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Nominations now open for dvm360®/VHMA Practice Manager of the Year award

Should the EPA warn the public? vvvita / 

A report released today by the Midwest Center for Investigative Reporting and 

 alleges that Seresto flea and tick collars have harmed many of the dogs and cats that wear them as well as the owners who love them. The US Environmental Protection Agency (EPA), which regulates pesticide-containing products, has received 

 of dogs, cats, and people allegedly being harmed by the collars, including 1698 pet deaths and just under 1000 incidents involving people.

The active ingredients in Seresto—developed by Bayer Animal Health and now owned by Elanco—are the pesticides imidacloprid (10%) and flumethrin (4.5%). Imidacloprid is commonly used in US farming, whereas Seresto is the only product that contains flumethrin. The product is labeled to provide up to 8 months of protection for cats against fleas, flea larvae, and ticks and for dogs against fleas, flea larvae, ticks, sarcoptic mange, and chewing lice. 

It is unclear whether flumethrin or imidacloprid—or a combination of the 2 products—is responsible for these incidents. As of now, there is no established link between these harmful events and the active ingredients in Seresto.

, clinical signs in humans related to these incidents vary widely, with most involving skin rashes or lesions; numbness, tingling, or pain; and nasal, ocular, or throat irritation after placing the collar on the pet, after nuzzling with the pet, or after sleeping in bed with the pet. More serious events were also reported. In many cases, clinical signs improved after the collar was removed.

Except for erythema and hair loss below the collar—potential adverse effects acknowledged by Elanco spokesperson Keri McGrath—the signs of harm related to Seresto in dogs and cats are unclear. The reported pet deaths appear to have been sudden.

Elanco “takes the safety of our products very seriously and thoroughly investigates potential concerns related to their use,” McGrath says in an email to dvm360®. “Keep in mind that the existence of an adverse event report does not necessarily mean the product caused the problem,” she says. “Causality between the observed signs and the use of the product is evaluated on a case-by-case basis.”

The reported incident numbers are actually “just the tip of the iceberg,” according to Nathan Donley, PhD, a senior scientist at the Center for Biological Diversity and an expert on U.S. pesticide regulation who feels strongly that the EPA should warn the public about this issue. Not only must a connection be made between the pet’s or person’s illness and the collar, but affected individuals must know whom to contact about it. “Most of the time, people are not going to make the connection or they’re not going to take an hour or so out of the day and figure out how to call and spend time on hold,” he says.

"Since its initial approval in 2012, Seresto has protected more than 25 million US pets from fleas and ticks," McGrath says, adding that it is important for consumers to make sure they’re purchasing collars from an authorized retailer. "Regrettably, there are counterfeits out there."


The EPA memo notes that flumethrin incidents were first reviewed in 2016, at which time the agency said it would continue to monitor incident data. It also states that the number of flumethrin incidents have been increasing steadily over time.

The EPA did not comment about the safety of Seresto compared with other flea and tick collars, but an agency spokesperson did note that flumethrin and imidacloprid both remain eligible for continued registration and that it is important to follow label directions when applying the product. “Some pets, however, like some humans, are more sensitive than others,” the spokesperson said.

Karen McCormack, a retired EPA employee, told 

 that more incidents have been reported with Seresto than with any other pesticide pet product. “I think this is a significant problem that needs to be addressed sooner rather than later,” she says.

Seresto products generated revenue in excess of $300 million for Bayer in 2019, according to an annual company report. At this time, the EPA is in the final stages of re-approving both pesticides, according to McGrath. There is no timeline on the final decision.

Articles

The EPA has received 75,000 incident reports involving Seresto since the flea and tick collar was introduced nearly a decade ago.



Seresto collar linked to nearly 1700 pet deaths, EPA monitoring situation

Of the 15 veterinary practices that entered the 2021 dvm360

Hospital Design Competition, 5 earned awards for their beautiful and functional designs, including 2 overall winners and 3 merit award winners.

“We are honored to have had many submissions for our 2021 Hospital Design Contest given the year of uncertainty,” says Chief Veterinary Officer Adam Christman, DVM, MBA. “Our winners have truly shown innovation, creativity and ingenuity. We thank them for elevating the veterinary profession and wish them all the great success in their new hospitals.”

Here is a sneak peek at all 5 winning hospitals. Be sure to keep an eye out for feature articles and gorgeous color photographs on these award-winning designs in the coming months right here on dvm360.com and in 

magazine. And watch for our special Hospital Design Supplement coming with 

 magazine’s June 2021 issue for more tips, tricks and ideas from architects, interior designers, and builders that you can borrow to implement in your future projects.

VCA West Coast Specialty and Emergency Animal Hospital, Fountain Valley, CA

 Everett Skinner IV, Great Country Timer Frames

Fenton River Animal Hospital, Stafford Springs, CT

 Scott D. Morey, DVM, MS, and Heidi L. Morey, MS, DVM

Turning Stone Animal Hospital, Cibolo, Texas

 Randy Cottingham, DVM, and Amie Hooper, DVM

GoodVets Lee’s Summit, Lee’s Summit, Missouri

President of medical operations, medical director:

Top honors went to Fenton River Animal Hospital in Stafford Springs, Connecticut, and VCA West Coast Specialty and Emergency Animal Hospital in Fountain Valley, California.

dvm360 announces 2021 Hospital Design Competition winners

The University of Illinois College of Veterinary Medicine (UIC) recently announced a brand-new $500,000 scholarship to help tackle diversity issues within veterinary medicine.

The Hadley Diversifying Opportunity in Veterinary Education (DOVE) scholarship, provided by UIC professor Stephen Hadley, DVM, MS, and family, will be awarded to veterinary students from underrepresented populations and those committed to advancing diversity, equity, and inclusion (DEI) within the profession.

Stephen Hadley, DVM, MS. (Photo courtesy of University of Illinois)

“My family and I wanted to put care into action and start removing the systemic barriers that have been preventing access to the veterinary profession for decades. It is our common responsibility as the leaders to make a difference that will lead to greater equity and diversity within the profession,” says Hadley in a UIC 

Veterinary medicine is still considered one of the least diverse professions, but according to recent Association of American Veterinary Medical Colleges (AAVMC) data, the percentage of veterinary students from underrepresented backgrounds has

 gone from less than 5% in 1980 to about 21% in 2020

An overdue awakening: Addressing systemic racism in veterinary medicine

New nonprofit to tackle the lack of diversity in veterinary medicine

New commission aims to enhance diversity, equity, and inclusion

Episode 39: Breaking glass ceilings in veterinary medicine

Despite these numbers, there’s still work to be done, according to Sean C. Garrick, vice chancellor for 

 at the University of Illinois Urbana-Champaign. He’s hopeful that the scholarship will help to create lasting change.

“By increasing access to the world-class education and training at the University of Illinois College of Veterinary Medicine, the Hadley Family DOVE Scholarship will significantly transform the lives of our students and the field of veterinary medicine itself,” he says, in the release.

Yvette Johnson-Walker, DVM, PhD, a clinical instructor at the veterinary college agrees. “The Hadley Family DOVE Scholarship is a shining example of veterinarians taking the initiative to invest in the future of veterinary medicine by recognizing the value of having a diverse and inclusive profession,” she says in the release.

The Hadley family is also recognized for their long history of philanthropic support, establishing the 

Dr. Stephen P. and Mrs. Denyse L Hadley Christian Veterinary Mission Scholarship

 back in 2005, a scholarship designed to encourage veterinary students to serve people and communities in developing countries.

A seasoned veterinary professor and his family create a new scholarship to help increase representation of underrepresented populations in the profession and support students committed to advancing diversity, equity, and inclusion (DEI).

New scholarship to promote DEI efforts in veterinary medicine

Hypotension is one of the most common intraoperative complications seen in small animals under anesthesia. A variety of injectable and inhalant anesthetic drugs can cause varying degrees of hypotension triggered by numerous factors including heart rate, preload, afterload, contractility, and systemic vascular resistance. Hypotension can lead to decreased perfusion in vital organs (eg, liver, kidneys, heart), which leads to reduced oxygen delivery. Veterinary technicians working with patients under anesthesia need to understand how to measure blood pressure, the factors that lead to hypotension, and how to properly address hypotension in these patients.

Palpating pulses in the anesthetized patient is essential. However, simply palpating a pulse is not a strong indicator of adequate blood pressure. When you are feeling pulse pressure, you are thought to be sensing the difference between systole and diastole. However, when anesthetic agents are on board, especially agents that cause vasoconstriction, you may feel a decreased pulse pressure despite normal blood pressure readings. Therefore, merely feeling a pulse should not be used as a barometer of your patients’ blood pressure.

There are 3 ways to measure blood pressure in patients are under anesthesia.

Direct arterial blood pressure measurement involves arterial catheter placement and continuous readings via a pressure transducer. An appropriately sized catheter is inserted into an artery such as the dorsal pedal artery. Arterial cannulation of an artery can take a bit of skill because the tunica media in the arteries contains smooth muscle cells and elastic tissue, thicker than that in veins. Once a catheter is secured properly into an artery, this measurement is easier to perform than you might think (

. Basic setup for placement and monitoring of arterial blood pressure. From left to right: pressure bag for sodium chloride (NaCl), heparinized NaCl bag, heparin 1000 U/mL, fluid bag spike and transducer appropriate for your multiparameter monitor, appropriate-sized catheter, T set flushed with heparinized saline, extra heparinized saline flush, medical tape to secure catheter.

. Placement of catheter into the dorsal pedal artery.

. Direct arterial pressure waveform shown during a surgical procedure.

Critical patients undergoing surgery should be considered for this method, which is beneficial in the following scenarios:

Patients that are hypovolemic due to trauma or hemoabdomen

Patients with pre-existing cardiovascular disease (eg, severe dilated cardiomyopathy)

Patients undergoing procedures in which significant blood loss or large fluctuations in blood pressure are anticipated (eg, surgery in patients with pheochromocytoma)

Indirect methods of measuring blood pressure, such as Doppler ultrasonography and oscillometric measurement, are used more frequently in small animal practices than is direct arterial placement. Doppler ultrasonography blood pressure measurement (

) using a sphygmomanometer is preferred in cats and small dogs (< 10 kg [~22 lb]). Oscillometric measurement involves use of equipment that automatically inflates and deflates a cuff to determine blood pressure continuously. This is probably the easiest of all the blood pressure monitoring options.

. The noninvasive Doppler blood pressure method is a good way to monitor overall trends during anesthesia and treatment.

Some veterinary practices may be intimidated by the cost of equipment needed to measure blood pressure via direct arterial catheter placement. However, the equipment required to determine mean arterial pressure alone is inexpensive compared with equipment for indirect oscillometric measurement. In addition, arterial catheters can be used to collect samples for blood gas analysis, which can provide valuable information, especially in patients with respiratory compromise.

Regardless of which method you choose, keep in mind that a single reading is not used to determine treatment; instead, we look at trends in blood pressure readings. Also, remember that the placement of the cuff is important. The most consistent cuff location in small patients is mid-forelimb.

For the purpose of this article, I will apply a mean arterial pressure of under 60 mm Hg to determine hypotension. If using a Doppler method, I will apply any readings of under 100 mm Hg systolic arterial pressure to describe hypotension.

Once a hypotensive trend has been identified, the next step is to work with the veterinarian to determine a course of action for correction.

There are several ways to treat hypotension once the underlying cause has been identified. First, it is important to record each patient’s preoperative heart rate to establish an average (base) resting rate for that individual. If your patient is bradycardic and hypotensive because of a decrease in heart rate, consider an intraoperative intravenous dose of glycopyrrolate (0.01 mg/kg) until the heart rate returns to an acceptable range. On the other hand, if your patient is bradycardic and hypotensive because of administration of an α2-adrenergic receptor agonist (commonly called an α-agonist), such as dexmedetomidine, consider administering a reversal drug, such as atipamezole (0.10-0.30 mg/kg IM). If your patient is hypotensive due to the vasodilating effects of anesthetic inhalant agents, consider decreasing the dose of the agents.

Inhalant anesthetic agents can also cause a decrease in cardiac output and, when combined with vasodilation, may lead to decreased organ perfusion. Increased circulating volume can be achieved by administering boluses (5-10 mL/kg) of intravenous crystalloid fluids, which will help if hypotension is secondary to hypovolemia and peripheral vasoconstriction. In some patients, reducing anesthetic depth and administering an increased volume of crystalloid fluids is not enough to correct hypotension. In these cases, the addition of colloids or inotropic agents should be considered. Colloidal solutions can be either natural (eg, albumin) or synthetic (eg, dextran, hydroxyethyl starch). Patients that do not respond to these treatments will need intervention with drugs to improve systemic vascular resistance and contractility. These drugs act on α- and β-adrenergic receptors. Stimulation of these receptors can have varying effects at varying doses.

Of course, before starting any therapy, talk with your clinician to verify both the drug and the dose.

Dobutamine is a synthetic catecholamine that acts on α- and β-adrenergic receptors, stimulating cardiac contractility, cardiac output, and coronary blood flow. Low doses can cause an increase in cardiac output while simultaneously initiating a moderate increase in heart rate. The therapeutic dose ranges from 2 to 20 µg/kg/min.

Dopamine is a short-acting norepinephrine precursor with α- and β-agonist properties (ie, binds to α1-, α2-,and β2-receptors plus 2 dopamine receptors). The dosing schedule is important with this drug, as different doses can stimulate other receptors and thus trigger different effects. Medium doses (eg, 3-5 µg/kg/min) can stimulate β-adrenergic receptors that act as a positive inotrope and increase heart rate.

Higher doses (6 to 10 µg/kg/min) stimulate α-adrenergic receptors that cause an increase in systemic vascular resistance. Doses higher than 10 µg/kg/min can trigger tachycardia and increased afterload, leading to decreased cardiac output.

Ephedrine is a noncatecholamine sympathomimetic agonist that stimulates α- and β-adrenergic receptors. Another benefit of ephedrine is improved oxygen delivery to tissues via increased hemoglobin. Ephedrine can also be administered as a single-bolus intravenous injection of 0.10 mg/kg.

Norepinephrine acts on α- and β-receptors by increasing mean arterial pressure and peripheral vascular resistance. Coronary blood flow also increases. Norepinephrine may be beneficial in increasing mean arterial pressure in patients with sepsis or patients currently on β-blocking drugs such as atenolol.

 Often, norepinephrine infusions are started at 0.10 to 0.20 µg/kg/min and can be increased by increments of 0.10 to 0.20 µg/kg/min as needed. It is important to note that norepinephrine is not usually the first choice for hypotensive patients that are otherwise healthy. It is often used in the treatment of vasodilatory shock and commonly administered with an inotrope (such as dobutamine) if myocardial depression is suspected.

Mazzaferro E, Wagner A. Hypotension during anesthesia in dogs and cats: recognition, causes, and treatment. 

Wagner AE, Dunlop CI, Chapman PL. Effects of ephedrine on cardiovascular function and oxygen delivery in isoflurane-anesthetized dogs. 

Tasha McNerney, BS, CVT, VTS (anesthesia and analgesia), CVPP, is an author, lecturer, and administrator for Veterinary Anesthesia Nerds.

During anesthesia, trends in blood pressure must be monitored to develop a protocol and manage hypotension.


Measuring blood pressure and managing hypotension in the surgical patient

Caring for critically ill patients has its own set of unique challenges, according to Courtney Waxman, MS, CVT, RVT, VTS (ECC), an instructional technologist at Purdue University’s Veterinary Nursing Program. During a lecture at the 

 virtual conference last week, Waxman discussed patient care strategies and provided suggestions for managing professional and personal stressors technicians may encounter in small animal intensive care units and critical care services.

An important area of focus is on strategies to provide consistent, high-quality patient care in a setting that is often very busy, with critical patients whose care crosses over many shift changes. Waxman stressed the value of checklists and care bundles, which can prevent lapses in recall of important but perhaps less prominent details and provide a less labor-intensive way to capture all facets of a particular standard of care. Checklists and care bundles also create a culture of accountability, provide consistency, establish patient care standards, improve patient care quality, and reduce morbidity and mortality.

One example of a widely used checklist is Kirby’s Rule of 20, which is a suggested list of 20 parameters for daily assessment of critically ill patients. Similarly, care bundles can provide a standardized approach to patient care related to a particular disease or procedure to prevent common oversights. Examples include all treatments (major or minor) associated with urinary catheter care or ventilator care.

The value of care bundles is illustrated by 2 nationally recognized care bundles: the RECOVER Initiative, which is an evidence-based care bundle providing guidelines for veterinary cardiopulmonary resuscitation (CPR),

and the Surviving Sepsis Campaign, which is a human adult and pediatric care bundle to provide reduced morbidity and mortality for patients with sepsis.

Given the critical and often fragile nature of these patients, biosecurity practices are also of great importance as patients may be infectious or immunocompromised. Waxman directed the audience to the American Animal Hospital Association’s 2018 biosecurity consensus statement, which details protocols for those sites that need guidance.

 Necessary routine practices include wearing gloves for all patient care, changing gloves between patients, and frequent hand washing. Where appropriate, personal protective equipment may be required of the nursing staff or any visiting owners, and in some cases, owner visits may need to be minimized.

An additional area of importance is the transition between nursing shifts. Waxman presented some startling data from human medicine. In a study of nurses, information retention from verbal rounds was only 26%. This rate improved to approximately 31% to 58% when written notes were taken in addition to verbal rounds. However, where a preformatted rounding form was used, the retention rate jumped to 96% to 100%.

 It is worth noting that for patients undergoing long hospital stays, the loss of information during verbal rounds can be compounded over multiple shifts and multiple days, potentially translating to patient care mistakes or omissions. Waxman likened this to a real-life game of “telephone,” which may be amusing as a children’s game but is far from ideal in a critical care setting.

Another strategy to standardize rounds and improve information transfer is to overlap shifts to allow for a dedicated rounds time during each shift change. The amount of time needed should be estimated as 1 to 3 minutes per patient for rounds associated with each shift change, and 5 to 10 minutes per patient for more detailed daily rounds that involve the entire interdisciplinary care team. Rounds are most effective when conducted cage-side to better visualize the status of each patient while discussing the case details.

In addition to rounds, each technician should do a walkthrough at the start of their shift to familiarize themselves with cases and review patient orders and treatment sheets. Talk to the clinician on the case about the patient care plan for that day. When performing patient care, attend to the most critical patients first. Additional tasks that are not specific to an individual patient are to check fluid pump programming for each patient, verify alarm parameters for each monitoring device, check all intravenous catheters, and ensure at the beginning of each shift that the CPR area and resuscitation supplies are stocked and ready for emergency use.

In addition to medical strategies, Waxman addressed the important professional and personal stressors that exist in the critical care setting. These stressors are not necessarily unique to veterinary medicine or critical care, but are very common in the veterinary critical care setting. Burnout, compassion fatigue, decision fatigue, and imposter syndrome are the 4 types of emotional tolls that affect veterinary professionals working in these environments.

Although there are similarities across these 4 conditions, they are not alike. Burnout is a physical or mental collapse that results from overwork or stress in one’s work or personal environment. This is slightly different than compassion fatigue, which is a traumatic stress disorder that occurs in caregiving environments as a result of emotional challenges. Although symptoms may overlap, there are some differences, and the causes of burnout and compassion fatigue are different.

Decision fatigue is another condition that occurs in the critical care environment. After making decision after decision, eventually the quality of decisions can deteriorate over time as if the decision-maker’s ability is getting “worn out.” One strategy to offset this fatigue is to minimize decisions in situations that you are able to control, and to reduce the stress of decision-making.

Finally, imposter syndrome is characterized by feelings of inadequacy despite evidence of competence and success. Imposter syndrome is common in the veterinary community, affecting both veterinarians and technicians. Strategies to combat imposter syndrome include focusing on successes, focusing on the value provided by your work, and avoiding the tendency to compare yourself with others. Ultimately, although there are differences between the signs associated with these 4 emotional conditions, the underlying theme is to focus on physical, mental, and emotional elements self-care.

Rebecca A. Packer, DVM, MS, DACVIM (Neurology/Neurosurgery), is an associate professor at Colorado State University College of Veterinary Medicine and Biomedical Sciences in Fort Collins. She is active in clinical and didactic training of veterinary students and residents and has developed a comparative neuro-oncology research program at Colorado State University.

Fletcher DJ, Boller M, Brainard BM, et al. RECOVER evidence and knowledge gap analysis on veterinary CPR. Part 7: Clinical guidelines. 

 2012;22(S1):S102–S131 doi:10.1111/j.1476-4431.2012.00757.x

Levy, M.M., Evans, L.E. & Rhodes, A. The Surviving Sepsis Campaign Bundle: 2018 update. 

 44(6):925–928 (2018). doi:10.1007/s00134-018-5085-0

Stull JW, Bjorvik E, Bub J, Dvorak G, Petersen C, Troyer HL. 2018 AAHA Infection Control, Prevention, and Biosecurity Guidelines. 

. 2018;54(6):297-326. doi: 0.5326/JAAHA-MS-6903

Starmer AJ, Spector ND, Srivastava R. Changes in medical errors after implementation of a handoff program.

 2014;371:1803-1812. doi: 10.1056/NEJMsa1405556

Discover the strategies you need to develop standard protocols and best practices in critical care units, as well as important tools to maintain mental health while working in such a stressful and demanding environment.

ICU bootcamp

The American Association of Feline Practitioners has announced the publication of a digital 

 to help veterinary professionals diagnose and treat systemic arterial hypertension in cats. Sponsored by Boehringer Ingelheim, the toolkit emphasizes the importance of checking blood pressure routinely to aid in tracking trends and detecting hypertension in cats early.

“Assessing blood pressure in the feline species is an important part of feline preventive care, yet it is uncommon for practices to routinely perform this test,” says Kelly St. Denis, MSc, DVM, DABVP (Feline), chair of the task force that created the guidelines, in an association press release. “This toolkit provides a quick, go-to reference that will help veterinary professionals overcome the difficulties and obstacles associated with assessing blood pressure in cats.”

When cats have high blood pressure, a lack of accompanying clinical signs often makes diagnosis difficult. While the toolkit encourages using the information provided on all feline patients, cats aged 10 years and older are at higher risk for hypertension and should be monitored more frequently than younger cats.

The toolkit provides tips for successful blood pressure management, including cuff selection and placement, recommendations for taking blood pressure measurements, and the equipment and environment. Each page also has an associated printable PDF that you can use in your practice. A new Blood Pressure Assessment Form is available to download for recording results and other necessary information. Tabbed sections on clinical signs of hypertension, treatment, classifications, frequently asked questions, client resources, and more make the toolkit easy to navigate.

“With its user-friendly format, veterinary professionals can quickly learn how to perform a Cat-Friendly blood pressure assessment, how to interpret the numbers, and how to treat hypertensive cats,” says St. Denis.

This new digital resource will help veterinary professionals access and gather vital information quickly. 

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