Euthanasia, Spay/Neuter and “The Board”

OH MY!

Dr. Solveig EvansGwinnett County Animal Welfare and

EnforcementMedical Director

How to avoid “The Board”!(In Georgia)

The letter you NEVER want to see

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• The Office of Secretary of State• Date:• • Veterinarian, DVM • 237 Coliseum Dr• Macon GA 31217• • Respondent Email: pleasedontsendmetotheboard@helpme.com• Re: A dog,”Happy” owned by Angry Client • • Dear Dr.Veterinarian:• • The Georgia Board of Veterinary Medicine has received a formal complaint regarding the

treatment you provided to the above referenced patient.• • The Board is charged to investigate every complaint received in this office. In an attempt to

further understand the complaint; please send the Board a certified copy (form provided) of the patient’s treatment records, and copy of the financial records, and a statement explaining the treatment you rendered, within ten (10) days of receipt of this letter. Your statement must contain a legible translation of the treatment notes. Each page of the patient treatment record must contain the patient’s and treating providers’ name. Please do not send two-sided copies and do not fold, staple, or glue any records. Do not provide records on a Disc. You should also include a copy of this letter with any documentation you provide to the Board.

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• Please be advised that any materials you provide become a part of the Board’s confidential investigative file and therefore will not be returned to you. It is recommended that you retain the originals and provide our office with duplicates. Please send the requested records to:

• • The Georgia Board of Veterinary Medicine • 237 Coliseum Drive • Macon GA 31217• • We thank you in advance for your cooperation in this matter and you will be advised

of any Board action taken as a result of this complaint. If you have any questions you may call (478)207-2440 for assistance.

• • Sincerely, • • GEORGIA BOARD OF VETERINARY MEDICINE• • • 237 Coliseum Drive ● Macon, Georgia 31217 ● (478) 207-2440 ● www.sos.ga .gov

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• The Office of Secretary of State• CERTIFICATION OF RECORDS

• I hereby certify that the attached ________pages are a true and correct copy of the • (# of pages)

• complete original patient record of ____________________________________________.

• (Patient Name)

• I further certify that the attached ____________ x-rays, are a true and correct • (# of x-rays)• All of the above-listed original and/or true and correct copies of patient records are

maintained under my care, custody, and control at _______________________________________________

• (Office Name and Address)• ___________________________________________________________________

_________.

• Said original records are made and kept in the usual and ordinary course of business at the above-named office.

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• _________________________________• PRINTED Name of Provider• • _________________________________ • PRINTED Name of Custodian of Records• • _________________________________• Signature of Provider• • _________________________________ • Signature of Records Custodian• • • Sworn to and subscribed • • Before me this ______ day of ________________, ______.• _• • • __________________________________ _________________________• (SEAL) NOTARY PUBLIC SIGNATURE MY COMMISSION EXPIRES• • • • • • • • 237 Coliseum Drive ● Macon, Georgia 31217 ● (478) 207-2440 ● www.sos.ga .gov•

Georgia Code 43-50-21

General powers of board Liberal construction of powers

. • The board shall have the power to: – (1) Examine and determine the qualifications and fitness

of applicants for licenses or registrations to practice veterinary medicine and veterinary technology in this state;

– (2) Issue, renew, refuse to renew, deny, suspend, or revoke licenses or registrations to practice veterinary medicine or veterinary technology in this state or otherwise discipline licensed veterinarians and registered veterinary technicians; and to issue, renew, deny, suspend, or revoke veterinary faculty licenses, consistent with this chapter and the rules and regulations adopted under this chapter;

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– (3) Conduct investigations for the purpose of discovering violations of this chapter or grounds for disciplining persons licensed or registered under this chapter;

– (4) Hold hearings on all matters properly brought before the board; and, in connection therewith, to administer oaths, receive evidence, make the necessary determinations, and enter orders consistent with the findings. The board may designate one or more of its members to serve as its hearing officer;

– (5) Appoint from its own membership one member to act as a representative of the board at any meeting within or outside the state where such representative is deemed desirable;

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– (6) Bring proceedings in the courts for the enforcement of this chapter or any regulations made pursuant to this chapter; and

– (7) Adopt, amend, or repeal all rules necessary for its government and all regulations necessary to carry this chapter into effect, including without limitation the establishment and publication of standards of professional conduct for the practice of veterinary medicine and veterinary technology.• (b) The powers enumerated in subsection • (a) of this Code section are granted for the purpose of

enabling the board to supervise effectively the practice of veterinary medicine and veterinary technology and are to be construed liberally to accomplish this objective.

Georgia Rules and Regulations Chapter 700-8

Unprofessional Conduct

Rule 700-8-.01

Unprofessional Conduct

.• Advertising - defined: Advertising shall mean any information

communicated in a manner designed to attract public attention to the practice of the licensee or registrant. Advertising shall include but not be limited to, a communication, published or displayed through the use of newspaper, internet, telephone directory, pamphlets or handouts, radio, television, signs, billboard, window display or any other means of medium.– A licensee or registrant shall not make any false,

misleading or deceptive communication in any form of advertising.

– Advertisement of prices must contain a complete description of veterinary services included in any advertised price and disclosure of any extra charges that may be required to serve the consumer's needs.

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• Professional Relationships– It shall be unprofessional conduct for a licensee or

registrant without just cause and in bad faith or for the purpose of soliciting patronage or personal pecuniary gain to disparage the profession or professional capabilities of another licensee or registrant.

– It shall be unprofessional conduct to aid any person, firm, or corporation to engage in the unauthorized practice of veterinary medicine.

– It shall be unprofessional conduct for a licensee or registrant to guarantee a cure or to offer his name in a commercial setting in a testimonial as to virtues of proprietary remedies or foods.

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– Consultation by an attending veterinarian with other veterinarians expert in the particular matter on which consultation is sought is in the public interest and thus is expected of the attending veterinarian when the need arises. But such consultation is discouraged if the consulting veterinarian employs the relationship so created to disparage the attending veterinarian or to solicit business; such practices are not in the public interest.

– It shall therefore be unprofessional conduct for a licensee called as a consulting veterinarian to disparage in the presence of the client the competence of the attending veterinarian. The Board does, however, expect any incompetence or negligence to be reported to it and nothing in this rule prohibits such reports or the giving of testimony in public or private litigation.

– It shall be unprofessional conduct for a consulting veterinarian to assume unauthorized control of the case or to utilize the consulting relationship to solicit business for himself or others.

– It shall be unprofessional conduct for a licensee employed to render professional advice by one party in negotiations concerning the sale of an animal to accept to a fee from the other party.

In a nut shell!• Don’t speak poorly of other veterinarians or practices• Don’t help non-veterinarians practice veterinary medicine

w/o a license• Don’t guarantee a cure or offer your name as testimony for

proprietary remedies or foods• It’s ok to consult veterinary experts but they are not allowed

to speak poorly of you (the referring veterinarian)• A consulting veterinarian should not speak poorly about the

referring veterinarian in front of the client– But the consulting veterinarian should report any

incompetence or negligence to the board• The consulting veterinarian should not steal the client• During the sale of an animal you cannot advise one party and

get paid by the other

Failure to Maintain Patient Records

– A veterinarian shall prepare and maintain a record reflecting the care and treatment of animals treated.

– These records shall contain clinical information sufficient to justify the diagnosis and warrant treatment and shall, if applicable, include but not limited to the following information:• Name, address and telephone number of the animal’s

owner• Name of attending veterinarian and staff rendering care• Patient identification, including name, ages, sex and breed• Dates of examination, treatment and custody of the

animal• Patient history• Presenting complaint

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• Vaccination history• Findings from physical examination, including

temperature and weight• Clinical lab reports, if applicable• Medication and treatment, including frequency• Anesthetic, including type and amount, if applicable• Details of surgical procedure with complications and/or

abnormalities noted, if applicable• Progress and disposition of the case• Differential diagnosis• X-rays, if applicable

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– All records shall be kept in readily retrievable form, shall be recorded contemporaneously, and shall be filed promptly following treatment

– Patient records shall be kept by a veterinarian for three (3) years after a patients last visit notwithstanding any other provision of law

– Copies of patient records must be made available to the owner of the animal upon written request to the veterinarian who treated the animal or to the veterinarian facility where the treatment was provided. • Such records must be made available within ten (10)

business days from request.

• The veterinarian may charge a reasonable charge for the search, retrieval, duplication and, if applicable, mailing of the patient records.

– Failure to keep records as required by this subparagraphs shall constitute a failure to confirm to the minimal standards of acceptable and prevailing veterinary medical practice.

Failure to have an appropriate Veterinarian/Client/Patient Relationship

– An appropriate veterinarian/client/patient relationship will exist when:• The veterinarian has assumed the responsibility for

making medical judgments regarding the health of the animal(s) and the need for medical treatment, and the client (owner or other caretaker) has agreed to follow the instructions of the veterinarian;

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• There is sufficient knowledge of the animal(s) by the veterinarian to initiate at least a general or preliminary diagnosis of the medical condition of the animal(s). – That means that the veterinarian has seen the animal

within the last twelve (12) months and is personally acquainted with the keeping and care of the animal(s) by virtue of an examination of the animal(s), and/or by medically appropriate and timely visits to the premises where the animal(s) are kept; and

• When the practicing veterinarian is readily available for follow-up in case of adverse reactions or failure of the regimen of therapy.

Prescription Drugs:

– After a valid veterinary/client/patient relationship has been established, a veterinarian must make available, upon request, at a reasonable cost, a written prescription.

– It is unlawful for a veterinarian to release, prescribe, and/or dispense any prescription drugs without having examined the animal and established a valid veterinary/client/patient relationship.

Chapter 700-12

Minimum Standards

Rule 700-12-.01

Definitions

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• “Appropriately/as appropriate" for the purposes of these rules means the expected level of care and environmental quality in accordance with the animal species and the scope of veterinary services being offered, as determined by the State Board of Veterinary Medicine.

• "Clean and orderly" for the purposes of these rules means the expected level of care and environmental quality in accordance with the animal species and the scope of veterinary services being offered, as determined by the State Board of Veterinary Medicine.

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• "Good State" for the purposes of these rules means the expected level of care and environmental quality in accordance with the animal species and the scope of veterinary services being offered, as determined by the State Board of Veterinary Medicine.

• "Proper" for the purposes of these rules means the expected level of care and environmental quality in accordance with the animal species and the scope of veterinary services being offered, as determined by the State Board of Veterinary Medicine.

• "Veterinary facility" means any premises owned or operated by a veterinarian or his or her employer where the practice of veterinary medicine occurs, including but not limited to veterinary hospitals, clinics, or mobile clinics; provided, however, that such does not include a client's private property where a licensed veterinarian treats the client's animals. For the purposes of these rules, veterinary facility does not include vehicles used for large animal ambulatory practice.

Rule 700-12-.02

Facility Standards

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• A licensed veterinarian employed at a veterinary facility is responsible to assure that the following criteria pertaining to facilities are met:– Facility must maintain appropriate federal, state and local

permits.– Facility must be appropriately secured.– Facility must be sanitary.– Facility must be well ventilated.– Facility must be appropriately illuminated.– Facility must be in a good state of repair.– Facility walls and floors must be easily sanitized.– Facility must have means for disposal of dead animals,

tissue, hazardous materials, medical waste which must meet local and state requirements.

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– Facility must have exterior legible sign.– Facility must keep grounds clean and orderly, if applicable.– Facility must have a restroom in working order which is

maintained in a clean and orderly manner. Mobile clinics are exempt from this requirement.

– Facility must have clean and orderly receiving area.– Facility must have a telephone answering machine or

answering service available after business hours.– Facility must have a holding or housing area with proper

sanitation, ventilation, lighting, size, and temperature appropriate for the animal species.

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– Facility must have appropriate waste receptacles available.– Facility must have effective insect and rodent control.– Facility must store pharmaceuticals, biologicals, reagents

and lab samples in accordance with label directions or other instructions.

– Facility must have fire extinguisher with current annual inspection.

– Facility must post in a prominent public area a copy of the current license issued by the Georgia State Board of Veterinary Medicine or current online verification of licensure from the Board website for each veterinarian and veterinary technician working at the facility.

Rule 700-12-.03

Housing

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• A licensed veterinarian at a veterinary facility is responsible to ensure that the following criteria pertaining to housing animals are met:– Each animal must be contained in a secure manner.– Each animal must be identified as appropriate.– Contagious animals must be isolated as appropriate.

Rule 700-12-.04

Record Keeping

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• Complete, accurate and legible records must be maintained on all animals, or animal groups, including but not limited to, animal owner information, animal identification, and veterinary care.– All records must be maintained for a minimum of 3 years

(including diagnostic imaging and other patient data).– The veterinarian must furnish clients with an established

mailing address for obtaining medical records.

Rule 700-12-.05

Required Equipment

• A licensed veterinarian employed at a veterinary facility must ensure that equipment is available as appropriate.

Rule 700-12-.06

Emergency Coverage

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• A licensed veterinarian employed at a veterinary facility must ensure that emergency treatment or access to emergency treatment to clients with an established veterinary-client-patient relationship is provided.

• If emergency coverage is not provided, there must be established, documented referral coverage available to cover emergencies.

Rule 700-12-.07

Drugs and Pharmacy

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• A licensed veterinarian employed at a veterinary facility must ensure that the following criteria pertaining to drugs and the pharmacy are met:– All controlled substances must be maintained in

compliance with federal and state requirements.– All pharmaceuticals dispensed must be properly labeled in

accordance with state and federal requirements.– Outdated pharmaceuticals must be separated, stored,

returned or disposed of in accordance with federal, state and local requirements.

– The pharmacy must be maintained in a clean and orderly manner.

– If utilizing controlled substances, documentation of U.S. Drug Enforcement Administration certificates must be on premises.

– All pharmaceuticals on the premises must be properly labeled with drug name, concentration or activity, and expiration date.

– A valid veterinarian-client-patient relationship must be established before prescription medications can be dispensed or prescriptions released.

Georgia Drugs and Narcotic Agencyhttp://gdna.georgia.gov

• All prescriptions must be issued for a specific patient. (O.C.G.A. 16-13-74 and 16-13-41). Prescriptions issued for “office use” are not valid.

• Only a licensed veterinarian (DVM) may authorize prescription medications for animals. (Georgia Veterinary Practice Act O.C.G.A 40-5-3)

Required Record Keeping for Controlled Substances

• Documentation is required every time a controlled substance changes hands. You must have a paper trail.

• The trail is from the manufacturer, to the distributor, to the pharmacy and/or the practitioner, and to the end user.

• State and Federal controlled substance laws require maintenance of controlled substance records for period of 2 years from the date of each inventory.

• The GA Board of Veterinary Practice requires maintaining records for 3 years.

• The Statute of Limitations under FDA law is 5 years, so a 5 year retention policy may be advisable

Key Details for Record KeepingControlled Substances

• Registrants MUST maintain the following information for all controlled substances received:– Date of receipt– Drug Description• Name, Drug strength, Dose, Quantity receive

– Name, address and DEA number of the supplier– Name, address and DEA number of the recipient– Name or initials of employees verifying receipt of

the drugs

Initial Inventory of Controlled Substances

• On the date of receipt and stocking of any controlled substance, you must perform an initial inventory of the controlled substances on hand.

• The following information must be documented: – Date– Documentation of whether the inventory was taken at

Opening or Close of business, or if the practice location is open 24 hours a day, the time of the inventory

– Drug name– Drug strength– Dosage form– Quantity of dosage units on hand

Inventory Count

• The initial inventory of Schedule II drugs must be maintained on a separate form and document then the initial inventory of Schedule III—V drugs.

• According to the DEA, after an initial inventory is taken, the registrant shall take a new inventory of all controlled substances on hand at least every two years

• I recommend an inventory should be done yearly– Annual inventories should always be separate documents

that stand-alone and are maintained separately.• Include all controlled substance dosage units in your inventory

regardless of whether they are in stock bottles, have been set aside for destruction, are samples, or are outdated.

• You must have an exact count for Schedule II controlled substances

• When Schedule II controlled substances are counted, they must be hand-counted every time. No estimates!

• If you stock all schedules, you must have two annual inventory documents; one for Schedule II and one for Schedules III—V.

Schedule II

• Substances have a high potential for abuse, but have accepted medical uses in the United States.

• Examples are oxymorphone, meperidine (Demerol) and pentobarbital.

• C-II substances are of particular interest to law enforcement agencies.

• Discrepancies involving C-II agents may result in vigorous regulatory action.

Schedule III

• Schedule III drugs, substances, or chemicals are defined as drugs with a moderate to low potential for physical and psychological dependence.

• C-III, IV and V substances have decreasing potential for abuse and accepted medical uses in the United States.

• Examples of C-III substances are acetaminophen with codeine, ketamine and the anabolic steroids.

Schedule IV

• Schedule IV drugs, substances, or chemicals are defined as drugs with a low potential for abuse and low risk of dependence.

• Examples are: Xanax, Tramadol, Diazepam, midazolam, butorphanol, and phenobarbital

Logging your Inventory-Daily

• Many practitioners choose to maintain an ongoing log of all drugs administered or dispensed. This provides an ongoing count every day of what they have used and what they still have on hand.

• Perpetual logs are useful and encouraged, and deter theft and diversion, but do not replace the requirement to have a specific annual inventory document.

• They are not required by law.

GA Board of Pharmacy Law

• Effective October 2011, the Georgia Board of Pharmacy now requires that all Schedule II prescription drugs be sequentially numbered and written on approved security paper.

• Keep a separate file of copies of your Schedule II prescriptions.

Labels for Controlled Substances

• All controlled substances dispensed must bear a warning sticker that informs the owner that it is illegal to transfer controlled substances to anyone other than the patient for whom it was dispensed.

• Controlled substance samples in FDA approved pre-packaged containers are not required to be repackaged.

• Controlled substances cannot be dispensed in envelopes, plastic bags or other unapproved containers.

Rule 700-12-.08

Surgical Standards

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• A licensed veterinarian employed at a veterinary facility must ensure that the following criteria pertaining to surgical standards are met if surgical procedures are performed in the facility:– Dose and type of anesthesia, and weight and physical

exam findings, as appropriate, must be recorded in the patient record.

– Name of licensed veterinarian performing the surgery must be recorded in the patient record.

– A surgery table must be used as appropriate. Such table must have an impervious surface suitable for cleaning and disinfecting.

– The surgical area must be clean, orderly, and well illuminated.

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– All surgery must be performed by a licensed veterinarian utilizing aseptic technique as appropriate for the procedure.(e)Surgical equipment must be sterilized in the following manner:• Cold sterilization must be limited to instruments used in

minor or other procedures as appropriate, or limited to those instruments that can not be sterilized otherwise.

• Surgical instruments other than those applicable to 1. above must be sterilized utilizing autoclave, gas, or other technique acceptable to the Board.

– Oxygen and equipment for administration must be available as appropriate.

– Facilities and equipment for resuscitation must be readily available as appropriate.

Rule 700-12-.09

Examination Area

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• A licensed veterinarian employed at a veterinary facility must ensure that the following criteria pertaining to the examination area are met:– Area must be maintained in a clean and orderly manner.– Impervious waste receptacle must be provided.– Disposable towels and a sink must be readily accessible as

appropriate. A sink in a restroom is NOT considered acceptable.

– The examination table must have an impervious surface suitable for cleaning and disinfecting.

Rule 700-12-.10

Radiology

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• A licensed veterinarian employed at a veterinary facility must ensure that the following criteria pertaining to radiology are met:– Radiological equipment must be of sufficient quality to

produce acceptable diagnostic images.– Facility must comply with all federal, state, and local

radiological safety requirements.– If radiological services are not offered at a facility, referral

radiological services should be made available.

Rule 700-12-.11

Patient Care

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• For hospitalized or sick animals that are maintained in a veterinary facility, a licensed veterinarian must physically visit the facility and see each animal daily.

• Patients recovering from anesthesia must be properly monitored as appropriate.

Rule 700-12-.12

Renewal Statement

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• During the biennial license renewal period, each licensed veterinarian who is employed at a veterinary facility and providing veterinary care must state on his or her renewal application that the facility in which he or she is employed is in compliance with the minimum standards outlined in this Chapter.

• Such application form must have clear instructions on how the applicant is to complete the application subject to this requirement.

Client Communication

Statistics

• 96% of unhappy clients never contact the business that upset them

• For each complaint there is approximately 26 unspoken complaints

• 95% of people that complain with return if the complaint is resolved quickly

• For every complaint heard- 260 potential clients will hear about your “bad” service

Nonverbal Communication

• Can account for approximately 60% of your communication• Negative signals that you might not realize you are exhibiting– Wrinkled forehead, clearing of throat, LACK OF EYE

CONTACT– Scratching your head, tinkering with jewelry, rubbing your

neck, shifting weight, arms crossed, cocking head.• Everybody does these things from time to time, but done in

excess can be a problem

Written Communication

• The written material you provide to your clients has a large impact on the image of your practice• Are they typeset and printed professionally

• Prepared Estimates• Authorization for professional services

– Surgical consent– Annual blood work

• Standardized medical discharge instructions that you can modify per patient– Proper restraint, food and water, elimination, exercise and

activity, medications, sutures, appointments, monitoring, and any special instructions.

Email Rules

• Consider the purpose of your message• Keep it short and simple• Consider legal ramifications– You can’t ever truly delete and email

• Protect your reputation– Can be forwarded with your address attached

• Save the email and copy it to the client record

Verbal Communication

• Low, deep tone = more authoritative• Timing- short pauses can accentuate your point• Atmosphere• 60% failure of communication

• Succinctness is critical• Speaking too much is as bad as not enough

• Keep in mind that we typically only recall 25% of what was heard from the last few days

• The human brain can process more than 500 words per minute while the average speech rate is 120-150 words per minute.

• Speaking to slowly can cause you to lose your listeners attention, think about what you say before you do.

Communication Skills

• Look For Clues– If you know how to read nonverbal clues you might be

able to tell what the client in thinking or feeling• Which may contradict what they are saying

– Pay attention to tone, facial expression, posture• This may help you clarify the situation before a

misunderstanding occurs• Show Your Empathy– Empathetic listening is a process of actively responding to

what clients are saying, either verbally or nonverbally• Acknowledge that the owner may be feeling nervous

about their pet’s condition

• Make statements to help clients feel accepted• Speak quietly and slowly in times of sadness–Offer tissue if you notice them starting to get

emotional• There are three types of statements you can make to help

clients feel accepted:– Non-judgmental statements» You were placed in a very difficult situation

– Normalizing statements» It’s very common for pet owners to miss these

masses– Self-disclosing statements»My cat has behavioral issues too.

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• Ask Open Ended Questions– . It helps to solidifying client bonds and increase the feeling

of a partnership in veterinary care– This will help not only to obtain an accurate history but

also to assess clients’ understanding preferences, and goals for diagnostics and treatments• Begin with what or how• Avoid why which can sound accusatory

– Rule of thumb: Ask, don’t tell. In presenting the diagnosis, ask what the client knows about the disease rather than jumping into a description. • This shows the client you value their knowledge and

helps in deciding where to begin your client educations

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– Closed ended questions begin with:• When, is, did, who, and where– Results in 1 word answers

• Repeat After Them=Reflective Listening– Repeating what clients say or imply• Shows interest in their thoughts and feelings• Shows empathy and clarifies their understanding• You may start these responses with standard phrases

such as “So, you’re saying that…” and “It sounds like…”– Reflective listening can also be communicated

nonverbally, with nods and smiles

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• If you want a pet owner to expound without your input, try repeating the client’s last word or phrase.– If a client says, “Fluffy has just been acting crazy,”

you may respond with a simple, “Crazy?” – The pet owner will instinctively elaborate for you.

• Good communicators can assess reactions by interpreting body language– If you aren’t getting appropriate responses, change your

approach.– Is you language to complicated, is the client distracted

How to improve your skills

• Video tape your interactions in rooms, so you can review them later to critique yourself

• People want them to appreciate them, listen to them, help them, use their name, be creative, be honest

• Ask questions, react positively with gestures, facial expressions and voice tone

• Use simple answers and avoid jargon• Remain objective• Remember clients are usually angry with you, they are angry

with the situation

• It is ok to say, “I don’t know, but I will find the information for you”.

• Try to be aware of client emotional state• Listening carefully

• Talking is considered active and dominant • Listening is more passive and respectful

Records• Keep complete, accurate and legible record– Write all records within 24 hours of the visit of the pet– If it is not in record it was not done– Time and date stamp in computer or paper record then

initialed – Never erase, white out or cover mistakes.• Cross out and correct notation with initials

– Standard and approved abbreviations and notations are acceptable

– Do not disclose the record to anyone without the clients approval• Exception would be law enforcement

Humane Euthanasia

AVMA GuidelinesGeorgia Law

HSUS Reference Manual

AVMA Definitions

• Euthanasia is derived from the Greek terms:– eu meaning good and thanatos meaning death.

• The term is usually used to describe ending the life of an individual animal in a way that minimizes or eliminates pain and distress.

• A good death is tantamount to the humane termination of an animal’s life.

• In the context of these Guidelines, the veterinarian’s prima facie duty in carrying out euthanasia includes, but is not limited to:– his or her humane disposition to induce death in a manner

that is in accord with an animal’s interest and/or because it is a matter of welfare, and

– the use of humane techniques to induce the most rapid and painless and distress-free death possible.

– These conditions, while separate, are not mutually exclusive and are codependent.

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• While recommendations are made, it is important for those utilizing these recommendations to understand that, in some instances, agents and methods of euthanasia identified as appropriate for a particular species may not be available or may become less than an ideal choice due to differences in circumstances.

• Conversely, when settings are atypical, methods normally not considered appropriate may become the method of choice.

• Under such conditions, the humaneness (or perceived lack thereof) of the method used to bring about the death of an animal may be distinguished from the intent or outcome associated with an act of killing.

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• Following this reasoning, it may still be an act of euthanasia to kill an animal in a manner that is not perfectly humane or that would not be considered appropriate in other contexts.– For example, due to lack of control over free-ranging

wildlife and the stress associated with close human contact, use of a firearm may be the most appropriate means of euthanasia.

– Also, shooting a suffering animal that is in extremis, instead of catching and transporting it to a clinic to euthanize it using a method normally considered to be appropriate (eg, barbiturates), is consistent with one interpretation of a good death.

• The former method promotes the animal’s overall interests by ending its misery quickly, even though the latter technique may be considered to be more acceptable under normal conditions.

• Neither of these examples, however, absolves the individual from her or his responsibility to ensure that recommended methods and agents of euthanasia are preferentially used.

Accepted Methods in Companion Animals

• Noninhaled Agents– Barbiturates and barbituric acid derivatives• Intravenous injection of a barbituric acid derivative (eg,

pentobarbital, pentobarbital combination product) is the preferred method for euthanasia of dogs, cats, and other small companion animals.

– Nonbarbiturate anesthetic overdose—• Injectable anesthetic overdose (eg, combination of

ketamine and xylazine given IV, IP or IM or propofol given IV)

Acceptable with Conditions Methods

• Noninhaled Agents– Barbiturates and barbituric acid derivatives (alternate

routes of administration)• The IP route is not practical for medium or large dogs

due to the volume of agent that must be administered and a prolonged time to death.

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• Inhaled Agents– Inhaled anesthetics• Overdoses of inhaled anesthetics administered via

chamber (eg, isoflurane, sevoflurane) are acceptable with conditions for euthanasia of small mammals and some other species < 7 kg because most vertebrates display aversion behavior to inhaled anesthetics

– Inhaled anesthetics may also be used to anesthetize small fractious animals prior to administration of an injectable euthanasia agent.

Physical Methods

– Gunshot• Gunshot should only be performed by highly skilled

personnel trained in the use of firearms (eg, animal control and law enforcement officers, properly trained veterinarians) and only in jurisdictions that allow for legal firearm use.

– Penetrating captive bolt• Use of a penetrating captive bolt by trained personnel

in a controlled laboratory setting has been described as an effective and humane method of euthanasia for rabbits and dogs.

UNACCEPTABLE Methods

• With the exception of IM delivery of select injectable anesthetics:

• SC, IM, intrapulmonary, and intrathecal routes of administration are unacceptable for administration of injectable euthanasia agents because of the limited information available regarding their effectiveness and high probability of pain associated with injection in awake animals.

• Household chemicals, disinfectants, cleaning agents, and pesticides are not acceptable for administration as euthanasia agents.

• Other unacceptable approaches to euthanasia include hypothermia and drowning.

Dangerous or Fractious Animals

• Animals that are unable to be safely and humanely restrained should be sedated by means of drugs delivered orally or remotely (eg, darts, pole syringes) before administration of euthanasia agents.

• Doing so will assist in relieving anxiety and pain for the animal, in addition to reducing safety risks for personnel.

• There is a variety of pre-euthanasia drugs that can be administered PO, SC, or IM, alone or in combination, to render animals unconscious with minimal handling in preparation for euthanasia

FETUSES AND NEONATES

• Scientific data indicate that mammalian embryos and fetuses are in a state of unconsciousness throughout pregnancy and birth. – For dogs and cats, this is in part due to moderate

neurologic immaturity• Euthanasia of dogs, cats, and other mammals in mid- or late-

term pregnancy should be conducted via an injection of a barbiturate or barbituric acid derivative (eg, sodium pentobarbital) as previously described. – Fetuses should be left undisturbed in the uterus for 15 to

20 minutes after the bitch or queen has been confirmed dead.

.

• During ovariohysterectomy of pregnant dogs and cats and small mammals with altricial (requiring nourishment)neonates, ligation of the uterine blood vessels with retention of the fetuses inside the uterus will result in death of the fetuses. – The uterus should not be opened for, at least 1 hour or

longer. • In the case of caesarian section in late-term pregnancy, IP

injection of pentobarbital is recommended for fetuses that must be euthanized for congenital deformities or illness and that have been removed from the uterus (creating the potential that successful breathing may have occurred).

Animal Control, Sheltering, and Rescue Facilities

• The preferred method of euthanasia in these facilities is injection of a barbiturate or barbituric acid derivative with appropriate animal handling.

• When euthanizing animals that are well socialized without pre-euthanasia sedation or anesthesia, appropriate handling usually involves two trained people. – One individual restrains the animal and the other

administers the euthanasia agent.

• When euthanizing distressed, dangerous, or fractious animals, a sedative or anesthetic should be administered prior to attempting euthanasia.

• When the necessary restraint can be performed, a pre-euthanasia sedative or anesthetic can be delivered IM or PO.

• After administration of the sedative or anesthetic, the animal is released so that it can return to a comfortable low-stress location (eg, dimly lighted cage or area) while the drug takes effect.

• Once the drug has taken effect safe euthanasia agents can be administered

Humane Society of the United States Euthanasia Manual

Criteria to Evaluate Acceptable Methods of Euthanasia

• Ability to induce loss of consciousness and death with a minimum of pain and distress

• Time requires to induce loss of consciousness• Reliability• Safety of personnel• Irreversibility• Compatibility with intended animal use and purpose• Documented emotional effect on observers or operators• Compatibility with subsequent evaluation examinations, or

use of tissue

• Drug availability and human abuse potential• Compatibility with species, age, and health status• Ability to maintain equipment in proper working order• Safety for predators or scavengers should the animal’s

remains be consumed• Legal requirements• Environmental impact of the method or disposition of the

animal’s remains

Topics to Consider

• Sodium Pentobarbital• Pre-Euthanasia Drugs• Verification of death• Unacceptable methods

Sodium Pentobarbital

• Why?: When used in high doses it works to quickly and completely depresses the animal’s central nervous system, resulting in death.– When introduced into the bloodstream, it moves rapidly to

the heart and then into the brain, where is quickly and painlessly depresses all vital life functions.

– The animal loses consciousness within seconds and results in clinical death within minutes.

• Stages of anesthesia that each animal undergoes once the drug has been administered– Stage I: Voluntary Excitement aka Induction– Stage II: Involuntary Excitement aka Delirium– Stage III: Surgical Anesthesia– Stage IV: Medullary Paralysis aka Irreversible anesthesia

Acceptable Routes of Administration• Intravenous (IV)• Intraperitoneal (IP)

– Requires 3 times more drug than IV dosage– When performed properly, completely painless and can be

more humane than IV in some circumstances– Used for kittens, puppies, birds, reptiles, small mammals

and small wildlife– Proper location:

• On linea alba, just below umbilicus– Landmarks:

» Linea alba, xyphoid, hip joints» AVOID lower abdomen, muscles, spleen and liver

• Intracardiac– Excruciatingly painful in a conscious animal– NEVER administered unless full UNCONSCIOUS– Fastest most efficient delivery of drugs• Compromised veins• Compromised circulatory system• Sodium Pentobarbital has already been administered IV

or IP and has not effectively resulted in death– Procedure:• Determine if pet unconscious after administration of

pre-euthanasia medications– Palpebral reflex– Toe pinch reflex-checking for deep pain.

.

• Palpate area where heart beat is felt most prominently• Reference area having animal in lateral recumbancy,

bending elbow to 45-degree angle and the heart should be directly behind the elbow

• Longer needle is necessary• Insert at 90-degree angle, aspirate to confirm location,

inject, leave needle and syringe in place until the heart has stopped – If blood is not easily aspirated or if only a quick

flash of bright red blood is observed, then the needle may be in the heart muscle» This would be considered an IM injection

which is NOT an acceptable route of administration

Methods NOT Acceptable

• Intraperitoneal– Adult dogs and puppies over 5 weeks of age – Late term pregnancy

• Intravenous– Jugular vein in companion animals

• Intramuscular, subcutaneous, intrathoracic, intrapulmonary, intrahepatic, intrarenal, intrasplenic, intrathecal or any other nonvascular injection site

Where Permitted by Law

• Oral administration can be useful in very difficult or fractious animals

• Goal:– Not to fully complete the euthanasia process but simply

get the animal to ingest enough drug to render it fully unconscious for direct injection of additional sodium pentobarbital or at least manageable to gain control of the animal• Bitter taste• High dosages of 3 times IV dose

Georgia Law

• Code of Georgia Annotated• §4-11-5.1 Substances and procedures for euthanasia of dogs

and cats by animal shelters• Who can perform:– Licensed veterinarian or physician– Lay person properly trained in the proper and humane use

of a method of euthanasia under the supervision of a licensed veterinarian or physician (does not require veterinarian to be present)

• Who may possess: – Veterinary clinics– Animal shelters or other facilities which are operated for

the collection and care of stray, neglected, abandoned, or unwanted animals

• Method: – Sodium pentobarbital or a derivative of sodium

pentobarbital– Any substance which is clinically proven to be as humane

as sodium pentobarbital and which has been officially recognized as such by the AVMA

.

• *Georgia adopted a law outlawing the use of gas chambers beginning December 31, 2010

• Emergency Euthanasia: – In cases of extraordinary circumstances where the dog or

cat poses an extreme risk or danger to the veterinarian, physician, or lay person performing euthanasia, such person shall be allowed the use of any other substance or procedure that is humane to perform euthanasia on such dangerous dog or cat.

Standards of Care for Early Spay and Neuter

Early Neuters vs. Testicular Cancer

• Neutering will totally prevent testicular cancer.• Testicular tumors account for 90% of all cancers originating

from the male reproductive system. • Most tumors are contained to the testicles, but may spread in

10-20% of the cases.• Especially prevalent in older dogs, testicular tumors are the

second most common tumor in male dogs. • Sertoli cell tumors, interstitial (Leydig) cell tumors, and

seminomas are the three most common tumors. – Seminomas (42%) and interstitial cell tumors (50%) are

most common with sertoli cell tumors being the least common (8%).

.

• About one third of dogs that develop a tumor will have more that one of these types of tumors present.

• Other types of testicular tumors (i.e. embryonal carcinoma, lipoma, fibroma, hemangioma, chondroma, teratoma) can occur, but are rare.

• Male dogs that have one or both testicles cryptorchid are much more likely to develop a tumor than dogs with normal (scrotal) testicles.– Undescended testicles are at increased risk to develop malignant

behaving tumors (seminomas and Sertoli cell tumors). • Tumors of normal descended, or scrotal, testicles are usually benign.

• Testicular tumors can spread to regional lymph nodes, liver and

lungs.• Neutering by four months will take care of all these concerns!

Testicular Tumor

Early Spay vs Mammary Cancer• Early Spays (by four to five months of age) = 98% Decrease In

Mammary Cancer • Mammary tumors are the most common tumors of female

dogs, accounting for half of all tumors, and are the third most common tumor for cats.

• They are malignant about 50% of the time in dogs and 80% of the time in cats.

• The risk of mammary tumors rises quickly with every heat cycle.

• Spaying by four months can prevent not only mammary cancer but uterine, cervical, and ovarian tumors as well.

• While the latter are not so frequent as mammary tumors, they are still very serious when they occur.

• Once a mammary tumor spreads to the lungs or bones, the cancer will be fatal.

• An unspayed dog is approximately 4 times more likely to develop mammary tumors than a dog spayed after only two heats– 12 times more likely than a dog spayed before her first

year (by 6 -8 months of age)• An unspayed cat is 7 times more likely than a spayed cat to

develop mammary tumors.

AVMA Policy Statement onPediatric Spay/Neuter

• The AVMA supports the concept of pediatric spay/neuter in dogs and cats in an effort to reduce the number of unwanted animals of these species. Just as for other veterinary medical and surgical procedures, veterinarians should use their best medical judgment in deciding at what age spay/neuter should be performed on individual animals.

Making Sense of the Studies on Early Spay/Neuter in Golden Retrievers

•

• The Golden Retriever study from UC Davis has gotten a lot of publicity, and being used to raise concerns about early spay/neuter.

• What does it really say, and is it fair to extrapolate this to all early spay/neuter?

• This study is specific to Golden Retrievers and some issues to which the breed is prone. The number of affected patients is small and the authors themselves warn the information cannot be extrapolated to other breeds.

• The database used was from the University of California's small animal hospital, a hospital staffed mostly by board certified veterinary specialists.

•

• Abstract• In contrast to European countries, the overwhelming majority of dogs in the U.S. are

neutered (including spaying), usually done before one year of age. Given the importance of gonadal hormones in growth and development, this cultural contrast invites an analysis of the multiple organ systems that may be adversely affected by neutering. Using a single breed-specific dataset, the objective was to examine the variables of gender and age at the time of neutering versus leaving dogs gonadally intact, on all diseases occurring with sufficient frequency for statistical analyses. Given its popularity and vulnerability to various cancers and joint disorders, the Golden Retriever was chosen for this study. Veterinary hospital records of 759 client-owned, intact and neutered female and male dogs, 1–8 years old, were examined for diagnoses of hip dysplasia (HD), cranial cruciate ligament tear (CCL), lymphosarcoma (LSA), hemangiosarcoma (HSA), and mast cell tumor (MCT). Patients were classified as intact, or neutered early (,12 mo) or late ($12 mo). Statistical analyses involved survival analyses and incidence rate comparisons. Outcomes at the 5 percent level of significance are reported. Of early-neutered males, 10 percent were diagnosed with HD, double the occurrence in intact males. There were no cases of CCL diagnosed in intact males or females, but in early-neutered males and females the occurrences were 5 percent and 8 percent, respectively. Almost 10 percent of early-neutered males were diagnosed with LSA, 3 times more than intact males. The percentage of HSA cases in late-neutered females (about 8 percent) was 4 times more than intact and early-neutered females. There were no cases of MCT in intact females, but the occurrence was nearly 6 percent in late-neutered females. The results have health implications for Golden Retriever companion and service dogs, and for oncologists using dogs as models of cancers that occur in humans.

• There may be socioeconomic variables that can skew the findings. For example, the majority of dogs will never see the inside of a specialty referral center, either because their owners can't afford the service or it is impractical for them to make the travel, or maybe the dogs were just plain healthy and didn't need specialty services.

• When the data is carefully reviewed, there are several categories where spayed or neutered dogs actually scored better than intact Goldens.

• The authors made this generalization from their study: “For all five diseases analyzed in the present study, the disease rates in males and/or females were significantly increased when neutering was performed early and or late.”

• This generalization is much too broad and conflicts with the data reported.

• Every breed is predisposed to its own unique list of medical conditions, so studies within a single breed cannot be extrapolated to other breeds.

• The number of dogs affected in each category was fewer than 20, with some in single digits.

• Compare this to the millions of companion animals at risk of euthanasia in shelters, or those impacted by mammary cancers, pyometra (infection of the uterus), or puppies, and sometimes mothers, lost to difficult deliveries.

• There are other recent studies that show the benefits of early spay/neuter that cover a much larger sampling.

• A 2013 study from the University of Georgia shows that neutered and spayed dogs live 14% and 23% longer, respectively, than intact dogs.

• The Georgia study looked at more than 70,000 dogs and 185 different breeds, thereby lending it more validity.

• Those results were backed up by an even more recent study from Banfield that shows neutered dogs live 18% longer and spayed females live 23% longer

• According to the Georgia study, spayed and neutered dogs are dramatically less likely to die from infectious disease, trauma, vascular disease, and degenerative disease than intact dogs.

• The UC Davis study fails to mention or compare the protective effect preventing mammary cancer by spaying dogs before their first heat.

What is the earliest you can spay/neuter kittens and puppies?

•

• For puppies and kittens in a shelter situation, they may be spayed or neutered as early as eight weeks. – Approximately 2 pounds

• One of the main reasons for altering them at this age is so they can find loving permanent homes as quickly as possible.

• Shelters have an obligation, and are often required by law, to spay or neuter every pet before it is adopted.

• Veterinarians attending to shelter kittens and puppies are quite experienced in pediatric surgery ensuring their safe care.

• Even though youngsters in this group may have been vaccinated one or more times, and may already be spayed or neutered, the new adopted family will still need to take them to their veterinarian for a general health exam and finish up their vaccination series, which typically concludes around 12 weeks or so for kittens, and around 16 weeks for puppies.

• What can be said for sure is that spaying or neutering is recommended by the age of 4 to 5 months.

• This will prevent accidental litters, avoid any heat cycles, and markedly reduce the likelihood of mammary cancer.

• Early age surgery is safe with fewer post-surgery concerns, is less stressful on the patient, provides a quicker recover time, and is generally less expensive than later age spay/neuter.

• Although there are always variations, cats can have their first heat as early as 4 months old

• Dogs can have their first heat as early as 5 to 6 months old

• With 50% of litters being accidents, you can see how unwanted litters can add up quickly.

• Pregnancy at an early age can be tough physically, but can also start a cycle of babies having babies.

• Cats can have up to 3 litters a year with an average of 4 kittens– Many people don’t know that the new mom can become

pregnant again while still nursing a litter! • Dogs can have up to 2 litters a year with an average of 4

puppies

AVMA Support

• The AVMA supports the concept of pediatric spay/neuter in dogs and cats in an effort to reduce the number of unwanted animals of these species.

• Just as for other veterinary medical and surgical procedures, veterinarians should use their best medical judgment in deciding at what age spay/neuter should be performed on individual animals.

PetSmart Charities study

• PetSmart Charities shows us how people’s attitudes toward spay/neuter are based on incorrect assumptions.

• The study uncovered a real problem among unaltered cats, showing that 19% of the feline population has had at least one litter.

• Furthermore, the research shows that 59% of these litters were unintentional “accidents” — a full 10% increase from when this survey was first conducted in 2009!

• The main reason respondents chose not to spay/neuter their recently acquired pet, the study shows, was that they believed their pet to be too young.

• More specifically, it was shown that 72% of recent adopters estimated that pets needed to be 6 months of age or older, or simply didn’t know when the operation was safe.

• Furthermore, 81% of potential adopters thought 6 months was the earliest age possible, or didn’t know when spaying/neutering was safe.

Bad Behavior

• Spaying/neutering early helps eliminate annoying behaviors like spraying, roaming, yowling, and fighting. Not to mention stopping heat cycles.

• Spaying and neutering early stops many unwanted behaviors from even starting in both cats and dogs.

• For example, female cats can go into heat up to ten times in a year, and the heat cycle can last up to 2 weeks.

• That means that for 20 weeks a year you could be dealing with the thrashing, the howling, the flirting, and the escape attempts that go along with having an intact female cat!

• Male cats and dogs that have not been fixed have a strong desire to mark their territory by spraying strong-smelling urine.

• They constantly roam in search of mates, which makes them more likely to get hit by a car, and they are likely to get in fights with other males to compete for mates.

• Female dogs can also become aggressive during their heat cycles, which can pose a risk to other animals and small children.

• Taking away the desire to breed at an early age, however, does not take away your pet's beloved personality.

• Your male cat or dog’s sense of manliness won’t disappear either.

• Animals have no concept of their sexual identity, so Spike isn’t going to suffer any kind of identity crisis once he’s neutered.

• By eliminating the sexual drive that can cause a dog to bolt from the house or yard, neutering helps protect dogs from injuries and diseases associated with roaming in search of a mate.

• Neutering decreases roaming, one study found, in 90 percent of male dogs.– On the loose, a dog may be hit by a car, harmed by an act

of cruelty, or infected with a disease transmitted by another animal.

– He can also be seriously wounded in a dog fight - always less likely if a dog has been neutered since neutering reduces aggressiveness toward other male dogs

Help stop teenage pregnancy! Early-age neutering in cats.

Joyce A1, Yates D.

PRACTICAL RELEVANCE:• Neutering kittens at an early age, typically between 6 and

14 weeks, has received increasing attention and gained prominence in recent years, particularly in the United States and in shelter medicine in the UK. However, in private practice it has yet to be generally endorsed.

GLOBAL IMPORTANCE:• Among many of the animal welfare charities, early

neutering is seen as a crucial step in conquering and controlling cat overpopulation.

CLINICAL CHALLENGES:• Physiological differences between kittens and adult cats are

very important to consider before undertaking elective early neutering. Increased sensitivity to drugs, prolongation of effects and a limited capacity for cardiovascular compensation are the principal anaesthetic concerns in kittens.

EVIDENCE BASE:• The optimal age for neutering, traditionally deemed to be

between 5 and 8 months, is now questioned, as short- and longer-term studies demonstrate no significant behavioral and physical advantages conferred by traditional-age neutering.

• Furthermore, a number of safe anesthetic and surgical protocols have been documented that produce lower morbidity and similar mortality rates in early-age neuters compared with traditional-age neuters.

Effect of age at gonadectomy on the probability of dogs becoming overweight

Lefebvre SL1, Yang M, Wang M, Elliott DA, Buff PR, Lund EM.

OBJECTIVE:• To determine whether gonadectomy or age at gonadectomy

was associated with the risk that dogs would subsequently become overweight.

DESIGN:• Retrospective cohort study.ANIMALS:• 1,930 dogs gonadectomized between 1998 and 2001 at ≤ 6

months of age (n = 782), > 6 months to ≤ 1 year of age (861), or > 1 to ≤ 5 years of age (287) and 1,669 sexually intact dogs.

PROCEDURES:• Dogs were followed-up through medical records for ≥ 10 years

or until a diagnosis of overweight (defined as overweight, obese, or having a body condition score ≥ 4/5) was recorded. Information extracted included age at study entry, sex, breed, breed-size category, hospital visit frequency, and diagnosis (yes or no) of overweight or diseases that might affect body condition. Relative risk of a diagnosis of overweight was assessed among age groups of gonadectomized dogs and between gonadectomized and sexually intact dogs.

RESULTS:• No difference was detected among dogs grouped according to age at

gonadectomy with respect to the risk of being overweight. This risk was significantly greater in gonadectomized dogs than in sexually intact dogs, but only during the first 2 years after gonadectomy. Sexually intact male dogs were approximately 40% less likely to have this diagnosis (hazard ratio, 0.61; 95% confidence interval, 0.52 to 0.72) than were sexually intact female dogs; no difference in risk between the sexes was evident for gonadectomized dogs.

CONCLUSIONS AND CLINICAL RELEVANCE:• Gonadectomized dogs had a greater risk of being overweight than

did sexually intact dogs, but this risk was not influenced by age at gonadectomy. Opportunities exist for veterinarians to provide counseling during the first years after gonadectomy to help dogs maintain a healthy weight.

Pedicle ties provide a rapid and safe method for feline ovariohysterectomy.

Miller KP1, Rekers W2, Ellis K3, Ellingsen K2, Milovancev M4.J Feline Med Surg. 2015 Mar 13.

OBJECTIVES: • The specific objectives of the present study were to evaluate

the rate of hemorrhage-related complications across a large number of feline pedicle tie (PT) procedures, and evaluate for a difference in surgical time between traditional pedicle double ligation (PDL) and PT procedures.

. RESULTS: • Six of 2136 (0.281%) cats experienced a hemorrhage-related

complication associated with the ovarian pedicle. Five of the six ovarian pedicle hemorrhage-related complications were recognized and corrected intraoperatively, with the remaining hemorrhagic event being detected postoperatively. Surgical times were significantly shorter in PT kittens compared with PDL kittens (4.7 ± 0.1 mins vs 6.7 ± 0.1 mins) and PT adult cats compared with PDL adult cats (5.0 ± 0.2 mins vs 7.0 ± 0.2 mins).

CONCLUSIONS AND RELEVANCE:• This study demonstrates that the PT technique is associated

with a very low risk of hemorrhage-related complications and is significantly faster than double ligating the ovarian pedicle in kittens and adult cats. Use of the PT technique has the potential to be of significant economic benefit in institutions performing large numbers of feline ovariohysterectomies.

Guidelines for Preoperative Care• Patient transport

– Proper confinement and security of enclosures– Environmental temperature regulation

• Heating and cooling, proper ventilation– Verification of identity of patients

• Name bands, collars, microchip– Continuous monitoring

• Patient selection– Owned animals should be 4 months of age to allow for

development of immunity– Shelter animals can be as young as 6 weeks of age– Physical examination– Staffing, economics

• Client communication– Client confirmation of patient’s health– Acknowledgement of risk of infections disease exposure– Acknowledgement of risk of anesthesia and surgery

including death– Authorization for surgery– Recommendation of ongoing health care at full-service

veterinary clinic– Client contact information– Description of fees– Other vaccines as per AAFP, AAHA recommendations

• Record keeping– Comply with state and local practice acts and guidelines– Medical record

• Vaccination– Rabies should be required

• Withholding of food but not water– Pediatric-feed 2-4 hours prior to surgery and should not be

withheld for more than 4 hours after surgery– Juvenile and adults should have food withheld for a

minimum of 4 hours but more than 6 is not warranted

• Physical examination– Verification of sex and reproductive status– Body weight

• Patient housing– Identification– Adequate temperature and ventilation– Housing properly cleaned and disinfected– Littermates may be house together– Feral animals should be housed in traps

• Infections disease control– Proper cleaning of equipment in direct contact with

patients– Anesthesia breathing circuits should be cleaned weekly– Staff hygiene

• Equipment– Properly maintained– Scavenger system-active and passive• Charcoal canisters changed every 8 hours or

determined by weight of canister

Guidelines for Anesthetic Procedures

• Perioperative and intraoperative thermoregulation– Limit direct contact with cold surfaces– Limit body cavity exposure– Protected contact with external heat sources• Avoid heating pads, heat lamps, blow dryers, drying

cages and hot water containers– Minimize hair removal and moistening of skin in pediatric

patients• Oxygen supplementation and ventilation– Mask-2-5 liters/minute

.

• Fluid therapy– When needed subcutaneous or intravenous– Should be warmed

• Monitoring– Pulse quality, rate and rhythm– Respiratory rate and pattern– Jaw tone• Moderately relaxed is indicative of a surgical plane of

anesthesia– Eye position and pupil size• Moderate ventral strabismus of both eyes is indicative

of a surgical plane of anesthesia

– Palpebral reflex• Mildly sluggish or slow is indicative of a surgical plane

of anesthesia.• Anesthetic protocol– Multimodal• Provision of analgesia or a lack of pain• Stress reduction• Immobility or muscle relaxation• Safe, controlled reversible depression of

CNS=unconsciousness

.

• Administration of analgesics– Alpha-2 adrenoceptor agonist– NSAIDS– Local anesthetics– Opiods

• Anticholinergic agents– Not recommended as part of routine protocol

• Induction and maintenance of anesthesia with inhalant anesthetics– Mask administration of inhalant anesthetics for induction

or maintenance of anesthesia should be minimized– hi

• Mask induction should be avoided– High degree of stress– Loss of consciousness is poorly controlled– Severe sympathomimetic effects and bronchial irritation– Increased risk of aspiration of gastric contents– Expense

• Mask maintenance should be used only for short periods of time

• Preparation for emergencies– Crash cart– Emergency drug charts which contain volumes of drugs per

body weight– Staff training for CPR

• Accurate drug calculation and administration– Dosing chart based on weight– Keep in mind to account for health status for dosing

administration• High-risk patients– Based on history and physical examination– Brachycephalic– Geriatric

• Intubation– Does not necessarily need to be part of protocol, but

should be available if needed.

Guidelines for Surgical Care

• Operating-area environment– Dedicated area– Scheduled cleaning and disinfection policy in place– Traffic limited

• Surgical-pack preparation– Separate sterile instruments for each patient– Cleaned and sterilized by steam, gas or plasma• Indicator strip• Double wrapped packs

• Patient preparation– Bladder expression– Skin• Hair removal and skin disinfected

– Draping• Required for all abdominal procedures and castrations– Exception is pediatric castration

• Surgeon preparation– Surgical attire– Surgical caps and masks • Required

– Surgical hand and arm scrub• Required• Approved waterless surgical prep agents are acceptable

alternatives to traditional scrub techniques– Surgical gowns• Recommended but not required

– Surgical gloves• Sterile single use gloves are required for all surgeries

except for routine cat castration• Suture materials– Sutures or surgical clips

• Surgical procedures– Acceptable• Female-ventral midline, flank, laparoscopic–Ovariohysterectomy and ovariectomy» Closure must incorporate the external rectus

fascia• Male-prescrotal, scrotal• Interrupted or continuous suture pattern for abdominal

closure• Scrotal incisions for pediatric castrations can be

sutured, glued or left open for second intention healing.

• Identification of neutered animals– Unilateral ear tipping for feral cats– Tattoo• Directly to the surgical incision after SQ closure• Cutaneous incision other than surgical incision• Intradermal injection of tattoo ink• Tattoo gun with sterile needle for each patient

• Use of antimicrobials– Routine perioperative usage is not recommended– Specific indications acceptable

Guidelines for Postoperative Care• Patient transport within the clinic– Safe delivery to and from the recovery area• Minimize stress, maintain thermoregulation and airway

• Recovery– Minimize complications– Continuous direct observation– Pediatric patients best recovered with littermates

• Analgesia– If not administered prior to during surgery

• Anesthetic reversal– At veterinarians discretion

• Thermoregulation– As previously described

• Kennel environment– Under supervision water and food should be offered as

soon as patients are ambulatory– Encourage urination and defecation once ambulatory

• Release– Evaluate immediately prior to release– Provide written post operative instructions for owner

Anesthesia ProtocolsHumane Alliance a program of the ASPCA

• Feline single injection protocol – Dexdomitor, Telazol, Morphine– Previously Dexdomitor, Morphine, Ketamine

• Maintenance – Oxygen 1.5%, Isoflurane max 1-2% via mask• Anecdotal research indicates that Iso levels greater

than 2% can cause laryngospasm in “masked” cats • Pain Management– NSAID• Meloxicam if over 4 months of age• Buprenorphine transmucosal if under 4 months of age

• Local anesthetic– Splash linea block• Bupivacaine

• Reversal if needed– Naloxone, Antiseden

• Canine – Premed• Acepromazine, Morphine

– Induction• Ketamine, Diazepam/Midazolam

– Maintenance• Isoflurane/Oxygen via endotracheal tube

– Pain Management• Meloxicam

• Local anesthetic– Testicular block• Lidocaine or Bupivacaine

– Splash linea block• Lidocaine/Sterile water

• Reversal if needed – Naloxone

Questions:

Solveig.evans@gwinnettcounty.comsolveigevans@hotmail.com