2012 summer externs - ohio state university...2012 summer externs . extern: dana lemoine, aslap...
TRANSCRIPT
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
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
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
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
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
2. Satisfy hand washing condition
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
2. Satisfy hand washing condition
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
2. Satisfy hand washing condition
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
Different Heating Conditions
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
Different Heating Conditions
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
Baseline Day 1 Day 2 Day 3
Oral Meloxicam
0
1
2
3
4
5
6
7
8
9
Baseline Day 1 Day 2 Day 3
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
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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.
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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!