VETgirl April 2024 Beat e-Magazine

The VETgirl Beat is a quarterly publication available to all subscribed members of VETgirl. The digital newsletter features highlighted webinars (small animal, large animal, veterinary technician, leadership), tech tips, provider spotlights, and recent happenings.

QUARTERLY BEAT / APRIL 2024 ISSUE 20 • APRIL 2024 BEAT

EMAGAZINE

PURINA PRO PLAN VETERINARY SUPPORT MISSION HELPS VETERINARIANS ANSWER CALL TO CARE

WHAT'S ON THE CALENDAR? TECH TIPS 31

ME-OUCH! FELINE PAIN ASSESSMENT

26 MIND MASSAGE RECAP

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

beat ISSUE 20 • APRIL 2024 TABLE OF CONTENTS

04 FEATURED STORY: PURINA PRO PLAN

16 WEBINAR HIGHLIGHTS: ME-OUCH! FELINE PAIN ASSESSMENT AND INTERVENTION

26 MIND MASSAGE

VETERINARY SUPPORT MISSION HELPS VETERINARIANS ANSWER CALL TO CARE

08 WEBINAR HIGHLIGHTS: TIPS AND TRICKS FOR SEDATING FEARFUL AND

FRACTIOUS DOGS AND CATS 20

28 TECH TIPS

WEBINAR HIGHLIGHTS: CATS ARE NOT SMALL DOGS: FELINE DENTAL AND ORAL DISEASES

14 WEBINAR HIGHLIGHTS: SETTING YOURSELF UP FOR SUCCESS AS A LEADER - GUIDING PRINCIPLES FOR SUCCESSFUL VETERINARY LEADERSHIP

31 WHAT'S ON

THE CALENDAR

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

The family knew nothing about parvovirus and had no idea what the diagnosis would be. It was gut-wrenching to have to explain to them how seriously ill their new puppy was and what treatment would entail. I explained that the best option was to hospitalize the dog and treat him in our hospital’s ICU facility. Due to the level of care required and the anticipated length of treatment, the minimum cost would be $2,000. At the same time, I felt it was my duty to provide a full range of options, so I explained in detail everything from my most aggressive treatment approach to the most minimal. I even suggested that it might be possible to surrender the puppy to the hospital, knowing the puppy would then no longer belong to the family. After I finished outlining these options, the mother asked to speak to me in the hallway, away from her daughter. There she told me that she had literally spent all her money for Christmas on everything else a healthy puppy would have needed—and there was nothing left. She simply couldn’t afford to have the puppy treated. My heart was bleeding for the family because I wanted to do something. When I asked the mother to consider a minimal approach—outpatient treatment that would include fluid therapy

and some injections to help with symptoms—she asked me, “Do you think that is going to work?” And I had to tell her it was unlikely given the status of her pet. We could see the puppy getting more and more debilitated, right in front of our eyes. She responded that the only option she could see that would minimize his suffering was to put him to sleep. And that’s what we did. It’s been 10 years since then and I’ve had to help many more families make this final, yet difficult, decision for their pets. But I’m still troubled when I remember this case. First, I knew the disease could easily have been prevented if the puppy had been vaccinated. Second, it involved a child, and I have always found cases like these—when the owner is very young or very old—to be the hardest. Third, while I know there was no guarantee that even the best treatment would have saved the puppy, with proper treatment he would have had a fighting chance. Instead, I was powerless to help him or his family.

FEATURED STORY

In this VETgirl feature article sponsored* by Purina Pro Plan Veterinary Diets, Dr. Callie Harris discusses the REACH (Reaching Every Animal with Charitable Healthcare) Program, which was created by the AVMF to increase assistance to the most vulnerable communities. Read on to learn how Purina Pro Plan Veterinary Diets has teamed up to support this critical mission! * Please note the opinions of this blog are the expressed opinion of the author and not directly endorsed by VETgirl.

PURINA PRO PLAN VETERINARY SUPPORT MISSON HELPS VETERINARIANS ANSWER CALL TO CARE

BY CALLIE HARRIS, DVM Veterinary Communications Manager, Purina Pro Plan Veterinary Diets

Early in my veterinary career I worked for eight years in emergency medicine and critical care at a large metropolitan hospital outside Atlanta. Because we were open 24 hours a day, seven days a week, I saw a wide range of clients from a cultural and socioeconomic status, as well as a broad spectrum of patients. But a particular case I handled early in my career continues to haunt me.

PARVO PUPPY LEADS TO HOLIDAY HEARTBREAK

It was late on Christmas Eve when a mother and daughter came in with a very sick puppy. The dog was the daughter’s Christmas present and the family had brought him home that day. Shortly after, the puppy began to break with vomiting and diarrhea. By the time they brought him to the hospital, he was severely dehydrated and lethargic. I ran some minimal diagnostics and diagnosed him with parvovirus. I don’t recall where the family had acquired the puppy, but he obviously had not received the vaccinations he needed.

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

0372950_VMX_Vet Mission Print.pdf 1 2/22/24 2:48 PM

Had I had access to a program like REACH on that Christmas Eve, that parvo puppy might have had a chance, and a mother might not have had to make such a painful, heart-wrenching decision. By partnering with REACH, we hope to help practitioners navigate challenging situations like these and ultimately answer their call as veterinarians to care for patients and ensure the bond with their clients and patients continues to thrive.

PRO PLAN VETERINARY SUPPORT MISSION GIVES PATIENTS AND PET PARENTS NEW HOPE Like all veterinarians, I chose my profession because I want to heal pets and help families. Because Purina Pro Plan Veterinary Diets shares this vision with the veterinary profession, they recently created their Veterinary Support Mission and, as their first act, donated $1 million to the American Veterinary Medical Foundation REACH Program™. Through REACH, veterinarians can apply for reimbursement grants when owners experience financial hardship. It’s truly life-giving.

According to the AVMF, the REACH Program delivers financial grants to practices whose clients may be experiencing financial hardship. Through the REACH Program, financial barriers can be lifted, the burden placed on veterinarians can be eased, and more help provided to ensure pets receive the expert veterinary services they need. Veterinarians can visit www.ProPlanVetSupport.com to learn more about the Pro Plan Veterinary Support Mission and the AVMF REACH Program.

VETERINARY SUPPORT MISSION EXPANDS “REACH” OF REACH

The REACH (Reaching Every Animal with Charitable Healthcare) Program was created by the AVMF to increase assistance to the most vulnerable communities and bring the foundation’s “Helping Veterinarians Help Animals” motto to life. The program, which received $200K in funding from Purina Pro Plan Veterinary Diets in addition to the $1 million Pro Plan Veterinary Support Mission donation in 2023, has grown since its inception in 2022 and has the resources now to assist thousands of animals.

There are A MILLION REASONS you love what you do, and we want to help. That’s why we’ve dedicated $1,000,000 to the AVMF REACH Program™ to help you care for pets in need.

Visit ProPlanVetSupport.com to learn more.

Purina trademarks are owned by Société des Produits Nestlé S.A. Any other marks are property of their respective owners.

Live size: 7” x 9.5” Trim size: 7.5” x 10” Bleed size: 7.75” x 10.25”

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

dogs, injectable sedation or anesthesia protocols (given intramuscularly) are reliable and can be used if the pet can be safely restrained, preferably with a muzzle. A second choice would be to have a large E-collar on the pet. For tips on how to inject a dog that cannot be restrained watch the videos created by Mele Tong, CVT, VTS Anesthesia & Analgesia (see resources, p. 13). Injectable techniques are also reliable in cats if they are safely enclosed in a carrier. The best carriers for difficult cats are constructed with soft-sided and mesh inserts, as you can inject through these. If the cat can be coaxed or transferred into a community cat trap, injection is easily performed just as it’s done in community (feral) cat clinics. For recommendations on cat equipment (see resources, p. 13). Assess each situation and create plan A as your goal; be sure to have plans B and C in place as a backup - and know when to switch plans. If things become dangerous, it may be necessary to abort and reschedule. In these situations, identify the trigger that caused the escalation and devise another plan. If the pet cannot be safely restrained for an injection, pre-visit drugs will be necessary. Dogs and cats with behavioral problems will often respond to drugs very differently compared to mentally healthy patients. Functional MRI studies demonstrate abnormal brain circuitry in anxious dogs. 3 They are “wired’ differently and when aroused, seem to be able to “fight” the sedative effects of many drugs, likely due to high sympathetic nervous system activity and circulating catecholamines. It is important to inform owners that you have a plan, but that their pet’s behavior makes things less predictable.

TIPS AND TRICKS FOR SEDATING FEARFUL AND FRACTIOUS DOGS AND CATS

SHEILAH A. ROBERTSON BVMS (Hons), CertVA, PhD, DACVAA, DECVAA, DACAW, DECAWBM (AWSEL), FRCVS Senior Medical Director, Lap of Love Veterinary Hospice, Courtesy Professor (University of Florida) In this VETgirl Real-Life Rounds “Drug Protocols for Fractious Dogs and Cats” on February 7, 2024, Dr. Sheilah A. Robertson reviews the pharmacologic approach to sedating and anesthetizing fractious dogs and cats, including pre-hospital visit drugs. Tune in to get a clinical update on managing these challenging patients! Check it out HERE!

pet’s behavior, this is for their safety, their pet’s safety, and your safety. Ask the owner if they can safely transport the pet to your hospital and have it restrained or can they use an escape-proof carrier. If this is not possible, or they feel it will be extremely stressful for their pet, you may want to refer them to a veterinarian who performs in-home visits.

INTRODUCTION Dogs and cats with fearful and aggressive behaviors can be challenging to deal with during veterinary visits. This often results in clinical examinations and required procedures not being performed and owners becoming reluctant to return due to the stress associated with the journey and visit for them and their pet. However, there are many ways to approach these situations and clear communication between all stakeholders is the key to a desired outcome. There is emerging data to show that the COVID-19 pandemic strongly impacted the behavioral development of dogs and we are now seeing more dogs with fearful and aggressive behaviors in adulthood. 1,2 The Royal Veterinary College in the United Kingdom is conducting a survey on “pandemic puppies” that began in 2020: www.rvc.ac.uk/vetcompass/research-projects- and-opportunities/projects/rvc-pandemic-puppies-survey. COMMUNICATION It is essential to gather as much information as possible about the dog or cat before the appointment. If pre-visit drugs are necessary (dispensed or prescribed), then a veterinary client patient relationship (VCPR) must be established, if one is not already in place. It is important that you gain the owner’s trust and that they provide truthful information about their

DRUGS P re - visit drugs ( often referred to as pre - visit pharmaceuticals or PVP s )

RECOGNIZING FEAR, ANXIETY, AND STRESS

Using PVPs can render patients calm and relaxed, and can be used for any pet, regardless of their behavior. For fearful and aggressive dog and cat appointments, PVPs are a key step in the process and there are several options for oral administration. PVPs may be given the night before (as a priming dose) and on the day of the appointment. In many cases a single drug will not be sufficient, and combinations must be carefully selected to suit the specific situation. The goal of pre-visit drugs is to decrease anxiety and fear and slow the patient down to facilitate handling, targeting the mind and the body.

Recognizing dog and cat behaviors and reading their body language quickly are superpowers we must develop to avoid being injured. We have to know when to back off and use plan B or C because once things escalate, it is hard to regroup. There are several options for individual and team training to enable us to collaborate with difficult patients, including but not limited to Fear Free® training and cat friendly programs offered by the American Association of Feline Practitioners (see resources, p. 13). PLANNING, STANDARD OPERATING PROCEDURES, AND TRAINING It is essential that you feel safe and confident during these appointments with reactive animals, and this requires pre-planning with the owners and the veterinary team. In

WEBINAR HIGHLIGHTS

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

THE CHILL PROTOCOL (see resources, p13).

NON-INJECTABLE DRUG ADMINISTRATION AT THE TIME OF APPOINTMENT DOGS: Transmucosal detomidine gel (Dormosedan Gel®, detomidine hydrochloride, 7.6 mg/mL, Zoetis, US): Published studies report that doses between 0.35 and 2.0 mg/m2 result in good sedation, with an onset time of less than 15 minutes. In these studies, the gel was placed in the buccal pouch but clearly for aggressive dogs alternatives must be used. These may include mixing it with peanut butter, whipped cheese, or thick syrup and placing it on a plastic plate or smearing it on a favorite toy for the dog to lick. A dose of 1.0 mg/m2 produced lateral recumbency in approximately 40 minutes. 11,12 If needed, the effects can be reversed with atipamezole (0.1 mg/kg IM). 13 In a study of 8 cats, transmucosal detomidine gel produced moderate sedation but all subjects vomited. 14 CATS: Transmucosal tiletamine/zolazepam (100 mg/mL): Following buccal administration of 0.1 mL/kg, cats were laterally recumbent (but some could raise their head), did not respond to clippers being turned on, and did not resist physical restraint within 15 minutes. 15 With cats that cannot be approached, I have been successful spraying the tiletamine/zolazepam orally into the mouth through the cage or carrier, or offering it mixed with gravy or maple syrup. Compared to oral ketamine, there is less salivation, but it may still occur. INJECTABLE DRUG COMBINATIONS Many injectable protocols will result in deep sedation or anesthesia. In dogs, combinations of ketamine, alpha2-adrenergic drugs (dexmedetomidine, medetomidine), acepromazine, and an opioid are often used. If you have a total intramuscular anesthetic technique you use to anesthetize cats for surgery (e.g., some version of “kitty magic”), use this.

ORAL DRUGS

This protocol combines gabapentin, melatonin, and acepromazine and is recommended to facilitate interactions with aggressive and fearful dogs in a clinical setting. It is a three- step process. All three drugs can be administered by the owner, but this protocol requires planning as the shortest lead time needed for it to work is 2 hours (if the first dose of gabapentin is omitted). The protocol also works in cats.

DOGS: Individual drugs are listed below; however use of a single drug is rarely sufficient in many fearful and aggressive dogs and it cannot be emphasized enough that responses are highly variable.

T razodone : Individual variation in response to administration of trazodone is common and not surprising based on a pharmacokinetic study in which time to peak plasma concentration and oral bioavailability were highly variable. 4 Suggested doses range from 3 -18 mg/kg; however, some dogs will be sedate on doses at the lower end of the range, and some will appear unaffected. Doing a “test dose” before the scheduled visit is suggested to assess the individual dog’s response. G abapentin : Gabapentin can also be used in dogs with a wide range of recommended doses (10-80 mg/kg) the evening before the appointment and 1 to 2 hours prior to the appointment. This drug has anxiolytic properties and can “slow” some dogs down. Because the drug is renally excreted gabapentin may have more profound and prolonged effects in dogs with renal disease. A lprazolam : Alprazolam is often used as an adjunctive drug in anxious and / or aggressive dogs and those that show panic reactions to specific triggering events. Alprazolam should be administered 30-60 minutes before a known

triggering event (e.g. the presence of a stranger). Its use in aggressive dogs is controversial because there may be paradoxical reactions, including worsening of anxiety and aggression. Because it is not possible to predict the response, evaluating a dose ahead of the appointment would be ideal. Suggested doses range from 0.02 – 0.1 mg/kg. A cepromazine : Acepromazine is a sedative / tranquillizer (it is not an anxiolytic) and is available in liquid (injectable), tablet, and gel formulations. It should not be used as a sole drug in fearful dogs as they can be aroused and paradoxical reactions can occur. Tablets can be used but the onset time is variable with suggested doses ranging from 0.5 to 4 mg/kg. If the liquid formulation can be given transmucosally (on the gums, or into the buccal pouch, or with peanut butter or whipped cheese that is licked from a plate) onset time is usually more predictable, noticeable sedation usually occurs within 20-30 minutes, and lower doses are often sufficient (0.02-0.05 mg/kg). C ombinations of drugs : Alprazolam and acepromazine can be combined as can gabapentin and acepromazine (this latter combination is part of the “Chill protocol,” discussed next, and in resources, p. 13).

ORAL DRUGS

CATS: G abapentin : Gabapentin has a suitable pharmacokinetic profile for oral administration, with a reported mean systemic availability of 90 to 95%. 6 It is frequently used to decrease stress and anxiety in cats caused by transport and veterinary visits. Gabapentin was shown to reduce fear responses in community cats (i.e., unsocialized or feral cats). 7 The time to maximum plasma concentration and peak clinical effect is between 1 and 2 hours. Doses are usually given as “mg per cat;” most often 100 mg, 150 mg, or up to 200 mg in large cats. In published studies the effective dose on a mg/kg basis range from 10 to 30 mg/kg. Oral gabapentin often results in a very sedated or “sleepy” cat, but do not let your guard down as they are still arousable. Because the drug is predominantly renally excreted, dose adjustment is required for cats with chronic kidney disease. 8 P regabalin : Pregabalin was recently approved by the FDA for “the alleviation of acute anxiety and fear associated with transportation and veterinary visits in cats.” It is an oral solution with the trade name Bonqat® (Zoetis, US). Bonqat is administered orally as a single dose of 5 mg/kg (0.1mL/kg) approximately 1.5 hours before the start of a journey or veterinary visit.

TRANSMUCOSAL DRUGS

T razodone : This drug has variable effects in cats, but 50-100 mg/ cat is suggested. 9,10

Transmucosal dexmedetomidine gel (Sileo® dexmedetomidine oromucosal gel, 0.1 mg/mL, Zoetis): At the label dose, Sileo® alleviated fear and anxiety during veterinary visits; the ability to perform a physical examination or short minor procedure was 41% in treated dogs compared to 4% in the placebo group. 5

WEBINAR HIGHLIGHTS

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

REFERENCES AND READINGS

TIPS AND TRICKS TO MAXIMIZE SEDATION

INJECTION TECHNIQUES It would be negligent not to mention safety during these appointments. This was touched on earlier but includes training yourself and staff, knowing when to back off, and always having an escape route and something to protect yourself with or throw over the patient (big blanket, pillows, etc.). Appointments with pets that have behavioral issues can be challenging, however, with good planning, training, the correct drug or drug combination choices, and extra time, they can be well conducted with minimal stress for the patient and without putting you and your staff in harm’s way.

1. A hungry animal is more likely to eat food with drugs in it (maropitant may be given prior to other drugs that may cause vomiting, e.g., the alpha2-adrenergic agonists). 2. Choose high-value food and treats. 3. Avoid known triggers, e.g. strangers, restraint. 4. Minimize noise, activity, and the number of people in the area where the sedation will take place. In some cases, the owner may offer drug-laced food in their car outside the clinic (give them gloves to wear to avoid contact with the drugs). 5. Leave the pet undisturbed after drugs have been administered, regardless of route.

1. Boardman H, Farnworth MJ. Changes to Adult Dog Social Behaviour during and after COVID-19 Lockdowns in England: A Qualitative Analysis of Owner Perception. Animals (Basel) 2022;12. 2. Sacchettino L, Gatta C, Chirico A, et al. Puppies Raised during the COVID-19 Lockdown Showed Fearful and Aggressive Behaviors in Adulthood: An Italian Survey. Vet Sci 2023;10. 3. Xu Y, Christiaen E, De Witte S, et al. Network analysis reveals abnormal functional brain circuitry in anxious dogs. PLoS One 2023;18:e0282087. 4. Jay AR, Krotscheck U, Parsley E, et al. Pharmacokinetics, bioavailability, and hemodynamic effects of trazodone after intravenous and oral administration of a single dose to dogs. Am J Vet Res 2013;74:1450-1456. 5. Korpivaara M, Huhtinen M, Aspegrén J, Overall K. Dexmedetomidine oromucosal gel reduces fear and anxiety in dogs during veterinary visits: A randomised, double-blind, placebo-controlled clinical pilot study. Vet Rec 2021;189:e832. 6. Adrian D, Papich MG, Baynes R, et al. The pharmacokinetics of gabapentin in cats. J Vet Intern Med 2018;32:1996-2002. 7. Pankratz KE, Ferris KK, Griffith EH, Sherman BL. Use of single- dose oral gabapentin to attenuate fear responses in cage-trap confined community cats: a double-blind, placebo-controlled field trial. J Feline Med Surg 2018;20:535-543. 8. Quimby JM, Lorbach SK, Saffire A, et al. Serum concentrations of gabapentin in cats with chronic kidney disease. J Feline Med Surg 2022;24:1260-1266.

9. Stevens BJ, Frantz EM, Orlando JM, et al. Efficacy of a single dose of trazodone hydrochloride given to cats prior to veterinary visits to reduce signs of transport- and examination-related anxiety. J Am Vet Med Assoc 2016;249:202-207. 10. Orlando JM, Case BC, Thomson AE, et al. Use of oral trazodone for sedation in cats: a pilot study. J Feline Med Surg 2016;18:476- 482. 11. Hopfensperger M, Messenger KM, Papich MG, Sherman BL. The use of oral transmucosal detomidine hydrochloride gel to facilitate handling in dogs. Journal of Veterinary Behavior 2013;8:114-123. 12. Messenger KM, Hopfensperger M, Knych HK, Papich MG. Pharmacokinetics of detomidine following intravenous or oral- transmucosal administration and sedative effects of the oral- transmucosal treatment in dogs. Am J Vet Res 2016;77:413-420. 13. Kasten JI, Messenger KM, Campbell NB. Sedative and cardiopulmonary effects of buccally administered detomidine gel and reversal with atipamezole in dogs. Am J Vet Res 2018;79:1253-1260. 14. Smith P, Tolbert MK, Gould E, et al. Pharmacokinetics, sedation and hemodynamic changes following the administration of oral transmucosal detomidine gel in cats. J Feline Med Surg 2020;22:1184-1190. 15. Nejamkin P, Cavilla V, Clausse M, et al. Sedative and physiologic effects of tiletamine-zolazepam following buccal administration in cats. J Feline Med Surg 2020;22:108-113.

RESOURCES

T raining P rograms – A nimal handling and recognizing the body language of fear , stress , and anxiety • Fear Free® https://fearfreepets.com • Foote and Friends www.drsallyjfoote.com • Sophia Yin’s Low Stress Handling https://cattledogpublishing.com • American Association of Feline Practitioners Cat-Friendly Programs – Practice and Individual https://catvets.com/cfp/cat-friendly-recognition-programs

T he C hill P rotocol to M anage A ggressive & F earful D ogs • www.cliniciansbrief.com/article/chill-protocol-manage- aggressive-fearful-dogs

IM I njection by M ele T ong , CVT, VTS A nesthesia & A nalgesia

• www.youtube.com/watch?v=6EXV1_QJHP0 • www.youtube.com/watch?v=36XmpWZwqPg

C at H andling E quipment • Tomahawk Live Trap: www.livetrap.com

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

SETTING YOURSELF UP FOR SUCCESS AS A LEADER GUIDING PRINCIPLES FOR SUCCESSFUL VETERINARY LEADERSHIP

RANDY HALL Founder and CEO, VetLead Huntersville, North Carolina

In this VETgirl leadership webinar, “Setting Yourself Up for Success as a Leader” on February 13, 2024, Randy Hall reviews how to set yourself up for success as a leader! Tune in to get a leadership and check it out HERE!

TEAM SUCCESS QUESTIONS

It is critical to any successful journey that you choose a destination that is compelling, clear, and helps to guide your choices along the way. Leadership is no different. Creating your definition of success helps you ensure that the choices you make support you in achieving your goals. Getting very clear about what you think success looks like for you helps your brain begin to focus on steps that can help you move in the right direction and lays the foundation for you to build habits and patterns that help you achieve that vision. A sk yourself these questions to create your own picture of success :

The focus on your definition of success in a consistent, repeatable, clear way helps you do the things that move you in that direction. Making conscious choices about how you want to behave, and what you want to become or achieve essentially trains your brain to start caring more about those things. You want to get your brain focused on all the things you might do that help you reach a particular destination. But to do that, you must define it as clearly as you can. The more detailed your picture of success is, the more your brain can figure out connections that might help you achieve it. The more time you spend focusing on your definition of success, the more your RAS will think it is important to you, and it will begin to alert you to opportunities in your world to make it happen.

Leadership is about building a connected set of skills and capabilities that work together to help you achieve everything you want. Your brain doesn't really learn in a straight line; it connects all your experiences, ideas, thoughts, observations, and beliefs to form a mental map of what good looks like or how to handle a certain situation. All you need to do is build that mental map in a way that supports your choices, not just the patterns you have had in the past.

• How do I want my team to show up? • How do I want them to prepare for the day? • What kind of attitude would I like them to have? • How do I want my team to handle challenges? • How do I want my team to feel at the end of the day? • How should my team approach learning and their own development?

ABOUT THE AUTHOR R andy H all , F ounder and CEO, V et L ead

Randy spent over 15 years of his career in the animal health industry. Since founding his consulting business in 2009, he has worked with thousands of veterinary hospital leaders and staff members to help them capture their full potential of their own veterinary practices.

LEADER SUCCESS QUESTIONS

KEYS TO SUCCESS

The more clearly you define your vision of success, the more your brain becomes aware of the things you might focus on to make those choices happen. It’s called the Reticular Activating System (RAS). Essentially, it allows your brain to focus more on the things you care most about. And choosing what you really want helps to turn it on. The RAS wakes your brain up into a more conscious state when something important to you is nearby or happening. Here's an example: Have you ever been in a crowded situation at a bar or a conference and heard your name somewhere in the conversation? There are thousands of inputs happening at that moment, visual inputs, audio inputs, and so on, yet that one word captures your complete attention. It happens automatically. Your brain has learned from a young age that the word, your name, is important to you. This causes your brain to focus on it whenever it happens around you.

• What kind of leader do I want to be? • How do I want my team to think about me? • What kind of difference do I want to make? • What will be better if I show up and lead the team well? • What kind of team culture do I want to create?

• Outline your definition of success and update it often. • Choose the skills and knowledge you want so that you can achieve your definition of success. • Practice the skills consistently and help others practice them as well. • Get regular feedback from your team and others so that you can continue to improve and succeed. • Explore leadership resources & tools that help you consider new approaches.

• Why will it matter for the patients? • Why will it matter for the clients? • Why will it matter for me?

WEBINAR HIGHLIGHTS

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

ME-OUCH! FELINE PAIN ASSESSMENT AND INTERVENTION

KELLY M. FOLTZ AAT, CVT, LVT, RVT, VTS (ECC) BluePearl, Tampa FL USA

In this VETgirl veterinary technician webinar, "Me-OUCH! Feline Pain Assessment" will provide you with a review of the physiology of pain, common behaviors, pain scales, and assessment tools to best evaluate and handle pain in cats. Cats are not dogs! Use tips discussed here to better recognize feline pain signals and individualize multimodal analgesic protocols. Check it out HERE!

of pain behaviors to assign a score; these scales are evaluated for objectivity, reliability, repeatability, and applicability across individuals and disease states. Assessment includes evaluation of spontaneous behavior (e.g., when the evaluator is not handling or stimulating the patient) and evoked behavior (e.g., when a surgery site is palpated). An advantage of multidimensional pain scales, aside from their rigorous validation process, is that many establish a score where interventional analgesia (rescue analgesia) is recommended. Several multidimensional pain scales for cats have been developed in the past decade including the Colorado State University Feline Acute Pain Scale (CSU-FAPS), the UNESP-Botucatu multidimensional composite pain scale for cats, the Glasgow Composite Measure Pain Scale (CMPS-Feline), and the Feline Grimace Scale (FGS). When selecting a pain scale and reviewing the available literature, it is important to remember that sample populations in veterinary research are significantly smaller than in human medicine. A veterinary study may have a sample size of 8, 12, 24, 60, or 200 patients rather than the several thousand found in a human study exploring a similar hypothesis. Each practice should select a validated, multimodal pain scale that meets the needs of their practice, ensure that all personnel are trained in use of the pain scale, and use it consistently.

Veterinary analgesia has made enormous strides since the 1980s and 1990s, when it was first realized that small animal patients could benefit from multimodal analgesia. Prior to that time, analgesics were rarely prescribed for canine and feline patients and principles of analgesia were seldom taught in veterinary professional programs for DVMs and technicians. In the intervening decades, veterinary medicine has come to understand that untreated pain has detrimental effects on quality of life, glycemic regulation, cortisol regulation, wound healing, and immune function. Veterinary research has established dose recommendations, safe drug classes, modes of action, and pharmacokinetic data for a variety of animal species. The specialty of veterinary anesthesia and analgesia has emerged for both veterinarians and veterinary technicians. Practitioners continue to explore new drugs and to adapt advanced analgesic techniques from human medicine for animal species, including felines—yet according to many studies, feline patients are prescribed analgesic medications less than canine patients and chronic pain in cats is poorly understood. This is concerning given that there are approximately 75 million companion cats in the Unites States. Veterinary technicians are on the front line of pain recognition, evaluation, and intervention in feline patients; as client educators, they are also in an excellent position to help clients understand feline pain and the value of appropriate pain management.

social components.” In applying this definition to clinical practice, almost every facet of animal disease and most clinical procedures have the potential to induce or intensify pain. Acute pain and perioperative pain are not the only analgesic concerns in small animal medicine. Sensitization of the central nervous system and pain pathways lowers pain thresholds, inducing responses to both noxious stimuli (i.e., hyperalgesia) and to non-noxious stimuli (i.e., allodynia). Chronic pain in cats is under diagnosed and under treated. Many factors affecting the recognition and treatment of pain in cats have been proposed, including the following: challenges in pain assessment in this species, lack of validated pain scoring instruments for cats, deficiencies in the education of DVMs and technicians in regard to feline pain, concern over drug diversion/side effects/drug availability/drug cost, and the fear that analgesic use will blunt recognition of patient decompensation/ worsening clinical condition. Cats “behaving badly” may not have their pain addressed due to concerns about personnel safety. Much “bad” feline behavior in the clinical setting can be attributed to pain, fear, or the misinterpretation of the cat’s communication by handlers. Escalated restraint frequently results in an escalation of fight/flight behavior by the cat, is never appropriate in a cat that may be in pain, and results in an increased number of bite/ scratch injuries and an increase in worker’s compensation claims. Feline pain responses are not synonymous with canine pain responses although their nociceptive pathways are identical. A better understanding of feline body language can minimize miscommunication. When assessing behavior or temperament,

it is important to consider the role of pain, especially since degenerative joint disease is under-diagnosed in cats. Pain behaviors in cats include, but are not limited to reduced activity (including jumping onto higher perches), hyporexia/anorexia, reduced curiosity/exploring/interactive behavior, hiding/ vocalization/hissing, guarding parts of body, excessive or reduced grooming, stiff gait/altered body posture, tail flicking, increased sleep/more time spent in one place, and periuria (urinary or fecal accidents near the litter box or outside the box). It is reasonable to assume that if a condition or injury is painful for a person or dog, it is also painful for a feline patient (e.g., a laceration, arthritis, pancreatitis, exploratory laparotomy, or liver disease). Recent attention to the recognition of pain as “the fourth vital sign” has led to the development of a variety of pain scoring systems for cats. Pain scales are classified as unidimensional or multidimensional. Visual Analog Scales (VAS), Simple Descriptive Scales (SDS), and Numeric Rating Scales (NRS) are examples of unidimensional pain scoring scales. These scales commonly feature a horizontal line with vertical right and left borders; sometimes segmental dividers are present with or without numeric ratings. The user selects a numeric signifier that correlates to the patient’s perceived level of pain; in human medicine, the patient selects their own level of pain. The signifiers may range from 0 (least painful/no pain) to 10 (worst pain imaginable/severe pain). These scales are prone to bias and lack objectivity. Multidimensional pain scales are also known as composite pain scales and use quantitative assessments

WEBINAR HIGHLIGHTS

Pain is defined as “a distressing experience associated with actual or potential tissue damage with sensory, emotional, cognitive, and

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

The CSU-FAPS is relatively easy to use and can help drive analgesic assessment and intervention but has not been fully validated in all settings and patient populations. It is somewhat subjective. Shipley et al. (2018) evaluated 68 female cats after OHE using the CSU-FAPS and found it to have moderate to good inter-rater reliability when used by veterinarians with advanced training in anesthesia; however, their conclusion was that the scale required further refinement before being widely applied in clinical practice. It is mentioned in the most current version of the AAHA/ AAFP pain management guidelines. The UNESP-Botucatu pain scale was originally developed in Brazilian Portuguese but has since been translated into and validated in English, Spanish, French, and Italian. It is easy to use but can be time-consuming to execute. The instrument is 3 pages long and uses three subscales encompassing 10 variables grouped around pain expression, psychomotor change, and physiologic variables. Pain expression variables include elements like vocalization, reaction to palpation, and other miscellaneous behaviors (tail movement, eye shape, limb movement, etc.). Psychomotor changes include activity, attitude, comfort, and posture. Physiologic variables include elements like appetite and blood pressure. The UNESP-Botucatu scale has been found to be discriminating, reliable, sensitive, specific, and valid in cats undergoing OHE when used by trained veterinary professionals (DVM and technician); however, it has not been applied to cats with chronic pain, other types of surgical pain, orthopedic pain, or trauma. Training materials, including a video tutorial, are available. Ketamine use may affect scoring of the psychomotor elements. Shy or fearful cats may score differently than extroverted, confident cats; scores should be interpreted carefully in these patients. The CMPS-Feline or Glasgow feline pain scale has been revised intensively since its creation; it has good validity and responsiveness but requires further evaluation for reliability. It is less time-consuming than the UNESP-Botucatu scale and has the advantage of being applicable to any type of acute pain, not just that associated with OHE; it also provides a score cut-off for rescue analgesia (≥5/20). It includes similar elements to the UNESP-Botucatu (activity, demeanor, facial expression, posture, vocalization, etc.). The CMPS-F is 2 pages long. Training materials including video tutorials are available. Fearful, introverted cats may score differently than extroverted, more interactive cats.

The FGS was first presented in 2019 after several years of development. Grimace scales have been in use for many years in laboratory animal medicine and have also been developed for horses, ferrets, piglets, and sheep; they are predicated on facial expressions that can be assessed using facial action coding systems, or FACS. FACS measure action units, or specific changes in the elements of expression (ears, eyes, whiskers, lips, etc.) and have been validated by thousands of measurements. Alterations in action units can be specific to individual species (for example, mice exhibit bulging cheeks when painful while horses show lip tightening). To develop and validate the FGS, photo analysis software was used to assess video stills of cats believed to be painful and those from a colony who had no documented health problems. Five action units were identified: ear position, orbital tightening, muzzle tension, whiskers change, and head position. Each action unit is graded on a scale of 0 (absent), 1 (moderately present), or 2 (markedly present) for a composite score of 0-10. Rescue analgesia is recommended if the score is ≥4. The FGS has demonstrated high correlation with the CMPS-F, internal consistency, and good to excellent intra-rater reliability. It has not been validated in brachycephalic cats or black cats. Further evaluation has shown that the FGS provides good agreement between scores assessed by DVMs and those assessed by veterinary technicians, pet owners, and veterinary students; it can also be used with reliability by untrained raters. There is a wide variety of safe analgesic drugs currently available for cats; many are injectable, and some are reversible. Multimodal analgesia is recommended (administration of a variety of drugs from different classes that will reduce the dose needed of all drugs while also addressing all potential pain pathways). Common classes of drugs used in multimodal feline analgesia include opioids, alpha-2 adrenergic agonists, nonsteroidal anti- inflammatory drugs (NSAIDs), and adjunctive medications such as local anesthetics, ketamine, or gabapentin. Loco-regional anesthetic techniques, such as epidurals, line blocks, or fascial plane blocks are also effective to provide analgesia in the immediate post-op period. If possible, analgesic drugs should be administered before a painful event occurs (such as a surgery). The ideal protocol is one that takes the patient’s comorbidities, temperament, pain score, vascular access device(s), hydration, and perfusion status into account. There is no “one size fits all” analgesic protocol for feline patients, and the best protocol is one that preserves normotension and cardiorespiratory function while also alleviating pain.

Opioid drugs, such as buprenorphine, fentanyl, hydromorphone, and methadone are an excellent choice for moderate-to-severe and acute pain. They can be titrated to effect, combined with other drugs, given as an intermittent bolus, or delivered as a constant rate infusion and are reversible with naloxone or partially reversible with butorphanol, which halts the objectionable effects of opioids while preserving their pain-relieving properties better than naloxone. Documented side effects of opioids in cats include euphoria, mydriasis (eye dilation), nausea/vomiting/ ptyalism, and hyperthermia. Opioid drugs that are well-studied in cats include methadone, buprenorphine, butorphanol, morphine, hydromorphone, oxymorphone, fentanyl, and fentanyl analogues. Not all are considered 100% safe (e.g., morphine may cause histamine release when administered IV). Butorphanol is best reserved as a sedative since it has weak analgesic properties. Nonsteroidal anti-inflammatory drugs such as robenacoxib can be added once hypovolemia is corrected and kidney function has been evaluated. Robenacoxib is labeled specifically for feline patients and has good analgesic and anti-inflammatory effects. It can be administered orally or subcutaneously. Other drugs

• Simon BT, Scallan EM, Carroll G et all. The lack of analgesic use (oligoanalgesia) in small animal practice. Journal of Small Animal Practice. 2017;58:543-554. • Simon BT, Steagall PV. Feline procedural sedation and analgesia: when, why, and how. J Fel Med Surg. 2020;22:1029-1045. • Shipley H, Guedes A, Graham L et al. Preliminary appraisal of the reliability and validity of the Colorado State University Feline Acute Pain Scale. J Fel Med Surg. 2019;21(4):335-339. • Steagall PVM, Monteiro-Steagall BP, Taylor PM. A review of the studies using buprenorphine in cats. J Vet Intern Med. 2014;28:762-770. • Steagall PV, Benito J, Monteiro BP et al. Analgesic effects of gabapentin and buprenorphine in cats undergoing ovariohysterectomy using two pain-scoring systems: a randomized clinical trial. J Fel Med Surg. 2018;20(8):741-748. • Wiese AJ. Canine and feline pain scales. Vet Team Brief. October 2018;28-32. • World Small Animal Veterinary Association Guidelines for Recognition, Assessment, and Treatment of Pain. WSAVA. Wsava.org/WSAVA/media/PDF_old/jsap_0.pdf such as ketamine or gabapentin also have a role in multi-modal pain relief. Gabapentin has also been shown to improve stress behaviors in hospitalized cats and may be a good adjunct for cats who require extended hospitalization and associate handling with pain. If surgery is required, soaker catheters and regional blocks provide additional analgesic coverage. Specific dosing information is available elsewhere. The understanding and recognition of feline pain have grown by leaps and bounds in the past 30-40 years. Multiple multimodal, validated pain scoring instruments are available for use in cats and many provide comprehensive training in the use of the instrument (e.g., interactive practice scoring scenarios are available for the FGS). Regardless of which instrument is selected, veterinary technicians have the unique ability to drive practice improvements in feline analgesia by advocating for their patients, educating themselves and their peers, staying current on new research, using analgesic medications with confidence, and being a bridge between the patient, the client, and the DVM.

REFERENCES

• Adrian D, Papich M, Baynes R et al. Chronic maladaptive pain in cats: a review of current and future drug treatment options. The Veterinary Journal. 207;230:52-61. • Belli M, De Oliveira AR, de Lima MT et al. Clinical validation of the short and long UNESP-Botucatu scales for feline pain assessment. Peer J. 2021;1-21. • Bortolami E, Love EJ. Practical use of opioids in cats: a state-of- the-art, evidence-based review. J Fel Med Surg. 2015;17(4):283- 311. • Brondani JT, Mama KR, Luna STL et al. Validation of the English version of the UNESP-Botucatu multidimensional composite pain scale for assessing postoperative pain in cats. BMC Veterinary Research. 2013;9(143):1-15. • Buisman M, Wagner MC, Hasiuk MMM et al. Effects of ketamine and alfaxalone on application of a feline pain assessment scale. J Fel Med Surg. 2016;18(8):643-651.

• Court MH. Feline drug metabolism and disposition:

pharmacokinetic evidence for species differences and molecular mechanisms. Vet Clin North Am Small Anim Pract. 2013;43(5):1-8. • Evangelista MC, Watanabe R, Leung VSY et al. Facial expressions of pain in cats: the development and validation a feline grimace scale. Scientific Reports. 2019;9(19128):1-11. • Monteiro BP, Steagall PV. Chronic pain in cats recent advances in clinical assessment. J Fel Med Surg. 2019;21:601-614.

WEBINAR HIGHLIGHTS

VETGIRL BEAT EMAGAZINE | VETGIRLONTHERUN.COM

QUARTERLY BEAT / APRIL 2024

There are five stages of tooth resorption as defined by the American Veterinary Dental College.

Tooth resorption is further divided into three types based on radiographic appearance:

CATS ARE NOT SMALL DOGS: FELINE DENTAL AND ORAL DISEASES

• Type 1: The appearance of the tooth is relatively normal radiopacity and a normal periodontal ligament space with either a focal or multifocal radiolucency. • Type 2: The appearance of the tooth has either focal or multifocal radiolucency within the tooth and a loss or narrowing of the periodontal ligament space. • Type 3: This includes both Type 1 and Type 2 and is only seen in multi-rooted teeth. There will be areas of normal and narrowed periodontal ligament space with either focal or multifocal radiolucency. 4

• Stage 1 (TR 1): Mild dental hard tissue loss of the enamel and/or cementum. This is the hardest stage to identify. It may be visual, but also may only be tactile and identified by running an explorer along the tooth. • Stage 2 (TR 2): Moderate dental hard tissue loss of the enamel and dentin, or the cementum and dentin without extending into the pulp. • Stage 3 (TR 3): Deep dental hard tissue loss of the enamel or cementum and dentin, extending into the pulp chamber or canal. Most of the tooth retains its integrity. • Stage 4 (TR 4): Extensive hard dental tissue loss extending into the pulp. Most of the tooth has lost its integrity. This stage is divided into substages: » TR 4a: Crown and root are equally affected. » TR 4b: Crown is more affected than the root. » TR 4c: Root is more affected than the crown. • Stage 5 (TR 5): The crown is no longer visible and there is no recognizable tooth structure remaining of the crown or root. There may be hard bump of tissue still present.

DENISE S. ROLLINGS CVT, VTS (Dentistry) Pet Dental Education, LLC. , Fort Myers, FL

In this VETgirl veterinary technician webinar "Cats Are Not Small Dogs: Feline Dental and Oral Diseases" on February 28, 2024, Denise Rollings reviews the top oral pathologies seen in cats! Tune in to learn details of feline oral and dental disease and potential treatment options — check it out HERE!

The standard of care and recommended treatment for any affected tooth to be extracted is that the complete periodontal ligament and entire root is extracted. The roots should not be drilled out, as this does not completely remove the root and can damage the bone and nerves. A crown amputation with intentional root retention can be performed with Type 2 tooth resorption when there is no visible periodontal ligament on the radiographs. This treatment is less invasive and can only be performed if there is no periodontal disease, endodontic disease, or mucositis (stomatitis). In the case of Stage 5 tooth resorption, if there are no root remnants and the gingiva has healed over and is smooth, no further treatment is needed. GINGIVOSTOMATITIS Gingivostomatitis is the inflammation of the gingiva and oral mucosa with ulcerative or proliferative lesions. These lesions can occur on the lateral aspects of the tongue, pharyngeal walls, palatal glossal folds, buccal mucosa, lips, and gingiva. It is very painful and debilitating. As with tooth resorption, there is no known cause.

Understanding our unique feline patients including the oral and dental diseases they can develop, helps us provide better treatment, thus improving the quality of their lives. The primary tooth eruption schedule for kittens is as follows: the incisors erupt at 2-3 weeks, the canines at 3-4 weeks, the premolars at 3-6 weeks, and there are no deciduous molars. A kitten has 26 teeth. The permanent tooth eruption schedule for a cat is as follows: the incisors erupt at 3-4 months, the canines at 4-5 months, the premolars at 4-6 months, and the molars at 4-5 months. 1 Felines are naturally missing their maxillary first premolars and their mandibular first and second premolars. The Triadan tooth numbering system reflects this and cats do not have 105, 205, 305, 306, 405, and 406. TOOTH RESORPTION Tooth resorption has been referred to using various names over the years including cervical neck lesion, cervical line lesion, and feline odontoclastic resorptive lesion (FORL). It is currently referred to as tooth resorption, also developed by many other species outside of cats.

Tooth resorption is the destruction (resorption) of the hard-dental tissue by odontoclasts. 2 Odontoclasts are also responsible for the resorption of deciduous teeth. The etiology of tooth resorption is not yet definitively known. Tooth resorption can be seen in cats of any age; however, the average age is 4-6 years of age. 3 The number of lesions also increases with age. While any tooth can develop tooth resorption, there seems to be an increased predilection of teeth 307 and 407 to develop it first. There is no way to predict which teeth will develop tooth resorption or predict how fast it will progress. The unknown can cause frustration for the pet parent so it is important to provide as much information as we have available on the disease process, the treatment, and the prognosis. Tooth resorption cannot be prevented with teeth brushing as it is not bacterial in nature. We know that once a cat has tooth resorption, it is highly likely that the cat will progressively develop more over time, although there is no way to predict when that will happen or which teeth will be affected.

food, oral bleeding, or less commonly, anorexia. Clients may notice missing teeth because as the disease progresses, the tooth is destroyed, and granulation tissue fills in the defect. To diagnose tooth resorption, a complete oral exam needs to be performed with the patient under anesthesia. This exam should include the use of a dental explorer, as well as full mouth intraoral dental radiographs. Tooth resorption cannot be diagnosed or treated properly with out dental radiographs. The plaque and calculus should first be scaled off. The explorer is run along the tooth; the most likely area for tooth resorption is the cementoenamel junction. The explorer will “stick” in the lesion; be sure to check any areas of granulation tissue as well.

One theory is that it is caused by a hyperimmune response to the plaque bacteria in the oral cavity. Viral etiologies such as

WEBINAR HIGHLIGHTS

Tooth resorption is painful because it exposes dentinal tubules and pulp. Signs include jaw chattering, head shaking, dropping

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 30-31 Page 32

vetgirlontherun.com

Made with FlippingBook - Online Brochure Maker