WSAVA Nov 2021 Proceedings

Bacteroides spp. 0 3 0205 Fusobacterium spp. 1 2 SURGERY OF THE LOWER URINARY TRACT Mycoplasma-like organisms were identified cytologically in 10/11 cats with bronchopneumonia that cultured positive for Mycoplasma spp. E. Monnet from BAL fluid. Organisms that appeared similar to Mycoplasma spp. were seen in BAL fluid cytology of 3 cats that cultured negative for the Fort Collins/United States of America organism. Mycoplasma-like organisms were not seen in the BAL fluid of any cats with AP. Qualifications: Mycoplasma species that grow in culture are not routinely speciated by Eric Monnet, DVM, PhD our laboratory, but they were in isolates from 3 cats in this study. All 3 had growth of M. arginini, 2 had growth of M. canis and 1 had growth of Diplomate ACVS, ECVS M. felis. A cat that had all 3 Mycoplasma species isolated had cytologic evidence of airway sepsis with no aerobic or anaerobic growth on culture, Professor Small Animal Surgery supporting the role of Mycoplasma as a primary pathogen in this cat. Colorado State University References [email protected] 1. Foster SF, Allan GS, Martin P, et al. Twenty-five cases of feline bronchial The most common indication for surgery of the lower urinary tract is an disease (1995-2000). Journal of feline medicine and surgery 2004;6:181- obstruction from urolithiasis. Other causes of obstruction are neoplasia in 188. the urethra, and neoplasia compressing the urethra. In the male, urethral calculi most commonly lodge caudal to the os penis. In the female, 2. Bart M, Guscetti F, Zurbriggen A, et al. Feline infectious pneumonia: a calculi may lodge at any location along the length of the urethra. Urethral short literature review and a retrospective immunohistological study on obstruction is more common in the male than female. the involvement of Chlamydia spp. and distemper virus. Veterinary journal 2000;159:220-230. Urinary obstruction requires medical treatment to stabilize the patient to surgery and surgical treatment to release the obstruction. Dogs and cats 3. Levy N, Ballegeer E, Koenigshof A. Clinical and radiographic findings in with urinary obstruction are presented with hematuria, stranguria, and cats with aspiration pneumonia: retrospective evaluation of 28 cases. J pollakiuria. Plain radiographs, radiographs with contrast material or ultra- Small Anim Pract 2019;60:356-360. sound will confirm the presence of a urinary stones or mass in the urethra. 4. Dear JD, Vernau W, Johnson EG, et al. Clinicopathologic and radiograph- MEDICAL MANAGEMENT ic features in 33 cats with aspiration and 26 cats with bronchopneumonia (2007-2017). Journal of veterinary internal medicine / American College Blood work with complete blood count, and biochemistry is required to of Veterinary Internal Medicine 2020. evaluate kidney function of the patient. Urinary obstruction is associated with severe post renal azotemia and severe electrolytes imbalance. Hyper- kalemia is the most common electrolyte abnormality. Hyperkalemia can induce severe bradycardia if the concentration is over 5 mEq/dl. There- fore, it is important to reduce hyperkalemia before anesthetizing patients with urinary obstruction. The most efficient technique to lower the potassium concentration is to diurise the patient. If the patient can still urinate on its own intravenous fluid therapy will induce a diuresis. If the patient cannot urinate cysto- centhesis can be performed to empty the bladder. The concentration of potassium is monitored very closely to be able to anesthetize the patient as soon as the potassium is back to normal limits. If diuresis is not efficient insuline/glucose and bicarbonate can be used. This technique lowers the potassium within 30 minutes. If the potassium concentration is not reduced then calcium gluconate is used to protect the myocardium from the effect of potassium. SURGICAL MANAGEMENT When the potassium concentration is within normal limits general anes- thesia can be performed. After induction of general anesthesia the urinary stones lodged in the urethra can be retropulsed in the bladder. All the efforts should be made to retroflux the uroliths in the bladder. It is easier to performed a cystotomy than an urethrotomy, and there is less morbidity associated. Retropulsion To perform a successful repulsion the following steps have to be per- formed after inducing deep general anesthesia with intubation a) Pass the catheter up to and against the calculus. If the patient is a male place a gauze sponge around the tip of the penis and occlude the penis 301

13–15 NOVEMBER, 2021 around the catheter by squeezing it with thumb and finger. calculi in Dalmatians). b) Using a back and forth action on the catheter, simultaneously inject the Scrotal urethrostomy saline/lubricant mix under pressure. The calculi and urethra are lubricated and the viscosity of the mix encourages the calculus to dislodge and flush Scrotal urethrostomy is the technique of choice in male dogs because into the bladder. This technique is attempted regardless of how many the urethra has its largest diameter at the level of the scrotum. The dog stones are in the urethra. is placed in dorsal recumbency and a urethral catheter is placed. After castration and scrotal ablation, the retractor penile muscle is retracted If the above technique fails, place a finger in the rectum, palpate the on the side to expose the ventral aspect of the urethra. The urethra is urethra, and occlude its lumen, repeat step C above and when maximum incised longitudinally over 3-4 cm. The periurethral tissue is sutured to the pressure is exerted on the urethra by the saline/lubricant mix, suddenly subcutaneous tissue with a 4-0 absorbable suture in a simple interrupted release digital urethral occlusion allowing lodged calculi to flush into the pattern. The urethral mucosa is then sutured to the skin with 4-0 non-ab- bladder. This technique allows maximal dilatation of the urethra. sorbable monofilament in a simple continuous pattern. The urethra is more superficial in the scrotal area, surrounded by less cavernous tissue. This technique is successful in most of cases. Lidocaine can also be Complications of an urethrostomy are hemorrhage, stricture, and dermati- injected while the catheter is in contact with the stone to release a spasm tis from urine scalding. Hemorrhage happens for 6 to 7 days after surgery of the urethra around the stones. when the dog urinates or becomes excited. Sedation might be required for a week to 10 days after surgery to help control bleeding. Stricture mostly If the stones are successfully retroflux in the bladder, the urinary catheter occurs is the dogs is self-traumatizing the surgical site. An E collar is is left in place to prevent migration of the stones back into the urethra. recommended for 10 days. After a urethrostomy dogs are at more risk of ascending UTI because the urethra is shorter. If the stone cannot be retroflux in the bladder then a urethrotomy or ure- throstomy is performed. Cystotomy Perineal urethrostomy After a midline incision in the caudal abdomen, a ventral cystotomy is per- In cats a perineal urethrostomy is performed. The cat is positioned formed to expose the inside of the bladder. After placing three or four stay in ventral recumbency at the end of the table. An elliptical incision is sutures in the wall of the bladder to minimize trauma during manipulation performed around the prepuce and the scrotum. The cat is castrated. The of the bladder, the uroliths are removed either with a spoon, or suction. penis is isolated and the ischiocavernosus muscles are exposed by blunt The bladder neck and lumen should be explored with a finger to detect dissection and transected to their attachment to the ischium. After care remaining large uroliths. A biopsy of bladder wall should be performed blunt dissection ventrally posterior displacement of the penis is possible. then for culture and sensitivity. Bladder wall culture gives more reliable The retractor penile muscle is transected near the external anal sphincter results regarding bacterial infection than urine culture. Bladder neck is muscle. The penile urethral is incised dorsal to the bulbourethral glands. flushed with warm sterile saline to remove small uroliths. The urethra is At this point the urethra is wide (4 mm). The pelvic urethra and 3 cm flushed with the catheter placed to retroflushed the stones in the bladder. of the penile urethra are sutured to the skin with 4-0 monofilament in a While sterile saline is flushed profusely in the urethra the catheter is simple interrupted pattern. The remaining of the penile urethra and penis removed. With this technique little uroliths left in the urethra are flushed are amputated. An Elizabethan collar is used to prevent self-mutilation. in the bladder. Then a catheter is introduced in the proximal urethra and Complications are hemorrhage, cystitis, urethral stricture, self-mutilation, large amounts of saline are used to flush the urethra normograde. Before and wound dehiscence. closing the bladder a catheter is introduced from the bladder in the urethra to confirm patency of the urethra. It is not necessary to maintain a urinary PATIENT MONITORING catheter postoperatively. Post operatively patient needs to be monitored for signs of uroabdomen. It is recommended to take a post-operative radiographs to make sure all Animals presenting with complete urinary obstruction and post-renal the stones have been removed. azotemia are continued on crystalloid IV therapy until serum urea nitrogen and creatinine return to normal. Post-obstruction diuresis happened after Urethrotomy the obstruction has been released. Fluid rate should be increased to maintain the hydration status of the patient. Treatment for UTI and dietary A urethrotomy (an incision over the calculi) may be performed to remove management are required to prevent reoccurrence. After a cystotomy calculi that cannot be retropulsed. It is usually performed in the prescrotal hematuria is possible for 2 - 3 days post-operatively. After a urethrotomy or perineal region. With a urinary catheter in place to the obstruction a 5 or a urethrostomy, hemorrhage from the urethral stoma is common in the cm midline incision is made over the uroliths. The subcutaneous tissue immediate post-surgical period. It generally occurs 4 - 5 days post-opera- is dissected and the retractor penis muscle is retracted on one side. The tively, but occasionally will last up to 2 weeks. Apply an Elizabethan collar urethral is dorsal to the retractor penile muscle. A 15 scalpel blade is to prevent self-mutilation. use to longitudinally incise the urethra over the uroliths. The uroliths are removed and the catheter advanced. If other uroliths are present they can either be retrieved through the urethrotomy or they can be flushed back in the bladder. Then a cystotomy is required. The urethrotomy incision can be left open or suture with an absorbable suture in a continuous pattern on the urethra . Subcutaneous tissue and skin are closed. If the incision is left open it is going to granulate and closed by second intention. Urine is leaking through the incision for several days. The corpus spongiosum will bleed when the dog urinates or becomes excited. Urethrostomy A urethrosotmy (a permanent opening to allow calculi to pass) may be indicated in animals that are chronic recurrent calculi formers (e.g., urate 302 WSAVA GLOBAL COMMUNITY CONGRESS

0206 Systolic heart murmurs are very common, even in normal cats. Gallup sounds (S3, S4) may be present and are never normal. Some have arrhyth- FELINE HEART DISEASE - HOW TO DIAGNOSE AND mias. CHF causes includes acute respiratory distress, acute paralysis MANAGE? from arterial thromboembolism, or sudden death. Pulmonary edema is the most common manifestation, followed by pleural effusion. P. Fox Diagnosis: New York/United States of America Thoracic radiography shows cardiomegaly signs consistent with CHF Qualifications: (patchy, diffuse or focal pulmonary interstitial and alveolar infiltrates and or effusions). Echocardiography is the diagnostic gold standard. Some Philip R. Fox HCM have a fourth (S4) gallop sound, while a third (S3) gallop sound is associated with DCM. Atrial or ventricular premature complexes common. DVM, Dipl.ACVIM (Cardiology), Dipl.ECVIM-SA (Cardiology), Dipl.ACVECC Noninvasive blood pressure measurement identifies systemic hyperten- [email protected] sion which can increase left ventricular wall thickness. Hyperthyroidism can also cause LV hypertrophy. Anemia can promote high output CHF. FELINE HEART DISEASE- HOW TO DIAGNOSE AND MANAGE Elevated serum troponin can be associated with myocarditis. NT-proBNP snap test can differentiate cats with moderate to severe LVH vs mild or Summary: normal; the quantitative test > 99pm/L is 100% sensitive and 71% specific for occult cardiomyopathy The best clinical outcomes require detailed consideration of clinical data: review all diagnostic information (history, examination, ECG, radiography, The Preclinical (Asymptomatic) Cat echo, clinical pathology, SBP); identify risk factors for cardiovascular mor- bidity; formulate treatment options; incorporate recommendations from Cats with preclinical HCM are at substantial risk for cardiac morbidity the recent ACVIM Consensus Statement Guidelines for Classification, and mortality. The epidemiology of preclinical HCM has recently been Diagnosis, and Management of Cardiomyopathies in Cats (JVIM 2020).1-7 described from 1730 cats (1008 HCM/HOCM and 722 apparently healthy cats without heart disease (Fox et al., REVEAL Study. JVIM, 2018).2 Risk Introduction: for CHF/ATE assessed 1, 5, and 10 years after study entry was 7.0%/3.5%, 19.9%/9.7%, and 23.9%/11.3%, and for cardiovascular death, 6.7%, 22.8%, Cardiomyopathy, the most common feline heart disease, accounts for 95% and 28.3%, respectively. There were no statistically significant differences of cardiac morbidity and mortality. Hypertrophic cardiomyopathy (HCM) between HOCM compared with HCM for cardiovascular morbidity or mor- accounts for the majority of these cases. Two myosin binding protein-C tality, time from diagnosis to development of morbidity, or cardiovascular gene mutations (MYBPC3) are linked to HMC (Maine Coon and Ragdoll survival. Cats that developed cardiovascular morbidity had short survival cats); An ALMS1 gene mutation occurs with some HCM cases in Sphynx (mean+/-standard deviation, 1.3+/-1.7 years). Prolonged longevity was cats. The heart often remodels over time. Some hearts express attributes recorded in a minority of preclinical HCM/HOCM cats- 10% reached 9-15 that overlap with other diseases. HCM represents a significant health years of age. burden and cause of all-cause mortality and reduced survival. Treatment of Preclinical Cats: Terminology and Classification There is no current evidence that treating asymptomatic cats prevents car- Structural and functional phenotypes can change or overlap. Some cats diac disease progression, reduces risk of cardiac morbidity, or prolongs do not conform to strict definitions. There are 5 classic forms of cardio- cardiac survival. Nevertheless, certain potential risk factors provide raison myopathy. d’être for pharmacologic intervention. Evidence for treatment efficacy is sparse. 1. Hypertrophic (HCM)- Hypertrophied, non-dilated LV (IVS or LV wall at end diastole ≥ 6mm thick) in absence of causative diseases (no aortic Potential risk factors- stenosis, systemic hypertension, hyperthyroid). Many cases have dynamic LV outflow tract termed hypertrophic obstructive cardiomyopathy (HOCM). ►Myocardial Infarction inferred by thinned, hypokinetic LV wall segments (consider ACEI) 2. Restrictive (RCM)- Severe, bi-atrial dilation without severe volume overload, relatively normal LV/ RV cavities; restrictive diastolic LV filling ►Tachyarrhythmia reduce cardiac filling, promote ischemia, and result in (E:A ratio [>2.5:1] hemodynamic instability. Sustained tachyarrhythmias are usually asso- ciated with myocyte necrosis, fibrosis, or inflammation (consider sotalol 3. Endomyocaridal form- Prominent endocardial scarring (hyperechoic and other drugs). echo lesions) bridging the septum and LV free wall. Variable LVH ►Severe LV Hypertrophy (diastolic septal or LV wall thickness > 8mm) 4. Dilated (DCM)- LV dilation (LVs>12mm, LVd>20mm), systolic failure risk cardiovascular events. (%FS<25%), thin LV walls. ►Severe Left Atrial Dilation promotes blood stasis and thrombus (consid- 5. Arrhythmic cardiomyopathy (ARVC)- severe RVE, often thin RV walls, er Plavix). abnormal RV pectination, RA enlargement, variable LA/LV changes. May have tricuspid regurgitation. ►Restrictive LV Filling Pattern (Restrictive Physiology) may suggest end-stage diastolic dysfunction. This physiology may occur in any form of Cardiomyopathy with nonspecific phenotype (formerly called ‘unclassified cardiomyopathy. cardiomyopathy’).Described adding relevant structural and functional de- scriptions- eg, cardiomyopathy with nonspecific phenotype characterized ►Spontaneous Echo Contrast (“Smoke”) presages thromboembolic risk by apical LV thinning, focal basal hypertrophy, etc. (consider Plavix). Clinical Findings: 303

13–15 NOVEMBER, 2021 ►Myocardial Failure (e.g., fractional shortening <25%; LV end-systolic 5 Fox PR, Liu SK, Maron B. Echocardiographic assessment of sponta- dimension >12 mm). (consider taurine, pimobendane, diet change). neously occurring feline hypertrophic cardiomyopathy An animal model of human disease. Circulation 92:2645, 1995. ►Arrhythmic Right Ventricular Cardiomyopathy (severe RV/RA dilation with arrhythmias). (consider pimobendane, ACEI, sotalol). ACE inhibitors 6 Fox PR, Maron BJ, Basso C, et al. Spontaneously occurring arrhythmo- and pimobendan should be considered with advanced lesions. genic right ventricular cardiomyopathy in the domestic cat: A new animal model similar to the human disease. Circulation. 2000;102:1863-70. ►“Malignant” Familial History of Sudden Death (High Risk Genotype). (consider aggressive monitoring and focused, individualized therapies). 7 Fox PR, Schober KA. Management of asymptomatic (occult) feline cardiomyopathy: Challenges and realities. J Vet Cardiol 2015;17(Supp ►Hypertrophic Obstructive Cardiomyopathy (HOCM) by itself does not 1):S150-8. confer higher risk than cats with the non-obstructive form of (HCM) and is not by itself a target for therapy. GOALS FOR MANAGING HEART DISEASE No single test reliably identifies the failing heart (heart failure is a syndrome, and not a disease). Diagnosis requires an integrated approach including medical history, clinical signs, imaging, and clinical testing. Management are to reduce morbidity, assure quality of life, and prolong survival. Manage Acute CHF Pulmonary edema is life threatening. Initial IV bolus- furosemide (1- 2 mg/kg IV); repeat if needed in 1-2 hrs; then 1 mg/kg IV q8-12 hours until improved breathing rate and effort. Alternatively, CRI (0.25 – 0.35 mg/kg/ hr) following IV bolus. Thoracocentesis if needed. Pimobendan, 1.25 mg q12hr- controversial. Supplemental 40-60% O2- enriched inspired gas) im- proves pulmonary gas exchange. Trans-dermal 2% nitroglycerin ointment, ¼ to ½ inch q 6hr for the first day or two. Clopidogrel (18.75 mg daily) (eg, large atrium, blood stasis, myocardial failure). Withhold ACEI (enalapril [1.25-2.5mg q 24hr) until stable and eating; check renal function. CBC/ differential/biochemical profile (T4 if > seven years of age). Check renal function and electrolytes daily during hospitalization. Monitor SBP. Echocardiography. Radiographic clearing of alveolar infiltrates usually occurs usually by 24 to 36 hrs post therapy in first time CHF. Dehydration, azotemia, and hypokalemia result from over-diuresis. Close monitoring of creatinine and electrolytes is important. Appetite stimulants if anorexia. Managing Chronic CHF Decrease to lowest effective furosemide dosage. Pimobendan (contro- versial, 1.25mg q12h). Repeat echocardiogram. At risk for recurrent CHF/ ATE. RECURRENT OR RESISTANT HEART FAILURE Comprehensive evaluation; manage renal failure, electrolyte changes, hyperthyroidism, anemia, arrhythmias, and other systemic or metabolic conditions. Appetite stimulant. References 1 Luis Fuentes V, Abbott J, Chetboul V, Côté E, Fox PR, Häggström J, Kit- tleson MD, Schober K, Stern JA. ACVIM consensus statement guidelines for the classification, diagnosis, and management of cardiomyopathies in cats. J Vet Intern Med 2020 May;34(3):1062-1077. 2 Fox PR, Keene BW, Lamb K, Schober KA, Chetboul V, et al. International collaborative study to assess cardiovascular risk and evaluate long-term health in cats with preclinical hypertrophic cardiomyopathy and apparently healthy cats: The REVEAL Study. J Vet Intern Med. 2018 May;32(3):930- 943. 3 Borgeat K, Wright J, Garrod O, Payne JR, Fuentes VL. Arterial thrombo- embolism in 250 cats in general practice: 2004-2012. J Vet Intern Med 2014;28:102-8. 304 WSAVA GLOBAL COMMUNITY CONGRESS

0207 Reduce Preload: IV furosemide 2-4mg/kg bolus (IM/SC if IV not possible) HOW TO DIAGNOSE AND MANAGE CANINE Reduce Afterload: PO hydralazine (0.5-1mg/kg) MYXOMATOUS VALVE DISEASE (MMVD) P. Fox Pimobendan (Inodilator): 0.25-0.3mg/kg PO q12h. New York, NY/United States of America Centesis if severe effusion. Qualifications Record ECG, clinical pathology (BUN/creatinine/electrolytes) Philip R. Fox DVM, Dipl ACVIM (Cardiology), Dipl ECVIM-SA (Cardiology, Dipl ACVECC Measure SBP (delay if extremely dyspneic) [email protected] Incidence, Cause, and Pathology Secondly-1h later- Repeat Therapies 1 in 10 dogs presenting for primary veterinary care Assess respiratory rate/effort/auscultation Constitutes 75% of heart disease. Inherited in a number of dog breeds (suspected genetic component). Repeat furosemide bolus and oral hydralazine dose The mitral valve is most severely affected (tricuspid valve also common- ly). Thirdly-2hr later Repeat furosemide and hydralazine Disease prevalence increases with age (most dogs affected by 10yrs old). Most remain subclinical, but large proportion develop CHF. Attempt SBP. If >90mmHg AND still critically dyspneic, IV furosemide Effective management requires accurate disease staging 1-2mg/kg and hydralazine 0.5mg/kg PO Classification/Staging MMVD: Guidelines adapted from the American College of Cardiology/American Skip an hour between A, B, C if pet becomes hypotensive Heart Association, modified for dogs,1 characterize progressive stages and debilitation. Guidelines combine clinical signs and disease character- Discharge istics to frame context for management/follow up. Stage A- High risk to develop heart disease; no current disease. Furosemide, 2-4mg/kg q8-12h; pimobendan 0.25-0.3mg/kg PO q12h; Stage B- Structural heart disease (systolic murmur) but never signs of hydralazine (0.5-1mg/kg PO q8-12h for 1-2 days if congestion persists) heart failure. Subset B1-Asymptomatic- no radiographic/echocardiographic cardiac re- Comprehensive recheck in 24-48 hours modeling-and/or dogs with mild changes that do not meet EPIC treatment criteria.2 BUN/creatinine/electrolytes, possibly ECG/thoracic radiographs Subset B2 -Asymptomatic dogs- severe mitral regurgitation, LA and LV enlargement (via radiographs and echocardiography), that should merit/ Comprehensive patient reevaluation- 5-10days benefit from therapy: ie, vertebral heart scale ≥10.5; LA:Ao-2D-echo ratio ≥1.6:1; LV end-diastolic dimension normalized to body weight ≥ 1.7. Management of Progressive and Refractory CHF Stage C- Past or current CHF Stage D- Refractory to therapy (end-stage CHF). Additional drugs OVERALL GOALS of Heart Failure Therapy: 1) Relieve congestion (fluid accumulation) ACEI (enalapril, benazepril, others, 0.5mg/kg PO q12h). 2) Improve quality of life 3) Prolong survival Spironolactone (1-2mg/kg q12-24h PO). Outpatient Management- Severe Pulmonary Edema (Hospitalization is Not Feasible): Amlodipine (afterload reduction) 0.1mg/kg q24h- titrate over 3-4 weeks to Firstly-Initial Therapies 0.4mg/kg PO q12h; SBP assessment. Oxygen cage Sildenefil (2-8mg/kg q8-12h PO) for severe pulmonary hypertension (PA-systolic pressure >65-70 mmHg). Upward diuretic titration. Furosemide increase to 8-12mg/kg/day. Will ultimately lose potency/and-or cause azotemia. Torsemide (1/10th of the daily furosemide dose once daily, divided in two equal daily doses or titrated to q12h. Hydrochlorthiazide (0.5-1mg/kg q 12-48hrs) can be added to furosemide to promote sequential nephron blockade. Close renal function/electrolyte monitoring Control ventricular heart rate with supraventricular tachycarida (eg- atrial fibrillation). Dietary management; reduce excess sodium. Nutritional consultation in dogs that develop cardiac cachexia. Periodic thoraco/pericario/abdominocentesis PRN. Assess BUN, creatinine, electrolytes, blood pressure and body weight frequently during chronic therapy. Common Comorbidities: Many conditions coexist and cause similar clinical signs including upper/ lower respiratory disease, pulmonary hypertension, heartworm disease Obesity causes respiratory dysfunction. Complications of Heart Failure and Related Therapies 305

13–15 NOVEMBER, 2021 These include syncope with cough/excitement, tachyarrhythmias, acute Caution-azotemia chordae tendoneae or left atrial wall rupture, acute kidney injury, and impairs elimina- cardiac cachexia. tion, hypokalemia promotes toxicity Drugs Used to Treat CHF Associated Dogs With Chronic Myxomatous Valve Disease Digoxin Oral 0.003–0.011 mg/ Dose based upon (Cardiac glycoside) kg q12h lean body weight *(Table modified in part from Cardiac Education Group CEG Formulary: Cardiac Medications for Dogs. June 2020): http://cardiaceducationgroup. Diltiazem Monitor serum di- org/wp-content/uploads/2015/11/Canine_Drug_Formulary_June_2020_FI- (Calcium channel goxin concentration NAL.pdf blocker) (range– 0.8-1.2ng/ ml 8-12 h post NOTICE– Consult a registered pharmacist Dobutamine dose) (Positive inotrope) before reformulating into suspension or solution IV 0.1–0.2 mg/kg, IV Enalapril (ACEI) over 5 min; repeat Drug, Class * Administra- Usual dose range Notes CRI to cumulative 0.3- Effects of IV dilti- tion Route Esmolol 0.4 mg/kg dose, azem on AV nodal (beta-blocker) Oral (Dilti- then CRI or oral conduction may not Amiodarone [without 2–5 mg/kg over Monitor SBP and azem HCl) therapy) be immediate post preservative] Nex- 30–60 min rhythm for paren- Furosemide (loop bolus. Go slowly. terone® (antiarrhyth- teral; hepatotoxicity diuretic) Oral 0.1-0.6ug/kg/min mic) 8–10 mg/kg possible (monitor (sustained Maintain continuous q 12–24 h for liver enzymes); long Hydralazine (arterial release 0.2-0.4 mg/kg ECG monitoring 7–10 days, then elimination T½ dilator) capsules, q 8hr IV decrease to 4–6 Dilacor® Oral mg/kg q24 hr 3–8 mg/kg q12h IV (CRI) 2.5–15 µg/kg/min Dilute in saline or 5% dextrose Amlodipine Oral 0.1–0.2 mg/kg Titrate slowly to 0.4 solution (Arterial dilator) Oral q12h mg/kg q12–24h Gradual titration to Atenolol effect (Beta– blocker) Without CHF, higher Monitor creatinine, doses possible; 0.2–1.0 mg/kg discontinue with PO 0.25–0.5 mg/kg, BUN q12h gradual down-ti- q12h Contraindicated- re- tration nal failure Atropine Parenteral 0.005 to 0.02 mg/ Sinus tachycardia IV bolus, CRI IV Bolus 0.1- 0.5 Cautious in CHF (Anticholinergic) kg, IV 0.02– 0.04 mg/kg, IV over 2-3 mg/kg, IM or SQ Occasional paradox- minutes) Benazepril ical AV block with IV (ACEI) administration CRI 0.025 to 0.1 mg/kg/min IV 0.25-0.5 mg/kg Monitor renal IV boluses q 1-2 IM, SC if IV not q12–24h function h, then q4 - 8h in possible accordance with 0.1-0.2 mg/kg PRN response Taper to lowest effective dose as Butorphanol Parenteral 0.1–0.5 mg/kg, IV/ Parenteral CRI 0.25–0.5 mg/ soon as possible (Sedative) Oral PO kg/h IM/SC Anxiolytic Azotemia 1–6 mg/kg, 0.5–1.0 mg/kg, q8–12h (max. ↓Cl, ↓K, ↓Na, ↓Mg, q4–6h total daily dosage Metabolic alkalosis 12mg/kg) Capromorellin Entyce® Oral 3 mg/kg q24h Short-term appetite 0.5–3 mg/kg, stimulant q12h For acute fulmi- nating cardiogenic Measure SBP PO edema: 0.5 mg/ especially prior to 0.2–1.0 mg/kg, each dose q12h for normal kg initial dose, myocardial func- Lower doses Carvedilol® (alpha- tion (Start 0.2mg/ (0.1–0.5mg/kg q then 0.35-0.5mg/ and beta-blocker) kg, titrate upward 12h) with myocardi- Oral to 0.8-1mg/kg al failure/DCM kg hourly for 3-5 q12h) doses PRN 306 WSAVA GLOBAL COMMUNITY CONGRESS

Start at low end of Sildenefil (PDE–V PO 2–4 mg/kg dose when added inhibitor) q8–12h to loop diuretics for sequential nephron Spironolactone PO 1–2 mg/kg q12- Weak K sparing blockade with resis- (aldosterone receptor 24h diuretic Hydrochlorothiazide 1–4 mg/kg, tant effusion blocker (thiazide diuretic) PO q12–24h Anticipate azote- mia, electrolyte Sotalol (beta-blocker PO 1–3 mg/kg, q12h Caution in CHF depletion and antiarrhythmic) or DCM- or when combined with volume depletion, mexiletine acute renal failure Small dog: Hydrocodone with PO 0.25–2 mg/kg, Titrate to effect Taurine (amino acid) PO 250–500 mg q12h Confirm deficiency homatropine (cough q4–12h (or PRN) Medium: 500 mg, by measuring whole suppressant) q12h blood/plasma concentrations Large: 500–1000 IV Bolus 2-4 mg/ Initial bolus 2 mg/ mg q12h kg to cumulative kg Lidocaine (antiarrhyth- Parenteral dose of 9mg/kg, Contraindica- mic) over 20-30 min Bolus effect is short tions-dehydration, acting hyponatremia CRI 40–80 µg/ Telmisartan (ARB) PO 1-2 mg/kg q24h kg/min Toxicity (vomiting, Hyperkalemia, azo- tremors, seizure) temia, acute renal failure Mexiletine (antiarrhyth- Parenteral 4–6 mg/kg, q8h Give with meal mic) Anorexia, GI Caution with con- current ACEI Nitroglycerin ointment Topical 2% ¼-1 inch q12h up Apply to hairless Theophylline (broncho- PO 75-15 mg/kg q12h Anxiety, hyper- (vasodilator) paste (15mg to 15 mg in giant skin sites; remove dilator) activity, tremors, = 1 inch) breeds; remove previous dose gastrointestinal after ≈6h to pro- before next appli- signs, tachycardia vide a “nitrate-free cation interval 0.1–0.4 mg/ Hypochloremia, Avoid human skin kg q12–24h- hypokalemia, cotact Torsemide (loop or 1/10th or hypomagnesemia, diuretic) 1/20th total hyponatremia, renal PO furosemide dose failure Nitroprusside sodium Parenteral CRI IV 2–15 µg/ 24-48hrs (vasodilator) kg/ min No bolus 3-10 mg/kg q12h Starting doses: Monitor SBP (>90mmHg ok) <10 kg: 7 mg/kg EPA 40 mg/kg, Trazodone (sedative) PO 10-25kg: 5mg/kg Administer 1h prior daily to clinic visit Omega-3fatty acids DHA 25 mg/kg, May not be tolerat- >25kg: 3 mg/kg daily ed in some (Fish oil, nutraceutical) Prognosis for Dogs with CHF: Docosahexaenoic acid Combination Avoid products with (DHA) and Eicosapen- PO formulation vitamin A or D Once CHF develops, survival of 3–18 months is not uncommon. taenoic acid (EPA) capsules= combined in a fixed- 1gm (1000mg) Keene BW et al. ACVIM consensus guidelines for the diagnosis and treat- dose capsule (1.5:1 or capsule/5kg body ment of myxomatous mitral valve disease in dogs..J Vet Intern Med. 2019 2:1 EPA:DHA) weight, q24 hr May;33(3):1127-1140. doi: 10.1111/jvim.15488 Pimobendan (Inodi- PO 0.25–0.3 mg/kg Avoid formulating Boswood A. Et al. Effect of Pimobendan in Dogs with Preclinical Myxoma- lator) q12h (q8h in Stage into suspension tous Mitral Valve Disease and Cardiomegaly: The EPIC Study-A Random- D CHF) ized Clinical Trial. J Vet Intern Med. 2016 Nov;30(6):1765-1779. Procainamide (antiar- Parenteral IV 2 mg/kg, slow Give IV bolus over rhythmic) IV bolus (max 2-3 minutes cumulative dose- 25 mg/kg Monitor SBP after 8-10 mg/kg CRI 25–40 µg/ kg/min Hypotension, myo- cardial depression IM/SQ 10–20 mg/ kg, q4–6h 307

13–15 NOVEMBER, 2021 0208 ly, part of the deep digital flexor tendons may be removed (tendonectomy or tenectomy), which results in the claws being permanently retracted. WELFARE AND ETHICS IN COMPANION ANIMAL The claws become thick and brittle and must be regularly trimmed. In one COSMETIC SURGERY study3, of 164 cats undergoing declawing, 50% had one or more compli- cations in the immediate post-operative period and nearly a fifth (19.8%) S. Wensley developed complications after discharge. Additionally, cats may try to continue scratching after declawing, causing them frustration and chronic Telford/United Kingdom stress. Qualifications: The pain, discomfort and distress caused to sentient animals by these non-medical procedures has moral significance and requires ethical justifi- Sean Wensley cation. The proposed benefits of the procedures need to be understood to help inform ethical analysis. BVSc MSc FRCVS Proposed benefits [email protected] WELFARE AND ETHICS IN COMPANION ANIMAL COSMETIC SURGERY Some promote tail docking on the grounds that it can help avoid tail dam- age caused by a dog being in heavy vegetation and brambles. Others cite Sean Wensley BVS MSc FRCVS breed standards that require the tails of some dog breeds to be docked. People’s Dispensary for Sick Animals (PDSA), Whitechapel Way, Priorslee, Some propose that ear cropping prevents injuries and infections in dogs Telford, TF2 9PQ, UK with pendulous ears. The primary purpose for ear cropping is often to give a dog a more aggressive appearance. [email protected] Both debarking and declawing are surgical means of stopping behaviours Cosmetic surgeries, also known as ‘convenience’ or ‘utility’ surgeries, that can cause nuisance to some owners – i.e. barking (deemed to be are controversial surgeries performed on companion animals in some ‘excessive’) and scratching (either furniture or people). countries, but illegal in others (see Sandoe et al1 for an overview of leg- islation). These surgeries are notable for being performed for non-med- Each of these proposed benefits are open to scientific and ethical ical reasons; for example, to achieve a certain aesthetically desirable challenge. In the case of tail docking, while it may sound as though the appearance, to meet a breed standard, or to alter an animal’s function in procedure could be in an animal’s best interest – causing harm to prevent a way that makes them easier to co-habit with. The four most common a potentially greater harm – evidence suggests that a relatively large cosmetic surgeries are tail docking, ear cropping and debarking dogs, and number of puppies need to be docked to prevent tail injuries. Diesel et al4, declawing cats1. for example, indicated that approximately 500 puppies would need to be docked to prevent one tail injury. Other animal welfare-based challenges Welfare harms question the need to put some dogs at a higher risk of sustaining tail injuries in the first place and the legitimacy of drafting breed standards Each of these procedures causes welfare harms to animals, both from the – arbitrary descriptions of human aesthetic preferences – that require procedures themselves and from their longer-term effects on the animals animals to be mutilated to meet the standard. that undergo them. They cause acute pain, particularly when undertaken by lay persons, rather than by veterinarians who may administer a general Necessity for harm anaesthetic and/or analgesic. Pain and discomfort may also be experi- enced during healing. The suggestion that ear cropping helps to protect dogs with pendulous ears from sustaining injuries or infections is not borne out by the fact that Puppies are usually tail-docked at less than 5 days of age. A varying the typically cropped breeds are not those at increased risk of ear injuries amount of the tail tip is removed, typically using a scalpel blade or nail or infections. Nor is there evidence that the procedure prevents injuries in cutters. Surgical pain during the first week of life may lead to hyperalgesia dogs with pendulous ears. in response to subsequent surgical pain and chronic pain could arise from neuromas in tail stumps. While debarking and declawing may successfully stop behaviours that are deemed a nuisance to an animal’s owners (potential surgical com- Ear cropping is usually performed on puppies at 7 to 12 weeks of age, plications and ineffectual outcomes notwithstanding), a more humane involving the removal of a portion of the pinna. Up to two-thirds of the ear approach would seek to determine an animal’s motivation for performing flap is removed and the wound edges are closed with stitches. Ears may these behaviours, followed by the use of humane, evidence-based be- be ‘posted’ or ‘racked’ (wrapped or taped up) for several weeks or months, haviour modification techniques to treat them. From a broader perspec- so that they remain erect for the remainder of a dog’s life, with pain tive, it may be considered that some pet owners would benefit from having experienced during repeated bandage changes2. Both tail docking and a more realistic understanding of what owning certain species entails; un- ear cropping remove parts of a dog’s body that are important for canine derstanding, for example, that scratching surfaces is a normal part of cat communication. communication, is important to the cats and should be enabled through provision of appropriate scratching surfaces in their environment. Debarking involves removing a dog’s vocal cords under general anaes- thetic. It carries the risk of complications including aspiration pneumonia, Aside from utilitarian ethical approaches to cosmetic surgeries, an addi- chronic coughing and nerve damage, and may be unsuccessful, as the tional ethical perspective relates to animals’ bodily integrity; for example, development of scar tissue may allow vocal function to return. Debarked that bodily integrity should be respected, or that animals have a right not dogs may experience frustration from not being able to communicate to have their bodily integrity interfered with. vocally. Veterinary animal welfare advocacy Declawing (onychectomy) involves amputation of a cat’s distal phalan- ges of the front paws,. This may be performed using a scalpel, guillotine Enhancing, protecting and securing the health and welfare of animals is or laser. It is often performed along with neutering. It requires general the fundamental purpose of the veterinary profession5. The veterinary anaesthesia and post-operative bandaging of both front paws. Alternative- 308 WSAVA GLOBAL COMMUNITY CONGRESS

profession is an animal welfare-focused profession, as distinct from • American Veterinary Medical Association (AVMA). Policy on Ear Crop- a client-focused or veterinarian-focused profession5. While veterinary ping and Tail Docking of Dogs. https://www.avma.org/resources-tools/ professionals must work effectively with clients and be economically avma-policies/ear-cropping-and-tail-docking-dogs (Accessed 17 Oct 2021) viable and rewarded in their work, these are enablers for achieving our primary objective of improving animal welfare. There are both societal • British Veterinary Association (BVA). It’s time to #CutTheCrop. https:// and professional expectations for veterinarians to provide animal welfare www.bva.co.uk/take-action/ear-cropping-campaign/ (Accessed 17 Oct leadership6. Ensuring good animal welfare is a core mandate of individual 2021) veterinarians as well as the veterinary community at large7. Overall, the veterinary profession has a dual duty - to advocate the best interests of animals under the care of individual veterinary professionals, as well as to advocate for changes and solutions to address the root causes of animal welfare problems5. Given these professional responsibilities and expectations, the veterinary profession cannot support routine, non-medically indicated mutilations. As for painful mutilations performed on farmed animals, a tenable veteri- nary position is that the living environment and owner expectations should fit the needs of animals, not the other way round. Animals should not be routinely altered and harmed to suit their keepers’ needs. Some national and international veterinary associations espouse this positioneg 8, while others also have policy positions and campaigns against specific cos- metic surgerieseg 9. In the UK, the British Veterinary Association (BVA) has campaigned for strengthened legislation to stop a rising numbers of ear-cropped dogs; an increase which has occurred despite the procedure being illegal. BVA’s #CutTheCrop campaign10, run in collaboration with an NGO, resulted in over 100,000 signatures on the UK Government’s e-peti- tion website, followed by a legislative commitment in the UK Government’s 2021 Action Plan for Animal Welfare. References • Sandoe P, Corr S, Palmer C. Companion Animal Ethics. Wiley Blackwell; 2016 • Scottish Animal Welfare Commission. Scottish Animal Welfare Com- mission’s letter of 9 April 2021 with its opinion on cropping dog’s ears to the Minister for Rural Affairs and the Natural Environment. https://www. gov.scot/publications/scottish-animal-welfare-commission-opinion-on- ear-cropping-of-dogs---letter-of-9-april-2021-to-minister/ (Accessed 17 Oct 2021) • Tobias KS. Feline onychectomy at a teaching institution: a retrospective study of 163 cases. Veterinary Surgery 1994 23(4):274-280 • Diesel G, Pfeiffer D, Crispin S, Brodbelt D. Risk factors for tail injuries in dogs in Great Britain. Veterinary Record 2010 166(26):812-817 • Wensley S, Betton V, Martin N, Tipton E. Advancing animal welfare and ethics in veterinary practice through a national pet wellbeing task force, practice-based champions and clinical audit. Veterinary Record 2020 187:316-316. https://doi.org/10.1136/vr.105484 • Federation of Veterinarians of Europe (FVE), American Veterinary Medical Association (AVMA), Canadian Veterinary Medical Association (CVMA). Joint AVMA-FVE-CVMA statement on the roles of veterinarians in promoting animal welfare. April 2020 https://fve.org/cms/wp-content/up- loads/FVE-AVMA-CVMA-position-statement-on-animal-welfare-Clean-Ver- sion.docx.pdf (Accessed 17 Oct 2021) • World Veterinary Association (WVA). WVA policy on the Role of the Veterinarian in Animal Welfare. July 2021 https://www.worldvet.org/up- loads/docs/wva_revised_position_on_aw__-_july_2021.pdf (Accessed 17 Oct 2021) • Federation of Veterinarians of Europe (FVE). FVE reflection paper on Veterinarians’ Contribution to the UN Sustainable Development Goals (SDG). November 2016 https://fve.org/cms/wp-content/uploads/006_sus- tainability_adopted.pdf 309

13–15 NOVEMBER, 2021 0209 duration blocking maternally derived antibody. Although often labelled “booster”, the injection given at 6-12 months should be regarded as com- DOG AND CAT VACCINATION: BOOSTER DILEMMAS pletion of the primary vaccination course. True “boosters” are revaccina- tions given to adult animals that have already been effectively immunised, N. Whitley typically at 1 or 3 year intervals. Hertfordshire/United Kingdom Common Dilemmas Qualifications: Whether to give a booster to a pet that has recovered from an autoim- mune disease Nathaniel T Whitley Whether to give a booster to a pet that is receiving immunosuppressants BVMS, PhD, CertVC, DACVIM, DECVIM-CA, FRCVS Suggested Approach to these Dilemmas Member of WSAVA Vaccination Guidelines Group Background Ask yourself whether the booster would be indicated for the disease in question if the pet did not have a history of immune disease or immu- Controversy always surrounds vaccination. In the modern era, several nosuppressive therapy. Vaccine serology is very useful here. Remember factors have come together to fuel the debate regarding the necessity and that serology only interrogates antibody, does not help us with decisions optimal frequency of booster vaccinations for cats and dogs. In the early on Leptospirosis, and ignores cell-mediated immunity – the arm of the 1990s, vets first recognized feline vaccine associated sarcomas. Soon immune system where immunological memory resides in T-cells. Hence after, an early clinical trial on an FIP vaccine showed increased mortality a negative titre does not guarantee lack of immunity and in reality many in vaccinates (compared with controls), and a retrospective on canine seronegative pets may still be protected. However, if the titre is negative, immune-mediate haemolytic anaemia (IMHA) showed temporal associa- a risk-benefit analysis is required, based on medical history, lifestyle and tion between booster vaccination and onset of disease. The potential for environment of the pet. serious adverse effects of vaccination became widely recognized. In UK, an incendiary study in The Lancet purported a link between the combined Risks to consider – these all need to be weighed against each other in Measles, Mumps and Rubella vaccine and the development of autism in making a final decision children – this study was eventually fully retracted and declared fraudu- lent by the BMJ, but not before press coverage had caused major damage Risk of contracting a preventable and potentially fatal infectious disease to public confidence in vaccination, soon manifesting as an upsurge in if a booster vaccine is not administered: a lower risk environment is epito- measles outbreaks. The study’s author was found guilty of serious profes- mised by an indoor only cat, or a dog exercised only in the owner’s garden, sional misconduct and struck off the medical register, only to gain a cult with few other dogs in the immediate surroundings and minimal contact following in the powerful antivax movement in USA, including some direct with wildlife or waterlogged ground. Risks are higher for pets in deprived influence on former president Trump. urban environments, changing multipet environments, working dogs and those swimming in lakes or rivers. In many countries, there would be very Progress few dogs that are exercised in public places that are not at risk of poten- tial exposure to leptospirosis and parvovirus. It was appropriate that the outdated practice of administering “full” annual booster vaccinations to adult cats and dogs should come under Risk of giving a potentially unnecessary biological product. Minor adverse scrutiny through the lens of evidence based veterinary medicine. Excellent reactions are considered both uncommon and underreported, hence progress was made through global, regional and national guidelines on accurate figures are elusive. A massive study in USA documented adverse vaccination practices by professional bodies (such as WSAVA, European events within 3 days of vaccination in 0.3% of dogs. Risk was higher in Advisory Board on Cat Diseases, AAHA, amongst others), and research young dogs (1-3 year old), smaller dogs and those receiving multiple studies by vaccine manufacturers showing extended duration of immuni- injections, indicating that the greater dose of vaccine/kg bodyweight ty. Covid-19 has delivered some fascinating challenges and opportunities (“vaccine load”), the greater the chance of reaction. Breed predispositions – immunological terms are in constant use in the media and the need for were noted, with daschunds, Boston terriers, pugs, miniature pinschers rational application of infectious disease testing has created millions of and Chihuahuas overrepresented in the smaller breeds and boxers for the amateur immunologists! We are in the middle of the biggest vaccination medium to large breeds. Whilst a few publications suggest temporal rela- campaign in history. Fortunately the first human Covid-19 vaccines are tionships between different immune mediated diseases and vaccination proving highly effective, but the antivax movement, especially in USA, is in small case series or retrospective studies, incidence of immune-me- well funded and exploits social media to pray on the anxiety of vulnerable diated diseases occurring post vaccination has not been investigated in and disenfranchised people and those without easy access to accurate large studies. When infectious disease becomes less common because information. It is notable that one Covid-19 vaccine so far has been asso- of vaccination, serious adverse effects of the vaccine may become more ciated with an incredibly rare immune-mediated side effect (vaccine-in- prevalent than naturally occurring disease. A massive review in JAVMA duced thrombotic thrombocytopenia, predominantly in young women), but does not substantiate views that adverse reactions to leptospirosis vac- this phenomenon has not been documented in veterinary medicine. Note cines are more common than those against other vaccines. also that vaccines for canine enteric coronavirus and feline enteric coro- navirus are not recommended, neither is a new Russian vaccine designed Risk of spontaneous relapse of the immune-disease even without a to protect domestic animals against Covid-19 infections. booster being given. This risk needs to be understood and communicated to the client regardless of whether a booster is given. Risk likely varies Definition of a “Booster” Vaccination with disease and quantification is limited by the evidence base. A recent retrospective study on IMHA with long term follow up on 61 dogs showed The basic immunisation schedule recommended by WSAVA Vaccine a relapse rate of 23% (14 dogs) with a median time to relapse of 517 days Guidelines Group for puppies and kittens involves repeated vaccinations (i.e. quite late) with some relapsing after several years. In 7 dogs the re- with core vaccines up to 16 weeks of age, followed by a further injection lapse occurred whilst still on immunosuppressants. Notably 3 dogs in the of core vaccines at 6-12 months of age. The latter is designed to “catch” study developed Immune mediated thrombocytopenia (IMT) (none were individuals that have not responded to initial core vaccines due to long still receiving immunosuppressants). Previous retrospectives on IMHA 310 WSAVA GLOBAL COMMUNITY CONGRESS

suggested relapse rates between 11 and 15%. In a recent retrospective on 0210 IMT, most of the relapses (31%) occurred in the weeks and months imme- diately following discharge, mostly in pets still receiving immunosuppres- DO WE HAVE TO VACCINATE DOGS AGAINST sants. The relapse rate from 6 months after discharge was 11%. VISCERAL LEISHMANIASIS? Risk of relapse of the immune-mediated disease if a booster is given: M. Marcondes the temporal relationship between vaccination and development (not relapse) of IMHA suggested by the Duval and Giger in 1996 has not been São Paulo/Brazil convincingly documented by other investigators, although many have looked. The 2019 ACVIM consensus statement on the diagnosis of IMHA Qualifications: in dogs rigorously scrutinised the quality and weight of evidence (using an Integrated Metric of Evidence Score) for many disease associations, Mary Marcondes and out of 11 other studies considering the specific potential association between vaccines and IMHA, the only other good quality study found no DVM, MSc, PhD association and the other 10 studies showed negligible or low levels of evidence for an association. In a recent review of IMHA, 22 of 44 dogs [email protected] that had recovered from IMHA subsequently received boosters, with 4 Vaccination is an important and fundamental part of veterinary practice, dogs receiving more than one booster. 1 of the 22 dogs had a relapse of should be delivered as one part of a preventive annual health check visit, IMHA soon after a booster. For ITP one research abstract investigated and protocols should be personalized according to the requirements of boosters and disease relapse. 22 dogs in remission (off immunosuppres- the specific pet, carried out after careful assessment of the risk factors sants) were followed long term. 9 of these dogs did not receive boosters. based on lifestyle, geographic area of residence, age, and previous The other 12 did receive boosters, in some cases multiple boosters over vaccination history. To reduce the unnecessary administration of vaccine multiple years. No dog in either group relapsed. Whilst these numbers antigens to dogs and cats, vaccines can be classified as core, noncore, are small, my guidance based on these studies is that unless there was a and not recommended. A core vaccine is one which every dog or cat, no strong suspicion of the original onset of immune disease being triggered matter where or how they live, should receive because it protects that by a vaccine, if the patient is at least 6 months out from the illness and animal against infectious disease which may be lethal or cause high off immunosuppressants, and a booster vaccination is due and indicated morbidity. In contrast, the choice of giving a noncore vaccine should be based on lifestyle/environment, the benefits of the booster start to out- based on consideration of the geographic prevalence of infection, the life- weigh the very small potential risks. style of the individual pet and the risk for that animal to become infected. Vaccines against canine visceral leishmaniasis are considered noncore. Risks of giving boosters to patients still receiving immunosuppressants Visceral leishmaniasis (VL) is the most severe form of leishmaniasis, and - it depends whether the patient is receiving glucocorticoids or other domestic dogs are considered the main reservoirs of L. infantum, having immunosuppressants. Pets receiving glucocorticoids can still respond an important role in the epidemiology of the disease. favourably to vaccines, although the datasheet for veterinary steroid preparations is likely to advise against their use. For patients receiving The first vaccine against canine visceral leishmaniasis (CanVL), Leish- other immunosuppressants, the vaccine may be ineffective, or potentially mune® (initially Fort Dodge, later Pfizer and finally Zoetis), was registered dangerous (ciclosporin datasheets specifically advise against use of in Brazil in 2003. The vaccine had as antigen a glycoprotein complex con- modified-live vaccines). However, there is some interesting data on the taining fucose and mannose, obtained from Leishmania donovani promas- effects of ciclosporin on response to feline vaccines in a recent paper by tigotes, called FML (Fucose Mannose Ligand). As it did not satisfactorily Roberts et al. See WSAVA vaccine guidelines FAQ no 45 and 46 for more meet the requirements for phase 3 studies on vaccine efficacy, in 2014 it information on steroids and other immunosuppressants. was withdrawn from the market. At the moment there are three vaccines commercially available against CanVL: Leish-Tec® (initially Hertape References on request Calier Saúde Animal, now Ceva Saúde Animal), currently the only one in Brazil, commercialized since 2006, composed of recombinant protein A2 of L. donovani and saponin; CaniLeish® (Virbac Animal Health), licensed in Europe in 2011, which subsequently also obtained registration for its use in Argentina and Paraguay, composed of purified excreted-secreted proteins (LiESP) of L. infantum and saponin; and LetiFend® (LetiPharma Animal Health), which was authorized to be marketed in Europe in 2016, composed of a recombinant protein (Protein Q) without adjuvant. The vaccination protocol depends on the vaccine used and must follow the manufacturer’s recommendations. The effectiveness of the three products is around 70%. Leish- Tec® demonstrated a vaccine efficacy of 71.4% when the results were based on parasitological tests1. However, when the results of xenodiag- nosis were added, the vaccine efficacy was reduced to 58%. This means that some dogs, despite having negative parasitological results, were infected and were able to infect sand flies, and demonstrates the need for the concomitant use of topical insecticides in vaccinated dogs. Although the vaccine has reduced the incidence of infection, it was not shown to be effective in preventing the development of the clinical signs of the dis- ease2. Although there is evidence that CaniLeish® has a 68.4% vaccine efficacy in reducing the risk of progression to uncontrolled active infection or symptomatic disease3, some studies have not demonstrated that the vaccine can be effective in preventing infection or disease in dogs4. The use of Letifend® reduced the incidence of clinical signs related to 311

13–15 NOVEMBER, 2021 CanVL, demonstrating a vaccine efficacy of 72%, however, the number of 3. Oliva G, Nieto J, Foglia Manzillo V, Cappiello S, Fiorentino E, Di Muccio T, dogs with parasites was not significantly lower in the group of vaccinated Scalone A, Moreno J, Chicharro C, Carrillo E, Butaud T, Guegand L, Martin animals compared to placebo5. V, Cuisinier AM, McGahie D, Gueguen S, Cañavate C, Gradoni L. A ran- domised, double-blind, controlled efficacy trial of the LiESP/QA-21 vaccine From an epidemiological point of view, the use of vaccines against in naïve dogs exposed to two leishmania infantum transmission seasons. CanVL aims to reduce or interrupt the transmission of L. infantum, not PLoS Negl Trop Dis. 2014 Oct 9;8(10):e3213. just preventing the disease. The results achieved so far do not justify its large-scale use as a public health measure, since there is no evidence of 4. Velez R, Domenech E, Rodríguez-Cortés A, Barrios D, Tebar S, Fernán- a reduction in the incidence of infection in humans, in the prevalence of dez-Arévalo A, Aguilar R, Dobaño C, Alberola J, Cairó J, Gállego M. Evalua- the disease in dogs and in the transmission of the parasite to the vector. tion of canine leishmaniosis vaccine CaniLeish® under field conditions in Furthermore, some dogs vaccinated against CanVL, even when asymp- native dog populations from an endemic Mediterranean area-A random- tomatic, are capable of infecting sand flies. Evaluation of the potential ized controlled trial. Acta Trop. 2020 May;205:105387. infectiousness of vaccinated dogs (by xenodiagnosis) reported that 5.1% (2/39) of the dogs vaccinated with Leishmune® and 5.4% (2/37) of 5. Fernández Cotrina J, Iniesta V, Monroy I, Baz V, Hugnet C, Marañon F, the dogs vaccinated with Leish-Tec® were infectious to sand flies6. A Fabra M, Gómez-Nieto LC, Alonso C. A large-scale field randomized trial field study showed a reduction in the number of cases of CanVL in dogs demonstrates safety and efficacy of the vaccine LetiFend® against canine vaccinated with Leish-Tec® when compared to the placebo group (7.4% leishmaniosis. Vaccine. 2018 Apr 5;36(15):1972-1982. vs 17.7%), as measured by parasitological examination plus xenodiagno- sis. However, although these authors stated that there was a reduction 6. Fernandes CB, Junior JT, de Jesus C, Souza BM, Larangeira DF, Fraga in transmission to sand flies from vaccinated dogs with anti-A2 positive DB, Tavares Veras PS, Barrouin-Melo SM. Comparison of two commercial serology, there was no significant difference between the prevalence of vaccines against visceral leishmaniasis in dogs from endemic areas: IgG, positive sandfly pools that fed on dogs from the placebo (44.2%) and and subclasses, parasitism, and parasite transmission by xenodiagnosis. vaccinated (35.7%) groups when they were compared independently of se- Vaccine. 2014 Mar 5;32(11):1287-95. rology1. Mathematical models have suggested that CanVL vaccines have a limited or no effect on the prevalence of infection in dogs and humans7. 7. Sevá AP, Ovallos FG, Amaku M, Carrillo E, Moreno J, Galati EA, Lopes EG, Soares RM, Ferreira F. Canine-Based Strategies for Prevention Another problem when using CanVL vaccines concerns to the complexity and Control of Visceral Leishmaniasis in Brazil. PLoS One. 2016 Jul of diagnosing the disease, since serological tests may not distinguish 29;11(7):e0160058. between a naturally infected dog and a vaccinated dog, that can happen with some CanVL vaccines8. 8. Starita C, Gavazza A, Lubas G. Hematological, Biochemical, and Sero- logical Findings in Healthy Canine Blood Donors after the Administration The use of vaccines as an individual protection measure against CanVL of CaniLeish® Vaccine. Vet Med Int. 2016;2016:4601893. should be recommended by veterinarians according to the animal’s life- style, if living in endemic or non-endemic area, and the risk of infection. CanVL vaccines are one more tool to protect a dog that is exposed, in an endemic area for the disease, but that already makes regular use of topical insecticides (e.g. collars) as a protective measure. Owners who choose to vaccinate their dogs must be informed about the importance of the use of topical insecticides. Even vaccinated dogs can be infected, and vaccination does not exclude the possibility of developing the disease. Dogs living in non-endemic areas should not be vaccinated, unless they visit endemic areas regularly. CanVL vaccines should only be used in dogs with a negative serological test. However, asymptomatic dogs with neg- ative serology may also be infected. Therefore, carrying out a serological test before using a vaccine does not exclude the possibility that the dog is already infected, but it helps to identify at least part of the infected population that may have already developed antibody titers, but still does not show clinical signs of VL. A previous history of vaccination does not exclude CanVL in dogs with clinical signs or clinicopathological abnormal- ities suggestive of the disease. Summarizing, no vaccine against CanVL confers sterile immunity, however vaccination can prevent clinical signs of the disease in part of the dogs, but do not always prevent infection and, therefore, even vaccinated dogs can act as a reservoir for L. infantum and infect sand flies. References 1. Regina-Silva S, Feres AM, França-Silva JC, Dias ES, Michalsky ÉM, de Andrade HM, Coelho EA, Ribeiro GM, Fernandes AP, Machado-Coelho GL. Field randomized trial to evaluate the efficacy of the Leish-Tec® vaccine against canine visceral leishmaniasis in an endemic area of Brazil. Vac- cine. 2016 Apr 27;34(19):2233-9. 2. Grimaldi G Jr, Teva A, Dos-Santos CB, Santos FN, Pinto ID, Fux B, Leite GR, Falqueto A. Field trial of efficacy of the Leish-tec® vaccine against canine leishmaniasis caused by Leishmania infantum in an endemic area with high transmission rates. PLoS One. 2017 Sep 27;12(9):e0185438. 312 WSAVA GLOBAL COMMUNITY CONGRESS

0211 rabies and preventing transmission to people. UPDATE ON DOG-ASSOCIATED RABIES Much research has been carried out to demonstrate the operational feasibility of mass dog vaccination. Contrary to widely held perceptions, S. Cleaveland, K. Hampson, D. Nadal the vast majority of dogs in Africa and Asia have owners, and sufficient dogs are accessible to parenteral vaccination to allow target vaccination Glasgow/United Kingdom coverages to be reached. The presence of a less accessible community or ‘street’ dogs in areas of south and southeast Asia makes the situation Qualifications: more challenging, but target levels of vaccination coverage have also been achieved in these communities where campaigns are well organ- Sarah Cleaveland ised6. Developments in oral vaccination of domestic dogs may also allow opportunities for vaccination of hard-to-reach populations where this is BSc BA VetMB PhD MRCVS needed to reach target vaccination thresholds or to avoid a high degree of patchiness in vaccination coverage that can delay progress to elimination. [email protected] Rabies is a fatal progressive encephalomyelitis caused by zoonotic virus- A final important element of the feasibility of canine rabies elimination es in the Lyssavirus genus. The disease has been recognised for many relates to wildlife reservoirs as it is known that wildlife populations can centuries and has been the subject of more than 100 years of research maintain different rabies virus variants in different parts of the world. but remains one of the most distressing and devastating human diseases. However, in area where rabies virus variants are maintained in domestic Safe and highly efficacious vaccines have been developed for preven- dog reservoirs, as occurs throughout most of Africa and Asia, there is tion, control and elimination of rabies in human and animal populations. little evidence that these variants are maintained independently in wild Although the disease rabies can be caused by several Lyssaviruses, carnivore reservoirs, even in wildlife-rich areas. In these situations, maintained worldwide in several different mammalian host populations, although wildlife cases may occur, wildlife cycles do not appear not to be dog-transmitted rabies causes >99% of human rabies deaths worldwide. sustained once dog rabies has been brought under control7. Considerable advances have been made towards the elimination and control of canine rabies in many parts of the world, but the disease con- With the very strong body of evidence now available to demonstrate the tinues to kill tens of thousands of people every year in Africa and Asia1. epidemiological and operational feasibility and cost-effectiveness of The disease also exerts a substantial economic burden, estimated at canine rabies elimination, policy efforts are now being directed towards $8.6 billion per year1. While these costs primarily relate to the high costs a global target of zero human deaths from dog-mediated rabies by 2030, of human rabies vaccine and premature human deaths, several other with the ‘Zero By 30’ strategy coordinated through the United Against components of the canine rabies burden are also of concern. These relate Rabies forum8. The strategy is based on One Health principles, with both to livestock losses, which still remain poorly quantified but can have improved provision of PEP in combination with scaling up of mass dog important impacts for livestock-keepers in Asia and Africa and to wildlife vaccination shown to be the optimal strategy for reaching a target of conservation, with canine rabies threatening several endangered wildlife zero human deaths by 20309. Recent commitments by Gavi, The Vaccine populations2. Alliance, to include human PEP within their investment portfolio have provided a critical catalyst for progress, but are contingent upon parallel Human rabies is a disease that can be prevented through (a) prompt efforts being made in scaling up of mass dog vaccination. While it is clear administration of post-exposure prophyalxis (PEP) for people who have that rabies remains a high national priority in many countries of Africa and been bitten by suspected rabid dogs, and (b) by controlling infection at the Asia, challenges remain in the effective implementation of national dog animal source through mass vaccination of domestic dogs, which are the rabies control plans. Campaigns will need to be scaled up substantially major reservoir. The occurrence of human rabies, with deaths occurring at national level, regional coordination will be required and surveillance primarily in poor, rural areas of Asia and Africa, is a clear indicator of measures will need to be enhanced. The limited resources available to inequalities in provision of both human and animal health services. For government veterinary services in Africa and Asia are directed primarily PEP, the high costs, limited access and complex vaccination regimens on control of production animal diseases and further investment is likely represents a substantial challenge and health emergency for more than 30 to be needed to reach the global goal of zero human deaths. million people a year bitten by suspected rabid dogs and who require ur- gent life-saving PEP3. The high costs of PEP often result in major financial To overcome these funding challenges, many advocate the need for hardship, particularly for the poorest and most vulnerable families, and charging dog owners for dog vaccination, but this is unlikely to be effec- any delay in accessing PEP invariably results in intense anxiety as people tive in the poorest and most vulnerable communities where dog rabies re- await an uncertain outcome and, in some cases, the development of fatal mains endemic. Furthermore, in human disease elimination programmes, clinical disease. such as polio and measles, it is generally unquestioned that vaccines should be administered to people free of charge. It remains unclear why Despite the on-going threat of rabies, a considerable body of research now this is not considered appropriate for animal interventions. For rabies, the exists to demonstrate the feasibility of canine rabies elimination. Across a elimination goals are the same as for polio and measles - elimination of a range of settings worldwide, the basic reproduction number, R0, for canine deadly human disease - and strategies are based on similar interventions rabies consistently falls between 1 and 2, despite very wide variation in involving mass vaccination campaigns. Yet cost-recovery for public health dog density and demography4. This suggest that rabies should be feasibly vaccination campaigns seems only to be invoked when the intervention controlled through mass dog vaccination, and a vaccination threshold involves veterinary service delivery. of 70% coverage (achieved during annual campaigns) has been shown empirically and theoretically to be sufficient to control the disease and While Covid-19 has raised global awareness as to the value of One Health, can result in elimination4. Conversely, the lack of a strong relationship the pandemic has also highlighted some of the prioritisation and percep- between R0 and dog density suggests that approaches based on reducing tion barriers associated with implementation and operationalisation of dog density, such as culling, are likely to be ineffective and can often be One Health, with mass dog vaccination disproportionately affected10. counterproductive, with replacement and movement of dogs having the Nonetheless, rabies provides an excellent exemplar of how action on an potential to accelerate the spread of the disease5. There is now strong endemic disease problem that is of local concern to communities can evidence to indicate that mass vaccination of domestic dogs provides the generate the cross-cutting benefits, capacities and trust relationships most effective and cost-effective approach of controlling domestic dog needed by health systems to respond effectively to health emergencies. 313

13–15 NOVEMBER, 2021 There is no doubt that animal health services have a critical role to play 0212 and that animal interventions have scope to deliver on a wide range of development and health outcomes, but there is a need for solutions that INTERDISCIPLINARY APPROACH-AN EFFECTIVE provide more equitable access to services, particularly in supporting the TOOL FOR RABIES CONTROL IN SIKKIM, INDIA essential health and welfare needs of the most vulnerable communities. T. Bhutia References Gangtok/India • Hampson K et al. 2015. Estimating the Global Burden of Endemic Canine Rabies. PLoS Neglected Tropical Diseases. 9(4). doi: 10.1371/ Qualifications: journal.pntd.0003709. Dr Thinlay Nedup Bhutia • Woodroffe R et al. 2004. Infectious disease - Infectious disease in the management and conservation of wild canids. In: Biology and Conserva- B.V.Sc & AH tion of Wild Canids (ed. D.W. MacDonald) pp. 123-42. Blackwell’s. [email protected] • Sambo M et al. 2013. The burden of rabies in Tanzania and its impact on Due to significant increase in stray dog population, rabies deaths in local communities. PLoS Neglected Tropical Diseases. 7(11):e2510-e. doi: both human and animals and non existence of a scientific and humane 10.1371/journal.pntd.0002510. method for rabies and stray dog population control, the State Government of Sikkim in the year 2006 began implementing a separate dedicated • Hampson K et al. 2009. Transmission Dynamics and Prospects for the programme called Sikkim Anti-Rabies and Animal Health (SARAH) Division Elimination of Canine Rabies. PLoS Biology.7(3):462-71. doi: 10.1371/ in collaboration with Vets Beyond Borders, Fondation Brigitte Bardot and journal.pbio.1000053. local Sikkim SPCA. It is the first state-wide rabies program in India and demonstrates a successful One Health model of dog-mediated rabies • Morters MK et al. 2013. Evidence-based control of canine rabies: a elimination. SARAH activities are directed to canine rabies vaccination, critical review of population density reduction. Journal of Animal Ecolo- humane dog population control, community education, clinical training, gy.82(1):6-14. doi: 10.1111/j.1365-2656.2012.02033.x. implementation of wild life conservation measures, rapid response during natural disaster and animal disease outbreak, enforcement of animal • Gibson AD et al. 2015. Vaccinate-assess-move method of mass canine welfare and rabies control laws. SARAH is also playing an important role rabies vaccination utilising mobile technology data collection in Ranchi, in developing veterinary medicine and surgery with its highly skilled staff India. BMC Infectious Diseases.15. doi: 10.1186/s12879-015-1320-2. in Sikkim. • Lushasi K et al. (2021). Reservoir dynamics of rabies in south-east The achievements and benefits of this state-wide ABC/AR and animal Tanzania and the roles of cross-species transmission and domestic dog welfare programme are widely accepted in Sikkim and have created nu- vaccination. Journal of Applied Ecology, 00, 1– 13. merous positive ramifications especially on public health, animal welfare, economic savings, wildlife preservation etc. • World Health Organization (WHO), Food and Agriculture Organization of the United Nations (FAO) and World Organisation for Animal Health (OIE). Prior to establishment of the SARAH Programme, Sikkimese authorities, 2021. United against Rabies Forum. https://www.who.int/publications-de- confronted with the problem caused by ever-increasing numbers of tail-redirect/WHO-UCN-NTD-VVE-2021.1 dogs, resorted to mass shooting in the hope of finding a quick solution. However, as has been found in all parts of the world where such measures • Hampson K et al. 2019. The potential effect of improved provision have been utilized, this inhumane and dangerous slaughter policy was of rabies post-exposure prophylaxis in Gavi-eligible countries: a mod- totally ineffective in controlling street-dog numbers and rabies. Despite elling study. The Lancet Infectious Diseases, 1. Doi: 10.1016/S1473- carrying out such horrible, short-term and cruel practice, the rabies and 3099(18)30512-7 stray dog population were never under control; instead, the situation was more insurmountable where numerous human and animal rabies deaths • Nadal D et al. et al. 2021 Rabies and the pandemic: lessons for One were reported. As per the data available from the Department of Health, Health. 2021. Trans R Soc Trop Med Hyg. doi: 10.1093/trstmh/trab123. Government of Sikkim, numerous human rabies deaths were reported Epub ahead of print. PMID: 34392375. during pre-2005. As a result of concerted effort of the SARAH Programme, there is marked decline in human rabies deaths compared to 2005 and also there is reduction in the incidence of other zoonotic diseases posed by dogs and cats. The potential financial cost of uncontrolled rabies to Sikkim would have been significant running in crores, if the SARAH Programme would not have been implemented. The cost would include vaccines, medicines for humans and animals, other costs like production losses through direct loss of manpower and animal production. Deaths, psychological trauma are the other costs which are incalculable. There is also a positive impact on the tourism related industries due to this ongoing holistic, humane and sustainable approach and outside visitors are expected to grow as Sikkim is becoming known as a desti- nation with extremely-low Rabies risk. The SARAH Programme believes that people and animals are intrinsically linked and is an advocate for the relief of suffering and distress of animals. Instead of violent shooting or culling of street dogs, which was in practice during pre-2005, department of AH&VS is now implementing a non-violent approach to mitigate the 314 WSAVA GLOBAL COMMUNITY CONGRESS

street dog population and rabies. The erstwhile practice of controlling dog 0213 population and rabies through Mass Shooting was against the socio-re- ligious ethos of Sikkim and this may have led to profound degradation SHARE THE BOWL in values and ethics and now everybody is happy about this method. The SARAH Programme is helping to maintain these very values and ethos. S. Verton-Shaw Many citizens especially the children and elders no longer have to witness that cruel and barbaric shooting of dogs. Guelph/Canada Critical elements in the early stages of the program were provision of Qualifications: facilities and staff by Government of Sikkim, training of local staff in sur- gery, clinical medicine and humane dog catching through VBB volunteers Shoshana Verton-Shaw, RVT, VTS (Nutrition) and experts, provision of operational funding by FBB, garnering program support through involvement of stakeholders and community education [email protected] and animal welfare activities. In 2010, the American Animal Hospital Association (AAHA) released the Nutrition Assessment guidelines (https://wsava.org/global-guidelines/ The success of this programme, its degree of local staff capacity building global-nutrition-guidelines/), which included classifying nutrition as the and a consistent political support led to the creation of a separate 5th vital assessment, following temperature, pulse, respiration, and pain. Division under the aegis of the state government Department, ensuring its It is a vital parameter which can vastly improve patient quality and length sustainability and prompting calls for it to be used as a model for other of life for wellness and therapeutic use. Side effects of this modality of state-wide programmes. treatment are virtually non-existent, with better compliance than other methods of care. After all, this is the only treatment option that we can SARAH has eliminated dog-mediated human rabies for over ten years. guarantee all clients have already put into practice. The specific diet, dose Maintaining freedom from dog-mediated rabies has been challenging and frequency may require some adjustment! with distemper outbreaks diminishing the rabies vaccinated dog popu- lation and socioeconomic developments on the West Bengal borders of The majority of our clients are seeking a diet recommendation from their Sikkim. Two rabies incursions have been investigated using a One Health veterinary healthcare team, and most trust their veterinary healthcare approach with Chief Medical Officers and Department of Forestry Officers team as a reliable source of information on their pet’s nutrition. However, in the South of Sikkim notifying the SARAH Division with suspect rabies very few clients perceive that they are receiving a specific recommen- in people, dogs and cattle. The two outbreaks investigated occurred in dation. (Coe et al, 2008, 2020) This may be due to an error in communi- early January 2015 and 2016, the first involving a jackal biting two people cation, rather than negligence on the part of the veterinary team. Once and a dog and the second report involving an unvaccinated imported dog source demonstrates that more than half of clients will purchase a recom- biting its owner who subsequently died five weeks later with symptoms of mended diet and clients shared they would spend more if they understood rabies. Laboratory confirmed diagnosis of human rabies is difficult due to how it would help their pet. (AAHA, 2010) community resistance and remote location. The rapid antigen test is used to test suspect animal rabid cases but further laboratory diagnosis and One must consider the implications of neglecting this vital parameter. molecular testing is difficult. Rapid response teams were sent to the area Clients will continue to seek professional guidance, through their own to conduct tracing of in-contact animals. research online, or consultations with other paraprofessionals such as pet store employees, breeders, trainers, and groomers. The veterinary Buffer zones of vaccinated dogs have been effective in preventing and healthcare team builds their veterinary training and experience on a strong containing rabies incursions in to Sikkim. Socioeconomic development at foundation of animal science, understanding the unique biological needs the Sikkim/West Bengal border is a complicating factor. Loss of habitat of each species, breed-specific considerations, and various disease pro- has increased the risk of sylvatic rabies incursions. Increasing numbers of cesses. Only the veterinary healthcare team has access to the individual migratory workers for Hydropower plants has increased the risk of re-in- medical history and a strong relationship of trust preexisting with the troduction of rabies from unvaccinated pet dogs. Effective intersectoral client. Nutrition is a key component of patient wellness and the treatment communication between Health, Veterinary, Forestry and Police officers of disease, whether alone or synergistically with other modalities of care. is essential to enable rapid response to dog or jackal bite incidents and possible rabies incursions. Ongoing challenges include prevention of The busy, short-staffed practitioner may also cite a lack of time to fit rabies incursions by creating more secure buffer zones on the borders and nutrition into an already overflowing schedule. Not surprisingly, as the pet an active rabies surveillance program. population continues to climb with ongoing advancements in veterinary care increasing the life expectancy of the pet population. Veterinary med- icine is a team sport, with veterinary healthcare teams reporting better overall satisfaction and staff retention when every team member has an essential role to play in every client interaction. Veterinary technicians report increased job satisfaction, lower rates of mental health strain and overall improvement in workplace experience when they perceive a com- plete utilization of skills. Veterinary healthcare teams are highly skilled, highly knowledgeable pro- fessionals, with training in a variety of species’ biological and psycholog- ical needs. Through extensive training and practical experience, the team members are aware of breed-specific health risks and potential negative or positive health outcomes based upon environmental factors within a pet’s home. Veterinary healthcare teams are therefore the best source of information and nutrition recommendations. In the case of disease treat- ment, nutrition prescriptions can be written by the practitioner, including specific diet and food dosage. Therapeutic duets can be utilized indepen- dent of, or synergistically alongside, other treatment modalities such as medications and nutraceuticals. This will lead to improved treatment out- 315

13–15 NOVEMBER, 2021 come and client satisfaction. In some cases, medication can be reduced Step 4: Physical Exam or even entirely replaced by nutrition. During the physical exam, the patient’s body condition score can again This lecture will provide guidelines on the integration of nutrition into all be highlighted and key areas of interest from the diet history should also consultations as part of the existing appointment flow and protocol, with be noted. Based upon the results of the physical exam, the client should minimal additional time commitment from the practitioner. always receive a nutrition prescription from the veterinarian. One may consider that this is not worth mentioning if the pet is healthy, lacking in When implementing a new nutrition protocol in practice, one may consider nutrition risk factors and overall doing well on it’s current diet. However, the simple modification of the current client care touchpoints to build the veterinarian must congratulate their client on the work they have done upon the existing appointment flow throughout practice. By breaking the to ensure their pet’s good health and highlight that the current feeding nutrition consultation into several steps, it is easier to plan for nutrition plan is ideal for their pet. This will help to avoid diet drift or food transi- plan implementation in a variety of practices. tions later in the year. Step One: Collecting Nutrition History Step 5: Summary When: At booking/ appointment reminder call. If a new diet was prescribed by the veterinarian, another team member can then summarize the nutrition prescription, including dose. This can be There are several options for collecting a nutrition history. One can be carried out alongside other treatment plans such as new medications or orally over the phone, where the client is asked to report the diet history. A procedure estimates. At this time, the team member can communication study by Coe, J et. all, found that by asking a singe open-ended question, FAB: Feature, Advantage, and Benefits to the diet. The author encourages followed up by specific, closed questions. This has been described as highlighting 3 features: 1 feature of the diet plan that the client will appre- a cone-shaped approach, starting with a broad, information-gathering ciate based upon the diet history, and 2 features which will directly benefit question and exploring greater details using yes or no answers. The the patient. If the client is changing their food dose, review and demon- question used by Dr. Coe was, “Tell me everything that your pet eats or strate how to measure the food. If changing to a gram scale, consider goes into his or her mouth, from the time she gets up in the morning until demonstrating how to measure the food and send home instructions. If she goes to bed.” Although many veterinary professionals anticipate that changing from free choice feeding from measuring cups, or even scoops this may take much longer to collect a diet history, Coe demonstrated that to measuring cups, the measurement and dose should also be demon- this resulted in a greater number of foods and treats, compared to…., The strated. advantage to collecting diet history while the client is at home is more ac- curate representation of foods and treats fed, as the client is able to verify Step 6: Closing packaging for product name and caloric and other needed information. The diet prescription should again be reviewed, ensuring that the client The second approach would be to mail or email the client a diet-histo- understand the measuring instructions. Ensure that the client understands ry form prior to their consultation. There are two attached examples the nutrition prescription and answer any additional questions they may available on the WSAVA Nutrition Toolkit. This could be distributed and have. Remind the client how follow up will occur and when. returned to the practice prior to the appointment. Step Two: Admission Step 7: Follow up The patient is weighed on admission, and the client is provided with an Follow up should be conducted by the same individual who reviewed the expectation of the appointment. Clients will want to know at this time how nutrition prescription, wherever possible to ensure continuity of care. the pet’s weight compared to prior visits, it is helpful to share with the Ideally, if clients are followed up during the food transition, this can help client any changes. If comfortable, the body condition score could also be to address any challenges that the client may have with the transition assessed at this time. process or food measurement. Step Three: History Collection Nutrition history can be collected prior to, or with other patient history collection. When a nutrition history form has been utilized take this time to verify unclear information or to explore the extended nutrition history, should any nutritional risk factors (table) have been identified. Body condition score, can be verified at this time, as well as a muscle condition score. Clients can be taught to body condition score at this time and encouraged to check their pet’s body condition score weekly and monitor for any changes. If nutrition risk factors have been identified and the patient requires nutri- tion intervention, this can be outlined as a possibility, following findings from the physical exam. A fecal scoring system should be utilized to rule out a history of acute or chronic abnormal bowel movements. The team member should be aware that some clients may not recognize their pet’s bowel movements as abnormal. The fecal score chart provides a quantita- tive system for verification of digestive health. If history is collected by a team member other than the veterinarian, the team member can highlight any areas of nutritional concern or need for intervention to the veterinarian prior to the exam. 316 WSAVA GLOBAL COMMUNITY CONGRESS

0214 is likely the most referenced peer reviewed source of nutritional tools worldwide. HOW NEW DIGITAL TOOLS CAN PROVIDE BETTER OUTCOMES & PET PARENT ADHERENCE FOR The Pet Nutrition Alliance was started in 2016 and although originally NUTRITION CASES created by funding from two well known food companies it has since become totally independent and is funded only by the AVMA foundation. K. Lambrecht Their newest tool “Dare to Ask ‘’ has the potential to become a “game changer” to allow the veterinary team to assess the quality/safety of an Waunakee/United States of America OTC food at least in the USA. Their dog and cat calculators for weight management have been translated into 3 languages. Qualifications: Ken Lambrecht [email protected] There are also many veterinary universities (Tufts, Davis) in the USA with robust websites and resources we can send our clients to and I am sure Abstract Body: The pandemic along with increased caseload has reduced many others worldwide. our face to face time with clients for many if not most veterinarians. Pets are increasingly being diagnosed as obese with some studies showing up The Challenge: Finding out what and how much food is currently being fed to 60% of pets being overweight (1)Today’s diagnostics are picking up CKD and other diseases that can benefit from nutritional intervention Often just finding out what the client is feeding and how much is offered is earlier. Now is the time more than ever to embrace and leverage technolo- a major undertaking taking up valuable veterinary time & resources. “Mrs gy and peer reviewed tools to our advantage to help treat obesity and Jones says it is brand xx the blue bag and isn’t sure if she is feeding the other nutritionally treatable & preventable diseases. chicken or beef version.” is a common comment in my clinic on a daily, if not hourly basis. Calorie counts, levels of EPA/DHA are often hard to Is the veterinarian still the trusted nutritional source? Yes, fortunately we determine and treats and supplements pose a whole other challenge. are, but that status is in jeopardy unless we continually try to stay ahead of the overwhelming number of foods and treats that are being presented The Solution: Emerging veterinary pet parent apps/PMS to pet parents, many without much (if any) safety testing and research and guide them towards evidence based Rx foods whenever possible. Pet parent apps are starting to incorporate good home information and Fortunately, there are tools being developed to help. could provide a vital link for that data to get to the veterinarian easily. Feeding & exercise data is starting to emerge from the home environment I am NOT a board certified veterinary nutritionist. I AM a practitioner that via IoT (internet of things) IoMT (internet of medical things) devices. has focused on nutritional management of diseases (obesity, osteoarthri- tis, CKD) most of my career and have always looked to technology as a At least two cloud based practice management systems (PMS) Digitail & time saving tool in clinical practice. I am convinced that emerging Rhapsody are making it easier for clients to share that type of information technology available to both practitioners and pet parents in the home can directly or indirectly into patient records using a pet parent app. help us achieve better client adherence to our recommendations & provide better outcomes. Our pet parent clients, their pets and our overworked veterinary team members need these tools as soon as possible. The Challenge: Misinformation that we have to counter The Challenge: Food stealing & sharing in multiple pet households The diet-associated dilated cardiomyopathy controversy that began in the In the US the average cat household is 2.1 (3)The average number of pets USA in 2018 has perhaps more than anything highlighted what happens per household in the US is similar. This means that MOST of the house- when major ingredient changes are made to foods and those foods are holds we are advising have more than one pet which opens the door to fed without adequate testing. food sharing/stealing . The only two solutions I have had prior to recent technology advances were the “empty bowl” and the “food bowl referee” Food recommendation sites that claim to rate foods according to their methods to make sure each pet got the food they needed and the proper health value without scientific basis have existed for some time in the amount. USA. (Dog Food Advisor, Whole Dog Journal etc) These sites often divert pet parents to buy foods that may not have had adequate testing to What about the situation where a senior/frail cat needs to have food left ensure safety & quality. Home IOT devices (feeders etc) also sometimes out to graze but there is an overweight cat in the household ? Or a cat/dog recommend foods to monetize, bypassing the veterinary team’s recom- on special diets? Both were highly challenging feeding situations until mendations. Social media is full of nutritional claims and counterclaims recently. by non-scientists or biased individuals based on their business affilia- tions. The Solution: Smart feeders that are pet and/or portion controlled All of these put the veterinarian in the difficult position of trying to choose At least 2 companies (SurePet Care & PortionProRx) have developed pet an OTC food without adequate scientific basis. Fortunately for most restricting feeders to limit who and how much the pet eats and one of nutritionally responsive diseases we have Rx foods to prescribe made by them how often food is delivered. ethical and science based companies dedicated to research. While there is variability in the accuracy and size of pets they can serve The Solution: Good science based resources there is little doubt these products work. A recent study showed that using Surepet feeders in a home health ecosystem (baby scale, webcam, activity WSAVA has done a fantastic job of building a base of nutritional resourc- monitor & smart feeders) in multiple cat households was 4x more es to help busy practitioners all over the world (2)Their nutritional toolkit effective than traditional methods in getting cats to lose weight (4) 317

13–15 NOVEMBER, 2021 several diseases and achieve better outcomes The Challenge: Determining Ideal weight for obesity management We know that body condition score (BCS) is the “gold standard” but it is The solution: Accurate body weight and food weighing (passive or active) not a precise tool. A pet’s one year age body weight is often their ideal lifetime weight unless of course they are already overweight at that age. The emergence of affordable food scales & accurate body weight scales Unlike BMI which is very successful as a target/baseline in humans there for human infants is an incredible opportunity for both obesity manage- is a plethora of dog breeds (cats are easier) that make establishing a ment and inadvertent weight loss in smaller pets. Adding wifi, bluetooth or starting ideal weight for a beginning caloric determination difficult. Their even cellular connectivity could drastically improve client adherence to is also the exception of obese cats which go well above the 40% limit of our recommendations.. Incorporating them into a bed, in front of a feeder the 1-9 scale. The HIlls Body Fat Index Scale (BFI) does a much better job or under the litter box for cats making passive weights available would for them but takes more time and a cooperative patient. even be better. The Solution: Better methods of estimating ideal weight Summary Consensus has finally emerged on the 1-9 scale and classifying obesity I know I have laid out what may seem like a fantasy of devices, apps & 8/9 up as a disease thanks to the Global Obesity Consensus Statement (5) practice management systems. Just imagine if even a few home pet which especially when ½ scores are used will help us be more precise health devices start providing reliable data for the veterinary team’s uset. than the 1-5 scale. Given how dedicated today’s pet owners are to their pets’ health and how focused they are on technology and given the explosion of wearable We know that certain breeds are prone to obesity. Labradors & Golden technology for humans I believe it will be commonplace in the future for Retrievers, pugs & beagles are all over represented. There is considerable us to leverage these tools for the improved health of our clients’ pets. variation within breeding lines making it impossible to pinpoint an ideal Let’s embrace the possibilities to both improve outcomes, our bond with weight. What about mixed breeds? I have had personal discussions with pet parents and their pets and save time & effort of the veterinary team. all major cat & dog DNA companies about the possibility of either identifying obesity related genes or being able to predict ideal body weight. Perhaps even more futuristically the use of impedance to measure muscle condition score. Fanciful? Possibly, but with today’s emerging technology and the pet obesity epidemic still increasing I personally don’t feel we should leave any possible solution overlooked. Of course any tool would need to be validated using Dexascan as are all current systems we use (Hills, Purina, WSAVA, Hills BFI) The challenge: Osteoarthritis detection and treatment success We know that 90% of cats have radiographic signs of OA (6). We also know that their signs of OA are subtle and we are very unlikely to be observed in our exam rooms. Obesity is of course a common comorbidity and often a complicating one. Dogs are only slightly easier to detect arthritis in. The solution: Apps that share activity & observational data with veterinari- ans Reliable, inexpensive wearable devices like Fitbark, Whistle & are now available and many more robust products are on the way. Like all electronics they will only get more useful and inexpensive as technology advances. They include indicators of activity and amount of exercise that can be shared with veterinarians to help check compliance with either restriction of exercise in the case of an orthopedic device or more exercise to help in weight management. Emerging use of video cameras, accelerometers and refined questionnaires show the potential of helping us assess the effectiveness of our nutritional recommendations related to osteoarthritis & obesity. As these devices mature, valuable information can help improve outcomes and show pet parent adherence The challenge: Unintentional weight loss in cats due to CKD, hyperthyroid- ism, IBD etc It is well established that although cats gain weight between 6 and 9 years of age they often lose weight when over 10 years of age (7) The need for early detection of weight loss would be invaluable to detect early onset of 318 WSAVA GLOBAL COMMUNITY CONGRESS

0215 inflammation is also the pathology producing pain, control of inflamma- tion decreases further tissue damage and promotes healing. A traditional DEVELOPING ACUTE PAIN PROTOCOLS TO NSAID or EP4 receptor antagonist should be administered to all appropri- MAXIMIZE ANALGESIA AND MINIMIZE PATIENT ate patients. STRESS Advantages: Anti-inflammatory!!! Most surgical and trauma pain is due to T. Grubb pain of inflammation. Uniontown/United States of America Disadvantages: Can cause or exacerbate hepatic/renal disease, GI ulcer- ation and bleeding disorders. Qualifications: Contraindications: Most patients with renal or hepatic dysfunction, GI Tamara Grubb ulceration, clotting dysfunction, etc… DVM, PhD, Diplomate ACVAA, IVAPM President Elect, Fear Free Level 3 Precautions: Dose carefully in cats, but do not with-hold NSAIDs from Certified cats. Pain can be a powerful and unrelenting trigger and/or amplifier of fear, anxiety and stress (FAS). FAS can exacerbate pain and pain can exacer- Local anesthetic drugs bate FAS. Thus, painful patients often require higher dosages of drugs for sedation and analgesia, potentially causing dose-dependent adverse The pain signal is transmitted from the periphery to the central nervous effects, including negative health, behavior and welfare/quality of life system almost solely by opening and closing of sodium channels. This effects. provides a unique opportunity to control pain because propagation of the pain signal is almost totally dependent on this mechanism. Local Ideally, treatment of the patient with FAS and/or pain should start at anesthetic drugs block sodium channels and provide complete pain relief home. This may mean long-term therapy (eg, serotonin/norepinephrine from the nerves that are blocked. This fact led to the recommendation ‘… reuptake inhibitors (SNRIs) or benzodiazepines for FAS; NSAIDs and/ because of their safety and significant benefit, local anesthetics should be or gabapentin for chronic pain) or immediate therapy the day before and utilized, insofar as possible, with every surgical procedure.’ (AAHA/AAFP day of the veterinary visit (eg, trazodone, gabapentin, sedatives, opioids, Pain Management Guidelines, Epstein et al. 2015). Often overlooked is the etc…). Once in the hospital, Fear Free techniques should be utilized. The fact that local anesthetic blockade provides not only intra-operative but pet should spend minimal (or no) time in noisy lobbies, should be placed also post-operative pain relief. In humans, the inclusion of local blocks in a quiet exam room, and should be handled by veterinarians/techni- in analgesic protocols also decreases the likelihood that acute pain will cians/staff with appropriate training and compassion for the FAS/pain lead to chronic pain. Because of the similarity of the pain pathway across status of the animal. The use of pheromones, music and other calming mammalian species, this benefit is predicted in our patients. techniques may also benefit the patient. Advantages: Total loss of pain sensation! Cheap, easy to use, very effec- Building Effective Analgesic Protocols tive. Pain has many sources and can impact the pain pathway in a myriad of Disadvantages: None. Would be nice to have longer duration drugs. different ways. Unfortunately, there is no ‘one drug treats all’ analgesic drug to address the complexity of pain. Balanced or multimodal analgesic Contraindications: None protocols are essential for provision of adequate analgesia, which is es- sential for controlling FAS. The choice of analgesic drugs and techniques Precautions: Dose carefully in cats and maybe in goats. to balance the protocol should be made based on the location of action of that drug in the pain pathway. This is one of the most effective, inexpensive and easy to use drug classes. Where do drugs work? Mammals have a pain pathway that is very well-pre- served across species. Thus, we can scientifically say that animals do Common blocks include: caudal maxillary, infraorbital, caudal mandibular, experience pain. The pain pathway includes: mental, auriculotemporal, brachial plexus, manus/pedus, thoracic, testicu- lar, intraperitoneal, lumbosacral epidural, sacrococcygeal epidural, etc… Transduction – activation of noxious (ie, painful) stimuli by peripheral receptors Infusions (lidocaine only, controversial in cats) have been shown to provide analgesia in both acute (animals, humans) and chronic pain condi- Transmission – transmission of that stimuli up peripheral nerves tions (humans only so far – research needed in animals!) Modulation – modulation of that stimuli in the spinal cord (modulation Opioids often means amplification) Opioids are potent, rapidly acting analgesic drugs, making them excellent Perception – recognition of pain by the brain for acute pain protocols. Full mu-opioid receptor agonists (morphine, etc) are the most potent but also the most impacted by regulatory control. Descending inhibitory pathway – reflex feedback from the brain to the Buprenorphine is less potent but with a long duration, especially the spinal cord FDA-approved buprenorphine for cats (24-hour duration). When listing drugs for treating acute pain, the opioids are often listed as Advantages: Potent class of systemically administered analgesic drugs; the first class we consider. However, based on their effect on the pain high safety margin, reversible. pathway, perhaps we should start with NSAIDs and local anesthetics. Disadvantages: Short duration when compared to duration of pain if Non-steroidal anti-inflammatory drugs (NSAIDS) – traditional + piprants administered IV or IM; Potential for sedation in dogs (usually a good thing for anesthesia) and excitement in cats and horses; Potential for GI effects Inflammation is generally a major component of acute pain. Because (nausea/vomiting, slowed motility) that are generally clinically insignif- icant but might impact certain patients; Some decrease in respiratory function but almost always clinically insignificant. 319

13–15 NOVEMBER, 2021 Contraindications: No absolute contraindications. Preemptive analgesia Precautions: Patients in which vomiting, slowed GI motility, excitement/ Drugs administered prior to the pain stimulus are more effective. In part sedation or slight decrease in respiratory function could be problematic. because the block input to or decrease the response of the neurons in the dorsal horn of the spinal cord, which decreases the likelihood of central Infusions allow decreased opioid dosing. Butorphanol duration of action sensitization. can be prolonged if the drug is administered as an infusion. Multimodal analgesia Alpha-2 agonists Using drugs from different classes or by different delivery routes (eg, IV Consider sedation as soon as possible in patients with FAS. Dexmedeto- vs epidural) ‘interrupts’ the pain pathway at different sites, allowing the midine and medetomidine provide both sedation and analgesia and their effects of the drugs to be synergistic or even additive. This is one of the analgesic effects are synergistic with those of the opioids, thus enhancing most important components of an effective analgesic protocol. the effects of the lesser potent opioids. Postoperative and post-discharge analgesia Advantages: Sedation AND analgesia, reversible Pain does not end at discharge from the hospital (in most cases) so an- Disadvantages: Increases cardiac work because of vasoconstriction algesic drugs should not be discontinued on discharge from the hospital (in most cases). Pain should be controlled (remember – we don’t usually Contraindications: Most cardiovascular diseases eliminate pain – we just control it and improve quality of life!) until it dissipates to the level that it is not impacting patient welfare. Precautions: Any precautions associated with deep sedation (ataxia in horses, cows; mild respiratory depression, etc…) Summary: Balanced analgesic protocols are more effective than sin- gle-drug protocols at controlling pain and more efficacious pain manage- Infusions provide calming (or sedation if administered at higher dosages) ment equates to lower FAS. Balance the protocol by choosing drugs from and analgesia. Excellent addition to multimodal CRI. as many drug classes as appropriate, balancing both efficacy and safety. Include drugs to control FAS since FAS can amplify the sensation of pain. N-methyl-D-aspartate (NMDA) -receptor antagonist (ketamine) Ketamine, administered as a sub-anesthetic dose infusion in a multi-mod- al protocol, prevents or decreases the development of central sensitiza- tion, a condition that significantly amplifies the pain signal. Ketamine can play a major role in the reduction of both pain and with opioid consump- tion. Consensus guidelines promoting the use of ketamine in both acute and chronic pain states in humans have been developed (Schwenk et al. 2018; Cohen et al. 2018). Advantages: Role in controlling central sensitization, which can be tough to treat. Disadvantages: Must administer as a constant rate infusion (CRI) to achieve this effect Contraindications: None (CRI dose is REALLY low!). Precautions: Patients that may not be able to clear the drug through hepatic or renal pathways; patients with seizures. Potential adjunctive drugs Maropitant is a neurokinin-1 (NK-1) receptor antagonist. NK-1 recep- tors are found both in the emetic and pain pathways. Although minimal alveolar concentration (MAC) reduction studies do not prove analgesia (Reed and Doherty 2018), in a visceral pain model maropitant decreased MAC in cats (Niyom et al 2013) when administered at the label dose and in dogs when administered as an infusion (Boscan et al 2011). If not a true analgesic, the potential for increased patient comfort secondary to decreased vomiting makes maropitant a valid addition to a perioperative analgesic protocol. Gabapentin is used for treatment of chronic neuropathic pain and is un- likely to provide analgesia for acute inflammatory pain. However, gabapen- tin might be appropriate in patients with pre-existing neuropathic pain. NOTE: If administered for analgesia, the recommendation is continued dosing, rather than a single dose, at a minimum of 10 mg/kg PO BID. Gab- apentin will also decrease FAS, which can decrease the intensity of pain. Designing analgesic protocols for perioperative pain: To use analgesic drugs most effectively, the principles of analgesia should be followed to provide balanced analgesia: 320 WSAVA GLOBAL COMMUNITY CONGRESS

0216 J Feline Med Surg. 2019;21(1):25-34. WHAT ARE THEY HIDING? FINDING PAIN IN DOGS A brief pain exam can easily be incorporated as part of the postoper- AND CAT ative physical exam. The patient should be examined more in-depth if T. Grubb abnormalities are identified on the pain exam, just as the patient would be examined more in-depth if any abnormalities were identified on the Uniontown/United States of America ‘normal’ physical exam. Qualifications: What is assessed in a pain exam? Tamara Grubb DVM, PhD, Diplomate ACVAA, President-elect IVAPM For the ‘quick look’ (these can all be assessed from outside the cage): [email protected] Pain Assessment: From Facial Scales to Futuristic Technology CATS: Facial expressions or ‘grimace’: One physical change that was Tamara Grubb DVM, PhD, Diplomate ACVAA not attributed to animals until recently is change in facial ‘expressions’. The main barrier to treating pain in animals: Due to an evolutionary need However, with the publication of the ‘rat grimace scales’ (Sotocinal SG, et for survival, animals hide pain from humans. This instinct may be even al. Molecular Pain 2011, 7:55), the ability to identify pain-related changes stronger in cats and this, along with their more sedentary lifestyle when in facial expressions has been described and validated in a number of compared to dogs, results in pain being diagnosed less frequently in cats species. The Feline Facial Grimace Scale a validated, easy to use scale than in dogs. Difficulty in diagnosing/recognizing pain in both species (Evangelista et al. 2018) that can be used first as a screening tool as part is true for both acute and chronic pain and for in-hospital and at-home of a ‘quick’ look and second as the actual pain scoring tool to assign a pain. In addition, surveys show that many pet owners and veterinary team pain level to the cat. The scale and a training manual for the scale are members are unsure of which pharmacologic/non-pharmacologic options available as open access (see links in list of scoring systems). You need are appropriate for analgesia, especially for administration at-home. this! The same facial pain indicators can be used in dogs but have not yet One thing we do know is that animals do feel pain. We can scientifically been validated by research. In part, this is because there is more variabil- say that animals feel pain since the pain pathway is very similar across ity in dog skull/facial anatomy, this potential more variability in exhibition mammalian species – thus, if a stimulus is painful to a human, it is painful of facial expressions. to a dog or cat. So we have to find ways to identify and treat pain in our patients and pets. Body posture: Changes in posture like ‘tucked’ abdomen or ‘hunched’ back often indicate pain. Head down, neck stretched, ears back (cat) or Acute Pain flat and tail down/tucked are also all signs that could indicate pain. Body Instead of solely relying on the patient to exhibit easily recognizable posture while lying down is also important. For instance, cats generally signs of pain, analgesic plans should be made based on the presumed sleep ‘curled up’ in cold environments like most veterinary hospitals and level of pain from the procedure that the patient will undergo or disease/ cats that are laying stretched out in this environment may be experienc- condition that it presents with. We can do this using our knowledge of ing pain. Dogs laying in awkward or not normal positions may also be what the pain level would be in humans to anticipate the degree of pain experiencing pain. that the animal will feel (examples of expected pain levels: Mathews KA, Vet Clinics of North America, Small Animal Practice 2000;30:729-755.). Behavior: Has the patient’s behavior changed? There may be some However, we should also always look for signs of pain after a potentially residual effects of drugs in the immediate postoperative period but a painful incident. Even if we have utilized excellent analgesia, pain is a very major behavior change should be obvious and subsequent assessments individual sensation and the analgesic protocol may not be adequate for will be less impacted by anesthetic drugs. Common behaviors to watch all individual patients. for: defensive/aggressive (growling/hissing in a previously non-vocal cat; growling, excessive barking in a previously quiet dog), hiding or not inter- Assessment acting in a previously friendly cat or dog. Although this is first assessed Recommended review of assessment of acute pain in cats: Steagall PV, from outside the cage, the cage door should be opened so that the person Monteiro BP. Acute pain in cats: Recent advances in clinical assessment. assessing pain can pet and interact with the patient. Vital signs (should be part of the routine post-surgical exam anyway): Since pain is a stressor, physiologic signs of stress can occur and include tachycardia, tachypnea, hypertension, arrhythmias, etc… However, a change in physiologic parameters without any other change may not indicate pain and pain can be present without changes in physiologic parameters. Also, physiologic parameters can be altered by any stress, in- cluding hospitalization, loud environment (eg, barking dogs!), etc… so they must be assessed in conjunction with other signs of pain. Regardless, the cause of changes in physiologic parameters should be determined. A little deeper look: If abnormalities are detected on any parameter above, do a more focused pain exam. GENTLY palpate the incision or wound, palpate the areas around the wound or incision to assess for expanding pain areas, watch the patient move around the room and/or use other manipulations specific for the source of pain (eg, flex/extend joints). Obviously the patient will receive analgesia if pain is detected. If unsure, assume pain is present, administer analgesics and evaluate the response. We call it ‘asking’ the animal if it is in pain and this is the most useful way to determine whether or not an animal is in pain. For acute pain, an opioid 321

13–15 NOVEMBER, 2021 is often the best option because of the rapid onset and ‘high’ potency http://painfreecats.org/about-us/ of the drug. If the patient’s behavior returns to normal after treatment, then the diagnosis has been made – PAIN, and now we can move on Excellent owner (and veterinary professional and staff!) resources are to developing a treatment plan that will address the patient’s analgesic available at: https://www.zoetisus.com/oa-pain/feline-screening-resourc- needs. If the patient’s behavior does not return to normal but pain is still a es.aspx and https://www.zoetisus.com/oa-pain/canine-oa-pain.aspx likely diagnosis, try another dose of the analgesic drug and/or add a drug from another drug class (eg, use opioids and NSAIDs together). Relief of A number of very good scales are available at www.wsava.org/Commit- severe pain often requires multimodal therapy and may require higher than tees/Global-Pain-Council, including the Feline Musculoskeletal Pain Index expected drug dosages. Lack of response to aggressive analgesic therapy (FMPI), the Client Specific Outcomes Measure (CSOM), the Montreal can be used as a diagnostic tool since continued abnormal behavior Instrument for Cat Arthritis Testing (MI-CAT) and the Owner Behaviour would unlikely be due to pain if analgesic therapy is adequate but the pa- Watch (OBW). There is also a very good website on OA pain in cats, com- tient doesn’t improve. Pain is ruled out and further diagnostics are begun. plete with videos: https://www.zoetisus.com/oa-pain/feline-exam-videos. aspx. Other excellent websites are: https://painfreecats.org/ and https:// Scoring Systems: Acute Pain www.galliprantvet.com/us/en/coast-tools. All of the information from the pain assessment should be put into a pain score to documented in the patient’s record (and on the cage card if your practice uses them). No pain scoring system is perfect, especially since we rely on a human’s perception of what the animal is feeling – or what the animal is trying to hide. There are many scoring systems that range from simple numeric scales with no descriptors to more complex scales with physiologic, postural and/or behavioral indices to evaluate. Thus, each clinic can choose the one that works best for them. Ideally, the same person will score the animal before and after a painful procedure (like sur- gery) or before and after pain relieving treatment. Using the same person to score the patient improves the consistency of results from the scoring system. Systems are available for both acute and chronic pain. As stated, the Feline Grimace Scale can be used to obtain a pain score. Another easy to use descriptive scale is the Colorado State University pain scale, which is available for both dogs and cats. Another commonly used scale is the Glasgow Composite Short Form, which is not as intuitive as the CSU scale but has been validated to identify pain in both dogs and cats. Another validated pain scale for cats is the UNESP-Botucatu scale from Brazil. The scale is located at an excellent website (http://www.animalpain.com.br/ en-us/avaliacao-da-dor-em-gatos.php) that includes a series of videos of painful cats for scoring practice. The Feline Grimace, CSU, Glasgow and Botucatu scales can be download- ed at the following sites: Feline Grimace: https://www.felinegrimacescale.com/ CSU Canine: http://www.csuanimalcancercenter.org/assets/files/csu_ acute_pain_scale_canine.pdf CSU Feline: https://www.csuanimalcancercenter.org/assets/files/csu_ acute_pain_scale_feline.pdf Glasgow Canine: http://www.isvra.org/PDF/SF-GCPS%20eng%20owner.pdf Glasgow Feline: https://novacatclinic.com/wp-content/uploads/2016/06/ CMP_feline_eng.pdf UNESP-Botucatu: http://www.animalpain.com.br/assets/upload/esca- la-en-us.pdf Scoring Systems: Chronic Pain Changes in mobility & behavior should be included in the owner assess- ment. Detailed QOL assessment tools, some validated by research to identi- fy pain, are available at these websites (this list is not inclusive of all resources): http://www.lapoflove.com/Pet_Quality_of_Life_Scale.pdf https://pawspice.com/clients/17611/documents/QualityofLifeScale.pdf http://www.newmetrica.com/vetmetrica-hrql/ 322 WSAVA GLOBAL COMMUNITY CONGRESS

0217 Identify the first day of cytological diestrus (D1) through sequential vagi- nal smears every 2 days and/or confirm serum P4 values > 5.0 ng/ml HOW I TREAT MISMATING IN BITCHES AND QUEENS Wait 10 days after D1 (or D10) S. Romagnoli Administer one of the following compounds SC for 6 days: Legnaro/Italy Cloprostenol, once daily, 1 mcg/kg Qualifications: Alphaprostol, BID, 20 mcg/kg Stefano Romagnoli Natural PGF2a, BID: DVM, MS, Ph.D, Dipl. European College Animal Reproduction 50 mcg/kg on day 1, am and pm [email protected] 65 mcg/kg on day 2, am and pm Abortion in the Bitch 80 mcg/kg on day 3, am and pm The rationale for early pregnancy termination is to act early following an Perform uterine ultrasound on the last day of treatment unwanted mating thereby preventing conception. Because of the possibil- ity that up to 50% of mismated bitches are actually not pregnant, such an Table n. 1 – Treatment protocol to induce early pregnancy termination in approach is often avoided unless the probability of pregnancy is very high, the bitch following an unwanted mating. Abortifacient treatments need such as when: to be started no earlier than on diestrus day 10 but can be started as late as day 12. This allows for some flexibility as a therapy can be initiated on - breeding is confirmed with an inside tie (the dog’s penis remains blocked a Monday instead of during the weekend. Little if any clinical or experi- into the bitch’s vagina until mental data are available for some active principles such as Fluprostiol, Luprostiol or Fenprostalene. In general, the high concentration of these detumescence of penile cavernous bodies occur) compounds makes their use dangerous when compared to natural PGF products - both male and female are of proven fertility ______________ - the bitch was in the highly fertile period (vaginal smear fully cornified and serum progesterone between 2 and 20 ng/ml) Progesterone receptor blockers such as aglepristone bind to uterine progesterone receptors without producing the biological effects of pro- If these 3 possibilities sare verified the probability of pregnancy ap- gesterone. Thus it can be used to block the action of P4 during all stages proaches 100%, and therefore using an early treatment is justified. The of pregnancy. It is an oily injectable solution for subcutaneous administra- early approach to an unwanted mating requires the use of estrogens or tion at the dose of 10 mg/kg repeated on two consecutive days, 24 hours prostaglandins or antiprogesterone drugs. apart. Although the drug leaflet states that it can used starting from day 0 it is probably best to make sure that in early pregnancy corpora lutea are Estrogens act by inducing a persistent closure of the tubal-uterine junction present by assaying serum P4, as if the bitch has not ovulated yet the drug (thereby preventing embryo transport) as well as a potential direct em- may start decreasing its concentration in the general circulation when bryotoxic effect. Therefore, these compounds can only cause abortion at progesterone is rising. an early stage of pregnancy, between breeding and the arrival of embryos in the uterus. Treatment is normally done on days 3 and 5 post-breeding. The rationale for late abortion is to lower progesterone concentration thus These scheme is based on the assumption that mismating generally causing miometrial contractions and effect placental detachment as soon occurs on the day of ovulation (day 12 after onset of proestrus). However, as possible after pregnancy diagnosis. Maximum precocity of pregnancy if the mismating occurs later than day 12, such as on the last day of heat, diagnosis can be achieved with ultrasound: under the best circumstances treating on day 3 and 5 means that estrogens will be administered well (good equipment, experienced ultrasonographer, bitch not too overweight into the luteal phase, with potential negative consequences for uterine and without excess feces or gas in the large intestine) embryonic vesicles and general health. The risk of aplastic anemia should never be underes- can be observed as early as day 16-18 after breeding. Therefore, if the timated. Even if no bone marrow problem has ever been reported so far decision is to wait until pregnancy diagnosis ideally one should perform when using low doses (10 mcg/kg) of estradiol benzoate, it should be uterine ultrasound every 2-3 days acting immediately after pregnancy kept in mind that no estrogenic compounds should ever be used at doses confirmation. higher than 1.0 mg/dog. A commercial preparation with a very low doses (10 mcg/kg) of estradiol benzoate was marketed in Europe until 2012, and The reason why it is best to perform abortion as early as possible is no serious side effect were reported in the bitch until then. because the longer the time elapsing from placental development, the stronger the placental attachment becomes. A well developed placenta Prostaglandin F2alpha (PGF) compounds, whether natural or the more will make it harder to detach foetuses from the endometrium using an potent PGF-analogs, are luteolytic and uterotonic agents very effective in abortifacient treatment, which means that the treatment will have to be terminating the canine/feline pregnancy at any stage. Although using PGF longer. Currently, late abortifacient treatments are preferred to early ones to terminate pregnancy in small animals is an extra-label and experimen- because of the fear to treat non pregnant dogs. However, owners should tal use of the drug, their clinical use is based on a vast body of literature be advised that the later the treatment is started after day 18 of pregnan- confirming their efficacy for this purpose. PGF are administered sucutane- cy the longer it will take to achieve a complete abortion. Treatment length oulsy (SC) once, twice or 3 times/day depending on active principle (see (interval from treatment onset to complete abortion) may go from 4-5 Table 1). Bitches should be treated starting from day 10 after onset of days (when starting on day 18) to 10-14 days when starting after day 35. diestrus based on vaginal cytology (see Table 1). Late abortion can be performed with PGF, antiprolactinics, PGF+ antipro- lattinics, progesterone antagonists, or corticosteroids. ______________ Antiprolactinics - Antiprolactinics can cause abortion due to their prolac- tin-lowering effect as prolactin has a luteotrophic action from day 23 of 323

13–15 NOVEMBER, 2021 pregnancy onwards, Therefore, these compounds can be used alone from 0218 day 23 post-ovulation, although they are not as effective as prostaglan- dins when used as a single treatment. Dosages and side effects of the HOW I TREAT FELINE DIABETES 3 most common antiprolactinics used in veterinary medicine are sum- L. Weeth marised on table n. 2. Los Angeles/United States of America Antiprolactinic drug Daily dosage in the Side effects Qualifications: bitch/queen (incidence) Lisa Weeth Cabergoline 5 mcg/kg MID Emesis, anorexia (20%) DVM, DACVIM (Nutrition) Bromocriptine 10-20 mcg/kg BID (*) Emesis, anorexia (50%) [email protected] Metergoline bitch 100 mcg/kg BID Emesis, anorexia (20%), behavioral Feline diabetes mellitus (DM) is one of the most common endocrine dis- Metergoline queen 125 mcg/kg BID changes orders diagnosed in companion cats worldwide1, the prevalence of which appears to vary by region.2-5 The United States has the highest overall No information available prevalence of feline DM with an estimated 124 cases per 10,000 cats2, while in Sweden only 11-21 cases of DM are seen per 10,000 cats.3 There Table n° 2 – Dosages of the 3 antiprolactinics most commonly used in is also a strong breed predisposition with Burmese cats having a higher small animals. ( risk of developing DM compared to the general feline population4,5; as an example the overall prevalence of feline DM in Australia is estimated at 74 Prostaglandins and antiprolactinics - The combined use of prostaglandins cases per 10,000 cats, but for Burmese the prevalence increases to 221 and antiprolactinics is a good solutions as it couples the direct luteolytic cases per 10,000 cats.4 Low activity, increasing age, neutering, obesity, effect and the miometrial contracting action of PGF with the indirect lu- and being male are also consistently found risk factors for development teolytic action of antiprolactinics, and it allows to use lower doses of PGF. of this disease irrespective of breed.2-5 A variety of different combined protocols exist, all of which employ either cabergoline or, less frequently, metergoline or bromocrptine . The simplest Diet and Diabetes Management one is the following (day 1 = 1st day of treatment): PGF + antiprolactinic on day 1, 2 and 3 followed by daily antiprolactinic treatment to be contin- Specific diet changes are often attempted at the time of initial diagnosis, ued from day 4 on until abortion is confirmed. but the decision to change diet should be made on an individual case ba- sis. Administering twice daily injections while making changes to the diet Progesterone receptor blockers - The administration of aglepristone and daily feeding regime can be daunting for many caregivers and result later in the course of pregnancy, at day 26 to 45 after mating induces in food refusal by some cats. Additionally, the optimal diet for manage- resorption or abortion within seven days in approximately 95% of cases ment feline diabetes will vary with underlying etiopathogenesis and stage studied. Although the drug leaflet states that it can be used as late as day of disease. Cats that are considered pre-diabetic or are in early stages of 45 of pregnancy, it is probably better to avoid treating with aglepristone diagnosis and treatment may be able to maintain glycemic regulation with alone bitches who are pregnant beyond day 35, as foetus/es after 45 diet alone and without the need for additional medical treatment if fed days may occasionally survive treatment and either be born/expelled live a higher protein, reduced carbohydrate diet.6,7 Diet selection should be around day 53-55 or die and not be expelled from the uterus. Treatments made relative to the current carbohydrate intake and severity of diseases. with aglepristone can be started after day 35 provided that the issue is In those patients with more advanced DM long-acting insulin may be re- thoroughly discussed with the owner and a PGF treatment is associated to quired to normalize blood glucose levels initially and may ultimately lead help evacuating the uterus. to euglycemia without continued parenteral insulin therapy (i.e., diabetic remission) irrespective of diet type.6-11 Either a higher protein, lower Abortion in the queen carbohydrate or a moderate protein and carbohydrate, higher fiber diet are effective at aiding in glycemic regulation in these patients when given with Aglepristone can induce abortion in cats at any stage of pregnancy. The twice daily insulin.6-11 Though obese, diabetic cats fed higher protein, suggested dosage is higher than in the dog, being 15 mg/kg twice 24 lower carbohydrate diets in an amount to promote weight loss may experi- hrs apart. As to timing, queens are induced ovulators therefore assaying ence improved glycemic control and diabetic remission sooner.8-9 serum progesterone is imperative in mismated queens, as a low proges- terone value (<1.5 ng/ml) rules out ovulation thus eliminating the need for Diabetes mellitus can increase daily energy requirements though the ex- an abortifacient treatment. Blood sampling should be done on the third tent will vary with each patient depending on severity of disease. Even in day after mismating or later. Queens are not as prone to side effects of overweight or obese cats, the initial recommendation should be made for PGF compounds compared to bitches. Therefore, natural PGF doses can weight maintenance until glycemic control is established. This will allow be increased to 100 mcgkg and cloprostenol can be increased to 2.5 mcg/ the veterinarian and caregiver to evaluate the efficacy of insulin therapy kg. Timing and route of administration are the same as in the bitch, while independent of intentional calorie restriction. Initially feed 10-15% above there is no need to estimate the onset of diestrus as PGF compounds are pre-diabetes requirements and recheck weight regularly. This starting effective in causing luteolysis and abortion only from day 30 of pregnancy amount can be based off the calculated maintenance energy requirement onwards. Combined treatments aglepristone+PGF, aglepristone+antipro- (MER) of 70xBWkg0.75x1.2 (neutered adult cat factor), but as individual lactinics or PGF+antiprolactinics are all effective in queens during the cats can vary up to 50% above or below this amount even without concur- second half of pregnancy. rent disease, evaluating current and previous dietary intake may provide a more accurate starting estimate. Weight and body condition should be measured and recorded at each recheck examination with adjustment in energy intake as needed. In overweight or obese stable diabetic cats, a modest reduction in energy intake can then be made each day to help achieve a rate of no more than 324 WSAVA GLOBAL COMMUNITY CONGRESS

1% of body weight lost per week. Loss of adiposity may help improve diabetes mellitus. Vet Ther 2001;2:238-46. exogenous and endogenous insulin efficacy through a decrease in effects of peripheral insulin resistance. Frequent re-evaluations of weight and • Mazzaferro EM, et al. Treatment of feline diabetes mellitus using an clinical signs of disease are required to monitor for any needed change alpha-glucosidase inhibitor and a low-carbohydrate diet. J Feline Med in insulin dosage.8,9,12,13 Hypoglycemia can occur if the overweight Surg. 2003;5:183-9. or obese diabetic cats lose weight without a corresponding decrease in insulin. • Bennett N, et al. Comparison of a low carbohydrate-low fiber diet and a moderate carbohydrate-high fiber diet in the management of feline diabe- The initial treatment recommendations for diabetic cats should concen- tes mellitus. J Feline Med Surg 2006;8:73-84. trate on owners becoming comfortable and competent with insulin ther- apy and making adjustments to the daily feeding regime if needed rather • Hall TD, et al. Effects of diet on glucose control in cats with diabetes than making any specific diet changes. Longer-acting insulin allow for mellitus treated with twice daily insulin glargine. J Feline Med Surg more flexibility in feeding regime and meals for diabetic cats to be spread 2009;11:125-30. out over 4 or more feedings each day with 2 of those meals coinciding with the insulin administration. • Gottieb S, Rand JS, Marshall R, and Morton J. Glycemic status and predictors of relapse for diabetic cats in remission. J Vet Intern Med 2015 Once the cat is stable or if medical management alone is not controlling Jan;29(1):184 blood glucose levels during the day, transitioning to a higher protein, lower carbohydrate diet should be considered to aid in glycemic regulation. • Mimura K, et al. Impact of commercially available diabetic prescription Obese cats should be transitioned to a higher protein, lower carbohydrate diets on short-term postprandial serum glucose, insulin, triglyceride and diet formulated for active weight loss. There are a number of commercial- free fatty acid concentrations of obese cats. J Vet Med Sci 2013;75:929- ly-available veterinary therapeutic wet and dry diets that meet the profile 37. recommended dietary profile for both weight maintenance and weight loss in cats with DM. Over-the-counter (OTC) dry cat foods are often too high • Rucinsky R, et al. AAHA Diabetes Management Guidelines for Dogs and in dietary carbohydrates due to manufacturing requirements for higher Cats. JAAHA 2010; 46:215-24. starch contents for kibble formation, though OTC wet foods do not have this manufacturing limitation and may be suitable for weight maintenance in diabetic cats not requiring concurrent weight reduction. Summary Dietary and medical management of Diabetes Mellitus have the same therapeutic goals: minimize clinical signs related to hyperglycemia, avoid life-threatening hypoglycemia, maintain lean muscle mass, and improve quality of life parameters for patient and caregiver. In the face of inade- quate insulin production, twice daily parenteral insulin is often required, but feeding a higher protein, lower carbohydrate diet to cats with DM may help lower insulin requirements and promote diabetic remission. There is no one perfect diet strategy and recommendation should be tai- lored to the individual’s medical history, food preferences, and concurrent disease states to ensure patient acceptance and owner compliance. An individual cat’s needs may also change throughout the course of disease and monitoring body weight, body condition, musculature, and clinical signs of DM at each visit are good indicators of overall glycemic regula- tion. References • Rand JS, et al. Canine and feline diabetes: Nature or nurture? J Nutr 2004;134:2072S-80S. • Prahl AL, et al. Time trends and risk factors for diabetes mellitus in cats presented to veterinary teaching hospitals. J Feline Med Surg 2007;9:3651-8. • Öhlund M, et al. Incidence of Diabetes Mellitus in Insured Swedish Cats in Relation to Age, Breed and Sex. JVIM 2015;29:1342-7. • O’Neill DG, et al. Epidemiology of Diabetes Mellitus among 193,435 Cats Attending Primary-Care Veterinary Practices in England. JVIM 2016;30:964-72. • Lederer R, et al. Frequency of feline diabetes mellitus and breed predis- position in domestic cats in Australia. Vet J 2009;176:254-8. • Nelson RW, et al. Effect of dietary insoluble fiber on control of glycemia in cats with naturally acquired diabetes mellitus. JAVMA 2000;216:1082-8. • Frank G, et al. Use of a high-protein diet in the management of feline 325

13–15 NOVEMBER, 2021 0219 0220 HOW I DISCUSS PARASITE TREATMENT WITH HOW I TREAT SUBCLINICAL PANCREATITIS VETERINARIANS WHO ASK FOR ADVICE D. Bowman J. Steiner Ithaca/United States of America College Station/United States of America Qualifications: Qualifications: Dwight D. Bowman Joerg M. Steiner, Dr.med.vet., PhD, DACVIM-SAIM, DECVIM-CA, AGAF MS, PhD University Distinguished Professor Professor of Parasitology Dr. Mark Morris Chair for Small Animal Gastroenterology and Nutrition [email protected] Director, Gastrointestinal Laboratory Introduction [email protected] I am not a veterinarian; therefore, I am very careful when I talk with Introduction veterinary practitioners about the treatment of animals. Usually, I am responding to calls when things are unusual, atypical, or have already not The clinical presentation of both dogs and cats with pancreatitis varies responded to normal anti-parasiticides. widely. While most textbooks describe pancreatitis as an acute disease with severe systemic signs, such as vomiting and abdominal pain, other Objectives patients have non-specific clinical signs, such as lethargy, hyporexia, or behavioral changes. However, some also have apparently subclinical I will present in this talk how I try to go over the history about what I know disease or truly subclinical disease. There is an ongoing debate whether abut the subject at hand, who I might contact when specific treatments dogs and cats with apparently subclinical disease or truly subclinical are considered, and the means of verifying that the treatment is success- disease should be treated. It is important to note that chronic pancreatic ful. inflammation, clinical or subclinical, will lead to destruction of both endo- crine and exocrine pancreatic tissue, and thus could lead to both exocrine Methods pancreatic insufficiency or diabetes mellitus. At the same time pancreatic inflammation, even subclinical, may lead to an acute exacerbation and For this presentation, I will present various examples of questions that thus lead to acute on chronic severe disease. have arisen within the field and have finally made their way to my email or telephone. Evaluation for Concurrent Conditions Results Often times dogs and cats with mild forms of pancreatitis have concur- rent conditions, most notably IBD or hepatobiliary disease. Very little is I hope to show that veterinarians are very careful, are very interested in known about appropriate therapy for these patients and management is obtaining up-to-date information, and are willing to listen to new informa- often limited to evaluation and treatment of the concurrent condition, and tion and usually are happy to read any materials that I send their way. careful monitoring of the pancreatitis. Conclusions Evaluation for Risk Factors I hope to show that it is possible to be helpful for the normal and the Serum calcium and triglyceride concentrations should always be evaluat- atypical case when one is willing to listen and work with the veterinarian ed in these patients in order to identify any risk factors that can potentially to make certain the diagnosis is correct and that the effects of treatment be addressed therapeutically. can be measured to insure a successful resolution in most cases. Diet Also, nutrition appears to be very important in these patients. In dogs, the use of ultra low-fat diets (these are diets that contain less than 20 g of fat per 1,000 kcal) is recommended. Anecdotal data is very strong suggesting that these diets are efficacious in improving clinical signs and well as de- creasing serum cPLI concentrations. In addition to changing the diet to an ultra low-fat diet it is also important to avoid treats that are often high in fat. Vegetable or fruits can often be used as treats. Alternatively, canned ultra low-fat diets can be shaped and either dried or baked to produce an ultra low-fat treat. In cats fat content of the diet maybe less important. However, diets specifically high in fat (i.e., renal diets and low-carbohy- drate diets) should be avoided. Monitoring Regardless of the management, progress of the disease should always be monitored. Just as in human patients with chronic pancreatitis, canine and feline patients with chronic pancreatitis are at risk for developing 326 WSAVA GLOBAL COMMUNITY CONGRESS

episodes of severe pancreatitis at any time or exocrine pancreatic 0221 insufficiency and Diabetes mellitus later in life. Initially, while there are adjustments in management, cPLI or fPLI should be measured every 2-3 CANINE INFECTIOUS RESPIRATORY DISEASE weeks. Also, risk factors that have been identified, such as hypercalcemia COMPLEX - A REVIEW OF PREVENTION AND or hypertriglyceridemia should be monitored at the same time. As the TREATMENT situation stabilizes the frequency of monitoring can be decreased. J. Dear Immunosuppressive Agents Davis/United States of America Over the last two decades a new form of pancreatitis, autoimmune pancreatitis has been well described in humans. Autoimmune pancreatitis Qualifications: is now more commonly recognized in humans and is characterized by a lymphocytic-plasmacytic infiltration of the pancreas. Human patients with Jonathan D. Dear, DVM, MAS, DACVIM (SAIM) autoimmune pancreatitis respond favorably to the administration of corti- costeroids. Anecdotally, many clinicians cautiously treat canine and feline Associate Professor of Clinical Internal Medicine patients with chronic pancreatitis with corticosteroids and have found this treatment strategy to be beneficial in a portion of cases. Also, successful [email protected] treatment of a canine patient with chronic pancreatitis with cyclosporine has been reported in the literature. CANINE INFECTIOUS RESPIRATORY DISEASE COMPLEX – A REVIEW OF PREVENTION AND TREATMENT Canine infectious respiratory disease complex (CIRDC) is a complex rather than a single disease in which viruses, bacteria and Mycoplasma, can coinfect both naïve, immunocompromised and previously vaccinated dogs.1 CIRDC usually presents in an acute, self-resolving (uncomplicated) form characterized by a dry, hacking cough that might include retching and gagging. This syndrome is generally suspected to be initiated by viral pathogens. Occasionally, the pathologic changes induced by viral disease predispose dogs to subsequent infection with opportunistic bacteria and Mycoplasma thereby resulting in more severe (complicated) upper respira- tory signs, bronchopneumonia and death. CIRDC usually presents as a dry, hacking cough often followed by a terminal wretch. In particular, paroxysms of cough may be elicited by gentle tracheal palpation. In most cases the infection is isolated to the upper respiratory tract so most affected dogs lack systemic signs, though mild lethargy and exercise intolerance are sometimes reported. A history of recent exposure to other animals or housing facilities increases the suspicion of this disease. Although B bronchiseptica was the most isolated bacterium in some stud- ies, research has suggested that there are numerous viruses likely to play a role in CIRDC. Molecular techniques and virus isolation have identified mycoplasmal organisms, previously recognized viruses known to cause disease (e.g., canine adenovirus-2, canine herpesvirus-1, canine parain- fluenza virus, canine distemper virus, various canine influenza viruses), and emerging and novel viruses in which the link to clinical disease is not as well-recognized (e.g., canine respiratory coronavirus, canine reovirus, canine bocavirus, canine hepacivirus, canine pneumovirus) CIRDC has been documented worldwide, and no host-susceptibility–re- lated genetic factors have been identified. Seasonal patterns of CIRDC have been observed as B bronchispetica infections have been more commonly identified in dogs during cold months. Any dog can be infected with CIRDC-associated pathogens; however, young dogs and those with a pre-existing airway disease (e.g., bronchiectasis, airway collapse, ciliary dyskinesia) may be more susceptible due to impaired airway clearance. In addition, dogs in high-density environments or those that are immunolog- ically naive or immunocompromised (endogenous or exogenous) are at greater risk and appear to develop more severe disease. Prevention The most effective strategy for prevention employs strategic immuniza- tion and environmental controls to prevent exposure and limit passage of disease. According to AAHA vaccination guidelines,2 most owned dogs are immunized (parenterally) against CDV and CAV-2 as part of their core vaccines. Parenteral CAV-2 vaccination is considered a core 327

13–15 NOVEMBER, 2021 vaccine due to its ability to cross-protect against CAV-1. Though consid- 0.4 mg/kg PO every 8-12 hours]) can be used when bacterial pneumonia ered to be non-core, routine vaccination for CPiV and B. bronchiseptica is unlikely. Antimicrobial therapy is not typically needed, but doxycycline are recommended for animals likely to enter facilities where the diseases (5 mg/kg PO every 12 hours for 7-10 days) can be administered if disease may be encountered (boarding and grooming facilities, training kennels). persists >10 days or as a first-line antimicrobial if clinical signs progress When administered appropriately, core vaccines provide robust immuni- to systemic signs (ie, fever, lethargy, decreased appetite).3 ty against these viruses. Immunization with noncore vaccines may not prevent infection but does appear to limit the severity of clinical signs Complicated Disease and duration of shedding post infection. Oral, intranasal, and parenteral B bronchiseptica(modified-live and killed) vaccines are commercially Inpatient therapy should be considered for dogs with bacterial pneumonia available. In general, parenteral vaccines produce a profound serologic if hydration would be inadequate with outpatient therapy or if oxygen response, but oral and intranasal vaccines appear to provide more effec- therapy is necessary. In these dogs, IV fluid therapy and parenteral anti- tive mucosal immunity, with intranasal vaccines resulting in less severe biotics are generally warranted; empiric antimicrobial therapy with either disease in dogs challenged with infection in experimental studies, thus doxycycline (5 mg/kg IV every 12 hours) or a combination of clindamycin intranasal vaccination has been shown to produce protective immunity (5-10 mg/kg IV every 8 hours) or ampicillin (10-20 mg/kg IV every 8 hours) for at least 1 year; to the author’s knowledge these studies have not been and a fluoroquinolone (ie, enrofloxacin [10 mg/kg IV every 24 hours]) published for oral or parenteral B bronchiseptica vaccines. Vaccines can be considered. At discharge, enteral therapy can be continued with are available as monovalent products or combined with other respira- doxycycline (5 mg/kg IV every 12 hours) or amoxicillin/clavulanate (12-20 tory pathogens (e.g., canine parainfluenza virus, canine adenovirus-2). mg/kg PO every 12 hours), ideally, based on culture and susceptibility Vaccines are available for 2 strains of canine influenza (H3N2 and H3N8) testing.3 Patients with significant respiratory compromise should be as both monovalent and bivalent formulations. As killed vaccines, these provided with supplemental oxygen in an oxygen cage (if available) or induce a less robust immune response than avirulent live viruses and are through a nasal cannula. likely to reduce severity of disease rather than prevent infection. Bronchodilators (eg, theophylline [5-10 mg/kg PO every 12 hours], terbu- When dealing with dogs suspected of having infectious respiratory taline [0.625-5 mg/dog SC every 8-12 hours]) are rarely indicated in dogs disease, adequate sanitation is critical to prevent nosocomial infection. with CIRDC but can be administered in patients suspected to have bron- B bronchiseptica can spread rapidly in hospital environments; thus strict chospasm that is impairing appropriate ventilation. If used concurrently isolation is critical. These patients should be strictly isolated from other with fluoroquinolones, theophylline dosage should be reduced due to drug patients, and veterinary staff should use personal protective equipment interactions leading to reduced metabolism and subsequent increase in and proper hygiene to prevent transmission via fomites. Following basic plasma levels which might result in adverse effects. cleaning to remove organic material, contaminated cages and equipment should be disinfected using accelerated hydrogen peroxide (0.5%) or CIRDC is a common cause of acute cough in dogs, especially those diluted bleach (1:30), allowing for 10-minutes of contact time. Likewise, if cohoused with or exposed to other dogs (i.e. shelters, dog shows, or a dog is quarantined at home, owners should be made aware of the ability grooming facilities). Generally, this condition is self-limiting with support- of B bronchiseptica to spread to other animals in the household. Own- ive care, though some dogs need more advanced intervention including ers should also be instructed to maintain excellent hygiene and confine hospitalization or antimicrobial therapy should bacterial or mycoplasmal infected animals from other household pets and areas of high canine pneumonia develop. density for at least 1 month. Most viral respiratory pathogens are only shed for 2-3 weeks post infection, but Bordetella spp can be shed for up 1. Viitanen SJ, Lappalainen A, Rajamaki MM. Co-infections with respirato- to 4 months post-infection. Dogs with known B bronchiseptica infections ry viruses in dogs with bacterial pneumonia. Journal of veterinary internal should be kept away from other dogs during this time period. In outbreak medicine / American College of Veterinary Internal Medicine 2015;29:544- situations, adequate ventilation to ensure 10-20 air exchanges per hour is 551. recommended. 2. Ford RB, Larson LJ, McClure KD, et al. 2017 AAHA Canine Vaccina- Therapeutic Plan tion Guidelines. Journal of the American Animal Hospital Association 2017;53:243-251. Treatment of the acute cough in dogs with infectious respiratory disease should be aimed at minimizing the patients’ clinical signs while interven- 3. Weese JS, Blondeau J, Boothe D, et al. International Society for Com- ing with specific medical therapy when evidence suggests that this might panion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis improve the patient’s outcome. In cases of mild clinical signs the most and management of bacterial urinary tract infections in dogs and cats. important therapy is good nursing care, including appropriate hydration, The Veterinary Journal 2019;247:8-25. nutrition and separation from other dogs. In dogs with progressive clinical signs or indicators of systemic involvement such as oculonasal discharge, fever or adventitious lung sounds, judicious use of antibiotics is warrant- ed. Definitive diagnosis provides the best opportunity to provide optimal therapy for either upper or lower respiratory tract disease. However, often empiric therapy is more advisable for dogs with CIRDC due to the likeli- hood of spontaneous resolution. Uncomplicated Disease Outpatient therapy and isolation from other dogs for 2 to 3 weeks is recommended to minimize the risk for transmission. Therapy should include adequate nutrition, hydration, and hygiene. Cough suppressants (eg, hydrocodone [0.22 mg/kg PO every 8-12 hours] or butorphanol [0.1- 328 WSAVA GLOBAL COMMUNITY CONGRESS

0222 effects stemming from antimicrobial administration (i.e., intestinal dysbiosis, gastrointestinal signs, risk of MDR infection, hassle, and cost of WHEN TO TREAT? UTI VS SUBCLINICAL medication administration). BACTERIURIA (CASE BASED) Dogs with urinary incontinence and a positive urine culture J. Dear Urinary incontinence is generally not considered to be a common LUTS Davis/United States of America of bacterial cystitis. However, bacterial cystitis can certainly result in detrusor hyperreflexia. In my experience, dogs with well managed urethral Qualifications: sphincter mechanism incompetence (USMI) will occasionally present for worsening incontinence and a positive bacterial urine culture. A positive Jonathan D. Dear, DVM, MAS, DACVIM (SAIM) response (i.e., improved continence) following short course antimicrobial therapy in many instances has suggested to me that these dogs might Associate Professor of Clinical Internal Medicine either a) have incontinence as a single LUTS related to their bacterial cystitis or b) have other LUTS that went unnoticed. In any case, at the [email protected] present time, a short (3-5 day) course of antimicrobials based on culture and susceptibility findings seems reasonable. WHEN TO TREAT? UTI vs. SUBCLINICAL BACTERIURIA Struvite forming dogs with a urease producing SB Antimicrobial stewardship has forced us to revisit how and when we pre- scribe antibiotics for all variety of infections and non-infectious disease. Struvite uroliths and encrusting cystitis have been associated to urease Thus, a conscientious and global re-evaluation of antimicrobial is critical producing bacteria such as Staphylococcus, Proteus, Klebsiella spp. to reduce the spread of multidrug resistant infections in both humans and and Corynebacterium urealyticum due to their alkalizing effect on urine animals. pH.5 The risk of recrudescence of these comorbid conditions if these or- ganisms are isolated from urine in patients with SB is unclear. Meanwhile, Urinary tract infections (UTIs) accounts for a considerable percentage of organisms like C. urealyticum are often to MDR making empiric therapy antimicrobial prescribing in veterinary patients. The cost and lag time in haphazard.6 diagnostics necessitated by urine culture likely results in empiric antimi- crobial prescribing that might result in excessive and/or poorly targeted Given the potential risk of recurrent disease the approach to these therapy, furthering concern for AMR development. patients should have two main goals: 1) reducing incidence of bacteriuria and 2) avoiding selective pressure that further cultivates AMR. Some of Given these challenges it is important to understand when our patients the most prolific struvite forming and encrusting cystitis dogs are those require antimicrobial therapy versus when withholding therapy is more with recurrent UTI. These dogs require comprehensive clinical evaluation prudent in dogs or cats with subclinical bacteriuria. Subclinical bacteriuria to evaluate for concurrent metabolic, anatomic, or functional disease (SB) is defined as the presence of bacteria on urine sediment exam or that predisposes to recurrent UTI. Furthermore, for these cases culture microbiologic testing in the absence of lower urinary tract signs (LUTS; is essential to identify antimicrobial susceptibility – moreover, these are i.e., hematuria, pollakiuria, stranguria). patients where consultation with either a veterinary microbiologist or pharmacologist to ensure that achieving urine concentrations capable of There are a limited but growing number of studies that support discuss treating the bacteriuria effectively. The goal here is to avoid persistent or SB in dogs and cats which suggest that it is relatively common in dogs relapsing infections where AMR is cultivated. and cats with positive urine cultures.1 These studies also suggest that the absence of antimicrobial therapy does not lead to the development Immunocompromised dogs or cats with SB of LUTS later on2 and is not associated with survival.1,3 This primary literature and practice guidelines borrowed from human medicine lead While data suggests that immunocompetent dogs and cats will likely not to recommendations in the recent International Society for Companion develop pyelonephritis or, worse, bacteremia when SB goes untreated, Animal Infectious Disease (ISCAID) UTI guidelines to not treat animals data supporting this approach in immunocompromised animals is lacking. with SB with antimicrobials.4 Human medical guidelines recommend against screening for asymptom- atic bacteriuria in most cases other than in patients with severe neutrope- Despite benign neglect apparently being a reasonable strategy for some nia (<100 cells/uL).7 There is evidence in in dogs with hypercortisolism dogs and cats with SB, there are instances where an argument can be that treatment with antimicrobial therapy results in progressive AMR made for judicious and targeted antimicrobial administration and others without resolution of SB.8 There lacks consensus in veterinary medicine, where absence of antimicrobial treatment is clearly a more suitable strate- but perhaps guidelines similar to those used in human medicine should be gy. The following discussion is based mainly on opinion and not sup- adopted for companion animals? ported by evidence-based medicine (nor is it refuted by evidence-based medicine)! Dogs and cats with AKI Apparently healthy dogs and cats with incidental SB Pyelonephritis is an important and treatable cause of acute kidney injury in dogs and cats and a recent study found that pyelonephritis account- This is scenario is likely the most encountered. When a dog or cat ed for 15% of dogs diagnosed with acute on chronic kidney disease presents to you for a wellness examination and bacteriuria and/or pyuria (ACKD).9 Presumably, both animals with AKI and ACKD have a similar are detected on urine sediment or positive urine culture, there’s growing risk of SB, so differentiating these patients from those with pyelonephritis evidence that this animal has SB and should not receive antimicrobial can be challenging. When presented with a dog or cat with AKI or ACKD, therapy. In instances such as this, I will generally verify the absence of establishing the presence of bacteriuria either via urine sediment exam or LUTS then explain the situation to the owner/guardian of the animal. It’s point of care assay is critical. These patients generally also have a urine critical that these people understand why we are choosing not to treat culture submitted, but results take 3-5 days to obtain, making time sen- with antimicrobials. Most people are receptive to this thought when they sitive decisions challenging. Patients with clinical or imaging findings of understand that a) the lack of treatment will likely not chance their pet’s characteristic of pyelonephritis should be treated for at least 10-14 days outcome and b) may improve their prognosis due to lack of adverse 329

13–15 NOVEMBER, 2021 using susceptibility results and clinical response to therapy as guides. 0223 Animals with SB and urinary implants LARYNGEAL PARALYSIS From time to time, cats with a subcutaneous ureteral bypass (SUB) E. Monnet systems or ureteral stents, and less often dogs with trigonal bladder masses and a urethral stent develop bacteriuria. Due to the mechanical Fort Collins/United States of America effects of these prostheses, patients might develop signs consistent with cystitis with or without bacteriuria. In these patients there is a concern Qualifications: for bacterial colonization due to the development of biofilms on implants and denudation of the urinary epithelium that typically prevents bacterial Eric Monnet, DVM, PhD, FAHA adherence. When positive urine cultures are obtained from these dogs and cats in the absence of LUTS, antimicrobials should probably be with- Diplomate ACVS, ECVS held. In the presence of lower urinary tract signs, it seems reasonable to administer a short course (i.e., 3-5 days to determine response). If there Professor Small Animal Surgery is no response, it is likely that the clinical signs stem from sterile cystitis, while a positive response might support cystitis. Appropriate duration of Colorado State University therapy for these patients is debatable [email protected] References: The laryngeal functions are to regulate airflow, voice production, and prevent inhalation of food. If the intrinsic muscles and/or the nerve supply 1. White JD, Cave NJ, Grinberg A, et al. Subclinical Bacteriuria in Older of the larynx are not normal laryngeal functions are compromised. Cats and its Association with Survival. Journal of veterinary internal med- icine / American College of Veterinary Internal Medicine 2016;30:1824- The dorsal cricoarytenoide muscle abducts the arytenoid cartilages at 1829. each inspiration. The laryngeal recurrent nerve innervates this muscle. Central lesions or lesions to the laryngeal recurrent nerve or to the dorsal 2. Wan SY, Hartmann FA, Jooss MK, et al. Prevalence and clinical outcome cricoarytenoide muscle result in laryngeal paralysis in dogs and cats. of subclinical bacteriuria in female dogs. Journal of the American Veteri- Laryngeal paralysis can be unilateral or bilateral nary Medical Association 2014;245:106-112. ETIOLOGY 3. Rafatpanah Baigi S, Vaden S, Olby NJ. The Frequency and Clinical Impli- cations of Bacteriuria in Chronically Paralyzed Dogs. Journal of veterinary Congenital and acquired forms of laryngeal paralysis have been recog- internal medicine / American College of Veterinary Internal Medicine nized in dogs and cats. 2017;31:1790-1795. Congenital Laryngeal Paralysis 4. Weese JS, Blondeau J, Boothe D, et al. International Society for Com- panion Animal Infectious Diseases (ISCAID) guidelines for the diagnosis Congenital laryngeal paralysis has been reported in Bouvier des Flandres, and management of bacterial urinary tract infections in dogs and cats. bull terrier, Dalmatian, Rottweiller and Huskies. Bouvier des Flandres and The Veterinary Journal 2019;247:8-25. bull terrier have mostly been reported from Europe while the Dalmatian and Huskies from United States. Laryngeal paralysis has a hereditary 5. Bailiff NL, Westropp JL, Jang SS, et al. Corynebacterium urealyticum transmission in Bouvier des Flandres with an autosomal dominant trait. urinary tract infection in dogs and cats: 7 cases (1996-2003). Journal of Dogs with congenital laryngeal paralysis are clinical at an early age the American Veterinary Medical Association 2005;226:1676-1680. (before one year old) than dogs with acquired laryngeal paralysis. Usually dogs with congenital laryngeal paralysis have several neurological deficits 6. Maurey C, Boulouis HJ, Canonne-Guibert M, et al. Clinical description like ataxia. of Corynebacterium urealyticum urinary tract infections in 11 dogs and 10 cats. J Small Anim Pract 2019;60:239-246. Acquired Laryngeal Paralysis 7. Nicolle LE, Gupta K, Bradley SF, et al. Clinical Practice Guideline for the Acquired laryngeal paralysis is most commonly reported in Labrador Management of Asymptomatic Bacteriuria: 2019 Update by the Infectious retriever, Golden retriever, St Bernard and Irish Setter at an age of 9 Diseases Society of America. Clin Infect Dis 2019;68:e83-e110. years old. It has been reported in cats. Acquired laryngeal paralysis is more frequently idiopathic; however, other causes should be ruled out. 8. Machado L, de Oliveira MC, Barbieri CR, et al. Clinical and microbiologi- Several diseases and conditions may contribute to laryngeal paralysis. A cal characterization of subclinical bacteriuria and sporadic bacterial cysti- cranial mediastinal or neck mass stretching or compressing the laryngeal tis in dogs with spontaneous hypercortisolism. Comparative immunology, recurrent nerves can induce a laryngeal paralysis. Trauma to the laryngeal microbiology and infectious diseases 2021;75:101624. recurrent nerve during dogfights or during surgery in the neck can cause of laryngeal paralysis. Laryngeal paralysis in the cat has been diagnosed 9. Dunaevich A, Chen H, Musseri D, et al. Acute on chronic kidney disease after bilateral thyroidectomy. Finally, a ployneuropathy involving the la- in dogs: Etiology, clinical and clinicopathologic findings, prognostic ryngeal recurrent nerve is the most common cause of laryngeal paralysis. markers, and survival. Journal of veterinary internal medicine / American The polyneuropathy can be due to an endocrine insufficiency (hypthyroid- College of Veterinary Internal Medicine 2020;34:2507-2515. ism) . However most of the time a diagnosis of idiopathic polyneuropathy is made because no causes can be identified. A myopathy involving the intrinsic muscle of the larynx. CLINICAL FINDINGS History The presenting signs are similar for the congenital and acquired forms. 330 WSAVA GLOBAL COMMUNITY CONGRESS

Progression of signs is often slow; months to years may pass before an Medical Treatment: Emergency Treatment animal develops severe respiratory distress. Early signs include change in voice, followed by gagging and coughing, especially during eating or drink- Animals are usually presented with acute cyanosis or collapse as a result ing. Endurance decreases and laryngeal stridor (especially inspiratory) of upper airway obstruction. Most animals in a cyanotic crisis precipitated increases as the airway occlusion worsens. Episodes of severe difficulty by upper airway obstruction recover initially with medical therapy. Excite- breathing, cyanosis, or syncope occur in severely affected patients. Male ment or increase in the ambient temperature can trigger an acute onset of dogs are approximately three times more affected than female. Laryngeal inspiratory dyspnea. Excitement or increase in the ambient temperature paralysis can be accompanied with various degrees of dysphagia, which increases the respiratory rate, which results in trauma to the mucosa of significantly enhances the probability of aspiration pneumonia after surgi- the arytenoid cartilage. Inflammation and acute swelling of the mucosa cal correction of the laryngeal paralysis. of the arytenoid cartilages can exacerbate the chronic airway obstruction and induce an acute onset of inspiratory dyspnea. A vicious circle is then Physical Examination initiated. Dogs have a difficulty breathing on inspiration that is not alleviated with Corticosteroids are given intravenously (dexamethasone, 0.2 to 1.0 mg/ open mouth breathing. Mild lateral compression of the larynx significantly kg BID) to reduce laryngeal inflammation and edema. At the same time, increases inspiratory effort. Referred upper airway sounds are present oxygen is administered by mask or oxygen cage to alleviate hypoxia. during auscultation of the thoracic cavity. Auscultation of the thoracic Hyperventilating hyperthermic animals (temperature > 1050 F) must be cavity and the lung field may reveal the presence of pneumonia in the cra- cooled. Sedation with acepromazine intravenously is indicated (0.1 mg/ nial lung lobe due to aspiration. Palpation of the muscle mass may reveal kg with a maximum dose of 3 mg) if the animal is still stressed. Fluid skeletal muscle atrophy in cases of polyneuropathy. A complete neurolog- therapy is administered with caution, because some animals with severe ical examination is required to evaluate the animal for a polyneuropathy. upper respiratory tract obstruction develop pulmonary edema. Diuretics are indicated in these patients. If the patient condition is deteriorating, an Laboratory Findings emergency tracheostomy is recommended to bypass the upper airway. Temporary tracheostotomy increases the risk of complication nine time in Complete blood count and chemistry profile are usually within normal the post-operative period. limits. Hypercholesterolemia, hyperlipidemia, and augmentation of liver enzymes activity are present on the chemistry profile for dogs with Surgical Treatment hypothyroidism. A thyroid profile with endogenous TSH and free T4 is then required to further define the diagnosis. Laryngeal surgery is directed at removing or repositioning laryngeal carti- lages that obstruct the rima glottidis. The surgical procedures commonly Radiographic Examination used to correct laryngeal paralysis are a unilateral arytenoid cartilage lateralization, aventricular cordectomy and partial arytenoidectomy via Aspiration pneumonia is a common finding pre-operatively in dogs with the oral or ventral laryngotomy approach, and a permanent tracheostomy. laryngeal paralysis. If aspiration pneumonia is present the surgical inter- Arytenoid cartilage lateralization is getting the gold standard technique. vention should be delayed until the aspiration pneumonia resolved. Pulmo- nary edema is not uncommon in dogs with an acute exacerbation of their Arytenoid Cartilage Lateralization clinical signs. Pulmonary edema needs to be treated aggressively and the surgery for the laryngeal paralysis does not need to be delayed. Megae- The animal is positioned in lateral recumbency for unilateral lateraliza- sophagus might be present in dogs with laryngeal paralysis especially if tion, and a skin incision is made over the larynx just ventral to the jugular the paralysis is due to polyneuropathy or polymyopathy. Megaesophagus groove. The larynx is rotated to expose the thyropharyngeal muscle, which places the animal at more risk for aspiration pneumonia after surgery. is transected at the dorsocaudal edge of the thyroid cartilage. The wing of the thyroid cartilage is retracted laterally. The dorsal cricoarytenoid mus- Laryngeal Examination cle or the fibrous tissue left is transected. The opening of the joint capsule should be minimal to prevent excessive abduction while tightening the A laryngeal examination under general anesthesia is required for the diag- suture. The sesamoid band connecting the arytenoid cartilages dorsally is nosis of laryngeal paralysis. A light plane of anesthesia is required to be left intact. able to evaluate the laryngeal function during each inspiration. Alfaxolone or propofol is used intravenously as needed for light anesthesia. During One 2-0 non-absorbable suture is placed in a simple interrupted suture the laryngeal examination, motion of the arytenoid cartilage is observed pattern from the muscular process of the arytenoid cartilage to the during inspiration. Dopram intravenously can be used to stimulate the caudo-dorsal edge of the cricoid cartilage and tightened to maintain the central respiratory center and have a better laryngeal examination. The arytenoid in position. The amount of abduction of the arytenoid cartilage animal should be placed in sternal recumbency and the head elevated to should be controlled to palliate the clinical signs but not increase the risk the level that it is normally carried. In the normal animal the vocal fold and of aspiration pneumonia. the arytenoids should abduct during inspiration and passively relax during expiration. The arytenoid cartilages and the vocal cords are immobile Complications associated with laryngeal lateralization include aspiration and drawn toward midline during inspiration if the animal has laryngeal pneumonia, persistent cough exacerbated after drinking, seroma, and paralysis. Paradoxical motion of the arytenoid can be present and makes breaking of the suture and fragmentation of the arytenoid cartilage. Sero- the diagnosis more difficult. ma formation is very common and is self-limited. Aspiration pneumonia is present in 10 to 20% of the cases. It affects the long term survival. TREATMENT Dogs are at risk for aspiration pneumonia during the rest of their life. The incidence of aspiration pneumonia is more common in bilateral laryngeal Medical treatment is reserved for the emergency treatment while the lateralization compared to unilateral. surgical treatment is for the long term treatment of the condition. Surgery will improve the quality of life of the patient Metoclopramide or cisapride peri-operatively can be used to try to reduce the incidence of regurgitation and aspiration pneumonia in the peri-oper- ative period. Limited utilization of opiod is also recommended to allow sternal recumbency as soon as possible after surgery. A local skin block with bupivacaine might be valuable to control pain post-operatively and 331

13–15 NOVEMBER, 2021 minimize the utilization of opioids. Water and food should be completely 0224 withdrawn after surgery until the patient is fully awake. The animal is at risk for aspiration pneumonia for its entire life after surgery. The quality of TEMPORARY AND PERMANENT TRACHEOSTOMY life of the dogs is significantly improved in the long term. E. Monnet Permanent Tracheostomy Fort Collins/United States of America Permanent tracheostomy is a surgical option for the treatment of dogs with laryngeal paralysis. Permanent tracheostomy requires attention and Qualifications: maintenance from the owners. Eric Monnet, DVM, PhD, FAHA Diplomate ACVS, ECVS Professor Small Animal Surgery Colorado State University [email protected] Temporary trachesotomy is a procedure that can be used to temporarily bypass the upper airway in an emergency situtation or after a surgery in the upper airway. Severe trauma in the head and neck may occlude the upper airway and require a temporary trachesostomy until the trauma is repaired. Animal with laryngeal paralysis may be presented in an emergency situation with complete obstruction of the larynx. A temporary trachesotomy is necessary until arytenoid lateralization can be performed. Permanent tracheostomy can be an option for the treatment of laryngeal paralysis if the animal is at high risk for aspiration pneumonia. The trachea originates caudal to the cricoid cartilage, passes through the thoracic inlet, and terminates at its bifrication at the base of the heart. C-shaped hyaline cartilages give the trachea its rigid structure. The trache- al cartilages are united by the fibroelastic annular ligaments. The tracheal membrane forms the dorsal aspect of the trachea and is composed of the smooth muscle (trachealis muscle) and connective tissue. The trachea is lined by ciliated columnar epithelium rich in mucus producing goblet cells. Vascular supply to the trachea is carried by branches of the cranial thy- roid, caudal thyroid, and bronchoesophageal vessels. These vessels form delicate lateral vascular pedicles on each side of the trachea. Autonomic innervation to the trachea is supplied by branches from the vagus nerve (recurrent laryngeal nerve) and sympathetic chain. The recurrent laryngeal nerves must be preserved when performing tracheal surgery to avoid causing laryngeal paralysis. TEMPORARY TRACHEOSTOMY Temporary tracheostomy is indicated for emergent or short term relief of severe upper airway obstruction or for airway access to accomplish posi- tive pressure ventilation or other forms of ventilatory therapy in conscious animals. Temporary tracheostomy is accomplished by placement of a tracheostomy tube. Trachesostomy tube Commercially available tracheostomy tubes come in a variety of sizes, with or without an inflatable cuff, and with or without an inner cannula. An adequate tracheostomy tube can be fashioned by cutting an endotracheal tube. An inflatable cuff is only necessary if positive pressure ventilation will be administered, in which case a tube with a low-pressure high-vol- ume cuff is preferred to minimize damage to the tracheal mucosa. The majority of tracheostomy tube applications do not require a cuffed tube. In fact, if an inflatable cuff is available, it is better not to inflate the cuff because doing so disrupts mucociliary clearance and increases the risk of tube obstruction by a mucus plug. Deflation of the cuff allows mucociliary clearance of mucus past the tube. Surgical technique Temporary tracheostomy is performed with the animal in dorsal recum- 332 WSAVA GLOBAL COMMUNITY CONGRESS

bency if possible, but may have to be performed in a variety of positions 0225 and with a minimum of anesthesia. If necessary, the procedure can be performed under local anesthesia only A longitudinal skin incision is SPLENECTOMY performed caudal to the larynx over the trachea. After the dissection of the sternothyroideous muscle, the trachea is exposed. An incision E. Monnet in performed in the fibroelastic annular ligament between the 3rd and the 4th tracheal ring. The incision should be in the ventral portion of Fort Collins/United States of America the trachea to avoid damaging the laryngeal recurrent nerves. It is not necessary to cut tracheal rings to perform a tracheostomy and doing so Qualifications: only enhances the risk for tracheal collapse after surgery. Externalizing a suture placed in the caudal margin of the incision facilitates access to the Eric Monnet, DVM, PhD, FAHA tracheostomy. The temporary tracheostomy tube is then introduced in the trachea. The suture placed in the caudal margin of the incision allows for Diplomate ACVS, ECVS rapid replacement of the tube if it is dislodged or removed for cleaning. After placement, the tracheostomy tube is secured by cotton ribbons tied Professor Small Animal Surgery to the external flange of the tube and then tied over the neck. Colorado State University Postoperative care [email protected] The tracheostomy incision should be packed with povidone-iodine oint- Spleen represents an important source of disease in older dogs associat- ment and lightly bandaged. As long as a tracheostomy tube is in place, ed with high morbidity and mortality. Hemoabdomen is the most common it must be periodically removed and cleaned with an antiseptic solution, clinical signs associated with surgical diseases of the spleen. Splenic such as chlorhexidine or povidone-iodine. This procedure is facilitated by trauma and laceration or by a bleeding mass are the most common an inner cannula that can be removed and cleaned without removing the causes of hemoabdomen. Both neoplastic and non-neoplastic masses entire tracheostomy tube. Airway maintenance should be performed every are present in the spleen; 50 % of the lesions are benign. Non-neoplastic two to six hours depending on how quickly the tube is collecting debris masses can be hematomas, nodular hyperplasia, fibrohistiocytic nodules, and mucus. Airway maintenance must be performed with increasing abscess, and cysts. Neoplastic masses can be hemangiosarcomas (50 to frequency the longer a tracheostomy tube is in place. 60% of splenic masses), fibrosarcomas, mast cell tumors, leyomyosarco- ma, and lymphoma. Neoplastic masses can also be metastasis. Splenic After the tracheostomy is no longer needed, the tube is removed and the torsion, and splenic abscess are also indications for surgery. Animals tracheostomy wound is allowed to heal by second intention. with splenic torsion or abscess are presented with an acute abdomen and in shock. If the abscess has ruptured the animals will have a severe PERMANENT TRACHEOSTOMY peritonitis. Splenectomy is the most common procedure performed. It is associated with life-threatening complications. The most common cause Permanent tracheostomy is a salvage procedure for severe and refractory of splenectomy is the diagnosis of a splenic mass. upper airway obstruction. Examples of such condition include severe laryngeal collapse, inoperable pharyngeal or laryngeal neoplasia, or com- Anatomy plicated laryngeal paralysis.. The spleen is a large organ in the left cranial part of the abdomen. It is Surgical technique a tongue shaped organ with a triangular cross-section. The head of the spleen is closer to the border of the stomach than the tail of the spleen. The patient is placed in dorsal recumbency. A longitudinal skin incision The head of the spleen is between the fundus of the stomach and the left is performed caudal to the larynx over the trachea. After the dissection kidney. When the stomach is empty, ribs might cover the entire spleen. of the sternohydeus muscle, the trachea is exposed. The sternohydeus Normally the tail of the spleen lies caudal to the last rib. The spleen has muscle can be pulled dorsal to the trachea to gain better exposure of a capsule and a parenchyma. The capsule is thin and consists of elastic the trachea. Such a procedure may increase the risk of damaging the and smooth muscle fibers. The parenchyma is made of trabeculae, blood laryngeal nerves. The tracheostomy will be performed over 3 to 4 tracheal vessels, lymphatics, and nerves. rings in length and a third of the tracheal diameter in width. The segment The blood supply of the spleen enters on the visceral surface of the spleen of the tracheal rings should be removed without damaging the tracheal at the hilus. The splenic artery is the major source of blood for the spleen. mucosa. The tracheal mucosa is then incised and sutured to the skin with It is a branch of the celiac artery. It also shares arterial blood supply a 4-0 monofilament non-absorbable suture. A simple interrupted suture with the stomach with the short gastric artery and the left gastroepiploic pattern is used. artery. The splenic vein flows in the portal vein. Complications The white and red pulps make the parenchyma of the spleen. The white pulp is the largest collection of reticuloendothelial cells in the body. It is a Complications associated with permanent tracheostomy include chronic collection of lymphoid cells and lymphoid nodules. The red pulp consists respiratory infection, inhalation of foreign materials, aspiration of water mostly of erythrocytes, lymphocytes, macrophages, and megakaryocytes. during bathing or swimming, and chronic mucus discharge from the Splenic sinuses between the splenic artery and vein are located in the red tracheostomy. Stricture is a common complication after permanent pulp. tracheostomy in cats. Functions of the spleen The spleen is not essential for life however, its role is important. The spleen provides the maintenance of erythrocytes by removing damaged erythrocytes when they traveled through the red pulp. Macrophages remove intracellular particulate matter and portion of the cell membrane as well. The erythrocytes then become spherocytes. Erythrocytes newly released by the bone marrow spend several days in the spleen for matura- 333

13–15 NOVEMBER, 2021 tion. The spleen has an anaerobic environment causes older erythrocytes the patient. The blood vessels are doubled ligated en masse with a large to stiffen which make them unable to pass through the sinuses. They are suture material if blood vessels cannot be isolated and ligated separately. then phagocytosed by the macrophages. Erythrocytes covered by IgG are There is an increase risk of bleeding after such a ligation. also phagocytosed by the macrophages. Since splenectomies are performed in large breed dog it might be prudent The spleen is also a reservoir of erythocytes for the systemic circulation. to pexy the stomach if a large splenic mass has been removed to prevent The amount of blood stored in the spleen represents 10 to 20% of the gastric dilatation-volvulus. total amount of blood. It is also a major depository of platelets. During hemorrhage, the spleen will contract to release erythrocytes and platelets Complications of splenectomy in the systemic circulation. Splenectomy is associated with life-threatening complications that need The spleen has hematopoietic abilities in the neonatal animal. This to be recognized early in the post-operative period. Hemorrhage, thrombo- activity ceases in the adult dog or cat. However, the spleen can resume sis of the splenic vein and portal vein, ventricular arrhythmias, dissemi- hematopoietic functions under some pathologic conditions (immune nated intravascular coagulation (DIC), and sepsis are the most common mediated hemolysis, immune mediated thrombocytopenia). It can result in complications after splenectomy. Ventricular arrhythmias are mostly splenomegaly. related to the hemoabdomen that induced ischemia of the ventricular wall. Since the spleen is the largest reticuloendothelial organ, it has a major Blood work should then be performed to monitor white blood cell count, role in filtration of microorganism and immunological response to circulat- platelet count, and coagulation profile. Patient should be monitored by ing antigens. electrocardiograms for the first 24 hours. Ventricular arrhythmias (sus- tained, R on T , and multiform) are treated with either lidocaine (1 to 2 mg/ Diagnosis kg bolus IV plus 50 to 100 microgm/kg/min CRI). Potassium is usually added at the dose of 60 mEq/L to the IV fluid to prevent arrhythmias. Pa- The diagnosis of a splenic enlargement or a splenic mass is made tient will be sent home with Sotalol for 2 weeks. If DIC occurs, the patients with abdominal radiographs and ultrasounds. Ultrasounds give better are treated with heparin (100 IU/kg SQ three times a day) plus fresh frozen information on the shape, the blood supply, and the composition of the plasma. Thrombosis of the portal vein is recognized with acute abdominal parenchyma than radiographs. Hypoechoic areas in the parenchyma can pain, and bloody diarrhea. be consistent with splenic torsion, lymphoma, congestion, or hematoma. Localized lesions are more likely cysts, abscess, hematomas, and primary angiogenic neoplasia. Fine needle aspirates of the spleen is usually non-diagnostic except for lymphoma. Complete blood work is required before surgery. Coagulation profile to evaluate the dog for disseminated intravascular coagulation is very important since this is a common complication after surgery. Thoracic radiographs are required before surgery to evaluate for potential metas- tasis. Echocardiography is also highly recommended to evaluate for right atrial masses. Splenectomy Splenectomy is indicated for any splenic mass, ischemic obstruction, or generalized enlargement (infiltrative disease). The patient is prepared for a large abdominal exploration with an incision from xyphoid to pubis. Balfour retractors are required to maintain the abdomen opened. Spleen can be friable upon manipulation therefore a large incision and retractors are required to allow an easier manipulation. If the patient has an hemoab- domen, suction should be used to remove the important amount of blood present in the abdomen. Splenectomy is performed with either hand ligation or with stapling equip- ment. There is no need to ligate vessels close to the hilus of the spleen. It is recommended to ligate the major splenic artery and vein after the last branch to the pancreas. Then the branches to the left gastroepiploic artery and the short gastric arteries are ligated. This technique does not affect blood flow to the stomach. The splenic vein and artery should be ligated separately to avoid the creation of an aterio-venous fistula. Monofilament 2-0 non-absorbable suture should be used for this ligation. The splenic artery is triple ligated with two encircling sutures and one transfixation. The splenic vein is double ligated. Splenectomy can also be performed with stapling equipment: LDS: Ligat- ing Dividing Stapling device. It places two staples and cut between the two staples. The splenic artery in large breed dogs should be ligated with sutures and not with the LDS (artery > 4 mm). In the case of a splenic torsion, the splenectomy should be performed with the spleen in a torsed position. Untwisting the spleen would release toxins and free radicals in the systemic circulation that would be fatal for 334 WSAVA GLOBAL COMMUNITY CONGRESS

0226 Femoral arterial pulse pressure (PP)- this is the absolute difference between systolic and diastolic blood pressure translated is a subjective, HOW TO DIAGNOSE HEART DISEASE WITHOUT palpable sensation when lightly occluding the femoral arteries with your ECHO OR XRAYS fingertip. A hyperkinetic PP can result from a high cardiac output state P. Fox as can occur with severe anemia, hypothyroidism, stress, fever, or left to right shunting PDA. A hypokinetic state can result from myocardial failure New York/United States of America (decreased contractility), dynamic or fixed left ventricular outflow tract obstruction, congestive heart failure, severe bradycardia, shock, cardiac Qualifications: tamponade, dehydration. Philip R. Fox DVM, Dipl. ACVIM (Cardiology), Dipl.ECVIM-SA (Cardiology), Dipl. ACVECC Effusions- the presence of moderate to severe ascites can readily be de- [email protected] tected during palpation. Moderate to severe pericardial or pleural effusion can muffle auscultation of heart and lung sounds, respectively. Peripheral edema- an occasional consequence of right heart failure this can be observed and palpated as ‘pitting edema.’ HOW TO DIAGNOSE HEART DISEASE WITHOUT ECHO OR Auscultation- heart murmur XRAYS Systolic heart murmur L and/or R apex, plateau-shaped- consistent with Overview: mitral/tricuspid regurgitation, respectively, or L-to-R shunting VSD. Diagnosing heart disease in the dog and cat need not wait until an echo- Systolic heart murmur L base, crescendo-decrescendo (“dia- cardiogram or thoracic radiographs are performed. Rather, heart disease mond-shaped”) it is consistent with pulmonic or aortic valvular stenosis. can be detected in many dogs and cats based upon a skillful medical history, thorough physical examination, ECG, and biomarker tests.1-3 Continuous heart murmur, L parasternal it is nearly pathognomonic for left to right shunting PDA. Medical History Auscultation- extra heart sounds An insightful history helps reveal the system or disease(s) responsible for clinical signs, determine degree of disease development or progression, Presystolic S4 gallop sound- occurring right before the first heart sound, distinguish cardiac from pulmonary disease, establish differential diagno- this is most often observed in cats with hypertrophic cardiomyopathy. ses, assess response (or lack of response) to therapy, and uncovers other medical conditions. Early diastolic S3 gallop sound- occurring right after the second heart sound is most consistent with myocardial failure, especially with DCM. Physical Examination Split 2nd heart sound- can be heard in some cases of pulmonic stenosis, Optimal Cardiopulmonary Examination Performs/evaluate the following: pulmonary hypertension, or right bundle branch block. • External patient inspection at rest and during activity (assess respiratory Auscultation- lung sounds- fine, diffuse inspiratory crackles often occur rate with cardiogenic pulmonary edema. Coarse crackles associated with chronic lower airway disease can often be heard at the beginning of and effort) expiration. • Oropharynx examination Auscultation- Irregularly irregular, rapid heart rate suggests atrial fibrilla- tion. • Neck palpation for tracheal conformity and masses Jugular distention/pulsations- May indicate elevated R heart diastolic • External jugular vein examination for abnormal distension or pulsations pressure with right-sided CHF; cardiac tamponade, obstruction (jugular vein or anterior vena cava, mass lesions within the right atrium or right • Femoral arterial pulse palpation (evaluate strength, regularity and ventricle. contour Electrocardiogram [normal, hypokinetic, hyperkinetic]) The ECG records real-time transcription of heart rate and rhythm. It is sim- • Precordial palpation to assess cardiac apex beat (location [point of ple, rapid, and essential when auscultation detects slow or rapid rhythms, maximal extra- systoles, or irregularities. An irregularly irregular rapid heart rate is consistent with atrial fibrillation. A rapid left to right bundle branch block impulse] and strength) and thrills QRS–T morphology with atrioventricular dissociation infusion complexes are consistent with ventricular ectopy. A slow junctional or ventricular • Heart and lung auscultation escape rhythm (35 – 40 bpm) with more P waves then QRS complexes, that are not conducted indicate complete AV block. Very low voltage R • Abdominal palpation for masses and hydroperitoneum wave amplitude can suggest severe pericardial or pleural effusion. Very tall R waves may be indicative of left heart enlargement. • Body temperature; Body weight Biomarkers- NT-pro BNP Palpation- A feline point-of-care snap test can detect cats who have moderate to Precordial thrill- this clinical finding can be detected by gently placing the severe left ventricular hypertrophy. A commercial quantitative NT–pro fingertips of each hand over the left and right precordium. In animals with BNP test result >99 pmol/L cut-off was 100% specific and 70.8% sensitive a loud (5/6 or 6/6) systolic or continuous murmur, a humming vibration for occult feline cardiomyopathy. A host of publications investigating can be appreciated accompanying a loud, harsh, or rumbling murmur felt during palpation. 335

13–15 NOVEMBER, 2021 NTproBNP in dogs are available. 0227 References POINT OF CARE ECHOCARDIOGRAPHY - KEY DISEASES TO RECOGNIZE 1. Fox PR. The history. In: Fox PR, Sisson D, Moise NS, eds. Textbook of P. Fox Canine and Feline Cardiology: Principles and Clinical Practice. 2nd ed. Philadelphia, PA: WB Saunders; 1999:41–45. New York/United States of America 2. Sisson D, Ettinger SJ. The physical examination. In: Fox PR, Sisson D, Qualifications: Moise NS, eds. Textbook of Canine and Feline Cardiology: Principles and Philip R. Fox Clinical Practice. 2nd ed. Philadelphia, PA: WB Saunders; 1999:46–64 DVM, Dipl.ACVIM (Cardiology), Dipl.ECVIM-SA (Cardiology), Dipl.ACVECC 3. Fox PR, et al. Multicenter Evaluation of Plasma N-Terminal Probrain Natriuretic Peptide (NT-pro BNP) as a Biochemical Screening Test Philip. [email protected] for Asymptomatic (occult) Cardiomyopathy in Cats. Vet Intern Med 2011;25:1010–1016 POINT OF CARE ECHOCARDIOGRAPHY - KEY DISEASES TO RECOGNIZE Introduction: Focused assessment of the chest and abdomen using diagnostic ultra- sound has been promoted for the past 20 years and is a well-established technique in dogs and cats. Not only can it identify fluid in the pericardial space, thorax, and abdomen, but it can provide critical information related to cardiac structure and function and lung disease.1-6 Point of Care Echocardiography (POCE) does not replace traditional examinations POCE without Lung Ultrasound- ►To answer specific questions, apply to assesses key structures ►Provides a quick study suitable to unstable patients and cage side evaluation ►Taylor examinations to suit patient clinical status; utilize the most stress-free position (sternal or standing when dyspneic; right and left lateral imaging from below most optimal if possible) ►Always utilize copious coupling jell (wet skin with alcohol) POCE’s 5 basic echo views (and limited color/spectral Doppler) ►Right Parasternal 4-Chamber ►Right Parasternal IFOF (LV inflow/outflow) ►Right Parasternal short Axis (base for LA:Ao, sweep down through LV and apex) ►Left Apical 4/5 Chamber ►Subcostal CLINICAL QUESTIONS TO RESOLVE BY POCE ►Is pericardial or pleural effusion, free air, or abdominal effusion pres- ent? ►Mild, moderate, or severe? ►Is pericardial tamponade present? ►Is there severe cardiac chamber enlargement? ►LAE,LVE,RVE/RAE ►Is the heart wall thickened? ►Qualitatively, does the LV wall contract ‘well’ or not? ►Is pulmonary hypertension present? 336 WSAVA GLOBAL COMMUNITY CONGRESS

►Are masses present? LA, LV. RA, RV 6. Boysen SR, Lisciandro GR. The use of ultrasound for dogs and cats in the emergency room: AFAST and TFAST. Vet Clin North Am Small Anim Common Heart Diseases benefits from POCE examination. *Note* – this Pract. 2013 Jul;43(4):773-97. imaging technique is not intended to identify mild cases with the following conditions, but rather, is intended to identify substantially abnormal cardi- ac structure and function. ►Feline Hypertrophic Cardiomyopathy- generally characterized by LA enlargement and hypertrophy of the ventricular septum, free wall, or both. Severe LAE is generally considered to be present when LA:Ao at the basilar short axis >1.6-1 ►Canine- Chronic Myxomatous Valve Disease (MMVD)- thickened, pro- lapsing mitral valve leaflets coupled LA enlargement indicated by LA:Ao > 1.6:1; color flow echocardiography reveals large jet of mitral regurgitation. ►Canine- Dilated Cardiomyopathy- notably, the left ventricle is extremely dilated and hypokinetic. ►Canine and Feline- Pericardial, pleural, abdominal effusion- effusion generally images as a dark, anechoic, “echo free” free space. Cardiac tamponade is suggested when severe pericardial effusion with diastolic right ventricular collapse is imaged. ►Canine and Feline Masses- hemangiosarcoma is the most common cardiac tumor in the dog. It is generally heterogeneous, invades the right atrial wall or right auricular appendage. Often it can be visualized at the junction of RA and RV. Transmural invasion is not uncommon. Neuroendo- crine tumors can be visualized at the heart base, particularly in a cranial right parasternal long axis inflow and outflow view where it can be seen “wrapping around” the aortic root. Intracardiac masses can be detected in all chambers. In cats with cardiomyopathy, left auricular thrombi may be difficult to identify and require angulated views. LA in LV thrombi can be seen in cats with cardiomyopathy. Spontaneous echo contrast sometimes referred to as “smoke” can be detected within severely enlarged left atri- um in cats and is thought to relate to risk of thromboembolism. ►POCUS With Lungs Point-of-care lung ultrasound (LUS): This effective tool helps diagnose left-sided congestive heart failure (L-CHF) in dogs via detection of ultrasound artifacts (B-lines-ie, bright, hyperechoic streaks that do not fade and extend through the far field) caused by increased lung water. It also identifies thoracic effusions and air, lung pathology, and cardiac disease. References 1. Murphy SD, Ward JL, Viall AK, Tropf MA, Walton RL, Fowler JL, Ware WA, DeFrancesco TC. Utility of point-of-care lung ultrasound for mon- itoring cardiogenic pulmonary edema in dogs. J Vet Intern Med. 2021 Jan;35(1):68-77. 2. Ward J et al. Accuracy of point-of-care lung ultrasonography for the diagnosis of cardiogenic pulmonary edema in dogs and cats with acute dyspnea. J Am Vet Med Assoc 2017:250:6, 666-675. 3. Lisciandro GR. Cageside Ultrasonography in the Emergency Room and Intensive Care Unit.Vet Clin North Am Small Anim Pract. 2020 Nov;50(6):1445-1467. 4. Walters AM, O’Brien MA, Selmic LE, Hartman S, McMichael M, O’Brien RT. Evaluation of the agreement between focused assessment with sonography for trauma (AFAST/TFAST) and computed tomography in dogs and cats with recent trauma. J Vet Emerg Crit Care (San Antonio). 2018 Sep;28(5):429-435 5. McMurray J, Boysen S, Chalhoub S. Focused assessment with sonog- raphy in nontraumatized dogs and cats in the emergency and critical care setting.J Vet Emerg Crit Care (San Antonio). 2016 Jan-Feb;26(1):64-73 337

13–15 NOVEMBER, 2021 0228 dial dysfunction, especially with conditions of reduced contractility such as dilated cardiomyopathy and severe, chronic volume overload (MMVD, L FOUR CRITICAL ARRHYTHMIAS- HOW TO to R shunts such as PDA). Drugs used in controlling ventricular response DIAGNOSE AND TREAT include calcium channel blockers, digoxin, sotalol, and beta-blockers P. Fox VENTRICULAR TACHYCARIDAS New York/United States of America Impulses originating in the ventricle (eg, ventricular tachycardia) alter patterns of electrical activation, reduce forward stroke volume, and neg- Qualifications: atively impact cardiac function. Rapid, sustained ventricular tachycardia decreases cardiac output, results in hypotension and organ ischemia. Philip R. Fox Ventricular extrasystoles with short coupling intervals may be electri- cally unstable, especially if they fall on the vulnerable portion of cardiac DVM, Dipl.ACVIM (Cardiology), Dipl. ECVIM–SA (Cardiology), Dipl. repolarization- the downslope of the T wave. These events may precipitate ACVECC ventricular flutter and rapid, precipitous deterioration leading to ventricular fibrillation, where all circulation ceases. [email protected] Depolarizations occurring within the preceding T wave are extremely FOUR CRITICAL ARRHYTHMIAS- HOW TO DIAGNOSE AND dangerous). The underlying state of ventricular function, systemic and TREAT metabolic alterations, and concurrent drug or anesthetic agents influence electrical stability. Atrial fibrillation, ventricular tachycardia, high grade atrioventricular block (AVB), and sinoatrial node dysfunction (Sick Sinus Syndrome) are 4 of the Electrical instability is increased by rapid ventricular rates and multifocal most common arrhythmias responsible for clinical signs, hemodynam- impulse origination, timing of the ectopic ventricular impulse (i.e., the ic instability, reduced cardiac function, and can lead to cardiac death. earlier the premature complex relative to the preceding T wave, the greater Clinical signs include lethargy, exercise intolerance, seizures, ataxia, loss electrical liability); underlying ventricular dysfunction, systemic and meta- of consciousness, hypotension, exacerbation of congestive heart failure, bolic alterations, and concurrent drug or anesthetic agents. or sudden death.1-7 Acute management of ventricular tachycardia includes treatment of the Clinical assessment begins with an insightful medical history and detailed underlying cause and lidocaine boluses and CRI. Additional cardiac drugs physical examination, followed by an optimal database including clinical used to control ventricular tachycardia include Sotalol, Mexiletine, Esomo- pathology testing, thoracic radiography, echocardiography, and often lol, Procainamide, parenteral magnesium administration, and Amiodarone. abdominal ultrasonography. BRADYCARDIAS Radiography, echocardiography, and abdominal sonography help to identify and confirm diseases suspected from the history and physical Bradycardia associated with high grade second-degree atrioventricular examination, assesses disease severity, distinguish between cardiac and block reduces cardiac output, cardiac perfusion, and can lead to syncope respiratory disease, 4) screen for unsuspected conditions, and 5) helps and congestive heart failure. In the dog, complete (third-degree) atrio- monitor disease progression and response to therapy. Echocardiogra- ventricular block (AVB) is most common where is in the cat, complete AV phy assists cardiac examination when the heart is obscured by pleural block often waxes and wanes with high-grade second-degree AV block. effusion; diagnoses pericardial effusion; provides quantitative assess- Complete heart block in the cat is generally associated with a ventricular ment of cardiac structure (valves; chamber dimensions, wall thickness); escape rhythm between 90 – 110 bpm which is often sufficient for indoor assesses systolic (contractile) and diastolic function; quantifies gradients cats to remain asymptomatic. However, cats with this bradyarrhythmia are via Doppler echocardiography; detects disturbances of blood flow; detects prone for it to transition in and out of a more impactful bradycardia called intracavitary masses (clots, tumors); and helps characterize congenital high-grade second-degree AV block, which can result in 5 to 15 seconds and acquired heart diseases. of blocked atrial impulses (P waves) without ventricular conduction or ventricular escape rhythm. Affected cats can become syncopal and shock TACHYCARDIAS can develop. For symptomatic high-grade second-degree AV block in dogs or cats, medical therapy is rarely successful and pacemaker therapy is Rapid tachyarrhythmias reduce cardiac output, cause hypotension, and required. result in organ ischemia, and create further substrate for worsening ar- rhythmia that can lead to ventricular fibrillation and cardiac arrest. Short- Bradycardia associated with Sick Sinus Syndrome due to dysfunction of ened diastolic filling decreases coronary blood flow, reduces myocardial the sinoatrial node is relatively common in the dog. This can result in long oxygen supply, causes ischemia and results in more serious arrhythmias. periods of asystole without ventricular escape rhythm. Some affected Certain tachyarrhythmias may promote electrical instability. Others reduce dogs also have long periods of sinus pause interrupted by paroxysms cardiac output and contribute to worsening of heart failure. Hemodynamic of supraventricular tachycardia, which has been referred to an older impact of tachyarrhythmias are influenced by factors related to underlying literature as tachy-brady syndrome. While this does not commonly result cardiac disease and the particular type of arrhythmia (i.e., (a) loss of in sudden death, it can significantly affect quality of life in some dogs are synchronized atrial systole, (b) altered ventricular activation sequence, (c) euthanized because of this. Medical therapy is usually not effective and rapidity of ventricular rate, (d) timing of ectopic beats relative to preceding pacemaker therapy is generally required. P‑QRS‑T complexes, (e) background vasomotor tone, (f) cardiac effects of antiarrhythmic drugs, and (g) underlying cardiac dysfunction or health. References Because cardiac output = heart rate x stroke volume, sustained tachycar- dia may reduce cardiac output and arterial BP. 1. Pedro B, Fontes-Sousa AP, Gelzer AR. Canine atrial fibrillation: Pathophysiology, epidemiology and classification. Vet J. 2020 Atrial fibrillation with rapid ventricular response shortens ventricular filling Nov;265:105548Meurs KM, Spier AW, which is further reduced by loss of atrial contraction, variation in cycle length, and high ventricular rate. This contributes to and worsens myocar- 2. Wright NA, Atkins CE, DeFrancesco TC, Gordon SG, Hamlin RL, Keene BW, Miller MW, Moise NS Comparison of the effects of four antiarrhythmic 338 WSAVA GLOBAL COMMUNITY CONGRESS

treatments for familial ventricular arrhythmias in Boxers. J Am Vet Med 0229 Assoc. 2002 Aug 15;221(4):522-7. 5 EASY STEPS TO MANAGE ACUTE CONGESTIVE 3. Ward JL, DeFrancesco TC, Tou SP, Atkins CE, Griffith EH, Keene BW. HEART FAILURE Outcome and survival in canine sick sinus syndrome and sinus node dys- function: 93 cases (2002-2014). J Vet Cardiol 2016 Sep;18(3):199-212 P. Fox 4. Côté E. Feline arrhythmias: an update. Vet Clin North Am Small Anim New York/United States of America Pract. 2010 Jul;40(4):643-50. Qualifications: 5. Kellum HB, Stepien RL. J Third-degree atrioventricular block in 21 cats (1997-2004). Vet Intern Med. 2006 Philip R. Fox 6. LeBlanc NL, Agarwal D, Menzen E, Nomi K, Sisson DD, Scollan KF. DVM, BSc, Dipl ACVIM (Cardiology), Dipl ECVIM-SA (Cardiology), Dipl. Prevalence of major complications and procedural mortality in 336 dogs ACVECC undergoing interventional cardiology procedures in a single academic center. [email protected] FIVE EASY STEPS TO MANAGE ACUTE CONGESTIVE HEART FAILURE General Outlook: Chronic acquired heart disease is the most common form of heart disease in the dog. Most small dogs are affected with myxomatous valve disease by the time they are 8 to 10 years of age. It causes significant morbidity and is the leading cause of cardiac death in small breed dogs. While the majority of affected dogs do not develop con- gestive heart failure (CHF), others develop disease progression and CHF. Severity is staged based upon the presence or absence of structural heart disease and the magnitude of cardiac chamber remodeling (dilation). Dilated cardiomyopathy occurs almost predominantly in large and giant breed dogs. Heartworm disease continues to cause significant morbidity and dogs where this parasite is endemic. Because heart failure is a syndrome and not a singular disease, it can be associated with a wide range of structural or functional disorders that cause a variety of neurohormonal, hemodynamic, and pathophysiological changes, and lead to a spectrum of clinical outcomes. Terminology can distinguish between stages or states of disease. CHF refers to patients who have developed pulmonary edema, ascites, pericardial effusion, pleural effusion, or both from cardiac disease. Acute heart failure defines sudden clinical signs, usually attributable to dyspnea with pulmonary edema caused by severe volume overload (mitral regurgitation). Decom- pensated heart failure represents new or worsening clinical signs of dys- pnea, shortness of breath, associated with pulmonary edema, pericardial/ pleural/abdominal effusion. Diastolic heart failure (now referred to as Heart failure with preserved ejection fraction) denotes conditions causing pulmonary edema associated with left ventricular diastolic dysfunction (as occurs commonly in cats with hypertrophic cardiomyopathy). Dilated cardiomyopathy is characterized by cardiac chamber dilation, especially the left ventricle couple with myocardial failure (also called systolic failure or systolic dysfunction). Compensated heart failure refers to patients with substantial heart disease whose congestive signs have been controlled with cardiac therapy. CLASSIFICATION SCHEMES TO CLASSIFY CANINE HEART DISEASE Several classification schemes have been proposed to characterize progressive cardiac severity, and rely upon a combination of clinical signs or disease characteristics. These schemes help frame a clinical context for managing heart disease. A newer classification scheme has been adapted from guidelines from the American College of Cardiology/ American Heart Association, and modified for use in dogs (see Guidelines for the diagnosis and treatment of canine chronic valvular heart disease. Keene BW et al).1This scheme relates the severity of clinical signs, stage of heart disease, and treatments, using four stages of heart disease and failure:Stage A- dogs at high risk to develop heart disease, but without 339

13–15 NOVEMBER, 2021 structural disease.Stage B1- dogs with mitral regurgitation without evi- (1.5- 2 mg per kilogram orally q 8-12 hrs) reduces afterload and regurgi- dence of cardiac remodeling, as well as dogs with mitral insufficiency with tant volume, improving cardiac output. Short term inotropic infusion of mild to moderate remodeling but not extensive enough to merit pimoben- dobutamine (5-15mcg/kg/min) may be necessary with severe systolic dys- dan therapy.Stage B2- asymptomatic dogs with radiographic or echocar- function (DCM with cardiogenic shock). Spironolactone (1mg/kg q12-24 diographic evidence of substantial left heart enlargement. Evidence for hr) can be given to block adverse actions of aldosterone. ACE inhibitors severe remodeling that would merit pimobendan therapy include (EPIC (enalapril, 0.5mg/kg q 12hr) may help blunt neurohumeral activation, but TRIAL criteria)2- vertebral heart scale ≥10.5 (non-bracheocephalic breeds); are generally not given until the pet is stable and eating, to avoid acute LA: Ao ratio ≥ 1.6:1; left ventricular end-diastolic dimension normalized kidney injury the body weight ≥ 1.7.Stage C- dogs with past or current CHF.Stage D- dogs with end-stage CHF refractory to therapy. TREAT HEMODYNAMICALY UNSTABLE ARRHYTHMIAS MANAGEMENT OF ACUTE CONGESTIVE HEART FAILURE Tachyarrhythmias may depress cardiac output, cause hemodynamic impairment and related hypotension and organ ischemia. Certain tach- An accurate history is important. Clinical signs associated with volume yarrhythmias may deteriorate and become electrically unstable. Hemo- overload are ultimately associated with acute pulmonary edema caused dynamic impact of tachyarrhythmias are influenced by factors related to by elevated left ventricular filling pressures. Respiratory distress is acute, underlying cardiac disease and arrhythnua type. With supraventricular generally less than 24 hours. If history indicates intermittent signs over tachycardias, vagal maneuvers may occasionally convert the arrhythmia. weeks or months that suddenly worsen, then acute exacerbation of Resting ventricular response to atrial fibrillation or atrial tachycardia or respiratory disease- not CHF, should be suspected. A chest radiograph or flutter > 160 beats per minute can substantially reduce cardiac filling and TFAST should be performed to confirm CHF if the dog can safely tolerate function, and efforts should be directed to reduce this heart rate. Calcium this. Dilated cardiomyopathy also generally presents with acute cardio- channel blocking agent diltiazem hydrochloride (2 mg/kg q 8 hrs PO) or genic pulmonary edema. dilacor (2 – 4 mg/kg q 12 hr PO or in crisis, 0.1 mg;kg IV, repeat in 20-30 min. twice if needed, then 2-6 ugkg/min CRI) are first-line agents to reduce Treatment Goals the ventricular response. Digoxin (0.0025 – 0.005 mg/kg q 12 hr) with a target concentration 8 hours post administration of 0.8-1.5ng/ml, may Rapidly resolve pulmonary edema (preload and afterload reduction). Iden- be added for cases of persistent rapid atrial fibrillation, if renal function tify/treat serious arrhythmias (rapid supraventricular tachycardias, esp. is normal. Lidocaine is used to control electrically or hemodynamically Atrial fibrillation; hemodynamic or electrically unstable ventricular arrhyth- unstable ventricular arrhythmia (2-8 mg/kg using 2mg/kg IV boluses, mias (sustained or rapid or multifocal VTach or R on T phenomenon). Use followed by 50 – 80 mcg/kg/min CRI), plus oral sotalol (1-2mg/kg PO cardiac drugs shown to prolong survival or reduce morbidity (pimoben- q12 hours)- or if resistant to these therapies, procainamide 5-10 mg/kg IV dane, etc). Avoid acute renal injury (monitor biochemical parameters, be slowly or 25-50 ug/kg/min CRI). If all are ineffective, amiodarone, 5mg/kg careful to avoid overzealous diuretic doses). Judicious surveillance and IV bolus slowly. monitoring with dose adjustment over time. REFRACTORY CHF Outpatient Management (When Feasible): With recurrent heart failure, upward drug titration may be necessary. Supplement O2 ;Reduce Preload: IV furosemide bolus (2-4 mg per kg), then Furosemide can be increased to 8mg/kg/day but will ultimately lose its 2-4mg/kg q8-12 hrs potency. Torsemide (1/10th of the daily furosemide dose divided in two equal daily doses or titrated to q 12 hrs) may provide more potent diure- Administer Pimobendan: 0.3mg/kg PO q 12 hours. sise. Hydrochlorthiazide (0.5-1mg/kg q 12-48hrs) can be added to pro- mote sequential nephron blockade. Amlodipine can be added for afterload Reduce Afterload if severe dyspnea/congestion: hydralazine (1-2 mg/kg reduction, starting at 0.1mg/kg once daily and titrating over 3-4 weeks up PO q 8 hours for 1-2 days); to 0.4mg/kg PO q 12 hours with blood pressure assessment. Sildenefil (2-8mg/kg q 8-12hr PO) is administered to treat advanced chf complicat- Record ECG, check renal function and electrolytes; echo when stable; mea- ed by severe pulmonary hypertension. failure. Nutritional consultation sure Systolic BP and Creatinine (Ideally, to guide further therapies- Note, may be of value in dogs that develop cardiac chachexia. Periodic thoraco, delay if dog is extremely dyspneic and in critical condition); tap chest if pericario, or abdominocentesis may help in cases of chronic, severe right severe pleural effusion is present sided CHF. It is prudent to assess BUN, creatinine, electrolytes, blood pressure and body weight frequently. Repeat steps to restore normal respiratory rate and effort References Comprehensive patient recheck in 24 hours 1. Keene BW, Atkins CE, Bonagura JD, Fox PR, Häggström J, Fuentes VL, Inpatient Management of Acute CHF Oyama MA, Rush JE, Stepien R, Uechi M. ACVIM consensus guidelines for the diagnosis and treatment of myxomatous mitral valve disease Treatment goals -rapidly resolve pulmonary edema; hemodynamic stabil- in dogs..J Vet Intern Med. 2019 May;33(3):1127-1140. doi: 10.1111/ ity: jvim.15488 Supplemental oxygen. 2. Boswood A, Häggström J, Gordon SG, et al. Effect of Pimobendan in Dogs with Preclinical Myxomatous Mitral Valve Disease and Cardiomeg- Furosemide- Initial IV bolus (2 to 4 mg per kg) produces rapid diuresis. aly: The EPIC Study-A Randomized Clinical Trial. J Vet Intern Med. 2016 Repeat boluses (1-2mg.kg) q 6- 8 hrs PRN, or- furosemide is changed Nov;30(6):1765-1779 to continuous rate infusion (0.25 to 0.5 mg/kg/hr). Non-responsiveness associated with escalating diuretic dose is a sing of poor outcome. Ag- gressive loop diuretic use promotes hypovolemia, reduces GFR, promote renal dysfunction (acute kidney injury) and electrolyte abnormalities (K, Cl, Na). Torsemide if used to replace furosemide for recurrent CHF, start at 1/10th total furosemide dose q 12-12 hrs PO. Pimobendan, 0.25 to 0.3 mg/kg PO q 12hr. Afterload reduction. Nitroprusside constant infusion (2 – 15 mcg/kg/min IV) can reduce preload and afterload, promoting forward cardiac flow and reducing myocardial oxygen demand. Or, hydralazine 340 WSAVA GLOBAL COMMUNITY CONGRESS

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