VETgirl Q3 2022 Beat e-Magazine





04 A Case of Chronic Canine Enteropathy: Should Diet Change Be Your First Option? 08 10 Things to Do When You’re Not Okay

10 Tech Triage: What’s your superpower?

14 What Matters Most in Pet Food Selection?


18 Local Anesthetic Blocks of the Head and Limbs

24 Infection Control Practitioner for the Win


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OPTION 3: A DIET TRIAL Given the likelihood that Toby has a diet-responsive chronic enteropathy, I would strongly recommend a diet trial as the first option to try. And if the first diet I try doesn’t get results, trying a second or third diet may be advisable before prescribing other therapeutic options. Here’s why: • Efficacy . Finding the right diet can sometimes take time, but most dogs with CE will ultimately improve on a diet. 4 If you are successful in getting his owner on board, Toby is likely to have a positive outcome that is lasting. • Compliance . Provided the patient has a good appetite, dietary therapy is easy to administer. However, you must take the time to explain to Toby’s owners what compliance looks like (e.g., strict adherence to the prescribed diet with no unapproved treats, table-scraps, etc.) and make sure they understand the anticipated timetable for evaluating—and revaluating—success. • Safety . While the convenience of a “quick fix” is always appealing to clients, owners ultimately want what is best for their pets. Here again, take the time to explain why alternatives such as antibiotic and immunosuppressive therapies are best reserved for patients that truly need them. Making the dietary recommendation Now that Toby’s owner is on board to try dietary therapy, which diet should you recommend? Three nutrients to consider when selecting a therapeutic diet for CE dogs are fat, fiber and protein . • Protein . Protein can be the culprit for many dogs suffering from food intolerance and/or food allergy . A trial with a hydrolyzed protein or amino acid-based therapeutic diet can lead to improvement of clinical signs in chronic enteropathy dogs in as little as 10 to 14 days. 5,6 Truly food-allergic dogs often suffer from concurrent nonseasonal pruritis and otitis as well as GI signs and may require up to eight weeks to show improvement in their extraintestinal (i.e., dermatological) clinical signs. • Fat . Clinical signs such as burping, regurgitating, vomiting and/or discomfort after eating are indications that a patient may be experiencing delayed gastric emptying. These dogs may benefit from a lower-fat diet so that food can exit the

stomach more quickly. Meanwhile, dogs with protein- losing enteropathy and/0r lymphangiectasia are candidates for ultra-low fat therapeutic diets. They do not always require immunosuppression. 6 • Fiber . Dogs with large-bowel diarrhea may benefit from diets with increased fiber to add bulk to their stool. Diets formulated with prebiotic soluble fibers, such as psyllium, can provide further healing for the colon due to the fiber fermentation and conversion to short-chain fatty acids that feed colonocytes. An answer for Toby Based on his clinical signs, you recommend a hydrolyzed protein diet for Toby, giving detailed instructions as to the transition from the current diet, the amount to feed, and what to expect. Two weeks later, his owners reported that his stools are more formed and less frequent. This rapid response suggests that Toby has a diet-responsive chronic enteropathy . In such cases, it isn’t always necessary to determine the offending protein—nor do all dogs need to stay on hydrolyzed diets for the rest of their lives. For some, a food intolerance may have been triggered by an inflammatory episode that may resolve with time, allowing them to tolerate components of or even their entire previous diet. In other cases, reintroduction of intact proteins or the previous diet triggers a flare-up of CE signs. Realistically, I find that many owners who have endured months of GI upset with their dogs prior to a successful diet trial will opt to stay on the trial diet rather than rock the boat and risk a relapse. Successful management of Toby’s condition required taking time to educate his owners and enlist their partnership in finding a solution that was both safe and effective. Making diet trial the first choice—versus the second or third choice—is a paradigm shift to consider when managing patients with CE. Sidebar: Elemental diet offers a new diet trial option I recently conducted a prospective, uncontrolled study 7 to evaluate the effectiveness of feeding Purina® Pro Plan® Veterinary Diets EL Elemental Canine Formula—an amino acid-based diet—to client-owned dogs with CE. I recruited 23 dogs experiencing signs such as diarrhea, vomiting, reduced appetite and/or unexplained weight loss. The gastrointestinal (GI) mucosa of the dogs was evaluated via upper and lower GI endoscopies, with all showing evidence of intestinal inflammation. After a gradual food transition, the dogs were exclusively fed EL Elemental for two weeks and monitored closely at home. Of the 23 dogs, only one refused to eat the diet. The remainder were fed the diet for a total of eight weeks, with

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


ALISON MANCHESTER , DVM, DACVIM (SAIM) Veterinary Specialist and One Health Fellow Colorado State University College of Veterinary Medicine and Biomedical Sciences A Case of Chronic Canine Enteropathy: Should Diet Change Be Your First Option?

In this VETgirl featured article sponsored by Purina Pro Plan Veterinary Diets, Dr. Alison Manchester, DACVIM discuss how to manage chronic enteropathy.

Is this scenario familiar? A client comes in with a 1-year- old Labrador retriever—let’s call him Toby—who has been suffering from intermittent diarrhea for several months. Toby’s body condition and appetite are both good. His blood work and albumin levels are normal. Given the length of time he’s been experiencing clinical signs, you’ve ruled out stress diarrhea and dietary indiscretion. Knowing that Toby’s owner is eager for a solution, what do you recommend? OPTION 1: AN ANTIBIOTIC Understandably, Toby’s owner would love you to prescribe a pill that would resolve his dog’s diarrhea quickly and inexpensively. And many of us might respond

Antibiotics—especially those that target anaerobic bacteria— can have long-lasting effects on a patient’s GI microbiome. I’m especially hesitant to give antimicrobials to young animals because their microbiomes are still developing. While we don’t yet have animal studies on this, there are compelling human data showing that antibiotic exposure early in life can set people up for serious problems such as Crohn’s disease, asthma and allergic rhinitis later on. 1,2,3 Antimicrobial resistance is another potential consequence. For example, if Toby were to develop a urinary tract or other infection in the future, it is possible the repeated antimicrobial courses he was given for diarrhea will have selected for antimicrobial-resistant bacteria, thus complicating his treatment. OPTION 2: A COURSE OF STEROIDS Another tool many of us consider in managing CE is an immunosuppressive medication such as prednisone, budesonide or cyclosporine. The rationale is that steroids can be effective in managing patients with conditions such as inflammatory bowel disease and protein-losing enteropathy. Once again, sending Toby home with a bottle of prednisone may temporarily meet the owner’s desire for a quick and inexpensive solution. But he or she will probably not be happy with the side effects (e.g., polydipsia, polyuria and polyphagia) that accompany steroid use—especially if it becomes necessary to keep Toby on long-term therapy. While specific immunomodulatory drugs have their place in the management of serious enteropathies, reserving this option for situations where you are certain the patient will not respond to other treatment modalities may be best.

in that spirit by sending him home with a course of metronidazole or another broad-spectrum antibiotic. After all, we know from experience that these antimicrobials will likely suppress clinical signs, at least for a time. The problem is that

the antibiotic probably won’t resolve his chronic

enteropathy (CE) long-term. Why? Because Toby probably isn’t suffering from a primary bacterial enteritis. Once he’s finished his course of antibiotics, you will likely see him in your office again when his clinical signs return. And while another course of metronidazole might, again, suppress these signs temporarily, you will not have addressed the underlying cause of his diarrhea.

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evaluations taking place at both the two-week and eight-week marks. Of 22 dogs, 16 experienced adequate relief* along with a substantial decrease in their Canine Inflammatory Bowel Disease Activity Index (CIBDAI) score at the two-week or eight-week- marks*—overall, a 73% success rate. EL Elemental offers another option in the armament of therapeutic diets that can help dogs gain relief from their CE.

*Due to changes in response, the dogs that experienced relief at the two and eight-week-marks were not the same dogs.

References: 1.

Kronman MP, Zoutis TE, Haynes K, et al. Antibiotic Exposure and IBD Development Among Children: A Population-Based Cohort Study. Pediatrics October 2012; 130 (4): e794–e803. 2. Mitre E, Susi A, Kropp LE, et al. Association Between Use of Acid- Suppressive Medications and Antibiotics During Infancy and Allergic Diseases in Early Childhood. JAMA Pediatr 2018 Jun 4;172(6):e180315. 3. Aversa Z, Atkinson EJ, Schafer MJ, et al. Association of Infant Antibiotic Exposure with Childhood Health Outcomes. Mayo Clin Proc. 2021 Jan;96(1):66-77. 4. Allenspach K, Culverwell C, Chan D. Long-term outcome in dogs with chronic enteropathies: 203 cases. Vet Rec 2016;178(15);368. 5. Luckschander N, Allenspach K, Hall J, Seibold F, Gröne A, et al. Perinuclear antineutrophilic cytoplasmic antibody and response to treatment in diarrheic dogs with food responsive disease or inflammatory bowel disease. J Vet Intern Med 2006;20:221-227. 6. Wennogle SA, Stockman J, and Webb CB. Prospective evaluation of a change in dietary therapy in dogs with steroid-resistant protein-losing enteropathy. J Small Anim Pract 2021; 62: 756-764. 7. Manchester AC, Dow S, Gagné J, Lappin M. Efficacy of an elemental diet in achieving clinical remission in dogs with chronic inflammatory enteropathy [abstract]. In: Proceedings of American College of Veterinary Internal Medicine Forum; June 2022; Austin, TX, USA.

Alison Manchester, DVM, DACVIM (SAIM) Veterinary Specialist and One Health Fellow Colorado State University College of Veterinary Medicine and Biomedical Sciences




8 PHONE A FRIEND We all need caring others who can listen to our most difficult truths without judging, interrupting, or fixing. Identify at least two people who are trustworthy in this role and create a shorthand manner of requesting their attention. With my own “witnesses,” as I call them, this sounds like, “Do you have 10 minutes?” (which actually means, “Help me, I’m struggling”). 9 GET INTO NATURE Contact with the natural world (fresh air, trees and plants, wildlife) is deeply grounding, bringing us back into our bodies and allowing our over-active brains to rest. Quiet time in nature – or mindful movement in green spaces – does wonders for mental and physical health.

10 FOCUS ON THE PRESENT MOMENT When everything seems like it is spinning out of control, focusing on what needs attention right now gives the anxious, searching brain a task. Make the task something quick and achievable (like making a phone call, writing a grocery list, washing the dishes, or feeding the dog). Start small and give yourself a “win.”


10 Things to Do When You’re Not Okay

BY JEANNINE MOGA, MA, MSW, LCSW Chief Happiness Officer, VETgirl


In this VETgirl online veterinary continuing education article, VETgirl’s Chief Happiness Officer, Jeannine Moga, MA, MSW, LCSW, clinical veterinary social worker, discusses what to do when you’re not okay …because, you know: COVID caseloads, virtual learning, hospital closures, crabby clients. It’s the big things, the little things, and everything in between. And sometimes it’s all just too much.

4 PLAYLIST IT Music has the capacity to alter mood, blood pressure, and heart rate. Using the “ISO Principle,” identify a song that represents how you feel right now, a song that represents how you want to feel, and a few songs in between that might move you from here to there. Think of playlists as mobile tools that help us to both up-regulate (energize and focus) and down-regulate (calm and soothe). 5 EXPOSE YOURSELF TO COLD Splashing ice water on your face, taking a cold shower, and drinking ice water activate the vagus nerve, which helps the body down-regulate after stress exposure. 30 seconds of cold exposure improves vagal tone, thereby allowing the body to reset. 6 LAUGH Find something – anything – that allows a sense of playfulness or joy to emerge for even a short time. Laugher can increase heart-rate variability and improve your stress response. 7 WRITE IT DOWN Giving difficult feelings and thoughts a literal place to land can help our brains manage overwhelm.

HERE ARE 10 ACTIVITIES TO TRY WHEN YOU ARE FEELING OVERWHELMED: 1 BREATHE Deep breathing triggers a relaxation response and gives us access to the toolbox that otherwise goes off-line when we are overwhelmed. Breathe in through the nose and out through the mouth. Count to 4 on the in-breath, pause for 2 counts, and then count to 6 on the out- breath. Repeat until you feel your shoulders drop and your belly relax. 2 MOVE Move your body with the intention of discharging built- up stress and tightness. This can be accomplished via a short walk, a few minutes of stretching, or some yoga poses. Short bursts of movement help us to reset, and if you can get your heart rate up a bit, it will be even more effective. 3 HUG IT OUT We are wired for connection, and our body-mind finds comfort in the deep pressure of a good hug with someone safe. Find a willing other (a friend, a pet, a partner, a child) and hug them – aiming for a ‘medium’ squeeze – for about 20 seconds. Feel yourself relax as your vagus nerve triggers a calming response and oxytocin gets released.

Photo by Luis Villasmil on Unsplash




An individual’s objective is not intuitive, assessment will determine the urgency of care. The question remains how can we ensure that our technicians are triaging the patients appropriately? • Training • Use of Protocols A 1994 study out of the University of Pennsylvania established the first veterinary scoring system which applied to animals presenting after acute trauma. This is referred to as the Animal Trauma Triage (ATT) scoring system. This system was used to aid in categorization, outcome prediction and in determining the need for immediate medical or surgical intervention. In this system physical exam findings were categorized into six classifications and scored on scale 0-3. The higher the ATT score indicates the need for immediate treatment and provides the veterinarian with survival prediction. A 2012 JVECC study looked at the evaluation of a veterinary triage list. This list was modified from a human triage scoring system but was modified to apply to common conditions that are seen in veterinary medicine. The Veterinary Triage List (VTL) can be applied to all emergency patients as compared to the Animal Trauma Triage System which was devised to provide stratification of veterinary trauma patients (4). The VTL aids the technical staff in categorizing the patient, determining the urgency of care, and establishing wait times. The results of this study suggested that the use of the VTL was more effective at categorizing emergency patients with target waiting times as compared with intuitive triage performed by veterinary technicians. (4)

a primary survey to quickly identify urgency of care and begin intervention. The primary survey uses both subjective and objective evaluations to guide appropriate treatment. Items required in the “resuscitation area” include: • Multiparameter -ECG, ETCO 2 , SpO 2 , NIBP • Intravenous catheters of variable sizes and accessory supplies for their proper placement • IVF/pressure bags • Oxygen • Crash Cart (ET tubes/trach tubes, defibrillator, ambu bag, drugs, etc.) • Suction unit including tubing and suction tips • Diagnostic equipment for the minimum data base blood work, blood gas evaluation, electrolytes, and lactate • Ultrasound • Immobilization board RESPIRATORY SYSTEM The main goal of respiratory evaluation is to determine ventilation status and oxygen delivery. Evaluation includes visualization, palpation, and auscultation. Determining patency of the upper airway should be assessed first. The noise (stertor/stridor) of breathing and effort should be assessed to determine if the upper airway is compromised. If the upper airway is patent, the next step in evaluation should include obtaining a respiratory rate and effort. During the primary survey an SpO 2 and arterial blood gas can be used to help assess the blood oxygen levels and ventilation status. If there is any clinical evidence or subjective evidence of oxygen deprivation or respiratory distress, oxygen support should be initiated as soon as possible. CARDIOVASCULAR The assessment of the cardiovascular system is to determine the effectiveness of oxygen delivery to the tissues and if the cardiovascular system is compromised. This includes evaluation of mucous membrane color, capillary refill time, heart rate, rhythm, and blood pressure. It is important to remember that in the earlier stages of shock the patient vitals may only be slightly outside of the normal range. Also, abnormally normal values may be present as in the case of cats in the hospital with a heart rate under 160 beats per minute. NEUROLOGIC Evaluation of the nervous system should include the patient’s level of consciousness, cranial nerve deficits and stance or gait abnormalities.


Tech Triage: What’s your superpower?

BY TIFFANY GENDRON CVT, VTS (ECC) Veterinary CE Coordinator, VETgirl

Triage is a process of sorting and treating patients based on assessment of perceived illness. The most critical patients are awarded priority of treatment. In veterinary medicine we have used human triage models and applied these principles to create veterinary triage scoring systems. Although there are a number of triage scoring systems the goal is similar, to accurately assess a patient’s status based on parameters to better classify the patient and their need for care. Triage occurs over the phone, in the lobby and/or within the initial treatment room. It is important to remember that hospitalized and triaged patients alike require reassessment of their status on a constant basis as their status can change at any time. This allows the veterinary professional to triage the order of treatment required based on the patient’s status. This follows the veterinary technician practice model. Regardless of where the initial triage takes place, clear and concise communication and assessment are essential to provide expedited patient care.

• Vomiting/Diarrhea-character and frequency • Toxin exposure if indicated HOSPITAL TRIAGE Proper communication is one of the most important aspects of a successful triage system. The triage should begin with the veterinary technician introducing themselves to the client, determining the patient’s name and using this information to develop an open dialog during the examination. Explain to the client what you are doing and obtain a brief medical history as outlined above. To make an initial assessment the veterinary technician must be familiar with normal vs. abnormal vital parameters and the use of an established triage scoring system can improve these assessments.

PHONE TRIAGE The phone triage is going to be performed by either a client service representative or a veterinary technician based on the practice. This further signifies the importance of staff training. Knowing what questions to ask is a critical aspect of phone triage communication. For this reason, some hospitals may develop a telephone communication script for their staff to utilize. This triage should be quick and concise if immediate care is required the attending staff needs to clearly convey this message to the client. Telephone triage should include: • What is your primary concern today with your pet? • How is the animal doing (Owner’s chief concern)? • Signalment • Pertinent medical history (i.e., diabetic, asthmatic) • Any medications the patient is receiving • Determine urgency- this is based on what the client can provide to you • Respiratory (fast, slow, hard, loud) • Cardiovascular (mm color, heart rate fast or slow) • Neurologic (mentation, seizures, paralysis) • Urogenital (dystocia, urination status, uterine prolapse, paraphimosis) • Eating/Drinking- include frequency

Table 2. Veterinary Triage List Color Urgency

Target Wait 0 Minutes 15 Minutes


Immediate Very urgent

Orange Yellow


30-60 Minutes 120 Minutes 240 Minutes


Standard Nonurgent


THE STAT! TRIAGE A patient requires immediate attention when there is an imminent and immediate risk to the life of the patient or in a situation where end-organ damage can be prevented with immediate therapy, as for example in ethylene glycol toxicosis. There are also other urgent presentations that require immediate intervention such as active bleeding, toxin ingestion, severe pain, and trauma. If an animal requires immediate treatment the patient should be expedited to a “resuscitation area”. This area should be stocked with all the necessary equipment required to facilitate immediate intervention. During this time the veterinary team will conduct

Table 1: Vital Parameters for Adult Small Animals TPR Values Temp, o F

Heart Rate Respiratory Rate

Dog Cat

100.0-102.2 60-160 bpm 16-32 bpm 100.0-102.2 140-220 bpm 20-42 bpm

The veterinary technician’s assessment is what determines the prioritization and allocation of resources, diagnostics procedures, and treatments.

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UROGENITAL This should include visual examination of the patient and include palpation of the urinary bladder. As part of the primary survey in evaluation of the urogenital system an ultrasound may be performed to assess for fluid filled structures as seen in a pyometra or scan for free fluid. During the primary survey several diagnostic and interventions can be performed to aid the practitioner in establishing appropriate treatments and/or lead to a diagnosis. Following the primary survey and initial resuscitation (if indicated), a more complete evaluation of the patient should be performed, this is the secondary survey. During the secondary survey the patient is reassessed looking at all body systems and reassess response to therapy. Triage requires trained staff to make accurate assessments to identify life-threatening emergencies. The use of established protocols and staff training can improve patient outcomes. RuysL.J., Gunning M., Teske E., Evaluation of a veterinary triage list modified from a human five-point system in 485 dogs and cats, J Vet Emerg Crit Care, 2012; 22(3)303-312. 2. Mackway-Jones K, Marsden J, Windle J. Emergency Triage, Manchester Triage Group, 2nd ed. Oxford: Blackwell Publishing LTD.; 2006. 3. References 1. Weltman J. G, Prittie J.E, The influence of a fast-track service on case flow and client satisfaction in a high-volume veterinary emergency department, J Vet Emerg Crit Care 2021:31(5):608-618. 4. Silverstein D., Hopper K. Small Animal Critical Care Medicine. 2nd Ed. St. Louis: Elsevier, 2015, Chapter 1: p. 1-5.

5. Lisciandro GR. Abdominal and thoracic focused assessment with sonography for trauma, triage and monitoring in small animals. J Vet Emerg Crit Care 2011;21(2):104-122. 6. Creedon J., Davis H. Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care. West Sussex: Wiley-Blackwell, 2012, Chapter 1: p. 5-10. 7. MCMurray J, Boysen S, Chalhoub S. Focused assessment with sonography in non traumatized dogs and cats in the emergency and critical care setting. J Vet Emerg Crit Care 2016:26(1):64-73.

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



VICKIE CARMELLA , DVM, FFRCP Director of Veterinary Scientific Affairs, Blue Buffalo Company NOLAN FRANTZ , PHD, MS Director of Research & Development, Blue Buffalo Company What Matters Most in Pet Food Selection?

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Photo by Ayla Verschueren on Unsplash


In this VETgirl feature article sponsored* by Blue Buffalo, Dr. Vickie Carmella and Dr. Nolan Frantz discuss what matters most in pet food selection.

Veterinarians are often faced with the challenge of making specific nutritional recommendations to healthy pets, or for pets requiring therapeutic dietary formulations. But how often do clients follow the recommendations of their veterinarian? Even though veterinarians are the most trusted source of pet food recommendations, clients only follow them about one-third of the time. In our field of expertise (animal nutrition), we spend a lot of time and resources evaluating and understanding why pet parents select the diets that they do for their pets. When asking pet parents what attributes are extremely important in diet selection, ingredients that are recognizable always rises to the top. This can be frustrating for veterinarians, who are often recommending very efficacious therapeutic diets that often contain ingredients that may be less attractive to pet parents. We know that veterinarians spend a significant amount of time educating clients about nutrition and the importance of specific nutrients, especially with disease state nutrition. But veterinarians aren’t the only source of “expertise” pet parents are hearing from - there’s a lot of swirl out there, and so pet parents are receiving messages about what’s best for their pet every time they turn on the television, through digital experience, or when walking into a pet store. With so many different priorities in pet food decision-making, how can we as animal health experts, help provide resources to help simplify discussions with your clients regarding pet food decision making? And how can veterinarians, as the experts in making pet food recommendations, feel confident that your clients are feeding an adequate diet from an adequate pet food manufacturer?

If your pet parents have strong food preferences, ask them to do their research. Most manufacturers share a tremendous amount of information about their company on their website. When discussing pet food with your clients, sharing key features that they should look for in a manufacturer may help you to navigate challenging nutrition discussions. By asking your client to answer a few key questions about their preferred pet food brand, you can work together to find adequate nutrition solutions that meet your clients’ preferences and your standards for nutritional excellence. • Validate who is formulating the diets for the food brands that your clients prefer. Ensure they have credentialed animal nutritionists (either PhD animal nutritionists or DVM board-certified nutrition specialists) with expertise in pet nutrition. In addition to product formulation, a team of expert nutritionists will often be responsible for ongoing testing to ensure formula compliance with guaranteed analysis and product claims. • Knowing that a diet includes desired ingredients is not always enough. If your clients have a food brand preference, encourage them to do their research to ensure the manufacturer has a robust quality assurance program to validate product safety and efficacy. This may include: • Rigorous ingredient testing prior to approval for use in their formulations, testing certifications and certificate of origins and certification of ingredient specifications for every shipment they receive. Additionally, routine ingredient nutrient and specification testing should be performed to help ensure consistency in formulation. Manufacturers should be doing routine ingredient supplier audits to ensure consistency, efficacy, and ingredient safety.



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• Robust quality control protocols in place for manufacturing, including both at in-house and co- manufacturing facilities. These protocols would include ingredient traceability and formula verification with authentication processes in place. • If your clients have a food brand preference, relay the importance of manufacturer feeding studies , which may include: • Feeding trials to ensure adequate acceptance (palatability studies) and digestibility studies. Additional studies, such as urine pH testing, may also be indicated depending on diet indication. • AAFCO adequacy: AAFCO requires every bag or can of food to have a nutritional adequacy statement specifying whether the diet is complete and balanced. This statement will identify how a “complete and balanced” claim is substantiated (either by an AAFCO feeding trial or through the diet formulation) and will also specify the species and life stage for which the product is intended to be fed. • Finished product testing, including nutrient verification and shelf-life stability studies. • Therapeutic diets may also undergo specialized studies to demonstrate product efficacy, such as RSS testing for urinary support diets. Clinical trials demonstrating specific benefits in disease-states are often listed on product webpages or support materials and are generally available for download. Can’t find the information you need? Contact your sales representative or professional services veterinarian and ask them for a run-down of support material. Evaluating manufacturer answers to these few critical questions will provide solid, objective information for evaluating pet food. This will dramatically help to simplify exam room nutrition discussions so that you, as a veterinary professional, and your client, as a pet parent, can find nutritional solutions that meet everyone’s needs and expectations.



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plane of the head. The area desensitized by the block depends on placement of the needle and the volume used. If the local anesthetic is placed outside of the canal, only the ipsilateral skin of the nose and the upper lip are desensitized. If the drug in placed in the canal (by inserting the needle in the canal and/ or by increasing the volume and gentle pressure with the finger on the injection site) some premolar, canine, incisor teeth and associated soft tissues will be desensitized as well. Mental Nerve Block: This block is performed with the animal in lateral recumbency with the side to be blocked facing up. The middle mental foramen can be identified by palpating the root of the second premolar in dogs and the area between the canine and third premolar in cats. A transcutaneous or transmucosal approach can be used. The needle is placed between the finger palpating the foramen and the lateral aspect of the mandible and the local anesthetic is injected. This block only desensitizes the rostral lower lip. If the needle is placed inside the mental canal, the rostral inferior alveolar nerve can be blocked desensitizing also premolar, canine, and incisor teeth. LOCAL BLOCKS FOR THE LIMBS Most blocks can be performed using a nerve locator and/or an ultrasound machine to localize the nerves. Bupivacaine 0.5% or ropivacaine 0.5% are generally used. Doses and volumes may vary depending on the specific nerve and location. Insulated needles are used for nerve stimulation with a nerve locator. Most of these needles can also be seen with an ultrasound; however, if only the ultrasound machine is used to localize the nerve, a spinal needle will be sufficient. Brachial plexus block: This block provides anesthesia to the distal humerus and everything distal to this location. It can be performed with a nerve locator, with an ultrasound or with both techniques. The use of an ultrasound increases the chance of a complete block. When using a nerve stimulator alone, the animals is positioned in lateral recumbency with the affected leg in a non-dependent position. The block is performed by palpating the point of shoulder and the first rib and inserting a long needle parallel to the spinal cord. The index on the non- dominant hand that is palpating the first rib can be used to protect the chest cavity and the needle can be inserted above of the index. Risks include hemorrhage and pneumothorax. When using an ultrasound machine, the animal is placed in dorsal recumbency with the affected leg flexed in neutral position. The linear transducer is positioned in the axillary space and a spinal or insulated needle is inserted in-plane cranio-caudally. The nerve bundle is located cranial to the axillary artery. The total volume of local anesthetic used is approximately 0.3-0.4 ml/kg of 0.5% bupivacaine or ropivacaine.

RUMM block: This block anesthetizes the radial nerve (lateral approach) and the ulnar, musculocutaneous, and median nerves (medial approach). It is indicated for surgical procedures of the thoracic limb distal to the elbow (antebrachium, carpus, and foot). When using a nerve stimulator alone, the needle is inserted in the lateral aspect of the limb between the middle third and the distal third of the line connecting the point of the shoulder and the lateral epicondyle of the humerus. To block the medial nerves (ulnar, musculocutaneous, and median), the needle is inserted in the half-way point of the line connecting the point of the shoulder and the medial epicondyle of the humerus avoiding the biceps brachii muscle. When using the ultrasound, the linear transducer is placed transverse to the longitudinal axis of the humerus (same location described for the nerve locator technique). The needle is inserted in-plane cranio-caudally. The radial nerve is hyperechoic and is located caudal to the humerus between the brachialis and the triceps brachii muscles. To block the medial nerves, the transducer is placed on the medial aspect of the limb at the level of the mid-diaphysis of the humerus. Just caudal to the humerus, the brachial artery can be identified and the brachial vein is located caudal to the artery. The median and ulnar nerves can be found between these two vessels and the musculocutaneous nerve is located cranial to the brachial artery. The volume of local anesthetic used for these blocks is 0.2-0.3 ml/kg of 0.5% bupivacaine or ropivacaine, half for the radial nerve and the other half for the medial nerves. Bier block: This block, also known as intravenous regional anesthesia, is used to anesthetize the thoracic or pelvic limb caudal to the injection site of the local anesthetic. It is paramount to use lidocaine instead of bupivacaine or ropivacaine due to their cardiotoxicity. After prepping the limb, an intravenous catheter is placed proximal to the area of interest and directed distally. An Esmarch bandage is applied starting from the distal portion of the leg until the IV catheter is covered to remove the blood from the limb. A tourniquet is then applied at the proximal end of the bandage to prevent blood from perfusing the distal limb and the bandage is removed. A dose of 6 mg/kg of 2% lidocaine is injected in the IV catheter before the surgical procedure starts. The tourniquet should be removed after 60- 90 minutes from its application to avoid nerve injury. Once the tourniquet is removed, the local anesthesia of the block ends and systemic analgesia should be provided. Sciatic and femoral-saphenous nerve blocks: Both sciatic and femoral-saphenous nerve blocks are required to anesthetize structures distal to the mid femur. When using the nerve locator alone, the patient is positioned in lateral recumbency with the affected leg up. With the non-dominant hand, the operator palpates the greater trochanter of the femur and the ischiatic tuberosity. The insulated needle is inserted halfway between these two points and perpendicular to the skin in the biceps femoris muscle until the contraction/extension of the


MICHELE BARLETTA , DVM, MS, PHD, DACVAA University of Georgia, College of Veterinary Medicine, Department of Large Animal Medicine, Athens GA Local Anesthetic Blocks of the Head and Limbs

In this VETgirl anesthesia webinar “Ten Most Popular Local Nerve Blocks in Small Animals,” Michele Barletta, DVM, MS, PhD, DACVAA discusses how to improve your analgesia in your small animal patients with the use of local anesthesia blocks. In these proceedings, he reviews local blocks of the head and limbs. Missed the webinar? Check it out HERE!

margin of the mandible and on its medial side. Avoid the lingual nerve by keeping the needle as close as possible to the mandible. Maxillary nerve block: This block desensitizes the ipsilateral upper lip, skin of the nose, mucosa of soft and hard palate, maxilla including the teeth and associated soft tissues. This block can be performed using 3 approaches: 1. Intraoral: the animal’s mouth is kept open (use mouth gag) and the needle is inserted caudal to the last molar perpendicular to the hard palate. 2. Subzygomatic: the needle is inserted through the skin perpendicular to the median plane of the head. The point of insertion is ventral to the zygomatic arch and between the caudal aspect of the maxilla and the coronoid process of the mandible. 3. Infraorbital: after identification of the infraorbital foramen via palpation (dorsal to the 3rd maxillary premolar, rostroventral to the eye) a thin needle or a catheter is inserted in the infraorbital canal to reach the caudal position and exit the maxillary foramen where the local anesthetic is deposited. There is a higher risk of damaging neurovascular structures in the canal when a needle is use. To avoid nerve damage, use a catheter instead of a needle. Once the catheter is close to the foramen, advance only the catheter in the canal without the stylet. Infraorbital Nerve Block: The identification of the infraorbital canal can be done via palpation (see “Maxillary Nerve Block, infraorbital approach” for location). The needle is inserted through the skin (transcutaneous approach) or the mucosa (transmucosal approach) with the syringe parallel to the median

LOCAL BLOCKS FOR THE HEAD General anesthesia or heavy sedation are required to perform local blocks for dental procedures in small animals. Needle size and volume of the local anesthetic injected vary based on location and size of the animal. Generally, 25- to 30-gauge, 12-25 mm long needles are used. Bupivacaine, ropivacaine or lidocaine are usually selected and volumes injected are between 0.2 and 2.5 ml (total volume per block). Always calculate the maximum dose you can inject and do not exceed that limit. For bupivacaine and ropivacaine stay under 1.5-2 mg/kg in dogs and cats, for lidocaine 6 mg/kg in dogs and 2-3 mg/kg in cats. Once the needle is placed close to the nerve that needs to be desensitized, always aspirate before performing the block to make sure you are not injecting the local anesthetic into a vessel. Inferior alveolar nerve block: This block desensitizes the ipsilateral lower lip, mandibular teeth and associated soft tissues. It can be performed using 2 approaches: 1. Intraoral: the mandibular foramen is palpated just caudal to the last molar while the mouth is kept open. The use of an appropriate mouth gag is recommended to protect the operator’s hand in case the animal is not adequately sedated/anesthetized. The needle is directed ventrocaudally on the medial side of the mandible aiming towards the angle of the mandible. It is important to stay as close as possible to the mandible to avoid blocking the lingual nerve. 2. Extraoral: with the animal in lateral recumbency, the uppermost mandibular foramen is palpated intraorally (use mouth gag). The needle is placed close to the foramen by inserting it through the skin perpendicular to the ventral

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the transducer needs to be moved more distally toward the stifle. The saphenous nerve can only be blocked using an ultrasound machine because this nerve provides only sensation (no motor), therefore the nerve locator will not stimulate any contraction/ extension of the limb. The volume of local anesthetic used for these blocks is 0.1 ml/kg of 0.5% bupivacaine or ropivacaine for each block.

leg is noticed. The sciatic nerve can also be identified with an ultrasound linear transducer placed perpendicular to the long axis of the femur just distal to the greater trochanter. The sciatic nerve is located between the biceps femoris (lateral) and the adductor muscle (medial). The nerve has the shape of a figure 8, since the sciatic bundle is formed by the common fibular and the tibial nerves. The needle is inserted in-plane caudocranially. The femoral-saphenous nerve complex can be blocked with a nerve locator. On the medial aspect of the limb, the operator palpates the femoral artery in the femoral triangle with the non-dominant hand. The insulated needle is inserted cranial to the artery and advanced until the iliac fascia is punctured. When using the ultrasound machine, the linear transducer is placed on the medial aspect of the pelvic limb, perpendicular to the long axis of the femur over the femoral artery. The transducer is moved proximally until the superficial circumflex iliac artery is identified. The femoral-saphenous nerve complex is located below (lateral to) the artery. The needle is inserted in-plane directed craniocaudally and lateromedially toward the ultrasound transducer. The iliac fascia needs to be punctured before the injection of the local anesthetic. This technique (same orientation of ultrasound transducer and needle) can also be used to block only the saphenous nerve. To accomplish this,

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buy-in will be difficult to attain. Without that buy-in, the program will struggle to make it off the ground. • Infection Control Plan Communication to Clients: Infection control will be a priority for the practice clients. They want to know that their pet is safe when coming into the practice and won’t come home with an infection that could threaten their life or come with expensive medical bills. Clients will also want to be reassured that their health is a priority as well, especially in the time of a pandemic or during times when seasonal infections are at a high. Product Selection and Product Expert: The ICP will work with leadership and vendors to select the proper disinfectant for each situation based on the practice’s needs. Things to be considered would be pathogens seen in the area, the finishes (metal, wood, concrete, etc.) in your practice, and the scheduling in the practice. Disinfectant qualities like contact time, toxicity, and overall ease of use need to be considered when picking products. Once the products are chosen, protocols need to be put in place so everyone in the practice knows what products should be used in what situation and how to use them. Always keep in mind something that is easy to use will have the best compliance. How to Introduce the Role: The role of Infection Control Practitioner needs to be introduced for team buy-in. The role should be well defined and communicated to the team and questions should be addressed. Leadership needs to take the opportunity to introduce the role, who will be filling the role, and their responsibilities to the team in a positive and supportive manner. The team needs to understand the ICP has the full support of leadership, and their purpose is to help the plan succeed. Communication surrounding the program should be informative and always direct back to the “why” behind the changes. The team will appreciate that not only the health and safety of the patients are a priority, but that their health and safety are also top of mind. CONCLUSION Infection control falls on everyone in the practice, no matter what their role. By designating an ICP the practice is placing priority on their infection control program and putting someone in place to focus efforts on those plans. The ICP will work with everyone on the team to help ensure the program succeeds. Patients, clients, and team members will all benefit from the creation and support of this position.

Compliance Evaluation: The ICPs role does not stop at the initial training. The ICP, with the help of leadership, should also be evaluating the skills of team members, constructively coaching, and retraining as necessary. They will continue to monitor how well the team is following the protocols put in place and evaluate protocols if they are consistently not being followed. Is the product too difficult to use, does the disinfection take too long, and is there a better product that your team could use with more compliance? Quality Control and Surveillance: As the common quote from Peter Drucker states, ”You cannot manage what you don’t measure.”; It is easy to say, “My practice is not contaminated with a specific organism”,; but if you are not testing for that pathogen, you cannot say with certainty it is not there. This lack of measurement or certainty is why a successful infection control program will incorporate quality control and environmental surveillance as a way of measuring the success or identifying the challenges of the program. This is again where the ICP comes to the rescue.

Infection Control Practitioner for the Win

AMY JOHNSON , BS, LVT, RLATG, CVJ Manager of Content Development, VETgirl

WHO CAN BE AN ICP? The ICP can be anyone in your practice, no matter what their role, but who is more prepared for the role than a veterinary technician? Vet techs have the knowledge of microorganisms, disinfection and sterility, and infection transmission. Practices should choose their most motivated go-getting germaphobe. TASKS OF THE ICP Initial Assessment: The ICP will begin by doing an initial assessment of the practice and its current infection control efforts. With this assessment, protocols and improvements can be suggested and explored. The ICP will not be working alone; they will need the help of the practice leadership, manufacturer/distributor representatives, and other resources made available to them. Creating Protocols and a Manual: All protocols and plan documentation should be stored together as a manual for easy access and reference. Digital storage in the cloud is highly recommended, but a binder would work well for practices that prefer non-digital storage. Everyone in the practice should know how to access the manual when necessary. Once protocols are written and signed off on by the leadership, the ICP will organize them and all other plan documentation into that Infection Control Manual. They will also be responsible for any updates to the manual when protocols are updated, or products are changed. Training: Most infection control mistakes stem from a lack of proper training. The ICP will work with practice leadership to determine the necessary training protocols. Once the training has occurred, the ICP should organize documentation. This documentation includes who was trained, how the training was delivered, on what protocols, and when the training occurred. Training should consist of the use of printed educational materials and have the team members sign off on the receipt of these materials and training.

Infection control in every veterinary practice is of utmost importance. Not only are there implications to the quality of medicine we practice, but there are also financial, legal, and reputation implications. An effective infection control program involves everyone in the practice, but there are those that may have a bigger role in putting that plan together, implementing the program, and making sure everyone on the team is prepared to step up to the role they play. For an infection control plan to work to its fullest, practice leadership needs to identify, empower, and support those people with the bigger roles. An Infection Control Practitioner (ICP) is one of those roles that need to be created. The ICP will work with leadership to carry out administrative tasks, including writing and recording the infection control procedures and protocols, team training, putting quality control measures in place, being a champion of the proper use of PPE, and being the go-to source for any team questions or concerns. The administration of an infection control program can be complex and involve many moving pieces. The Infection Control Practitioner will be working with the leadership and the practice team to execute the plan. Leadership must give the ICP the appropriate amount of time during working hours to organize and implement a plan and support them in their efforts. In a smaller practice, this may be an additional duty, but there may be practices (or practice groups) big enough to require a full- time position to monitor all the moving pieces of the infection control plan and execution. The role of the ICP is to be the champion your infection control program by organizing, training, and facilitating conversations. The ICP should not be working in a silo or going into this new endeavor thinking they are alone, and they need to have all of the answers. The ICP needs to be the go-to person, but when they cannot answer a question or is unsure of a process, they need to call in the experts and know where to go to get the answers.

The minimum quality control measures that should be put in place and logged on a regular basis include:

• Testing disinfection solutions • Testing autoclaves and gas sterilizers • Surveillance for bacterial pathogens

Quality control and surveillance logs are a must. These logs will help the practice track values, quickly spot deviations in results, and can be an essential way of proving the infection control efforts made by the practice in the event of an outbreak or other adverse event. These logs should be kept as a record of measurements over time with the ICP creating these logs, helping to determine what should be monitored and how often, and reviewing the logs on a regular basis to see when there is a deviation or problem detected. Developing Communication Plans: There is a lot of communication that needs to happen surrounding the infection control efforts made by your veterinary practice. The ICP should help in creating these communication plans, train the practice team, and if necessary, write scripts to be put in use. Some of these communications include: • High-Risk Patient Communications: Once a high-risk patient is identified, whether it be before the appointment or during, a cascade of communications needs to be set off alerting everyone in the building so the appropriate infection control measures can be put in place. • Infection Control Plan Communication to the Team: The infection control plan and the reasoning behind it need to be communicated clearly and regularly to the team members. Without the “why” behind the program, team



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