Veterinary Track :Veterinary Track Presenters: Dr. Karla Brestle Dr. Brenda Griffin Dr. Phil Bushby Dr. Stephanie Janeczko Dr. Brian DiGangi With gratitude to the Veterinary Track sponsor: Maddie’s Fund


Veterinary Medical Guidelines for Spay-Neuter Programs :Veterinary Medical Guidelines for Spay-Neuter Programs The Association of Shelter Veterinarians’ S-N Task Force Brenda Griffin, DVM, MS, DACVIM Director of Clinical Programs Maddie’s Shelter Medicine Program College of Veterinary Medicine Cornell University, NY Phil Bushby, DVM, MS, DACVS Marcia Lane Endowed Professor Of Humane Ethics and Animal Welfare College of Veterinary Medicine Mississippi State University


The Spay/Neuter Summit :The Spay/Neuter Summit ASPCA and PETsMART Charities Convened a group of veterinarians in 12/06 To advance high-quality, high-volume spay/neuter Out of this: A Task Force of the ASV Tasks: Publish Practice Guidelines for S/N Additional resources online Epidemiologic studies to measure impact Recruitment and training methods Guidelines for working with veterinary community


22 Veterinarians :22 Veterinarians Representing academic and private practice, all models of S/N programs, all regions of the country Leslie Appel, Mark Bohling, Karla Brestle, Phil Bushby, Susan Eddlestone, Kelly Farrell, Nancy Ferguson, Brenda Griffin, Lisa Howe, Ellen Jefferson, Julie Levy, Andi Looney, Michael Moyer, Sandra Newbury, Melissa Saxton, Jan Scarlett, Dave Sweeney, Kathy Tyson, Adrie Voors, Jim Weedon, Sara White and Christine Wilford CU 12/06; LSU 4/07; Fix It Forum 10/07


Advancing High-Quality, High-Volume Spay/Neuter :Advancing High-Quality, High-Volume Spay/Neuter A definition: HQHVS/N programs are efficient surgical initiatives that meet or exceed veterinary medical standards of care in providing accessible, targeted sterilization of large numbers of cats and dogs in order to reduce their overpopulation.


Guidelines for the Many Models :Guidelines for the Many Models Stationary clinics Mobile clinics MASH-style operations Shelter services Feral cat programs In clinic clinics Programs at veterinary colleges Proliferation and diversity of these programs creates a need to develop practice guidelines…


Guidelines for the Many Models :Guidelines for the Many Models Stationary clinics Mobile clinics MASH-style operations Shelter services Feral cat programs In clinic clinics Programs at veterinary colleges Proliferation and diversity of these programs creates a need to develop practice guidelines…


Guidelines :Guidelines Kept broad Standards vary depending of the nature of the program and local standards and practice acts Establish a level of consistency, acceptability and professionalism needed to promote HQHVS/N


Goals :Goals Inaugurate HQHVS/N as a practice area within veterinary medicine Promote the confidence of the general public in these programs Promote acceptance by the profession and encourage increased participation Provide guidance for vets in this practice area Encourage existing programs to recognize and adhere to these guidelines (recognizing variation)


Goals :Goals Promote confidence and referral by private veterinarians Provide a reference for use by state boards and other governing agencies and professional associations Provide a marker for excellence by which donors/funders can evaluate their investments


Historically… :Historically… Negative perceptions Worry about professional reputations Targeted for complaints


Negative perceptions of “high volume” or “low cost” spay/neuter surgery… :Negative perceptions of “high volume” or “low cost” spay/neuter surgery… Comments such as: “There is no such thing as 50% off safe or 50% off sterile” “If you are making a small incision, you can not possibly be removing the entire reproductive tract”. “Doing high volume surgery cannot possibly be doing a good job--the standards of care must be below those that are acceptable.”


Slide 16:June, 1990 “Organized veterinary medicine objects to humane society hospitals that practice with a tax-exempt advantage.” “There is no such thing as 50% off safe or 50% off sterile.” “highly controversial issue”


Conflict Among Veterinarians :Conflict Among Veterinarians Locally Nationally


It is personal… :It is personal… “Why are you interviewing at a shelter…that’s not the only job you can get, is it?” “That crazy Dr. Griffin, who knows what she is doing…” “Shelter medicine is a no-brainer: no special knowledge or experience needed.” “What are you doing with your (ACVIM) credentials?” “For you to work at the shelter would be a waste.” “It is not possible to provide an acceptable standard of care to that many animals.” “It is dangerous to spay through a small incision.”


Important Work :Important Work


Higher volume (or lower cost) is NOT obtained by lowering quality. :Higher volume (or lower cost) is NOT obtained by lowering quality. Support teams, equipment, and protocols are geared towards safety, efficiency and humane quality care of large numbers of companion and feral cats and dogs. In pursuit of this effort, surgeons become extremely proficient at performing sterilization procedures and develop techniques unique to the field or utilize existing less well-known techniques that lead to increased efficiency.


Track Records to Prove It :Track Records to Prove It Angels of Assisi, Dr. Kelly Farrell 6,885 in 2006; 3 deaths, MR = 0.044 SNAP Texas, Dr. Jim Weedon 21,478 in 2006; 8 deaths, MR = 0.037 Feral Cat S/N Project, Dr. Christine Wilford 8,592 in 2006; 15 deaths, MR = 0.175 Emancipet, Dr. Ellen Jefferson 69,000 since opened; 19 deaths; MR = 0.028 MR = 0.10% (1/1,016 cats) and 0.14% (2/1,459 dogs) Pollari, et al. JAVMA 1996; 208: 1882-1886.


Practice Guidelines for S-N Programs :Practice Guidelines for S-N Programs Include recommended surgical, anesthetic and peri-operative practices Based upon: Accepted principles of research Anesthesiology Critical care medicine Microbiology Surgical asepsis and technique Review of the scientific literature (evidence based medicine) Expert opinions Intended as achievable in programs that practice HQHVSN


A New Day is Dawning… :A New Day is Dawning…


Preoperative Guidelines :Preoperative Guidelines


Goals of the Preoperative Period :Goals of the Preoperative Period Address client concerns and expectations Select patients appropriately Ease stress for clients, patients, staff Increase patient safety and quality of care Foster confidence in S-N programs Reduce legal liability


Patient Selection :Patient Selection Varies depending on: Clinic staffing Anesthetic capabilities Differing locales Technical training Economics


Patient Selection: Vet’s Discretion :Patient Selection: Vet’s Discretion Final decision regarding acceptance of a patient = vet’s discretion Based on history Physical examination Clinic surgical schedule Minimum and maximum age and weight = vet’s discretion Based on program expertise


Patient Selection: Vaccination :Patient Selection: Vaccination Client-owned pets May best be served by scheduling surgery at 4 months or older to allow time for development of immunity through vaccinations Animals without current vaccinations can be scheduled with the understanding of an increased risk of infectious disease Shelter setting Best served by neuter before adoption Ensures compliance Decreases risk of future relinquishment


Patient Selection: Disease :Patient Selection: Disease Patients with mild infectious or other disease URI, heartworm dz, parasite infestation Must weigh the risks and benefits May be a one time opportunity for S/N If these patients selected, adjust anesthesia and perioperative care accordingly


Patient Selection: Complex OVH :Patient Selection: Complex OVH Complex Ovariohysterectomy In-heat spays routinely performed Pregnant spays routinely performed Pyometra surgeries often performed


Client Communication :Client Communication Ask about patient history Current meds Medical hx Allergies Instruct about pre-operative fasting Discuss individual patient risk assessment


Client Communication: Consent :Client Communication: Consent Pre-Surgical Consent Forms Reviewed and signed by the client prior to anesthesia and surgery Specific topics of consent will vary by program Blanket consent may be established


Recommended Subjects for Consent Forms :Recommended Subjects for Consent Forms Client confirmation of patient’s health when possible Acknowledgement of: Risk of infectious disease Increased risk without current vaccines Anesthetic/surgical risk Including death Authorization for surgery Recommendation for ongoing total health care by a full-service veterinary clinic Client contact information for emergency purposes Description of fees (if any)


Medical Records :Medical Records Required for each patient PE, weight, dosages/route of all drugs, surgical procedure, any abnormalities Standardized operative reports okay In accordance with state and local practice laws Guided by state and national veterinary medical associations


Vaccination :Vaccination Vaccination always recommended prior to surgery Perioperative vaccination is acceptable when necessary Rabies vaccinations should be required or administered as mandated by state regulations All vaccine protocols should follow current AAFP and AAHA guidelines


Patient Fasting :Patient Fasting Pre-operative fasting for dogs and cats is ideal Exception for feral cats Not necessary or recommended to withhold water Prolonged fasting not warranted 4-6 hours recommended for c and d 2-4 hours for pediatric patients Pediatric patients should be fed a small meal 2-4 hours prior to surgery


Physical Examination :Physical Examination Animals should be screened as thoroughly AND efficiently as possible PE should be performed by a vet or vet student under supervision PE’s should be attempted prior to anesthesia Aggression, anxiety, feral status may prevent a complete PE


Physical Exam :Physical Exam At the veterinarian’s discretion: Whether the PE is performed prior to or after the pre-med or induction Temperature assessment Pre-anesthetic diagnostic testing


Physical Exam: Gender and Body Weight :Physical Exam: Gender and Body Weight Gender and repro status should be verified prior to anesthesia and surgery when possible Intact female Spayed female Intact male Neutered male Body weight Verified as close to surgery as possible May be estimated in feral/fractious patients Used to guide surgical appropriateness, drug choices, drug dosing


Patient Housing :Patient Housing Housing should allow for patient safety and comfort Should be appropriate for each individual animal


Recommendations for Patient Housing :Recommendations for Patient Housing System in place for ID of animals Allow for adequate temperature, ventilation, and stress reduction Properly clean/disinfect between patients Adult tractable animals: house in individual enclosures With good visibility Adequate turn around space Allow for safety at various stages of sedation and anesthesia Pediatric littermates or housemates often benefit from being housed together


Recommendations for Patient Housing :Recommendations for Patient Housing Intractable or feral animals: house in traps or other enclosures Allows for administration of anesthesia without extensive handling Increases staff safety and decreases animal stress Intractable or feral animals should be removed for surgery only after sedation and then returned to their enclosure as soon as safely possible


Infectious Disease Control :Infectious Disease Control As is typical for any surgery or clinic: Standard protocols for controlling potential infectious diseases should be practiced!


Infectious Disease Control :Infectious Disease Control All equipment that has direct patient contact (eg: et tubes) s Thoroughly clean/disinfect between patients Breathing circuits Clean/disinfect and dry 1-2 times per week at minimum Dome and one way valves and absorbent canisters Disassemble and clean weekly at minimum


Infectious Disease Control :Infectious Disease Control Staff should wash hands between patients and litters Surgery of infected animals should follow healthy animals within the day’s schedule


Equipment :Equipment An equipment safety checklist should be performed prior to anesthesia on a regularly scheduled basis Inspection should include: General machine inspection Confirmation of oxygen supply Breathing circuit check Ventilator safety and function check (if used)


Equipment :Equipment Waste gas scavenge system should be in use Active and passive systems are acceptable Charcoal canisters are acceptable ONLY for short term use Usually less than 8 hours Or as determined by the weight of the canister


Anesthesia Guidelines :Anesthesia Guidelines


Balanced Anesthesia :Balanced Anesthesia Analgesia Stress reduction Loss of consciousness Muscle relaxation Develop safe general protocols and protocols for higher risk patients


Success of Anesthesia :Success of Anesthesia More to do with the following than with any specific drug protocol… Care of animals perioperatively Equipment, warmth, appropriate fasting, at risk care Flow of cases and stress reduction Minor modifications to fit individual patient needs Vigilant monitoring from induction to recovery Surgical technique and time


Thermoregulation :Avoid: Wide surg clip areas Moistening of hair coat Cold SQ fluids Alcohol Aggressive scrubbing Thermoregulation Think ahead! From time of premed onward Reduce contact with cold environments Paper or cloth bedding Circulating warm water blankets Stand off/protected warm water containers Rice mamas, water bottles Convective warm air systems If intubated, low flow oxygen Not with non-rebreathing circuit Limited body cavity exposure


Slide 58:Preventing Hypothermia: Warmth


Oxygenation and Ventilation :Oxygenation and Ventilation Oxygenation Especially helpful for debilitated/compromised patients Via appropriate functioning anesthesia machine Via oxygen tank with a regulator Ventilation Different than oxygenation Implies removal of carbon dioxide Via Anesthesia machine Carbon dioxide absorbent Correct breathing circuit Appropriate oxygen flow rate for circuit Via ambu bag Via ventilator


Fluid Therapy for HQHVSN :Fluid Therapy for HQHVSN Improves Hydration Perfusion=organ function Drug performance Recovery For higher risk patients Subcutaneous Chills patient if fluids cold Corrects dehydration but not volume as much Intravenous- Directly improves volume Avoid: Very cold fluids Stressful awake administration High potassium loaded fluids


Anesthetic Monitoring :Anesthetic Monitoring Monitor many variables vs. one Focus on trends of variables vs. one value once Monitoring = vigilance No monitor replaces well trained personnel Hands on Monitoring! Pulse quality, rate, and rhythm Respiratory rate and pattern Temperature Jaw tone Eye position, pupil size, palpebral reflex


Anesthetic Monitoring :Anesthetic Monitoring Beware CRT and MM color Electrocardiographs alone Esophageal stethoscope with unprotected airways Watching for bag movement Lack of any objective means or a single means


Anesthesia Protocols :Anesthesia Protocols Selection depends upon… Daily schedule: number and types of patients Skill and efficiency of technical staff and surgeons Financial considerations The anesthesia protocol should provide: Long term (>surgical procedure) analgesia Stress reduction = anxiolysis Muscle relaxation (immobility) Depression of the CNS = unconsciousness Safe, controlled, reversible


Pain Medications ShouldAlways Be Included In the Plan :Pain Medications ShouldAlways Be Included In the Plan Within the anesthesia protocol Use of as few injections as possible when patient is awake Opioids Alpha two agents Local anesthetics NSAIDS To go home Dogs and cats: Appropriate handling Limit activity Wound cleanliness Nonsteroidal anti-inflammtories Tramadol Cats: Transmucosal buprenorphine


Anesthetic Protocols :Anesthetic Protocols Analgesia Required Preemptive Multimodal Opiods Alpha 2 agents NSAIDS Anxiloytic agents Ace, benzos Numerous protocols exist Combinations of injectables and/or inhalants for both peds and adult Combine pre-meds, analgesics and induction agents in single injection Eg. Alpha 2, opioid and dissociative drug


Anticholinergics: Not Routinely Recommended :Anticholinergics: Not Routinely Recommended Improved understanding of possible mal effects GI ileus Increased tenacity of secretions CNS stimulation Anxiety Mydriasis Tachycardias aren’t as healthy as we once thought! Increase myocardial work Increase oxygen consumption Decrease myocardial perfusion Hypertension Not even for pediatrics


Inhalant Gas Induction and Maintenance :Inhalant Gas Induction and Maintenance Mask induction = effecting general anesthesia from consciousness with gas anesthesia via mask Chamber induction = the same via chamber Not recommended Mask maintenance = supplementation or continuation of anesthesia with gas via mask Use should be minimized


Mask Induction :Mask Induction Stressful Poorly controlled loss of consciousness Sympathomimetic effects Bronchoirritation Waste gas contamination Increased risk of aspiration Expensive due to high flow rates required


Mask Maintenance :Mask Maintenance Realistically may be required for a few patients For light planes of anesthesia in “injectable only protocols” Should not be relied upon for majority of patients If use is frequent, alternatives are suggested: Intubate Employ better analgesics and sedatives Administer additional of analgesics


Preparation for Emergencies :Preparation for Emergencies Emergency readiness is essential! Crash kits- fully stocked Emergency drug charts Regular staff training and rounds


Accurate Drug Calculation and Administration :Accurate Drug Calculation and Administration Avoid “one-size-fits-all” dosing Dose based on weight Estimate weight or size for feral/fractious animals Best to use reversible agents Avoid “hub” doses Volume by weight charts help prevent calculation errors Use drugs of appropriate concentration for patients Dilute stock solutions as needed to aid in proper dosing


High Risk Patients :High Risk Patients Select less cardiopulmonary depressive drugs Midazolam and Opioid premedication +/- Reversible agents +/- Local block Oxygen supplementation Warmth and fluids, preferably IV Monitor diligently


Intubation :Intubation Pros Assures a patent protected airway Cons Requires experience Requires heavy depth of anesthesia in veterinary patients Requires time Can create problems if not done with skill Tracheal tears Laryngeal inflammation Infection potential?


To Intubate or Not :To Intubate or Not Pros and cons must be weighed Not every patient must be intubated, but it should be possible if needed Those that should be intubated Brachycephalics cats and dogs Severe upper respiratory disease Most overweight or large breed dogs


Surgical Standards :Surgical Standards


OR Environment :OR Environment Broad definition of OR Includes MASH and mobile operations Dedicated surgical area with proper equipment Scheduled cleaning and disinfection policies Traffic limited to essential surgical personnel


OR Environment :OR Environment


Surgical Pack Preparation :Surgical Pack Preparation Separate sterile instruments for each patient True sterile instrumentation No “cold sterile” Steam, EtOxide, plasma permissible Pack prep Clean before sterilize Appropriate wrap (270 TC pima cotton or disposable paper) Processing indicators Required on inside and outside of each pack


Patient Preparation :Patient Preparation Skin integrity must be maintained Hair removal Clipper Hair plucking OK for feline neuter Large enough area of prep: to prevent contamination of field allow for extension of incision Entire area scrubbed with surgical scrub used according to accepted patient prep guidelines Bladder expression - care to prevent iatrogenic damage


Draping :Draping Required for: All abdominal procedures Canine castration (except pediatrics) Large enough to maintain sterile field Material to resist penetration by fluid and microorganisms Adhere to guidelines for useful service life Feline and pediatric canine castration Draping optional at surgeon’s discretion Care must be taken to prevent contamination if not draped


Surgeon Preparation :Surgeon Preparation Attire - “appropriate surgical attire” for OR Gown - “preferred,” but use is at surgeon’s discretion Caps/masks - required except for cat and puppy neuters Surgeon Hand/Arm Scrub Appropriate scrub with approved product Sterile single use surgical gloves Not required for routine feline castration Approved waterless scrubs acceptable when used as directed.


Surgeon Preparation :Surgeon Preparation


Surgical Procedures :Surgical Procedures Performed by veterinarians or supervised vet students Adhere to golden surgical principles: Gentle tissue handling Meticulous hemostasis Aseptic technique Always ensure and verify hemostasis Either interrupted or continuous suture patterns are acceptable


Females: Spay :Females: Spay Ventral midline, flank or laparoscopic Ovariohysterectomy or ovariectomy Always remove both ovaries! Procedure and length and location of incision = surgeon’s preference Closure: VMI = rectus sheath Flank = transversus abdominus and int & ext abd obliques


Males: Castration :Males: Castration Prescrotal and scrotal approaches Always remove both testes! Procedure and length and location of incision = surgeon’s preference Tomcats- incisions commonly left open


Pediatric Surgeries :Pediatric Surgeries 6 -16 weeks Well described and endorsed by the AVMA Procedure and length and location of incision = surgeon’s preference Pediatric puppies and kittens- scrotal incisions common, may be left open


Surgical Materials :Surgical Materials Biomedical grade (no cable ties, sewing thread, or bailing twine!) Absorbable or inert non-absorbable suture materials (SS is OK) Continuous or interrupted patterns OK


Ear-Tipping of Feral Cats :Ear-Tipping of Feral Cats Should be performed


Tattooing :Tattooing Recommended for all spayed females Ventral abdominal location Sterile instrumentation Method left to surgeon


Antibiotic Usage :Antibiotic Usage Routine use NOT recommended Specific indications Pyometra Break in surgical asepsis


Postoperative Guidelines :Postoperative Guidelines


Patient Recovery :Patient Recovery Careful transport/safe delivery to recovery area Secure, level surfaces Infectious disease control Continuous, direct observation of patients Clean, dry, warm environment Prevent hypoglycemia and hypothermia Separate animals by species Allow pediatric littermates to recover together


Continuous, direct observation of patients :Continuous, direct observation of patients


Parameters to be Assessed :Parameters to be Assessed Heart rate and pulse quality (except in feral animals after first signs of recovery) Airway patency Keep head and neck extended RR and character Pain, Anxiety Degree of arousal or sedation Movement/ambulation


Analgesia :Analgesia Administer additional analgesics as needed NSAIDs, opioids, alpha 2’s or combinations


Anesthetic Reversal? :Anesthetic Reversal? Reversing anesthetic agents also reverses their analgesic properties Reversal causes pain and anxiety Reverse in emergency cases Reverse in programs in which animals are promptly returned to owner or caregiver (avoid IV reversal)


Thermoregulation :Thermoregulation Ensure patients experience neither severe hypothermia or hyperthermia Monitor body temp as needed


Postoperative Housing and Care :Postoperative Housing and Care Verify ID prior to return to housing Continue to evaluate Keep clean and dry Provide food, water, and access to area for urination and defecation, especially if housed over 12 hours


Provide food for pediatric patients :Provide food for pediatric patients


Patient Transport (if applicable) :Patient Transport (if applicable) In situations where transport vehicle is used, safe delivery of patients (preop and postop) should include: Safe and comfortable temperatures with heat, air conditioning, and proper air circulation Verifying appropriate identification Proper confinement and securing enclosures appropriately Continual monitoring of patients during transport


Release :Release Evaluate patients immediately prior to release Alert Able to stand and walk Pain-free Normal RR and character Check incision if possible Clean, dry, intact incision


Release :Release Owner/Guardian instructions Clear and concise Guidelines for postoperative care Include resources and contacts for questions, concerns and emergencies Written and Verbal


Written Instructions :Written Instructions


Written Instructions :Written Instructions


Verbal Instructions :Verbal Instructions


Emergencies and Complications :Emergencies and Complications Must have a plan to deal with postoperative emergencies When possible, a clinic should perform its own rechecks. Does not mean that the S/N clinic has to be open 24/7 Emergencies may be referred, but a clear plan must be in place so everyone knows it In the event of a death, necropsy should be performed if possible Diagnostic lab (neutral source) Within clinic with appropriate documentation


Conclusions :Conclusions HQHVSN is a very important practice area High volume and high quality can be achieved! These programs… Increase the numbers of cats and dogs that are sterilized in communities And decrease untimely euthanasia of cats and dogs Standards of care should be AND CAN BE equal to or greater than that of a routine private practice.


Spay Neuter Guidelines :Spay Neuter Guidelines


:Thanks to: PETsMART Charities ASPCA The Organizers Bert Troughton Dr. Leslie Appel Dr. Karla Brestle Carol Moulton Aimee St. Arnaud The Task Force The ASV


Questions :Questions