Integrative veterinary medical education and consensus guidelines for an integrative veterinary medicine curriculum within veterinary colleges

Integrative veterinary medicine (IVM) describes the combination of complementary and alternative therapies with conventional care and is guided by the best available evidence. Veterinarians frequently encounter questions about complementary and alternative veterinary medicine (CAVM) in practice, and the general public has demonstrated increased interest in these areas for both human and animal health. Consequently, veterinary students should receive adequate exposure to the principles, theories, and current knowledge supporting or refuting such techniques. A proposed curriculum guideline would broadly introduce students to the objective evaluation of new veterinary treatments while increasing their preparation for responding to questions about IVM in clinical practice. Such a course should be evidence-based, unbiased, and unaffiliated with any particular CAVM advocacy or training group. All IVM courses require routine updating as new information becomes available. Controversies regarding IVM and CAVM must be addressed within the course and throughout the entire curriculum. Instructional honesty regarding the uncertainties in this emerging field is critical. Increased training of future veterinary professionals in IVM may produce an openness to new ideas that characterizes the scientific method and a willingness to pursue and incorporate evidence-based medicine in clinical practice with all therapies, including those presently regarded as integrative, complementary, or alternative.

Analgesic effect of the transdermal fentanyl patch during and after feline ovariohysterectomy

OBJECTIVE

To evaluate the efficacy of the transdermal fentanyl patch in relieving perioperative pain and stress associated with ovariohysterectomy in cats.

STUDY DESIGN

Prospective laboratory trial.

ANIMALS

Twenty-four female, purpose-bred cats.

METHODS

Each cat was randomly assigned to groups 1-3. Group 1 received a 25-microg/h transdermal fentanyl patch only. Group 2 received the patch and anesthesia. Group 3 received anesthesia only. Patches were left in place for 72 hours. Rectal temperature, heart rate, respiratory rate, indirect blood pressure, blood glucose, serum cortisol concentration, plasma fentanyl concentration, pain score, and excitement/sedation score were monitored at prescribed intervals over an 81-hour period. Cats from groups 1-3 were reassigned to groups 4 and 5. Group 4 received the patch, anesthesia, and an ovariohysterectomy. Group 5 received anesthesia and an ovariohysterectomy only. The study period and monitored parameters were the same as for groups 1-3.

RESULTS

Serum cortisol concentrations were significantly lower in group 4 than group 5 during the surgical and early postsurgical time periods. A similar effect was noted in blood glucose concentrations during the surgical period. Rectal temperature was significantly higher in group 2 when comparing all anesthetized groups during the early postsurgical period. Pain scores were significantly higher in groups 4 and 5 than in groups 2 and 3 during the early postsurgical period. There was no significant difference in pain scores between groups 4 and 5 during this period, however.

CONCLUSIONS

The transdermal fentanyl patch affects biochemical markers of perioperative pain and stress associated with ovariohysterectomy in cats, attenuating rises in serum cortisol and blood glucose concentrations during the surgical and early postsurgical periods.

CLINICAL RELEVANCE

The transdermal fentanyl patch is effective in alleviating perioperative pain and stress associated with ovariohysterectomy in cats as evidenced by attenuated rises in cortisol and blood glucose concentrations in cats that were operated on and treated with the patch.

Open-heart correction of tetralogy of Fallot in an acyanotic dog

Tetralogy of Fallot was diagnosed in an acyanotic 11-month-old dog. Predicted pressure gradient across the pulmonic valve, as assessed by use of continuous wave Doppler echocardiography, was 94.5 mm Hg. Bidirectional shunting was identified by means of selective angiography. Open-heart correction was performed, using a transatrial approach with limited ventriculotomy and cardiopulmonary bypass. The hypertrophied infundibulum was resected, the ventricular septal defect was closed primarily, and a transannular pericardial patch graft was applied. Pressure gradients across the pulmonic valve were 52.9 and 22.8 mm Hg 2 weeks and 4 months after surgery, respectively. Advances in cardiopulmonary bypass, anesthetic management, and use of the transatrial approach may improve the success of open-heart correction of tetralogy of Fallot in dogs.

Comparison of plasma fentanyl concentrations by using three transdermal fentanyl patch sizes in dogs

OBJECTIVE

To compare plasma fentanyl concentrations attained after the application of three transdermal fentanyl patch sizes (50, 75, and 100 micrograms/hour) in dogs.

DESIGN

Repeated Latin square controlled study.

ANIMALS

Six intact, mixed-breed adult dogs (2 males, 4 females) weighing 19.9 +/- 3.4 kg.

METHODS

Each dog was randomly assigned to receive each of three treatments: 50 (P50), 75 (P75), or 100 (P100) micrograms/hour transdermal patches. Patches were left in place for 72 hours. Jugular venous blood was collected at 1, 2, 4, 8, 12, 24, 36, 48, 60, and 72 hours after patch application and for 1, 2, 4, 8, and 12 hours after patch removal. Plasma fentanyl concentrations were measured using a radioimmunoassay technique. After a 96-hour washout period, each dog was moved to another treatment group and received a different patch size.

RESULTS

The following results were obtained (mean +/- SD): average plasma fentanyl concentration from 24 to 72 hours, 0.7 +/- 0.2 ng/mL (P50), 1.4 +/- 0.5 ng/mL (P75), 1.2 +/- 0.5 ng/mL (P100); the total area under the concentration versus time curve (0 hours to infinity), 46 +/- 12.2 ng/h/mL (P50), 101.2 +/- 41.4 ng/h/mL (P75), 80.4 +/- 38.3 ng/h/mL (P100); and the apparent elimination half-life, 3.6 +/- 1.2 hours (P50), 3.4 +/- 2.7 hours (P75), and 2.5 +/- 2.0 hours (P100). There was a high degree of variability in plasma fentanyl concentrations achieved. Plasma fentanyl concentrations declined rapidly after patch removal.

CONCLUSIONS

The attainment of steady-state plasma concentrations takes up to 24 hours, and there is a great deal of variability in the final concentrations reached in different individuals. In this study, the 100 micrograms/hour patches did not provide statistically increased plasma concentrations when compared with the 50 micrograms/hour patches.

CLINICAL RELEVANCE

Because of the interindividual and intraindividual variation in plasma fentanyl concentrations, patches should be applied 24 hours before the anticipated time that analgesia will be required. Adequacy of analgesia and potentially deleterious side effects, such as sedation and respiratory depression, should be monitored while the patches are in place. Skin reactions may occur, and the patches should be removed if such skin irritation is seen. After the patch is removed, it is expected that analgesia will wane rapidly because of the brief elimination half-life.

Deep hypothermic low flow cardiopulmonary bypass in small dogs

OBJECTIVE

To evaluate the feasibility of and morbidity and mortality associated with cardiopulmonary bypass (CPB) using deep hypothermia and low flow perfusion in adult dogs weighing less than 10 kg.

STUDY DESIGN

Prospective, descriptive study.

ANIMALS

Two groups of three dogs underwent CPB. Group 1 dogs underwent deep hypothermia (15 to 18 degrees C), 45 minutes of low perfusion flow (20 mL/kg/min) and 1 hour of aortic cross clamp time. In group 2, ultrafiltration of perfusate before discontinuation of bypass was added to the standard treatment. Complete blood counts, serum biochemistry, urine output, ejection fraction, and cardiac output were monitored before and for 7 days after surgery.

RESULTS

All dogs were successfully weaned from bypass. Four of six dogs survived, three without major complications. One dog developed and recovered from septic pleuritis. Two dogs died or were euthanatized after surgery because of respiratory or gastrointestinal complications. Minor complications included anemia, hypoproteinemia, and electrolyte disturbances. Transfusion requirements and edema formation were reduced by ultrafiltration.

CONCLUSIONS

The observations in this study support the feasibility of low flow hypothermic CPB. Meticulous tissue handling, precise equipment, ultrafiltration, and aggressive postoperative potassium supplementation are recommended for smaller patients.

CLINICAL RELEVANCE

Increased sensitivity to adverse sequelae of CPB may be associated with small patient size. Further evaluation is necessary before routine clinical application of low flow hypothermic CPB in this patient population.

Cardiopulmonary effects of propofol infusion in llamas

OBJECTIVE

To evaluate selected cardiopulmonary responses to propofol 2 infusion rates in nonpretreated llamas breathing room air.

ANIMALS

5 adult llamas (3 males, 2 females) with mean +/- SD body weight of 135 +/- 17.7 kg.

PROCEDURE

After anesthesia induction with propofol (2 mg/kg of body weight, IV), llamas received either propofol infusion 0.2 mg/kg/min (group 1) or 0.4 mg/kg/min (group 2) for 60 minutes. Measurements, taken before anesthesia induction and at regular intervals during infusion were: direct blood pressures, heart and respiratory rates, cardiac output, and arterial blood gas tensions. Systemic and pulmonary vascular resistance, cardiac and stroke indices, and plasma bicarbonate and base excess concentrations were calculated.

RESULTS

At 3 to 60 minutes after either dosage of propofol, PaCO2 and heart rate increased in all llamas; at the same time, PaO2 and arterial pH decreased. Mean pulmonary artery and central venous pressures, and stroke index decreased at 3 to 60 minutes after either dosage of propofol. Mean arterial pressure decreased at 30 to 60 minutes after infusion of 0.4 mg of propofol/kg/min; pulmonary arterial wedge pressure decreased at 20 to 40 minutes and 3 to 60 minutes after infusion of 0.2 and 0.4 mg of propofol/kg/min, respectively. Mean time from termination of infusion to sternal recumbency was 7 (group 1) and 13 (group 2) minutes. Standing was achieved in a mean 11 (group 1) and 22 (group 2) minutes.

CONCLUSION

Propofol infusion rate of 0.2 mg/kg/min was considered too low to maintain a suitable depth of anesthesia, but 0.4 mg/kg/min was considered sufficient for noninvasive procedures with minimal cardiopulmonary depression.