American Association of Feline Practitioners Conference
September 26-29, 2013 – Dallas, Texas
Feline Dentistry, Pain Management, and Nutrition
Seminar & Social
The Role of Stress in Feline Medicine, Dr. Susan Little
1. The highly territorial nature of cats becomes a problem when the cat is removed from its home range (e.g., a trip to the veterinary clinic or a boarding facility) as any number of things may make the cat feel threatened. A common response of cats to stress is to hide – most cats would rather flee than fight. Indoor environments, including veterinary clinics, often neglect to provide enough hiding and perching areas for cats.
2. Undesirable physical effects of stress confound our clinical evaluation and treatment, and may prolong hospitalization. Changes include increased blood pressure (“white coat” hypertension), increased heart rate, cardiac murmurs (via catecholamine induced dynamic narrowing of the right ventricular outflow tract), and increased respiratory rate. In addition, stressed cats may have erratic responses to sedation and anesthesia. Certain physiologic changes in response to stress can complicate interpretation of laboratory data, such as decreased serum potassium concentrations and increased serum creatinine phosphokinase concentrations.
Supporting Senior Cats with Cancer, Dr. Susan Little
1. Cachexia appears to be more significant in cats compared with dogs. BCS is prognostic – normal weight or obese cats with cancer live longer than underweight cats. It is important to institute nutritional support early as it may improve both quality of life and response to treatment. Nutritional intervention should be implemented if the cat is eating less than 85% of RER, the cat is anorexic for 3 or more days, or the cat has lost 10% BW or more in a short period of time.
2. Cancer patients should undergo regular nutritional assessment that includes a detailed diet history (brand names, format (canned, dry, semi-moist), flavors, amount fed, frequency of feeding, supplements, etc.) The extent of voluntary food intake should also be assessed, as well as gastrointestinal signs associated with the disease or with therapy, assessment for pain, and assessment for food aversion.
When Good Bladders Go Bad: Feline Idiopathic Cystitis, Dr. Susan Little
1. Feline idiopathic cystitis (FIC) involves complex interaction between the central nervous system and the endocrine system. Cats with FIC have been described as “sensitive cats in a provocative or deficient environment.” These cats may be unusually sensitive to changes in their environment and diet.
2. Proper interpretation of urinalysis samples takes into account changes induced by collection method and other factors. It is important to evaluate urine samples within 60 minutes of collection. Storage for longer periods of time, especially with refrigeration, may cause in vitro formation of struvite or calcium oxalate crystals. In vitro formation of struvite crystals is especially a risk in stored urine samples from cats fed dry food diets.
De-frustrating Kitten Diarrhea, Dr. Susan Little
1. Antibiotics are often injudiciously administered to cats with diarrhea. Indiscriminate antibiotic usage can lead to alterations in the commensal intestinal microflora and exacerbation of diarrhea or development of antibiotic resistance.
2. Diagnosis of bacterial diarrhea is problematic because many agents are isolated from healthy cats as often as they are from cats with diarrhea. In fact, fecal enteric diagnostic panels are often used indiscriminately and the results are easy to misinterpret. Fecal cultures and toxin analysis should be reserved for specific circumstances, such as acute onset of bloody diarrhea, diarrhea outbreaks in multi-cat environments, or screening for enteropathogens when zoonotic disease is a concern.
Dentistry Track
Pandora Syndrome: It’s More than Just the Bladder, Dr. Dennis Chew
1. Offer environmental enrichment to all of your clients to improve the health and welfare of their cats, starting whenever possible at weaning. Doing this will help reduce the incidence and severity of stress-related (including upchucking, litter box dis-use, and “finicky” eating) behaviors, improve your ability to differentiate whether signs are due to stress or to structural disease, and keep enrichment skills high so they can be smoothly implemented whenever they are needed.
2. For cats with Pandora Syndrome, help the owners understand the situation from the cat’s point of view. Clients often misinterpret objectionable behaviors as “mean” or “spiteful” rather than as a result of fear. Helping the client change their perspective of the cat from one of anger and frustration to one of empathy will help them understand that while PS is a chronic recurring, relapsing syndrome, these cats usually can be very successfully managed, even if they cannot be cured.
Feline Gingivostomatitis: What We Know & How We Treat It, Dr. Cindy Charlier
1. The first step in evaluation of a cat with stomatitis is to perform a complete intraoral exam and full mouth radiographs on all patients with suspected gingivostomatitis. Extraction of all teeth with tooth resorption or periodontal disease is indicated.
2. Gingivostomatitis is most often a surgical disease, but there are some cases that are refractory to surgical treatment and require continued medical management.
3. Gingivostomatitis is most often a bilateral disease.
Skyrocket Your Feline Dental Practice, Dr. Jan Bellows
1. Everyone has a dental practice within their own practice.
2. A “dental eagle” needs to be appointed as dental team leader.
My Cat Can’t Close Its Mouth! How to Close the Case, Dr. Cindy Charlier
1. When evaluating a cat’s occlusion, the teeth should interdigitate normally, the midlines of the maxillae and mandibles should align and the right and left mandibular arcades should be at the same height.
2. With a unilateral rostrodorsal temporomandibular luxation the mandibles shift away from the side of the luxation.
3. Fractures in the caudal mandible result in ‘collapse’ of the mandible toward the side of the fracture and a shifting of the mandibles toward the side of the fracture.
4. Periodontal disease affecting the maxillary canine tooth can lead to a cat not being able to close its mouth due to mesial and palatal deviation of the maxillary canine tooth causing occlusal interference with the mandibular canine tooth.
Solid Dental Concepts to Guide Your Feline Dental Practice, Dr. Jan Bellows
1. If a dental abnormality is functional, it does not need to be treated.
2. Q-tip dipped in tuna juice rubbed at the gingival margin twice daily helps to control plaque induced gingivitis.
Oral Tumors: Diagnosis & Treatment, Dr. Cindy Charlier
1. Radiographs alone cannot differentiate between osteomyelitis and squamous cell carcinoma. An incisional biopsy is necessary.
2. Pre-extraction radiographs should always be obtained to rule out neoplasia as a cause for mobile teeth.
3. It is important to keep in mind the less common malignant oral tumors, odontogenic tumors, and non-neoplastic proliferative oral lesions in the differential diagnosis list for oral masses as they are often clinically indistinguishable from common malignant oral tumors.
Red Gums: It’s Not All Stomatitis, Dr. Jan Bellows
1. Not all oropharyngeal inflammation should be termed stomatitis.
2. Extraction of adjacent teeth to the areas of inflammation is usually curative.
Interpreting Intraoral Radiographs, Dr. Jan Bellows
1. Do not attempt crown amputation and gingival closure without intraoral films.
2. Type two tooth resorption can be treated with crown amputation and gingival closure.
Review of Skull & Tooth Anatomy, Dr. Cindy Charlier
1. Fractures of cat canine teeth often require treatment because the most coronal extent of the pulp chamber is in close proximity to the enamel of the tooth.
2. Radiographs of a 10 year old cat canine tooth with a wide pulp cavity indicates cessation of the production of secondary dentin occurred early in the cat’s life and the tooth is non-vital and requires treatment.
Feline Tooth Resorption, Dr. Jan Bellows
1. Greater than half of cats older than three years old have tooth resorption.
2. Radiographically tooth resorption should be classified by stage and type.
Diagnostic Full Mouth Dental Radiographs: How Do I Do That?, Dr. Cindy Charlier
1. Veterinarians cannot properly diagnose and treat oral disease without dental radiography.
2. Full mouth radiographs should be obtained for all cats.
3. A properly trained staff member should be able to obtain diagnostic full mouth radiographs in 10 minutes or less.
Feline Dental Brain Teasers, Dr. Jan Bellows
1. Extraction is the treatment of choice to treat moderate to marked oropharyngeal inflammation in cats.
2. Crown reduction and gingival closure may be used to treat type two tooth resorption.
Oral Surgery to Extract Teeth: Tips & Techniques to Avoid Complications, Dr. Cindy Charlier
1. Pre- and post-extraction radiographs should ALWAYS be obtained.
2. Oral surgery to extract teeth requires the use of a mucogingival flap, removal of the buccal bone and sectioning the teeth. Sectioning teeth allows for proper placement of the dental elevator into the periodontal ligament space.
3. Sharp, properly maintained instruments in an oral surgery pack should be utilized for successful surgery.
Pain Management Track
Building an Acute Pain Management Pyramid, Dr. Robin Downing
1. Our moral imperative is to advocate on behalf of beings who cannot advocate for themselves. When facing acute pain, whether surgical or traumatic, it is useful to think of “building a pyramid,” adding layers that compliment what has been put in place before.
2. General anaesthesia does NOT mitigate the pain experience, it merely prevents the conscious experience of it. It is critical that we take advantage of every target in the nervous system that will allow us either to block or modulate pain signals.
Pediatric Anesthesia & Analgesia: Why Kittens are Different, Dr. Sheilah Roberston
1. Hypothermia is the commonest cause of bradycardia and delayed recovery from anesthesia in kittens.
2. Early life pain experiences have long lasting effects and all kittens undergoing surgery or painful diagnostic procedures must receive analgesic agents.
Building a Chronic Pain Management Pyramid, Dr. Robin Downing
1. Begin managing all chronic pain cases with as thorough and complete a diagnosis as possible. Treat the treatable, and treat all the treatable. This will enhance the results you get when treating pain.
2. Obesity is the single most common preventable disease in cats. Obesity contributes to pain both mechanically and biochemically. You cannot effectively relieve pain without normalizing body condition.
Meouch! Assessing Acute Pain, Dr. Sheilah Roberston
1. Heart rate, blood pressure, and other physiologic variables alone are not good indicators of pain in cats.
2. Accurate assessment of acute pain depends on observing behavior, postures, and facial expressions.
Drug Infusions: Roller Coaster or Smooth Ride?, Dr. Sheilah Roberston
1. Constant rate infusions of drugs can prevent the ups and downs of intermittent boluses and when used for pain management they can be titrated to effect and reduce break through pain.
2. Mistakes in calculating dose rates and dilutions of drugs for infusion are very common. Standard operating procedures and a mechanism for checking calculations before administration must be in place to prevent accidents.
Chronic Pain & Cats: Understanding “The Gift That Keeps on Giving,” Dr. Robin Downing
1. Chronic pain involves anatomic and physiologic changes in the nervous system itself. Chronic pain is maladaptive or maldynic, and requires aiming at multiple targets in order to get it under control.
2. Pain assessment remains the greatest challenge to managing painful cats. Until there is one “right” answer, the pain palpation for diagnosing fibromyalgia provides an excellent analogy/adaptation for use in veterinary medicine.
NSAIDS: Short & Long Term Use, Dr. Sheilah Roberston
1. There are no NSAIDs approved for long term use in the USA, however prolonged use of meloxicam in cats with degenerative joint disease has been successful based on several prospective and retrospective studies.
2. The key to avoiding adverse events with long term use of NSAIDs includes careful patient selection, monitoring, and client education.
Chronic Pain & Cats: Pharmacological & Non-pharmacological Pain Management Tools, Dr. Robin Downing
1. A multi-modal approach to chronic pain management in cats is the most effective strategy. This means utilizing both pharmacological and non-pharmacological means.
2. NSAIDs alone will not get the job done for chronically painful cats. Gabapentin has become the gold standard in my pain management referral practice for assisting cats to get out of the vicious cycle of chronic maladaptive pain; sedation is the dose-limiting step.
Comfort, Safety & Hygiene for Felines at the End of Life, Dr. Robin Downing
1. Palliative care and hospice medicine is a very new approach to end-of-life care in veterinary medicine. Palliative care involves improving quality of life by preventing and relieving suffering without treating for a cure.
2. Managing feline patients approaching the end of their lives means balancing techniques, procedures, and medications. It is critical to provide families with a way to measure their beloved cat’s quality of life. Dr. Alice Villalobos’ Quality of Life Scale allows for objective measurements of a very subjective experience, the ending of a life.
Palliative Care & Hospice for Cats, Dr. Robin Downing
1. Hospice for pets was first described by Dr. Eric Clough in the 1980’s. Dr. Alice Villalobos, oncologist, who created the Quality of Life Scale for pets, calls this “pawspice”. This activity is focused on providing a dying pet with the most reasonable and acceptable quality of life as death approaches.
2. Palliative care and hospice for pets is not a substitute for humane euthanasia. Rather it is work to be done in the “gap” between withdrawing care to cure and the time for death.
Nutrition Track
Feeding Cats: Healthy Nutrition from Kittenhood to Geri’s – Part One, Dr. Deb Zoran
1. Cats learn what is food during kittenhood, and only maintain food flexibility if different foods are fed throughout their life (e.g. canned and dry, flavors, textures, home-cooked food). Food flexibility is especially important for cats later in life who may require alternative or therapeutic foods.
2. The protein needs of cats required to maintain lean body mass are much higher than the requirements published by the NRC for protein in commercial diets (5.2 g/kg/day vs. 1.5 g/kg/day, respectively). This difference is because cats use protein for production of glucose for energy continuously – and when fed diets containing less than 5.2 g/kg/day (approximately 36% protein by ME) they will use their own muscle mass to make up the difference. Over time this leads to reduced metabolic rate, reduced insulin sensitivity, reduced muscle mass to support normal skeletal mass, and other changes in metabolism linked to loss of muscle.
Feeding Cats: Healthy Nutrition from Kittenhood to Geri’s – Part Two, Dr. Deb Zoran
1. Some development of sarcopenia is a normal consequence of aging, but excessive loss of muscle due to sarcopenia is detrimental to health, as muscles are infiltrated with fat and a permanent loss of mass and function result. Muscle can only be maintained with appropriate amounts of protein in the diet, and consistent exercise (healthy cats remain active throughout life).
2. Aging felines start to lose the ability to digest protein and fat (including fat soluble vitamins, and protein dependent cobalamin) less efficiently as they reach their teens. This reduced ability to digest these nutrients can reach up to 25% – by age 15. This means, contrary to traditional thinking, older cats need more, and higher quality protein, not less. In fact, the only reason to significantly reduce the amount of protein in an older cat’s diet is significant renal azotemia.
Kitten Diarrhea: Diagnosis & Therapy with Special Focus on Diet Issues, Dr. Deb Zoran
1. Diarrhea in kittens is often due to relatively common, but not always easy to find parasites. It is very important to look for evidence of cryptosporidia, tritrichomonas, and other diseases of these young felines that may be hiding from normal fecal float/smear methods of detection.
2. Kitten diarrhea is frequently due to dietary intolerance or diet changes resulting in development of dysbiosis. Some of these kittens with the most long standing cases of diarrhea will require use of very highly digestible, high protein, no carb, homemade diets to regain their intestinal balance.
The Feline Pancreas: Understanding Pancreatitis & Insufficiency in the Cat, Dr. Deb Zoran
1. Feline pancreatitis is a common, but insidious, difficult to diagnose disease that has associations with both IBD and cholangitis in cats – but no proven cause. Therapy at this time remains symptomatic and supportive, with control of nausea and pain with maropitant being an important tool. And although cats can do quite well for long periods of time, the disease remains a diagnostic and treatment challenge in many cats.
2. Exocrine pancreatic insufficiency in cats has previously been unrecognized but now is believed to be an increasingly diagnosed complication of chronic pancreatitis. The most common clinical sign of EPI in cats is weight loss, with diarrhea only occurring late and only in 50% of cats. Concurrent loss of cobalamin absorption (either due to lack of instrinic factor or dysbiosis or both) is a frequent finding and can be quite severe in some cats. Life long replacement therapy with both enzymes and B12 is required.
The Long Term Diabetic: Managing the Ups & Downs, Dr. Deb Zoran
1. Management of diabetic cats that do not go into remission can be complicated by multiple other conditions of older cats. Thus, it is extremely important to carefully evaluate the cat physically and biochemically to develop a plan that tries to balance the (often competing) problems. For example, many diabetic cats develop kidney failure thus making it challenging to continue high protein, low carbohydrate diets or to maintain hydration. The key is trying to balance the most important issues for life support while maintaining life quality.
2. Diabetic management in the brittle diabetic cat requires careful consideration and assessment of other concurrent diseases that make diabetic management difficult: hyperthyroidism, hyperadrenocorticism, acromegaly, chronic pancreatitis, or diseases such as IBD requiring immunosuppressive therapy. These diseases should be carefully ruled out in any poorly regulated diabetic cat for whom proper insulin therapy and home monitoring has failed to control.
Feline Colon Diseases: Understanding the Role of Diet & Drugs in the Management of Colitis & Constipation, Dr. Deb Zoran
1. Diseases of the feline colon causing signs of colitis are relatively few in number, but can be challenging to diagnose or treat due to the limited ways of evaluating the colon functionally or via imaging. Colitis in cats is rarely due to the same bacterial diseases found in other species with stress related dysbiois, but nevertheless, reduction of inflammation and control of bacterial disruption via antibiotics or diet remain mainstays of therapy.
2. Chronic constipation is a common and often recurrent problem in indoor, obese and sedentary cats. One of the most important causes of this increased tendency to stool dryness and difficult evacuation is consumption of dry, insoluble fiber enhanced diets in cats who are marginally dehydrated (diet or other causes) and who are sedentary or obese or both – both of which reduce normal defecation function. Increasing the amount of water in the diet (physically and by feeding high protein) can greatly reduce the number and severity of constipation events in these cats. Further, use of diets containing mixed fiber (soluble and insoluble fiber) would be preferable as soluble fiber increases stool water and softness.
Para-Professional Track
Developing the Nursing Care Plan, Mr. Harold Davis
1. It is helpful to have an understanding of the pathophysiological changes that occur with commonly seen diseases, and knowledge of actions of drugs helps you anticipate potential problems. To develop the care plans you follow the sequence of the nursing process components in the order that they occur (assessment, technician conclusions, planning, implementation, and evaluation).
2. The ability to prioritize and to select appropriate interventions should follow naturally from the identification of the technician conclusions (evaluations). Part of the planning process includes consideration of general nursing care procedures. It is helpful to have a checklist of daily nursing care tasks.
Critical Care Nursing Techniques, Mr. Harold Davis
1. The veterinary technician must be knowledgeable in the concepts of nursing care. Technicians should be aware of the indications for the technique, equipment needed, how the technique is performed, potential complications or risk factors, and post procedure nursing care associated with the technique or procedure.
2. As a part of nursing care, technicians should constantly evaluate the patient’s condition. The technician should ask him or herself if risk factors are turning into complications. It is better to be proactive rather than reactive to potential complications.
The Ins and Outs of Fluid Therapy, Mr. Harold Davis
1. The basic components of a fluid therapy plan include the determination, calculation, and replacement of the volume deficit (percent dehydration); abnormal on going losses; and maintenance needs.
2. To determine the volume replacement, multiply the percent of dehydration by the patient’s body weight, this will equal the amount of fluids in liters estimated to correct dehydration.
3. Losses through vomiting, diarrhea, excessive, and urination are considered to be abnormal ongoing losses. These losses should be included in the fluid therapy plan. Typically, abnormal losses should be replaced mL for mL.
4. Normal losses occur through breathing, salivation, urination, and defecation. To address these losses, maintenance needs is included in the fluid plan. A rough rule of thumb for the administration of maintenance fluids is to give 50 75 mL/kg per day or using the formula 80 x BW (kg)0.75.
An Update on Cardiopulmonary Resuscitation, Mr. Harold Davis
1. Early recognition, intervention, and effective technique will increase the chances of success in CPR. It is imperative to perform effective basic cardiac life support. Basic cardiac life support entails the establishment of an Airway, breathing for the patient and performing chest compressions.
2. Once it has been recognized that a CPA has taken place, an airway is established by inserting an endotracheal tube.
3. If there is absence of effective ventilation, then positive pressure ventilation should begin with 100% oxygen. The ventilatory rate is one breath every six seconds (10 breaths / min) with a tidal volume of 10 ml/kg and an inspiratory time of 1 second. Chest compression can be instituted without waiting to intubate the patient.
4. Chest compressions are performed with the patient in lateral recumbency unless it has a barrel chest confirmation in which case the patient is placed in dorsal recumbency and the sternum is compressed. We should apply pressure laterally, directly over the heart and compress the chest 1/3 – ½ its width, at a rate of 100 to 120 compressions per minute. In the case of medium to large patients, the hands are placed over the widest portion of the chest and compressions are performed. Allow the chest to recoil completely between compressions, approximately equal compression and relaxation modes. It is not necessary to try and synchronize breaths between compressions. The person delegated to compress the chest should change every 2 minutes to prevent fatigue. Minimize interruptions to chest compressions; make interruptions no longer than 10 seconds.
Meeting the Needs of the Pet Cat, Dr. Ilona Rodan
1. Cats are often considered “low maintenance” pets, but they have multiple needs to prevent boredom, stress, and even illness. By meeting their feeding, territorial, and social needs, we can prevent health and behavioral problems, preventing suffering, surrender, or euthanasia.
2. Fortunately, most of the problems can be prevented or addressed by understanding cats and their needs. Although many people consider cats to be their family members, even of the status of significant other or child, we must continue to allow cats to be cats to prevent a variety of health and behavioral issues.
Recognizing & Preventing Pain in the Practice & at Home, Dr. Ilona Rodan
1. Technicians are the mainstay to preventing pain and providing a comfortable environment and handling for hospitalized patients. They are also essential in client education about environmental changes to allow the painful cats at home, especially arthritic cats, to have the best quality of life.
2. Follow-up communication by technicians also helps keep the bond between clients and the practice strong, and ensures that the patient receives what is needed.