August 16, 2014 Implementing High Quality, High Volume Spay/Neuter: Challenges & Solutions Carolyn Brown, DVM Spay/Neuter Operations carolyn.brown@aspca.org Kathleen Makolinski, DVM Shelter Medicine Service kathleen.makolinski@aspca.org 1
Who are you? What type of spay/neuter program do you work with? 2 Are you familiar with The Association of Shelter Veterinarians veterinary medical care guidelines for spay neuter programs (JAVMA 2008)
Where will we go? Review highlights of medical care guidelines What challenges are faced when implementing? How have programs overcome such challenges? Training available to implement guidelines Small surprise at the end!! Feel free to ask questions as we go along or at end 3
Definition High-quality, high-volume spay/neuter programs are efficient surgical initiatives that meet or exceed veterinary medical standards of care in providing accessible, targeted sterilization of large numbers of dogs and cats in order to reduce their overpopulation and subsequent euthanasia. 4
5 JAVMA (2008)
Medical Guidelines for Spay/Neuter Programs Goals Instill confidence in public regarding use of spay/neuter programs Promote acceptance of this practice area by veterinary profession Provide guidance for veterinarians involved in spay/neuter programs 6 Provide reference for use by state boards of veterinary medicine Allow funding agencies to determine if spay/neuter programs provide acceptable level of animal care
Medical Guidelines for Spay/Neuter Programs Recommendations meant to enhance, not replace, state veterinary practice acts. Where differences exist between guidelines and state acts, veterinarians are encouraged to comply with the more stringent guidelines 7
8 The Association of Shelter Veterinarians www.sheltervet.org Task Forces and Committees Veterinary Task Force to Advance Spay/Neuter Medical Care Guidelines
Four sections of guidelines document Preoperative care Anesthesia Surgery Postoperative care 9
Preoperative Care Withholding food prior to surgery - Pediatrics to be fed 2-4 hours prior to surgery - Other animals: Fast minimum of 4 hours Client communication about animal - Any medical problems? Medications? Client consent Acknowledging risk, authorizing surgery Establish medical record for each patient 10
Preoperative Care Every animal to be examined by veterinarian Helps establish vet/client/patient relationship Helps protect against certain liability issues Good medicine! 11
Preoperative Care Every animal to be examined by veterinarian Helps establish vet/client/patient relationship Helps protect against certain liability issues Good medicine! Cooperative Animals Examined prior to sedation/anesthesia May find something that affects anesthesia/surgery Fractious Animals Done after sedation but prior to surgery 12
Preoperative Care Exam General appearance Mucous membrane color Hydration Auscult heart/lungs Confirm gender Is patient already spayed/neutered? Assess reproductive system Hernias External parasites Evidence of infectious disease Record body condition score Ensure body weight recorded 13
14 Animal Housing Proper identification Preoperative Care Adequate temperature, ventilation, stress reduction Good visibility of animal Adequate space & safety at various stages of sedation Pediatric littermates can be housed together Intractable animals in cages/traps that allow for administration of anesthetics without handling of animal
Preoperative Care Infectious Disease Control Tables, equipment, kennels cleaned and disinfected between patients with appropriate agents Staff to wash or sanitize hands between patients and litters Animals with any evidence of infectious disease should undergo surgery at end of day 15
Preoperative Care Despite label claims, independent studies have shown quaternary ammonium compounds to be unreliable in activity against non-enveloped viruses such as canine parvovirus, feline panleukopenia & feline calicivirus 16
Anesthesia Needs to achieve Pain control - Opioid - Non-steroidal antiinflammatory - Alpha2 agonist - Local anesthetic Stress reduction Muscle relaxation 17 Unconsciousness
Anesthesia Pain control Multimodal analgesia Preventative administration of analgesics 18
Anesthesia Mask/Chamber Induction of Anesthesia Refers to effecting general anesthesia from consciousness through the delivery of inhalant anesthetics via mask or chamber 19
Anesthesia Mask/Chamber Induction of Anesthesia NOT recommended for following reasons Higher degree of patient stress Loss of consciousness is poorly controlled Bronchial irritation risk aspiration of gastric contents - unprotected airway High concentration of anesthetic may harm patient Substantial environmental contamination 20
Anesthesia Anesthesia supplementation via mask Should be minimized to avoid bronchial irritation & environmental contamination If extensive, consider other options - Intubation - Better analgesia/sedation 21
Thermoregulation Anesthesia Reduce contact with cold surfaces Provide carefully protected contact with circulating warm water, heated containers, or use of forced hot air warming devices Avoid close contact with electric heating pads, blow dryers, heat lamps, drying cages Avoid excessive use of alcohol 22
23 Rice Sock
Anesthesia Fluid Therapy Consider fluids in patients predisposed to hypothermia, hyperthermia, or dehydration (pregnant, lactating, small, or ill patients) 24
Anesthesia Be prepared for emergencies Source of oxygen with means of ventilation Drugs, reversal agents Emergency drug charts (volume of drug by body weight) Staff training - ID respiratory/cardiovascular arrest vs. depression - Fundamentals of CPR - Role in emergency 25
Surgery Separate, sterile instruments for each patient, maintain sterile gloves and surgical field Surgeon: Properly performed hand and arm scrub with appropriate agent Surgeon should wear cap, mask, and separate pair of sterile gloves for each surgery (sterile gown is optional) 26
Surgery Ovariohysterectomy and ovariectomy are acceptable Both testes and ovaries need to be removed Prescrotal and scrotal approaches for neuter are acceptable Ventral midline, flank, and laparoscopic approaches for ovariohysterectomy are acceptable Gentle tissue handling, meticulous hemostasis, aseptic technique Either interrupted or continuous suture pattern is acceptable for abdominal closure 27
Surgery Permanent identification of animals as spayed/neutered 28 Choose a consistent means of identifying animals that have been neutered TATTOOS EAR TIPS FOR FERAL CATS
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30 Ear Tipped Cat
Postoperative Care 31 Minimize risk of complications observe Heart rate/pulse quality Respiratory rate/character Airway patency Temperature in patients at risk for developing hypothermia or hyperthermia Also look for Emergence delirium Hemorrhage Pain, stress Urination, defecation
Postoperative Care Offer small amount water to all patients as soon as ambulatory Offer small amount of food to pediatric, geriatric, frail patients as soon as possible 32
Postoperative Care Before release of patient Patient should be ambulatory with no signs of distress If animal allows, check surgical site Review with animal s caregiver Oral and written discharge instructions 33
Postoperative Care Spay/neuter programs to establish policies for handling postoperative questions, complications, & emergencies within at least 48 hours following surgery Staff member carries cell phone that receives calls Voice mail that is checked frequently Establish relationship with local veterinarian or emergency hospital who will see patients for recheck 34
Morbidity and Mortality Data In the event of patient death, necropsy should be performed to establish cause Program to identify Trends in deaths that occur during stay at spay/neuter program or following surgery Trends in post operative complications (Ex: Incision site infections, dehiscence, suture reaction) Compare data collected from one year to the next and to other similarly structured programs 35
36 Discuss and Let s Hear From You!
What challenges have you faced when striving to implement recommendations or making changes within your organization? 37
38 Discuss and Let s Hear From You!
How has your organization overcome challenges and implemented guidelines or made changes within organization? 39
Here s what we have seen in regard to how others have implemented spay/neuter guidelines 40
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Preoperative Care $0.16 per triplicate form 42 Standardized consent forms assist in collection of information and can be combined with medical record
43 Physical Exams
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45 Anesthesia
46 When considering a change in anesthetic protocol
When considering a change in anesthetic protocol Change is SCARY!!! 47
What can make this easier? Speak with veterinarians and visit spay/neuter programs who routinely utilize protocol Help staff realize what are normal and abnormal animal responses 48
Anesthesia The following anesthetic protocols Follow discussed guidelines Used in HQHVSN settings Prices of drugs recently researched Does not include cost of isoflurane or staff Drug doses may vary from one protocol to next Mortality rates & further information can be obtained 49
Anesthetic/Analgesic Protocol Cost for 6 Pound Cat Cost for 30 Pound Dog Acepromazine/Buprenorphine SubQ as pre-med for CATS Acepromazine/Morphine SubQ as pre-med for DOGS Diazepam/Ketamine IV as induction for CATS & DOGS Meloxicam SubQ following spay/neuter $0.72 $3.00 50
Anesthetic/Analgesic Protocol Cost for 6 Pound Cat Cost for 30 Pound Dog Acepromazine/Buprenorphine IM as pre-med for CATS Acepromazine/Morphine IM as pre-med for DOGS Telazol IV as induction for DOGS IM as induction for CATS Meloxicam SubQ following spay/neuter $1.83 $2.48 51
Anesthetic/Analgesic Protocol Cost for 6 Pound Cat Cost for 30 Pound Dog Dexmedetomidine (Cats 45 mcg/kg) (Dogs 35 mcg/kg) Butorphanol (10 mg/ml) Ketamine $4.34 $17.60 Combined IM to cats/puppies Combined IV to adult dogs Rarely supplement with isoflurane Antisedan to reverse pediatrics Meloxicam SubQ following spay/neuter 52 $6.72
Anesthetic/Analgesic Protocol Cost for 30 Pound Dog Medetomidine (compounded) Morphine Ketamine $1.32 Combined IM to dogs Meloxicam SubQ following spay/neuter 53
Surgery Various surgical techniques allow for safe and efficient spay/neuter surgeries Veterinary Seminars in Spay-Neuter Surgery: Pediatrics Obese Dog Spay (Humane Alliance) 54
General Operations When doing 30 spays/neuters per day - One veterinarian to three well trained medical staff members is ideal Need to determine responsibilities of medical versus administrative staff - Medical stations What time can veterinarian leave for the day? 55
56 Standard Operating Procedures
Standard Operating Procedures 57
What s it for? Standardize policies / procedures Define expectations Define quality of care and service Act as a training tool Enforce work standards and accountability 58
59 Training Opportunities
60 Training Opportunities
61 Guess What s Coming Next?
Guess What s Coming Next? Upcoming Revisions!! 62
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