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Fear Free Medicine During COVID-19

Last night I attended a great #FearFree webinar sponsored by Elanco and presented by Monique Feyrecilde, a VT specializing in behaviour, practicing in Seattle. Here is a summary in bullet point form: - anticipate that clients will be emotional, and may give you feedback that you won't expect - clients will need to be supported through this - explore telemedicine - postpone elective care - see patients if 1) they have an illness that may represent human health risk, and 2) they have an illness that will threaten the life of the patient within the next 90 days (CDC recommendations) - ask clients if they've travelled in the past 14d - preserve PPEs for the human supply chain - it will be difficult practicing FF when pets are separated from owners, as this is a trigger for some - PVPs for these animals if possible - a good convo about FF is off the table, more or less - pets can be afraid of staff wearing PPEs. - LOOK AT EMR BEFORE APPT - if there is no EMR, try to email the questionnaire to clients in advance of the appt. - even things like treat preference, where they prefer to be examined are important - manage clients' expectations - you want to make sure all concerns are addressed in hx taking, describe what the visit will be like for the pet - this will reduce client's anxiety - develop a SAFE transport strategy in and out - clinic leashes ONLY to bring in and out, she uses new leash for each patient, then throws them in the laundry - have client remove leash/harness, coats/sweaters, as these are potential fomites - use the same FF body language if curbside - face the direction of travel and keep leash loose with minimal pressure - trail of treats to lure if ok to do so - use gloves handling carriers, disinfect before and after appt. - offer clients Zoom, Google Hangouts, Facetime, WhatsApp, or even over speaker phone during appt, in order to allow them to participate during the appt - if the wifi you have reaches outdoors, this is the next best thing if they can't be present, and helps maintain client trust -USE ALL THE FF STRATEGIES YOU NORMALLY WOULD USE IF THE CLIENT WERE PRESENT - continue to pause, postpone, plan if needed based on FAS score - use telemedicine - her practice is using this for most things - can do curbside skin diagnostics - call in Rx's to pharmacy or place curbside

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Sid has the best job (Bair Hugger foreman).

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New obsession: unchartedvet.com podcasts and blogs. We've all been there, done that. The advice is practical and the presentations highly motivational. Well done, Dr. Andy Roark and Stephanie Goss!

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Dr. Debra Horwitz’ Purr Podcast interview is not to be missed. Amazing behaviourist!

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As veterinarians, we tend to compartmentalize our emotions, because we often go from a “bad news” appointment to a joyful new puppy appointment. Compassion fatigue is very real, and is not a static condition. There are great resources at navc.com for those seeking help sorting it all out.

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WSAVA 2019 Friday, Part 2

The Feline Anesthesia Enigma - this was a case-based presentation by Dr. Paulo Steagall, beginning with...

THE BLOCKED CAT - these guys have reduced GFR, hypothermia, hyperK, acidemia, and circulatory collapse - the hyperK and acidosis are the major concerns.

- get a catheter in and draw your bloodwork sample - he will typically bolus with NaCl, but LRS is fine (the K concentration is too low to make the hyperK worse), 10-20 ml/kg at a time according to need.  Rates will typically be 45-60 ml/hr when there’s obvious poor perfusion and severe dehydration, as long as there isn’t CVS disease.

- he won’t sedate/anesthetize the cat if the K is > 6 mEq/L - uses Ca gluconate to address the hyperK, if this is too short lived, will use dextrose and perhaps insulin.  Ideally, should have ECG in order to see the pattern normalize as the hyperK resolves

- sedates with a combo of torb and midazolam IV

- he likes to use propofol at a low dose, 1-2 mg/kg, usually followed by midazolam 0.25 mg/kg - doesn’t mix these in the same syringe.  The addition of midazolam as a co-induction drug allows you to reduce your propofol dose by 25%.  Obviously no ketamine, as this is excreted largely unchanged. 

- discussed the sacral-coccygeal epidural - 2% lido, 0.1-0.2 ml/kg, but this is risky if done before fluid therapy d/t autonomic effects leading to hypotension.

Sue Little is a proponent of therapeutic cystocentesis for pain relief before unblocking these cats - I am not sure how I feel about this.  I’ve never experienced bladder rupture in a cat and I never, ever want to!

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THE GIFB CAT:  uses an opioid in combination with incisional/intraperitoneal analgesia and avoids using NSAIDs - studies have shown there is a higher incidence of leakage when NSAIDs are given. IP bupivacaine will provide analgesia for up to 8 hrs.  He does this at the time of closing. He likes opioid or ketamine CRIs for these cats. Cautions that regurg can occur at the time of induction for these cats, so there is an enhanced risk of aspiration pneumo - care should be taken in how these cats are positioned during induction. Uses Cerenia 1 mg/kg IV.

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THE HYPERTHYROID (potentially aggressive cat you can’t get your hands on) going under for a dental tx:

- don’t use ketamine, as these cats already have higher sympathetic tone, and they don’t need a drug that will elevate HR more.

- likes Alfax + midazolam IM, sometimes uses a pure mu opioid like hydro or methadone

- likes Emla application to facilitate IVC placement

- for cats you can’t get your hands on, as a LAST resort - try OTM dexdomitor 30-40 ug/kg

- for acute pain: buprenorphine 0.02 mg/kg, but this should be used in a multimodal pain management plan

- there is nothing published yet, but pre-visit gabapentin doesn’t appear to change the physiologic parameters in these cats, so go ahead and use it

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Dr. Steagall’s next presentation was Anesthetic Challenges in Geriatric Patients.

- there is an increased risk of GER in these patients (gastroesophageal reflux), obesity, CVS disease (assymptomatic valvular disease is present in 25% of dogs > 9 yrs), periodontal disease, reduced muscle mass (hypothermia risk increases), their pain inhibitory system is down-regulated, and they often have up to a 50% decrease in functional nephrons, so should be IRIS-staged.

- 30% of dogs > 8 yrs have changes related to cognitive dysfunction - I think we need to better educate our clients.  What we will see is a higher incidence of emergent delirium (huskies, dogs that start to flip over etc) and dysphoria (the constant vocalization) after anesthesia, so they need anxiolytics. He likes trazodone for these dogs as a PVP.  Dysphoria is often related to opioid overdose, so he will often give them some naloxone.  He’s a huge fan of the microdose of dexdom IV (0.5 to 1 ug/kg).

- avoid ace if there is liver disease, as it will take a long time to be metabolized, and if they become hypotensive, you will need higher doses of a pressor to address it.

- if DM, they should have 1/2 their insulin dose that day

- preoxygenate these dogs for at least 3 min prior to and during induction - this has been shown to prevent post-induction hypoxemia related to propofol or alfax - keep it going until you are able to intubate.

- he doesn’t use benzodiazepines in his premeds, but does use the midazolam as a co-induction agent with propofol or alfax as above.

- likes midazolam and fentanyl - these are very CVS-friendly drugs.

- he only uses anticholinergics to TREAT bradycardia, not to prevent it.

LUNCH and more time chatting with other vets and reps, plus collecting lots of free pens, lip balm, mints, treat bags, and even a beach ball (for Angus, I think). I finally found a couple of classmates of mine and did some catching up!

I sat in on Dr. Monteiro’s lecture on Treating Postoperative Abdominal Pain Using Intraperitoneal and Incisional Anesthesia, hoping to settle once and for all how incisional blocks should be performed.  IP blocks seem to do a better job at circumventing post op pain than the incisional blocks, so I’m going to begin doing them for my spays - calculating the total dose, using 1/4 of the volume for my incisional block, and reserving 3/4 of the volume for splash blocks onto both ovaries and the uterine body.  As for the incisional blocks, here’s how they recommend doing them at Ste. Hy:

https:youtu.be/76dwKuirqt0

Friday afternoon was spent in the WSAVA hereditary diseases stream - the lectures were: The Welfare Impact on Dogs When Breeding for Extreme Conformation with Dr. Megens from the Netherlands, followed by Sue Little’s lecture Brachycephaly and Other Breed-Associated Problems in cats. Very impactful presentations.

I had such a great time at WSAVA 2019!  Next year’s conference is in Warsaw, Poland!  I elected to head home a bit early on Fri., to hopefully avoid experiencing a parking lot on the DVP, so I left just after the 3:30pm coffee break.  Drive TO the city was just slightly over 4 hrs.  Drive home was 5 1/2 hrs! Max speed on the DVP was 60 KPH....

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WSAVA 2019 Friday

It was a hot and steamy day in TO!

First lecture of the day was “The Efficient Orthopedic Exam” with Dr. Clara Goh (CSU) - I think it was taped, so should be available on CommuniVET eventually.

CSU has a grading system for lameness:

- hock hyperextension is a feature of chronic hip or stifle disease

- make use of technology in gait analysis - she uses a selfie stick for little dogs (I have the Coach’s Eye app on my iPad, which is great)

- doing stairs is useful (maybe clients could video their lame dogs doing stairs for us) - do they lead with the better leg? Or do they bunny hop? - bilateral disease.

- a positive sit test is suggestive of either stifle or tarsal disease - dogs with hip dysplasia don’t mind sitting - they are most painful with hip extension. 

- the Ortolani can be done standing, but she prefers lat recumbency - she uses a smartphone app Handy Carpenter to measure the angles of reduction and subluxation - cool!  But the absence of the Ortolani does not rule out HD.

- Elbows: medial compartment pain can be tough to confirm on an ortho exam, so warn owners about this.

- for shoulders: remember, the scapula is mobile, so it must be stabilized when flexing and extending the shoulder - extended abduction is the maneuver we should try to do in order to ID medial shoulder pain.

For those wanting to fine tune their orthopedic exam, there’s also a great video on Vetfolio, but I am not sure if it’s open access. 

I spent the rest of the morning in the Anesthesia & Analgesia stream.  The speaker was Dr. Paulo Steagall, anesthesiologist at St. Hy. Fantastic speaker and a real cat guy. He reviewed the MCPS pain scoring system (validated, but too lengthy for use in practice, better for research) and the Glasgow CMPS scale. Then onto the Feline Grimace Scale, which is brand new and correlates well with the Glasgow pain scale. Using GoPro cameras, he and his colleague identified 5 “action units”: ear position, orbital tightening, muzzle tension, and whiskers and head position.  Right now, their manuscript is under review and the scale will probably be fully validated before long. If you want to read about it, here is the paper, which is open access - I have the journal, so I’ll leave it at POW too:

Steagall PV, Monteiro BP (2019) Acute pain in cats: Recent advances in clinical assessment. J Feline Med Surg 21, 25-34

Here’s a cat with Feline Grimace Scoring, before and after buprenorphine:

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WSAVA 2019, Thursday.

Started off the day attending Dr. Abbigail Granger’s (LSU) lecture, How I Diagnose Causes of Pulmonary Patterns, because it is something I feel I struggle with, and I felt I needed a good review. 

Then it was on to Pharmacotherapy for Canine Fear and Aggression with Dr. Landsberg. Take-away points:

- always ask owners to video their pet’s behaviour.

- drugs will not take behaviour problems away, but can facilitate learning, therefore behaviour modification exercises are critical.

- start drugs the minute you see the abnormal behaviour - don’t wait, because the behaviour will become more intense d/t windup.

He talked a lot about gabapentin being “anxiolytic”, so I approached him afterwards with a question about that. There was a paper in the JFMS a few months ago implying that gabapentin doesn’t significantly lower stress markers (cortisol and glucose) in treated cats - both owners and veterinarians perceive that gaba-treated cats are less stressed, but they are merely sedated.  So is it really anxiolytic?  Dr. Landsberg told me he hadn’t read this paper, but that he’d take a look at it.  He said we really don’t know for certain about this. Here is the reference:

https://journals.sagepub.com/doi/10.1177/1098612X19830501

On to Approach to the Acute Abdomen with Dr. Alexa Bersenas (she is Chief of the SA Emergency/Critical Care Service at OVC) and Dr. Philipp Mayhew (boarded surgeon at UC Davis, picture Richard Gere with a British accent) - this was case-based and a lot of fun - one case was a FB requiring bowel resection/anast. which dehisced and went septic 3 days later, and the 2nd was a GDV case. 

- if a client presents a cat with a sublingual FB but refuses surgery citing finances, don’t immediately euthanize - cut the string under the tongue and see what happens. Dr. Mayhew has seen some pass the string if given a chance, even though it’s not ideal and they need to be monitored closely (not a nice way to go if it doesn’t work, though). 

- if you suspect a septic effusion, spin your centesis sample down and pour off the supernatant - it is otherwise much more challenging to find neuts with intracellular bacteria on your slide most of the time. 

- I don’t think we see enough of these for a lactate analyzer, but if septic, your effusion glucose will be lower than your serum glucose - there has to be a difference > 1.1 mmol/L.  This doesn’t apply if there is a hemorrhagic effusion though. And you can’t use glucose or lactate measurements if you have an intraabdominal drain in place. On FAST, the fluid will show up around the caudal hepatic lobes. If we’re not doing an U/S, the 4 quadrant tap will do - fluid in the needle hub, you don’t need to attach a syringe. 

Stephanie, I bought the new edition of the pocket reference I love that went MIA, and got it at about half the price I would have paid had I ordered it!

After lunch: Managing Patients with Concurrent CVS and Renal Disease with Dr. Ettienne Cote from AVC.

- for patients with azotemia and CHF, identify the more severe disease

- identify and address anything reversible (CHF d/t excess Na consumption, pyelonephritis etc.)

- is there a gallop? This low frequency sound is better appreciated with the bell vs the diaphragm - if you hear it during fluid therapy, the patient is on the verge of CHF because you are increasing the end diastolic pressure with your fluids. 

- manage electrolyte abnormalities - hypoK can cause VPCs - if not addressed, the patient won’t respond to lidocaine

- use injectables rather than oral meds

- thoracic radiology consults are money well spent

- don’t use diuretics to address cavity effusion - tap them instead

That is enough blogging for today....

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WSAVA 2019 Day 2 continued...

Oral masses - Dr. Sarah Boston - suggests incisional vs excisional biopsies if we intend to refer to a surgical oncologist, otherwise the landmarks vanish and it’s more difficult to get clean margins. 

- High Low Fibrosarcoma should be on our radar with any oral mass in a Golden.

- she’s someone I really admire, and is also very funny. She does standup in her spare time.

Dr. Duncan Lascelles from NCSU wants us to recognize OA as a disease of young dogs, and I’m now fully convinced this is the case.  

- checklists are a great way to generate info - the Previcox and Zoetis websites have very good, interactive questionnaires

- the COAST forms are available on the Galliprant site, galliprantfordogs.com

- he will recommend a 3 month trial period of NSAID, gradually increase the leash exercise after about 2 wks of rest, if doing well after a couple of months he will wean off the NSAID as he introduces O3FA and works on weight optimization if indicated. 

- does the COAST staging at every exam

The man behind the podium is a LEGEND.  He’s also not as tall as I thought he’d be in real life. It’s Dr. Stephen DiBartola. I can’t speak for the youngest amongst us, but I am sure that everything Diane and I learned about kidneys, fluid therapy, acid base and electrolytes we owe to this man.  He spoke about his career in veterinary medicine for an hour, and you could have heard a pin drop. Epic. I almost went up afterwards to get a selfie with Dr. DiBartola, but I restrained myself. 

There is a giant wall display on the way to the exposition hall listing all of the WSAVA attendees and their countries.  Here I am!

Another hero of mine, Dr. Sheilah Robertson. She is a renowned anesthesiologist and pain management specialist, and is now the Medical Director for Lap of Love. She spoke on QOL assessment and decision-making around euthanasia and chronic pain.  

- the new WSAVA Animal Welfare Guidelines are worth reading

- there are also lots of tools for clients now with web-based delivery, such as those at www.newmetrica.com, and the Grey Muzzle app developed by Lap of Love

- she advocates discussing euthanasia early in the palliative care process - clients then have ample time to process everything vs rushing in to emerg with their dog and being compelled to make the decision then

- she often suggests clients make up a “bucket list” for their pet - I can see that this would great for families facing pet loss.

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Wednesday at WSAVA 2019

Yesterday I attended a talk by Dr. Craig Clifford ACVIM (Oncology) - updates in canine and feline lymphoma. He would like us all to try to phenotype our lymphoma dogs as either B or T cell, since T carries a worse prognosis. It doesn't have to be a specialist's test, as the PARR test (a PCR test that looks for clones) is inexpensive, and a stained slide is OK. IDEXX would probably send it on elsewhere to perform. Of course, phenotyping will not matter if the client isn't interested in referral for chemo. - studies are still underway regarding monoclonal Ab drugs like Rituxan in veterinary protocols because they have worked in human cancer patients - they bind to target cells or proteins, then the patient's own immune system attacks the targeted cells - it's really interesting. Rituxan is used to treat RA also. - Merial's lymphoma vx (Oncept) is available to veterinary oncologists only at this time - it extends CHOP remission time. - if you listen to "Dr. Sue Cancer Vet" you will have heard of Tanovea, the new lymphoma-specific drug - it is dosed every 3 wks and works best the first time, vs rescue therapy. There's a study underway to work out a dose for cats. It can cause pulmonary fibrosis in a small %, so is probably not the one to use in Westies, since they are genetically predisposed to PF. - we're not supposed to call feline lymphoma Type 1 and Type 2 anymore, the new terminology is EATL (enteropathy associated T-cell lymphoma), so the GI lymphoma we tend to encounter is now Type 2 EATL. I don't know why they do these things. DERM: Dr. Yu's lectures were largely the same as his presentation to the OAVM a few years ago, but he did have some interesting things to say about vaccination as it pertains to allergic skin disease: - vaccinate these allergy prone dogs outside of their "season" when the allergen load will be the lowest - move to a 3-year rotating vaccination protocol (like the published guidelines suggest) - for the annual ones, split them by 2-4 wk intervals - vaccination stimulates the immune system and can also sensitize these dogs to food antigens and environmental allergens

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WSAVA 2019, Day 1

Spent most of the morning listening to Dr. Jon Fletcher from LSU, discussing Diabetes and Cushings. Some takeaways:

- Toujeo is a 300 U/ml glargine which may be promising as an SID insulin for cats - it is only available in a pen. In general, he favours Glargine over ProZinc.

- Detemir/Levemir can be used in cats as well as dogs - I have only used it 1x in a dog I couldn’t regulate as a Hail Mary - it worked and the owners were ecstatic. If they’ve been on anything else you need to start it at the initial low U/kg.

- Insulin resistance - used to be anything > 2 U/kg, now anything > 1.5 U/kg. Screen for hypothyroidism in these dogs... and about 30% of hypothyroid dogs won’t have elevated TSH.

- Starting insulin, OK to start with 0.5 U/kg BID for dogs - curve 7-10 days before adjusting, BUT he will often increase it during the first week if continuously monitoring, because you will usually see how they are trending after about 4 days. He puts a Freestyle Libre on every newly dx’d patient.

I tried to get photos of the screen, but they would turn out like this (it’s an iPhone 4):

- when adjusting doses upwards, it’s 1-2 U for cats/small dogs and 2-3 U at a time for bigger dogs. In other words, no shilly-shallying, be bold.

- Freestyle Libre monitoring is the way to go. Readings every 15 min., scan it every 8 hrs., and we can get up to 2 wks of data. Cats will usually tolerate it for 5-7 days, but that’s still better than a home curve. We don’t need to buy a scanner, there’s an app for that, and clients can download it and scan the device with their smartphones, then send all the data to us.

- more recent studies suggest that hypersomatotrophism may be a resistance factor in 15-30% of cats. I’ve only seen it once and the cat had the obvious physical features. This % surprised me.

Cushing’s dogs on Vetoryl - the European manufacturers have changed their monitoring protocols - pre-Trilostane cortisol levels alone will often allow you to determine whether or not you need a dose adjustment, along with good clinical assessment - we may not need to be doing all these follow up ACTH stims. But if we see any evidence of cortisol deficiency, we need that ACTH stim.

I went to a Lymphoma update and the afternoon was all Derm, so I’ll post about those later on.

There was an amazing lunch buffet, and I had some real food. I met some very friendly Australians and a few Indonesian vets. Vets from India were asking me to take their photos in front of the WSAVA banner - I love hearing all of the different accents. Apart from Sue Little, I haven’t run into any classmates of mine. Or maybe I have, and we are just so old we no longer recognize one another, hahaha.

Here are a few photos from the expo: the first is the Euthabag, a moisture resistant zippered bag for take home pet remains, various puzzle feeders, and postop wound garments, and a cooling vest for outdoorsy dogs. There were big crowds around the cannabis displays.

Finally, some night photos from my window:

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In TO for WSAVA 2019. Here’s my view from my room on the 25th floor. Haven’t had such a long drive since the locum days in Northern Ontario, but stopped to reconnect with some friends along the way, which gave me a break. Tomorrow will be full of endocrinology and derm, and I can’t wait!

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Veterinary Bingo.

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Sid and his apprentices.

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Shared from Photos app

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Love this guy. #ClinicCat