What veterinarians need to know about high-volume spay/neuter clinics (Proceedings)

There is a homeless pet crisis in the United State that is a direct result of animals left unaltered in our communities. ASPCA and HSUS estimates are that 6-8 million animals are placed in shelters each year and of these 3 – 4 are euthanized. That equates to one animal euthanized every 2 seconds every working day each year. There are no reliable estimates of the number of stray dogs and feral cats that are killed on highways, die of disease or die of starvation each year. This paper deals with the need for high volume spay neuter clinics, the standards that those clinics are held to, and the relationships between high volume spay neuter clinics and private practitioners.

Many people view the overpopulation of unwanted dogs and cats as simply an emotional issue, and it is emotional. But it is much more as well. Stray dogs and feral cats are a public health hazard: the spread of zoonotic diseases to people, bite wounds, highway accidents are all concerns. Stray dogs and feral cats are a risk to the health of owned animals as well. The serve as reservoirs for heartworms, internal and external parasites, and may cause the spread of viral diseases such as FeLV and FIV.

As veterinarians we take an oath. "...I solemnly swear to use my scientific knowledge and skills for the benefit of society through the protection of animal health, the relief of animal suffering, the conservation of livestock resources, the promotion of public health..." Notice the key words, protect animal health, relieve animal suffering, promote public health. High volume spay neuter clinics contribute to all three of these. The missions of spay neuter clinics are to promote public heath, to relieve animal suffering; to stop the killing.

The objective of high volume spay neuter clinics is to end overpopulation of unwanted dogs and cats by providing high quality, high volume, affordable sterilization services for companion animals. They do this by providing spay neuter services to shelters, those that can't pay, and those that won't pay.

There are there major points to communicate. There is a misconception that high volume or low cost clinics must sacrifice quality, but that is not true. In fact, often the reverse is true. High volume can lead to high quality. Spay neuter programs now have published guidelines which promote quality. Contrary to those that view these clinics as a threat, high quality high volume spay neuter programs can actually benefit the private practitioner. We will address all three of these points in more detail.

High Volume Leads to High Quality

High volume clinic develop very efficient systems. Most veterinary practices are not designed for efficient spay neuter as they perform hundreds, if not thousands, of different things. High volume spay neuter clinics do two things, spay and neuter, and can direct every aspect of the clinic towards those two procedures. Although the mission is to sterilize as many animals as possible, spays and neuters are still elective procedures. If it is in the best interest to have the surgery postponed, then arrangements are made to do so. The health of the individual animal is always the highest priority.

Spay Neuter Guidelines

In fall of 2006 a group of 22 veterinarians representing all aspects of the spay neuter movement were convened as the national spay neuter task force. The group consisted of board certified specialists in surgery, anesthesiology, internal medicine, and critical care, as well as high volume spay neuter veterinarians from many different programs across the United States. One of the products of this task force is "The Association of Shelter Veterinarians veterinary medical care guidelines for spay-neuter programs." The guidelines are based upon accepted principles in anesthesiology, critical care medicine, microbiology and surgical asepsis and technique. The guidelines are intended as achievable in all programs that practice high volume spay neuter. They were divided into four section: preoperative, anesthetic, surgical and postoperative. This paper will only hit the highlights, but the full reference is available at the ASV website: www.sheltervets.org.

Preoperative guidelines

The preoperative guidelines are designed to address client concerns and expectations, patient selection and to ease stress for clients, patients and staff. If a patient is owned client communication is extremely important. A full history should be taken including any current medications, medical history, and any allergies. The owner must be made aware of preoperative fasting and must be counseled regarding any risks. Patient selection should always be the veterinarian's decision. The final decision regarding performance of surgery on a patient has to be the veterinarian's and should be based on history and physical examination findings as well as the clinic schedule and experience level of the surgeon. Any age and weight limitations must also be determined by the veterinarian. Current anesthetic protocols, surgical techniques, and methods for maintaining body temperature, blood glucose levels and blood pressure make it safe to do pediatrics. Many clinics will perform surgery on animals as young as 6 weeks; even on animals that weigh less than 1 pound.

Medical records are required for each patient and should include at least: physical examination findings, animals weight, the dosages and route of administration of all drugs, the specifics of the surgical procedures and any unusual occurrences. The specifics of the medical record may vary with state and local practices laws and should be guided by state and national veterinary medical associations.

Vaccination is always recommended prior to surgery, but perioperative vaccination is acceptable when necessary, for example in feral cats. Rabies vaccinations should be required or administered as mandated by state regulations. Vaccination protocols should follow current AAFP and AAHA guidelines.

Fasting patients preoperatively is always recommended. Adult dogs and cats should be fasted for 4 to 6 hours, pediatric patients for only 2 hours. Withholding water is not necessary nor is it recommended.

Prior to surgery patients should be clearly identified, housed in a place that allows for adequate temperature, ventilation and stress reduction. Adult animals should be housed individually; pediatric littermates or housemates can be housed together. Cages should be properly cleaned and disinfected between patients.

Anesthesia Guidelines

The anesthesia guidelines deal with care of equipment, balanced anesthesia, thermoregulation, anesthetic monitoring and preparation for emergencies. An anesthesia equipment safety checklist should be created and be performed on a regular basis prior to anesthesia. The equipment inspection should include, at least: general machine inspection, confirmation of oxygen supply, checking breathing circuits and checking ventilator function and safety (if a ventilator is used). The must be a waste gas scavenge system in use. Either active or passive systems are acceptable. Charcoal canisters are acceptable, but only for short-term use.

Balanced anesthesia should consist of analgesia, stress reduction, loss of consciousness and muscle relaxation. The success of anesthesia has more to do with perioperative patient care, the flow of cases, vigilant monitoring, and the specific surgical technique and length of surgical procedure than the specific drug protocol.

It is important to maintain the patient's body temperature, especially in pediatrics. Every effort should be made to avoid heat loss. This includes: reducing contact with cold environments, use of proper bedding, avoiding wide surgical clips and cold preparation scrubs or solutions. Avoid using alcohol in the patient prep as the evaporation of alcohol from the skin rapidly reduces body temperature. Circulating warm water blankets, rice mamas, hot water bottles, or convective warm air systems should be used to keep patients, especially pediatric patients, warm. Limiting body cavity exposure is also critical in preventing heat loss.

Anesthetic monitoring is essential and more than one parameter needs to be monitored. Pulse quality, rate and rhythm, respiratory rate and pattern, body temperature, jaw tone, eye position, pupil size and palpebral reflex should all be monitored.

The selection of anesthetic protocol depends upon the number and types of patients, the skill and efficiency of technical staff and surgeons and financial considerations. The protocol must provide analgesia, stress reduction, muscle relaxation and loss of consciousness. Ideally the protocol would be safe, controlled, and reversible.

Spay neuter clinics must be prepared for emergencies. Fully stocked crash carts, emergency drug charts, and regular staff training in emergencies are essential. Arrangements for emergency care for any post-operative complication is also required. This is especially important with mobile or mash type spay neuter programs in which the surgical team is not local. In these situations, arrangements must be made with a local veterinary clinic to provide emergency post-operative care.

Intubation is controversial and the pros and cons must be weighed. Not every patient needs to be intubated, but it should be possible to intubate any and all patients if needed. Those patients that should always be intubated include brachycephalic dogs and cats, animals with any signs of respiratory impairment and overweight patients.

Surgical Guidelines

The surgical guidelines deal with the operating room environment, surgical pack preparation, patient preparation, surgeon preparation, draping, the specific surgical procedures, surgical materials and antibiotic usage.

There can be a broad definition of operating room and many different facilities can be used as an operating room. Several basic principles are, however, required. The operating room should be a dedicated are with proper equipment. It must be able to be cleaned and disinfected, and a regular schedule of cleaning and disinfection must occur. Personnel traffic must be limited to essential surgical personnel.

Surgical packs must be sterilized and separate sterile instruments must be used for each patient. Sterilization should be steam, Ethylene Oxide, or plasma. Cold sterilization is not allowed. Instruments and any reusable linens must be cleaned before sterilization, should be wrapped in 270 thread count cotton or disposable paper, and must include sterilization indicators inside and outside the packs.

Patient preparation should include sufficient hair removal to prevent contamination of the surgical field and allow extension of the incision is necessary. But should be small enough to minimize heat loss. The entire clipped area should be scrubbed with an appropriate surgical scrub used according to accepted patient preparation guidelines. Bladders should be expressed in female patients.

Surgeon preparation includes wearing appropriate surgical attire. Gowns are preferred but not required and use is at surgeon's discretion. Surgical caps, masks and single use sterile gloves are required except for cat and puppy neuters. Surgeons should scrub hands and arms with appropriate surgical scrub.

Drapes are required for all abdominal procedures and adult dog castrations. The drapes should be large enough to maintain a sterile surgical field. In cat and pediatric dog castrations draping is optional, but if no drapes are used care must be taken to prevent contamination.

Surgical procedures must be performed by licensed veterinarians or by supervised veterinary students (where state practice acts allow). Surgeons should adhere to the golden surgical principles of gentle tissue handling, meticulous hemostasis, and aseptic technique. Surgeons should always ensure and verify hemostasis. In females, ovariohysterectomy or ovariectomy are acceptable and ventral midline, ventral paramedian, flank or laparoscopic approaches are acceptable. The specific procedure and length and location of the incision is surgeon's preference. Closure of ventral abdominal incisions must include the rectus sheath; closure of flank incisions must include the internal and external abdominal oblique muscles. Castration of the adult male can be through prescrotal or scrotal incisions. The procedure and length and location of the incision is surgeon's preference. In tomcats and puppies the scrotal incisions are often left open to heal by 2nd intention.

All surgical materials must be biomedical grade. Choice of absorbable or inert non-absorbable suture is at the surgeon's discretion as is the choice of interrupted or continuous suture patterns. Antibiotics should not be used routinely. There use should be limited to conditions in which antibiotics are specifically indicated or in which breaks in asepsis occur.

Postoperative Guidelines

Postoperative guidelines deal with patient monitoring and recovery, release of patients, and dealing with emergencies. Patients must be carefully transported/moved to the recovery area. This should be a secure, level surface that has been cleaned and disinfected, is clean, dry and warm. Continuous direct observation is required and measures must be taken to prevent hypoglycemia and hypothermia (especially in pediatric patients). Parameters to be monitored during recovery include; heart rate and pulse quality, airway patency, respiratory rate and character, presence of pain or anxiety, degree of arousal and ability to move/ambulate. Analgesics should be administered as needed and food should be provided for pediatric patients as soon as they are able to eat.

Patients should be evaluated prior to release to owner / caretaker. They should be alert, able to stand and walk and should be pain free. The incision should be clean, dray and intact. The owner / caretaker should be given clear and concise written and verbal instructions on the postoperative care of the patient.

Spay neuter clinics must have a plan to deal with any postoperative emergencies. When possible a clinic should perform its own rechecks, but where necessary emergencies can be referred.

High volume spay neuter clinics can benefit private practitioners

Many practitioners fear high volume spay neuter clinics; they consider them a threat. But the reality is these clinics take the pressure off the local veterinarian, provide a potential referral outlet for low-income clients, and increase adoption of animals from shelters resulting in potential clients for the practitioners.

Veterinary medicine has made tremendous advancements in the 38 years since the author graduated from veterinary school. We practice human level medicine on pets. But these advancements have come at a cost. Veterinarians now can provide better and better care, but to a smaller and smaller percentage of the animal owning public. The question we must consider is who provides spay neuter services for the animals of people who need financial assistance. The services of high volume clinics target humane societies, animal shelters and low-income families. The track record of high volume spay neuter clinics is outstanding proving the programs are safe.

There are basically three categories of animal owners: those who don't take animals to the veterinarian, those who shop around for best prices, and those who develop a loyalty to a single veterinarian or a single practice. Private practitioners build their practices on the third category, often lose money on the 2nd category and never see the first. High volume spay neuter programs focus their care on those who don't use veterinary services and those who need low cost services. Humane Alliance in Asheville, N.C., probably the most successful high volume spay neuter clinics has the statistics that confirm the fact that high volume spay neuter clinics don't compete with private practitioners. These programs focus on those who don't routinely use veterinary services and increase public awareness of the need for and benefits of spay neuter. High volume spay neuter programs would like to work in conjunction with local veterinarians to increase public awareness of spay neuter, increase the number of animals spayed and neutered, decrease the numbers of unwanted litters of puppies and kittens, thereby decrease shelter relinquishment and the number of euthanasias. Working together we can end the killing; we can solve the problem.