In plastic and reconstructive surgery flaps have an important place not only for the aesthetic results obtained but also because they can be used to cover an area without producing tension. The flap mechanism mainly consists of moving a piece of skin from the donor site and moving it to the recipient site (primary defect). The rhomboid flap have a big versatility because can be done anywhere on the surface of the body. Filling small and large wounds with tissue similar in texture, colour and thickness is the ideal objective of the flap. This article describes the surgical approach of two cases, one with an abscess and the other with a benign tumor located at the cutaneous level, both of which are approached by the use of the rhombic flap.
A skin flap represent a partial detachment of a piece of skin and the adjacent subcutaneous tissue with its vascular supply intact. All skin flaps have a pivot point or base. Survival of the skin flap is made by blood circulation through its base during the procedure. From this point of view, it is important that the base of the flap be large enough to prevent necrosis.
Local flaps are based on two types of vascularization: the subdermal plexus or a vein and an artery (figure A; right side- island flap).
The rhombic flap was invented by a human maxilofacila surgeon called Limberg Alexander Aleksandrovich in 1946. By name, the flap has rhomboid shape with two angles of 120 degrees and two angles of 60 degrees. Depending on the primary defect / lesion pattern which require coverage, the flap angles may change. It is often used in reconstructive surgery of the face in humans: eyelid, floor of nose, alar rim and chin defects with good cosmetic results. This skin flap also called Limberg flap is a transposition flap – the elevated skin will have both advancement and rotation movement when is applied over the primary defect.
How to design the rhombic flap
Whether it is a wound or a tumor, around a defect is drawn a diamond with angles of 120 degrees and 60 degrees as mentioned above. First, the short diagonal that joins the 120 degree angles (BD) must be measured and then extended in the desired direction. The extension (DE) to the outside must have the same length with the short diagonal (BD) and with the sides of the diamond. The next step is to extend another line wich is equal and parallel with the closest side of the diamond (EF). Finally the skin flap is obtained (ADEF).
The surgical defect created can be covered with the rhomboid flap from 4 sides (Picture 4).
Daisy, a six years old female cat of the Maine Coon breed presented with a sebaceous cyst, 2 cm diameter, round shape, locatad on the dorsal lombo-sacral area. The owner says that the cat have a decreased appetite. The pacient was rescued and adopted and was vaccinated just when was young. The cat lives with another 3 cats in the same house, all with the same vaccination status.
At clinical examination, apart from the wound, dehydration 6% and a small buccal ulcer behind the last molar on the right mandible were detected. The patient was initially treated with clindamycin and meloxicam for 7 days but no improvement observed. The cyst was infected, with bad smell, partially covered with agglutinated hair and inside soft tissue necrosis was present.
After inspection, dead space was noticed under the skin around the wound. One day before the surgery we noticed fever (40,1°C) and dehydration 8%. CBC, serum biochemistry and FeLV/FIV test were performed. Neutropenia (0.15 x 109/L, normal range: 1.48 – 10.29) and hyperglobulinemia (57g/L, normal range: 28-51) and decreased ALKP (<10 U/L, normal range: 14-111). IDEXX Snap FeLV/FIV was negative. The cat was hospitalized 24 hours for fluid therapy and i.v. antibiotic (Cefuroxime-Zinacef). After stabilizing the patient the intervention was performed.
Descripting the surgical steps
The area was clipped and clorhexidine was used for local antisepsis. Sterile marker was used to draw the rhombic shape around the primary defect.
Due to the presence of dead spaces under the skin, the round shape of the primary defect was converted to a rhomboid and the rhombic lines were positioned about 1 cm from the wound margin. In this way the tissue that was not healthy was removed. Identifying the area with the highest laxity is the next step. This was done by pinching the skin around the primary defect. After choosing the appropriate area, the flap that must be transferred was drawn.
The first side of the flap (the extended line outward of the defect) and the second side of the flap (line that is the same length as the first, to the adjacent side of the defect and makes an angle of 60 degrees at the flap apex) were cut and the flap was elevated after undermining
Skin cuts were made perpendicular with No.10 scalpel blade and and the flap was mobilized with help of Metzenbaum scissors. The surrounding tissues are widely undermined to avoid any tension and the flap is rotated into the recipient site. After rotation, the flap is locked in place by fixing its corners by subcutaneous sutures. The donor site is closed as the flap moves over into the new location. Finally the skin was closed with 4/0 PDX in simple interrupted suture pattern.
A common unaesthetic appearance after transposed flap was the “dog ears” at the pivot point. In this situation, dog ear was corrected by excising one triangle along one side of its base.
Coco, a mix breed male dog, three years old was brought to the clinic because a lump was identified on the skin. Owner reports that the mass was seen some days ago and does not believe it has increased significantly. Also says it makes itching and that the dog often scratch there and bleeds. This was the owner’s only concern.
No abnormalities were detected after clinical examination except the lump. With a cauliflower aspect, the lump had a small base of implantation and 1,2/1,4 cm in diameter. After palpation of the skin around, no pain or local temperature were identified. FNA and blood tests were recommended before surgery and histopathological examination after. The owner declined for financial reasons the FNA and blood test but accepted the histopathological examination. In this situation, a two centimeter safety margin clearance was decided.
Surgical steps along with flap drawing were described above except for asepsis. In this case iodine povidone was used.
Description: Cutaneous/ subcutaneous mass composed of chistic masses well delimited by a cheratinized multilayered epithelium with epithelial cells with squamous differentiation oxifiles, mixed with abundant, granular and amorphous keratin; multifocal with the tendency of confluence, inflammatory infiltration with neutrophils, macrophages and epithelial cells is observed. Malignant neoplastic cells are not present in the examined sections.
Interpretation: Benign follicular tumor – pilomatrixoma with associated granulomatous inflammatory process.
Common complication of the flap
Short indications for proper surgical procedure
The World Small Animal Veterinary Association (WSAVA) is the latest veterinary association to highlight concerns about the impact of extreme breeding in dogs by supporting a Position Paper launched in June 2018 by the Federation of Veterinarians of Europe (FVE) and the Federation of European Companion Animal Veterinary Associations (FECAVA).
The FVE/FECAVA Position Paper is a response to the explosion in popularity of dog breeds with exaggerated traits or genetic disorders and, in particular, those with extreme brachycephalic conformation, such as French and English bulldogs and pugs. While these breeds are increasingly popular with owners, they can suffer severe health and welfare issues. The Position Paper calls for health and welfare to be given priority over looks and offers detailed recommendations to address both the rising demand for these dogs and the increase in supply. They include:
Measures to reduce demand
Measures to reduce supply
FVE and FECAVA have also produced an infographic explaining the causes and consequences of extreme breeding and listing a number of recommendations.
“Extreme breeding is a global concern with our members seeing the results of brachycephalic conformation in practice on a regular basis. The suffering it causes is beyond dispute,” said Dr Walt Ingwersen, President of the WSAVA.
“Following detailed review by our Hereditary Disease Committee, our Animal Wellness and Welfare Committee and the WSAVA’s Executive Board, we are delighted to endorse the joint FVE/FECAVA Position Paper and congratulate both associations on highlighting the issue and setting out a clear strategy to tackle it. It builds on momentum established by the Brachycephalic Working Group (BWG), an initiative which brings together all of the major stakeholders in dog welfare in the UK to improve the welfare of brachycephalic dogs.”
Dr Ingwersen continued: “Lasting change requires commitment and collaboration between veterinarians, breeder associations and other stakeholders on a global basis. We are ready to play our part and look forward to working with our colleagues in the FVE and FECAVA and our member associations to deliver on the recommendations made in the Position Paper.”
Dr Wolfgang Dohne, FECAVA President, commented: “We’re delighted that the WSAVA has offered its support to the joint FVE/FECAVA Position Paper. It is important for veterinarians to speak up on this important welfare issue and together we are stronger.”
The WSAVA aims to advance the health and welfare of companion animals worldwide through creating an educated, committed and collaborative global community of veterinary peers. It represents more than 200,000 veterinarians through 104 member associations. Its annual World Congress brings together globally respected experts to offer cutting edge thinking on all aspects of companion animal veterinary care.
Notes to editors:
The Federation of Veterinarians of Europe (FVE) is an umbrella organisation of 44 veterinary organisations from 38 European countries, representing a total of around 240 000 veterinarians. The FVE strives to promote animal health, animal welfare and public health across Europe.
The Federation of European Companion Animal Veterinary Associations (FECAVA) is the platform for the promotion of the professional development and representation of companion animal veterinarians in Europe. Founded in 1990, it currently has 40 national member associations and 13 associate member associations. FECAVA represents over 25,000 companion animal practitioners throughout Europe
Dr Ivana Jovandin, veterinarian from Serbia, attened our education program Learn and Travel with Vets on The Balkans. She did her externship at Central Vet Clinic in Sofia, Bulgaria. Let her tell more about it:
Thanks to Vets from Balkan and Luba Gancheva, I had a chance to spend a week in April at a great Central Veterinary Clinic in Sofia, Bulgaria. The clinic is spacious, well equipped and the place where you can see the “state of art” veterinary medicine, and colleagues who work there are exceptional in various fields and together make a great team that is capable of finding the best solutions even for the most serious and difficult situations. It was a special pleasure to get to know and spend time with Dr. Melinda De Mul and Dr. Georgina Georgieva who work with exotic animals that I am professionally interested in. It was great to exchange our experiences, since in Serbia number of colleagues who are interested in exotic animals is very low. In addition to the work that is closely related to the profession, it was extremely useful to see the organization of work in such a large team where every person knew their task at all times, and everything was managed in order to provide better quality prevention, diagnostics and therapy of pets. Although the time I spent at the clinic was short, it will serve as motivation to strive to improve myself constantly, since the knowledge I got from working there with my colleagues is the experience that cannot be measured. The acquaintances and contacts made during the stay at the clinic are also something that is invaluable and something that will last for a long time. Enriched with this wonderful and unique experience, I believe that I have moved in the direction of what we all strive for, and that is to be, above all, better people and only then better veterinarians. And that’s why I am so thankful to Dr. Ranko Georgiev, Luba Gancheva and Vets from Balkan on everything!
Brussels, 25 June 2018 – Extreme breeding causes serious health and welfare problems: veterinarians are voicing their concern about the promotion of flat-faced dogs in films and social media, as this is likely to boost consumer demand for such dogs. Recent reactions were prompted by the announcement of the upcoming Disney film ‘Patrick’, in which a pug plays a feature role.
‘Pugs are a so-called brachycephalic or flat-faced dog breed, just like French and English bulldogs. Due to their extreme conformation, they are prone to many health issues,’ stressed Wolfgang Dohne, president of the Federation of European Companion Animal Veterinary Associations (FECAVA). While pets are bred this way to make them more appealing to buyers, ‘the reality is that these exaggerated features can lead to breathing difficulties, recurring skin infections, eye diseases and spinal or neurological problems, severely impacting their health and welfare.’
To raise awareness about health and welfare issues in breeding, FECAVA recently adopted a position paper on healthy breeding, jointly with the Federation of Veterinarians of Europe (FVE).
‘Celebrities, social media and filmmakers strongly contribute to increasing the popular demand of certain breeds. Over the past few years, this has led to a real explosion in the number of brachycephalic dogs such as the French bulldog,’ confirmed Monique Megens, FECAVA representative of the joint animal welfare committee of FVE and the Union of European Veterinary Practitioners. ‘This is a worrying trend, as the exaggerated features of these dogs means that many need invasive surgery to allow them to breathe normally.’
‘Our profession is very concerned about this development, which not only has an impact on dog health and welfare but also on consumer protection,’ stressed Rafael Laguens, FVE president. ‘As vets, it is our role to educate our clients and to speak up and raise awareness about the consequences of exaggerated breeding. The FVE general assembly recently adopted a joint FECAVA/FVE policy paper on this topic.’
The BWG, comprised of vets, breed clubs, welfare charities and academics, also expressed concerns that the film could lead to a surge in demand for pugs. Steps agreed by Disney and BWG include:
– an added a welfare message to the credits section, explaining the health issues pugs face
– leaflet distribution to journalists and the public at UK cinemas, raising awareness of leading health issues in the breed and explaining that ownership should not be undertaken lightly
– images of pugs dressed in human clothing will not be used in marketing for the film
– no merchandising of Patrick pug memorabilia
BWG will also support development of film industry initiatives to ensure that potential animal welfare implications are considered prior to future movies that prominently feature animals
On 26 June, FECAVA and FVE representatives will furthermore join forces with the EU Dog and Cat Alliance to raise awareness about extreme breeding in the European Parliament.
‘This is not just a European issue,’ confirmed Walt Ingwersen, president of the World Small Animal Veterinary Association (WSAVA), ‘Extreme breeding is a global concern. Our members see the results of extreme brachycephalic confirmation in practice on a regular basis and it is one of our top animal welfare concerns. We have therefore been in discussions with FECAVA and FVE with a view to supporting this policy paper on healthy breeding.’
FECAVA, FVE and WSAVA fully support initiatives such as that of the BWG and urge filmmakers to refrain from using such animals – whether live-action, animated or online videos – as this will increase their popularity.
On 24-25th of May 2018 in Bucharest, Romania, held 6th edition of annual congress of Romanian Society of Feline Medicine.
Vets on The Balkans was part of the congress to celebrate 3th birthday. It was an initiative organised by SRMF and Vets on The Balkans and 7 veterianrians from the region came to present their clinical cases, as they do in the journal in general.
The veterinarians who attend were:
Dr Elli Kalemntazki from Greece. She is a graduate the Faculty of Veterinary Medicine of Aristotle University in Greece and held postgraduate degree in Public Health from The National School of Public Health in Athens, Greece. She is also Profesional Coach accreditated by the International Coach Federation since 2010 and a Certified Practicioner of Neuro Linguistic programming since 2012. Her subject was “Management of communications with clients”.
Dr Mila Bobadova is graduate the Faculty of Veterinary Medicine of University of Foresty in Sofia , Bulgaria. She is head manager of „ Dobro Hrumvane” veterinary clinics in Bulgaria. Mila paricipate ESAVS Dermatology courses.Her subject was „ Dermatolgy Puzzle”.
Dr Zoran Loncar from Serbia. Workin as full time Doctor of Veterinary Medicine Regional refferal veterinarian in Neurology and Orthopedic field. Member of ECVN, ESVOT, SCIVAC, SITOT, AO-Active member, jounior speaker. Author of sciantific publications. Clinical research surgeon. I can say the she showed 40 % of the pathology in cats through the point of view of Neurology.
Dr Daniela Drumea from Romania. Veterinary doctor, Dr. Daniela Luciana Drumea graduated the University of Veterinary Medicine in Bucharest, promotion 2014. Became a member of the non-stop veterinary clinic Tazy Vet in 2011, working as a veterinary assistant during her student years. Her passion and ambition to learn as much as possible about veterinary dermatology and the ongoing training at numerous national and international congresses and workshops led to the experienced and dedicated doctor that she is today.
Dr Bianca Bofan, PhD student, veterinarian in Centru de endoscopie si chirurgie minim invasive in Bucharest, Romania. Stgrongly involved in respiratory pathology in dogs and cats. Her subject was Interventional Treatment of Nasopharyngeal Stenosis- different approach on 2 cats.
Dr Constantin Ifteme, the head manager of Centru de endoscopie si chirurgie minim invasive in Bucharest, Romania. Member of VES&VIRIES,speaker, owner and manager of Vet Traing Center in Bucharest, Romania. His subject was Esophageal stricture-it is not always easy.
Dr Luba Gancheva, owner of Vets on The Balkans presented dermatology case from Bulgaria, managed together with romanian vet Dr Rares Capitan, as a great job between balkans vets. Because we strongly believe that hand by hand we all be better.
On 24th as a precongress course, she present the difference between veterinary medicine between Romania and Bulgaria. Both countries has what to learn and in that way will be more easy and fast. The motto of the journal is „ Sharing is Caring”. 25 veterinarians participated the workshop.
The organization of the Congress was in high professional level and more than 200 veterinarians attended.
We would like to express our gratitude to SRMF and Dr Tache Epure and Dr Valentin Nicolae for the opportunity to be part of it and to share these moments together.
Correspondence: Stroe Marina-Stefania, DVM, Marina-Stefania.Stroe-Giurca@uliege.be
Cataracts may occur at any age and in any location in the lens. Cataracts can block tapetal reflection and fundic examination partially or completely and are often classified by stage of maturation and cause.
Cataract surgery are facilitated by a central position of the eye ball within the palpebral fissure. A centrally positioned eye is normally achieved by using of neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. Use of these agents necessitates intermittent positive pressure ventilation (IPPV).
Objective: Offering alternatives for anesthesia to perform cataract surgery in dogs and cats without using the neuromuscular block.
The safety of anesthetic protocols consisting of midazolam, tramadol, lidocaine, propofol, fentanyl, ketamine, isoflurane without using the neuromuscular block was studied in 16 cataract surgeries in dogs and cats. The protocol’s safety was expressed by monitoring heart rate, oxygen saturation and pulse rate using pulse oximetry, respiratory rate, end-tidal carbon dioxide provided by capnography, arterial blood pressure using oscillometric method. Assessments were made for quality of induction, maintenance and recovery from anesthesia.
Animals: Sixteen animals, eleven dogs and five cats, all client-owned.
Methods: All animals were examined prior to premedication, were performed blood tests hemoleucogram and biochemistry and monitored during induction, surgery and recovery. Blood samples were analyzed for standard biochemistry panel including glucose, creatinine, ureea, hepatic transaminases and hemoleucogram. Before anesthesia, HR was measured using cardiac auscultation and MAP was measured using automated oscillometry, respectively. Protocols consisting of midazolam, tramadol, or lidocaine iv was performed. IV propofol was administered to abolish the palpebral reflex, produce jaw relaxation and facilitate ETI. Topical ocular administration of oxybuprocaine (Benoxicaine®) 0.4% drops to anesthetize cornea was performed before general anesthesia. All patients received topically sprayed laryngeal 2% lidocaine. The cough response at ETI was recorded.
After intubation, auscultation of heart and lung sounds was possible by means of an oesophageal stethoscope. Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and pulse rate. The patient was connected to the inhalational anesthesia machine. The maintenance of anesthesia was achieved using isoflurane like inhalant agent and fentanyl or mixture of fentanyl, lidocaine and ketamine. Respiratory rate and end-tidal carbon dioxide was provided by capnography. Assessments were made for quality of induction, maintenance and recovery from anesthesia by evaluation of the animal’s eye position, jaw tone, heart and respiratory rates and autonomic responses to surgical stimulation.
Results: The purpose of this work was to perform anesthesia protocols without use of the neuromuscular block for phacoemulsification in dogs and cats and make preliminary investigation into safety for patient and to record the advantages and disadvantages. Cataract surgery are facilitated by a central position of the globe within the palpebral fissure. A centrally positioned eye is normally achieved by using neuromuscular blocking agents (NMBAs). NMBAs also decrease the ocular muscle tone and that is very useful because an increased tonus may cause ocular structures to become displaced and distorted and can also influence IOP. But if there is no possibility of using NMBAs solutions must be found.
Conclusion: The aim of the project was to test several variants of anesthetic protocols to compare the various effects of molecules including lidocaine, ketamine, fentanyl, tramadol, propofol, isoflurane have on the organism.
The use of anesthetic drugs without using of neuromuscular block for cataract surgery may be challenging bringing both advantages and disadvantages. The recovery period after a classic anesthesia without neuromuscular block probably is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises for the surgery.
Keywords: cataract, anesthesia, phacoemulsification, cat, dog,
Patients with ophthalmic disease, such as cataract, vary from young, healthy animals with congenital cataract to geriatric patients, which may have significant diseases like diabetus mellitus. When planning anesthesia for cataract surgery is important to consider the general health status because there are many patients with concurrent disease and that may present significant challenges for the anesthetist . It required investigations before anesthesia like blood tests and if there are changes ideally their condition should be stabilized before anesthesia. Also need to consider that animals that are blind are more likely to be stressed and fearful compared with patients that have vision, especially if the onset of blindness was acute .
A complete ophthalmic examination should be performed and should include examination of PLR and menace response, Schirmmer tear test, fluorescein stain test, intraocular pressure (IOP) and a fundic examination if possible. A complete physical examination is also pertinent, as cataracts may be related to extra-ocular disease.
Electroretinography and ocular ultrasonography are standard pre-operative screening tools to confirm an eye’s candidacy for cataract surgery. Although pre-operative preparation and postoperative management can be intensive, canine cataract surgery is often successful and rewarding. Risks, time commitment, and financial demands of phacoemulsification should be discussed with the pet owner.
Materials and methods
Eleven dogs and five cats presenting to the ophthalmology service with ophtalmological conditions that cause blindness. All patients received the cataract diagnosis after a full ophthalmic examination. Once a cataract forms, surgery is the only treatment method to restore vision. Phacoemulsification uses ultrasonic energy to fragment and extract cataractous lens material from its capsular bag. Exclusion criteria of the patients were concurrent diseases that could not be stabilized before anesthesia. Any pre-existing medical conditions and drugs administered were recorded.
Food and water were withheld from all patients for a minimum of 12 hours prior to surgery
Animals were gently restrained in a sitting or standing position for drug administration and data collection.
Mydriasis is obtained with topical mydriatic agents (Tropicamide) applied with 2-3 hours before intraocular surgery. Also, topical ocular administration of oxybupracaine (Benoxicaine®) 0.4% drops to anesthetized cornea was performed before general anesthesia. Topical local anesthetics are effective because of a direct action on the cornea and minimizing systemic side effects but their use is limited to diagnostic procedures and intra-operatively as they delay corneal healing, are epitheliotoxic and have a short duration of action .
The position of the animals during surgery was in lateral position for unilateral cataract and dorsal for bilateral cataract (Fig.1). HR was measured using cardiac auscultation and MAP was measured using automated oscillometry.
Anesthesia was maintained with isoflurane in a oxygen delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. Oxygen saturation as measured by pulse oximetry, pulse rate and respiratory rate were recorded every 5 minutes after anesthetic induction until the end of anesthesia (vaporizer turned off). Pulse quality was established by manual palpation of the femoral artery and respiratory rate was recorded by observation of the capnogram and chest movement.
Measurement of rectal and esophageal temperature was performed by use of 2 thermistor probes. Rectal temperatures were measured at initial hospital intake and after the end of anesthesia. Once each patient had been induced esophageal temperature was measured by placement of an esophageal thermistor probe and was removed at the end of anesthesia.
The premedication has been achieved with lidocaine 2 mg/kg iv or tramadol 2 mg/kg iv (Fig. 2). All the patients received the propofol-midazolam combination for anesthetic induction. The dose utilized for midazolam was 0,4 mg/kg iv.
The use of ketamine was accomplished in combination with lidocaine and fentanyl for dogs and for one cat was used the ketamine-propofol combination. There is significant interest in this combination of propofol and ketamine because has several benefits in the terms of hemodynamic stability, absence of respiratory depression, post-operative analgesia and recovery . The ketamine dose that was used was low at 0,6 mg/kg iv and was mixed in the same syringe with propofol 3 mg/kg.
Steroidal anti-inflammatory drug (Betametazone, Diprophos®) was administered intraconjuctival at the end of the surgery.
In total sixteen animals (eleven dogs and five cats) were enrolled in the project.
All patients were in good condition of general health just 2/11 dogs were stable diabetic patients and for they measurements have been taken to monitoring the blood glucose level before, during and after surgery.
Premedication with lidocaine 2 mg/kg was performed for 6 dogs and was made observation about cough during endotracheal intubation. IV lidocaine can decrease the incidence of cough during endotracheal intubation but does not appear to have a sparing effect on the dose of propofol required for endotracheal intubation.
Two patients receive tramadol 2 mg/kg iv in premedication, one in combination with lidocaine 2 mg/kg iv and the other just the tramadol. For the patient that receive just tramadol was not observed any changes in the propofol dose.
One dog received fentanyl in premedication and after induction was observed significant respiratory depression compared with the others. Two dogs and 6 cats did not receive anything for premedication.
The diabetic protocol for phacoemulsification consist in tramadol 2 mg/kg iv for premedication, induction with midazolam 0,4 mg/kg and propofol at effect. Maintenance of anesthesia has been achieved using isoflurane like inhalant agent and mixture of fentanyl, lidocaine and ketamine. The glucose level was measured before and every hour during anesthesia.
For all patients, cats and dogs, the induction was performed with propofol and midazolam 0,4 mg/kg and topical laryngeal lidocaine was used prior to intubation. One cat received the ketamine-propofol combination for induction.
The cough response at ETI was observed for 3 dogs, the patient that receive tramadol in premedication and the others that was not premedicated and 2 cats. In propofol anaesthetized dogs iv and topical laryngeal lidocaine attenuated the pressor response to ETI where iv lidocaine reduced the cough response.
Duration of the anesthesia from intubation to extubation was 80 min ±10 min depending of the surgical procedure, unilateral/bilateral cataract.
After induction, a rotation of the eyes towards the internal angle was observed. To achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.
Cardiovascular and respiratory parameters were well maintained during induction, maintenance and recovery periods for all patients. All patients receive Ringer Lactate infusion at 5 ml/kg/h. The anesthesia was maintained with isoflurane delivered via a rebreathing anesthetic circuit with the oxygen flow rate set at 60 ml/kg/min and vaporizer setting of 2%. This was completed by analgesia offered by combination of fentanyl-lidocaine-ketamine for dogs and fentanyl CRI for cats. The doses utilized for fentanyl was 4 μg/kg/h in combination with lidocaine 2 mg/kg/h and ketamine 0,6 mg/kg/h and when fentanyl was used alone, the dose was between 5-10 μg/kg/h.
Pulse oximetry was used to monitor oxygen saturation of hemoglobin in arterial blood and was maintained at >95%. MAP was measured using automated oscillometry and was stabilized at 80-110 mmHg.
Respiratory rate, end-tidal carbon dioxide was provided by capnography. The respiratory rate was maintained at 10 ± 5 rpm and the level of CO2 was 45-60 mmHg. All patients breathed themselves spontaneously, just one cat need the controlled ventilation because of the elevated level of EtCO2, up to 65 mmHg and the low respiratory rate.
For all patients the recovery from anesthesia was fast and without any complication. The temperature at the end of anesthesia was 37,2 ± 5ºC.
The ideal anesthetic protocol for cataract surgery should provide central position of the eye, decrease the ocular muscle tone, provide analgesia and narcosis for optimal operating conditions, be safe for the patient and comfortable for the surgeon  (Fig. 5).
Good communication with the surgeon before the procedure and an understanding of the surgeon’s requirements are essential when formulating an anesthesia plan. The patient position with the head lower than the heart should also be avoided and at 15 degrees head-up position during intraocular surgery has been recommended in humans.
Also, the position of the animal during surgery may influence the choice of breathing system and endotracheal tube (ETT). Related to intubation should be remembered that the mouth during tracheal intubation can increase IOP as the choroid process of the mandible moves into the orbit. Care must be taken when positioning patients for tracheal intubation, as pressure may be exerted on the globe while the maxilla is held; this is especially the case for brachycephalic breeds. An armored ETT is recommended to use.
The ability to influence IOP is very important part of anesthesia management. Is necessary to avoid increased IOP because in these circumstances may result in a globe rupture, risk for intraocular bleeding or retinal detachment.
The use of ketamine, a dissociative anesthetic, for ophthalmologic procedures is controversial. Ketamine used alone is likely to significantly increase IOP because it causes an increase in extraocular muscle tone . The good benefits of ketamine administration consist in increased of the amount of circulating norepinephrine, increase in peripheral arteriolar resistance and muscle activity and decrease the extent of redistribution hypothermia . The use of ketamine has beneficial effects on the blood pressure, cardiac output, corporal temperature and contributes to realization of a balanced anesthesia based on a multimodal analgesia. On the other hand, ketamine can increase IOP but considering that in the protocols used in this study was never used alone and the fact that the surgical procedure involves making a break through the incision of the cornea and penetrating the eye globe this pressure can be adjusted naturally without becoming hazardous for the structures of the eye.
Is mandatory to avoid coughing, sneezing, vomits when there is a risk of globe rupture because this can result in an increased central venous pressure . Therefore, drugs like morphine that causes vomiting should be avoided. On the other hand, the use of alpha 2 adrenergic agonist is not prohibited; although may induce vomiting especially in cats the alpha 2 adrenergic agonist can be very useful when we are dealing with uncooperative patients and the risk of globe rupture is bigger because of the stress and manipulation. In this study, for avoiding the coughing response was used lidocaine. Both iv and topical laryngeal lidocaine attenuated the pressor response to ETI and iv lidocaine 2 mg/kg reduced the cough response to ETI in propofol anaesthetized dogs  .
Intraocular blood volume is influenced by intraocular vascular tone (vasodilatation or vasoconstriction), arterial blood pressure (ABP) and outflow of the blood from the globe . Is well known that exist an inverse proportional relationship between arterial carbon dioxide tension (PaCO2) and vascular tone. Increased carbon dioxide tension causes choroidal vessel vasodilatation and an increase in IOP. Hypoxaemia can be detect using pulse oximetry and should be avoided by oxygen supplementation and ventilation. PaCO2 can be monitored by capnography or arterial blood gas analysis and controlled using IPPV. However, inappropriate use of IPPV can increase CVP by increasing intrathoracic pressure during inspiration, resulting in an increase in IOP.
Cataract phacoemulsification is not a very painful procedure except during the incision and suturing of the corneal limbus. Traditionally, most anesthetic molecules mildly decrease IOP by increasing the outflow of aqueous humor. The use of anesthetic induction agents such as propofol, alfaxalone, ketamine and etomidate may all increase IOP. All are ameliorated by co-induction agents like opioids, midazolam or diazepam .
One limitation to the present study was the small number of the patients (sixteen animals – eleven dogs and five cats) used.
In conclusion, if the realization of the neuromuscular block for phacoemulsification is not possible, we can perform anesthesia for this procedure using just the standard molecules like lidocaine, propofol, midazolam, fentanyl, ketamine and tramadol. The recovery period after a classic anesthesia without neuromuscular block is much shorter than that achieved after a curarisation and the probability for hypotension is less likely. On the other hand, after induction, a basculation of the eyes towards the internal angle was observed for all studied cases. In order to achieve the phacoemulsification surgery, the eye was brought to the central position by means of the traction sutures.
The great disadvantage is the fact that without neuromuscular blocking agents we can`t obtain the central position of the eye globe and that implicate make some compromises from the surgeon.
The World Veterinary Association (WVA), the Federation of Veterinarians of Europe (FVE) and the Federation of Companion Animal Francophone Veterinary Associations (FAFVAC) have all thrown their weight behind a campaign led by the World Small Animal Veterinary Association (WSAVA) to secure equal access to veterinary therapeutics for veterinarians around the world. Ten WSAVA member associations have also endorsed it.
The WSAVA’s new Therapeutics Guidelines Group (TGG), which spearheads the campaign, has also appointed its first Chair, Dr Luca Guardabassi DVM, PhD, ECVPH. Dr Guardabassi is Professor of One Health Antimicrobial Resistance at the University of Copenhagen, Denmark.
In a survey of its members conducted by the WSAVA during 2016-2017, 75% of respondents confirmed that that problems in accessing veterinary medical products hampered their ability to meet the needs of their patients and 20% assessed the impact of this issue as resulting in a severe restriction on their ability to provide a high level of care.
Dr Olatunji Nasir, Medical Director and CEO of the Truthmiles Animal Hospital in south west Nigeria, one of the countries affected, explained: “We face a Herculean task in trying access everything from basic medical consumables, such as syringes and needles, right up to veterinary drugs. Registration fees are very high because they are the equivalent of what is charged for human drugs despite the fact that the volume used is much lower. The process of registering a new drug can also take up to 36 months which feeds demand for sub-standard products which are smuggled into the country. The procedures for importing drugs are also cumbersome and impractical.”
The WSAVA launched its campaign earlier this year to tackle these problems and is calling on all of its member associations to endorse its Position Statement on the issue and to support its campaign. It is also calling on other veterinary associations to become co-signatories of the Position Statement.
Commenting, Dr Luca Guardabassi said: “Difficulty in accessing therapeutics to treat patients is a critical issue for companion animal veterinarians in many parts of the world. It causes huge frustration and means that many thousands – probably millions – of animals do not receive optimum care. It’s a situation which requires urgent change and we are determined to bring this about.
“We’re delighted that so many veterinary associations are supporting our campaign and are now preparing for a high-level summit meeting which will be held during WSAVA World Congress in Singapore in September. At this meeting, we will bring together stakeholders from around the world to discuss the issues and recommend practical solutions.”
The WSAVA represents more than 200,000 veterinarians worldwide through its 105 member associations and works to enhance standards of clinical care for companion animals. Its core activities include the development of WSAVA Global Guidelines in key areas of veterinary practice and lobbying on important issues affecting companion animal care worldwide.
Note to editors:
The following veterinary associations are co-signatories of the WSAVA’s Position Statement on therapeutic access:
The following WSAVA member associations have endorsed its Position Statement on therapeutic access:
The Polish Small Animal Veterinary Association
It has long been accepted that canine atopic dermatitis (CAD), much like human atopic dermatitis is underpinned by dysfunction of the patients’ adaptive immune response. Specifically, inappropriate production of immunoglobulins and activation of an inflammatory response as a result of sensitisation to environmental allergens. However, newer research into the pathophysiology of the condition has also discovered an important deficiency in the skin of patients with CAD. It has been suggested that dogs have reduced skin barrier function allowing increased allergen permeation (1). These two mechanisms are not mutually exclusive and it is possible that both play a role in the development of atopy. The abnormal presence of allergens that have permeated the epidermis may be a potential trigger for cell sensitisation during development of CAD.
Structural changes in the skin of atopic dogs are notably a reduction in the intercellular lipid layer with disorganised lipid lamellae (1). Studies also show differences in the barrier function of skin in atopic and non-atopic patients (2). Transepidermal water loss (TEWL) has been used as a measure of skin barrier function to demonstrate this effect. A study using an experimental model of CAD showed increased TEWL assumed to be as a result of altered skin barrier function in patients with an experimental model of atopy (2). This finding has also been noted in dogs with naturally occurring AD (3). Importantly, in both of these studies the changes in barrier function could be measured in both lesional and non lesional skin.
This improved understanding of affected skin barrier function whether cause or consequence is highly relevant to the management of CAD. These deficiencies have been shown to be present both in lesional and non lesional skin and structural changes are constant and present both during and between episodes of clinical signs. The International Task Force on Canine Atopic Dermatitis (4) has recommended a gold standard approach to management of CAD, which is to use more aggressive therapy for periods of clinical signs or atopic flares in addition to long-term maintenance therapy between flares that aims to reduce the incidence and severity of clinical episodes. One of the big considerations for clinicians when selecting such long-term management therapies for CAD patients is interventions with mild or no side effects. Use of carefully selected nutrients that can support the skin and coat could fit this brief. Considering the importance of maintaining barrier function as well as tempering the inflammatory response to allergens there are nutrients that may play an important role in these areas of recent interest.
Nutrients of interest in CAD
There are two nutrients to consider that can be utilised for their effects on cell sensitisation and cell activation during the induction and effector phases of CAD. The first is the use of egg, which has multiple potential benefits, including antioxidant and immunomodulatory properties (5,6). The immunomodulatory benefit of egg has been explored in skin sensitisation in dogs (7). Three groups of dogs were exposed to a novel antigen (keyhole limpet hemocyanin (KLH) in weeks 9 and 11 of a controlled food trial. The three groups were a control food, the control food and prednisone (at 2.2mg/kg bodyweight orally per day) and a food containing egg. An intradermal skin test (with KLH) was performed at week 12 and the results were as follows: both the prednisone treated group and the egg fed group had statistically significant reductions in the immediate and delayed-type (cell-mediated) hypersensitivity reactions compared to the control group. This response was similar between the egg and prednisone groups. These results support the findings that egg have immunomodulating properties (5,6), in particular in reducing allergen-induced hypersensitivity reactions. This nutrient may be of use when considering a food for patients with CAD.
The other important nutrient group to consider are polyphenols, which are sourced from plant ingredients such as green tea, herbs and green vegetables. Polyphenols do also have strong antioxidant properties. Antioxidants are beneficial in foods for patients with CAD as it is a markedly inflammatory condition. Supplementation can support the patient’s own antioxidant defences in the face of free radical cellular injury caused by inflammation. Polyphenols, like egg, have also been shown to have specific effects tempering cell-mediated immune responses. Notably, they may inhibit antigen presentation, T cell cytokine release, B cell IgE production and mast cell degranulation (8-13). Use of these ingredients in pilot feeding studies of botanicals, containing polyphenols and antioxidants, in CAD has yielded reductions in levels of IL-31, IL-12p40 and other cytokines as well as reduced itching, hair loss and erythema (14).
Image 1. Fast and simple completion of the CADESI-4 skin scoring for CAD in the ‘Atopy Index’ APP developed by Hill’s. Download in your phone’s APP store .
Following the identification of impaired barrier function in patients with CAD, studies have been conducted to identify nutrients to support the skin barrier. A key area has been to target the deficiencies noted in the intercellular lipid layer. A major component of this layer is ceramide; lower ceramide levels have been identified in the stratum corneum (SC) of patients with CAD compared to normal dogs (15,16). Oral supplementation of polyunsaturated fatty acids (PUFAs) appears to support improvement in at least some of these structural changes. One study found supplementation of AD dogs with PUFAs resulted in increased ceramide content in the SC and improved organisation of lamellae in the SC to be comparable to that of normal dogs (17).
PUFAs have been widely trialed in both research and clinically as a management strategy for CAD for their anti-inflammatory effect and to nourish the skin and coat. The benefits of using PUFAs as an anti-inflammatory are through a reduction in production of pro-inflammatory eicosanoids and a reduction in stimulation of inflammatory cells. (18). This effect is largely mediated through Ω-3 PUFAs in contrast to the epidermal barrier support described above which is considered to be a factor of total Ω-6 intake.
This requirement for both Ω-3 and Ω-6 fatty acids can complicate the interpretation of research findings in relation to PUFAs. Further work is required to completely understand PUFAs in this regard. From the current literature it is advisable to consider both the level of Ω-3 and Ω-6 PUFAs and their ratio to one another for optimum support. A low Ω-6 to Ω-3 ratio is considered anti-inflammatory, with an inclusion of sufficient total Ω-6 for skin barrier support. For this reason their inclusion in a complete food rather than supplementation on top of the patient’s own food will give better control.
To complete the review of nutrients there are also macro and micro nutrients that can be added to the food and optimised for skin and coat support. These nutrients are applicable to all dogs not just patients with CAD. Protein, vitamins A and E, Ω-3 and Ω-6 fatty acids, zinc and copper all contribute to maintenance and repair of skin and coat. These benefits are well described in more detail in nutrition texts (19).
Figure 1. Median (range) dermatological scores in 20 dogs with CAD at baseline and at 4 and 8 weeks after being put on a dietetic food indicated for CAD. * p<0.05 vs. baseline.
To assess the holistic impact of the discussed nutrients a study was conducted using a food indicated for patients with CAD. The food is a complete canine food optimised for skin support to include zinc, copper, antioxidant vitamins E and C and also containing egg, polyphenols and supplemented with both Ω-3 and 6 PUFAs. The study was constructed as an open label non-controlled feeding study of adult dogs with pre-existing AD. Patients were included on the basis of presenting with 5 or more of Favrot’s criteria for the diagnosis of AD (20). The dogs could be maintained during the study on standard therapy for AD including allergen avoidance, allergen-specific immunotherapy, symptomatic anti-inflammatory therapy and antimicrobial therapy as long as drugs, doses, and frequency of administration remained constant from the time of previous food administration through to completion of the study . Dogs were excluded on the basis of untreated infectious or parasitic dermatitis or concurrent skin or major systemic conditions. Also dogs were excluded if they had been fed with either food or supplements with high levels of Ω-3 fatty acids in the 12 weeks preceding the study. Dogs using oclacitinib were also excluded from the study.
The owners were instructed to feed the dogs the food exclusively for 8 weeks and discontinue all any homeopathic remedies and other supplements. The dogs were assessed at 0, 4 and 8 weeks and at each assessment the attending vet completed a dermatological evaluation based on the Canine Atopic Dermatitis Extent and Severity Index (CADESI) (21) and owners completed an evaluation form at each visit and gave their opinion on their dog’s quality of life, skin and coat appearance, and food acceptance. The CADESI-4 scoring system is an important tool to provide an objective assessment of the situation and to monitor progress. Hill’s has developed a simple in-clinic APP to facilitate CADESI-4 scoring completion, storage and visualisation to the pet owner. It can be downloaded via your app store on your mobile phone (Image 1).
20 dogs were included in the data analysis, 28 dogs were excluded prior to this due to various medication and supplement changes or missing data and 3 were excluded due to food refusal. For the analysed patient group both mean BCS and mean weight were stable during the study. The results shown below show the median dermatological scores for the dogs decreased significantly at both 4 and 8 weeks when compared to the baseline (Fig 1).
Owner assessments also showed significant improvements at the end of the study compared to baseline in the following categories: scratching, licking, scratching of ears, disruption to the family redness of skin and overall condition of skin and hair coat (Fig 2).
Figure 2. Owner assessments (Least square mean (range); Scale from 0 (not present) – 10 (always present) of various skin parameters in 20 dogs with CAD at baseline and at 4 and 8 weeks after being put on a dietetic food indicated for CAD. * p<0.05 vs. baseline
Overall food acceptance was good with 90% of dogs eating the food for the entire study duration. Many dogs had to be excluded due to medication changes. The number that started and stopped medication was almost equal during the study removing selection bias towards milder or more severe cases. This results suggest use of these nutrients in a complete food shows improvement from both an owner perspective and in reducing dermatological scores for patients. The application of a food designed for use in patients with AD to reduce the inflammatory response, support skin barrier function and optimise skin and coat health could be considered as part of a multimodal approach to managing the patient with AD. Particularly considering that nutrition can be used simply on a daily basis both during and between clinical flares with no adverse effects to the patient.