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August 16, 2014
Implementing
High Quality, High Volume
Spay/Neuter:
Challenges & Solutions
Carolyn Brown, DVM Kathleen Makolinski, DVM
Spay/Neuter Operations Shelter Medicine Service
2
Who are you?
What type of spay/neuter program do
you work with?
Are you familiar with… The Association of Shelter Veterinarians
veterinary medical care guidelines for
spay neuter programs
(JAVMA 2008)
3
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
4
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.
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JAVMA (2008)
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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
Allow funding
agencies to
determine if
spay/neuter
programs provide
acceptable level of
animal care
Provide reference
for use by state
boards of
veterinary
medicine
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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
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The Association of Shelter Veterinarians
www.sheltervet.org
Task Forces and Committees
Veterinary Task Force to Advance Spay/Neuter
Medical Care Guidelines
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Four sections of
guidelines document
• Preoperative care
• Anesthesia
• Surgery
• Postoperative care
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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
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Preoperative Care
Every animal to be examined by veterinarian
• Helps establish vet/client/patient relationship
• Helps protect against certain liability issues
• Good medicine!
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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
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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
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Preoperative Care
Animal Housing
• Proper identification
• 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
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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
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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
17
Anesthesia
Needs to achieve
• Pain control
- Opioid
- Non-steroidal antiinflammatory
- Alpha2 agonist
- Local anesthetic
• Stress reduction
• Muscle relaxation
• Unconsciousness
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Anesthesia
Pain control
• Multimodal analgesia
• Preventative administration of analgesics
19
Anesthesia
Mask/Chamber Induction of Anesthesia
Refers to effecting general anesthesia
from consciousness through the
delivery of inhalant anesthetics
via mask or chamber
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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
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Anesthesia
Anesthesia supplementation via mask
• Should be minimized to avoid bronchial irritation &
environmental contamination
• If extensive, consider other options
- Intubation
- Better analgesia/sedation
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Anesthesia
Thermoregulation
• 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
23
Rice Sock
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Anesthesia
Fluid Therapy
• Consider fluids in patients predisposed to
hypothermia, hyperthermia, or dehydration
(pregnant, lactating, small, or ill patients)
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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
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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)
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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
28
Surgery
Permanent identification of animals
as spayed/neutered
Choose a consistent means of identifying
animals that have been neutered
TATTOOS
EAR TIPS FOR FERAL CATS
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Ear Tipped Cat
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Postoperative Care
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
32
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
33
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
34
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
35
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
36
Discuss
and Let’s
Hear
From You!
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What challenges have you faced
when striving to implement
recommendations or making
changes within your organization?
38
Discuss
and Let’s
Hear
From You!
39
How has your organization
overcome challenges and
implemented guidelines
or made changes within
organization?
40
Here’s what we have seen
in regard to how others have
implemented spay/neuter
guidelines…
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Preoperative Care
Standardized consent forms assist in collection of
information and can be combined with medical record
$0.16 per triplicate form
43
Physical Exams
44
45
Anesthesia
46
When considering a change in
anesthetic protocol…
47
When considering a change in
anesthetic protocol…
Change is… SCARY !!!
48
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
49
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
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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
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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
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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
• Combined IM to cats/puppies
• Combined IV to adult dogs
• Rarely supplement with isoflurane
• Antisedan to reverse pediatrics
Meloxicam • SubQ following spay/neuter
$4.34 $17.60
$6.72
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Anesthetic/Analgesic
Protocol
Cost for
30 Pound
Dog
Medetomidine (compounded)
Morphine
Ketamine
• Combined IM to dogs
Meloxicam • SubQ following spay/neuter
$1.32
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Surgery
Various surgical techniques
allow for safe and efficient
spay/neuter surgeries
Veterinary Seminars in Spay-Neuter Surgery:
Pediatrics
Obese Dog Spay
(Humane Alliance)
55
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?
56
Standard Operating Procedures
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Standard Operating
Procedures
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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
59
Training Opportunities
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Training Opportunities
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Guess What’s Coming Next?
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Guess What’s Coming Next?
Upcoming Revisions!!
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