VETgirl Q4 2021 Beat e-Magazine

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ISSUE 11 | DECEMBER 2021

CONTENTS DECEMBER 2021

ARTICLES

19 Feline Thyroid Disease: What’s the TSH? 21 On Simone Biles, Emotional Agility, and Leading with Mental Health 04 The Latest Scoop on Feline Vaccines 10 Monitoring the Anesthetized Patient - Part 2 14 Fluid Therapy Chart 16 The infection is just the beginning: Tips for long-term ear care

Every moment counts

Every choice matters

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QUARTERLY BEAT / DECEMBER 2021 ///

It is encouraged to create an individualized, lifestyle-based vaccination plan for each cat. Questions must be asked about the lifestyle of that specific cat as well as any other cats in the household or potentially introduced into the household. Travel, boarding, housing, and enrichment activities or excursions outside of the home should also be considered. This risk assessment for exposure to disease should be done at least once a year. It’s important to note that a generic vaccination plan or protocol cannot be applied to every cat. Each cat must be evaluated individually and a plan formulated between the cat owner and their clinician for that particular cat. As with multi- cat households, the vaccination plan for the individual cat must be considered in relation to the entire population. An easily accessible chart has been made available for download that breaks down CORE and NON-CORE vaccine recommendations for pet cats and shelter cats due to the difference in risk category. Core vaccines are for all cats with an unknown vaccination history. The targeted diseases cause significant morbidity and mortality and are widely distributed. In general, vaccination for core diseases results in good protection. The Task Force recommends the following vaccinations: • Rabies • FeLV (cats younger than 1 year of age) • (FCV) feline calicivirus; (FHV-1) feline herpesvirus-1; (FPV) feline panleukopenia The FVRCP series are recommended to be given at a 3–4-week interval starting no earlier than 6 weeks of age until 12-20 weeks of age with ADDITION of revaccination at 6 months* of age rather than at a year old to decrease the window of susceptibility if the kitten had MDA (maternal derived antibodies) at the last kitten booster of 16-20 weeks of age. Revaccinate every three (3) years thereafter. Non-Core vaccinations are optional vaccines that should be considered in the light of exposure risk; that is, based on geographic distribution and the lifestyle of the cat. Optional or non-core vaccines for cats include FeLV (for cats older than 1 year), Chlamydia felis , and Bordetella bronchiseptica vaccines. 5 The only vaccination that is currently not generally recommended for use is the FIP (intranasal- attenuated live) vaccine. This vaccine contains a serotype II strain of FIP virus. Serotype I FIP virus strains predominate in the field, and do not have cross-reactive neutralizing epitopes with serotype II strains. There is insufficient evidence that this vaccine induces clinically relevant protection in the field. With the concerns of over vaccination by clients and the veterinary community, the question of serology testing before vaccination has been discussed and a chart providing

a breakdown of the usefulness of the testing for the pathogens under fire has been created. The interpretation of an antibody test result can be complex because antibody testing is used for many reasons. Depending on the antibodies tested for, antibody testing can be used for: • Diagnosis of infection • Identification of previous exposure to pathogens (particularly in unvaccinated animals • Assessment of immunity prior to or following vaccination. Clinicians should understand when and why they should perform antibody testing and use this knowledge to make evidence-based decisions prior to vaccination. Unfortunately, antibody testing is not reliable for assessment of immunity for FHV-1 and FCV as they both require an antibody and cell-mediated immune response. Test results should not be used to decide whether to vaccinate. Vaccination against rabies is essential in regions where it is required by statute/law or where the virus is endemic and should follow label recommendations. Serum neutralization results cannot be used to decide whether to vaccinate against rabies. No vaccination is without the potential for an adverse response as each individual is unique in how it responds to foreign material being introduced for an immune response. The currently available feline vaccinations have an excellent safety record; however, the true prevalence of adverse reactions is likely to be underestimated owing to underreporting by both veterinarians and owners. It is important to document any adverse response in the pet’s personal medical records for future vaccine considerations regardless of severity. The vaccine manufacturers should be contacted, as well as consideration to report known or suspected adverse events directly to the Center for Veterinary Biologics of the U.S. Department of Agriculture’s Animal and Plant Health Inspection Services. The most commonly reported vaccine reactions are lethargy, anorexia and fever for a few days after vaccination, or local inflammation at the site of injection, which is one of the reasons why it’s important to track the location where the vaccination is given as injection site sarcomas are of concern in the feline patient. While anaphylaxis is rare (it may manifest as vomiting, diarrhea, respiratory distress, facial or generalized pruritus, facial swelling, and collapse) it still can occur regardless of the cat receiving

WEBINAR HIGHLIGHTS

ELLEN M. CAROZZA , LVT AAFP/AAHA Feline Vaccine Guidelines Task Force Member The Latest Scoop on Feline Vaccines

Learn what’s new with the 2020 AAHA/AAFP Feline Vaccine Guidelines, thanks to Merck Animal Health, with this free webinar on “The Inside Scoop!” with Ellen M. Carozza LVT, AAFP/AAHA Feline Vaccine Guidelines Task Force Member.

Vaccines are meant to help prevent disease, yet in practice many cats do not return in time for booster vaccines as kittens, let alone maintain a consistent vaccine history throughout their life. What can result is vaccine failure and poor immunity in our feline friends that can lead to the spread of disease and even death. The goal of the veterinary practice is to provide their clients with science-based evidence on what vaccinations are necessary to keep their cat(s) healthy and to prevent any outbreaks of disease in the pet populations seen in practice. Recently, The American Association of Feline Practitioners (AAFP) and The American Animal Hospital Association (AAHA) have made necessary updates to the Feline Vaccine Guidelines that reflect the cats we see in practice by defining their populations and breaking down what vaccines are necessary to keep these cats disease free. A key component of the guidelines are comprehensive, easy-to-reference tables listing approved core and non-core feline vaccines and the relevant considerations for their use. The guidelines are complemented by an online resource center at aaha.org/feline vaccination and supplemental materials at vaccinations. The online resources include frequently asked questions about vaccination that clinicians and pet owners raise as well as a vaccine protocol calculator that uses a cat’s life stage and lifestyle information to suggest an appropriate, individualized vaccination protocol. 1 Cats have been defined into five (5) populations, which included the additions of TNR (Trap-Neuter-Return/Trap- Neuter-Release) and foster cats, since the explosion of feline rescue and the public’s desire to help with care and control of these populations at the local level has increased. While these cat populations may not make up a high percentage of cats seen in your practice, they do need to be recognized as

part of the cat populations that the public and the veterinary clinics they come into contact with for preventive care. Cattery cats, while formally defined as “cats that are maintained in commercial facilities; for example, breeding or boarding facilities, and pet stores with a showcase model,” can also include the popular “cat cafes’’ as those facilities tend to house a large number of cats that are under chronic stress. This makes them more susceptible to communicable disease as the number of cats directly affects the possibility of illness to occur. PRO TIP: It is important that ALL homes with families that have permanent resident cats while also fostering cats for shelters and rescues be defined as a HIGH-RISK home. ALL permanent resident cats should be currently up to date on all necessary vaccinations with the proper immunity time given before any foster cats are allowed into the home. Not only have cats been separated into populations, but lifestyle has been taken into consideration as well and a Lifestyle-based Calculator has been provided to allow easier breakdown for vaccination recommendations for the feline patient. One of the current recommendations that has changed for a particular life stage is the addition of FeLV for ALL kittens as a CORE vaccine regardless of lifestyle. Vaccine Risk-Benefit Assessments still play a major role for vaccination recommendations. The practitioner should be taking the following into consideration:

• Age and lifestyle • Health Status • Agent Exposure • History • Immunodeficiency

Continued on page 6

QUARTERLY BEAT / DECEMBER 2021 ///

WEBINAR HIGHLIGHTS

ELLEN M. CAROZZA , LVT AAFP/AAHA Feline Vaccine Guidelines Task Force Member The Latest Scoop on Feline Vaccines

a previous vaccination for the pathogen. Where revaccination is considered necessary in a cat that has experienced an allergic reaction, using a different vaccine formulation and premedication with an antihistamine and glucocorticoid 20–30 minutes prior to vaccine administration is recommended, followed by close observation of the patient for several hours. Currently, the Feline Vaccination Guidelines Task Force recommends that veterinarians and owners monitor the vaccination site for swelling or lumps using the “3-2-1” rule.

Utilize the recommended vaccination site as seen in the diagram provided (tail and distal limb) and document any other vaccinations in the chart where given to track any adverse responses. It is currently recommended to administer the vaccines in the following manner in the feline patient:

• FVRCP given in RIGHT front limb • Rabies given in the RIGHT hind limb • FeLV given in the LEFT hind limb

It is recognized that practitioners may need to use medically appropriate discretion regarding the anatomical location of vaccinations given. It is strongly advised to keep complete, accurate records for site and route of vaccination. Everyone in the veterinary practice plays a crucial role in ensuring our feline patients are kept properly vaccinated. The Centers for Disease Control (CDC) provides a useful resource and online training module, “You Call the Shots: Vaccine Storage and Handling,” for staff training on vaccination. Practices are encouraged to have a designated person to be the primary vaccine coordinator for the facility. Always have a secondary person to serve as an alternate in the absence of the primary coordinator. Both coordinators should be fully trained in the routine and emergency policies and procedures. The Veterinarian’s Role: • Patient assessment, regardless of appointment type of current vaccine status • Discussion of an individualized vaccination plan for the patient and then discussed and agreed upon in collaboration with the cat owner In addition to the development of a vaccination protocol for the cat, the veterinarian should provide staff education on the following:

Biopsy of any mass present is warranted if it: • Remains present 3 months after vaccination • Is larger than 2 cm in diameter • Increases in size 1 month after vaccination

It is recommended to obtain an incisional biopsy on any masses meeting any of these criteria. Fine-needle aspirates may not provide diagnostic cellular tissue, whereas excisional biopsies rarely meet appropriate margins (5 cm in two fascial planes) as required in the case of injection-site sarcomas, which increases the morbidity and mortality risks associated with sarcoma invasion. It is important to have follow up examinations and phone calls to check on any clients with pets experiencing an adverse response where a Feline injection site sarcoma (FISSs) is of concern. Since FISSs are a risk, the Task Force recommends vaccination in the lower distal limbs to facilitate clean margins if surgical amputation is required. Other recommendations are as follows: • No vaccination in the interscapular space • No decrease in vaccine volume size • No ventral abdomen subcutaneous injections due to the need to remove to fascial planes and 5 cm margins. This requires aggressive tissue removal from the abdomen and abdominal cavity

Continued on page 8

QUARTERLY BEAT / DECEMBER 2021 ///

WEBINAR HIGHLIGHTS

ELLEN M. CAROZZA , LVT AAFP/AAHA Feline Vaccine Guidelines Task Force Member The Latest Scoop on Feline Vaccines

Vaccination is a medical procedure, and while vaccines are available through sources other than a veterinarian, they may not protect a cat against disease unless properly stored, handled, and administered. It is recognized that many rescues/shelters are giving vaccinations themselves instead of a licensed veterinarian. It is strongly encouraged to have the discussion on vaccine storage/ handling, as well as complete records (including injection site, serial number and expiration date) shared to help ensure the cats are receiving the current recommendations based on risk assessment and life-stye with these groups. Educational material and supplemental resources are available to the public by AAHA and the AAFP. Talking points to all clients should include: • Vaccines help protect against specific diseases • A veterinarian is the best person to evaluate a cat’s individual vaccine needs. • Veterinarian-administered vaccines are particularly important with respect to Rabies. Rabies, while fatal, is preventable and in many US states it is against the law for anyone other than a licensed veterinarian to administer a Rabies vaccine. Rabies vaccination for the cat is required by law in many but not all states. Ontario is currently the only Canadian province that requires rabies vaccination of cats. Even when areas do not require it, rabies vaccination is STILL recommended (see CORE VACCINE above.) • Severe vaccine reactions are rare, yet veterinarians should convey the risk-benefit analysis of any vaccination

• Zoonotic disease prevention • Separate administration sites • Potential life-threatening adverse events(anaphylaxis) and minor events(swelling) following vaccination • Vaccine reconstitution and handling (AAFP recommends use within 30 minutes of reconstitution) • Sharps safety procedures and accidental sticks Credentialed Veterinary Technicians or Veterinary Assistant Roles/Responsibilities: • Vaccine coordinator • Vaccine Storage and inventory management • Implementing Feline Friendly handling techniques in the hospital to minimize stress during examinations and vaccine administration • Client communication and follow up, including verbal and written instructions on potential adverse events after vaccine administration and disease prevention Reception/Client-Service Personnel: • Maintain patient files with vaccination information (date, serial number and exp date of vaccines given) • Scheduling follow up appointments for booster and yearly vaccines in advance. It is strongly encouraged to forward book appointments to minimize the possibility of missing the recommended boosters, especially in vaccines that require a series for proper immunity to develop. • Understand potential life threatening and minor adverse events that can occur following vaccine administration that require veterinary assistance Believe it or not, pet owner clients are an essential member of the cat’s healthcare team. While they can be instrumental in helping improve healthcare for their cats, the Task Force recommends that vaccination be performed by a veterinarian.

Remember, the client and veterinary practice team have the same goal: to provide the best possible care for the pet.

/// QUARTERLY BEAT / DECEMBER 2021

QUARTERLY BEAT / DECEMBER 2021 ///

WEBINAR HIGHLIGHTS

Monitoring the Anesthetized Patient - Part 2

JANE QUANDT , DVM, MS, DACVA, DACVECC Professor, University of Georgia VETgirl, Forum Consultant/Contributor

Need a review of anesthesia and missed Dr. Jane Quandt’s last anesthesia webinar? Get the highlights here on “Monitoring: What monitors tell you and what is considered standard of care.” Dr. Jane Quandt DVM, MS, DACVA, DACVECC reviews the importance of monitoring the anesthetized patient. Check out Part 1 of this article HERE in this 2-part series.

•

Oscillometric • Advantages are it is noninvasive, requires little technical experience, reads systolic, mean (measured) and diastolic (calculated) values, automated readings, every minute to every 120 minutes, and some units are battery operated and portable. • Disadvantages they can be unreliable in hypotensive or very small (< 5 kg) patients, • Motion artifact in awake animals can be a problem, readings are affected by an inappropriately sized cuff, large cuffs read low, small cuffs read high. The width of an appropriately sized cuff should be 40% of the circumference of the animal’s leg or tail.

• Advantages of pulse oximetry are they alert to early desaturation, little technical experience is necessary, and is noninvasive. • Disadvantages of pulse oximetry include, readings can be adversely affected by poor perfusion (hypotension, vasoconstriction, hypothermia), anemia (Hct<10%), movement, and improper probe placement, poorly designed (non veterinary) probes, skin pigmentation, cautery interference, and ambient light. Probes may require frequent changes in placement position to prevent vascular compression and reading errors. E. Capnography Capnography, or “respiratory gas monitoring”, measures the partial pressure of carbon dioxide in expired air. This concentration of carbon dioxide at the end of a normal “tidal” volume is the “end tidal C02”, or ETC02. Mainstream capnographs measure respiratory gases directly in the airway, between the ET tube and the circle. They can be bulky and cumbersome. Sidestream capnographs have a small adapter and a sample line which carries the gas sample to a separate analyzer. Four phases make up any capnogram, (waveform): • Phase I is the inspiratory phase, consisting of fresh gas with little CO2 • Phase II is the expiratory upstroke, illustrating the air breathed from the patient’s anatomic dead space (trachea and main bronchi, areas not involved in gas exchange) • Phase III is the expiratory plateau, consisting of high CO2 levels from the alveoli • Phase IV is the inspiratory downstroke, which is the beginning of inhalation

In this part-2 article, learn about key monitoring devices that are a must in your veterinary patients. Monitoring the anesthetized patient is the most important job during anesthesia. Thorough monitoring is the best way to assess the condition of your patient and avert disasters before they occur. Waiting for difficulties to arise not only delays solving the underlying problem(s) but also delays treatment of the obvious abnormalities. Monitoring basic parameters will draw attention to involved body systems. Although the sheet upon which we record information is divided into five-minute increments, monitoring should be constant from the time premedications are given until the patient returns to consciousness and is extubated. An ECG only monitors only the electrical activity of the heart and therefore measures the HEART rate, not the PULSE rate. A NORMAL LOOKING ECG MEANS NOTHING WITHOUT A PALPABLE PULSE! During euthanasia, the mechanical activity and the pulse/arterial wave form is lost long before the electrical activity (ECG). However, ECGs are essential in cardiac arrests in order to distinguish ventricular fibrillation from asystole, remember, a pulse is not generated with either, but the treatment is different! MECHANICAL MONITORING A. Electrocardiogram (ECG or EKG) Needle electrodes (EEG needles) are useful for ECGs in awake animals and during anesthetic induction. Traditional alligator clips are better once the animal is anesthetized, since the clips are less likely to be displaced or fall off. Lead II, R arm and L leg is most commonly used for monitoring. Because the heart sits on a more vertical axis in large animals, a “base apex” lead (lead I) is used to compare potentials between the right jugular furrow and the left cardiac apex. B. Esophageal Stethoscopes This is one of the cheapest, most easily used devices. It provides an accessible way to monitor cardiac function and

ventilation rate. A simple esophageal probe is passed after anesthetic induction, and it is positioned to hear the best sounds of the heart.

C. Blood Pressure Normal blood pressure (BP) values are:

systolic = 100-160 mm Hg mean = 80-120 mm Hg diastolic = 60-100 mm Hg

D. Pulse Oximetry (SpO2) Pulse oximetry indicates the percentage of hemoglobin saturated with oxygen ; the two wavelengths of light absorbed by oxyhemoglobin and reduced hemoglobin are detected. Pulse oximetry offers a noninvasive, continuous assessment of pulsatile arterial flow. Acceptable minimal levels of saturation are 95%-100%. A pulse oximeter will alert the clinician to the early desaturation that often precedes clinical hypoxemia and cyanosis. Cyanosis is not clinically visible until the hypoxemia is severe (i.e. Pa02 << 60 mm Hg); therefore, hypoxemia can be occurring even before cyanosis is noted. Saturations between 90-95% indicate mild hypoxemia and values < 90% indicated serious desaturation (PaO2 < 60 mmHg). Known relationships do exist between Sp02 (pulse oximeter values) and Pa02 (blood gas values):

Blood pressure (BP) is result of cardiac output (CO), vascular resistance (SVR=systemic vascular resistance; PVR=peripheral vascular resistance, same thing) and relative blood volume.

BP = CO x SVR

So, when treating hypotension, consider the possible cause(s). Low BP can result from severe bradycardia (= HR), decreased cardiac contractility (= SV), or vasodilation (= SVR). By knowing what is most likely causing the hypotension, you can effectively and rapidly treat it. Mean blood pressures below 60 mm Hg, assumed to result in inadequate coronary, renal and cerebral perfusion, should be aggressively treated; mean blood pressures should be 70 mm Hg (minimum), and preferably within the normal range (80 120 mm Hg). 1. Indirect blood pressures can be measured by: • Doppler requiring a piezoelectric crystal/ transducer/ amplifier unit, cuff and sphygmomanometer. • Advantages are noninvasive, works in any size patient, from pediatrics to large horses, constant audible indicator of pulsatile blood flow, can be used in awake patients, and is portable and rechargeable. • Disadvantages are it reads systolic only, diastolic can be estimated, with experience, and the mean must be calculated [MAP= [(SAP-DAP) / 3)+DAP] and it requires some technical experience for probe placement.

Sp02 or Sa02 (%)

Pa02 (mm Hg)

Perfect

100

>100

No cyanosis

Normal

>95

>85

No cyanosis

Serious hypoxemia Severe hypoxemia

Cyanosis NOT visible

<90

<60

<70

<40

Cyanosis visible

Continued on page 12

Near death

<60

<30

Cyanosis visible

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QUARTERLY BEAT / DECEMBER 2021 ///

WEBINAR HIGHLIGHTS

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SAFE FOR USE AROUND PEOPLE, PETS, WILDLIFE & LIVESTOCK

Monitoring the Anesthetized Patient - Part 2

JANE QUANDT , DVM, MS, DACVA, DACVECC Professor, University of Georgia VETgirl, Forum Consultant/Contributor

Normal ETCO2 levels are 35-40 mm Hg , with a normal shape. • Increased ETCO2 levels (45 mmHg) can be due to decreased alveolar ventilation (HYPOventilation), increased metabolism (sepsis, malignant hyperthermia, rebreathing carbon dioxide (broken one way valves, exhausted carbon dioxide absorbent), and increased CO2 production (bicarbonate injection). • Decreased ETCO2 levels (30 mmHg) can be due to increased alveolar ventilation (HYPERventilation), decreased CO2 production, normal CO2 production, but decreased perfusion /return of CO2 to lungs, and respiratory arrest. • Abnormal capnogram waveforms can signify esophageal intubation, obstructed/ kinked ET tube, obstructed breathing circuit, leaking anesthetic circuit, disconnection of ET tube from circuit, and sample port and scavenge port are interchanged. F. Temperature Small, thin and/or very sick patients often become hypothermic under anesthesia. Heat loss is accelerated by cold, dry oxygen flowing into the respiratory tract, exposure of viscera to a cold operating room, vasodilating drugs (ace), drugs that alter thermoregulation (opioids) and alcohol-based surgical scrubs. Hypothermia can be minimized by using warm fluids or fluid line warmers, water circulating heating pads, wrapping legs and bodies in insulating material (i.e. bubble wrap) and minimizing oxygen flows. Every effort should be made to return a patient’s body temperature to near normal postoperatively. This includes the use of heating pads, heat lamps and warm air circulating pads; when using any warming device, always be careful not to burn patients. Although these external devices may not dramatically increase the core body temperature, further heat loss will be prevented. Permissive hypothermia is a method used during anesthesia to reduce the metabolic rate and cellular function during cardiovascular or neurosurgeries.

Hyperthermia may occur with excessive muscle activity or malignant hyperthermia. Hyperthermia in cats has been documented. Treatment includes cooling extremities with alcohol, removal of any external heat sources (i.e. pads, lamps), and low doses of vasodilating drugs (acepromazine) if necessary. Most animals return to a normal body temperature within 1 hour following initiation of treatment. Animals with a history of possible malignant hyperthermia should be monitored closely for signs of hyperthermia; dramatically increased PaCO2 (arterial blood gas) and/ or ETCO2 (capnometer) levels will confirm the diagnosis. ALL inhalant anesthetics , including isoflurane and sevoflurane, should be avoided in patients prone to malignant hyperthermia. Exercise induced collapse (EIC) in Labrador retrievers is associated with hyperthermia. However, this form of hyperthermia is NOT malignant hyperthermia, and patients with EIC can be safely anesthetized as any other patient would be. G. Anesthetic Machine The anesthetic machine should be monitored throughout the anesthetic period. Things that should be check regularly including, liquid inhalant levels and vaporizer settings, oxygen flowmeter, oxygen line pressures/E tank levels, patency of endotracheal tube, airway pressure, pressure relief (“pop off”) valve patency, reservoir bag, CO2 absorbent (color change and heat) and ventilator control settings. Summary “You don’t have to provide monitoring for every patient…only those you can’t afford to lose” -Anonymous

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FLUID THERAPY CHART / JANE QUANDT , DVM, MS, DACVA, DACVECC ///

/// FLUID THERAPY CHART / JANE QUANDT , DVM, MS, DACVA, DACVECC

ADDITIVES

Glucose (g/L)

Na+ (mEq/L)

Cl- (mEq/L)

K+ (mEq/L)

Ca++ (mEq/L)

Buffer (mEq/L) Organic anion

Osmolarity (mOsm/L)

Mg+ (mEq/L)

SID mEq/L

Solution

Cal/L pH

Glucose (g/L)

Na+ (mEq/L)

Cl- (mEq/L)

K+ (mEq/L)

Ca++ (mEq/L)

Buffer (mEq/L)

Osmolarity (mOsm/L)

Cal/L

5% Dextrose

252

170

8.4% NaHCO3

1000

1000 Bicarb 2000

10% Dextrose

100

505

340

10% CaCl2

2720

1360

4080

5.5-7.5

2.5% Dextrose in 0.45% NaCl 5% Dextrose in 0.45% NaCl 5% Dextrose in 0.9% NaCl

280

4.5

14.9% KCL

2000

4000

406

170

50% Dextrose

500

2780

1700

4.2

154

560

170

0.45% KPO4

4400

7400

0.9% NaCl

154

308

Ca gluonate

465

680

6-8

Plasmalyte 148™ or Normosol-R™

Acetate (27) Gluconate (23)

140

294-296 0

5.5

27-50

COLLOIDS

25% Human Albumin Can have fatal reactions

LRS

130

109

Lactate (28)

272-275

6.5

6% Tet- rastarch

6% Tet- rastarch Hex- tend™

Isotonic crystal- loids

6% Het- arstarch Hespan™

Canine Albumin lyophilized

6% Tetrastarch Tetraspan™

10% Pen- tastarch

6% Pen- tastarch

Whole Blood

2.5% Dextrose in LRS

Properties

FFP

130

109

Lactate (28)

398

Volu- ven™

5% Dextrose in LRS 50

130

109

Lactate (28)

524

179

MW in KD

450

280

130

LRS + 16 mEq/L KCL 0

129

124

Lactate (28)

304

LRS + 2.5% Dextrose + 16 mEq/L KCL LRS + 5% Dextrose + 16 mEq/L KCL

Number Av

110

304

123

118

Lactate (26)

420

mOsm/L

250-308 300-310 308-326 308

310

308

300

296

117

113

Lactate (25)

526

COP mmHg

23-50 31-36 190-200

30-35 31

Plasmalyte 56

Acetate (16)

110

5.5

Plasmalyte 56 + 2.5% Dextrose

% vol expansion

20-25 100-200 100-200 130

300-500 1.2 times

Acetate (12)

406

Acetate (27) Gluconate (23) Acetate (24) Malate (5)

Hrs of expansion

1-4

8-26

12-24 2-6

12-24

Plasmalyte-A™

140

294

7.4

27-50

5.5

4-5.5

5.9

varies

5.6-6.4

Sterofundin-™ Iso 0

145

127

309

5.5-5.9 2

25.5

Na+ mEq/L Cl- mEq/L K+ mEq/L Mg++ mEq/L" Ca++ mEq/L

7.5% NaCl Hypertonic

154

143

140

140-145 140

1283

2567

5.5

154

124

100

105-110 118

Normosol-M

Acetate (16)

364

4-5

Ringer’s

148

156

4.5

309

0.9

0-1.5

NaCL 0.45%

154

5.6

Plasmalyte-56 in 5% dextrose

0-5

2.5

Acetate (16)

363

170

3.5-6

Dextrose g/L

0.99

0-4

References: •

Guideline for potassium supplementation for hypokalemia Patient potassium

DiBartola SP, De Morais HA. Disorders of Potassium in DiBartola SP ed, Fluid Therapy in Small Animal Practice 2nd ed, WB Saunders, 2000, pg 73-107. • DiBartola SP. Introduction to fluid therapy in DiBartola SP ed, Fluid Therapy in Small Animal Practice 2nd ed, WB Saunders, 2000, pg 265-280. • Muir WW. Current Controversies of Fluid Selection: Crystalloids vs. Colloids - What Difference Does it Make? IVECC’s 2016 proceedings, Gapevine, TX. • Rudloff E, Hopper K. Crystalloid and colloid compositions and their impact. Frontiers in Veterinary Science 2021,8: 1-11. • Silverstein DC, Santoro-Beer K. Daily intravenous fluid therapy in Silverstein DC, Hopper K eds Small Animal Critical Care Medicine 2nd ed. Elsevier 2015; 316- 321.

0 Bicarb (24)

Acetate (24) Malate (5)

Rate of potassium supplementation

Organic anion mEq/L

Lactate (28)

Normal to mild hypokalemia > 3.5 mEq/L

0.05 to 0.1 mEq/kg/hr

Moderate hypokalemia 2.5 to 3.5 mEq/L

0.3 mEq/kg/hr

Plasma half-life in hrs 0.5

2-12

16-24

Severe hypokalemia < 2.5 mEq/L 0.4 to 0.5 mEq/kg/hr do not exceed 0.4 to 0.5 mEq/kg/hr do not exceed this rate!

SID mEq/L

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they leave. Once the client has returned home, as their pet’s ear improves and the animal grows accustomed to being rewarded for having the pinnae manipulated, the client will gain confidence in performing maintenance ear cleanings once we confirm the resolution of infection at the recheck exam. Client compliance is hugely important in veterinary medicine, and like many dermatologic diseases, a simple ear infection is never truly the only problem. Claro® allows for treatment of S. pseudintermedius, Malassezia spp. or both, while I get to work finding and addressing common underlying causes, such as food or environmental allergies, hypothyroidism or autoimmune disorders. By using Claro® as part of a multifaceted approach, I can clear the current infection, get the client on board with my long-term recommendations, improve patient temperament in the clinic and at home, and satisfy every member of the patient care team. PRECAUTIONS: For use in dogs only. Do not use in cats (see POST APPROVAL EXPERIENCE). CLARO® has been associated with rupture of the tympanic membrane. Reevaluate the dog if hearing loss or signs of vestibular dysfunction are observed during treatment. Signs of internal ear disease such as head tilt, vestibular signs, ataxia, nystagmus, facial paralysis, and keratoconjunctivitis sicca have been reported (see POST APPROVAL EXPERIENCE) with the use of CLARO®. Wear eye protection when administering CLARO®. (See Human Warnings, PRECAUTIONS, POST APPROVAL EXPERIENCE).

Antibacterial, antifungal, and anti-inflammatory For Otic Use in Dogs Only CAUTION: Federal (U.S.A.) law restricts this drug to use by or on the order of a licensed veterinarian. DESCRIPTION: CLARO® contains 16.6 mg/mL florfenicol, 14.8 mg/mL terbinafine (equivalent to 16.6 mg/mL terbinafine hydrochloride) and 2.2 mg/mL mometasone furoate. Inactive ingredients include purified water, propylene carbonate, propylene glycol, ethyl alcohol, and polyethylene glycol. INDICATIONS: CLARO® is indicated for the treatment of otitis externa in dogs associated with susceptible strains of yeast ( Malassezia pachydermatis ) and bacteria ( Staphylococcus pseudintermedius ). DOSAGE AND ADMINISTRATION: CLARO® should be administered by veterinary personnel. Wear eye protection when administering CLARO®. ( see Human Warnings, PRECAUTIONS, POST APPROVAL EXPERIENCE). Splatter may occur if the dog shakes its head following administration. Persons near the dog during administration should also take steps to avoid ocular exposure. Shake before use. Verify the tympanic membrane is intact prior to administration. ( see CONTRAINDICATIONS, PRECAUTIONS, POST APPROVAL EXPERIENCE). Administer one dose (1 dropperette) per affected ear. 1. Clean and dry the external ear canal before administering the product. 2. Verify the tympanic membrane is intact prior to administration. 3. Remove single dose dropperette from the package. 4. While holding the dropperette in an upright position, remove the cap from the dropperette. 5. Turn the cap over and push the other end of the cap onto the tip of the dropperette. 6. Twist the cap to break the seal and then remove cap from the dropperette. 7. Screw the applicator nozzle onto the dropperette. 8. Insert the tapered tip of the dropperette into the affected external ear canal and squeeze to instill the entire contents (1 mL) into the affected ear. 9. Gently massage the base of the ear to allow distribution of the solution. Restrain the dog to minimize post application head shaking to reduce potential for splatter of product and accidental eye exposure in people and dogs ( see POST APPROVAL EXPERIENCE) . 10. Repeat with other ear as prescribed. 11. The duration of the effect should last 30 days. Cleaning the ear after dosing may affect product effectiveness. CONTRAINDICATIONS: Do not use in dogs with known tympanic membrane perforation (see PRECAUTIONS ). CLARO® is contraindicated in dogs with known or suspected hypersensitivity to florfenicol, terbinafine hydrochloride, or mometasone furoate. WARNINGS: Human Warnings: CLARO® may cause eye injury and irritation ( see PRECAUTIONS, POST APPROVAL EXPERIENCE). If contact with eyes occurs, flush copiously with water for at least 15 minutes. If irritation persists, contact a physician. Humans with known hypersensitivity to any of the active ingredients in CLARO® should not handle this product. PRECAUTIONS: For use in dogs only. Do not use in cats ( see POST APPROVAL EXPERIENCE) . Wear eye protection when administering CLARO® and restrain the dog to minimize post application head shaking. Reducing the potential for splatter of product will help prevent accidental eye exposure in people and dogs and help to prevent ocular injury ( see DOSAGE AND ADMINISTRATION, Human Warnings, POST APPROVAL EXPERIENCE) . Proper patient selection is important when considering the benefits and risks of using CLARO®. The integrity of the tympanic membrane should be confirmed before administering the product. CLARO® has been associated with rupture of the tympanic membrane. Reevaluate the dog if hearing loss or signs of vestibular dysfunction are observed during treatment. Signs of internal ear disease such as head tilt, vestibular signs, ataxia, nystagmus, facial paralysis, and keratoconjunctivitis sicca have been reported ( see POST APPROVAL EXPERIENCE) with the use of CLARO®. Do not administer orally. Use of topical otic corticosteroids has been associated with adrenocortical suppression and iatrogenic hyperadrenocorticism in dogs ( see ANIMAL SAFETY). Use with caution in dogs with impaired hepatic function ( see ANIMAL SAFETY). The safe use of CLARO® in dogs used for breeding purposes, during pregnancy, or in lactating bitches, has not been evaluated. ADVERSE REACTIONS: In a field study conducted in the United States (see EFFECTIVENESS ), there were no directly attributable adverse reactions in 146 dogs administered CLARO®. POST APPROVAL EXPERIENCE (2019) : The following adverse events are based on post-approval adverse drug experience reporting for CLARO®. Not all adverse events are reported to FDA/CVM. It is not always possible to reliably estimate the adverse event frequency or establish a causal relationship to product exposure using these data. In humans , accidental exposure leading to corneal ulcers and other ocular injuries such as eye irritation and redness have been reported. Exposure occurred when the dog shook its head after application of CLARO®. Skin irritation has also been reported. In dogs , the adverse events reported are presented below in decreasing order of reporting frequency: Ear discharge, head shaking, ataxia, internal ear disorder (head tilt and vestibular), deafness, emesis, nystagmus, pinnal irritation and ear pain, keratoconjunctivitis sicca, vocalization, corneal ulcer, cranial nerve disorder (facial paralysis), tympanic membrane rupture. CLARO® is not approved for use in cats . The adverse events reported following extra-label use in cats are presented below in decreasing order of reporting frequency: Ataxia, anorexia, internal ear disorder (head tilt and vestibular), Horner’s syndrome (third eyelid prolapse and miosis), nystagmus, lethargy, anisocoria, head shake, emesis, tympanic rupture, and deafness. To report suspected adverse drug events and/or obtain a copy of the Safety Data Sheet (SDS) or for technical assistance, contact Elanco at 1-800-422- 9874. For additional information about adverse drug experience reporting for animal drugs, contact FDA at 1-888-FDA-VETS or online at http://www.fda.gov/reportanimalae. Information for Dog Owners: Owners should be aware that adverse reactions may occur following administration of CLARO® and should be instructed to observe the dog for signs such as ear pain and irritation, vomiting, head shaking, head tilt, incoordination, eye pain and ocular discharge (see POST APPROVAL EXPERIENCE ). Owners should be advised to contact their veterinarian if any of the above signs are observed. Owners should also be informed that splatter may occur if the dog shakes its head following administration of CLARO® which may lead to ocular exposure. Eye injuries, including corneal ulcers, have been reported in humans and dogs associated with head shaking and splatter following administration. Owners should be careful to avoid ocular exposure (see PRECAUTIONS, POST APPROVAL EXPERIENCE ) CLARO ® (florfenicol, terbinafine, mometasone furoate) Otic Solution for use in dogs only Do Not Use in Cats.

Feline Thyroid Disease: What’s the TSH?

STEFANIE DEMONACO , DVM, MS, DACVIM Assistant Professor, Small Animal Internal Medicine Virginia-Maryland College of Veterinary Medicine

Did you miss Dr. Stefanie DeMonaco’s YouTube LIVE event on the use of TSH on the diagnosis of feline thyroid disease? Click below to watch it and read what you need to know!

hyperthyroidism can have tT4 fluctuating in and out of the reference range, and NTI can lower tT4 into the reference range. In those cases, measuring TSH with free T4 (fT4) can aid in the diagnosis. One of the limitations of using fT4 in cats with NTI is that 20% of cats will have a falsely elevated fT4, 1 further confounding the diagnosis of hyperthyroidism. TSH is commonly used in humans and dogs for the diagnosis of thyroid disease, but until most recently, has not been routinely used in cats. The current assay that is widely available uses canine TSH assay (cTSH) to measure feline TSH. The limitation of this assay is the lowest detection limit (<0.03 ng/dL), as this does not differentiate low-normal concentrations from those below the reference interval. A closer look at cTSH in hyperthyroid and euthyroid cats highlights how the lower limit of detection obscures the diagnosis of hyperthyroidism. Serum cTSH was undetectable in most – if not all – hyperthyroid cats, but it was also undetectable in one-third of euthyroid cats. The overlap of undetectable cTSH concentrations between hyperthyroid and euthyroid cats is a limiting factor in the diagnosis of hyperthyroidism. The accuracy of cTSH improves when measured in combination with tT4 and fT4. A tT4 concentration within the upper-third of the reference range with high serum fT4 and undetectable TSH is suggestive of hyperthyroidism. When considering cTSH for the diagnosis of thyroid disease, it is important to understand how NTI impacts the concentration in order to appropriately interpret the test. There are few studies that have evaluated cTSH in cats

The use of thyroid-stimulating hormone (TSH) in the diagnosis of feline thyroid disease has recently become more routine in clinical practice. Concurrent nonthyroidal illness (NTI) in hyperthyroid cats and those with mild hyperthyroidism can be problematic to diagnose when total T4 (tT4) concentration is within the reference interval. Concurrent TSH can be helpful in supporting the diagnosis. In addition to screening for hyperthyroidism, TSH has become part of the routine diagnosis of feline iatrogenic hypothyroidism that can occur after treatment for hyperthyroidism. The current use and best practices of TSH in cats with hyper- and hypothyroidism will be discussed. Use of TSH to diagnose hyperthyroidism Feline hyperthyroidism is the most common endocrinopathy in aged cats. Diagnosis is typically made by documenting an increased tT4 concentration in a cat with compatible clinical signs of hyperthyroidism. However, 10% of hyperthyroid cats will have a high-normal tT4 concentration due to early hyperthyroidism or NTI. 1 This occurs because cats with early

BRITTANY LANCELLOTTI, DVM, DACVD

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