Building Clinical Skills Teaching Materials: A Study of Cognitive Task Analysis Versus Free Recall Instruction to Teach Canine Indirect Ophthalmoscopy.

Ophthalmoscopy is a core component of a complete ophthalmic examination. Due to its complex technical aspects and patients becoming uncooperative if the procedure is prolonged, it can be a difficult skill for a novice to learn and develop proficiency in. Skills instruction is typically provided by subject matter experts (SMEs) through free recall without an agreed-upon instructional framework. This can lead to unintentional omission of essential steps and knowledge required to perform skills correctly. Cognitive task analysis (CTA) allows for construction of standardized instructional protocols that encompass the knowledge and skills experts apply when performing tasks. The objectives of this study were to (a) develop a CTA-based teaching protocol for canine indirect ophthalmoscopy and (b) compare the steps verbalized or demonstrated by SMEs during free recall instruction versus those ultimately identified by CTA. Four SMEs participated in free recall instructional sessions and interviews used for the development of a CTA-based teaching protocol for novice learners. The CTA-based protocol identified 66 steps and sub-steps considered essential for successfully performing canine indirect ophthalmoscopy. During instructional sessions, SMEs on average failed to verbalize 57.1% of clinical knowledge steps, did not verbalize or demonstrate 68.3% and 9.5% of action steps, and did not verbalize or demonstrate 73.2% and 40.4% of decision steps, respectively. This study demonstrates that SMEs teaching indirect ophthalmoscopy by free recall may unintentionally omit important steps, suggesting that compared with free recall, CTA may generate more comprehensive and thus potentially more effective instructional materials for teaching technical skills in veterinary medicine.

Validation of noninvasive hemoglobin measurements using co-oximetry in anesthetized dogs.

New technology allows noninvasive measurement of total hemoglobin (Hb) in humans through use of multiple wavelength co-oximetry. This monitor is now available to the veterinary market but no studies have been performed to validate its use in animals. This study investigated the use of co-oximetry to measure Hb in anesthetized dogs by comparing "gold standard" Hb measurements from a laboratory (LabHb) with those measured by the co-oximeter (SpHb). Bland-Altman analysis showed that the monitor had a bias of -3.01 (SpHb values were lower than LabHb values) and that 64.5% of measured SpHb values were greater than 20 g/L different from their associated LabHb values. Based on the results of this study, use of co-oximetry to measure Hb in anesthetized dogs is not accurate enough to direct treatment. Further studies are warranted in other animal species and under other clinical conditions.

Validation des mesures non invasives de l'hémoglobine à l'aide de la co-oximétrie chez les chiens anesthésiés. La nouvelle technologie permet la mesure non invasive de l'hémoglobine totale (Hb) chez les humains à l'aide d'une co-oximétrie à longueurs d'onde multiples. Ce moniteur est maintenant disponible pour le marché vétérinaire, mais aucune étude n'a été réalisée pour valider son utilisation chez les animaux. Cette étude a évalué l'utilisation de la co-oximétrie pour mesurer Hb chez des chiens anesthésiés en comparant les mesures Hb d'un laboratoire (LabHb) considérées comme les mesures étalons aux mesures effectuées par le co-oximètre (SpHb). L'analyse Bland-Altman a montré que le moniteur avait un biais de −3,01 (les valeurs SpHb étaient inférieures aux valeurs LabHb) et que 64,5 % des valeurs SpHb mesurées présentaient une différence supérieure à 20 g/L par rapport aux valeurs LabHb correspondantes. En se fondant sur les résultats de cette étude, on constate que l'utilisation de co-oximétrie pour mesurer Hb chez les chiens anesthésiés n'est pas suffisamment exacte pour orienter le traitement. De nouvelles études sont justifiées chez d'autres espèces animales et dans d'autres conditions cliniques.(Traduit par Isabelle Vallières).

Effects of acepromazine, hydromorphone, or an acepromazine-hydromorphone combination on the degree of sedation in clinically normal dogs.

OBJECTIVE: To determine the effects of IM administration of acepromazine, hydromorphone, or the acepromazine-hydromorphone combination on degree of sedation in clinically normal dogs and to compare 2 sedation scoring techniques. DESIGN: Prospective, randomized, blinded, controlled trial. Animals-46 random-source dogs. PROCEDURES: Dogs were assigned to receive IM administrations of acepromazine (0.05 mg/kg [0.023 mg/lb]; [DOSAGE ERROR CORRECTED] n = 12), hydromorphone (0.1 mg/kg [0.045 mg/lb]; 11), acepromazine-hydromorphone (0.5 mg/kg and 0.1 mg/kg, respectively; 12), or saline (0.9% NaCI) solution (0.05 mL/kg [0.023 mL/lb]; 11). Sedation scores were determined at 0 (time of administration), 15, 30, 45, and 60 minutes by use of a subjective scoring system (SSS) and a simple numeric rating scale (NRS). RESULTS: Acepromazine caused significantly greater sedation than did saline solution at 15, 30, 45, and 60 minutes. Acepromazine-hydromorphone caused significantly greater sedation than did saline solution at 15, 30, 45, and 60 minutes and than did hydromorphone alone at 30 minutes. Hydromorphone alone did not cause significantly greater sedation than did saline solution. All treatments, including saline solution, caused significantly greater sedation at 45 and 60 minutes, compared with sedation at time 0. There was a significant correlation (r(2) = 0.72) between scores obtained with the SSS and NRS, but the NRS was less sensitive for detecting clinically important sedation. CONCLUSIONS AND CLINICAL RELEVANCE: Administration of acepromazine or acepromazine-hydromorphone caused sedation in clinically normal dogs, whereas administration of hydromorphone alone did not. The NRS was a less-reliable measure of sedation.

Blood concentration of bupivacaine and duration of sensory and motor block following ultrasound-guided femoral and sciatic nerve blocks in dogs.

Peripheral nerve blocks are becoming increasingly popular for perioperative use as anesthetics and analgesics in small animals. This prospective study was performed to investigate the duration of motor and sensory blockade following use of bupivacaine for ultrasound-guided femoral and sciatic nerve blocks in dogs and to measure the plasma concentrations of bupivacaine that result from these procedures. Six dogs were anesthetized twice using a randomized cross-over design. At the first anesthetic, dogs were assigned to receive either an ultrasound-guided femoral nerve block or sciatic nerve block with 0.15 mL kg-1 of bupivacaine 0.5%. Two months later, the other nerve block was performed during a second anesthetic. At 5, 10, 15, 20, 30 and 60 minutes after injection, arterial blood samples were collected for laboratory measurement of bupivacaine. After 60 minutes, dogs were recovered from anesthesia. Starting at two hours post-injection, video-recordings of the dogs were made every two hours for 24 hours. The videos were randomized and the degree of motor and sensory blockade was evaluated using a three-point scoring system (0 = no effect, 1 = mild effect, 2 = complete blockade) by two blinded assessors. The median (range) times to full recovery from motor blockade were 11 (6-14) hours (femoral) and 12 (4-18) hours (sciatic), and 15 (10-18) hours (femoral) and 10 (4-12) hours (sciatic) for sensory blockade. There were no differences in the median times to functional recovery for the two techniques. Plasma concentrations of bupivacaine were no different following the blocks and were less than 0.78 µg mL-1 at all times. These results suggest that these ultrasound-guided nerve blocks do not result in potentially toxic systemic levels of local anesthetic and that their duration of action is useful for providing anesthesia and analgesia for pelvic limb procedures.

Effects of ketamine, diazepam, and their combination on intraocular pressures in clinically normal dogs.

OBJECTIVE: To evaluate the effects of ketamine, diazepam, and the combination of ketamine and diazepam on intraocular pressures (IOPs) in clinically normal dogs in which premedication was not administered. ANIMALS: 50 dogs. PROCEDURES: Dogs were randomly allocated to 1 of 5 groups. Dogs received ketamine alone (5 mg/kg [KET5] or 10 mg/kg [KET10], IV), ketamine (10 mg/kg) with diazepam (0.5 mg/kg, IV; KETVAL), diazepam alone (0.5 mg/kg, IV; VAL), or saline (0.9% NaCl) solution (0.1 mL/kg, IV; SAL). Intraocular pressures were measured immediately before and after injection and at 5, 10, 15, and 20 minutes after injection. RESULTS: IOP was increased over baseline values immediately after injection and at 5 and 10 minutes in the KET5 group and immediately after injection in the KETVAL group. Compared with the SAL group, the mean change in IOP was greater immediately after injection and at 5 and 10 minutes in the KET5 group. The mean IOP increased to 5.7, 3.2, 3.1, 0.8, and 0.8 mm Hg over mean baseline values in the KET5, KET10, KETVAL, SAL, and VAL groups, respectively. All dogs in the KET5 and most dogs in the KETVAL and KET10 groups had an overall increase in IOP over baseline values. CONCLUSIONS AND CLINICAL RELEVANCE: Compared with baseline values and values obtained from dogs in the SAL group, ketamine administered at a dose of 5 mg/kg, IV, caused a significant and clinically important increase in IOP in dogs in which premedication was not administered. Ketamine should not be used in dogs with corneal trauma or glaucoma or in those undergoing intraocular surgery.

Evaluation of the use of anesthesia and analgesia in reptiles.

OBJECTIVE: To determine anesthetic techniques and the drugs used to provide anesthesia and analgesia to reptiles. DESIGN: Mail-out questionnaire. SAMPLE POPULATION: 367 members of the Association of Reptile and Amphibian Veterinarians. PROCEDURE: 1,091 members listed in the 2002 directory of the Association of Reptile and Amphibian Veterinarians were asked to complete a questionnaire regarding anesthesia and analgesia. RESULTS: 367 of 1,091 (33.6%) individuals completed the questionnaire; 88.8% used inhalants (particularly isoflurane) for anesthesia, and ketamine, propofol, and butorphanol were the most commonly used injectable agents. Intubation, fluids, and having a dedicated anesthetist were most commonly used for patient support, and pulse oximetry and Doppler ultrasonography were most commonly used for monitoring. Respiratory depression, difficulty monitoring anesthetic depth, prolonged recovery, and hypothermia were the most frequent complications. Nearly all respondents believed that reptiles feel pain, but analgesics were used infrequently for many reasons. CONCLUSIONS AND CLINICAL RELEVANCE: Providing anesthesia in reptiles is difficult, especially regarding anesthetic depth and vital parameters, and methods of support are used less frequently than in domestic species. Provision of analgesia is uncommon. Research regarding pain and its assessment, response to analgesics, and drug pharmacokinetics is needed. Dissemination of this information to practitioners needs to be improved for enhancement of the standard of care for reptiles.

Cardiopulmonary effects and induction and recovery characteristics of isoflurane and sevoflurane in foals.

OBJECTIVE: To compare induction and recovery characteristics and cardiopulmonary effects of isoflurane and sevoflurane in foals. DESIGN: Prospective crossover study. ANIMALS: 6 healthy foals. PROCEDURE: Foals were anesthetized twice (once at 1 month of age and again at 3 months of age). Anesthesia was induced by administration of the agent in oxygen through a nasotracheal tube. During maintenance of anesthesia, foals were positioned in dorsal recumbency; intermittent positive-pressure ventilation was performed. Characteristics of induction and recovery were recorded. Cardiopulmonary variables were recorded 10 minutes after anesthetic induction and 15, 30, 45, and 60 minutes later. RESULTS: All 6 foals were successfully anesthetized with isoflurane and sevoflurane. There were no significant differences between the 2 drugs in regard to characteristics of induction or recovery, and induction and recovery were generally smooth and unremarkable. There were no significant differences between drugs in regard to measured cardiopulmonary variables; however, both drugs caused initial hypotension that resolved over time. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that isoflurane and sevoflurane can both be used for general anesthesia of 1- to 3-month-old foals. Significant differences between the 2 agents were not detected for any of the variables measured, suggesting that quality of anesthesia with these 2 agents was comparable.

Effect of hemi-circumferential periosteal transection and elevation in foals with experimentally induced angular limb deformities.

OBJECTIVE: To evaluate the effect of hemi-circumferential periosteal transection and elevation (HCPTE) in foals with, experimentally induced angular limb deformities. DESIGN: Prospective study. ANIMALS: 10 healthy foals. PROCEDURE: When foals were 30 days old, transphyseal bridge implants were placed on the lateral aspects of both distal radial physes. At 90 days of age (or when 15 degrees of angulation had developed), implants were removed, and HCPTE was performed on 1 limb. Foals were confined in small pens after surgery; the front feet of the foals were rasped weekly to maintain medial-to-lateral hoof wall balance. Dorsopalmar radiographic projections of the carpi were obtained before HCPTE and 2, 4, 6, 8, and 48 weeks later. RESULTS: At the time of transphyseal bridge removal and HCPTE, both treated and control limbs were observed to have a significantly greater carpal valgus, compared with the initial degree of angulation at 30 days of age. Following HCPTE or sham surgery, all limbs straightened over the subsequent 2 months of the study. Median angulation was not significantly different between treated and control limbs at any time during the study. CONCLUSIONS AND CLINICAL RELEVANCE: Results suggest that in foals with experimentally induced limb deformities, HCPTE was no more effective than stall confinement and hoof trimming alone for correction of the deformity.

A review of alpha2 adrenoreceptor agonists and the development of hypoxemia in domestic and wild ruminants.

Alpha2 agonists are commonly used in combination with other anesthetic agents to chemically immobilize wildlife and may cause potentially serious hypoxemia in wild ruminants. In some domestic ruminants, they are associated with significant changes to the pulmonary parenchyma, increased venous admixture, pulmonary edema, and hypoxemia. Effective and safe immobilization of these animals requires knowledge of the mechanisms behind these changes and the methods that offset their effects, including the use of supplemental oxygen.

Use of azaperone and zuclopenthixol acetate to facilitate translocation of white-tailed deer (Odocoileus virginianus).

Thirteen wild-caught white-tailed deer (Odocoileus virginianus) from two different holding sites were chemically immobilized to facilitate capture, processing, and translocation to a new facility. The deer were divided into two treatment groups on the basis of age and received i.m. injections of the immobilizing agents via remote drug delivery systems. Group 1 (<1 yr old; n = 6) animals were immobilized with a combination of xylazine 1 mg/kg i.m. and azaperone 0.3 mg/kg i.m. At the end of the procedure the deer received zuclopenthixol acetate 1 mg/kg i.m. and (to antagonize the xylazine) tolazoline 2 mg/kg i.m. Group 2 (>1 yr old; n = 7) deer were administered xylazine 1 mg/kg i.m.. tiletamine-zolazepam 1 mg/kg i.m., and ketamine 1 mg/kg i.m. The deer in this group received a combination of azaperone 0.3 mg/kg i.m. and zuclopenthixol acetate 1 mg/kg i.m. before reversal with tolazoline 2 mg/kg i.m. All deer were recovered in a trailer before being moved in small groups to the new facility and released into the new enclosures. Azaperone and zuclopenthixol acetate provided short- and long-term relief from anxiety and allowed the animals to gradually become familiar with their new surroundings without excitement, injuries, or mortalities. Two deer exhibited mild signs of extrapyramidal side effects, which suggests that they may have received a relative overdose of the tranquilizers.

Paravertebral block for forelimb anesthesia in the dog--an anatomic study.

OBJECTIVE: To determine the anatomic landmarks for performing paravertebral forelimb block in the dog. STUDY DESIGN: Technique description. ANIMALS: Nine canine cadavers. METHODS: Each intervertebral foramen between the C5 and T2 vertebrae was targeted. With the dog in lateral recumbency, a 20 SWG 3'' spinal needle was placed at a 45 degree angle from a vertical transverse plane (with the dog standing this plane would be perpendicular to the ground) 2-3 cm lateral to the median plane for the three cranial intervertebral foramina and at a 90 degree angle with the same transverse plane 2-3 cm lateral to the median plane for the T1-T2 intervertebral foramina. RESULTS: Three out of nine (33%) of the cadavers had successful staining of all four desired nerves and the remaining six (66%) cadavers had successful staining of three of the four nerves. The C6-C7 spinal nerve was successfully stained in all nine cadavers. The other three nerves were each successfully stained in seven out of nine (78%) cadavers. CONCLUSIONS AND CLINICAL RELEVANCE: The landmarks allow reliable placement of a solution at the nerves comprising the brachial plexus, allowing anesthesia of the entire forelimb in the dog.