2012 Summer Externs - Ohio State University...2012 Summer Externs . Extern: Dana Lemoine, ASLAP Foundation Summer Fellowship • Student, Ontario Veterinary College – University

2012 Summer Externs

Extern: Dana Lemoine, ASLAP Foundation Summer Fellowship • Student, Ontario Veterinary College – University of Guelph, Guelph, ON, Canada. • Projected graduation 2015 • Involved with ASLAP, Canadian Veterinary Medical Association and the Ontario Veterinary Medical Association Mentor: Carrie Freed, MLAS, DVM, DACLAM, Director, Rodent Clinical Medicine ULAR; Assistant Professor, Clinical Veterinary Preventive Medicine Dr. Freed is a clinical veterinarian for OSU facilities and as the Director of Rodent Clinical Medicine provides clinical and didactic support for the Laboratory Animal Residency Program. She is a member of ASLAP and AALAS, serves on the OSU IACUC, the Institutional Biosafety Committee, and is a Veterinarian for the BSL3. Research Project: “Assessment of Alternatives to Sterile Surgeon’s Gloves for Survival Surgery in Rodents”

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Dana LeMoineDr. Carrie Freed

July 19, 2012

Introduction Regulations Aseptic Technique

Part 1 – Can gloves be autoclaved? Background information Methods Results

Part 2 – Can disinfectants be used? Background information Methods Results

Conclusions Discussion

What are the standards & regulations regarding survival surgery in rodents? The Animal Welfare Act and Animal

Welfare Regulations exclude rats of the genus Rattus and mice of the genus Musbred for research.1

According to the Guide, survival surgery in rodents requires aseptic technique and instruments.2

What is “aseptic technique”? Reduces microbial contamination to the lowest

possible practical level According to the Guide2, this includes: Preparation of the patient Preparation of the surgeon, such as: Decontaminated surgical attire Surgical scrub Sterile surgical gloves

Sterilization of instruments, supplies & implanted materials

The use of operative techniques to reduce the likelihood of infection

The Guide2 also states:

“The species of animal may influence the manner in which principles of aseptic technique are achieved… General principles of aseptic technique should be followed for all survival surgical procedures.”

Post-surgical infections can occur in rodents Compromises animal’s well-being & research data Unknown rate of infection Infection-causing bacteria may come from a

number of sources

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Laboratory workers fail to follow the recommendation to wear sterile gloves for survival rodent surgeries Attributed to the high cost of surgical gloves3

PART 1

There is some existing data on the integrity and barrier quality of exam and surgical gloves4-7

Not a completely impermeable barrier4,5

Fail at rates ranging from 1-10%6,7

Evaluating glove integrity The FDA has a standard test

procedure for medical examination & surgeon’s gloves May not be sufficient to detect

micro-perforations7

One study used an air inflation test9

Database searches did not bring up any literature on the effects of autoclaving modern disposable exam gloves 1960: surgeon’s rubber gloves sterilized at high

temperatures (115-120°C) become vulcanized and unusable.10

1963: steam sterilization of surgeon’s rubber gloves reduced the tensile strength of the gloves and increased breaking elongation.11

Keep in mind This is before the widespread use of disposable gloves Glove manufacturing and quality control criteria have

changed since the 60s

Autoclave sterilization Sterilizes contents through exposure to high-

pressure saturated steam at high temperatures Pre-vacuum removes trapped air from the

autoclave to ensure proper steam sterilization Sterilization relies on a combination of

PRESSURE, TEMPERATURE and TIME

Temperature tape and chemical indicator strips are used to verify that sterilization parameters were reached.

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EXPERIMENTAL:

Glove Type

Standard Latex

Standard Nitrile

Pack Type

Drape

Drape + Instruments

Peel pouch + Instruments

Position in Pack

Top

Middle

Bottom

Days Post-Sterilization

0

3

7

CONTROLS: Sterile latex & nitrile, Unsterilized latex & nitrile exam gloves

Each pair of gloves represents 2 data points

3 reps of each glove/pack type combination 6 data points/condition

Gloves were visually inspected for defects prior to packing Any found to be

defective were removed from the study

Cuffs were folded over approximately 2 ½”

DRAPE:5 pairs of gloves wrapped in a blue surgical towel

DRAPE + INSTRUMENTS:5 pairs of gloves, 1 forceps, 1 scissors, 1 needle driver and 4 4x4 gauze pieces wrapped in a blue surgical towel

POUCH + INSTRUMENTS:5 pairs of gloves, 1 forceps, 1 scissors, 1 needle drive and 4 4x4 gauze pieces in a 7x12 autoclave pouch

Autoclave Cycle Settings:Temp: 270F

Sterilize Time: 4 min.Dry Time: 20 min.

1. Open pack and don one pair of gloves following

sterile gloving technique

2. Visually inspect gloves for holes and tears

3. Stretch Test 1

Stretch Test Will the gloves withstand reasonable levels of

stress placed on them? Stretched each finger of the glove to a length of 6” Stretched the cuff to a length of 6” on two sides Visually inspected gloves for holes and tears




3. Stretch Test 1

4. Performance Test

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Performance Test Will the gloves hold up to the manipulation of

surgical tools? 5 simple interrupted stitches

Visually inspected gloves for holes and tears




3. Stretch Test 1

4. Performance Test

5. Stretch Test 2

6. Pressure Test

Pressure Test If it’s free of visible defects, is the glove porous

or does it hold air? Anesthesia machine was

set up & pressure tested Cuff of the glove secured

around the end of the circuit

Filled glove with oxygen at a rate of 3 L/min until peak pressure was reached

Stopped oxygen flow and let glove sit 5 min

Glove melting Gloves firmly stuck together/shut Nitrile gloves did not melt at all 22.8% of latex gloves melted (37 gloves) Of these, 94.6% were from Box 2 16.7% of gloves from Box 2 were wearable Gloves from other boxes were “sticky” but were still

easy to separate & don

No further testing was possible on melted gloves

Wearable gloves Melted glovesGlove defects Holes, tears, or breaks in the glove No defects found in sterile latex, unsterilized

latex, and unsterilized nitrile gloves Overall defect rate (# defects/glove) Autoclaved Latex: 0.008

1 defect found after stretch test 1

Autoclaved Nitrile: 0.031 5 defects found in 4 gloves, all

created during stretch test 2

Sterile nitrile: 0.125 1 defect in 8 gloves tested,

created during stretch test 2

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Pressure Test Peak pressures May reflect the elasticity of the glove and/or the

presence of holes

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

sterile unsterilized autoclaved sterile unsterilized autoclaved

latex nitrile

Pressure (cmH2O)

Peak Pressure

latex nitrile

Pressure Test Pressure loss May reflect the porosity of the gloves or the presence

of small holes

0

2

4

6

8

10

12

14

16

18

20

sterile unsterilized autoclaved sterile nonsterile autoclaved

latex nitrile

Pressure Loss (ΔP)

latex nitrile

In general, nitrile gloves reached a higher pressure and lost more pressure during the pressure test than did the latex gloves.

Further analysis… ANOVA will be done to look for any effects of

pack type, position in pack, days post-sterilization or combinations thereof.

Preliminary calculations suggest that there are not statistically significant differences between them.

PART 2

Alcohol (70% isopropyl alcohol) The Guide specifically states that “alcohol is

neither a sterilant nor a high-level disinfectant”2

Effective at reducing bacterial counts, but not active against bacterial spores12

Does not provide sustained anti-microbial activity3

There is a fair amount of discussion in the literature as to whether or not alcohol works “well enough” for surgery

SPOR-KLENZ Ready To Use Manufactured by Steris Life Sciences Group Cold sterilant: 1.00% hydrogen peroxide with

0.08% peroxyacetic acid This combination is a chemical sterilant suitable for

use on “critical items”13

Label instructions Sterilization: immerse for a

minimum of 5 ½ hours Broad-spectrum disinfection:

treated surfaces must remain wet for 10 minutes

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Glove Type x Handwashing x Disinfectantstandard latex washed hands 70% isopropyl alcoholstandard nitrile unwashed hands Spor-klenzsterile latexsterile nitrile

Group Washed/Unwashed Glove Disinfectant nA Washed Sterile Latex - 8B Washed Sterile Nitrile - 8C Unwashed Sterile Latex - 8D Unwashed Sterile Nitrile - 8E Washed Latex Alcohol 8F Washed Latex Spor-klenz 8G Washed Nitrile Alcohol 8H Washed Nitrile Spor-klenz 8I Unwashed Latex Alcohol 8J Unwashed Latex Spor-klenz 8K Unwashed Nitrile Alcohol 8L Unwashed Nitrile Spor-klenz 8

Disinfected the hood according to standard ULAR procedures

Prior to starting each trial: BHI broth tubes

opened only in the hood

Sterile swab was placed in each tube

Donned PPE

Gloves Latex: Henry Schein

Criterion Surgeon’s Gloves

Nitrile: Kimberly-Clark Purple Nitrile KC500 Sterile Powder-Free Exam Gloves

The “Gold Standard” Assume gloves are

sterile after donning

1. Open gloves in hood following sterile

gloving technique

2. Satisfy hand washing condition

Handwashing condition: Washed hands: 1 minute of vigorous hand washing with

CliniClean Antibacterial Hand Soap and warm water prior to donning gloves

Unwashed hands Proceeded to donning gloves immediately

Gloves Latex: Henry Schein

Criterion Surgeon’s Gloves

Nitrile: Kimberly-Clark Purple Nitrile KC500 Sterile Powder-Free Exam Gloves

The “Gold Standard” Assume gloves are

sterile after donning

1. Open gloves in hood following sterile

gloving technique


3. Don gloves following sterile

gloving technique

4. Run in place 5 minutes

5. Culture

Glove culturing procedure: Swabbed the palmar surface of the distal

phalanges on the left hand in order from 1st to 5th

Returned swab to broth tube

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High Five brand exam gloves One box for each

glove type/handwashcombo

Stored in microisolatormouse cages

1. Open glove container inside hood


3. Inside hood, remove two gloves from the box touching only the cuff

and don.

4. Culture 1

5. Disinfect gloves

Disinfection procedure: At a distance of approximately 12”, sprayed each

side of both hands 2 times with disinfectant

Rubbed hands together until disinfectant dried 30 seconds for 70% isopropyl alcohol 90 seconds for Spor-klenz

1. Open glove container inside hood


3. Inside hood, remove two gloves from the box touching only the cuff

and don.

4. Culture 1

5. Disinfect gloves

6. Culture 2

7. Run in place 5 min.

8. Culture 3

Break off end of swabs & close tubes

Incubate tubes at 35°C for 24 hours

Evaluate tubes for growth (cloudy/clear)

A subset of the positive cultures (at least 20% from each group) underwent further testing for identification purposes Plated on Sheep’s Blood

Agar and incubated at 35ºC for 24 hours

Gram staining Gram negative rods: API

20 E biochemical ID strips

Staph spp.: MannitolSalt Agar

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0

1

2

3

4

5

6

7

8

1 2 3 4 5 6 7 8

Number Contaminated At Each Time Point by Group

Pre-disinfectant

Post-disinfectant

Post-activity

1-4: Alcohol Groups 5-8: Spor-klenz Groups

Overall, 47.7% of standard exam gloves were contaminated after donning 42% of latex, 53% of nitrile Contamination rates varied by box

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Latex Nitrile

Post-Donning Contamination Rate by Box

Washed

Unwashed

Post-disinfection contamination rates (culture 2) 0.03% of gloves disinfected with Spor-klenz were

contaminated 43.8% of gloves disinfected with alcohol were contaminated Statistical analysis (Cochran-Mantel-Haenszel)

No effect of glove type or hand washing Very significant effect of disinfectant (p<.05)

0.00%

10.00%

20.00%

30.00%

40.00%

50.00%

60.00%

70.00%

80.00%

90.00%

100.00%

Alcohol Spor-klenz

Contamination Rates Pre- and Post-Disinfection

Pre-Disinfection

Post-Disinfection

All sterile gloves were free of contamination after 5 minutes of activity

Post-activity contamination rates of standard exam gloves vs. sterile gloves Fisher’s Exact Test 25% of gloves disinfected with alcohol were

contaminated post-activity Significantly different from sterile gloves (p<.05)

0.03% of gloves disinfected with Spor-klenzwere contaminated post-activity NOT significantly different from sterile gloves

Result combinations for all 3 culturesResult Possible Explanations Overall Alcohol Spor-klenz

- - - Consistently clean 38.5% 9 16

+ - - Disinfectant effective 32.3% 6 15

+ + - Dessication, Slow action of disinfectant, Sampling error

7.7% 4 1

- + - Sampling error 7.7% 5 -

+ + + Disinfectant ineffective 4.6% 3 -

+ - + Sampling error in culture 2, Disinfection & recontamination

3.1% 1 1

- - + Contamination – skin, clothes,environment

3.1% 2 -

- + + Sampling error in culture 1 3.1% 2 -

32 33 Chryseomonas luteola

Sphingomonas paucimobilis

Bacillus spp.

Bacillus & Staph spp. Staph spp.

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The Staphylococcus species cultured was NOT S. aureus

Spores were observed in multiple Bacillus cultures

45%

4%4%5%

5%

14%

5%

18%

Overall Breakdown of IDs on Positive Cultures

Bacillus spp.

C. luteola

Pasteurella spp.

S. maltophilia

S. paucimobilis

Staph spp.

Strep spp.

No Growth

Autoclaving Gloves Autoclaved exam gloves may be an acceptable

alternative to sterile surgical gloves FDA’s Acceptable Quality Level for defects is 1.5%

for surgeon’s gloves and 2.5% for exam gloves8

0.8% of autoclaved latex gloves had visible defects 2.47% of autoclaved nitrile gloves had

visible defects, but only after the 2nd

stretch test

One box of latex gloves had a high proportion that melted in the autoclave

Autoclaving Gloves Duration of use has a significant impact on

failure rates6

Glove brand & glove type has a significant impact on the durability9

Variable response to autoclaving on a box-to-box or lot-to-lot basis?

Effects of time since manufacturing?

Autoclaving Gloves Other observations to consider Gloves often clung to the other gloves in the pack The cuffs of the exam gloves occasionally rolled under

while donning Rust/discoloration spots were noted when gloves were

packed with instruments

Potential limitations & sources of error Results of pressure test may not be

due solely to glove characteristics Not a random sample of gloves Small sample size

Disinfecting Gloves Alcohol applied in the manner prescribed in this

study does not consistently eliminate bacteria from the glove surface Noisy data on alcohol… Bio-film in alcohol bottle? Experimental error?

Alcohol disinfection procedure may have been insufficient Alcohol evaporated within 30 seconds 0.3 mL of alcohol no more effective than washing

hands with plain soap & water12

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Disinfecting Gloves Disinfecting standard exam gloves with Spor-

klenz may be a suitable alternative to sterile surgical gloves

Handwashing with antibacterial soap seems to be unimportant in determining contamination levels of the gloves Provided that care is taken to minimize skin contact

with the outer glove surface when donning Surgical scrubbing only eliminates bacteria from hands

62% of the time14

Disinfecting Gloves Generally 105-108 bacteria required to cause

infection3

Is the contamination observed in this study biologically relevant? Quantify bacteria picked up from gloves Are the organisms we find likely to cause infection?

Disinfecting Gloves Bacterial species found Bacillus, Staph, Strep and Pasteurella species are very

common Stenotrophomonas maltophilia15

Found in soil, water and contaminated medical solutions/devices

Has been reported as a source of nosocomial infections Chryseomonas luteola Reported as the causative agent in some post-surgical

infections16

Sphingomonas paucimobilis17

Widespread in the environment, has been found in hospital equipment and clinical specimens

Capable of causing infections, but they are rarely serious No growth – possibly anaerobic bacteria Unknown relevance to post-surgical infections due to

difficulty culturing3

Based on the results of this study… Disinfecting standard exam gloves with Spor-

klenz through the methods described in this study reliably eliminates bacteria and spores from the glove surface.

Autoclaving standard exam gloves did not appear to significantly impact their performance.

These methods of treating standard exam gloves provide cost-effective alternatives to using sterile surgical gloves for rodent survival surgeries.

1. Animal Welfare Act and Animal Welfare Regulations. United States Department of Agriculture Animal and Plant Health InspectionService. November 2005.

2. Guide for the Care and Use of Laboratory Animals: Eighth Edition. 2011. National Research Council. The National Academies Press, Washington, D.C.

3. Cooper, Dale M., McIver, Robroy, and Bianco, Richard. The Thin Blue Line: A Review and Discussion of Aseptic Technique and Postprocedural Infections in Rodents. Contemporary Topics by AALAS 2000:39(6), 27-32.

4. Olsen, Robin J et al. Examination Gloves as Barriers to Hand Contamination in Clinical Practice. JAMA 1993:(27)3, 350-353.

5. Calhoun, Andrew J., Rodrick, Gary E., and Brown, Frederic H. Integrity of powdered and powder-free latex examination gloves. Journal of Public Health Dentistry 2002:62(3), 170-172.

6. Kerr, Lesley N et al. Assessment of the Durability of Medical Examination Gloves. Journal of Occupational and Environmental Hygiene 2004: (1), 607-612.

7. Korniewicz, Denise M. et al. Failure rates in nonlatex surgical gloves. Am J Infect Control 2004: (32), 268-273.

8. 21 CFR Part 800 Medical Devices; Patient Examination and Surgeon’s Gloves; Test Procedures and Acceptance Criteria. Food and Drug Administration Department of Health and Human Services. Federal Register 2003: 68(61), 15404-15417.

9. Phalen, Robert N. and Wong, Weng Kee. Integrity of disposable nitrile exam gloves exposed to simulated movement. Journal of occupational and environmental hygiene 2011: (8), 289-299.

10. Oliver, R. and Tomlinson, AH. The sterilization of surgical rubber gloves and plastic tubing by mens of ionizing radiation. J Hyg, Camb. 1960, 58:465-472.

11. Fallon RJ and Pyne JR. The Sterilisation of Surgeon’s Rubber Gloves. The Lancet. June 1, 1963: pp.1200-1203.

12. Boyce, John M. Using Alcohol for Hand Antisepsis: Dispelling Old Myths. Infection Control and Hospital Epidemiology 2000: 21(7), 438-441.

13. Rutala, William A. and Weber, David J. Disinfection and Sterilization in Health Care Facilities: What Clinicians Need to Know. Clinical Infectious Diseases 2004: (39), 702-9.

14. Bukhari, SS, Harrison, RA and Sanderson, PJ. Contamination of surgeons’ glove fingertips during surgical operations. Journal of hospital infection 1993: (24), 117-121.

15. http://www.specialpathogenslab.com/SPL-Advantage/FactSheet-Stenotrophomonas.pdf.. Accessed July 18, 2012

16. Jay R. Kostman, Flora Solomon and Thomas Fekete. Infections with Chryseomonas luteola (CDC Group Ve-1) and Flavimonasoryzihabitans (CDC Group Ve-2) in Neurosurgical Patients. Reviews of Infectious Diseases 1990: (13)2, 233-236.

17. http://microbewiki.kenyon.edu/index.php/Sphingomonas. Accessed July 18, 2012.

THANK YOU!!! Dr. Freed Joann Petty Lori Mattox, Crystal Forrider, & Becky Glock Carrie McBride Dr. Bergdall, Dr. Hickman-Davis, Dr. Lewis & Dr. Coble ULAR

Extern: Michael Bradley, ASLAP Foundation Summer Fellowship • Student, The Ohio State University, Columbus OH • Projected graduation 2015 • Involved with ASLAP, OVMA, OSU student chapter AVMA, American Association of Bovine

Practitioners, American Association of Swine Veterinarians, OSU Shelter Medicine Club, Animal Behavior Club, Food Animal Club, Zoo & Wildlife Medicine Club, Veterinary Business Management Association and Class of 2015 Student Government Parliamentarian

Mentor: Dondrae Coble, DVM, DACLAM, Director Experimental Surgery Core ULAR, Assistant Professor Clinical, Veterinary Preventive Medicine Dr. Coble is a clinical veterinarian for OSU facilities and as the Director of the Experimental Surgery Core provides clinical and didactic support for the Laboratory Animal Residency Program. He is a member of AALAS, ACLAD, ASLAP, ASP, APV and serves on the AALAS Program Committee and the OSU College of Veterinary Medicine Admissions Committee and IACUC. Research Project: “Monitoring the Intraoperative Temperature during Swine Surgery: An Analysis of Heating Devices”

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Monitoring the Intraoperative Temperature During Swine Surgery: An Analysis of Heating Devices

Michael BradleyASLAP Summer FellowAugust 16th, 2012

http://www.talismancoins.com/catalog/Cute_Pig.jpg

Swine Surgical Models Size, physiology and anatomy are similar to man20

Common surgical research animal20

◦ Cardiovascular◦ Dermal◦ Transplantation◦ Renal◦ GI

Teaching/training exercises◦ CMIS◦ Emergency Medicine◦ Anesthesia◦ Urology◦ Electrosurgery

http://images.publicradio.org/content/2011/06/02/20110602_iaizzo3_33.jpg

Importance of Maintaining Intraoperative Normothermia

Normal rectal temperatures are 101.6˚-103.6˚F.7,19

Effects of hypothermia◦ Cardiovascular13

◦ Renal13

◦ CNS13

◦ Hepatic13

◦ Immune system13

Regulatory requirements and recommendations◦ AWA requires adequate veterinary care1

◦ The Guide states: “Maintenance of normal body temperature minimizes

cardiovascular and respiratory disturbances caused by anesthesia.”8

Physiology of Maintaining Normothermia In man, normal interthreshold range is1-2ºF15

◦ Physiologic responses occur outside of this range Hyperthermia Sweating Vasodilation

Hypothermia Shivering Vasoconstriction Metabolic heat production Utilized more by species weighing less than 50kg16

http://4.bp.blogspot.com/-x3rZ7SL5hoQ/TbHGMjeH_pI/AAAAAAAAAT8/ixWYHPAsnAU/s1600/pig-cartoon-looking-sick.jpg

Anesthetic-Induced Hypothermia

Anesthesia lowers the interthreshold range to 5-7ºF2,14,15,18

◦ Normal physiologic responses can still occur15

Anesthesia lowers Basal Metabolic Rate (BMR)12

◦ Body heat production decreases

Anesthesia decreases sympathetic tone3,13

◦ Blood (ie heat) becomes preferentially redistributed to the extremities9,13

Methods of Heat Transfer Radiation◦ The transfer of energy to or from a body by means of

electromagnetic radiation4

Ex: A heat lamp

Conduction◦ The transfer of energy between objects that are in physical

contact4

Ex: A warm hand touching a cold surface

http://www.roasterproject.com/wp-content/uploads/2010/01/heat-transmittance-means1.jpg

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Methods of Heat Transfer Convection◦ The transfer of energy between an object and its

environment, due to fluid motion4

Ex: A warm breeze

Evaporation◦ Heat transfers to liquid on surface, which then vaporizes4

Ex: Wet organs exposed in open laporatomy

Project Aims Evaluate intraoperative thermal loss in

swine ◦ Survival and non-survival surgery◦ 3 different heating devices

Examine the cost vs. benefit of the heating devices◦ Thermal supplementation $11.50 per use Water Blanket Bair Hugger®

Materials and Methods Treatment groups◦ Bair Hugger®

◦ Circulating Water Blanket

◦ Heated Surgical Table

◦ No heat applied (control)

Some pigs received warmed IV fluids◦ IV fluids kept in 120ºF warmer

◦ This data was analyzed separately

Survival Non-Survival

Bair Hugger® 6 4

Water Blanket 14 5

Heated Table 1 6

Control N/A 9

Heated Surgery Table Produced by Shor-Line

Evenly produced heat (97ºF)◦ Conduction

Heating elementfor table costs$500-900

Circulating Water Blanket Produced by Gaymar

Industries Circulates hot water (107ºF)◦ Conduction

Effective in avoiding hypothermia in dogs and cats3,7,11

$289 for the pump, $17 for each pad

Bair Hugger® Produced by Arizant Animal

Health Blows hot air (110ºF)

through holes in mat◦ Convection

Effective in avoiding hypothermia in cats and man during surgery5,13,17

$1150 for air blower, $12 for each mat (single use)

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Materials and Methods Temperature Monitoring◦ Esophageal temperatures Accurate measurement of core temp. in a variety of species6,10,13

Retrieval does not interfere with surgical techniques

◦ Temp. taken every 15 minutes

http://anatomy.wikispaces.com/file/view/dog_mouth_edit.jpg/127718945/dog_mouth_edit.jpg

Materials and Methods Treatment subjects◦ Yorkshire Pigs ~100lb◦ Survival surgeries Scrubbed and prepped with aseptic technique Covered with drapes Spent variable time in OR prep 97ºF cutoff for additional thermal support

◦ Non-survival surgeries Not covered with drapes Placed on heating device upon entrance to OR 95ºF cutoff for additional thermal support http://www.mahanaimfarm.org/images/yorkshire.jpg

Results: Survival Surgery

0.0000

0.0500

0.1000

0.1500

0.2000

0.2500

0.3000

0.3500

0.4000

0.4500

(Deg

. F/1

5min

)

Different heating conditions

Rate of Temp. Loss per 15 minin Survival Surgery from start time on table

Water Blanket N=10

Bair Hugger N=5

Results: Survival Surgery

96

97

98

99

100

101

102

Start 15 30 45 60

Tem

p. (

F)

Minutes

Individual Temperatures During Survival Surgery

Water Blanket

Bair Hugger

Results: Non-Survival Surgery

0.0000

0.1000

0.2000

0.3000

0.4000

0.5000

0.6000

0.7000

0.8000

Different Heating Conditions

Rat

e (D

eg. F

/15m

in)

Rate of Temp. Loss per 15 min in Non-Survival Surgery

Control N=4

Heated Table N=4

Water Blanket N=5

Bair Hugger N=4

*

Results: Non-Survival Surgery

94

95

96

97

98

99

100

101

102

60 75 90 105 120 135 150 165 180 195 210

Tem

p. (

F)

Time Increments (15 min)

Comparisons in Non Survival Surgeries of Temp. vs. Time

Control

Heated Table

Water Blanket

Bair Hugger

* **

*

*

*

*

*

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Results: Effect of Warmed IV Fluids

94

95

96

97

98

99

100

101

60 75 90 105 120 135 150 165 180 195

Tem

per

atu

re (

F)

Time increments (15 min)

Control Non-Survival

Fluids N=4 No Fluids N=4

94

95

96

97

98

99

100

101

60 75 90 105 120 135 150 165 180 195

Tem

per

atu

re (

F)

Time Increments (15 min)

Heated Table Non-Survival

Fluids N=2 No Fluids N=4

Results: Survival vs. Non-Survival

Difference in procedure

0.00

0.10

0.20

0.30

0.40

0.50


Rat

e (D

eg F

/15

min

.)

Water Blanket Rate of Temp. Loss

Survival N=10 Non-Survival N=5

0.00

0.10

0.20

0.30

0.40

0.50


Rat

e (D

eg F

/15

min

.)

Bair Hugger Rate of Temp. Loss

Survival N=5 Non-survival N=4

Discussion Bair Hugger® ◦ vs. Circulating Water Blanket No statistical difference

◦ vs. Heated Table Only difference is non-survival surgeries after 150 min Observed Survival surgeries were shorter than 150min Would Heated Table alone be sufficient for short survival surgeries?

◦ vs. Control Significantly different after 90 minutes in non-survival surgery Is no thermal support acceptable for short surgeries?

◦ Different shaped air mat?

Discussion Water Blanket ◦ Significantly different from heated table only at 180 min

◦ No difference between control Does have much slower rate of loss

Heated Table◦ No statistical difference between control

◦ Simultaneous use with other devices?

◦ Survival surgery data

Discussion Effect of drapes◦ Reduced rate of loss in survival surgeries◦ Could supplying drapes alone help retain heat?◦ Do drapes trap device-produced heat?

http://www.worldoffemale.com/wp-content/uploads/2010/09/pig-sleeping-new-york-456.jpg

Discussion Cost-benefit analysis◦ Bair Hugger® and CWB $11.50 Thermal supplementation cost Bair Hugger® is more expensive Bair Hugger® uses single use mats Bair Hugger® cost effective?

◦ No charge for Heated Table No difference between table and other devices before 150

min Charge?

http://takeiteasyinlife.files.wordpress.com/2010/09/piggy_bank.jpg

Extern: Ashley Berardi, OSU CASS Summer Fellowship • Student, The Ohio State University, Columbus OH • Projected graduation 2014 • Involved with ASLAP, OSU student chapter AVMA, OSU Shelter Medicine Club, Veterinary

Business Management Association, Student Chapter of the American Animal Hospital Association, Behavior Club- Fundraising Chair

Mentor: Stephanie Lewis, DVM, MS, DACLAM, Director, Large Animal Quality Assurance and Clinical Medicine, Principle Investigator Training, ULAR, Associate Professor Clinical, Veterinary Preventive Medicine Dr. Lewis is a clinical veterinarian for OSU facilities and as the Director of Large Animal Clinical Medicine provides clinical and didactic support for the Laboratory Animal Residency Program. She is the faculty advisor and student liaison for ASLAP, a member of AALAS and the OSU Radiation Safety Committee, and serves on the IACUC at OSU and the Veterinary Institute at Bradford. Research Project: “Assessment of Alternatives to Sterile Surgeon’s Gloves for Survival Surgery in Rodents”

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Ashley Berardi2012 ULAR Summer Extern

Our goal is to research approved analgesics for rodents and determine if we can find a better alternative to controlled drugs like buprenorphine and ulcerogenic NSAIDs.

What makes a good analgesic?

Ease of use by staff

Provides pain relief

Minimal side effects

Cost of use

Non‐Steroidal Anti‐Inflammatory Drugs (NSAIDs) Carprofen Ibuprofen Flunixin Meloxicam

Opioid Analgesic Buprenorphine

Buprenorphine

1. Given IP or SQ 0.05‐0.1 mg/kg

2.Opioid analgesic: partial mu agonist

3. Controlled substance

4. Side effects: nausea = no food consumptionhttp://sunnysidevetclinic.com/Articles/buprenorphine.htm

Carboxylic acid Enolic acid

Pyrazolones

(Phenylbutazone)Oxicams

(Meloxicam)

Salicylates(Aspirin)

Propionic acids (Carprofen)(Ibuprofen)

Aminonicotinic acids(Flunixin)

Phenylacetic acids(Acetaminophen)

Photos courtesy of J. Balasubramaniam

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COX‐1 Constitutive= part of normal

enzyme complement Maintains normal physiology

COX‐2 Inducible= released due to

stimulus Causes inflammation

http://pharmrev.aspetjournals.org/content/57/2/217.long

Specificity of a drug for a given COX isoform is

reported as a ratio.

Example: COX1:COX2 ratio >1.0 is the goal

▪ Less drug is needed to inhibit COX2 than COX1

▪ A given NSAID preferentially inhibits COX2

NSAID COX‐1 COX‐2 COX1:COX2

Flunixin 0.008 0.01 0.7

Meloxicam 0.9 0.3 3.0

Carprofen 13.2 0.1 129.0

For this table, the author based individual COX numbers on IC50, which is the concentration that produces 50% inhibition of enzyme activity.

Ibuprofen/ Motrin

1. Given 30 mg/kg in water bottle (~250 mL)

2. Non‐specific COX inhibitor

3. May be chondrotoxic with chronic use

▪ Questionable use in preg animals

Carprofen/ Rimadyl

1. Given 5‐10 mg/kg SQ daily

▪ Also comes in tablets

2. COX 1 sparing effects

3. Commonly used in dogs

4. Possible antineoplastic effects?

http://www.onlinepetmeds.info/tag/carprofen

http://www.vetdepot.com/vetprofen‐25‐mg‐60‐caplets‐carprofen.html

Flunixin Meglumine/ Banamine

1. Given 2.5 mg/kg SQ

2. No selectivity for COX 1 or 2

3. Subsequent dosing not helpful

4. Other indications ▪ Equine: foal diarrhea, colitis, post and pre race Tx

▪ Canine: heat stroke, parvovirus Tx, disk problems

▪ Bovine: acute respiratory dz, acute coliform mastitis

▪ Porcine: piglet diarrhea, agalactia/hypogalactia

http://www.vetdepot.com/banamine‐flunixin‐meglumine‐injectable‐50‐mg‐ml‐250‐ml.html

Available in oral and injectable formulations

1. Given 2 mg/kg SQ or in water bottle

2. Selective against COX 2

3. Common uses: Osteoarthritis and post surgical pain

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4 Treatments with four mice in each group 1. Oral Meloxicam in water bottles

2. Subcutaneous Meloxicam

3. Ibuprofen in water bottles

4. Injectable Meloxicam in water bottles

Mice separatedMeasure baseline weights, water, food; Hot Plate Test Baseline; Secure wheels

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

Food, Water, Wheel Activity, Weights measured everyday of study

Pre‐surgical meds administered

Surgery Day!

Mice euthanized

Post‐SxHot Plate Tests

Caudal

Cranial

WEEEEEEEEEEEEEE!

Criteria for removing mouse (any one of the following):1. Hind paw lick2. Hind paw flick3. Jumping4. No stimulus past 30 seconds

Laparotomies entering the abdominal cavity provided the post operative pain needed to test each analgesic.

You’re going to let her put what where?!?!I don’t remember

signing up for this…

Mice anesthetized with 1‐3% Isoflurane in an induction chamber 3 cm square area shaved on the abdomen Alternating chlorhexidine scrub with 70% isopropyl alcohol Eye lubrication applied to prevent corneal dessication

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Mice are moved from prep table to a separate surgery table with a heating pad

Deep plane of anesthesia acquired #15 scalpel blade to make a 1 cm incision on ventrum Tip of blade is used to enter abdominal cavity

Subcutaneous tissue layer is closed with 3‐0 suture using simple interrupted pattern

Skin is apposed and closed with a single wound clip Mouse is moved to recovery area

Photo courtesy of http://gardenrain.wordpress.com/2010/01/02/

What are we looking for? Weights: drop post‐op with a return to baseline

Food: less consumption post‐op

Water: difficult to measure

Hot Plate: increased time spent on hot plate

Wheel Activity: drop in activity post‐op

14.0

14.2

14.4

14.6

14.8

15.0

15.2

15.4

15.6

15.8

AvgWeights (g)

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Avg Food Consumption (g)

0.0

1.0

2.0

3.0

4.0

Avg Food Consumption (g)16.4

16.6

16.8

17.0

17.2

17.4

17.6

17.8

18.0

AvgWeights (g)

0.0

1.0

2.0

3.0

4.0

Avg Food Consumption (g)16

16.5

17

17.5

18

18.5

AvgWeights (g)

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0.0

1.0

2.0

3.0

4.0

5.0

6.0

7.0

8.0

9.0

Avg Food Consumption (g)

17

17.5

18

18.5

19

19.5

20

20.5

Avg Weights (g)

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

40.000

45.000

50.000

Oral Meloxicam (km/h)

0.000

10.000

20.000

30.000

40.000

50.000

60.000

70.000

Ibuprofen (km/h)

0.000

10.000

20.000

30.000

40.000

50.000

60.000

SubQ Melox (km/h)

0.000

5.000

10.000

15.000

20.000

25.000

30.000

35.000

40.000

45.000

50.000

Inj Melox in Water

0

2

4

6

8

10

12

14

Baseline Day 1 Day 2

Ibuprofen in Water

0

2

4

6

8

10

12

Baseline Day 1 Day 2 Day 3

SubQ Meloxicam

0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0


Oral Meloxicam

0

1

2

3

4

5

6

7

8

9


Inj Meloxicam in Water

What is the best drug?

Ibuprofen

Oral Meloxicam in Water

SubQMeloxicamIbuprofen

SubQMeloxicam

Oral Meloxicam in WaterInj. Meloxicam in Water

For next time…. More mice = larger n More wheels: good parameter to measure return to activity Look for continuing trends: which treatment brings animals closest

to baseline day 1 post‐op?

What we can take away….. Current treatments used by techs (Motrin water and SubQ

Meloxicam) seem to be effective Looking at cost/dose, oral meloxicam in water may be a

noteworthy treatment

Drug TotalVolume Dose Given Cost/Bottle Cost/Dose

Buprenorphine 1 mL 0.05‐0.1 mg/kg IPor SQ

$17.80 $17.80

Carprofen(50 mg/mL)

20 mL 5‐10 mg/kg SQ $111.00 $0.05

Ibuprofen(100mg/ 5 mL)

120 mL 30mg/kg in water $6.00 $0.11

Meloxicam (oral) 10 mL(1.5 mg/mL)

2.0 mg/kg in water

$22.18 $0.09

Meloxicam (injectable)

100 mL(5 mg/mL)

0.06 mL SQ(0.2 mL in 3.8 mL sterile water)

$122.10 $0.16

Cost/dose calculations are based on a 30 gram mouse that consumes an average of 5 mL of water daily.

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Episiotomy and Epistorrhaphy. (2010, February 1). Retrieved July 27, 2011, from Primumnon nocere: http://gardenrain.wordpress.com/2010/01/02/

Drug Metabolism. (2011). Retrieved July 30, 2012, from The Merck Manual: http://www.merckmanuals.com/professional/clinical_pharmacology/pharmacokinetics/drug_metabolism.html#v1109123

Basic Pharmacology. (n.d.). Retrieved July 27, 2011, from Pharmacokinetics: http://www.nurse‐prescriber.co.uk/education/modules/pharmacology/pharmacy3.htm

Boehringer IngelheimNew Zealand. (2011, May 20). New Zealand Data Sheet. Auckland, New Zealand, Australia. Bourque SL, A. M. (2010). Comparison of Buprenorphine and Meloxicam for Postsurgical Analgesia in Rats: Effects on

Body Weight, LocomoterActivity, and Hemodynamic Parameters. Journal of the American Association of Laboratory Animal Science, 617‐622.

Curry SL, C. S. (2005). NonsteroidalAnti‐inflammatory Drugs: A Review. Journal of the American Animal Hospital Association, 298‐309.

Gates, R. (2012). Phase I of Drug Metabolism. Retrieved July 30, 2012, from Sigma‐Aldrich: http://www.sigmaaldrich.com/technical‐documents/articles/biofiles/phase‐i‐drug‐metabolism.html

Gonzalez FJ, T. R. (n.d.). Drug Metabolism. Retrieved July 30, 2012, from McGraw Hill: http://books.mcgraw‐hill.com/medical/goodmanandgilman/pdfs/CHAPTER3.pdf

Hayes KE, R. J. (2000). An Evaluation of Analgesic Regimens for Abdominal Surgery in Mice. Journal of the American Association of Laboratory Animal Science, 18‐23.

Livingston, A. (2000). Mechanixm of Action of NonsteroidalAnti‐inflammatory Drugs. Veterinary Clinics of North America: Small Animal Practice, 773‐781.

Papich, M. (2007). Saunders Handbook of Veterinary Drugs. St. Louis: Elsevier Saunders. Plumb, D. (2008). Plumb's Veterinary Drug Handbook.Ames: Blackwell Publishing. Tubbs JT, K. G.‐H.‐P. (2011). Effects of Buprenorphine, Meloxicam, and FlunixinMeglumine as Postoperative Analgesia in

Mice. Journal of the American Association of Laboratory Animal Science, 185‐191. Ulrich CM, B. J. (2006). Non‐steroidal anti‐inflammatory drugs for cancer prevention: promise, perils, and

pharmacogenetics. Nature, 130‐140.

I would like to thank ULAR and OSU Research for this opportunity and for the resources needed to carry out the project.Thank you to Dianne and Dr. Lewis for keeping me on the right track.A special thank you to the Chioccas Lab for use of their hot plate.And thank you to Jeanne and Paul Green for troubleshooting my wheels!

Thanks for your attention!

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2012 Summer Externs - Ohio State University...2012 Summer Externs . Extern: Dana Lemoine, ASLAP Foundation Summer Fellowship • Student, Ontario Veterinary College – University