Evaluation of preoperative rectus sheath block with bupivacaine for analgesia in cats undergoing ovariohysterectomy: a cadaveric and randomized clinical study.

OBJECTIVE: Phase 1: to determine the feasibility of desensitizing ventral branches of spinal nerves within the rectus sheath using an ultrasound-guided rectus sheath block (USRSB). Phase 2: to determine the effect of preoperative USRSB on intraoperative responses to surgical stimulation and postoperative pain. STUDY DESIGN: Cadaveric study and prospective, randomized, blinded, parallel-arm clinical trial. ANIMALS: A group of five cat cadavers and 37 shelter-owned cats undergoing ovariohysterectomy. METHODS: Phase 1: anatomical dissection was performed on one uninjected cadaver. Abdominal walls were dissected in four cadavers (eight hemiabdomens) following bilateral USRSB using 1:1 new methylene blue and 0.5% bupivacaine (0.8 mL kg-1 total). Phase 2: preoperative bilateral USRSB was performed with 0.8 mL kg-1 of 0.25% bupivacaine (RSB) or equivalent volume of 0.9% saline (CONTROL). Intraoperative systolic arterial blood pressure (SAP), heart rate (HR), respiratory rate (fR) and vaporizer setting (vap%) were recorded before skin incision, during celiotomy and abdominal wall closure. In recovery, cats were administered robenacoxib (2 mg kg-1; CONTROL) or 0.9% saline (0.1 mL kg-1; RSB) subcutaneously. Postoperative pain was evaluated for 6 hours using the Glasgow Composite Measure Pain Scale. RESULTS: Phase 1: spinal nerves T9-L3 were identified within the rectus sheath, and stained in 0%, 40%, 63%, 75%, 100%, 88%, 50% and 13% of hemiabdomens, respectively. Phase 2: 37 cats were included (RSB, n = 17; CONTROL, n = 20). Intraoperatively, SAP, HR and fR were not significantly different between groups. Vap% was significantly lower in RSB during celiotomy (p = 0.036) and closure (p = 0.044). Postoperatively, RSB cats were 5.3 times (95% CI 1.8-8.3) more likely to require rescue analgesia than CONTROL cats. CONCLUSIONS AND CLINICAL RELEVANCE: During surgery, USRSB with bupivacaine offered minor benefits and provided markedly less postoperative analgesia than robenacoxib, indicating that relying on USRSB provides insufficient postoperative analgesia for ovariohysterectomy in cats.

Retrospective study of 20 cats surgically treated for insulinoma.

OBJECTIVE: To report the clinical signs, histopathology results, and prognostic factors for outcomes following excision for feline insulinoma (INS). STUDY DESIGN: Retrospective study. SAMPLE POPULATION: Twenty client-owned cats. METHODS: Medical records from 2006 to 2020 were reviewed by Veterinary Society of Surgical Oncology members for cats with hypoglycemia resulting from INS, with surgical excision and follow up. Clinical signs and histopathology results were summarized. Factors potentially related to disease-free interval (DFI), disease-related death (DRD), and overall survival time (OST) were analyzed with a Cox proportional hazards regression analysis. RESULTS: All cats were hypoglycemic on presentation with neurologic signs in 18 out of 20 and inappropriate insulin levels in 12/13. Excision of insulinomas resulted in immediate euglycemia or hyperglycemia in 18 cats. Eighteen cats survived to hospital discharge. The median time to death or last postoperative follow up was 664 days (range: 2-1205 days). Prognostic factors included age at presentation (for DFI); time to postoperative euglycemia (for DRD); preoperative and postoperative serum blood glucose concentrations; metastasis at the time of surgery (DFI and DRD), and histopathologic tumor invasion (for OST). The median OST for all cats was 863 days. The 1-, 2- and 3-year survival rates were 75%, 51%, and 10%, respectively. CONCLUSION: Excision of insulinoma resulted in euglycemia or hyperglycemia in most cats. Negative prognostic factors included young age, low serum glucose concentrations, metastasis at time of surgery, tumor invasion, and shorter time to euglycemia. CLINICAL SIGNIFICANCE: Surgical excision resulted in survival times comparable to those of canine INS.

Effect of the reverse Trendelenburg position on the incidence of gastroesophageal reflux in dogs anesthetized for elective stifle surgery.

OBJECTIVE: To determine if a 15° reverse Trendelenburg position decreases the incidence of gastroesophageal reflux (GER) compared with a horizontal position in dogs anesthetized for stifle surgery. STUDY DESIGN: Prospective, randomized parallel-arm study. ANIMALS: A total of 44 healthy client-owned dogs were enrolled and data from 36 dogs were analyzed. METHODS: Dogs requiring preoperative radiographs under anesthesia, or with a history of gastrointestinal signs or administered gastroprotectant therapy within 1 month of surgery were excluded. Anesthesia protocol was standardized to include hydromorphone, dexmedetomidine, ketamine, propofol and isoflurane. Dogs were randomly assigned at enrollment to be positioned in a 15° reverse Trendelenburg or a horizontal position for surgery. Continuous pH monitoring was documented throughout the procedure with a 6.4 Fr (2.13 mm) esophageal pH probe positioned in the distal esophagus via the oral cavity. GER was defined as pH < 4.0 (acidic) or > 7.5 (alkaline) for more than 30 seconds. The proportions of dogs developing GER were compared between groups using Fisher's exact test. Time to reflux was compared using survival curves and the Gehan-Breslow-Wilcoxon test. Statistical significance was set as p < 0.05. RESULTS: An episode of GER occurred in 11/36 (30%) dogs. Reflux was alkaline in two dogs and acidic in nine dogs. The proportion of dogs with GER was 5/18 (28%) and 6/18 (33%) for dogs in the reverse Trendelenburg position and horizontal position, respectively, and was not statistically significant (p > 0.99). Median (range) time until reflux was 44 (23-135) and 44.5 (9-56) minutes when dogs were positioned in reverse Trendelenburg position and horizontal position, respectively (p = 0.66; two-tailed Mann-Whitney U test). CONCLUSIONS AND CLINICAL RELEVANCE: Positioning the surgery table in a 15° rostral elevation for dogs anesthetized for elective stifle surgical procedures did not decrease the incidence of GER.

Can a poison center overdose guideline safely reduce pediatric emergency department visits for unintentional ß-blocker ingestions?

Poisoning is a leading cause cause for injury and death in pediatric patients. For this reason, ß-blocker ingestion has been an indication for emergency department (ED) referral and evaluation in pediatric patients even though significant clinical effects are uncommonly reported. We sought to determine whether an evidence-based triage guideline developed jointly by the American Association of Poison Control Centers, American Academy of Clinical Toxicology, and American College of Medical Toxicology safely reduces unnecessary pediatric ED visits after unintentional small dose ß-blocker overdose. This was a prospective study of patients aged 0-6 years with a ß-blocker ingestion managed by a regional poison center pre and postimplementation of the triage guideline. One hundred fifty-three cases met inclusion criteria. Before implementation of an evidence-based triage guideline for out-of-hospital management, 52 (67%) cases were referred for ED evaluation, and 26 (33%) cases were recommended for home observation. After guideline implementation, 38 (51%) cases were referred for ED evaluation, and 37 (49%) were recommended for home observation. No deaths occurred in either group. The triage guideline was accurately followed by poison center staff in 96% of cases after implementation. An out-of-hospital triage guideline for pediatric ß-blocker overdose was accurately followed by poison center staff and safely reduced unnecessary ED referrals with a 50% increase in home observation.

Scholarly Activities of Family Medicine Faculty: Results of a National Survey.

BACKGROUND AND OBJECTIVES: This survey examined how family medicine residency programs define scholarly activity, the productivity of programs, and perceived barriers to scholarly work. Five types of residency programs are compared: university-based, community-based (unaffiliated, university-affiliated, university-administered), and military. METHODS: A 13 item web-based questionnaire was sent to all 455 U. S. family medicine residency programs. The survey solicited demographic information as well as program expectations of faculty, presence of a research coordinator/director, activities considered scholarly, productivity, and perceived barriers. RESULTS: A total of 177 surveys were completed for a response rate of 38%, similar to response rates of web-based surveys in the literature. 67.6% of programs encouraged, but did not require scholarly activity, and 44.5% indicated their program had no research coordinator/ director. University-based programs had the highest levels of productivity compared to other program types. Primary barriers to scholarly activity noted were lack of time (73/138, 53%) and lack of supportive infrastructure (37/138, 27%). CONCLUSIONS: While interpretations are limited by the response rate of the survey, results provide an increased understanding of how programs define scholarly activity as well as reference points for faculty productivity. This information can help program directors when setting criteria for scholarly work.