday, 9:00AM–7:00PM EST)

Protection unites us.

References: 1. Jirjis FF, Davis T, Lane J, et al. Protection against feline leukemia virus challenge for at least 2 years after vaccination with an inactivated feline leukemia virus vaccine. Vet Ther . 2010;11:E1–E6. 2. Data on file. Merck Animal Health.

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

FEATURED STORY *Please note the opinions of this article are the expressed opinion of the author and not directly endorsed by VETgirl.

tissue trauma. When looking at the data, the national medical association cites that the rate of severe negative reaction is well below one per ten thousand injections. Even at one per ten thousand, this would equate to thirty-three thousand deaths versus six to ten million deaths. Vaccination remains a numbers game. This explains why the CDC recommends “annual influenza (flu) vaccination for everyone 6 months and older in the United States” but does not recommend anthrax, yellow fever, rabies, typhoid fever, or Haemophilus influenzae type B for civilians. In fact, only at-risk military personnel regularly receive these additional vaccines. Why? The risk outweighs the reward. Doctors provide vaccines to healthy individuals within at-risk populations. This, in turn, protects those individuals, and by extension, commonly known as herd health, to others. Here lies the dire situation for cats with their pandemic, technically a panzootic, known as the feline leukemia virus (FeLV). Should we worry about feline injection site sarcoma (FISS)? Yes, as with every injection we provide to a feline patient.

The balance of risk and reward is a dangerous task. What do the experts say? The American Animal Hospital Association (AAHA) recommends the FeLV vaccine as core for all kittens. Young felines should be boostered at one year and, thereafter, vaccination is based on lifestyle. Any cat who may encounter other cats of unknown FeLV status should be annually vaccinated… Translation: Cats who go outdoors or mingle with cats who go outside remain at risk for FeLV, regardless of age. The FISS rates mentioned above arise from a 2018 American Veterinary Medical Association (AVMA) publication. Since the inception of medicine, doctors have had to balance all therapies and prophylactics with judicious use. Overuse of any aspect of medicine jeopardizes the lives we seek to protect. Similarly, underuse of them does the same. As veterinarians, we face difficult choices and balance risk daily. We make our best decisions in an imperfect world. Tomorrow, everything may change, but today, we must stay strong and make the best choice with what we know and have.

Sponsored by

*Please note the opinions of this article are the expressed opinion of the author and not directly endorsed by VETgirl.

Pathogens

FOCUSING IN ON GI MICROBIOME HEALTH

In this VETgirl feature article sponsored* by Purina, Dr. Raj Naik, DACVIM (Nutrition) discusses the importance of the GI microbiome. We’ve all heard about it. But do we really know the importance of it on overall global health? Here, this article is a must read for tips on managing your veterinary patients!

Microbiota

• SYNBIOTICS. A probiotic/prebiotic combination, called a synbiotic, leverages the individual benefits of each to provide complementary and/or synergistic effects. A synbiotic supports a healthy intestinal

DYSBIOSIS: WHEN MICROBIAL BALANCE GETS OFF-KILTER Because the microbiota in the gut help support overall health, achieving and preserving a balance of beneficial to potentially pathogenic bacteria is particularly important. Dysbiosis is an imbalance in the makeup of gut microbiota and can be triggered by multiple factors, including antibiotic use, stress, age, illness, diet change, and weaning. It is also associated with a variety of health conditions, ranging from irritable bowel disease (IBD), obesity, and cardiovascular disease to immune-mediated conditions and neurodevelopmental conditions. 1

When considering the GI microbiome in dogs and cats, practitioners often focus on GI health and the importance of achieving a microbial balance that is favorable to the management of patients with clinical signs such as diarrhea. As knowledge about the GI microbiome’s role expands, veterinary researchers are defining what the GI microbiome does in a more macro way. Why? Studies have shown the GI microbiome may exert significant effects on multiple body systems. Besides its digestive function, the gut works as a kind of sensory organ for the immune system. Metabolites generated by digestion travel to other parts of the body through the bloodstream, with the potential to activate or suppress inflammatory processes.

microbiome by providing a prebiotic to increase GI microbial diversity and a probiotic to promote GI microbial balance.

PRACTICING ANTIBIOTIC STEWARDSHIP It is not uncommon for owners of dogs with acute diarrhea to request antibiotics in hopes of rapid improvement. Clinicians should explain that acute diarrhea is often caused by stress or dietary indiscretion and will likely resolve on its own in about a week. Practitioners should also emphasize that a course of antibiotics may make little difference in the duration of clinical signs, 6 and ultimately do more harm than good by inducing a state of dysbiosis. Plus, diarrhea is likely to recur in the

Image courtesy of the Purina Institute.

If no improvement is noted, a diet trial using a hydrolyzed, novel protein or amino acid-based diet may be indicated. Dogs with large bowel diarrhea and some with mixed bowel diarrhea may be more responsive to a high fiber diet (see below). If improvement in clinical signs is not achieved with diet alone, an immunosuppressive medication or an antibiotic can be considered.

While disruptions to the homeostasis of the microbiome can contribute to disease, dysbiosis on its own does not always cause it. For example,

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

WHAT WILL THE FUTURE HOLD? While the veterinary profession has learned a great deal about the importance of microbiome health, we have much more to discover, from understanding the effects of dysbiosis on immune function, cardiovascular health and obesity to further exploring the relationship between the GI microbiome and brain health. There are many insights yet to be uncovered in this burgeoning area of veterinary medicine.

patient once antibiotic treatment has stopped. This is not to say that antibiotics do not have a role in treating infections. But overuse can have a negative effect—especially in young patients, as their GI microbiomes are still developing. Instead of dispensing a broad-spectrum antibiotic, talk with clients about feeding a therapeutic diet that is tailored to their pet’s clinical signs. Recommending a highly digestible diet for patients with small bowel diarrhea or a high fiber diet for patients with large bowel diarrhea is a good starting place. In addition, a safe, research-backed probiotic that is indicated for patients with acute diarrhea can be a good adjunct therapy for most patients with these clinical signs.

CALM BEHAVIOR

✔ The GI microbiome is a complex microbial ecosystem comprising trillions of microorganisms that Gut Check ✔

References

play a significant role in the overall health of both humans and pets.

Barko PC, McMichael MA, Swanson KA, et al. The Gastrointestinal Microbiome: A Review. J Vet Intern Med. 2018. Jan;32(1):9-25. doi: 10.1111/jvim.14875. Jergens AE, Heilmann RM. Canine chronic enteropathy—Current state-of-the-art and emerging concepts. Front. Vet. Sci. x 2022 Sep 21;9:923013. doi: 10.3389/fvets.2022.923013. Cave N. Nutritional management of gastrointestinal diseases. In A. J. Fascetti & S. J. Delaney (Eds.), Applied Veterinary Clinical Nutrition . Wiley-Blackwell; 2012, 175-219. Food and Agriculture Organization and World Health Organization Expert Consultation. Evaluation of health and nutritional properties of powder milk and live lactic acid bacteria. Córdoba, Argentina: Food and Agriculture Organization of the United Nations and World Health Organization; 2001. Fenimore A, Martin L, Lappin MR. Evaluation of Metronidazole With and Without Enterococcus Faecium SF68 in Shelter Dogs With Diarrhea. Top Companion Anim Med. 2017 Sep;32(3):100-103. doi: 10.1053/j. tcam.2017.11.001. Epub 2017 Nov 28. PMID: 29291770. Shmalberg J, Montalbano C, Morelli G, et al. A Randomized Double Blinded Placebo- Controlled Clinical Trial of a Probiotic or Metronidazole for Acute Canine Diarrhea. Front Vet Sci. 2019 Jun 4;6:163. https://doi. org/10.3389/fvets.2019.00163. Richards P, Thornberry NA, Pinto S (2021). The gut-brain axis: Identification of new therapeutic approaches for Type 2 diabetes, obesity, and related disorders. Molecular Metabolism, 46, 101175. doi:10.1016/j. molmet.2021.101175.

✔ The gut contains 70 percent of the body’s immune cells, which protect against potentially harmful organisms (pathogens) and foreign substances (antigens). 11 ✔ The GI microbiome influences energy balance, metabolism, immune response, vitamin and mineral synthesis, endocrine signaling, gut function and neurobehavioral development through the gut-brain axis. 1 ✔ Dysbiosis, a disruption in microbial balance, can be triggered by many factors, including antibiotic use, illness and diet change.

TARGETED MICROBIOME SUPPORT FOR GI HEALTH AND BEYOND A healthy microbiome can impact a pet's overall health. That's why we've spent decades exploring microbiome science. From diets with specic prebiotic bers that support digestive health to supplements that support calm behavior, immune health, or dogs with diarrhea, we're dedicated to helping you improve your patients' lives in new ways.

IMMUNE HEALTH

GUT HEALTH

Image courtesy of the Purina Institute.

HEALTH BEYOND THE GUT Using nutrition to help foster GI health can have positive effects for other body systems as well. In recent years, more has been discovered about the “gut-brain axis.” This refers to how the gut microbiome affects brain function and behavior, and how the brain, in turn, influences the microbiome. 7 Research indicates that modifying the GI microbiome through nutritional intervention can potentially influence behavior. 8 For example, the probiotic strain Bifidobacterium longum BL999 has been shown to help dogs and cats maintain calm behavior 9,10 and can be used in conjunction with other tools, including behavior modification and medication.

MICROBIOME SUPPORT

✔ Soluble fibers are selectively

fermented by beneficial bacteria, which leads to the production of short-chain fatty acids (SCFAs) that nourish cells of colonocytes and impede pathogen growth.

Raj Naik, DVM, DACVIM (Nutrition) Board Certified Veterinary Nutritionist® Veterinary Communications Manager, Nestlé Purina PetCare

Purina trademarks are owned by Société des Produits Nestlé S.A. LEARN MORE AT PURINAPROPLANVETS.COM/MICROBIOME

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

STEP 3: LAVAGE (Note: this step is controversial and in many cases not necessary) • Create water column behind obstruction to soften and/or help advance into stomach • Requires mindful use of pump and adequate water (and water only!) while head is held down for safety • Pump until sufficient water goes in that it begins to flow back out nostrils

Diagnosis is generally relatively straightforward and involves consistent clinical signs and identification of an obstruction when attempting passage of a nasogastric tube. In more complicated cases, additional diagnostic modalities may be considered, including but not limited to endoscopy, ultrasound, radiographs +/- contrast, and ruling out other reasons for dysphagia (i.e., neurologic exam). Relieving the Obstruction STEP 1: PREPARATION • Key to success is appropriate preparation – of horse AND owner • Appropriate preparation of the horse involves adequate sedation and esophageal relaxation - Sedation key for patient tolerance of procedures (and thus client satisfaction), relaxation of the esophagus to facilitate bolus passage, and patient safety • Sedation with alpha-2 agonist of appropriate duration of action +/- opioid is preferred • No attempts to pass tube or relieve choke should be made prior to overt signs the horse is heavily sedated (i.e., nose close to ground, minimal response to stimuli, etc.)

IN THE HORSE Esophageal Obstruction

STEP 4: ATTEMPT TO PASS TUBE DURING LAVAGE • While pumping water in, gently use end of tube to advance obstruction • Continue until can advance into stomach (or STOP if no progress)

Clinical Assistant Professor, Large Animal Surgery and Emergency & Critical Care University of Georgia, College of Veterinary Medicine Naomi E. Crabtree DVM, MS, DACVS-LA, DACVECC-LA

STEP 5: REPASS THE TUBE • Once you think the obstruction has been relieved, repass to be sure • Sometimes, may have managed to push past it and then re-encounter obstruction on second pass STEP 6: CONSIDER POST-RESOLUTION CARE • Once obstruction is relieved, decide what (if anything) the horse needs; this may include: - Fluids - Antibiotics - Analgesics - Feeding plan (TIP: wait to feed and wait to house on bedding until back on feed) - Oral exam - Endoscopy? - Referral? When to Refer • Cases for which referral should be considered include: - Failure to resolve the obstruction - Concerns regarding the state of the esophagus - Concerns regarding the overall systemic picture of the patient • At the referral hospital, advanced management options include: - Repeated rounds of sedation/esophageal relaxation and lavage

LARGE ANIMAL WEBINAR

In this 1-hour, VETgirl large animal webinar, Naomi Crabtree, MS, DVM, DACVS-LA, DACVECC-LA reviews the clinical presentation, diagnosis, and treatment of equine esophageal obstruction. Tune in for tips and tricks for a successful outcome, a review of appropriate post-resolution care, and referral options for complicated cases!

WATCH FULL WEBINAR

•

In addition, the use of other chemical means of esophageal relaxation can be of great help - May include things like: buscopan for smooth muscle relaxation; oxytocin for striated muscle relaxation (mechanism not well understood); or intra-esophageal lidocaine

ESOPHAGEAL OBSTRUCTION Esophageal obstruction can be divided into primary or secondary obstructions. Primary obstructions are what we typically think of when we think about choke: some kind of intraluminal obstruction – most commonly with feed. Intraluminal obstruction with things other than feed can occur, but this is uncommon. Common risk factors for primary obstruction include: • Poor dentition (reported in >90% of cases in one study) • Bolting of feed (especially dry cubed or pelleted feed, inadequately soaked beet pulp, carrots, or apples) • Recent sedation or anesthesia • Dehydration or debilitation • Refeeding too soon following resolution of choke (or NOT feeding but allowing access to bedding)

• Anatomical abnormalities, which may be: - Intramural (e.g., tumors, strictures, diverticula, cysts, etc.) - Extramural (e.g., neoplasia, vascular ring anomalies, abscess, etc.) • Functional abnormalities, such as: - Megaesophagus - Neurologic dysfunction CLINICAL PRESENTATION & DIAGNOSIS Clinical signs of choke include: • Stretching • Retching • Coughing • Feed or foamy nasal discharge • Hypersalivation • Palpable bolus in the cervical region (reported in as many as 88% of cases in one study) • Signs attributable to sequelae (e.g., dull demeanor, fever, respiratory signs) • Panic

•

In addition to adequate preparation of the patient, preparing the owner is just as crucial for success - Before attending the emergency, prepare owner for how things are likely to go - Good time to explain you may not relieve the

obstruction right away, and that it may take additional rounds of sedation, muscle relaxation, and patience

STEP 2: PASS NASOGASTRIC TUBE • Have handler hold head as close to ground as possible (applying poll pressure can help) • Choose relatively firm, inflexible tube (can put it in cold water or fridge/freezer ahead of time if needed!) • Pass until encounter obstruction and stop • Gently use tube to palpate the bolus and get a feel for how “stuck” it is

Continued on Page 12

Webinar Highlights

Secondary obstruction is obstruction due to some other disease process. This can include:

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

Submitted by Tara Sager

Alaska Salmon Bake with Pecan Crunch Coating

INGREDIENTS •

6 salmon filets, about 4 oz. each

•

3 tablespoons Dijon mustard

•

3 tablespoons butter, melted

•

5 teaspoons honey

•

½ cup fresh breadcrumbs

•

½ cup finely chopped pecans

•

3 teaspoons chopped fresh parsley

•

salt and pepper, to taste

DOWNLOAD VETGIRL COOKBOOK ONLY $9.99

FAMILY FRIENDLY RECIPES FOR THE DOG-TIRED CHEF Dinner Simplified • 6 lemon wedges, for garnish

•

Endoscopy-assisted resolution

Prevention of recurrence involves: • Elimination of risk factors - Routine dental care -

•

Anesthetized lavage

Mixed Green Salad with Roasted Beets Submitted by Anna Simpson Evans

•

Surgical resolution

Slow feeders, puzzle mats, etc.

Note: As a general rule, prognosis decreases as you move down this list of possible interventions.

Remove offending dietary components

•

Educate the client about what to expect next time - There’s likely to be a next time - Most of this will be covered with how you handle this visit

INGREDIENTS •

mixed greens

• If referring for endoscopic evaluation of the esophagus, prepare the owner that: - In the acute stage this will be used to assess the present degree of esophageal trauma, which can be associated with the risk for secondary complications • It will not yet be possible to determine the likelihood of permanent changes - Maximum stricture formation is not seen until approximately 30 days post-obstruction - Many of these will remodel and look normal again by 60 days PROGNOSIS & PREVENTION Overall prognosis is excellent (>80%). However, complications are possible and should be discussed with the owner. These include: • Ulceration/esophagitis (assume this occurs in all cases) • Recurrence (occurs in up to 37% of cases) • Aspiration pneumonia (reported in 24-36% of cases, and risk increases with duration of episode) • Esophageal stenosis/stricture/diverticulum (uncommon) • Esophageal rupture/necrosis/perforation (rare)

• balsamic dressing (store bought or homemade below): - balsamic vinegar - olive oil - salt and pepper to taste •

WATCH the Webinar

whole beets (save some greens to mix in salad, if desired) fresh mozzarella pearls or ball, diced avocado, sliced or diced pine nuts, toasted until golden brown

•

DIRECTIONS 1.

Preheat the oven to 400 °F (200 degrees °C).

Preheat oven to 400 °F.

2. In a small bowl, mix together the mustard, butter, and honey. In another bowl, mix together the breadcrumbs, pecans, and parsley. 3. Season each salmon fillet with salt and pepper. Place on a lightly greased baking sheet. 4. Brush with mustard-honey mixture. Cover the top of each fillet with bread crumb mixture. 5. Bake for 10 minutes per inch of thickness, measured at thickest part, or until salmon just flakes when tested with a fork. Serve garnished with lemon wedges.

Remove greens from whole beets, reserving some to mix in with salad (optional). Roast whole beets in oven until fork inserts and comes out smoothly, about 45 minutes to an hour. Let cool, remove outer skin and cut into small cubes or desired pieces. This can be done a day ahead of time and refrigerated until ready to make the salad. Combine mixed greens and beet greens, if desired, for added color and flavor. Toss greens with balsamic dressing (I make my own whisking together good balsamic vinegar, olive oil, salt, and pepper). Add in mozzarella and avocado and toss. Sprinkle toasted pine nuts on top of the salad.

Note: Also works well with whole salmon or filleted side of salmon.

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

Heatstroke in Dogs

effective in hot, humid environments. Conduction is the transfer of heat from one object to another. This is why you will often find dogs seeking a cool place to lay down, as contact with their lightly-haired abdomens on a cool surface will cause a transfer of heat. (Likewise, how patients become hypothermic lying on a cold, stainless steel gurney or surgical table in the hospital!) Convection is when the movement of air over the body allows the dissipation of heat into the environment. This is most often seen with wind or a fan. Radiation is when the body dissipates heat into the environment naturally. This is less effective as the environmental temperature reaches that of a patient’s body temperature.

to increase heat loss through the integument. The cardiovascular system aids in this by first increasing heart rate. This, along with the decreased systemic vascular resistance, will ensure maximum blood flow and subsequently maximum heat loss through the periphery. If these initial compensatory methods are not effective, the body will continue to try and cool itself; however, deleterious side effects may be seen at this stage. Patients will start to exhibit splanchnic vascular dilation which can cause venous pooling and decreased circulating volume. The lack of forward blood flow significantly decreases heat dissipation through the integument and the venous pooling from splanchnic vasodilation leads to hypotension and inevitably circulatory shock.

Under normal conditions, greater than half of a patient’s total body heat is dissipated through convection and radiation. Heatstroke can occur when the body is unable to dissipate the accumulated heat.

LEXI HANSEN, BS, LVT, RVT, VTS(ECC)

ECC Veterinary Technician Manager, BluePearl Pet Hospital Cary, NC

Beat Heat THE

In veterinary medicine, as temperatures increase during the summer, we’re often presented with the dog with heatstroke! What is Heatstroke? • Injected mucous membranes

• • • • • •

Vomiting

Diarrhea

Heatstroke is defined as a non-pyrogenic elevation in core body temperature greater than 105.8 0 F/41 0 C along with central nervous system (CNS) dysfunction. In veterinary medicine, heatstroke can be broken into two categories: exertional and environmental. Exertional heatstroke is exercise-induced or can be seen in dogs who are not acclimated to their environment. Environmental heatstroke is due to an increase in environmental temperatures and can be exacerbated by an absence of adequate cooling means such as water or shade. When a patient suspected of heatstroke shows up at your veterinary clinic, it is vital to obtain a thorough history and diagnostics. This will inevitably help direct the treatment plan, as treatment needs to be quick and aggressive for success. Patients will commonly present with a history of collapse, tachypnea, and ataxia or disorientation.

Hematemesis

Hematochezia

Melena

Temperature > 105 0 F/40.5 0 C *

• Signs of coagulopathy (e.g., petechia, bruising, erythema) • Cardiovascular collapse/shock (e.g., tachycardia, poor perfusion, weak pulses) • CNS signs (e.g., dull mentation, coma, tremors, seizures). Often, we may not have an accurate peak patient temperature, as owners often try to actively cool their pet prior to presentation (e.g., cold water, fan, air conditioning, etc.). Normal Thermoregulation The body has normal cooling methods to help maintain homeostasis, including evaporation, conduction, convection, and radiation. Evaporation is one of the most important ways that a dog can cool themselves. This occurs through panting and subsequently evaporation of water. This method of cooling is less

As the body continues to decompensate secondary to global hypoperfusion, massive cellular destruction, thermal injury, and damage or failure of vital organs can occur. Multi-organ dysfunction syndrome (MODS), where body systems become affected secondary to heatstroke, can occur; it is important to recognize how to monitor and support each system to create an effective treatment plan and monitor for decline. Body System Complications from Heatstroke Patients often present with some level of CNS dysfunction. They may present with mild CNS signs such as ataxia or dulled mentation, all the way up to seizures, coma, and even death. This can be due to the hypoperfusion of the brain, thrombi, cerebral edema, cerebral hemorrhage,

The body has a thermoregulatory center located in the anterior hypothalamus that maintains core body temperature within a very narrow set point. This thermoregulatory center in the brain is so sensitive that it can sense a non-pyrogenic change in core body temperature as little as 1 0 C. When an elevation in body temperature outside the normal set point occurs, it triggers a cascade of changes within the body to maintain hemostasis. Pathophysiology of Heatstroke Once a patient starts accumulating more heat than they can dissipate utilizing normal methods, the body will trigger compensatory pathways to aid in more aggressive cooling. The first step is to peripherally vasodilate

With heat stroke, we can see the following clinical signs: • Tachycardia • Tachypnea

Continued on Page 16

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

•

COAGULOPATHY Vasculature such as arteries, capillaries, and venous structures are widely affected by heatstroke; increased vascular permeability can result in edema and hypoalbuminemia. Trauma to the endothelium causes the release of thromboplastin and factor XII, which activate the coagulation cascade. With heatstroke, global damage causes an exaggerated release and utilization of coagulation factors; prolonged PT/PTT and thrombocytopenia are commonly seen. At this point the body will start to exhibit signs of systemic inflammatory response syndrome (SIRS) and/or disseminated intravascular coagulopathy (DIC). DIC, which may not be seen immediately, presents as microthrombi in the vasculature, but also can present as spontaneous bleeding due to the severe overstimulation of the coagulation cascade. This can be seen on the skin as petechia or ecchymosis.

increased intracranial pressure (ICP), or direct vascular damage. To support a patient’s CNS and treat cerebral edema, it is recommended to elevate the head, while avoiding compression of the jugular veins. The use of hypertonic saline or mannitol can be used to decrease ICP. Mannitol, an osmotic diuretic, may be contraindicated in patients with dehydration, hypotension, and concerns for intracranial hemorrhage.

• • •

Melena

increased utilization of blood glucose with severely decreased production.

Hematuria

Seizures (resulting from bleeding into the CNS)

GASTROINTESTINAL TRACT (GIT) The gastrointestinal tract, which is the shock organ in our canine patients, can be severely affected with heatstroke. Mucosal damage, leading to hyperpermeability and concern for bacterial translocation out of the GIT (leading to sepsis), may occur. Supportive care for the GI tract may include anti-emetics (to prevent secondary aspiration pneumonia), anti-diarrheals, antacids (e.g., H2 blockers such as famotidine, proton pump inhibitors such as pantoprazole, etc.), and judicious antibiotics, if appropriate. Heatstroke can result in drastic injury to multiple organ systems. This critically ill population is at high risk for developing MODS (which is defined as a dysfunction of two or more organ systems). This disease process is known for having increased morbidity and mortality rates and significantly increases a patient’s ICU stay. Treatment for Heatstroke With the critically ill heat stroke patient, prompt stabilization is imperative. This may include oxygen therapy, establishing venous access with an IV catheter, checking blood glucose, treating for hypoglycemia, volume resuscitating with crystalloids, and cooling measures/thermoregulation. First, ensure that your patient has a secure, patent airway and is adequately oxygenating and ventilating. Flow-by oxygen is immediately warranted. Some patients, especially those at high risk of heat stroke (e.g., such as brachycephalic breeds, obese patients, black-furred or long-haired dogs, or patients with laryngeal paralysis) may need to be intubated or have a tracheostomy tube placed. Next, you want to rapidly gain venous access to start fluid therapy. It is ideal to collect blood while placing your intravenous catheter. A stat blood glucose, along with PCV/ TS should be immediately assessed. You will want to limit the number of times we phlebotomize these patients, especially

Once a patient is exhibiting signs of SIRS or DIC, treatment should focus on aggressive supportive care and transfusions with fresh frozen plasma (FFP) to try to replenish coagulation factors. RESPIRATORY With heat stroke, the pulmonary system may not be able to appropriately perform oxygen exchange due to pulmonary embolism (from secondary coagulopathy), alveolar hemorrhage, and pulmonary edema. Even with rapid identification and treatment, a continued decline in a patient’s respiratory status may occur. Other pulmonary complications such as aspiration pneumonia and non-cardiogenic pulmonary edema (NCPE)/acute respiratory distress syndrome (ARDS) may be seen, with the latter having a poor prognosis. It is important to provide oxygen support and ventilatory support, if needed. Patients should have respiratory rate and effort closely monitored, including pulse oximetry and blood gas monitoring. It is ideal to get baseline thoracic radiographs to monitor any changes during hospitalization. RENAL The renal system, which can be very sensitive to hypotension and acute injury, will need to be monitored closely. We often see azotemia and decreased urine production (e.g., oliguria and anuria) secondary to MODS. The secondary damage from heatstroke can send patients into acute kidney injury secondary to prolonged hypotension, SIRS, DIC, and renal tubular necrosis. Placing an indwelling urinary catheter and monitoring the ins and outs will be helpful in directing the treatment plan. LIVER The hepatic system, which normally helps produce Vitamin K-dependent factors of the clotting cascade, is unable to do so with severe heat stroke. It is common to see thermal injury from prolonged hypoperfusion and splanchnic vasodilation. Microembolisms may start to form due to coagulopathy. Hypoglycemia can also be seen with heatstroke secondary to decreased hepatic function, bacterial translocation, sepsis, or

•

CARDIOVASCULAR A multitude of dysfunctions affecting the cardiovascular system can be observed, including cardiac arrhythmias (e.g., ventricular tachycardia, etc.). Appropriate monitoring with an electrocardiogram (ECG) is imperative in the critically ill heatstroke patient. Ventricular arrhythmias should be treated with an antiarrhythmic such as lidocaine if signs of altered perfusion (e.g., hypotension, pallor, etc.) or sustained tachycardia are seen (e.g., HR > 180 bpm). Secondary causes of arrhythmias, such as electrolyte abnormalities (e.g., hypokalemia, hyperkalemia, etc.), acid-base disturbances, or pain should be evaluated and treated if appropriate, to maintain cardiac function. Side effects secondary to hypoperfusion, such as myocardial ischemia, are also of concern.

Clinical signs of DIC associated with heat stroke may include: • Epistaxis • Bleeding from intravenous catheter insertion sites • Hematemesis • Hematochezia

Two Divisions, One Focus: Improving patient outcomes with medications you’ve been trusting since 1975.

503A

503B

Type of Facility Product Purpose Regulatory Oversight Regulations Product Dating

FDA Registered Outsourcing Facility Manufactured drugs in bulk quantities for hospitals FDA cGMP (current Good Manufacturing Processes) Expiration Date (proven)

Traditional Compounding Pharmacy Customized prescriptions for individual patients State Boards of Pharmacy USP

(United States Pharmacopeia) Beyond-Use Date (limited)

Start Your Order! For Office Orders: 888-508-5032 | For Patient Prescriptions: 800-754-5222

Continued on Page 18

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

when we are not aware of their coagulation status. You will be able to gain information about the patient’s status by running a chemistry, complete blood count (CBC), packed cell volume (PCV), electrolytes, blood gases, prothrombin time (PT), and partial thromboplastin time (PTT). Even if we do not see abnormalities in these values on presentation, it is very helpful to have a baseline so we can continue to monitor trends. Clinicopathologic changes seen with heatstroke may include increases in serum hepatic and renal values, hyperlactatemia, hypoglycemia, thrombocytopenia, hemoconcentration, and prolonged PT/PTT. Electrolyte abnormalities can also be seen with heatstroke, including hypernatremia, hyperkalemia, or hypokalemia. Fluid therapy is warranted with heatstroke patients. A balanced, isotonic crystalloid should be used. Dextrose supplementation (2.5-5%) may be warranted, depending on what the blood glucose levels are; these should be frequently checked and adjusted as appropriate. The use of colloids should be limited to severe hypoproteinemic patients. The use of plasma transfusions may be warranted if the patient is coagulopathic (e.g., prolonged PT/PTT, etc.). Cooling the patient should be done in a controlled manner. Using a fan, placing cold wet towels between the inguinal region, placing the patient on a cool treatment table, or utilizing room-temperature intravenous fluids can help. We want to avoid submersion in an ice-cold bath or direct ice packs as these may cause peripheral vasoconstriction and lead to further damage by shunting all the patient’s warm blood to their vital organs. Temperature should be monitored at least every 5 minutes and active cooling efforts should stop once you reach a temperature of approximately 103.5 0 F/39.7 0 C. The body may continue to cool once active cooling is stopped, resulting in significant hypothermia. Monitoring Patients suffering from heatstroke require intensive nursing care and close monitoring. You should be continually assessing the patient’s perfusion, hydration status, blood glucose, lactate, blood gases, blood pressure, urine production, vitals, ECG, and mentation. Nursing care is a big part of managing these patients as they are often non-ambulatory and time intensive. Prognosis Patients suffering from heatstroke have a mortality rate of 40-50%. Unfortunately, even despite aggressive supportive care, the prognosis may be grave. Quick and aggressive care is imperative to achieve the best outcome. It is often the secondary complications such as SIRS, sepsis, MODs, and DIC that lead to death or euthanasia.

LOOKING TO LEARN MORE?

WATCH ON-DEMAND

•

HEATSTROKE IN DOGS: A LIFE- THREATENING EMERGENCY by Dr. Erik Zager, DACVECC

•

MANAGEMENT OF HEAT STROKE IN DOGS by Dr. Marie Holowaychuk, DACVECC

•

SHOCK TÉRMICO (HEAT STROKE) by Dr. Mariana Pardo, BVSc, MV, DACVECC (Spanish only) • HEATSTROKE FOR VETERINARY TECHNICIANS by Amy Newfield, CVT, VTS (ECC) References • Bruchim Y. (2018, September 25-28). Management of heat stroke in the dog. World Small Animal Veterinary Associates Congress, Singapore. • Bruchim Y. et al. (2006). Heat Stroke in Dogs: A Retrospective Study of 54 Cases (1999-2004) and Analysis of Risk Factors for Death. Journal of veterinary internal medicine / American College of Veterinary Internal Medicine. 20. 38-46. 10.1111/j.1939-1676.2006.tb02821.x. • Bruchim, Y., Ginsburg, I., Segev, G. et al. Serum histones as biomarkers of the severity of heatstroke in dogs. Cell Stress and Chaperones 22, 903–910 (2017). https://doi.org/10.1007/s12192-017-0817-6 • Bruchim,Y. Horowitz, M, Aroch,I. (2017). Pathophysiology of heatstroke in dogs-revisited, Temperature, 4(4) 356-370. DOI: 10.1080/23328940.2017.1367457 • Bruchim, Y., Kelmer, E., Cohen, A., Codner, C., Segev, G. and Aroch, I. (2017), Hemostatic abnormalities in dogs with naturally occurring heatstroke. Journal of Veterinary Emergency and Critical Care, 27: 315-324. https://doi. org/10.1111/vec.12590 • Bruchim, Y. Loeb, E. Saragusty,J. Aroch, I. (2009). Pathological findings in dogs with fatal heatstroke. J. Comp. Path. 140. 97-104. doi:10.1016/j. jcpa.2008.07.011 • Bruchim, Y., Segev, G., Kelmer, E. et al. Hospitalized dogs recovery from naturally occurring heatstroke; does serum heat shock protein 72 can provide prognostic biomarker?. Cell Stress and Chaperones 21, 123–130 (2016). https://doi.org/10.1007/s12192-015-0645-5 • Cray, C., Zaias, J., & Altman, N. H. (2009). Acute phase response in animals: a review. Comparative medicine, 59(6), 517–526. • Hall, E. Carter, A. Chico, G. Bradbury, J. Gentle, L. Barfield, D. O’Neill, D. (2022). Vet. Sci. 9(5) 231. https://doi.org/10.3390/vetsci9050231 • Iba, T. Helms, J. Levi, M. Levy, J. (2022) The role of platelets in heat-related illness and heat induced coagulopathy. Thrombosis Research. https://doi. org/10.1016/j.thromres.2022.08.009 • Johnson, S. McMichael, M. White, G. (2006) Heatstroke in small animal medicine: a clinical practice review. Journal of Veterinary Emergency and Critical Care. 16(2). 112-119. doi:10.1111/j.1476-4431.2006.00191.x • Mazzaferro, E. (2015, May 15-18). Treatment of Hyperthermia and Heat- Induced Illness. World Small Animal Veterinary World Congress. Bangkok, Thailand. • Romanucci, M., & Salda, L. D. (2013). Pathophysiology and pathological findings of heatstroke in dogs. Veterinary medicine (Auckland, N.Z.), 4, 1–9. https://doi.org/10.2147/VMRR.S29978 • Segev, G. Aroch, I. Savoary, M. Kass, P. Bruchim, Y. (2015). A novel severity scoring system for dogs with heatstroke. Journal of Veterinary Emergency and Critical Care. 25(2) 240-247. doi: 10.1111/vec.12284 • Tabor,B. Heatstroke in Dogs. Today’s Veterinary Practice 2014; 4(6), 50-56. • Tracy, A. Lynch, A. Messenger, K. Vaden, S. Vigani, A. (2020). Use of extracorporeal therapy in a dog with heatstroke. Journal of Veterinary Emergency and Critical Care. 32(4) 512-519. https://doi.org/10.1111/ vec.13169ww

CE annually 24 / 7 / 365 massive on-demand content library

Team Memberships

5 members for only $699 • easy enrollment •

associate management

•

save & learn

• membership packages available to fit any size team

Team “organizers” can monitor and manage their users to know their content history, completed credits, favorite educational materials, and MORE!

VETGIRLONTHERUN.COM

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / OCTOBER 2023 ///

/// QUARTERLY BEAT / OCTOBER 2023

5 Ways to Be a Leader Your Veterinary Team Wants to Follow

coach for them. Trust comes from others knowing that we have their best interests at heart as we work with them. And this use of stories that make us human, along with questions that help us learn about them does exactly that.

Create New Possibilities

When you are in a leadership role, you have an effect on the behavior of others, even if it’s only because of the way people think about hierarchy and authority. Your veterinary team knows that they are supposed to follow you. That means you need to make sure that you are doing the things you need to as a leader to be followable. The good news is you can make it easier, or more difficult, for others to connect, trust, believe in, and follow you. Your opportunity is to be a leader that people can follow without climbing over additional obstacles, taking significant risks, or incurring unnecessary stress.

People behave a certain way because, ultimately, they believe they should. Even when a member of your team is highly disengaged, it’s unlikely that they show up for work thinking, “I’m going to do the wrong thing all day today.”

For the most part, they are doing what they believe to be right or at least justified based on the patterns or habits that they already have. When we see a better way or a different way, we are presented with an option that wasn’t on our original list of choices. Sometimes this component, often referred to as insight, is the biggest driver of change, and you can be in a unique position to help them see these possibilities. As a leader, you can model behaviors to demonstrate that there are other choices out there. You can also create new possibilities using questions like “if you wanted to fill meds with 100% accuracy all the time, how would you change your process?” Help your veterinary team uncover new choices and they will begin to view you as a leader they naturally want to follow.

Being a LEADER Isn’t About Authority

Go First

As new possibilities present themselves, you - the leader - must be willing to embrace the change first. Changing how you work as you explore new opportunities and try new things is one of the ways that we help others think about how they might create their own changes in behavior. If you can create early momentum for change by demonstrating you are ready to go first, involving your team from the start, and setting a clear vision, then people are much more likely to follow. Once change begins, it increasingly becomes about support and growing as a team through the process.

Some of your veterinary team’s thoughts will be focused on what you want, what you expect, what you will think, and how you will react. That’s just part of being in an organizational structure where you have a supervisory title, and particularly true in the close quarters of a veterinary practice. But, if your team is constantly worried about what you want, how you would do it, if you will like the way they did it, or if you will find mistakes, they are not thinking about what their best might be. And choosing their best, and then pursuing their best, rather than chasing your definition of their success, is where human improvement actually happens. Similarly, if they are worried about how you will use your authority, they are not focused on how they develop their strengths further. And if they are trying to guess your thoughts, they are not exploring their own best thinking. Thus, as a leader, you may sometimes have to overcome your authority, not leverage it, to lead at your best.

Share Your Story

Once you’ve uncovered new possibilities and shown a willingness to act, getting there becomes a matter of confidence. In fact, confidence is what helps people move from idea to execution. Support with Vision

It’s important for your team to see you as a human who grows, learns, makes progress, sometimes doesn’t, and works at your craft as a coach and leader. It’s okay to say things like “Hey, I am still learning how best to support you as you work toward your success here, what ideas do you have on how we work together well?” Or, “I really struggled with this part of the job you are doing, what feels like your biggest challenge?”

Letting someone know that you believe they can make progress in a new direction is often the very catalyst that gets them to try. Think about having

We can use our stories and questions to build strong effective relationships with people on our team and that means that we can be more effective as a

Here are some things you can do to make yourself followable and cause your team to be more capable over time:

Continued on Page 22

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

Page 1 Page 2-3 Page 4-5 Page 6-7 Page 8-9 Page 10-11 Page 12-13 Page 14-15 Page 16-17 Page 18-19 Page 20-21 Page 22-23 Page 24-25 Page 26-27 Page 28-29 Page 30

vetgirlontherun.com

Made with FlippingBook - Online Brochure Maker