Patient Safety is Not Optional

Initial Broadcast: Thursday 25 March (Stream 1 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

How safe are your patients, and how do you measure, monitor and manage such a vital area of clinical practice? This is your opportunity to audit yourself, and develop a systematic, team based approach to a safer practice,

Key Learning Objectives

• Learn the basics of clinical audit process
• Discover what are SEA’s and M&Ms
• Learn how to employ safety checklists in your practice to best effect
  

Lecture Summaries

Clinical audit: an important part of patient safety?

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Patient safety: where do we start? - Catherine Oxtoby (UK)

‘Do no harm’ is a fundamental principle for any caregiver – in both human and animal worlds. Human healthcare has long acknowledged and quantified the iatrogenic harm inflicted on patients through the errors and mistakes of caregivers. In the complex world of healthcare, 1 in 10 visits to hospital involve an error in the chain of care, and an estimated 400,000 people a year die as a result of doctors’ or nurses’ mistakes (De Vries et al. 2008). In contrast, there are no published studies of incident rates in the veterinary literature. We acknowledge that they happen, yet we have no measure of them - how often, how severe, the most common, the most expensive, the most preventable. If we are looking to start somewhere with ensuring and improving patient safety, knowing the current situation would be the most logical place to start.

Clinical audit: where do we start and why? - Pam Mosedale (UK)

Patient safety is the priority for everyone in veterinary practice, but what has Clinical audit got to do with this? Well quite a lot actually. Clinical Audit provides the tools to look at results of procedures and put preventative methods in place, making veterinary procedures safer.

Collecting the data is only a small part of audit. Discussing the results with the team who are involved in the work on the ground, what could be changed, what prevents current systems working as they should be, is a very important part of the audit process. Once the team is on board and changes have been made re-audit is vital to see if the changes have had any impact. Implementing small changes that do make a difference can have a big impact on patient safety. T

his session will introduce delegates to Clinical Audit and the free learning materials, case examples, and the tools that have been created specifically for veterinary teams to put into practice straight away.

What are SEAs and M&Ms?

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SEAs: introduction and overview - Pam Mosedale (UK)

Accidents happen. Things do go wrong sometimes. Lab samples go astray. Animals escape during car park consults. These types of events can have a lasting effect both for the patients, their owners and for the team too. Sometimes the cause of these events might seem obvious at first, but when you study the event using a formal approach known as significant event auditing, you can find the root causes. This is used in human primary care and goes beyond the clinical, looking at anything that is significant to caring for patients or running the practice. Looking at these events is a great way to involve the whole practice team to learn from strengths and weaknesses in patient safety, animal and client care, then to make changes if required. The most important part of an Significant Event Audit ( SEA) is that team members understand that SEAs are about addressing systems, not about blaming individuals. They can help ensure negative outcomes do not recur & positive outcomes do! This session will introduce delegates to significant event auditing, including top tips, do’s and don’ts and free resources.

M&Ms: introduction and overview -  Helen Silver (UK)

It is a fact of life that we all make mistakes, but it is how we learn from our mistakes that truly matters. By talking about adverse events, we can prevent others making the same error again and therefore improve patient care.

Morbidity and Mortality rounds (M&M’s), (also known as MMC’s- Morbidity and Mortality conferences or reviews) have been taking place in human healthcare for over a century. Their use is mandated by the Accreditation Council of Graduate Medical Education and in veterinary medicine they now form part of the Royal College of Veterinary Surgeons Practice Standards Scheme.

M&M’s provide an open, non-judgemental, confidential, and collaborative setting for the review of adverse events. Through identification and presentation of a case where an adverse event has occurred, multidisciplinary reflective discussion, analysis, and identification of contributory factors provide a powerful tool to educate staff and improve patient safety and care.

By implementing an organised and structured approach based on a recognised M&M model with clear guidelines for staff, M&M’s can be scheduled regularly, enabling cases to be discussed soon after presentation, to ensure similar adverse events are avoided in the future.

Are safety checklists your new best friend?

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The practice and vet perspective - Angela Rayner (UK)

There is increasing evidence within the veterinary profession that the use of a surgical safety checklist reduces post-operative complications. In this presentation, we will present the science behind why checklists work and how they can help improve our performance by promoting teamwork and communication and increasing situational awareness. We will also give tips on implementing checklists in your practice.

The vet nurse perspective - Helen Silver (UK)

Everyone knows that horrible sinking feeling when they realise that they have made a mistake but to err is human, so how can we prevent error and keep our patients safe? In 1999, Atul Gawande suggested that at least 50% of surgical complications in people could be avoided by improving perioperative routines. The launch of the World Health Organisation (WHO) Safe Surgery Saves Lives campaign and the publication of the WHO Surgical Safety Checklist (SSC) in 2008, inspired veterinary hospitals to modify the WHO SSC for use with their surgical patients.

Studies on the success of the World Health Organisation Surgical Safety Checklist reported:

• 47% reduction in deaths
• 36% reduction in post-operative complications
• 48% reduction in infections

Checklists have also been found to improve communication and teamwork in the operating theatre. Checklists are quick to perform, cheap, easily modified to suit the intended clinical environment and straightforward to implement. The checklist is completed in three stages; sign in (before induction), time out (before skin incision) and sign out (before recovery). By performing each of these stages at the correct time errors which may occur due to slips, lapses, cognitive overload, and distraction can be avoided.

Supplementary On Demand Content

Webinar    Best practice for infection control: COVID-19 and beyond - Tim Nuttall (UK)

Sponsored by

Webinar    VetSafe: what is it and how do I use it?  - Catherine Oxtoby (UK)

Sponsored by

Webinar    Tackling post-op complications, including checklists and auditing - Helen Silver (UK)

Additional BSAVA Resources

Dermatology

Initial Broadcast: Thursday 25 March (Stream 2 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

This module will provide live discussions between experts on areas that cause primary care practice headaches – the alopecic small furry, the atopic dog and psychogenic alopecia. Each session will feature a live discussion forum between 2 experts, hosted by Sue Paterson. Alongside the live presentations will be pre-recorded content and resource for your practice to use to improve case management. Inflammatory skin disease in cats, alopecia in rabbits and what to do with non-pruritic alopecia when then endocrine skin tests come back normal.

Key Learning Objectives

• Describe the current approaches to treatment of canine atopic dermatitis to the rest of the practice team then be able to apply the right treatment options (in terms of their speed of onset and spectrum of activity) to induce and maintain remission in each atopic dog
• Discover if dermatologists or behaviourists think that there has been an increase in stress induced alopecia during the pandemic and how to recognise such cases
• Improve how you deal with alopecia in small mammals in practice
  

Lecture Summaries

Treatment of canine atopic dermatitis in 2021: what options, in what order?

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Options - Tim Nuttall (UK)

Atopic dermatitis is a very common condition that severely compromises quality of life for affected dogs and their owners. It is a lifelong disease that requires ongoing treatment to maintain remission and prevent flares. Atopic dermatitis is a complex disease that involves a poor skin barrier, abnormal skin inflammation, allergies (in most but not all dogs) to environmental and/or food allergens, and secondary skin and ear infections. It is important to identify the triggers for each dog and then use a multimodal treatment programme to address these. Treatment options include topical emollients, essential fatty acid (EFA) supplements or enriched diets, palmitoylethanolamide (PEA), allergen specific immunotherapy (ASIT), antihistamines, and anti-inflammatory medication. Anti-inflammatory treatments with good evidence of high efficacy include systemic and topical steroids, ciclosporin, oclacitinib and lokivetmab. It is essential that these treatment options are understood so that they can be used effectively in the management of canine atopic dermatitis.

Strategy - Ariane Neuber-Watts (UK)

Canine atopic dermatitis is a common skin disease in dogs. Affected patients and their owners can have severely reduced quality of life. Different treatment modalities need to be combined strategically for each patient to formulate a treatment plan that suits the given patient and carer. This may involve treatment of flare factors, symptomatic anti-pruritic therapy, immunotherapy and treatments to strengthen the skin barrier function. Optimal therapy depends on the patient, breed, temperament, body areas affected, severity of the skin disease, financial considerations and owner attitude and ability all come in the equation. Different scenarios are discussed in this presentation.

Has COVID caused stress related alopecias?

The dermatologist's view - Ariane Neuber-Watts (UK)

Stress is a physical, mental, or emotional factor that causes bodily or mental tension and can be internal or external. It is more than fair to say that covid has caused a great deal of stress for all of us. Has it also contributed to alopecia in our patients? This presentation will explore the causes of alopecia from a dermatological angle. It will discuss the potential of stress caused by covid and other situations to contribute to the development of alopecia. Specific emphasis will be put on the work up of the patient presented for hairloss. Some conditions for which stress is presumed to be a major factor in the pathogenesis, will be highlighted.

The behaviourist's view - Sarah Heath (UK)

The global pandemic has caused considerable disruption to the lives of most people, including pet caregivers. This presentation will consider whether this disruption has the potential to lead to emotional impact on the non-human animals in the household and whether any such impact could be relevant in relation to their dermatological health. The role of comprehensive history taking and clinical examination when considering the interplay between emotional, cognitive and physical health will be discussed. The presentation will consider clinical cases in which behavioural and dermatological factors are relevant and discuss the benefits of considering both of these when working up those challenging cases of alopecia. The behavioural medicine approach to that work up will be discussed.

How should I deal with alopecia in small furries in practice?

The dermatologist's view - Ariane Neuber-Watts (UK)

Small furries are less commonly seen in small animals practices than dogs and cat and individuals presented with alopecia may be slightly daunting to many small animal vets. Small furries are by no means small dogs, however, certain principles apply to all species. Alopecia is a common presentation in small furries and patients affected by it need to be worked up systematically- just like canine skin patients do. In house laboratory tests, such as cytology and skin scraping can be used in small furries, are quick ways to collect valuable diagnostic information and do not break the bank. Common alopecic conditions and the general approach to these cases are discussed.

The exotics practice view - John Chitty (UK)

Alopecic small mammals are a regular presentation in practice. As in dogs and cats they can be frustrating to investigate and this may be long, involved and expensive – in an older animal it may be difficult to resolve within the expected lifespan of that pet. Special difficulties are:

• Range of prognoses- in many cases, the likely treatments may be worse than the disease. In others, alopecia may reflect a major systemic disease (eg demodicosis secondary to internal neoplasia) or skin tumours, eg mycosis fungoides.
• Possible welfare issues- especially if pruritic.
• Possible zoonoses- especially dermatophytosis. This is important that many are in the care of immunonaive children.
• Lack of managed expectations- a survival time of 1-2 months in a mouse (usual lifespan approx. 18-24 months) for a managed mycosis fungoides case may be a clinical success, but will not be viewed as such unless the client is properly informed.
• Possible budgetary restrictions.

The latter factor does not always apply- in which case a thorough systemic and dermal investigation may be carried out. However, where it is a factor a more practical approach based on likely diagnoses should be undertaken, which will be the approach discussed in this talk.

Supplementary On Demand Content

Webinar    Approach to feline inflammatory skin disease  - Debbie Gow (UK)

Webinar    Alopecia: what to do when the endocrine skin tests are normal? - Tim Nuttall (UK)

Webinar    Alopecia in rabbits - Ariane Neuber-Watts (UK)

Additional BSAVA Resources

Diagnostic Imaging

Initial Broadcast: Thursday 25 March (Stream 3 | On Demand Stream)

Now available on the BSAVA Library

Module sponsored by

Module Summary

This module is focused on delivering interactive imaging experiences in respiratory and cardiac radiology and a case based approach to abdominal imaging with discussions between imagers and the clinicians that are using their reports.

It is underpinned by webinars directed at delegates who are already confident in the basics and wish to expand their experiences and skill sets to include imaging of adrenals, thoracic viscera (pleural and mediastinal) and the pancreas.

It is recommended that delegates view the content for this module via a laptop or desktop computer.

Key Learning Objectives

• Improve your interpretation of lower respiratory radiography through interactive cases
• Improve your interpretation of cardiac radiography through interactive cases
• Improve your interpretation of abdominal imaging through interactive cases

Lecture Summaries

Interactive lower respiratory radiography

Gawain Hammond (UK

Radiology is the most widely-available imaging modality use to assess the lower respiratory tract in veterinary practice (although CT (if available) will generally give the optimal visualisation of the pulmonary structures). Interpretation of pulmonary disease on radiographs can be challenging, and obtaining images of good diagnostic quality is critical (some apparent pulmonary pathology can easily be mimicked by underexposed radiographs) – a complete radiographic examination is also important as unilateral lesions can be missed if only one radiograph is obtained. When assessing pulmonary pathology, important factors to consider are the lung pattern(s) present and their distribution – these will significantly affect the priority given to the potential differential diagnoses. The most common lung changes seen are bronchial, alveolar and nodular patterns – genuine unstructured interstitial and abnormal vascular patterns are less frequently identified. For a bronchial pattern, the most common causes are incidental age-related mineralisation and chronic bronchitis. Alveolar change (classically seen as air bronchograms) can be due to pulmonary collapse or consolidation – when consolidation is distributed ventrally (and often asymmetrically), this is more suggestive of aspiration pneumonia or haemorrhage, while bilaterally symmetric peri-hilar and caudodorsal change would be more typical of pulmonary oedema. In the UK, nodular lesions are most commonly seen with neoplastic disease.

Interactive cardiac radiography

Kieran Borgeat (UK)

Do you worry that echocardiography has become the only method of imaging to evaluate cardiac patients? Unless you have managed to develop your echo skills, it would be easy to feel left behind. Even for vets with a particular imaging interest, echocardiography can be difficult to learn, even after undertaking practical CPD. Even the best echocardiographers cannot get as much information about the lungs and pulmonary vasculature as we can gain from reviewing a good chest radiograph. In this session, we will review how to get the most information about the heart that we can from thoracic radiographs in dogs and cats, and feature some top tips on how to differentiate cardiac from respiratory disease.

Interactive abdominal imaging

Bob O'Brien (USA) & Kenny Simpson (UK)

This session will be a fun, informative and interactive discussion of the clinical and imaging aspects of feline and canine pancreatic and hepatobiliary diseases.

Supplementary On Demand Content

Webinar    Thoracic radiology: it's not all about the lungs  - Gawain Hammond (UK)

Webinar    Imaging of the canine and feline adrenals  - Bob O'Brien (USA)

Webinar    Imaging of the canine and feline pancreas  - Bob O'Brien (USA)

Additional BSAVA Resources

Feline Medicine and Nursing

Initial Broadcast: Thursday 25 March (Stream 4 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

A diverse group of well-known UK veterinary and nursing speakers will lead discussions on how we can make our practices more cat friendly and then consider how we can practically deal with anaemia, chronic diarrhoea and recurrent cystitis in practice.

Pre-recorded resources available will include talks on feline IMHA, the causes of chronic diarrhoea and the investigation of behavioural factors underlying recurrent cystitis in cats.

Key Learning Objectives

• Make your practice more cat friendly
• Improve how you deal with anaemic cats
• Improve how you deal with chronic diarrhoea in cats

Lecture Summaries

How can we make our practices more cat friendly?

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How can we make our practices more cat friendly: the behavioral medicine approach - Sarah Heath (UK)

The cat friendly practice initiative has highlighted the importance of considering species specific factors when caring for veterinary patients. This presentation will consider the need to understand the emotional and cognitive health of patients during their veterinary practice experience as well as their physical health. The veterinary visit will be considered from a feline perspective and the concept of stress audits within veterinary practice will be discussed. The benefits of protective emotions such as pain, fear-anxiety and frustration will be considered as well as their potential detrimental impact and the importance of recognising these emotional states and their behavioural consequences will be discussed within the context of optimising patient welfare.

How can we make our practices more cat friendly: the clinicians viewpoint  -  Nicki Reed (UK)

For many years there was little regard paid to the specific needs of cats in small animal practice. However there have been huge advances in this area over the last 10 years or so, with many practices now starting to recognise the benefits of addressing feline needs separately from their canine counterparts. The behavioural needs of cats, which are fundamental to good feline practice, are covered in a separate talk. This talk aims to highlight some of the differences in medical management that may be required for cats, such as physical examination, drug administration and hospitalisation. Sometimes minor adjustments to working patterns can result in a much better experience for patients and clinicians alike, however this requires everyone in the practice to be working towards the same goals.

How should we deal with anaemic cats in our practice?  

How should we deal with anaemic cats in our practice: general approach: which tests to do and in what order? - Nicki Reed (UK)

The presence of anaemia may be harder to detect in cats compared to dogs, as their mucous membranes are typically slightly paler than those of dogs, and clinical signs such as exercise intolerance and weakness, may manifest as sleeping more in cats, and therefore may go unnoticed by the owner. As a result, cats may be more severely affected by the time investigations are undertaken. Clinical assessment of cardio-vascular stability is therefore important before proceeding to performing diagnostic testing. The minimum volume of blood should be obtained, but it is also important to think in advance what tests might be required to reduce the number of blood draws that have to be performed. For cats that are cardio-vascularly compromised, stabilisation may be required before full diagnostic investigations can be undertaken, whereas for mild to moderate anaemia the aim should be to identify the cause. The use of in-house automated haematology analysers has facilitated rapid diagnosis of the presence of anaemia, but the limitations of these machines must be borne in mind. Further in-house tests can increase the information given from the automated analyser, namely assessing PCV and total solids, blood smear evaluation and auto-agglutination, before submitting samples to external labs for further testing.

How should we deal with anaemic cats in our practice: blood transfusions - Elle Haskey (UK)

Currently there is no UK feline blood bank, so in-house feline blood donations are sometimes required as a life-saving therapy. This session will look at the requirements of a feline blood donor and how to make this a safe and stress-free procedure. The post-donation care of feline donors differs to canine donors, and this session will review the current recommendations of feline donor care. There are also a number of nursing considerations which RVNs should be able to add to the care plan of the recipient cat including pre, during and post transfusion.

How should we deal with cats with chronic diarrhoea in our practice?  

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The value and risks of GI biopsies in cats  -  Fergus Allerton (UK) 

Chronic diarrhoea in cats can be a thoroughly frustrating affliction for patients, owners and vets alike. What are the common underlying aetiologies? Do these change according to the age of the cat? Or the breed? Which extra-digestive causes should be considered? Can faecal analysis ever be useful? How can you get the most out of such samples? Does abdominal imaging provide any helpful clues? If you’re going to collect gastrointestinal biopsies, does it matter which parts of the gastrointestinal tract you sample? Is endoscopy as good as surgical biopsy? Do therapeutic trials have a role to play in the diagnostic algorithm? This on-demand lecture will delve into some of the common (and not so common) causes of chronic diarrhoea in cats and try to answer at least a few of the questions listed above.

The value of diets in the management of Feline IBD -  Nicki Reed (UK)

Inflammatory bowel disease (IBD) has a complex aetiology in which dietary antigens play a role but are not the sole cause. Dietary management alone can be effective in resolving around 50% of cases of feline IBD, but in order to optimise response to this line of treatment, it is essential to have obtained a good dietary history.

Three types of diets are available for dietary trials

1. Highly digestible
2. Restricted ingredient
3. Hydrolysed

The dietary history should enable the clinician to identify a novel protein source to which the patient has not previously been exposed, as well as food preferences of the patient (e.g. wet v dry; fish v meat flavours). There are a huge number of commercial diets to choose from and many diets advertised as hypoallergenic contain multiple ingredients. Highly digestible diets are not the same as restricted ingredient diets, hence some diet trials can fail due to selection of an inappropriate diet. It is therefore important to understand the rationale behind performing a diet trial for IBD and be able to advise clients on what are appropriate diets to use.

Supplementary On Demand Content

Webinar    Causes of chronic diarrhoea in cats and their investigation -  Fergus Allerton (UK)

Webinar    Investigation and management of behavioural factors in recurrent feline cystitis - Sarah Heath (UK)

Webinar    Feline IMHA - Nicki Reed (UK)

Additional BSAVA Resources

Anaesthesia

Initial Broadcast: Thursday 25 March (Stream 1 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

How to improve the anaesthesia in your practice and provide the best patient care throughout the anaesthetic. This stream will cover easy to do local anaesthetic techniques, how to manage some common anaesthetic complications and a discussion on the best sedation protocols. There are pre-recorded webinars to look at anaesthesia in more depth and CPR protocols.

Key Learning Objectives

• Explain how to do nerve blocks to help your patients during surgery
• Demonstrate the role of capnography in identifying problems and also outline the options for managing hypotension when just IV fluids don’t work
• Identify common anaesthetic complications and improve your solutions
• Check and where necessary update your practice’s sedative protocols both in terms of agents chosen and monitoring techniques

Lecture Summaries

Nerve blocks made easy

Caudal epidurals for blocked cats - Andrew Bell (UK)

Management of cats with urethral blockage can be challenging. Affected animals may have significant acid-base and electrolyte abnormalities and are invariably painful. Caudal epidural administration of local anaesthetics is an underused yet simple and highly effective procedure which not only provides excellent analgesia to these cases, but also facilitates sedation/anaesthesia and urethral catheterisation. This session will describe the practical technique and indications for caudal epidural anaesthesia alongside discussing current evidence supporting its use.

Dental nerve blocks - Daniel Pang (USA)

Dental nerve blocks are a relatively simple means to provide good analgesia and a stable anaesthetic. As many patients anaesthetised for dental procedures may be geriatric, with co-existing disease and reduced organ function, use of dental nerve blocks can promote a smooth peri-operative period. This session will describe the more commonly performed dental nerve blocks, with a review of drug pharmacology and reasons for block failure.

Identifying anaesthetic problems

How capnography can help you identify problems with your patient - Andrew Bell (UK)

Capnography is arguably the most reliable and least error prone anaesthetic monitoring modality available, and it can contribute significantly to patient safety. Capnography relies on the measurement of inspired and expired carbon dioxide and primarily gives information about respiratory adequacy. Distinctive capnograph trace patterns can also alert the user to breathing system faults, endotracheal tube problems and acute lung pathology. Additionally, capnography is recommended to prognosticate and judge the effectiveness of chest compressions during CPR. In this session, we will discuss an approach to using and interpreting the capnograph to diagnose problems under anaesthesia.

What options you have in managing hypotension under anaesthesia if fluids don’t work - Daniel Pang (USA)

This session will present an update on recent advances and controversies in managing hypotension during general anaesthesia. Hypotension is one of the most common adverse effects of general anaesthesia. Options for managing anaesthetic-induced hypotension include: 1. reducing the inhaled anaesthetic requirement: this can be achieved directly or indirectly (eg. by providing analgesia). 2. fluid administration: the efficacy and duration of crystalloid fluid boluses are limited but a number of tools are available to identify patients that will benefit from a fluid bolus (eg. pulse pressure variation) 3. vasoactive agents (eg. dexmedetomidine, dopamine, ephedrine): there are pros and cons to the different agents available. These options and practical approaches will be discussed.

Common anaesthetic complications

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Is it cold in here? Hypothermia under anaesthesia - Michelle Moran (UK)

Hypothermia is one of the most common complications that occur during anaesthesia. During the session we will explore:

• Why hypothermia occurs
• Why do we need to worry about hypothermia – what are the negative effects?
• Prevention is better than cure! Heat loss is more likely to occur during certain periods during the patients anaesthetic journey. When are these and what are the most suitable strategies to combat this heat loss during these different periods?
• The evidence behind some patient warming modalities.
• The importance of safety and the prevention of patient harm from warming devices. What strategies can be used to prevent these events?
• What techniques are available to monitor temperature?

The aim of this session will be to provide practical hints and tips that can be translated into day to day clinical practice.

Get the suction! Regurgitation under anaesthesia - Carl Bradbrook (UK)

Why do patients regurgitate during anaesthesia? How do we recognise that a patient has regurgitated? And what should we do when it happens? In this session we will review reflux and regurgitation during anaesthesia in dogs and cats, exploring the literature to enable us to best focus our management of this situation.

Reflux and regurgitation are common anaesthetic complications, requiring recognition and treatment to reduce the risk of unwanted sequelae. The number of cases of sequelae reported is low, but the development of an oesophageal or nasopharyngeal stricture, or oesophagitis can prolong hospitalisation and increase patient morbidity. What is the best approach to managing this complication- is suctioning the oesophagus alone enough, or should we be flushing with water/saline and administering any medications? What signs can we look out for to warn us that a patient has regurgitated, when is it most likely to happen and are there any risk factors we should be aware of? Finally, we will explore whether any preventative or prophylactic measures can be helpful, and what, if any treatments to consider for at risk patients or for a particular procedure with an increased risk.

Sedation wars!

Safe and effective sedation - Carl Bradbrook (UK)

When is it ok to use sedation safely and not induce anaesthesia? Are there any circumstances where anaesthesia should be chosen? In this session we will review options for sedation, and explore factors, both with regard to the patient and the procedure that will enable best practice.

Most diagnostic and minor procedures require our patients to be sufficiently immobilised to allow for good patient safety and a successful procedure. In the healthy patient the use of sedation for most procedures will have little, if any impact on the animal. What about those more challenging cases- the aggressive or fearful cat, the geriatric patient with multiple comorbidities, or the cardiac case requiring a prolonged procedure. A question useful to ask is; can we safely give sufficient sedation to allow the procedure to be completed successfully and for the patient and veterinary team to be stress free? If the answer to this is yes, then sedation is most likely to be sufficient. What if it’s not? Finally, we will explore options for providing good sedation in a number of case examples, along with a few scenarios where anaesthesia

Monitoring for sedation - Vicky Ford-Fennah (UK)

The importance of monitoring of patients during sedation is often underestimated. During the session we will explore:

• Why is close monitoring of these patients is so important?
• The importance of an understanding of the agents used to sedate the patient and how these effect the monitoring picture.
• What should be monitored during sedation?
• How can we maximise patient safety?
• Tailoring your monitoring techniques for different patients – practical hints, tricks and tips!
• Techniques to maximise the effectiveness of monitoring devices. How to check they are accurate?
• When sedation goes wrong – the early warning signs that the patient may not be coping and what to do.
• The recovery period – the forgotten period!
  

Supplementary On Demand Content

Webinar    Best practice for CPR techniques for patients under anaesthesia  - Paul Macfarlane (UK)

Webinar    Local techniques for celiotomy: new local anaesthetic techniques for celiotomy  - Jaime Viscasillas (ES)

Webinar    Neutering: provide the best anaesthesia every time. How to provide the best care to patients - Ian Self (UK)

Webinar    Cats hurt too - feline analgesia: peri-operative analgesic techniques for cats - Claire Woolford (UK)

Additional BSAVA Resources

BSAVA Publications

BSAVA Manual of Canine and Feline Anaesthesia and Analgesia

BSAVA Guide to Pain Management in Small Animal Practice

BSAVA Cognitive Aids for Anaesthesia in Small Animal Practice

BSAVA Manual of Canine and Feline Dentistry and Oral Surgery

Companion Articles

Ask the expert: Anaesthesia and analgesia – your questions answered by Carl Bradbrook (June 2017) 

How to anaethetize the geriatric patient by Carl Bradbrook (April 2016) 

JSAP Articles

Factors affecting respiratory system compliance in anaesthetised mechanically ventilated healthy dogs: a retrospective study

The effect of induction with propofol or ketamine and diazepam on quality of anaesthetic recovery in dogs

Veterinary Evidence Resources

Does the Use of Intratesticular Blocks in Cats Undergoing Orchiectomies Serve as an Effective Adjunctive Analgesic?

Developments in surgical fluid therapy rates in veterinary medicine

In dogs undergoing anaesthesia do pre-anaesthetic gastroprotectants reduce gastro-oesophageal reflux?

Liver Disease

Initial Broadcast: Thursday 25 March (Stream 2 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Explore the current thinking in hot topics in liver disease, like mucocoeles, triaditis and liver biopsies, with world class specialists in this area discussing their approach to these cases. To round off the session there is an interactive session on dealing with apparently healthy dogs that have high liver enzymes.

Pre-recorded resources available will include a practical approach to jaundice in the cat and options for porto-systemic shunts.

Key Learning Objectives

• To be able to explain to owners the benefits of liver biopsy as well as the advantages and disadvantages of different biopsy methods so that owners can be appropriately encouraged to have biopsies. In addition be able to undertake liver biopsies more confidently
• Advise owners more confidently about the latest thinking on biliary mucocoeles
• Advise colleagues about current thinking of the concepts of feline triaditis and be able to take well-informed treatment decisions
• Gain confidence in interpreting cases with increased liver enzymes

Lecture Summaries

Why and how should we do more liver biopsies in practice?

Why should we do more? - Mike Willard (USA)

Many clinicians view the liver as a “black box” that is difficult to understand and which has diseases that are only treated with basic supportive therapy. Hence, they see no reason to do something invasive like a biopsy. Or, perhaps they have been “burned” in the past by doing a biopsy incorrectly or at the wrong time, resulting in therapeutic failure and an upset client (outcomes that they want to avoid ever experiencing again). In fact, a lot of chronic hepatic diseases can be cured or controlled if diagnosed in a timely fashion. However, the only way to definitively diagnose most chronic hepatic diseases is by histopathology. Furthermore, it is extremely rare that a properly performed hepatic biopsy results in morbidity or mortality.

How should we do more? - Penny Watson (UK)

Taking a liver biopsy is central to diagnosis and effective treatment in most canine and feline liver diseases. I explain to the owner that the results of the biopsy will help treat their animal more effectively and that treatments such as copper chelators or immunosuppressives cannot be used without histology. Owners usually want the least invasive option, but a poor, unrepresentative sample is worse than useless. It is important to explain to them the strengths and limitations of different techniques and the value of taking larger, representative wedge biopsies. Fine needle aspirates are only indicated for bile culture and cytology and to help diagnose lymphoma or hepatic lipidosis, but even then have to be viewed with caution. Ultrasound-guided trucut biopsies are often poorly representative of the disease as a whole and carry an increased risk of bleeding. I discuss the benefits of wedge biopsies in making a more reliable diagnosis, allowing more effective treatment. I am lucky to have access to laparoscopic biopsies which we made cost effective by matching the price of ultrasound-guided biopsies so that owners do not make a decision based on finances. Wedge biopsy at laparotomy is a good alternative but owners can be harder to persuade because it is more invasive.

What should we advise owners about mucocoeles: surgery, medicine or ignore?

What are the medical options for mucocoeles? - Mike Willard (USA)

First, one must identify those animals whose gall bladder mucocoeles are suitable for medical management because medical therapy of mature “kiwi fruit” mucocoeles may result in substantial morbidity and even mortality. After selecting the appropriate cases, one should next look for co-morbidities (especially endocrine) that are believed to increase the risk of mucocoele, and if found need to be treated. Finally, choleretics (especially high doses of ursodeoxycholic acid) are used to help liquify the gall bladder contents, must like a diet designed to dissolve uroliths.

When and how should we intervene surgically with mucocoeles?  - Chris Shales (UK)

Interactive cases with increased liver enzymes

Mike Willard (USA)

Sponsored by

This will be a case-analysis of several cases ranging from mild disease to severe disease to things that look like liver disease but aren’t and things that look like other disease but are liver disease.

What Is the current thinking on feline triaditis: does it even exist?

Penny Watson (UK)

The term ‘triaditis’ is used to refer to concurrent pancreatitis, cholangiohepatitis and inflammatory bowel disease (IBD) in cats. It was first reported in a case series in 1996 in which an association with nephritis was also found. The disease associations were controversial for many years, but more recent clinical, post mortem and imaging studies provide strong evidence for concurrent disease in two or three of the gut, pancreas and liver in a significant number of cats. The reason for these associations remain speculative. It is very likely that cats suffer from not one but several different biliary tract diseases, some of which may be associated with pancreatitis and/or IBD and some of which might not. The relative involvement of bacteria, immune-mediated disease or sphincter of Oddi dysfunction remain unclear, the optimal treatment is unknown and even studies on the long term follow up of cases are lacking. Many questions still remain and future studies hope to characterise the disease better including advanced imaging of the biliary tract and the role of feline autoantibodies. Ultimately, we need better understanding to allow more effective diagnosis and treatment of cats in the future.

Supplementary On Demand Content

Webinar    The value of a good hepatic biopsy  - Penny Watson (UK)

Webinar    A practical approach to jaundice in cats - Penny Watson (UK)

Webinar    Diagnosis of congenital portosystenic shunts: the textbooks are misleading  - Mike Willard (USA)

Webinar    Medical and surgical options for portosystemic shunts - Gerard McLauchlan (UK) & Chris Shales (UK)

Additional BSAVA Resources

Cardiology

Initial Broadcast: Thursday 25 March (Stream 3 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

In the past 30 years there have been huge strides in Veterinary Cardiology with the continuous development of new drugs and studies looking at best therapy. Alongside this are the key issues of how we manage asymptomatic patients with murmurs and the ethics of managing heart disease in pets as we develop new and advanced techniques for catheter and surgical intervention.

Key Learning Objectives

• Explain the latest developments in the role of apps and devices in the future of cardiology
• Identify a management pathway for the asymptomatic heart murmur
• Develop an improved understanding of what is involved in catheter inventions and cardiac surgery and when these should be considered
• Consider the ethics of treating congestive heart failure
  

Lecture Summaries

Health technology: the role of apps and devices in the future of cardiology (a personal perspective)

Marc Kraus (USA)

Telecardiology -Telehealth or telemedicine are already showing considerable growth in the human medical fields. Telehealth is associated with lower mortality and emergency admission rates on the human side, driven by the need to provide lower health care costs; but can also be important and integral in providing optimal care for patients. This technology can also be applied to our animal patients.

This lecture will focus on advanced technologies such as leadless pacemakers, micro-PDA occluders, smart phone ECGs, advanced mitral valve repair surgeries/devices and more.

The asymptomatic patient

I am hearing a heart murmur for the first time in an adult dog: what should I do? - Adrian Boswood

Incidentally discovered heart murmurs in adult dogs are common. Degenerative (myxomatous) mitral valve disease (DMVD) is by far the most common cause of acquired murmurs in dogs. Other possible causes would include dilated cardiomyopathy, bacterial endocarditis, previously undiscovered congenital heart disease and non-cardiac causes such as haemic murmurs and flow murmurs. In dogs with an appropriate signalment, a murmur with timing and location consistent with mitral regurgitation makes DMVD very likely. Factors that might make this less likely (or rule it out altogether) would include; the finding of a murmur that is audible continuously or in diastole, finding a murmur in a large breed dog or the presence of clinical signs indicative of significant systemic disease e.g. pallor or pyrexia. The single best diagnostic test to determine whether or not a murmur is caused by cardiac disease and to characterise the specific cause of a murmur is echocardiography. In some circumstances, echocardiography may not be possible due to cost or lack of access to appropriate equipment or expertise. In a patient suspected of having DMVD it is important to stage their disease as accurately as possible to ensure appropriate treatment can be instituted if appropriate.

I am hearing a heart murmur for the first time in an adult cat: what should I do? - Jose Novo Matos

Cardiomyopathies are the most common heart diseases in cats with hypertrophic cardiomyopathy (HCM) being the most prevalent form. HCM affects 15% of apparently healthy cats. Cardiac auscultation in cats is challenging as it lacks both sensitivity and specificity. Cardiomyopathies may not cause a heart murmur, thus some cats with clinically significant heart disease have a normal cardiac auscultation. Conversely, a murmur may be present in some cats with structurally normal hearts. Thus, absence/presence of murmurs may not always help in determining which cats have heart disease. However, the majority of cats with a murmur do have structural heart disease, especially older cats with loud (≥3/6) murmurs. In HCM, murmurs are commonly caused by dynamic LV outflow tract obstruction. Normal cats can have murmurs due to dynamic RV outflow tract obstruction (clinically benign). NT-proBNP is increased in cats with moderate-severe asymptomatic cardiomyopathy, thus it may be used as a first-line test to assess the likelihood of heart disease in a cat with a murmur. But echocardiography is required to confirm the presence of heart disease, and most importantly to assess for risk factors associated with increased risk of CHF and ATE (e.g. left atrial size). Systemic diseases that may cause a murmur should also be excluded, i.e. check blood pressure, haematocrit and T4 (cats >6 years).

Normal and HCM cats may have heart murmurs, but a loud murmur in a cat >6 years is more likely to be associated with HCM and further investigations are recommended. Early interventions in cardiomyopathic cats may reduce the risk of serious complications, thus early detection of occult cardiomyopathies is paramount.

Catheter intervention or surgery?

Cardiac interventions: when and how? - Tobi Wagner (UK)

This presentation will give an overview of cardiac conditions which can be treated or palliated via minimally invasive catheter techniques. The talk will give the audience insight and general understanding how minimally invasive treatment works. It will also demonstrate variations of common cardiac conditions to help with the understanding about limitations of catheter interventions.

Cardiac surgery: when and how? - Poppy Bristow (UK)

Cardiac surgery in veterinary medicine has been slow to progress compared to other fields. It was previously thought that small dogs would not tolerate cardiopulmonary bypass (CPB) which severely limited potential case numbers, due to myxomatous mitral valve disease (MMVD) being the most common cardiac condition in dogs, and being primarily a disease of small breeds. Surgeries were therefore limited to congenital cardiac diseases as these are more commonly present in larger breeds e.g. pulmonic stenosis and double chambered right ventricle, and closure of patent ductus arterious. With the advent of interventional cardiology these surgeries are performed with decreasing frequency, and we will discuss when surgery may be considered preferable to an intervention for certain types of cases suffering with these conditions.

In the past few years, mitral valve repair (MVR) surgery has been shown to be a highly successful management option for MMVD. For those centres performing cardiac surgery, MVR’s now comprise the vast majority of cases and there are currently no interventional options available for this condition in dogs. We will also touch on which cases make good candidates for this condition, success rates and the future for this disease management.

The ethics of managing heart disease in pets

Fully live panel session - James Yeates (UK), Tobi Wagner (UK) & Poppy Bristow (UK)

There are always going to be ethical questions and concerns when introducing new treatment modalities, and rightly so. As veterinarians we must always have animal welfare at the forefront of our decision making. Heart disease is a very common disease in dogs and can have a huge impact on quality of life, a subject that until recent years has been largely unresearched in veterinary patients. When considering any treatment option we must always consider its likely effect on quality of life; expected detrimental effects weighed up against potential improvements, in addition to quantity of life expected to be gained. This is particularly challenging in veterinary patients when assessment of quality of life and decision making has to be made by proxy. Maintaining a good health related quality of life (HrQOL) is just as important as survival to most humans in chronic heart failure (Lewis et al. 2001) and is also more important than quantity of life in owners of cats and dogs with cardiac disease (Oyama et al 2008, Reynolds et al. 2010). It is imperative that with any intervention, be they medical or surgical that owners are fully informed of potential risks and consequences, and presented with the most up to date and accurate information candidly.

Supplementary On Demand Content

Webinar Nursing the cardiac patient  - Ed Durham (USA)

Webinar For the whole team: we have an echo machine - what can we do with it?  - Jo Dukes McEwan (UK)

Webinar How do I take my basic heart scan further?  - Jo Dukes McEwan (UK)

Additional BSAVA Resources

BSAVA Publications

BSAVA Manual of Canine and Feline Cardiorespiratory Medicine

Companion Articles

Notes on...Holter recording by Kieran Borgeat (January 2019)

JSAP Articles

Reliability of smartphone-based radiographic interpretation for evaluating cardiogenic pulmonary oedema in dogs

The Surgical Team: Practice and Principles

Initial Broadcast: Thursday 25 March (Stream 4 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

This module is all about improving surgical outcomes. It starts with a refresher of the principles of surgery, and then goes on to investigate how scrubbed assistants can help; which leads into schedule 3 amendments.

Removal of small skin tumours - lumpectomies - are often performed sub optimally in practice: correct staging and planning of the surgery will be covered. For those lumpectomies that become wider resections, skin reconstruction techniques and tips are discussed. Then consideration is given to prevention of wound infections and best ways to improve sepsis in practice.

The last session of the module gives an introduction to joint surgery and arthroscopy - a must for anyone wanting to start out in this field!

Leaders in the field of soft tissue surgery will present pre recorded content on tissue handling skills and axial pedicle flaps. An additional pre recorded webinar will help nurses (and veterinary employers) to better utilise their expanding skills under the new Schedule 3 amendments.

Key Learning Objectives

• Demonstrate how, by using Halsted’s Principles and maximising the potential of a scrubbed-in assistant, the surgical team can improve surgical performance
• Define how to perform better and more difficult ‘lumpectomies’
• Identify the wide range of factors that increase the risk of iatrogenic wound infections
• Develop the procedures for performing joint surgery and arthroscopy within your practice

Lecture Summaries

Getting the best out of the surgical team

How can Halsted’s Principles help me improve my surgical skills -  Dick White (UK)

Conceived in the late 19th century, Halsted’s Principles are as relevant for us in our surgeries today as they were then. Their central axiom is all about promoting wound healing; this seminar outlines some simple guidelines for incorporating the kind of tissue sympathy in our surgical technique that favours optimal wound healing.

Maximising the use of a scrubbed assistant in surgery - Alison Young (UK)

A scrubbed assistant benefits everyone involved in a surgical procedure, including the patient. As nurses we have a key role and need to understand how to support the surgical team. Developing our skills under schedule 3 of the Veterinary Surgeons Act 1966, also helps with our career progression and job satisfaction. It must be remembered though that all surgical procedures, however minor, have associated risk to the patient. This means it is important that nurses are fully trained and competent at performing surgical skills and understand the legality and limitations within their professional remit.

Improving outcomes from lumpectomies

Lumpectomies made interesting -  Jolle Kirpensteijn

Veterinary surgeons love lumpectomies but each extent of oncologic surgery depends on the type and stage of the tumour. A pre-resection biopsy is often necessary to anticipate sufficient margins of resection and behaviour of the primary tumour. Staging the tumour will prevent treatment failures caused by early metastasis and will help in deciding the type of resection and use of adjuvant treatment modalities. Diagnosis of intercurrent diseases often will alter surgical treatment options and should be evaluated beforehand to assess the risk versus benefit of surgical intervention. The surgical field should be prepared carefully to allow changes in the extent of resection based on new information obtained during the operation.

The necessary surgical margins depend on the tumour type, grade, and the anatomical location of the tumour. The most rational approach is to think of biologic rather than geometric margins and to combine this information with the expected growth behaviour of the given tumour type. Tumours with a high probability of local recurrence (e.g. mast cell tumours, feline mammary tumours) should have 2 to 3 cm margins removed three-dimensionally. Collagen/matrix-rich and poorly vascularised tissues are least vulnerable to tumour invasion and may be used for margin determination. All previously performed biopsy tracts should be removed in continuity with the primary tumour to prevent tumour seeding. With a proper resection the tumour is never visualized.

Skin reconstruction techniques - Jonathan Bray (UK)

The reconstruction of wounds – either traumatic or those created following resection of tumours – provides an opportunity to bring skin edges into approximation. Dogs and cats have very adaptable skin, and a range of reconstructive procedures are described allowing sections of skin to be rotated, advanced and transposed to cover an adjacent defect. However, skin can be very unforgiving of inappropriate technique. As the complexity of a reconstructive surgery increases, the potential for disastrous outcome increases with either partial or complete failure of the skin flap. A successful outcome requires an understanding of blood supply, effective management of tension and a sound operative technique.

Ideally, a wound should be closed without tension. Excessive tension may lead to vascular compromise and delayed healing. At worst, this may result in catastrophic dehiscence of the wound. Less serious complications include increased post-operative discomfort (which may lead to self-aggravation of the wound by the patient) and more unsightly scar formation. If excessive effort is required to achieve wound closure (e.g. brute strength, excessive use of stents, heavy gauge suture), it would be preferable to consider an alternative approach to wound reconstruction that recruits additional skin into the defect.

A successful wound reconstruction will take account of skin tension. The surgeon should have an understanding of the methods used to ameliorate the effects of skin tension on wound healing. Many of these methods are straightforward, whilst others require some innovation and ingenuity. In this lecture, we will explore some of the many local flap and reconstructive options available in the dog and cat. Case examples will be used to illustrate issues of importance and how to manage any complications should they develop.

Iatrogenic wound infections

Surgical preps and autoclaves -  Georgie Hollis (UK)

Asepsis has failed. Where do we start tracking down the culprit?  - Alison Young (UK)

As nurses patient care is our number one priority and this comes in many forms. Cleanliness of the environment and patient preparation all have a huge part to play as well as ensuring good aseptic technique is followed. Aseptic technique means using practices and procedures to prevent contamination from pathogens. We all work hard to apply the strictest of rules to minimise this risk, but what happens when things are out of our control? How do we work out where the break in the chain was? Why is this important to know and what implication does it have on our patients?

Joint surgery and arthroscopy: the basics

Preparing equipment and team for joint surgery -  Alison Young (UK)

Setting up for a surgical procedure and having all of the correct instruments and equipment available is a major part of the patient’s care. Without these items the likelihood of a successful surgery is limited, and may put a successful outcome at risk. There are some basic guidelines that can be used when setting up an operating theatre, others will very much depend on the options available to you. This lecture intends to discuss some of the procedures we can control as well as looking at ways to overcome some of the challenges we all experience in veterinary practice.

How to begin in arthroscopy and common pitfalls? - Andrew Phillips (UK)

Tips, tricks and considerations when stating arthroscopy, based predominantly from my own learning experiences so you can learn from my mistakes. We will discuss topics including technical skill acquisition and simulators. As well as important clinical factors such as case selection, positioning, patient and surgical team preparation.

Supplementary On Demand Content

Webinar    Axial pedicle flaps  - Jonathan Bray (UK)

Webinar    How to improve tissue handling skills  - Mickey Tivers (UK)

Webinar    Getting confident with Schedule 3 - Liz Mullineaux (UK)

Additional BSAVA Resources

Can The Profession Go Green?

Initial Broadcast: Friday 26 March (Stream 1 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Environmental awareness and the need for everyone to play their part in building a sustainable approach has never been more vital. With pioneers in the veterinary space learn why this matters, what is possible and how sustainability makes sense not only environmentally and ethically but also as part of your practice identity and mind-set.

Key Learning Objectives

• Explain what is needed and what is happening within the veterinary sector
• Identify the business case for sustainability and what this looks like at the level of the individual practice
• Illuminate to others, through a wide variety of ‘Pecha Kucha’ style talks, the wide range of issues that are raised by the concept of a greener future.
  

Lecture Summaries

One health, one planet: why sustainability is a necessity

Sponsored by

Leadership perspective: what is needed right now and how to change minds - Libby Kemkaran-Thompson (UK)

This non-hysterical look at the big picture will provide both the information regarding the crisis we are facing, and detail the leadership skills for you to personally take it forward with you into practice and your lives to feel like you’re making a difference. The time is past where we can all sit back hoping against hope that someone else will lead us out of this situation.

This will give you tangible data for when you begin to use our grass-roots power to effect behaviour change on the vet industry, however much of a small fish you may feel. There is a huge sense of urgency right now despite the world stage having so much else going on, we have very little time to make the difference we need to. So what can we do?

There are things that every individual can do, but more power to effect change comes with better strategy – these lectures focus on the practical delivery of change into existing structure (and even achieving delivery through our perhaps, less than enthusiastic colleagues). The further lectures in this stream will give you the tools and techniques to make these changes happen.

What is happening in the veterinary sector: a high level perspective - Ellie West (UK)

Medical journal The Lancet has called climate change “the biggest global health threat of the 21st century”, but also the greatest public health opportunity. The veterinary sector has a moral obligation to mitigate against and adapt for the triple threats of global heating, resource scarcity and biodiversity loss. The transformative change required for this endeavour has been forced by the global pandemic; the question is how we choose to emerge from one crisis, in order to deal with the next?

Small animal veterinary practice has a unique set of environmental impacts, not least the greenhouse gas effects caused by release of volatile anaesthetic agents, but also single use plastic consumption, hazardous waste production, and resource use. Some opportunities are clear; others present a wicked problem with interdependent impacts, inadvertent consequences of changes, and embedded behaviours all contributing to the tangled puzzle.

We will need to show the best of what we can do; work collaboratively, think laterally, dissect the detail whilst seeing the bigger picture, and showing leadership in the workplace and in our communities. This lecture will highlight the excellent environmental sustainability work that is underway in the small animal sector, and the opportunities for growth and participation.

What does environmentally friendly look like in a practice?

Sponsored by

The business case for sustainability - Becky Sedman (UK)

Embarking on a sustainability journey presents many opportunities for veterinary practices; cost savings through reduced resource use, encouraging staff engagement as well as innovation, and marketing opportunities to name but a few. If you aspire to reduce the environmental impact of your workplace, and realise the urgency of positive action, then this session is for you! We will discuss how to get started on your sustainability journey, what the key considerations should be and what can be achieved on a range of budgets. We will also introduce the support material available from Vet Sustain and demonstrate how to put it to use in practice. We will delve into the business incentives of operating sustainably, how to communicate your green vision with the team and how to overcome any barriers you might face. Now is the time for the veterinary profession to take action, to preserve our magnificent planet for the future generations and to ensure that we can continue to provide outstanding veterinary care. As they say, ‘be the change you want to see in the world’!

Practice level practical perspective - Zoe Halfacree (UK)

In the second half of this session on “can the profession go green?”, Zoe Halfacree, Chair of the Greener Veterinary Practice working group, provides an insight into the work that Vet Sustain is doing to support practices to make changes for environmental sustainability. Vet Sustain has produced a checklist, which is endorsed by BVA, BVNA and SPVS, as a guide for getting started in going green and this session outlines some of this advice. There are lots of great tips from becoming a little greener to embarking upon environmental management accreditation.

20x20 visions of a greener future now: 5 pecha kucha's

Sponsored by

There and back again: a tale of travel footprints - Matthew Sawyer (UK)

Come and learn about

• The distance travelled annually in the UK in our cars and vans
• Recognise the damage done by air pollution on human health in the short term •
• Understand the carbon emissions contribute to the climate crisis, causing damage in the short, medium and longer term
• The amount of staff and client generated carbon emissions and air pollution during their commute or travel to the surgery
• The actions we can take today which provide a lot of positive benefits to individuals, the practice staff, and the wider community
• How practices can facilitate behaviour change for staff and clients and the multiple co-benefits of doing so
  

Primary care practice experience of iE scheme - Sarah Sheppard (UK)

How nurses can drive one health - Claire Roberts (UK)

How is the green initiative going at our practice? -  Becky Sedman (UK)

A presentation demonstrating the sustainability journey of Minster Veterinary Practice so far. Since October 2020 we have been trying to reduce our environmental impact with the support from Investors in the Environment. See what we have achieved up to this point, what spurred the whole team to get on board, and what we envision for the future.

Going green: NHS experience - Clare Topping (UK)

The NHS is responsible for 5% of UK carbon emissions, and 5% of travel in the UK. It is also the largest employer and owns a vast estate across the country. This gives great potential for improvements using both technology and employee engagement. This short presentation will feature examples from Northampton General Hospital, a medium sized acute hospital, as well some drawn from other parts of the NHS, demonstrating the breadth of projects used to reduce the environmental impact of the Health Service.

Supplementary On Demand Content

Webinar    Shining a spotlight on waste: life through the COVID lens - Zoe Halfacree (UK)

Webinar    How exactly do you change minds? - Libby Kemkaran-Thompson (UK)

Webinar    Hospital case study: how did we make our anaesthesia practices more environmentally friendly? - Will McFadzean (UK)

Additional BSAVA Resources

Companion Articles

Companion interview with Jen Gale (March 2020) 

The Exotic Hideaway

Initial Broadcast: Friday 26 March (Stream 2 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Whether you see small furries and reptiles once in a blue moon, or more regularly, there are those problem cases that always stump you. Most common presentations are related to skin, or ENT conditions. This module is designed to give a methodical approach to these cases and to outline the most appropriate tests and therapeutics.

The last session covers emergency triage and stabilisation of emergency exotic cases, giving tips and hints for intravenous access and most likely differential diagnoses for collapse in reptiles, birds and rabbits.

The module is supplemented by pre recorded webinars by internationally renowned speakers of analgesia and anaesthesia; ultrasonographic techniques in small mammals and an overview on haematology and biochemistry of small animals and reptiles.

Key Learning Objectives

• Improve your approach to and (non-antibacterial) treatment of ENT infections in small mammals
• Update your knowledge of exotic skin disease
• Identify the principles of triage in exotic animals emergencies and how to apply these in reptile emergencies
  

Lecture Summaries

ENT infections in rabbits and small furries: what's up, Doc?

Sponsored by

How to approach ENT cases in practice - Thomas Donnelly (FR)

ENT infections in dogs, cats and rabbits have some similarities but more often differences. In dogs and cats, bacterial rhinitis is generally secondary to a primary nasal disease. In rabbits, the primary nasal disease is bacterial. It is a polybacterial infection, and the most frequent combination is Pasteurella multocida and Bordetella bronchiseptica. Other bacteria often isolated are Pseudomonas spp. and Staphylococcus spp. While plain radiographs and oral/dental examination are common diagnostic steps in all 3 species, bacterial culture and sensitivity are critical in rabbits. In chronic and advanced cases, a CT scan of the rabbit skull is recommended to evaluate the nasal turbinates and middle ears. Destruction and remodeling of nasal passages and P multocida spread from the upper respiratory tract to the middle ear frequently occurs in rabbits. Although chronic antibiotic treatment is often used to treat affected rabbits, surgery of the nasal passages and middle ear is required for resolution, as antibiotic treatment failure often occurs. This presentation covers the differences between dogs, cats and rabbits, and what evidence-based medicine has shown to be critical for the diagnosis and treatment of ENT infections in rabbits.

Sinusitis and rhinitis in rabbits: non-antibiotic therapies - John Chitty (UK)

Sinusitis/ rhinitis syndromes are common in rabbits as a part of the condition usually referred to as “snuffles”. Misleadingly this is often referred to as Pasteurellosis. Misleading as:

1. The implication of a primary bacterial cause would infer that a course of antibiotics will treat and cure- this is rarely the case in the pet situation.
2. Pasteurella is not always isolated and may not even be the most common isolate from diseased rabbits.

Sinusitis and rhinitis are often linked though may also occur separately with sinusitis usually being associated with dental disease and the filling of sinuses with pus. These cases generally require a surgical approach with dental therapy and flushing/ curettage of the sinuses. Rhinitis has a wider range of causes which may include airborne irritants and foreign bodies. In most cases, removal of potential irritants forms a major part of investigation and therapy. Other therapies may include anti-inflammatories, nasal flushes, and nebulization.

In both cases a holistic investigation should be performed that will include a thorough husbandry review as well as imaging (CT or radiography) and nasal endoscopy/ biopsy. The talk will cover the investigation and the role of non-antibiotic therapies including sinus surgery.

Common cases in exotic skin disease

Sponsored by

How to diagnose in-practice. Which diagnostic tests to do? - Tom Dutton (UK)

Investigating feather plucking in companion parrots can be both challenging and complex. A good understanding of the medical, psychological and environmental causes of this syndrome is required to give the best patient outcomes. Alongside a short review of common causes, this short presentation will cover the most useful diagnostic tests that can be performed in a primary care setting.

Factors involved in skin disease in reptiles: detecting infectious causes -  John Chitty (UK)

Infectious skin disease is common in reptiles, especially in young animals that have been captive bred and mixed in shops or with dealers. Underlying husbandry deficiencies will affect immunity and aid establishment of pathogens and even result in skin pathogens causing systemic infections. Social factors and stressors (eg mixing different species/ age groups/ sizes) will also increase the likelihood of seeing infectious dermatopathies. Once established, these infections can be extremely hard to treat and may require months of therapy. In some cases the infected reptile will be a source of infection for others in a collection. Early recognition of disease or likelihood of these diseases is essential so the correct diagnostics can be performed and therapy started as early as possible.

This talk will look at the most common infections, their diagnosis and treatment.

Help, it's an exotic emergency: what do I do?

Sponsored by

Principles of triage and immediate assessment of exotics  - John Chitty (UK)

While it is impossible to cover all triage and emergency assessment of all exotics in one talk (exotics can encompass several hundred species even in general non-zoo practice), there are important first principles that apply to emergency care of any animal. Unsurprisingly these are much the same as for dogs and cats.

This talk will cover a basic A,B,C …approach for emergency care of exotics showing examples of how dog/ cat emergency care can be applied to exotics (birds, reptiles, and small mammals) allowing any practitioner to fulfil their RCVS requirements and stabilize a patient before progressing to further diagnostics and treatment or referral to a more specialized centre.

Help, it's an exotic emergency: what do I do - reptiles - Tom Dutton (UK)

An accurate triage assessment of a sick or injured reptile is vital to enable a clinician to instigate correct first aid and emergency care. This short presentation will give the primary care veterinarian with the knowledge to perform a brief but thorough assessment of a reptile presented urgently, and provide correct stabilisation and first aid.

Supplementary On Demand Content

Webinar    Understanding blood results in small mammals and reptiles - John Chitty (UK)

Webinar    Analgesic and anaesthetic drugs in small mammals - Ian Self (UK)

Sponsored by

Additional BSAVA Resources

Ophthalmology

Initial Broadcast: Friday 26 March (Stream 3 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Take a clear sighted look at some of the most common and important ocular presentations. These highly practical sessions will cover ocular opacities, non-healing ulcers and ocular emergencies.

Pre-recorded resources available will cover canine and feline cataracts, corneal sequestrums in cats and brachycephalic ocular issues.

Key Learning Objectives

• Update and revise your knowledge of ocular opacities
• Review the aetiology and management of non-healing corneal ulcers in dogs and cats
• Give you the tool kit to recognise and manage true ocular emergencies

Lecture Summaries

Ocular opacities: what, when, where, why?

Corneal opacities - Lorraine Fleming (UK)

In order to function properly the cornea should be transparent, any opacity will impair function. If you can correctly identify the different types of corneal opacities and their cause, then you will know whether or not appropriate treatment (medical and/or surgical) will improve or restore corneal clarity. Do a thorough examination of the cornea, look from different angles, use a bright light and magnification. Think about the colour of the opacity, is it blue/grey, red, white or black/brown? There may be more than one colour present in an affected cornea, as there are only a limited number of ways that it can respond to insult. Blue/grey opacity is due to oedema, which may be the result of epithelial or endothelial cell loss. Red can be due to vascularisation, which may be superficial or deep, or more rarely due to intrastromal haemorrhage. White opacites are the most frequently seen and may be due to fibrosis, cellular infiltrate, lipid or calcium deposition. Black deposits are most likely to be pigmentation, usually superficial and sub-epithelial, but also occasionally endothelial. In cats, brown pigmentation associated with a sequestrum is also a possibility. There is one more opacity that doesn’t follow the above rules and that is a corneal foreign body, which can come in all shapes, sizes and colours!

Anterior chamber, lens and vitreous - Richard Everson (UK)

A number of different lesions, resulting from different disease processes, can cause an opacity of the ocular media, affecting the visual axis. In this short presentation we will discuss opacities affecting the anterior chamber, lens and vitreous. We will focus on recognising and identifying the opacity by looking at numerous examples. Lesions discussed will include uveal cysts, hypopyon, hyphaema, cataract and asteroid hyalosis.

These are the pits: non-healing corneal ulcers and how to deal with them

SCCEDs, endothelial degeneration - Richard Everson (UK)

Superficial corneal ulcers that fail to heal in the expected time are a common problem. Identifying the cause, however, can be a challenge. In this presentation, we will look at examples of two conditions: spontaneous chronic corneal epithelial defects (SCCEDs) and corneal endothelial failure.

Feline indolent ulcers - Lorraine Fleming (UK)

Superficial non-healing ulcers are not as common a problem in the cat as they are in the dog. However ,when they do occur, can be a real challenge to treat. Getting these ulcers to heal is difficult and the key is to understand the cause and treat that too. Interventions such as keratotomies (grid, punctate, diamond burr and phenol) can not be used in the cat, as they predispose to the development of corneal sequestra. Brachycephalic cats are at particular risk due to corneal exposure, this combined with poor corneal sensitivity and evaporative tear film loss, is the perfect recipe for poor healing. The other main consideration is the role of Feline Herpes Virus (FHV) in these cases. Once the diagnosis of ‘indolent ulcer’ is established then debridement of the loose epithelial edges is recommended, this can be combined with the use of a contact lens. Topical prophylactic antibiotics and tear replacement should be given and in cases where FHV is involved, topical or systemic antivirals should also be used. The debridement can be repeated several times but if the ulcer sill fails to heal then a superficial keratectomy is recommended. These cases are at risk of developing a corneal sequestrum in the ulcer bed, and if this does occur will definitely need a keratectomy to bring about healing.

Ocular emergencies: what the heck am I dealing with?

Part I - Richard Everson (UK

Emergencies can be pretty daunting! Most patients with an ocular emergency present with an uncomfortable (closed) eye, often red and cloudy, and the first challenge is working out what you’re dealing with. In this short presentation, we will consider some common ocular emergencies, including deep stromal ulcers, lens luxation and proptosis.

Part II - Lorraine Fleming (UK)

Emergencies can be pretty daunting! Most patients with an ocular emergency present with an uncomfortable (closed) eye, often red and cloudy, and the first challenge is working out what you’re dealing with. In this short presentation, we will consider some common ocular emergencies, including deep stromal ulcers, lens luxation, proptosis, glaucoma, corneal foreign bodies and sudden blindness. A live discussion will follow.

Supplementary On Demand Content

Webinar    Brachycephalic dogs: key ocular issues - Richard Everson (UK)

Webinar    Corneal sequestrums in cats: diagnosis and treatment options - Richard Everson (UK)

Webinar    Canine and feline cataracts: diagnosis, treatment and prognosis - Lorraine Fleming (UK)

Additional BSAVA Resources

Kidney Medicine and Nursing

Initial Broadcast: Friday 26 March (Stream 4 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Are kidneys keeping you up at night? This module delivers the answers to some key questions, with a focus on ensuring the basics are in place to achieve a comprehensive diagnosis, and allowing the development of the right management strategy for the patient. The module covers key biochemistry and urinalysis, acute kidney injury and nephrolithiasis.

Key Learning Objectives

• Expand your knowledge of the range of blood and urine tests available beyond the basic urea, creatinine, dipstick and specific gravity
• Improve your understanding of how to diagnose and manage acute kidney injury
• Advise owners about the current thinking on nephroliths when you have identified them
  

Lecture Summaries

Getting the basics right

Sponsored by

Blood tests in kidney disease: looking beyond urea and creatinine - Rebecca Geddes (UK)

One of our biggest tools in evaluating the unwell patient is to run blood tests. Traditionally we look at urea and creatinine on our biochemistry panel to tell us if the patient has kidney disease. These parameters can tell us if a dog or cat is azotaemic or not, but how do we then decide if the azotaemia is pre-renal, renal or post renal? And which parameters can we use to help decide if the patient has acute kidney injury or CKD? Does a really high serum creatinine concentration always equal a poor prognosis? This lecture will provide a quick, easy to follow overview of how to make the most of your blood tests when evaluating kidney function. We will discuss how to make the most of your routine biochemistry panel, touch on how haematology findings can help and talk about how to interpret SDMA concentrations.

Urine tests in kidney disease: beyond dipstick and USG - Sophie McMurrough (UK)

Renal disease is something we tackle every day in practice but how much do we know about the tests we have available? Urinalysis can tell us a lot about a patient’s renal function and it goes far beyond specific gravity and dipstick! Learn about the different tests we can utilise, how useful they are and what they can tell us about our patient. Urinalysis is a useful tool which complements bloodwork and together they can provide a well rounded diagnosis.

Acute kidney injury

Sponsored by

Making the diagnosis - Alix McBrearty (UK)

Acute kidney injury (AKI) is a sudden fall in renal function and results in retention of uremic toxins and fluid, electrolyte, and acid-base imbalances. Classically AKI has been defined as a sudden (usually less than 1 week) increase in creatinine above the reference range, but because of the importance of obtaining an early diagnosis and the lack of sensitivity of creatinine in detecting a decline in GFR, more stringent criteria have been defined. AKI should be suspected in patients presenting with acute onset lethargy, anorexia, vomiting and diarrhoea regardless of their urine output. Critically ill and post-operative patients are at high risk and should monitored for AKI development. Physical exam findings often include dehydration and renal pain. Uremic halitosis, oral ulceration, hypothermia and bruising may also be present. The diagnosis is made based on an acute increase in creatinine and/or abrupt decline in urine output. Glucosuria (without hyperglycaemia), proteinuria, pyruria, microscopic haematuria and granular casts may be detected in on urinalysis. Further investigations should include a complete blood count, full biochemistry profile, urine culture, abdominal imaging and acid-base measurement (if possible). Other tests for underlying causes such as Leptospirosis, ethylene glycol toxicity and Lyme disease may be indicated.

Managing the patient - Caroline Boothroyd (UK)

Acute kidney injury (AKI) is the rapid loss of kidney function leading to the accumulation of nitrogenous waste. AKI is potentially reversible either by resolution of the injury or by adaptation of the kidney or by both mechanisms. Management of the patient includes: correcting hypoperfusion, to the kidney., closely monitoring fluids ins and outs and adjusting intravenous fluid therapy as required, treating infections, such as pyelonephritis, leptospirosis and Lyme disease and alleviating blockages or repairing ruptures to the urinary tract. The holistic needs of the patient should be met:, padded bedding in a warm, clean stress-free environment, time to rest and sleep., recumbency changed every four hours., water should be freely available, fresh and easily accessible., clinical examination at least twice a day., pain scores every four hours or as required, intravenous catheter care., consider a jugular catheter to facilitate fluid therapy and blood sampling., frequent toileting opportunity as likely high rates of fluid therapy. A urinary catheter would allow monitoring of urine output, oral hygiene, patients may develop painful ulcers on their tongue and oral mucosa. Suitable nutrition to meet the patients RER, a feeding tube should be considered.

Nephroliths: when are they a problem and what should I do next?

Identifying kidney stones: incidental finding or the key to the patient's problem - Isuru Gajanayake (UK)

Nephrolithiasis can be an incidental finding or one that requires urgent action. In this combined session, the problem of kidney stones in dogs and cats will be discussed. This will include an overview of the types of kidney stones that occur in dogs and cats, and the underlying medical conditions that can cause these. There will also be a discussion about the imaging modalities used to confirm nephrolithiasis, as well as other diagnostics (e.g. laboratory testing) that help identify their composition.

Approach to calcium oxalate nephroliths: surgery, medicine or wait and see? - Tim Charlesworth (UK)

Nephrolithiasis is becoming more frequently diagnosed but remains an uncommon condition. Historically, nephroliths have not been associated with increased rates of progression of chronic kidney disease (CKD) but newer evidence has suggested a relationship between the presence of nephrolithiasis and a more rapid progression of CKD. Although the nature of this relationship remains unclear, it has prompted reassessment of how we treat nephrolithiasis. Many cases of nephrolithiasis are discovered incidentally and it is clear that they do not all require treatment. It is now accepted, however, that intervention should be sought for “complicated” nephroliths such as: stones associated with partial or complete obstruction of the uretopelvic junction and progressive hydronephrosis; stones associated with renal parenchymal loss, and stones associated with persistent pyelonephritis despite appropriate medical management. All surgical interventions are associated with renal damage and subsequent loss of function. This has led to recent recommendations to be as minimally-invasive and minimally-destructive as possible. The risks and subsequent potential loss of GFR caused by any intervention need to be justified by the anticipated clinical benefit to the patient. Techniques employed to remove complicated nephroliths range from nephrotomy, pyelotomy to endoscopic nephrolithotomy and these will be discussed during the lecture.

Supplementary On Demand Content

Webinar    Nutrition: stretching your knowledge. The evidence base for dietary intervention in renal disease - Isuru Gajanayake (UK)

Sponsored by

Additional BSAVA Resources

Dentistry

Initial Broadcast: Friday 26 March (Stream 1 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Get your teeth into one of the most frequently performed procedures in practice, and brush up on your dentistry. Join an international group of speakers as they give you the lowdown on dental imaging, challenging extractions in dogs and cats and feline chronic gingivitis-stomatitis, as well as tips on ensuring effective dental management in practice.

Key Learning Objectives

• Re-evaluate the ergonomics of dental stations for nurses and vets in the practice to improve comfort and raise standards to current best practice
• Develop an understanding of the differences and potential advantages of Cone Beam CT and conventional oro-dental radiography. Explain how to better radiograph multiple roots of maxillary molars
• Gain some top tips on difficult dental extractions in cats and dogs
• Revise your understanding of feline chronic gingivitis stomatitis and consider how to manage owner expectations. Learn about the role of stem cell therapy in this condition
  

Lecture Summaries

Dental management in practice

Sponsored by

Ergonomics in the dental station for the veterinary surgeon - Jens Ruhnau (DK)

Ergonomically good positions are very important when doing dentistry, since procedures are often long and numerous in awkward back and head positions. This lecture gives the basic guidelines to sit and work with ergonomically good manners to prevent headache, neck, shoulder and back pain to develop. We will discuss hand instruments grip, light, units, magnifiers, table and chairs, and give a number of solutions to go home and use immediately or to consider when buying new equipment.

Ergonomics in the dental station for the veterinary nurse - Claire Bloor (UK)

Ergonomics is extremely important in the dental station as the veterinary surgeon may frequently spend significant periods of time operating on individual patients, as well as undertaking multiple procedures per day. This can take its toll on the veterinary surgeon’s health and wellbeing due to the potentially awkward head and neck positions they often adopt throughout these procedures.

This lecture aims to provide the veterinary nurse with knowledge pertaining to ergonomics in the dental station to take back and apply in practice immediately, to minimise or eliminate the aforementioned negative impacts on their surgeons. We will discuss optimal set up of the dental station considering access to the dental unit, xray generator, anaesthetic machine and surgical instrumentation, including the positioning of the table and operating light, and explore the concept of four-handed dentistry.

Better dental imaging: techniques and practice

Sponsored by

Cone-beam CT in veterinary dental practice - Milinda Lommer (USA)

Cone-beam CT offers three significant advantages over conventional intraoral radiography. The first relates to the speed with which images are captured; the patient’s entire head is imaged in a 30-second time frame. With conventional intraoral radiography, a full-mouth series can be acquired in 6-10 minutes in the most experienced hands, and as long as 30 minutes for less experienced staff members. The second, most important advantage of CBCT is the ability to visualize structures that are difficult to evaluate on conventional radiographs. These include the maxillary molar teeth, the palatal root of the maxillary 4th premolar tooth, and rotated maxillary and mandibular premolar teeth in brachycephalic dogs and cats. In addition, CBCT allows evaluation of the nasal cavity, maxillary recess, frontal sinuses, TM joints, and tympanic bullae. Finally, use of specialized software to create 3D reconstructive images of the patient’s skull allows clinicians to better visualize the patient’s overall maxillofacial and dental structures and aids client education efforts. While CBCT is commonly employed to evaluate cases with maxillofacial trauma or neoplasia, we have found it extremely useful for every day periodontal and endodontic cases as well.

Dental radiology projections for three rooted maxillary teeth - Jens Ruhnau (DK)

For two-rooted teeth we can often get good conclusive radiographs using parallel technique or bisecting angle technique when obtaining pictures, but for the three rooted maxillary teeth (especially fourth premolar and first molar), getting a conclusive diagnosis from dental radiographs can prove to be more challenging.

This lecture presents the projections needed to obtain good pictures of both teeth, introducing a totally new projection that is very helpful to evaluate attachment loss and periapical pathology.

Dental surgery: difficult extractions - tips and tricks

Sponsored by

Difficult dog extractions: tips and tricks - Jens Ruhnau (DK)

Canines and carnassials most often cause problems when extracted. Root fractures, flap dehiscence and jaw fractures are among the most frustrating complications in the field of veterinary dentistry.

This lectures gives input – tips and tricks – to avoid these complications. Some of them you might know – some of them might be new?

Difficult cat extractions: tips and tricks - Milinda Lommer (USA)

Extracting teeth from cats poses many unique challenges, including a small space within which to work, fragile gingival tissues, a thin plate of bone separating the oral and nasal cavities, proximity of the maxillary teeth to the orbit, and tooth resorption. Preoperative imaging (radiographs and/or cone-beam CT) is imperative to assess the teeth and alveolar bone prior to extractions. Excellent lighting, magnification loupes, and specialized instrumentation will facilitate extractions. Specialized instrumentation includes fiber-optic or LED-lit high-speed handpieces with irrigation, small round and tapered diamond burs, small Molt or P24G periosteal elevators, cheek and lip retractors, 0.9-, 1.3- and 2-mm luxating elevators, root tip forceps (e.g. FX-49), 4.75” needle-holders, and 5-0 or 6-0 monofilament suture material on a reverse cutting needle. An open technique with removal of alveolar bone will prevent many root fractures, as will knowing when to perform surgical subgingival crown amputation (aka coronectomy) vs. extraction in toto for teeth with resorption. When root fracture does occur, enlarging the flap, removing more alveolar bone and using a tiny ¼ carbide bur to create a trough around the root will enable positioning of a luxator into the periodontal ligament space that may have previously been inaccessible.

Feline chronic gingivitis and stomatitis: an update

Part l: what it is and managing expectations? -  Boaz Arzi (USA)

Feline chronic gingivostomatitis (FCGS) is a painful oral mucosal inflammatory disease presented in cats. The observable characteristics of FCGS is ulcerative and/or proliferative mucosal inflammation in the area lateral to the palatoglossal folds with or without gingival inflammation. The cause of feline gingivostomatitis is currently elusive, but it can be inferred that a chronic antigenic stimulation, such as a viral infection, results in an inappropriate immune response. Full-mouth tooth extraction is the current standard of care to treat FCGS. About 70% of affected cats will have significant improvement with this dental procedure, but approximately 30% of cats will not respond and will have a poor quality of remaining life. Non-responding cats will need lifelong medical management and severely affected cats will often be euthanized. Therefore, managing client expectations is a very important aspect of managing the disease. This lecture will inform on current evidence-based knowledge on FCGS as well as therapeutic approaches.

Part ll:  stem cell therapy - Boaz Arzi (USA)

Feline Chronic Gingivostomatitis is an immune mediated oral mucosal disease. In that context, cats affected by FCGS demonstrate systemic elevation of cytotoxic T cells (CD8 cells) and other abnormalities indicating an aberrant immune system. Mesenchymal stem cells (MSC) are multipotent stem cells. MSC reside in most organs and tissues such as bone marrow, adipose, and periodontal ligament. Furthermore, MSC has a profound regenerative ability attributed in part to their ability modulate both innate and adaptive immunity. Hence, a therapeutic approach was designed whereby mesenchymal stem cells (MSCs) capable of immunomodulation and significant regenerative capacity were administered systemically to cats that did not respond to extraction therapy. MSCs immune modulatory properties include decreased T-cell and B cell proliferation and function and altered lymphocytes phenotypes. The efficacy of MSCs for the treatment of non-responsive FCGS has been an on-going study, for the past 9 years, tested in several clinical trials. In these clinical trials, approximately 60-70% of cats had a positive response rate. This lecture will discuss the general concept of MSC immunomodulation therapy as well as the clinical outcome of MSC therapy for cats with FCGS and future directions.

Supplementary On Demand Content

Webinar    Feline chronic gingivostomatitis: recent updates and future perspectives - Boaz Arzi (USA)

Webinar    The use of cone beam CT in veterinary dental practice compared with conventional dental radiology - Milinda Lommer (USA)

Additional BSAVA Resources

BSAVA Publications

BSAVA Manual of Canine and Feline Dentistry and Oral Surgery

Companion Articles

Notes on…Extraction of fractured root tips in dogs and cats by Matthew Oxford (July 2020)

Notes on…Treating tooth resorption: a pragmatic approach by Matthew Oxford (August 2020) 

JSAP Articles

A review of the frequency and impact of periodontal disease in dogs

Neurology on a Shoestring

Initial Broadcast: Friday 26 March (Stream 2 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Say goodbye to nervous neurology with a practical team-based approach. Covering the essentials of how to approach the neurological case in practice, our speakers will take you through a practical guide from examination to diagnostics, and key presentations – the neurotrauma patient, seizures and other paroxysmal events, and weakness and collapse.

Pre-recorded resources will cover canine epilepsy management, neurotrauma of the brain and spine and nursing the neurological patient.

Key Learning Objectives

• Perform a cost-effective approach to neurological diagnosis and start to confidently discuss your results with colleagues
• Demonstrate how to assess a relatively uncomplicated case of head injury and develop a basic clinical or nursing plan
• Explain the difference between seizures and other paroxysmal events and be able to list 3 or 4 alternatives to phenobarbitone in the management of epilepsy
• Successfully engage with clinical case presentations on weakness and collapse
  

Lecture Summaries

Where do I start? Keys to cost-effective neuro diagnosis

Sponsored by

An introduction to the neurological examination - Tom Cardy (UK)

Neurology cases are a common presentation for veterinarians in general practice but can frequently seem overwhelming. In many patients it can be challenging to establish a neuroanatomical localization making attempts to generate a list of focused differential diagnoses and determine a management plan feel like a lost cause. The aim of this lecture is to provide a simple and logical approach to the neurological exam that works within general practice. Participants will learn the skills to determine if a neurological abnormality exists and develop the knowledge and confidence to interpret their findings in order to localise the lesion to a specific anatomic region of the nervous system. We will also examine how the ‘Five-Finger Rule’ considers elements from the patient signalment, onset, progression, lateralization and pain of the presenting condition to improve clinical reasoning in neurology cases to generate a list of prioritized differential diagnoses.

Key diagnostic tests - Holger Volk (DE)

In the last decade there has been an exponential increase in diagnostic tools in veterinary medicine fueled by an even faster developing toolkit in human medicine. The developments of diagnostics, especially in advanced imaging and genetics, have not only improved our clinical diagnostic abilities, but also enhanced our understanding of their pathophysiology and treatment. The rapid development of the new diagnostics paralleled with an increase in costs. The development of diagnostics for veterinary medicine, especially in the field of imaging, will be slowed by the increase in costs, if we are not careful. Taking this into account and the current financial climate, inappropriate use of diagnostics leads to unnecessary cost to the owner and frustrations (which might end up in complaints) and potentially morbidity to the patient. Many of the advanced techniques used in veterinary neurology are invasive, require an anaesthetised or sedated patient, therefore a logical clinical reasoning approach is essential to ensure the correct body part is looked at, the lesion is accurately and correctly identified and one is not hijacked by an incidental finding. Using the five-finger rule (Onset and course of the disease, symmetrical or asymmetrical, painful or non painful, neuroin conjunction with the signalment will determine a handful of differentials which can then be verified by using your diagnostic toolkit. We will discuss in this lecture when, why and how you should use the various diagnostic tests can be grouped into

1. Clinical pathology
2. assessment of structure using diagnostic imaging techniques and
3. functional assessment (mainly electrodiagnostics).
   

How to approach neuro trauma in practice

Sponsored by

A vet's perspective : diagnosis and management - Tom Cardy (UK)

Neurotrauma, including traumatic brain injury (TBI) and acute spinal cord injury (SCI), is a relatively common emergency in small animal veterinary medicine that requires thorough patient assessment and a systematic approach to case management. Damage to the neuroparenchyma can be divided into primary injury directly associated with the trauma (e.g. contusion, compression, laceration and distraction) and secondary injury that occurs subsequently due to deficiencies in homeostasis and normal metabolic processes. Interventions are directed at addressing primary injury more so in SCI as well as minimizing the effects of secondary injury in both TBI and SCI. Initial investigations should be the same as any acute neurological case with a through history, physical examination and neurological examination. All patients should ideally have a minimum database performed with particular attention to electrolytes and glucose levels. Care must be taken to ensure the patient is systemically supported with a focus on airways, breathing and circulation. The level of intervention is patient dependent but can often be intense and hands-on. Prognosis for neurotrauma patients depends on the severity of injury, the site of the lesion, and the timing and efficacy of treatment, but with an appropriate response to initial management and stabilisation the outcomes of neurotrauma patients can be good.

A vet nurse's perspective: diagnosis and management - Holly Smith (UK)

What you might expect, what to prepare for and complications in neurotrauma.

Diagnosing seizures and other paroxysmal events

Odd episodes: when is a seizure not a seizure? - Tom Cardy (UK)

Dogs and cats presenting with abnormal episodes provide some of the most challenging and frustrating cases for veterinarians of all abilities. In veterinary neurology these episodes can be defined as ‘paroxysmal episodes’ with a defined start, defined end and relatively short duration. There are relatively few causes of paroxysmal episodes in dogs and cats including: seizures, syncope, vestibular syndrome, paroxysmal dyskinesia (movements disorders), narcolepsy/cataplexy, neuromuscular disease and idiopathic head tremors. Accurately classifying the paroxysmal episode is dependent on taking a thorough and systematic history that includes: a description of the event, the clinical status between episodes, asking if there is impairment or loss of consciousness, presence or absence of autonomic signs, description of muscle tone a lateralisation of presenting clinical signs. Where possible videos of the events should be reviewed with the owner. In this lecture we will use case examples and videos to review common paroxysmal episode presentations. Particular attention will be given to seizures, syncope, vestibular syndrome and paroxysmal dyskinesia. We will investigate the diagnostic approach to these conditions including genetic testing for certain breed associated conditions. Cases will review the appropriate use of pharmacological or dietary treatments and highlight how the provision of accurate information to owners is critical in ensuring the optimal management of these varied conditions.

Other causes - Holger Volk (DE)

Patients presenting with a history of paroxysmal episodes or “fits” can be a challenge for even the most experienced clinician. First, the patient presents usually in your practice when it is normal. Second, the identification of the nature of episode is heavily dependent on a good description from the person who witnessed the episode or a home-style video. Third, most of these paroxysms appear unpredictable and uncontrollable for the owner so their view of what has happened might be clouded. A meticulous history is essential before embarking on a diagnostic investigation. Syncope, narcolepsy/cataplexy, pain, compulsive behaviour disorders, vestibular attacks, certain movement disorders, neuromuscular weakness and seizures are paroxysmal events, which share commonalities in their clinical presentation. The inter-paroxysmal (inter-episodic) clinical examination can be completely unremarkable. If the animals present with inter-episodic deficits then this will guide your clinical reasoning and help you determine the body system involved. If you are ‘lucky’ then the patient will present during a ‘strange’ episode at your clinic, e.g. prolonged seizure activity (status epilepticus [>10min], cluster seizures [≥2 seizure/day]) or vestibular attack.

We will discuss in the lecture the ins and outs of how best to differentiate the wonderful bouquet of paroxysmal neurological episodes.

Approaches to weakness and collapse: a case based discussion

Holger Volk (DE), Gerard McLauchlan (UK) & Adrian Boswood (UK)

Sponsored by

Episodic weakness and collapse are common but frustrating clinical problems to investigate. They are frustrating because of the multitude of diseases that can manifest in this way and therefore the multitude of different organ systems that can be responsible for their development. Another challenging aspect of their investigation is that they are often intermittent, frequently occur in specific situations and are rarely observed by the clinician to whom the patient presents. If episodes are reasonably frequent asking the owner to video an episode and observe for specific changes in the patient can be very helpful. In a multidisciplinary hospital these patients can present to one of a number of different services and the initial challenge is often trying to decide which is the most appropriate service for which patient.

Important clues can be obtained from the history and physical examination including the following

• When do episodes occur? Is it at rest or on exertion?
• Does the patient seem to anticipate episodes, or do they occur out of the blue?
• Is the situation in which episodes occur always similar e.g. sprinting, barking at the postman or defecating?
• Does the patient lose consciousness? • How long do episodes last and what is the patient doing during the episode?
• How rapid is recovery and how long does it take until the patient is back to normal?
• Is the patient completely normal between episodes?
• Do the signs seem to lateralise?
• Are any other clinical signs apparent?

Careful physical examination may help to differentiate a patient with a neurological origin of their signs from one with cardiovascular or metabolic origins. Determining the system more likely to be responsible for the signs can allow more targeted diagnostic tests to be performed and prevent unnecessary expenditure on tests that are unlikely to be helpful. These points will be illustrated during discussion of different case presentations.

Supplementary On Demand Content

Webinar    A guide to the fundamentals of traumatic brain injury and spinal trauma - Tom Cardy (UK)

Webinar    Nursing the neurological patient  - Holly Smith (UK)

Webinar    Epilepsy management: beyond conventional drugs - Holger Volk (DE)

Additional BSAVA Resources

Brachycephalics

Initial Broadcast: Friday 26 March (Stream 3 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Short of face but long on potential problems, brachycephalics present many challenges. Explore some of the most common issues facing you when dealing with these cases, from respiratory assessment and BOAS surgery to anaesthesia and the importance of a team approach.

A review of a number of the other important conditions to watch out for, as well as regurgitation and hiatal hernia, brachycephalic ocular issues, and nursing the BOAS patient will also be covered.

Key Learning Objectives

• Re-evaluate your practice’s veterinary and nursing protocols for anaesthetising brachycephalics
• Develop your practice’s team approach to various problems posed by brachycephalics
• Improve your confidence in BOAS surgery including nose and soft palate corrections, dealing with laryngeal collapse and performing a tracheostomy
• Improve your knowledge of assessment of BOAS patients
  

Lecture Summaries

Gasping for air: how badly is my patient affected?

Assessment of a BOAS patient in the consultation room: what do these noises mean - Julia Riggs (UK)

Assessment of the airway under anaesthetic -   Chris Shales (UK)

Julia and Chris will each provide a short presentation demonstrating practical tips on how best to assess these patients in order to decide how severely they are affected by Brachycephalic Obstructive Airway Syndrome (BOAS). Julia will use her wealth of experience to discuss the physical examination of these patients in the consultation room and Chris will then lead you through examination of the anatomy of the upper airway under anaesthesia. There will then be time to discuss the points raised and ask any questions that you have from your own clinic.

Take a deep breath: BOAS surgery doesn't have to be scary

Nose and soft palate - Jane Ladlow (UK)

In various studies, about 60% of dogs with BOAS had stenotic nares and 90% had an elongated palate. Using advanced imaging, the palate is not only long but also thickened (hyperplastic) which may be a secondary change to other areas of airway obstruction. The lesions sites are also breed specific, with nasal stenosis being more of an issue in French bulldogs and pugs than bulldogs where the hyperplastic palate is the most noticeable lesion. In an objective study of airway function the nostril status was the most significant conformational factor associated with BOAS (though we still see unaffected dogs with severely stenotic nostrils). As lesion sites vary between breeds and also between individuals of the same breed it is important to assess individuals carefully prior to surgery with a functional assessment .

We use a nasal grading scheme which is breed specific to assess the nostrils. Open and mildly affected nostrils are desirable.

There are a myriad of techniques described for soft palate resection and nasoplasty. This presentation will cover the current surgical options for nasoplasty and soft palate resection, including alar fold resection and folding flap staphylectomy techniques along with the evidence behind them . Potential complications and outcomes (where known) will be discussed.

Laryngeal collapse and tracheostomy - Rob White UK)

Laryngeal collapse is a form of upper-airway obstruction caused by loss of cartilage rigidity that allows medial deviation of the rostral laryngeal cartilages. Although laryngeal collapse has usually been considered to be associated with progression of the BOAS, when it comes to the more advanced stages of the condition, the breed of dog is often indicative of the severity in laryngeal changes seen. Conventionally, the condition is sub-divided into three stages in the dog: in stage I laryngeal collapse there is eversion of the laryngeal saccules, in stage II there is loss of rigidity and medial displacement of the cuneiform processes of the arytenoid cartilage, and in stage III there is collapse of the corniculate processes of the arytenoid cartilages with loss of the dorsal arch of the rima glottidis. In its advanced forms, the condition is life-threatening and often very difficult to treat effectively. This presentation will discuss the condition and its potential management options (e.g., husbandry changes, surgical correction of primary abnormalities, sacculectomy, arytenoidectomy, cricoarytenoid and thyroarytenoid caudo-lateralisation, and permanent tracheostomy), highlighting the controversies and difficulties its treatment.

Anaesthesia in BOAS patients: protocols and pitfalls

Sponsored by

Vet perspective - Elizabeth Leece (UK)

Although the nursing care for the brachycephalic patient is the most vital part of hospitalisation and peri-anaesthetic care, there are recent clinical investigations that may help guide veterinary care for brachycephalics undergoing anaesthesia. The lecture will help to guide our anaesthetic care, provide brachycephalic checklists whilst incorporating the recent updates into our management to help minimise complications and provide effective treatment if they are encountered.

Vet nurse perspective - Jen Busby (UK)

Brachycephalic breeds are now all too common in our veterinary practices whether it be general practice or referral. At some point, regardless of the reason, they will require anaesthesia for a procedure. In this session, I aim to provide awareness of the common pitfalls we as nurses may encounter. The nursing responsibilities to these patients throughout all the stages of the anaesthetic are fundamental to ensuring these tricky patients survive and walk away! They can be some of the riskiest patients to monitor and manage during the anaesthetic period but with good preparation, a solid basic protocol and fantastic teamwork, there should be no reason why these patients need to be any more troublesome. I will aim to discuss some key preparations and protocols needed to ensure the safety of these patients, together with increasing the awareness of common pitfalls that might occur and what to do during them.

The team approach to the brachycephalic patient

Panel discussion - Julia Riggs (UK), Chris Shales (UK) & Lydia Smith (UK)

This live session will give delegates the opportunity to ask questions and discuss practical tips and techniques used by three experienced team members to manage their busy BOAS clinics. The session will complement the pre-recorded seminars and other live sessions that form part of this stream. This is your chance to get involved! We hope you will join us for what we are sure will prove to be a very useful exchange of ideas and experiences in this challenging but rewarding area.

Supplementary On Demand Content

Webinar    Now then, this is no ordinary dog: what should I be looking for? - Chris Shales (UK)

Webinar    Regurgitation and BOAS hiatal hernia: should this be treated surgically? - Rob White (UK)

Webinar    Nursing the BOAS patient: primary considerations - Lydia Smith (UK)

Additional BSAVA Resources

BSAVA Publications

BSAVA Manual of Canine and Feline Head, Neck and Thoracic Surgery

BSAVA Manual of Canine and Feline Anaesthesia and Analgesia

Companion Articles

Brachycephalic Obstructive Airway Syndrome – an update by Jane Ladlow (March 2018)

How to…Place and manage a tracheostomy tube by Ian Nicholson (December 2014)

How to anaesthetize the brachycephalic dog by Iago Asorey Blazquez and Enzo Vettorato (March 2018)

JSAP Articles

Relationship between brachycephalic airway syndrome and gastrointestinal signs in three breeds of dog

Outcome of temporary tracheostomy tube-placement following surgery for brachycephalic obstructive airway syndrome in 42 dogs

Position of maximal nasopharyngeal maximal occlusion in relation to hamuli pterygoidei: use of hamuli pterygoidei as landmarks for palatoplasty in brachycephalic airway obstruction syndrome surgical treatment

Complications following laryngeal sacculectomy in brachycephalic dogs

Anaesthesia of brachycephalic dogs

Nursing: The Cornerstone of Care

Initial Broadcast: Friday 26 March (Stream 4 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

This year’s BSAVA virtual nursing stream examines how we can provide the best nursing care for some of our most critical patients. With well-known and international speakers we will discuss how to gain intravenous access in collapsed patients, place and maintain urinary catheters, monitor high dependency patients and look into how we can help patients suffering with nausea.

Pre- recorded webinars will provide further insight into nursing critical patients and advanced treatments that are becoming available.

Key Learning Objectives

• Improve your understanding of the various types of catheters, when to use them, how to place a central line catheter and the various tricks to place catheters successful in difficult veins
• Improve your urethral catheterisation and nursing of a blocked bladder
• Update your knowledge of bleeding disorders
• Describe options for the treatment of nausea and how to care generally for the patient with pancreatitis

Lecture Summaries

Tame that vein

Bad veins: how to get IV access when all the veins have gone - Amy Newfield (USA)

Attendees will be taught a variety of different techniques of IV catheter placement on “naughty” veins. Catheter selection and vein selection will be discussed. A variety of trouble shooting methods will be reviewed of how to get catheters in difficult veins. Videos and step-by-step pictures will be shown to help participants conquer “naughty” veins.

Intravenous catheter care and maintenance - Sophie McMurrough (UK)

As nurses we place intravenous (IV) cannulas on a daily basis. Once placed, it is important to stay up to date on how to successfully maintain and care for cannulas to prevent complications and nosocomial infections. Catheter care should form part of our patient’s daily checklist to guarantee patency and check for signs of complications. From aseptic technique and preparation to handling and personal protective equipment (PPE), these are all factors to consider.

Team urology

Don’t hate urinate: urethral catheterisation - Sophie McMurrough (UK)

Urinary catheters can be placed for a variety of reasons from stranguria to spinal surgery. It is a useful skill for a nurse to master and utilise in practice. There are multiple different techniques to follow depending on the sex and species of the patient. Learn about the different types of catheters, how to successfully place, measure and monitor in practice.

Urine for a treat: nursing the blocked bladder - Kathryn Latimer-Jones (UK)

Urinary tract obstruction is a common, potentially life threatening emergency which requires immediate attention. Over-filling of the bladder causes an increase in pressure within the bladder, ureters and kidneys resulting in decreased glomerular filtration rate (GFR). The reduced GFR leads to reduction of urine production and excretion of potassium and acids. Without prompt recognition of the condition and immediate treatment, this can give rise to azotaemia, hyperkalaemia, metabolic acidosis and hypovolaemia. Many of these patients present cardiovascularly unstable secondary to these fluid deficits and metabolic derangements. After confirmation of obstruction, the patient is likely to need a period of stabilisation prior to sedation or general anaesthesia to allow for the obstruction to be relieved. Intravenous fluid therapy (IVFT) plays a vital role in the stabilisation of these patients. Bolus therapy with a balanced electrolyte solution should not be withheld in order to correct hypovolaemia, hyperkalaemia and metabolic acidosis. Severe hyperkalaemia can be life-threatening and the cardiotoxic effects of hyperkalaemia can greatly increase anaesthetic risks. IVFT will not only to help improve tissue perfusion but will also dilute the potassium lowering its serum concentration. Other stabilisation methods in severely hyperkalaemic patients may include the use of calcium gluconate, and insulin and dextrose.

Does all bleeding eventually stop..?

Common coagulopathies - Laura Rosewell (UK)

Coagulopathies are commonly encountered in practice, and the veterinary nurse plays a key role in the triage, diagnostics, treatment and nursing care of the bleeding patient. In order to provide the best possible care for these patients, it is important to understand the types of coagulopathies seen in practice, the patients they commonly affect, the clinical signs we see, and how these conditions are diagnosed.

This session will discuss how coagulation occurs in the body, the pathways involved, and what happens when these go wrong. We’ll examine the common congenital and acquired coagulopathies nurses encounter in practice, and discuss the common diagnostic tests performed.

Nursing the bleeding patient - Holly Witchell (UK)

We will discuss how to care for these patients in regards to patient handling, blood sampling and how to preserve these delicate vessels. We will also talk about monitoring for further deterioration and how to administer blood component therapy safely and what type of blood products to use and when.

Curb the queasiness

What can you do for the nauseated patient? - Laura Rosewell (UK)

Many inpatients present with anorexia, vomiting and/or diarrhoea, but nausea, in comparison, is a more subtle clinical sign. It is also something that veterinary nurses can play a large role in to maximise patient wellbeing, encourage voluntary food intake, and expedite a patient's recovery and discharge from the hospital. This session will examine what nausea is, the signs we commonly see in our nauseated patients and how we can improve these as nurses, both pharmaceutically and through non-pharmaceutical interventions.

Caring for the pancreatitis patient - Holly Witchell (UK)

Pancreatitis can lead to many other co-morbidities in our patients, in which they can become very critical patients that need intensive nursing care. We will discuss what signs of deterioration to look for, analgesia, sepsis, fluid therapy and nutrition.

Supplementary On Demand Content

Webinar    Addison's disease: the great imitator - Sophie McMurrough (UK)

Webinar    Hello haematology - Laura Rosewell (UK)

Webinar    Tubes, tubes and more tubes: nursing the high dependence patient - Elle Haskey (UK)

Additional BSAVA Resources

Orthopaedics

Initial Broadcast: Saturday 27 March (Stream 1 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Lameness is one of the most common presentations seen in general practice. This series will be both practical and interactive, with top tips on getting the most from your lameness examination, how to decide if it is orthopaedic or neurological, and a look at favourite orthopaedic myths.

Pre-recorded resources will cover a pragmatic approach to elbow dysplasia, hip replacement considerations and post cruciate repair lameness.

Key Learning Objectives

• Improve your ability to distinguish between orthopaedic and neurological gait abnormalities
• Develop a better understanding of the information that can be obtained during lameness examinations
• Learn about some ‘myths’ in orthopaedics as seen by orthopaedic surgeons
  

Lecture Summaries

Getting the most from your orthopaedic exam in the lame dog

Sponsored by

Orthopaedic exam review - Ben Walton (UK)

In this highly practical and clinically-applicable presentation, I will demonstrate how to approach the orthopaedic examination in order to maximise the amount of diagnostic information that can be gathered in a short time. It will be based mainly on video footage demonstrating various aspects of the examination, including practice tips on patient restraint and performing important manoeuvres. After this presentation and Miranda Aiken’s on subjective gait evaluation, myself and Miranda will participate in a live discussion regarding various aspects of the orthopaedic evaluation of dogs and cats.

This session will be heavily orientated towards the first-opinion clinical setting, and aims to provide delegates with useful tips and tools that can be applied to help improve the efficiency and usefulness of the orthopaedic consultation.

Visual gait analysis and how to be objective - Miranda Aiken (UK)

In the second part of this session on orthopaedic examination, we will discuss visual gait analysis. This is an extremely important part of an orthopaedic examination, being necessary to determine which limb is affected as well as the severity of the problem. The session will discuss how best to perform gait analysis, as well as what to look for and how to gain the most information from this part of an examination. The aim of the session will be to increase confidence in performing visual gait analysis so as to aid in ability to correctly diagnose orthopaedic disease.

Is this lameness orthopaedic or neurological?

Ben Walton (UK) & Bianca Hettlich (CH)

For most of us who see orthopedic and neurologic gait abnormalities in cats or dogs, differentiating the two is not difficult. We look for obvious deficits such as ataxia or paresis to confidently walk down the neuro route, or evaluate with a few practiced maneuvers joint effusion, instability or pain, taking us readily down the ortho path. Of course, there is more to this, but we are often quite lucky that most of our patients present with relatively obvious signs of ‘neuro or ortho’. But what of the sneaky ones - the ones that have such an obvious lameness but despite our looking and walking and testing and probing do not give up the cause for it easily? In this session, we dive deeper into the subtle nuances between orthopedic and neurologic lameness and how to hopefully determine, which direction to pursue with further diagnostics and treatments.

It can sometimes feel challenging to decide whether a gait abnormality is related to musculoskeletal or neurological abnormalities, but the differentiation is important to plan further diagnostics, or even refer appropriately! This determination is rarely ever done on the basis of further investigations, no matter how advanced. It is almost always achieved on the basis of clinical history, gait evaluation and clinical examination.

This session will draw on the experience of two clinicians who are well-used to investigating and managing both musculoskeletal and neurological gait abnormalities. Aimed at providing easy-to-remember, practical tips, the speakers will guide the delegates through useful aspects of the clinical history (what to ask), gait evaluation (what to look for) and clinical examination (what to test), that will give them the best possible chance of correctly identifying the cause of lameness in future patients.

My favourite orthopaedic myths

Sponsored by

My favourite myths around FHO -  Bianca Hettlich (CH)

Femoral head and neck ostectomy is a salvage procedure for various conditions affecting the coxofemoral joint of cats and dogs. Considering that it is a relatively common procedure done by general practitioners and specialists alike, it is fraught with wide-ranging options, some labeling it as a perfectly innocuous solution to many hip problems and others as a sure method to cripple the animal. Never in large breeds, perfectly fine in cats, never bilaterally, simple salvage after total hip prosthesis gone bad – not much to be found in the veterinary literature on these opinions. The goal of this talk is not to argue for or against FHO as a surgical option. It is aimed at evaluating different clinical situations and possible treatment options, and other considerations to help improve function after FHO if this was the chosen treatment.

Cat fractures will heal as long as the two bone ends are in the same room - Miranda Aiken (UK)

In this session, I will discuss one of my favourite orthopaedic myths: cat fractures will heal as long as the two bone ends are in the same room. I remember first hearing this as a veterinary student, believing for many years that cat fractures were pretty much bound to heal however they were treated and very unlikely to suffer complications.

There is very little in the literature regarding these common injuries, giving a limited evidence base for our decision-making. There is, however, some recent evidence showing that feline fractures suffer from exactly the same complications as canine fractures. We will discuss this evidence, aiding us in making the best choices for our feline patients and ensuring they have the best outcomes possible.

Supplementary On Demand Content

Webinar    Why is my dog still lame after cruciate repair? - Miranda Aiken (UK)

Webinar    My pragmatic approach to elbow dysplasia - Bianca Hettlich (CH)

Webinar    Does my patient need a hip replacement? - Ben Walton (UK)

Additional BSAVA Resources

Cytology for Vets and Nurses

Initial Broadcast: Saturday 27 March (Stream 2 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Improve your cytology in a blended module that starts with a few pre-recorded lectures covering the theory and practice of cytology and then moves on to live discussions about how to improve our cytology in practice and some of the challenges that we might face in diagnosing (or excluding) cancer and an interactive session.

Additional resources will be provided to take back to your practice laboratory to help you deliver better cytology for your patients

It is recommended that delegates view the related On-Demand webinars for this module, prior to attending the Live Sessions.

Key Learning Objectives

• Identify how we can improve a practice's cytological capabilities by better sampling techniques and initial assessment
• Develop your skills in identifying tumour cells and then learn to use the results better
• Test your cytological skills in an interactive format
  

Lecture Summaries

Improving your practice's skills in cytology 

Sponsored by

Common mistakes in sampling - Paola Monti (UK)

Optimal cytology smears, correct sample handling and contextualisation of the finings with the clinical history are all essential steps for achieving an accurate cytological diagnosis. Good quality cytology smears provide excellent morphologic details of cells and infectious agents, often allowing to differentiate between inflammatory and neoplastic processes, identify the tumour type and its behaviour (benign or malignant). When performing a fine-needle aspirate (FNA), the aim is to produce a monolayer of cells with minimal cell rupture. An incorrect technique can produce unsuitable samples precluding adequate evaluation and identification of the cells.

Another common pre-analytical mistake in cytology is to collect a single aspirate, especially from larger masses. A single mass may contain areas of necrosis, inflammation, neoplasia or normal tissue cells and a single slide is unlikely to be representative of the entire lesion. If a mass is fluid-filled, collection of fluid and adjacent solid areas would be recommended, as fluid cytology alone rarely reveals the nature of the surrounding mass. Labelling of the slides with patient name and origin of the FNAs is another crucial step. The importance of sample handling before processing and staining should not be underestimated. Fluid samples should be collected in the correct tubes and adequately stored; unstained cytology slides should not be exposed to formalin fumes.

Finally, adequate staining procedures are essential to guarantee and highlight the cellular details that are required for the diagnosis. Taking care of all these simple steps will prevent the most common sampling mistakes, increasing the diagnostic power of cytology.

Common mistakes in interpreting - Elizabeth Villiers (UK)

When interpreting cytology, it is vital to consider the clinical history and appearance of the lesion as well as the cytological appearance and to have likely differential diagnoses in mind. Organisms may not be visible in infected lesions if antibiotics are given before sampling. Bacteria are rarely seen in septic arthritis. Fungi and mycobacteria can be difficult to see with routine stains. The lesion may have mixed pathology such as focal areas of necrosis or inflammation within a tumour and sometimes the fine needle aspirate may harvest only some of these components and not be wholly representative. Hence if neoplasia is suspected but only inflammation is seen, resampling different areas would be recommended.

We are familiar with looking for criteria of malignancy to make a diagnosis of neoplasia. However, hyperplastic or dysplastic cells can sometimes be impossible to distinguish from neoplastic cells, since all three can show criteria of malignancy. This is a particular problem of mesenchymal cells because the fibroblasts in granulation tissue or in inflammatory lesions can resemble the neoplastic cells seen in soft tissue sarcomas. The history and appearance may help distinguish these although biopsy will often be required.

Just as non-neoplastic cells can look malignant, the converse is also true. Some malignant tumours consist of cells which do not display marked criteria of malignancy. Examples include haemophagocytic histiocytic sarcoma, some malignant melanomas and thyroid carcinoma. Knowledge of the clinical presentation and expected pathology will help minimise errors in interpretation. Cytology should never be performed in isolation

Is it cancer?

How does the cytologist do it? - Elizabeth Villiers (UK)

Although there are some exceptions, benign tumours consist of a uniform population of cells that resemble their normal non-neoplastic counterpart whilst malignant tumours generally show variability. In benign tumours cells are small and uniform, with small nuclei and a low nuclear:cytoplasmic (N:C) ratio. Nucleoli may be absent or nuclei may contain 1-2 small nucleoli. When in aggregates the cell arrangement is orderly and neat. Malignant tumours are recognised by identifying cellular, nuclear and cytoplasmic criteria of malignancy:

• Abnormal location for that cell type. E.g. metastatic carcinoma cells should not be present in a lymph node.
• Macrocytosis and karyomegaly with anisocytosis and anisokaryosis
• Cell clusters may be chaotic and disordered with cell or nuclear moulding
• Increased N:C ratio; large nucleus and sparse cytoplasm.
• Bi- and multinucleation; anisokaryosis within one cell is especially significant.
• Multiple nucleoli or a single large nucleolus
• Coarsely stippled to clumped nuclear chromatin
• Frequent/ abnormal mitoses
• Increased cytoplasmic basophilia and / or abnormal cytoplasmic vacuolation or granulation, or excessive secretory product.

The shape and arrangement of cells will help identify the ‘family’ of cells: Epithelial cells are columnar, cuboidal, roundish or polygonal and in cohesive clusters. Mesenchymal cells are oval to spindle shaped and seen individually or in loose aggregates, sometimes with a swirling pattern, with poorly defined cell borders. Round cells are discrete. The quantity and appearance of the cytoplasm distinguishes lymphoid cells, plasma cells, histiocytic cells and mast cells.

What else does the oncologist need to know (TNM)? - Laura Blackwood (UK)

Staging determines the extent of disease in cancer patients, to inform treatment decisions. Recommended staging is strongly influenced by the diagnosis and likely behaviour of the tumour: a diagnosis is essential. Full staging is most appropriate for high grade tumours, and in older patients (identifying comorbidities) or before invasive/expensive treatments. Cytology is particularly useful for superficial masses and those accessible by ultrasound guidance.

Carcinomas and round cell tumours tend to exfoliate well, sarcomas not. Primary tumour extent is assessed clinically and by imaging. Carcinomas, mast cell tumours, and malignant melanomas tend to metastasise by the lymphatic route, requiring assessment of locoregional lymph nodes. The closest node (moving from peripheral to central) is often likely to be the draining node, but lymphangiography can identify unexpected draining nodes in high grade tumours. Identifying and sampling these nodes leads to better staging. Imaging of retropharyngeal, axillary, medial iliac and inguinal nodes by ultrasound or CT is useful: CT allows imaging of sacral nodes e.g. in anal sac adenocarcinoma patients. FNA has a variable rate of false negatives in different tumours: in particular, FNA may be insensitive to oral melanoma metastases. For distant metastases, cytology is especially useful for assessing splenic and hepatic nodules.

Interactive cytology

Paola Monti (UK) & Elizabeth Villiers (UK)

In this case-based live session we will explore and discuss common but still challenging cytology cases using live cytology slide examination. You will be able to see the step by step process of how we examine a slide and how the findings lead us to a diagnosis or differential diagnoses. You will be able to participate in the discussion on each case through the live chat.

Supplementary On Demand Content

Webinar    Cytology 1: the first steps - Elizabeth  Villiers (UK)

Webinar    Cytology 2: inflammatory lesions - Elizabeth Villiers (UK)

Webinar    Cytology 3: common cutaneous and subcutaneous tumours in cats and dogs - Paola Monti (UK)

Additional BSAVA Resources

BSAVA Publications

BSAVA Manual of Canine and Feline Clinical Pathology

Companion Articles

Squamous cell quiz by Kate Sherry (March 2020)

Adipocyte quiz by Niki Skeldon (October 2019)

Cytology quiz by Niki Skeldon (September 2019)

JSAP Articles

A preliminary investigation of the effect of sample collection technique on the cell and RNA content of fine-needle aspirate of five canine tumours 

Current Topics

Initial Broadcast: Saturday 27 March (Stream 3 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

The speed of change within the profession and wider society has been profound in the last 12 months. Join a select group of experts as they reflect on where we are today and what the future may hold.

Key Learning Objectives

• Develop a better understanding of the psychology of uncertainty and how to apply this to veterinary practice during Covid lockdowns
• Discover current insights into the changing dynamics of telemedicine and how to maintain relationships whilst using it
• Learn what a VUCA world is and how this can be an opportunity or a threat to veterinary practice

Lecture Summaries

Mastering uncertainty: communicating to inspire confidence  

Sponsored by

Overview of psychology of uncertainty - Carolyne Crowe (UK)

So much change in 2020 and it hasn’t stopped yet in 2021! The “ifs” the “buts”, the “possibilities” or lack of them….Uncertainty is challenging, draining and can be very unsettling for many and yet nothing is ever certain! How do you manage yourself through periods of change and uncertainty? Do you:

• Spend countless hours and amounts of energy trying to control the uncontrollables?
• Feel anxious and unsure of what you could, should and will do?
• Feel drained by the situation and unsure of where to turn?

If so you aren’t alone, at the end of the day regardless of your role, you are a human with emotions not a robot….so what can you do?

This is an interactive session where we will discuss the impact of uncertainty on how we work, live and feel. We will share practical tools to use and take back to your team to help you feel more settled, less drained and more in control of what you are focusing on during these ever changing and uncertain times. We will discuss the role of the leader and how your role is not to know all the answers but to understand and manage expectations of your team, your clients and yourself to help you lead effectively through change and challenge.

Application of this from COVID lockdown perspective in practice - Alan Robinson (UK)

Lessons from lockdown: telemedicine is here to stay

Sponsored by

Insights into maintaining relationships and changing dynamics with remote consults, communication challenges and opportunities - Brian Faulkner (UK)

Consultations are the successful bricking bricks of all veterinary clinical organisations since they are the hub from which clinical-client-financial-colleague outcomes emanate. Adapting during the COVID pandemic provided an unexpected opportunity to experience the challenges and opportunities of Audio-Visual (AV) Consulting on our ability to manage the clinical, client, financial and logistical aspects of veterinary case management. Many of the challenges were as anticipated; most notably the widening of the ‘information-gap’ that all clinicians experience when they begin the clinical resolution process by acquiring information using only their physical senses – sight, sound, touch, smell…and taste. (The information-gap is the difference between what we actually know about a patient’s physical-physiological status and what we would like to know about a patient’s physical-physiological status.) Not only is a lack of information relevant to the process of resolving physical symptoms, it is relevant to the entire emotional experience of any consultation – but AV consultations in particular. The less information people have, the more uncertainty they feel. This increase in uncertainty is relevant to clinicians, clients and colleagues since uncertainty is a key ingredient of anxiety (‘stress’), especially when coupled with time-pressure (as per my ‘Stress’ equation; “Stress = Uncertainty x Urgency”). That said, AV consulting has its benefits and opportunities. Since a significant feature of case-management is simply knowing if our we are ‘on-track’ (ie as expected), AV consulting is a useful screening tool to touch-base and set, confirm or adjust expectations in many (but not all) clinical cases. In essence AV consulting highlights, is what we already know; an ability to manage expectations about the clinical, client, financial and logistical aspects of a veterinary case – within the limitations of the information we have available – is the foundation upon which successful clinical, client, financial and team morale outcomes are built.

Practice perspective: how have we used it, what have we learned? - Matt Flann (UK)

Video consultation was on the cards pre-COVID. Many practices have used one system another to help continue to work more safety since the first lockdown in March 2020. Telemedicine apps are now part of the fabric of the practice and are here to stay.

In this talk we will be covering the lessons we have learned using telemedicine since we first started in Jan 2020 from practice perspective. This will be broken down into what we have learned within the veterinary team and from the client’s point of view. A case will also be presented for keeping telemedicine in the long-term as one of the communication options of the practice.

Today's VUCA world: opportunity or threat?

Sponsored by

Overview of VUCA - Richard Casey (UK)

Today’s 21st century veterinary world is volatile, uncertain, complex and ambiguous (VUCA). In the past, new technologies and industry trends would take years to develop but, today, they arrive almost overnight. Practicing today involves a managing a diverse team and client base, coping with every rising consumer expectations and treatment costs against the backdrop of a global sustainability emergency. This new world is putting extreme pressure on veterinary leaders to lead in ways not before seen. If we want to navigate our patients, teams, clients and, not forgetting ourselves, through this new ‘normal,’ we need a different approach. Success for our practices, and everyone involved, requires 21st century leadership and, guess what, it may not be as scary as you think. This session explores the opportunities and threats in today’s VUCA world, and how they may impact veterinary practice. We’ll also explore simple tools and techniques for analysing your own VUCA practice, and your personal role in navigating it.

Key themes of change - Liz Somerville (UK)

Even before COVID 19 hit us in 2020, veterinary practices were having to cope with a huge volume of wide-ranging changes across the whole profession. Corporatisation, the development of technology and data management, rising client expectations, a gender shift and retention crisis were all providing a challenging environment for veterinary business leaders. Add in a global pandemic and clients who continue to demand high quality care at competitive prices, that focuses on them as much as their pets, it is no surprise that our leaders and practice teams are under huge pressure. This session will explore how the change management process has had to evolve within veterinary practices to keep up with the fast and rapid changes practice teams have experienced. These changes are happening across every practice and involve managers and leaders, team members and clients. As humans we all react and respond to change differently, some of us thrive on it and others struggle with it, so knowing your people and understanding how to navigate the challenges they are facing will be vital as we move forwards.

Supplementary On Demand Content

Webinar    The true value of a high performing team - Carolyne Crowe (UK)

Sponsored by

Webinar    Conflict resolution strategies for reception: top tips and tactics for the conflict front line - Brian Faulkner (UK)

Webinar    BREXIT: how has it changed the recruitment landscape? - Andreia Dias (PT)

Additional BSAVA Resources

Companion Articles

How to manage conflict at work by Carolyn Crowe (October 2019)

Practising in the Covid-19 era by Alison Lambert (January 2021)

Urogenital Tract Surgery

Initial Broadcast: Saturday 27 March (Stream 4 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Are kidneys keeping you up at night? This module delivers the answers to some key questions, with a focus on ensuring the basics are in place to achieve a comprehensive diagnosis, and allowing the development of the right management strategy for the patient. The module covers key biochemistry and urinalysis, acute kidney injury and nephrolithiasis.

Key Learning Objectives

• Identify when urinary incontinence requires surgical intervention from history, blood tests, urinalysis and diagnostic imaging
• Outline how to identify ectopic ureters and what the surgical options are for urethral sphincter mechanism incompetence
• Be alive to the possibility of urinary tract trauma that is causing urinary leakage and improve your knowledge of appropriate treatment options

Lecture Summaries

The broken tap: when do we need a plumber?

Critical history, blood tests and urinalysis - Alix McBrearty (UK)

Urinary incontinence is a common reason for presentation, particularly in neutered bitches. It is however, important to distinguish incontinence from pollakiuria, polyuria and behavioural problems. This necessitates asking the client the right questions, performing a thorough physical examination, and sometimes checking urine specific gravity. It is useful to establish the timing of the episodes, volume of urine passed and events surrounding the leakage of urine. Animals with incontinence usually present with intermittent or continuous dribbling of urine but can void normally.

Potential causes of urinary incontinence include urethral sphincter mechanism incompetence (USMI), ectopic ureters, neurological abnormalities, detrusor instability and genitourinary tract neoplasia. When incontinence is confirmed, a thorough history, physical examination, neurological examination, urinalysis and aerobic urine culture should be performed. Due to the high prevalence of USMI in adult, neutered bitches and the low cost and risk of treatment, if the results of these steps are consistent, alpha-agonists or estrodiol are frequently trialled prior to further investigations. If the presumptive diagnosis is correct, this treatment is often effective. If not or if the animal does not fit these criteria, further investigations including a complete blood count, biochemistry and abdominal imaging are required to establish the diagnosis.

Imaging the urogenital tract: what test when? - Gawain Hammond (UK)

Diagnostic imaging can be a very powerful tool in the investigation of urogenital disease, with the differing modalities having strengths and weaknesses for the different areas of the tract. Generally, ultrasound would be recommended as the most appropriate first-line investigation for most structures in the urogenital tract, allowing clear visualisation of the internal structure of the kidneys and reproductive structures (ovaries, uterus, prostate, testes). Radiography may allow diagnosis of altered shape or size of these structures but the changes seen are usually less specific than those that can be identified with ultrasound. Ultrasound and/or contrast radiography can be used for assessment of the bladder (with ultrasound usually being more convenient (and allowing guided cystocentesis if required), but care must be taken in interpretation of the bladder wall if the bladder is not particularly distended. For the ureters and urethra, positive contrast radiography (Intravenous urography, retrograde (vagino)urethrography) often allows clearer assessment of the length of these structures. If available, Computed Tomography can be particularly useful for the assessment of ureteric anatomy (e.g. for aberrant insertion/ectopia). In many cases, multi-modality imaging may be appropriate, particularly if investigation for changes in other body areas is required (e.g. metastatic spread from a neoplastic process).

The leaking tap: what's new?

Identifying ectopic ureters: tips and tricks - Laura Owen (UK)

Ureteral ectopia (EU) is a congenital abnormality, in which one or both ureteral openings form with their termination located distal to the bladder trigone. Intramural and extramural phenotypes are recognised, with >95% of canine cases identified as intramural, whilst the majority of feline EU are extramural. Diagnosis may be straightforward in patients presenting with significant urinary incontinence at a young age, but may be challenging in patients with a more atypical presentation, or in those with only subtle abnormalities of their urinary tracts.

In this session, delegates will be reminded of the variable clinical presentation of patients with ectopic ureters, learn about ultrasound findings that may increase their index of suspicion for this condition, find out how to optimise contrast imaging to highlight an abnormal ureter and more about our current gold standard of diagnosis, cystoscopy. This information should enable delegates to more confidently recommend additional diagnostic tests in the correct animals and avoid unnecessary testing in those patients unlikely to have this condition. More patients can then in turn receive appropriate treatment.

USMI when medicine fails: what next? - Alasdair Hotston Moore (UK)

Urethral sphincter mechanism incompetence (USMI) is the commonest cause of urinary incontinence in the bitch. Medical management is the first line treatment (usually with either an adrenergic agent (e.g. phenylpronolamine) or an oestrogenic agent (e.g. estriol). The majority of bitches have a good response to these, but other treatments need consideration in a minority of cases. Before surgery is planned, the clinician should review the diagnosis and consider underlying or secondary factors (such as obesity and urinary tract infection). If the diagnosis is confirmed and these have been considered, surgical management can be offered to the owners. There are several established surgical options (colposuspension, Artificial Urethral Sphincter placement, urethral sling), endoscopic management with urethral bulking agents and some less well established procedures (vaginectomy, vaginal septum transection). The session will look at each of these and make suggestions as to their application.

The burst pipe under the floorboards: how to spot urinary trauma?

Spotting urinary tract trauma - Ed Friend (UK)

This lecture gives an overview of urinary tract trauma, which is a serious presenting complaint in small animal practice but may be initially hard for a clinician to recognise. The presentation will specifically discuss presenting signs and the challenges of how to diagnose.

Treatment options for urinary tract trauma - Laura Owen (UK)

Injury to the urinary tract of the dog and cat is an uncommon, but serious potential sequel to blunt, penetrating or iatrogenic trauma to the caudal abdominal or pelvic regions. Bladder injury occurs most commonly, followed by urethral injury, with only rare occurrences of renal or ureteral injury reported. Preservation of function of the urinary tract is the optimal goal of treatment, but some procedures that achieve this may be technically challenging, require specialist equipment and/or may be associated with a higher risk of complications compared to salvage procedures; thus decision-making must be performed on an individual patient basis and requires consideration of multiple factors. In some cases urinary diversion alone will allow healing of the urinary tract without specific repair.

In this session, we will discuss the possible treatment options for each area of urinary tract injury, with a focus on the bladder and urethra as the most commonly traumatised organs, with the aim of enabling delegates to feel better equipped to provide management or advice for affected patients.

Supplementary On Demand Content

Webinar    The blocked dog: what are the surgical options?  - Ed Friend (UK)

Webinar    Urinary tract trauma: working through case examples - Alasdair Hotston Moore (UK)

Additional BSAVA Resources

Chronic Pain

Initial Broadcast: Saturday 27 March (Stream 1 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Chronic pain is widespread in veterinary patients, especially as our patients live longer and are more likely to suffer from degenerative joint disease among other conditions that cause pain. In this stream we will discuss how to assess pain and quality of life, how to build a plan with the owners and the role that nurses can play in managing a patient's pain and supporting owners.

Key Learning Objectives

• Explain what can, and what cannot be achieved in a 10 minute consultation with a case that is in chronic pain
• Describe how to engage owners in the management of their pets chronic pain
• Describe how to construct a pain management plan
• Update your knowledge on pharmacological and non-pharmacological management of pain using both older drugs and the newer agents

Lecture Summaries

What can be achieved in a ten minute consult?

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Establishing pain through owner questioning - Matt Gurney (UK)

Where to start can depend on whether the consultation was booked to specifically discuss pain or whether pain was detected as part of a routine examination. Validated pain scores are an essential resource to provide a structure to owner questioning. For the planned consultation these can be emailed to the owner prior to the consultation or where pain is noted in a routine consultation can be given to the owner for completion after the consultation. Pain scores are really useful not only for providing a baseline prior to initiating treatment, but as a basis for discussion and further history taking. I find they stimulate owners to mention additional information that can be useful. Options to consider are;

• Canine Brief Pain Inventory (CBPI)
• Liverpool Osteoarthritis in Dogs (LOAD)
• Helsinki Chronic Pain Index (HCPI)
• Feline Musculoskeletal Pain Index (FMPI)
• Vetmetrica Health Related Quality of Life System

During history taking I aim to establish 3-5 pain behaviours to use as a baseline. These may be new behaviours associated with pain or behaviours that the pet doesn’t not do anymore which could be attributed to pain. During the introduction session we will cover the different attributes of these pain scoring systems and when you may choose one over another.

What can be achieved in a ten minute consult - Samantha Lindley (UK)

Chronic pain takes time to develop and will take time to resolve or manage, therefore the first thing to emphasise to the client is that this initial consultation (or from wherever the clinician is picking up the case) is just that: initial, and that there will be a plan to progress the treatment. The first consultation should identify the owner’s concerns; try to establish the sources and classifications of pain present; identify some clear, initial outcome measures; and begin the process of reducing the patient’s suffering.

Owner concerns include: their pet’s suffering; inability to exercise; withdrawal and reduced interaction (especially cats); unwanted changes in behaviour (including toileting irregularities; restlessness at night; fearful behaviours); possible side effects of medication; absence of a firm diagnosis; and a potential misunderstanding of what can be achieved with chronic pain problems (i.e. management versus cure). The clinician should observe movement, gait and postural abnormalities.

The examination should be performed on as relaxed a patient as possible; aim to establish the presence or absence of secondary sensitization; and minimize pain and fear. From the history and the examination, the sources and classification of pain may be established; the clinician should aim to identify at least one sign of suffering and/or physical outcome measure, start on appropriate analgesia and arrange a review.

Owner engagement in chronic pain

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Managing expectations: client education - Samantha Lindley (UK)

Owners often need help to understand the difference between acute and chronic pain; that often we cannot cure the problem; and that the main priority is to reduce the patient’s suffering (which may include side effects and restricted access to resources).

Suffering is assessed by changes in individual behaviour and chronic pain is a chronic stressor. We cannot teach our patients not to feel stressed by the sensation of pain and owners must understand that the treatment of chronic pain necessarily involves more veterinary input because of this.

A dynamic approach will usually begin with pharmacological analgesia, but may be followed with more physical treatments to help reduce the amount of medicine required and to maintain the animal’s strength and mobility. The clinician should stay open to discussing any approach and be prepared to explore other avenues if the owner requests them.

Medicines often a carry a negative association for many clients and the clinician should be clear in explaining expected outcomes; possible side effects; monitoring; and frequency of review. Getting the owners involved in weight control; physiotherapy exercises; comfort; improved core territory; and replacement of lost resources will help with compliance by giving them a sense of control over their pet’s pain.

Monitoring pain therapies - Matt Gurney (UK)

Chronic pain can seem like trial and error sometimes. Having a firm understanding of the pet’s pain and a baseline pain score is essential for judging the efficacy of any future therapies. The identification of pain behaviours is recommended.

When asked what they want for their pet, most owners will reply that pain reduction and maintenance of quality of life is their goal. I do ask this directly to owners so we can establish common ground and start to manage expectations. However, when asked to rate quality of life as a direct question in the Canine Brief Pain Inventory owner response can vary according on the message they wish to convey to you. We will discuss this point in the session. Questioning across health domains associated with quality of life can give us vital information and this is the basis of the Vetmetrica scoring system. I adapt the pain/HRQL scoring system I use according to the owner – which can help with the spectrum of pain presentations – another point for discussion.

Writing down treatment goals and pain behaviours helps owners recall the consultation and draws focus to each aspect of management. Highlighting the importance of each intervention is valuable to the owners understanding.

Building a pain management plan: where to start

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Drug free management - Samantha Lindley (UK)

Owners must understand that medical analgesia is often vital to reduce suffering, especially at the start of the treatment of chronic pain. We cannot, by explaining that chronic and acute pain are distinguishable by the threat they pose to survival, teach our animal patients to be to be unafraid of their pain. We therefore need to reduce both the sensation and the emotion of pain and this process sometimes needs medication. Where the pain field has become exaggerated and expanded, physical therapies may be contraindicated until that field has been reduced.

Rather than “drug free” (which tends to give “drug use” a negative sense), the physical therapies should be thought of as integrated; relatively safe; and relatively free of side effects. Their use may reduce the use of medicines; may positively contribute to the animal’s health and mobility; and, often, indirectly contribute to owner compliance because the therapist can continue to educate and to build on the plan.

Physical therapies include but are not limited to: acupuncture; physiotherapy and hydrotherapy; laser; manipulation; and myotherapies of various kinds. This lecture will briefly describe the most common therapies, their indications, advantages and possible drawbacks.

Foundations of drug therapy: Into building the plan and an overview of NSAIDS - Stuart Carmichael (UK)

Medical treatments provide the cornerstone of most pain management plans, but how effective are they in addressing chronic pain? Osteoarthritis is a major cause of chronic pain and it is an excellent example of the need to properly understand how pain is being generated before attempting to resolve it. Management involves controlling the local disease, a source of nociceptive stimulation, while at the same time separately addressing non-nociceptive mechanisms, neuropathy and central processing.

NSAIDs have been used widely and successfully to address pain in OA. We almost know too much about these drugs and our knowledge restricts our use and client acceptance due to risk of toxicity. However, there are other limitations in managing chronic pain using NSAIDs. The use of unlicensed medications to treat chronic pain about has increased greatly. But are they safe or effective? Properties do not easily translate between species as we found in the past with NSAIDs and more recently with Tramadol.

Medical agents are important tools in building a management plan but due consideration must be given to therapeutic targets, effectiveness, duration of use, practicality and common sense.

Drug management in chronic pain: when basics are not enough

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Older drugs - Matt Gurney (UK)

This session will consider analgesic management for pain beyond the licensed options. Our current licensed options for pain management are NSAIDs, paracetamol (as Pardale V), tramadol and grapiprant in dogs and NSAIDs in cats. Starting with those options we will briefly address which one to choose as a first line for pain. We will cover how to work out when to add a second analgesic and what that analgesic should be. Consideration should be given to the type of pain we are treating and an assessment of the impact of the pain on the pet.

• Paracetamol – do we know which dose we should be using?
• Gabapentin – which pain types are best suited to gabapentin, what is the evidence and how do we avoid sedation?
• Pregabalin – when should we consider pregabalin? What does the evidence teach us?
• Amantadine – should this be our second line in addition to NSAIDs and why?
• Memantine – when should we consider memantine?
  

New approaches - Ian Self (UK)

In this introductory session we will consider new and emerging approaches to the pharmacological management of chronic pain conditions. This is an exciting field with an expanding range of options including recently licenced novel classes of NSAIDs (grapiprant), cannabidiol (CBD) compounds, anti-nerve growth factor monoclonal antibody treatment, and even the use of more traditional agents such as ketamine to ‘break the pain cycle’ and effectively reset the pain baseline.

We will take an evidence-based approach, where it exists, and try to assist participants in making logical pain management plans where the more traditional agents and methods have proven insufficient to effectively treat a particular case. We will also emphasise that it is very unlikely that any of the novel therapies used as the sole analgesic will sufficiently control pain, and that a holistic approach is essential to ensure the best outcome for our patients.

Supplementary On Demand Content

Webinar    Teaching owners to recognise pain? - Emma Love (UK)

Webinar    What can we do about the pain of arthritis?  - Stuart Carmichael (UK)

Webinar    Basics of acupuncture  - Sam Lindley (UK)

Additional BSAVA Resources

BSAVA Publications

BSAVA Guide to Pain Management in Small Animal Practice

BSAVA Manual of Canine and Feline Anaesthesia and Analgesia

Companion Articles

How to…manage the osteoarthritic dog by Hannah Capon and David Dycus (May 2018) 

JSAP Articles

Evaluation of renal and hepatic blood value screening before non-steroidal anti-inflammatory drug administration in dogs

Long-term use of non-steroidal anti-inflammatory drugs in cats with chronic kidney disease: from controversy to optimism

The lack of analgesic use (oligoanalgesia) in small animal practice 

Oncology Myths and Legends

Initial Broadcast: Saturday 27 March (Stream 2 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

There are many misconceptions amongst owners and vets about the treatment of cancer. In this module a team of the UK’s leading oncologists from referral hospitals will come together and identify the commoner misunderstandings. They will suggest how owners can be helped through the prejudice and misinformation (particularly from Dr Google) that surround cancer in pets. They will also show how you can do a lot of oncology in practice without referring for everything. Guidance on the most up to date thinking on incidental tumours, mast cell tumours and feline abdominal neoplasia will also be covered.

Key Learning Objectives

• List common side effects of chemotherapy in dogs and cats and describe how to reduce the owners and colleagues’ fear of these
• Develop a viable plan for how to deal with an incidental mass which takes into account the client and patient needs
• Describe how to deal with a client who has researched a miracle ‘cure for cancer’ on the internet
• Clarify critical client communication issues in oncology cases

Lecture Summaries

Chemotherapy: common myths debunked

Giving chemotherapy is too dangerous to the cat - Owen Davies (UK)

Many clients are very unnerved when the prospect of chemotherapy for their cat is discussed, fearing that their pet will endure the level of adverse effects (AEs) that many human chemotherapy patients do. While this preconception is perfectly understandable, it is a highly inaccurate! The majority of cats receiving chemotherapy either experience no AEs, or mild, self-limiting AEs. This difference arises from compassionate dosing of our feline friends. Since most of the AEs of chemotherapy are dose-dependent, rather than idiosyncratic, it is perfectly possible to control the risk by altering the doses of chemotherapy the cat receives. Although this approach also compromises cancer control, it still produces an acceptable outcome since cats have a much shorter life-expectancy than people; a remission of 2-3 years is often very acceptable for a cat whereas a cancer-free interval of decades (at least) would be the goal for people.

This lecture discusses avoiding and managing some of the common chemotherapy-associated AEs in cats, giving tips on how best to educate cat owners that chemotherapy is a safe and ethical treatment for their feline companion.

Giving chemotherapy is too dangerous to the dog - Sarah Mason (UK)

Chemotherapy is becoming more widely available and advocated as a treatment for many neoplastic conditions and is a generally well tolerated treatment which affords excellent quality of life in most patients. Some clients however are reluctant to pursue chemotherapy treatment for their dog due to concerns related to possible toxicity, often extrapolated from human medicine. This presentation will outline the risks, possible side effects and approximate frequency with which these are reported with the cytotoxic chemotherapy drugs commonly used in canine patients. The session will discuss toxicities associated to vinka alkaloids, anthracyclines and alkylating agents commonly used in the treatment of canine neoplasia, and give practical tips on how to avoid these, and to manage them should they occur.

The aim is to demonstrate that quality of life in veterinary oncology patients is paramount and to give practitioners the tools to recommend chemotherapy with confidence and to discuss the risk of chemotherapy toxicities in canine patients with clients.

How to deal with the incidental mass

Can we ever assume a mass is a lipoma? - Michael Macfarlane (UK)

In this lecture, I will cover the approach to the incidentally found cutaneous and subcutaneous mass. This can be a very broad spectrum from a pinpoint mass to a football-sized tumour which wasn’t there yesterday! The lecture will cover:

• Is it OK to remove a tumour without knowing what it is?
• Which masses are deserving of some additional testing or staging before surgery?
• A brief discussion on surgical margins.
• That I do sometimes assume a mass is a lipoma!
  

Incidental abdominal masses in dogs - Sarah Mason (UK)

As more animals undergo imaging evaluations in veterinary practice, and as these assessments increase in sensitivity, the possibility of finding an “incidentaloma” (incidentally found mass) increases. These are occasionally found in canine patients, often when staging is performed for more obvious external conditions. In the limited veterinary literature on abdominal incidentalomas, four percent of dogs undergoing abdominal ultrasonography in one study were found to have adrenal masses, and nine percent in another study on CT. Splenic masses are a relatively common incidental finding and one report documented that 30% of incidentally found splenic nodules were malignant. These findings are challenging for vets and clients in attributing relevance, especially in patients with other neoplastic diseases.

This presentation will focus on common presentations of abdominal incidentalomas and will use case studies to demonstrate decision making for these patients. The aim is to develop awareness of the significance of incidentalomas and skills in how to manage them.

The miracle cures: how to deal with Dr Google

Will changing my pet's diet help to cure the cancer? - Owen Davies (UK)

It is common for pet owners to seek advice on nutrition, herbs and dietary supplements when their best friends are diagnosed with cancer. A growing industry has developed to serve this need, and there are many, sometimes very compelling, sources of advice to be found online. Evidence to support such nutritional interventions in veterinary patients is sparse however. Many “cancer” diets stem from the alteration of cellular energetics seen in some cancers (the “Warburg” effect), however the importance of this effect, and clinical benefit of diets with different carbohydrate levels, has not been demonstrated in veterinary cancer patients. Currently the recommendation is to feed a balanced, cooked diet which is palatable to the animal, seeking to maintain a stable bodyweight. If cachexia develops, dietary alteration to support lean body mass and supplementation to minimise the associated inflammatory state (e.g. with omega 3 fatty acids) may be appropriate. A number of nutraceutical compounds are also widely touted as beneficial to veterinary cancer patients; since there is often no evidence, or weak evidence to support use of these compounds, it may be more pragmatic to consider their risk of adverse effects or interactions with other drugs before supporting or opposing their use.

I have read on the internet about… Using EBM to combat miracle cures - Sarah Mason (UK)

Evidence based medicine (EBM) is the conscientious, explicit, judicious and reasonable use of modern best evidence in making decisions about the care of individual patients. EBM integrates clinical experience and patient values with the best available research information. This presentation and discussion will include a summary of evidence-based medicine, the quality and relevance of this in veterinary Oncology decision making and how to use this to assist in empowering and including owners in the treatment decisions for their pet. The concept of goal driven care will also be discussed. The common situations in which owners present questions around their own research, motivations and questions about their pet's care will be outlined. We will discuss how to navigate this and how to guide clients to useful and appropriate sources of information.

The session will offer practical tips on how to answer queries from owners regarding 'miracle cures' using real life experiences to illustrate this. The aim is to develop tools to assist in supporting clients need to be involved in their pets care and treatment decisions.

Client communication: it's a two way street!

Top tips for getting the message across without losing the patient

Part I - Linda Ryan (UK)

The diagnosis of a pet’s cancer can be an emotional one for caregivers. Additionally, along with shock and grief, it can be the start of a long journey of decision-making, large financial and time commitments, home nursing, and more. Caregivers’ wishes for their pet may vary, from wanting to do everything possible, to not proceeding. Client‘s concerns may be diverse - from whether they can cope with caring for a pet with cancer, to whether their pet can cope with cancer treatment. No matter what decisions are made, or a treatment paths are followed, the veterinary oncology team must work with caregivers to build a strong & trusting working relationship. In this way, we can guide them through the reality of cancer treatment, prognoses & realistic expectations, ethical & welfare-centred outcome objectives, & treatment options.

This session will focus on some of the potential barriers perceived by clients, and how the oncology team working collaboratively, & in a multi-disciplinary way, can support the caregiver empathetically, considering theirs and the pet’s perspective, to facilitate optimal and ongoing patient care. Getting this right from the start is crucial, and can make all the difference to successful interventions, & to how the pet & client proceed through are plans.

Part II - Michael Macfarlane (UK)

We are all very different!

• Some owners want to know every detail of their pet’s condition;
• some want to put the care completely into our hands.
• Some owners will know that their dog drinks an average of 714mls of water a day;
• some will not have any idea their dog is drinking more than normal.

Neither is right or wrong or even good or bad but both owners want their pet to feel well and stay well for as long as possible. For these different owners, the way to reach the best treatment decision for their pet may be very different.

This lecture will use my experience of working in a multi-disciplinary team and with nurses who have been a big part of owner communication. I will let you know what I feel has worked well and what hasn’t and my top tips for stress-free communication.

Supplementary On Demand Content

Webinar    Are all feline abdominal masses lymphomas? - Sarah Mason (UK)

Webinar    Giving chemotherapy in practice is not too difficult! - Sarah Mason (UK)

Webinar    Mast cell tumours: what to do when  - Michael Macfarlane (UK)

Additional BSAVA Resources

The Profession Today: Recruitment and Retention

Initial Broadcast: Saturday 27 March (Stream 3 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Attracting, recruiting and retaining great vets and nurses is a critical part of building a successful team, and with the cost of a poor hire estimated to be £25-35,000, you want to get it right first time. This series of lectures will uncover some of the key factors to be aware of, and why it may be time to rethink the traditional approach.

Key Learning Objectives

• Develop your understanding of how to create a vet and nurse friendly team environment
• Improve your use of social media in recruitment and writing a compelling advert
• Review the different tools available for selection and how to use them to identify the essential attributes of excellent employees
• Identify the role of practice culture in retention and the effects of intrinsic and extrinsic motivation

Lecture Summaries

Build it and they will come: creating a vet and nurse friendly practice

Ernie Ward and Alan Robinson discuss the owner and the team perspective, what does it look and feel like - it's not just about perks.

Team perspective - Alan Robinson (UK)

I'll bet no-one had 'Global Pandemic' on your 3-year plan at the beginning of the year.... So far over this COVID lockdown we have had major disruption to all the critical business areas - profitability and financial strategies, team harmony and resilience, clinical care and vet performance and client experience and resilience - managed through the leadership lens of your unique COVID experience. Some of the consequences have been surprising and some down-right paradoxical. There are a lot of lessons to be learned from our experience so far... and I suspect, a lot more to come. That still leaves us, and our teams, in the liminal space of uncertainty and ambiguity. Time for planning, priority and perspective.

For some of them it is just a job. But it is their safety and security and most of them (and you maybe) are on the edge of meltdown. From a team perspective we are going to talk about the three fundamental Flow and Trust pillars that you can provide at work:

• Safety - physiological and psychological - and how they are linked. How does our veterinary neuroticism and need for meaning affect our sense of safety?
• Connection and belonging - how does our innate Social Protection System deal with our particularly strong vet need to belong, to be liked, to be accepted as well as the need for intimacy, mutuality, and relatedness.
• Self Esteem - how we balance Confidence (self-worth) with Competence (mastery). Are we just trying to be useful... or do we actually feel valued?
  

Productivity is more than a number: rewarding and recognising team excellence - Ernie Ward (UK)

To recruit and retain the best staff, you must reward them well. You must also measure their contributions in order to determine if they’re positively contributing to your practice. For most practice owners and managers, this means tracking revenue and financial productivity. For Dr. Ernie Ward, revenue is important, but not the only metric he relies on to recognize and reward excellence. Dr. Ward shares several other key performance indicators you should be tracking for your team.

Desperately seeking vets and nurses: how do I make my practice stand out?   

The unfair advantage: a digital strategy to fill your vacancies - Dave Nicol (UK)

Hiring clinical team members is harder today than ever before. A shortage of qualified and applicants has left many practices scratching their heads wondering where all the vets and nurses have gone. The old model of posting an advert on a job board and expecting the applications to roll in doesn’t work like it used to. Nowadays, successful recruiters must also be masters of digital marketing. To fill a vacancy, you are going to have to get a message that stands out, in front of as many vets and nurses as possible. You are going to need a campaign plan that ensures you deliver your message to the relevant places in a way that gets views, lots of views.

Your advert is going to start life as a long-form written document that is the foundational piece of content. This one piece of content is then cut up into as many as 15 smaller derivative media types including video, Instagram, Facebook and LinkedIn posts. Story arcs for Facebook and Instagram. Cross-posting/sharing onto influencer networks… And paid traffic advert campaigns.

In this session, I'll show you how to take a basic advert and turn it into a veritable feast of derivative content offerings that will help you reach your desired candidates. Practices may find this slightly overwhelming, but it is worth the investment because being able to reach the employment market in this way allows you a very big competitive advantage when it comes to fills your vacancies.

Writing a compelling advert - Brian Faulkner (UK)

A job advert is also an opportunity to market the practice and impress applicants and other interested parties. An advert will need to be designed that will attract candidates that meet the job description and should include:

• The job title, practice name, logo and website address
• An eye-catching headline
• Brief description of the practice and what it does
• Summary of the job such as, responsibilities, duties and hours
• The skills and abilities required to make an application considered
• The benefits that go with the post and employment
• Ways to apply such as, either an application form, application letter or cv
• Contact details for further information if appropriate or required
• The closing date for applications
• You may wish to include any additional relevant accreditations or awards that the practice may have.
  
  

Good team players are found not made: how to choose wisely

Review of different tools and criteria for selection - Carolyne Crowe (UK)

I’m a strong believer that very few people intend to be the bad team player, but too often we find ourselves working with others who seem to be pulling in a totally different direction or are just out for themselves. What can you do during the recruitment process to help reduce the chance of selecting the wrong person for the role or for your team? Are you 100% clear with who and what you are looking for in the first place-just a vet, a nurse, someone to fill the gap? Which behaviours are you looking for in your new employee? What values match the values and culture of the team and the practice? Are you even sure of the values and culture in your team? If not, how can you be sure to recruit the right person that will fit and be a “good team member” that you are looking for? These are some fundamental questions to be asked prior to recruiting anyone, skills can be learnt (as long as the relevant qualifications are present), forget the letters after the name and look at the person, the values and think about the match you are making.

During this session we will discuss how you can attract and retain the right people for your team.

How I hire: essential attributes of excellent employees - Ernie Ward (UK)

Dr. Ward offers the top attributes his management teams evaluate when hiring team members.

I’ve got ‘em, now how do I keep 'em? The keys to retention    

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Why culture matters  - Ernie Ward (UK)

Culture: a beguiling term used so casually that it’s actual impact is often overlooked. Culture isn’t something that happens; it is created. Culture is the foundation upon which patient care, client service, financial success, and job satisfaction is built upon. Culture requires considerable thought to construct and constant effort to maintain. In this session, Dr. Ernie Ward explains why veterinary practice culture matters to him and why it should matter to all of us.

Intrinsic vs extrinsic motivation - Alan Robinson (UK)

Why culture matters, creating a culture and framework that really works and intrinsic vs extrinsic motivation. The carrot-and-stick approach to motivation worked well for typical tasks of the early 20th century – routine, unchallenging and highly controlled. For these tasks, where the process is straightforward and lateral thinking is not required, rewards can provide a small motivational boost without any harmful side effects. But jobs in the 21st century have changed dramatically. They have become more complex, more interesting and more self-directed, and this is where the carrot-and-stick approach has become unstuck. This traditional approach can result in:

• Diminished intrinsic motivation (the third drive)
• Lower performance
• Less creativity
• “Crowding out” of good behaviour
• Unethical behaviour
• Addictions
• Short-term thinking

This led to the discovery of a possible third drive for human behaviour that argues for intrinsic motivation – the joy of the task itself - that human beings have an “inherent tendency to seek out novelty and challenges, to extend and exercise their capabilities, to explore, and to learn.” This new theory of motivation proposes that human beings have an innate drive to be autonomous, self-determined and connected to one another, and that when that drive is liberated, people achieve more and live richer lives.

Practices should focus on these drives when managing their teams by creating settings which focus on our innate need to direct our own lives (autonomy), to learn and create new things (mastery), and to do better by ourselves and our world (purpose).

Supplementary On Demand Content

Webinar    Beware the toxic achiever: successful teams are about we not me - Carolyne Crowe (UK)

Webinar    The recruitment conundrum: we need you - do you need us? - Dave Nicol (UK)

Webinar    On fire or burning out? Why self care really matters - Ernie Ward (UK)

Additional BSAVA Resources

Acute Abdomen

Initial Broadcast: Saturday 27 March (Stream 4 | On Demand Stream)

Now available on the BSAVA Library

Module Summary

Having a patient present with an acute abdominal problem is one of those situations where the entire veterinary team must spring into action. This module is designed to enable the veterinary team to develop a rational approach to the acute abdomen from initial presentation and triage, through to stabilisation and surgical management. Surgical techniques and equipment will be discussed, together with common pitfalls. Post-surgical complications can be devastating and require rapid and intensive intervention. Leaders in the soft tissue surgery field will outline the most current and effective methods for treating these - and avoiding them.

Prerecorded content includes useful tips for diagnosing gastrointestinal foreign bodies, laparoscopic techniques and best ways of obtaining abdominal organ biopsy.

Key Learning Objectives

• Identify the principles of triage of abdominal emergencies and how to assess them before surgery in terms of blood and other tests, plus initial drugs
• Explain current best practice in fluid therapy and anaesthesia of the acute abdomen
• Update your knowledge of the surgical management of the acute abdomen and how to improve outcomes
• Develop your understanding of how to deal with post-surgical complications, particularly septic peritonitis

Lecture Summaries

Help! Acute abdomen: what do I do?

Presentation and triage of acute abdomen - Alison Moores (UK)

An “acute abdomen” is defined as a condition of severe abdominal pain due to disease or injury of one or more abdominal organs, usually requiring surgery. The most common causes of acute abdomen in dog and cats are septic peritonitis and haemoabdomen. The purpose of this session is to consider different clinical presentations of acute abdomen, specifically the changes seen in different body systems, such as the cardiovascular system, and consider why this assessment is important.

What is the immediate management, in terms of bloods, drugs and tests? - Jackie Demetriou (UK)

A patient with “acute abdomen” may have a condition, or conditions affecting different organs or groups of organs and many will require eventual surgery. The purpose of the pre-surgical evaluation is to stabilise the patient appropriately but also to help diagnose the pathology, so the surgeon is better prepared. This presentation will discuss the assessment of these patients in terms of appropriate pre-surgical evaluation including blood, drugs and imaging including point of care diagnostics that might influence further therapy or provide prognostic information. The aim of this session is to enable the surgeon to optimise surgical outcomes for their patients and improve their confidence in managing these difficult cases.

Stabilising the acute abdomen

Fluid therapy in acute abdomen - Jess Herley (UK)

During this lecture we discuss the why’s, when’s, what’s and how’s of fluid therapy administration for the acute abdomen patient. We will briefly discuss what an acute abdomen means and what the clinical signs are. We will discuss why patients with an acute abdomen often present with shock, what the clinical signs of shock are and the importance of treating shock. During this lecture we will discuss the use of crystalloid fluid therapy administration vs colloid administration and the advantages and disadvantages of both. After the lecture, myself and Ian will answer questions regarding fluid therapy and anaesthesia for the acute abdomen patient.

Anaesthetic considerations for the acute abdomen - Ian Self (UK)

Unlike elective procedures, critically ill patients present a number of anaesthetic challenges such as an unstable cardiorespiratory system, altered circulating fluid volume and metabolic derangements. Despite these problems a thorough pre-operative clinical examination and subsequent anaesthetic plan is vital as the key to success lies in correct preparation and anticipation of problems and we will explore how preparation may maximise subsequent anaesthetic success.

Premedication may be unnecessary if the patient is obtunded and drugs such as the alpha-2 agonists which have major cardiovascular effects should generally be avoided. Induction of, and recovery from, anaesthesia are critical periods. This presentation will briefly describe a best practice approach to induction, maintenance and recovery of these patients. Finally, commonly encountered problems such as regurgitation, dysrhythmias and delayed recovery will be briefly discussed to aid correct planning.

Throughout the session the emphasis will be on practical first principles rather than offering an anaesthetic ‘recipe’ to allow adaption of the ideas into the participant’s own practice situation.

Optimising surgical management of the acute abdomen

Surgical management of the acute abdomen - Jackie Demetriou (UK)

When approaching the “acute abdomen” patient, the surgeon often does not have a clear understanding of the pathology prior to the celiotomy. It is therefore important that the approach to these patients should enable the surgeon to explore the entire abdominal cavity to determine the cause and extent of the condition and also, to obtain biopsies if definitive treatment is not possible. This presentation will review a thorough abdominal exploration of a patient via video and discuss practical ways (including instrumentation, approaches and biopsy techniques) that will allow the surgeon to optimise their approach to these tricky patients.

Otomies and ectomies in the acute abdomen: how to improve outcomes - Rob White (UK)

When managing cases with an acute abdomen that require surgical intervention, there is often the need for the surgeon to either enter a hollow viscus (for example, gastrotomy, jejunotomy, etc.), or, to remove a portion of the organ (for example, partial gastrectomy, enterectomy, etc.). This presentation will review the basic principles of such gastrointestinal surgeries using clinical examples and live video feed to emphasise key points, errors in technique and controversies. The talk will aim to provide clear and practical advice that the attendee will be able to use in their day-to-day surgical practice - hopefully, improving both their confidence and surgical outcomes.

How to deal with abdominal surgical complications

Post surgical complications: overview - Jackie Demetriou (UK)

An “acute abdomen” patient that is recovering from surgery may often have multiple and serious post-surgical complications. These complications are often due to a combination of surgery and the underlying disease process so management of these can be very challenging. The surgeon has to be well equipped to detect early deleterious changes in patient progress, whether this is bleeding, infection, leakage of bile or urine. This presentation therefore provides an overview of the most common post-surgical complications of these patients, how they can be diagnosed and practical ways to best treat them.

Dealing with post operative peritonitis - Jane Ladlow (UK)

Unfortunately, post-operative peritonitis is not unusual, intestinal surgery has about a 7% dehiscence rate and peritonitis may also be seen after other common abdominal procedures, including pyometra, prostatic surgery and cystotomy.

Clinical signs of post-operative peritonitis can be difficult to differentiate from post-surgical ileus, pain and medication-related nausea or anorexia. About 50% of peritonitis cases may have concurrent pancreatitis. Imaging can be confusing as it is normal to have free fluid and gas in the abdomen after an open surgical approach (although the gas with peritonitis tends to be more diffuse). If free fluid is present on ultrasound, then sampling and performing cytology and peritoneal glucose and lactate concentration comparisons with serum levels can be most helpful.

Other indications of peritonitis can include hypovolaemia, hypoproteinaemia (particularly a drop in albumin), development of respiratory acidosis and metabolic acidosis. Treatment involves intravenous antibiotics, haemodynamic support and repeat surgery to resolve the source of infection. Mortality rates are in the range of 20-50% depending on the study.

Post-operative peritonitis does occur, and early detection may improve outcome. Careful monitoring after surgery and the use of a closed active suction drain in any cases that may be at higher risk may aid early detection. This presentation will discuss risk factors in animals and prognostic indicators to guide decision making.

Supplementary On Demand Content

Webinar    Making the most of your exploratory laparotomy: how to avoid the peek and shriek  - Vicky Lipscomb (UK)

Webinar    Use of nursing care plans for acute abdomen  - Sophie Venables (UK)

Webinar    How to be sure of GIT foreign bodies - Jane Ladlow (UK)

Webinar    Laparoscopy and the acute abdomen - Phil Lhermette (UK)

Additional BSAVA Resources

BSAVA Manuals & Publications

BSAVA Manual of Canine and Feline Abdominal Surgery

BSAVA Manual of Canine and Feline Emergency and Critical Care

BSAVA Manual of Canine and Feline Endoscopy and Endosurgery

BSAVA Manual of Canine and Feline Anaesthesia and Analgesia

Veterinary Evidence Resources

Comparison of the safety of alfaxalone and propofol as anaesthetic induction agents in bitches undergoing c-section