Monthly Update
Issue Contributors: Karie Walton, VMD and Louisa Rahilly, DVM DACVECC   
Editor: William B. Henry DVM, DACVS  
May 2014

Risk Management of Anesthesia

Karie Walton, VMD and Louisa Rahilly, DVM DACVECC


Anesthesia is a necessary component to the practice of modern veterinary medicine and allows life saving procedures to be performed while decreasing pain and the associated physiologic stress response. Anesthesia, itself, is not without risks as anesthetics may have profound effects on the cardiovascular and respiratory system.  This is especially true in patients whose bodies are already compensating for an underlying disease process.


Because we are unable to completely remove the risk of morbidity and mortality related to anesthesia, the best we can do as clinicians is to manage the risk of anesthesia. Risk management in the practice of medicine is not a new concept as veterinarians and physicians constantly weigh the risks of side effects against the benefit of diagnostics, procedures, and medications. Risk management is defined as the identification, assessment, and prioritization of risks followed by the application of resources in order to minimize, monitor, and control the probability and/or impact of unfortunate events. When this definition is applied to the anesthetic setting, there are specific questions that can be asked to help identify and manage risks.


Which patients are most at risk for anesthetic related morbidity or mortality? The American Society of Anesthesiologists created physical status categories in order to assess the "sickness" or physical state of a patient before being placed under anesthesia. Veterinary medicine has adopted the standards created in human medicine with the exclusion of category 6 patients.  Category 6 are those who are brain dead and awaiting organ donation. This system does have faults in that it is somewhat subjective, it requires full assessment of the patient (including clinicopathologic data) and patients may fit into multiple categories. In the spirit of managing risk, the assumption should always be that the patient falls into the "highest" category. 


Physical Status
Possible Examples
Normal healthy patientsOHE, caudectomy, castration

Patients with mild systemic disease
Skin tumor, fracture without shock, uncomplicated hernia, localized infection, compensated heart disease
Patients with severe systemic diseaseFever, dehydration, anemia, cachexia, hypovolemia
Patients with severe systemic disease that is a constant threat to lifeUremia, toxemia, severe dehydration/hypovolemia, anemia, high fever, cardiac decompensation
Moribund patients not expected to survive 1 day with or without operationExtreme shock and dehydration, terminal malignancy or infection, severe trauma


Table 1. ASA physical status category definitions and examples


These categories of physical state are well documented in veterinary medicine to be associated with the risk of mortality during or within 48 hours of anesthesia. Studies classify "healthy" patients as category 1 and 2 patients and "sick" patients those which are categorized as 3, 4, or 5. Multiple studies have shown that "sick" patients have a higher mortality rate and increasing levels of sickness are associated with increasing mortality rates.

These categories can be used to identify patients most at risk for anesthetic related mortality allowing for appropriate alteration of preparation, anesthesia, monitoring, and client expectations.

What are the specific risk factors for an individual patient and have all potential risk factors been fully assessed? Once a patient has been identified to be at high risk, its individual risk factors need to be fully evaluated.
  • Example #1: A patient with a heart murmur should have chest radiographs to determine if the heart is enlarged and if there is any evidence of fluid congestion in order to determine if any existing heart disease is compensated or uncompensated (ie. heart fairlure). Additionally, an echocardiogram/cardiology consultation should be pursued to determine the etiology of the heart murmur.
  • Example #2: A patient which is newly diagnosed with azotemia should have a urinalysis, culture with sensitivity, and imaging of the kidneys such as abdominal ultrasound to determine the cause of the azotemia and if any treatments are indicated before an elective procedure is performed.
Based on all identified risk factors, what are preparations that should be performed, which may not be part of the hospital's standard procedure? Preparation requires examining the patient's problem list and confirming that all resources needed for the procedure or anesthesia are available for each problem (aka. risk factor). This is again very dependent on the specific risk factors that have been identified and will need to be altered on an individual patient basis.
  • Example #1: If a patient is anemic or if the procedure is likely to produce significant blood loss, are red blood cells or whole blood available as a transfusion? Are there available technicians to help if the care during anesthesia becomes more complicated?
  • Example #2: For azotemic patients, AAHA recommends intravenous fluids for diuresis starting at least 12 hours before anesthesia and continuing after anesthesia. There should also be consideration to increasing the intraoperative IV fluid rate as long as there is no indication of heart disease or oliguric/anuric kidney disease.
  • Example #3: Do you have enough IV catheters for this patient? If a transfusion becomes necessary or if other medications may be required, should a second catheter be placed?
Based on all identified risk factors, is there a way to alter the anesthetic protocol to mitigate the risk of severe physiologic consequences? In order to answer this question, there needs to be an understanding of both the patient's physiologic state in addition to how medications alter a patient's respiratory and cardiovascular status.

An excellent review of the effects of anesthetics on the cardiovascular and respiratory systems is Dr. Steve Haskins' 2006 JVECC State of the Art Review "Comparative cardiovascular and pulmonary effects of sedatives and anesthetic agents and anesthetic drug selection for the trauma patient". His final conclusions are to be kept in mind in high intensity situations that require quick thinking.
  • Conclusion #1: In patients who are cardiovascularly unstable, a slow induction is warranted to prevent irreversible cardiovascular collapse
  • Conclusion #2: In patients who are in respiratory distress, a fast induction is warranted in order to control their airway, ventilation, and oxygenation and prevent cardiovascular arrest from hypoxemia.
  • Conclusion #3: "It is not recommended to implement an unfamiliar protocol in critical patients". This statement reminds us not to use medications we are unfamiliar with in high risk situations as well as a prompts us to become familiar with many anesthetics. Utilizing less familiar medication on stable patients in order to gain familiarity with various anesthetic options enables us to use the most appropriate medications when the situation arises.
Is the appropriate monitoring being performed on this patient to identify changes which may occur under anesthesia?Appropriate monitoring may be the most important aspect of anesthesia as it offers insight into the patient's current status as well as how medications have altered the patient's physiology. Anesthesia serves as its own physiologic marathon and can have dire consequences for even healthy patients or patients with well compensated underlying pathologies (such as an excited puppy who becomes dehydrated while waiting for anesthesia).Without monitoring to find problems, early intervention is impossible.

Monitoring starts with hands-on assessment under anesthesia such as evaluating the patients stage and plane under anesthesia. Vital parameters (heart rate, respiratory rate, depth of breath, and temperature) are important windows into a patient's body function, but serve as parameters that are neither specific nor particularly sensitive for impending decompensation. When monitoring these parameters, it is not simply important to notice if they are outside of the standard normal range, but also to look for an underlying cause of a parameter changing in a specific patient (for example a heart rate may elevate due to compensation for low blood pressure or due to stimulation under anesthesia).

Monitoring can be broken down into 3 important categories: circulation, ventilation, and oxygenation.

The function of the cardiovascular system is to circulate blood in order to perfuse organs bringing tissues oxygen and nutrients while taking away waste products such as carbon dioxide. There are simple measures that can be taken in an attempt to ensure adequate circulation while under anesthesia. All patients should have their heart rate and rhythm monitored (by auscultation/palpation, EKG, pulse oximetry to listen to the pulse, and/or doppler sounds) and ideally their arterial pressure as well (AAHA recommends for all patients ASA category >2 that blood pressure be monitored throughout anesthesia). Arterial blood pressure can be monitored by noninvasive blood pressure monitoring (doppler or standard oscillometry methods) and via direct blood pressure monitoring by a pressure transducer attached to an arterial catheter. Other methods of monitoring the cardiovascular system include central venous blood pressure as a marker of blood volume to help guide intravenous fluid therapy, microcirculatory imaging (at some academic institutions), and blood parameters such as lactate.

As the cardiovascular system is vital as a transportation system, it is important to ensure that it is carrying the appropriate"passengers". One of the most important of these passengers is oxygen. First, it is essential to ensure that the blood has a high enough oxygen carrying capacity with an adequate red blood cell mass, which can be monitored through PCV/TS measurement. Pulse oximetry and/or arterial blood gas testing (or in some institutions, cooximetry) can be utilized to ensure that the red blood cells are actually carrying oxygen. Pulse oximetry is able to differentiate oxygenated and unoxygenated hemoglobin based on the absorption of different light wave lengths and presents this as a percentage of hemoglobin that is oxygenated.

Ventilation is the actual movement of air in and out of the lungs. It is vital to life in order to deliver oxygen as well as remove carbon dioxide from the cardiovascular system. Ventilation can be estimated by auscultation of the lungs (ensure that air is moving) and visualization of chest rise and fall, but is actually measured by carbon dioxide levels in the blood or in the exhaled breath (end tidal CO2). If this value is increasing it indicates that the body is not moving enough air in and out of the lungs, while if it is decreasing the patient may be over ventilating or suffering cardiovascular collapse with carbon dioxide not being transported from the tissues to the lungs or worse, not being produced by failing cells.

Should I refer this patient to a specialty hospital even though I feel comfortable performing the procedure? Even if the surgical procedure is a standard procedure performed regularly at a given hospital, some patients benefit from referral for anesthesia. Referral facilities frequently offer a greater selection of anesthetic medications which may be inappropriate to stock at a general practice due to cost/use benefit. Additional benefits include staff that specializes in dealing with more complicated anesthesia, additional staff available, and advanced monitoring capabilities.

References and Suggested Further Reading:


Gil L and Redondo JI. Canine anesthetic death in Spain: a multicentre prospective cohort study of 2012 cases. Vet AnaeshAnal 2013: epublished ahead of print.


Bednarski R, Grimm K, Harvey R, et al. AAHA Anesthesia guidelines for dogs and cats. JAAHA 2011:47;377-385.


Bille C, Auvigne V, Libermann S, et al. Risk of anesthetic mortalitiy in dogs and cats: an observational cohort study of 3546 cases. Vet Anaesth Anal 2012:39(1):59-68.


Robinson R and Borer-Weir K. A dose titration study into the effects of diazepam or mdiazolam on the propofol dose requirements for induction of general anaesthesia in client owned dogs, premdicated with methadone and acepromazine. VetAnaesth Analg 2013:40;455-436.


Lumb and Jones' Veterinary Anesthesia and Analgesia. Tranquilli W, Thurmon J, and Grimm K eds. 4th edition. 2007. Blackwell Publishing; Ames, Iowa.


Brodbelt DC, blissitt KJ, Hammond RA, et al. The risk of death: the confidential enquiry into perioperative small animal fatalities. Vet Anaesh Anal 2008:35(5):365-73.


Haskins, SC. Comparative cardiovascular and pulmonary effects of sedatives and anesthetic agents and anesthetic drug selection for the trauma patient. JVECC 2006:16(4);300-328.

Tech Tip

This months Tech Tip is a portion of a lecture given at the ACVS Symposium Technician Lectures in 2013. We use a lot of NSAIDs, tramadol, morphine, hydromorphone  pre and post OP everyday. They provide significant pain relief but they have limitations and side effects that as a tech you should understand. This brief discussion will help you understand how they function. The chart of dosages for the common NSAIDs and ancillary pain management drugs is a good reference to keep and use when necessary.


Sandra Z Perkowski, VMD, PhD, DACVAA 

University of Pennsylvania, School of Veterinary Medicine, Philadelphia, PA    


Pre-emptive and multimodal use of analgesics in the perioperative period is becoming increasingly common in veterinary practice, as awareness of the complexity of the pain pathways and the potential for interaction among those pathways has also increased. Improved comfort with the use of continuous rate infusions, new transdermal applications, increased use of locoregional analgesic techniques and better understanding of the pharmacokinetic and pharmacodynamic differences between our many species and with humans has led to new and multiple combinations of many drug types in the perioperative period, including opioids, local anesthetics, NSAIDs analgesics targeting different portions of the nociceptive pathways. The net analgesic effect is synergistic, allowing for decreased doses and side effects.


Understanding mechanisms of pain transmission and antinociceptive mechanisms allows a logical choice in prescribing analgesics for our patients. Analgesia may be directed at minimizing inflammatory changes at the site of injury (e.g. by using an NSAID) at inhibiting transduction or transmission of the nociceptive signal (both at peripheral and spinal endings, e.g. by using a local anesthetic), or at increasing the activity of descending inhibitory pathways acting at the CNS (e.g. by using an opioids: hydromorphone or morphine or synthetic opioid : fentanyl).



Opioids are a diverse group of agents that produce analgesia by their actions on specific opioid receptors (mu, kappa, delta). These receptors vary in their pharmacological effects and their distribution throughout the body. Pure opioid agonists, including morphine, oxymorphone, hydromorphone, fentanyl and methadone bind to all of these receptors and provide the most profound analgesia. In addition methadone is a racemic mixture, having both opioid and NMDA receptor antagonist properties (ie ketamine) that may improve the analgesia achieved from using an opioid agonist alone. Several studies in both rats and humans have demonstrated the development of both opioid tolerance and an opioid- induced hyperalgesia (OIH) with relatively short term use of opioids. These may be minimized by the concomitant use of an NMDA receptor antagonist (e.g. ketamine). In addition, addition of an NMDA receptor antagonist can be helpful in patients with a high potential for the development of neuropathic pain (disc herniation, limb amputation, lateral thoracotomy). Methadone has a relatively short half-life (1.75 h) after 1 mg/kg i.v.


Pure opioid agonists (fentanyl, morphine, remifentanil) are frequently used as continuous rate infusions during the anesthetic period. At lower doses, these infusions may be continued into the post-operative period and provide continued analgesia while minimizing respiratory depression (e.g. fentanyl: analgesic dose: 0.1 - 0.2 microgram/kg/min). More recently, combination infusions of morphine or fentanyl with lidocaine, and ketamine have been recommended (see below). Use of the NMDA receptor antagonist ketamine has been shown experimentally to attenuate the development of opioid tolerance and OIH in rodents,thereby providing an opioid sparing effect. Butorphanol may be preferred as a CRI in some cases. A loading dose equivalent to the low end of the CRI range is generally given for any of the above.


Opioid administration can produce clinically significant side effects, including sedation, dysphoria or excitement, respiratory depression, vomiting, and decreased GI motility. Therefore, opioid agonist-antagonists and partial agonists (butorphanol, buprenorphine) may be preferred in some cases. These drugs generally provide less analgesia than pure opioid agonists, but the side effects also tend to be less severe. Butophanol, a kappa agonist and mu antagonist, is generally considered a mild to moderate relatively short-lived analgesic, most effective in models of visceral pain (0.1 - 0.4 mg/kg IM, IV q 1 - 4h). Butorphanol also may be useful for its antiemetic
properties in patients that are nauseated. Buprenorphine, a partial mu agonist, provides effective analgesia for many types of procedures and has a relatively long duration of action (6 -20 microgram/kg IM,IV q 6 - 8h; peak effect at 2h). It is readily absorbed across the oral mucosa in cats. However, recent studies in cats suggest that IV or IM routes of administration is much more effective in providing analgesia than either SC or transmucosal routes.

The poor oral bioavailability of the above opioid compounds has led to an increased interest in and use of tramadol. The parent compound, tramadol, acts as a very weak mu-agonist and acts as an analgesic by inhibiting norepinephrine (NE) and serotonin reuptake. In dogs, it is very rapidly and extensively metabolized to several metabolites, including the active metabolite, Odesmethyltramadol (M1) that is a more potent analgesic than the parent compound. M1 acts as a weak mu agonist with 200X the binding affinity for the receptor than the parent compound. However, the affinity is still only 10% that of morphine. Tramadol (11 mg/kg PO) was 65% bioavailable with a short half life of 1.7 hours. For M1, however, the half life is also relatively short at 1.7 hours. Tramadol is metabolized through the cytochrome p450 enzyme system to a number of metabolites in both dogs and cats. Recent studies have shown that in many dogs, the M1 metabolite is a relatively minor metabolite, and suggest that efficacy as an analgesic may in part be dependent on rate of metabolism. Tramadol should not be combined with other psychotropic drugs (e.g. amitryptiline) due to the possibility of serotonin syndrome. In addition, decreased NE and serotonin reuptake may potentially lead to cardiovascular changes such as hypertension and increased platelet activation, potentially increasing the risk for GI bleeding.


Local Anesthetics

Lidocaine and bupivacaine are local amide anesthetics and act by blocking the sodium channel in the nerve membrane, inhibiting action potential generation and transmission of the nociceptive signal. Both lidocaine and bupivacaine may be used for local injection at the nerve. With the advent of nerve locators, both of these agents are being used with increased frequency for brachial plexus blockade in patients undergoing forelimb procedures and femoral and sciatic nerve blockade for hindlimb procedures. Generally a maximum dose of 4 mg/kg lidocaine or 1.5 mg/kg bupivacaine is used. When used epidurally, the site for injection in small animals is usually the lumbosacral space. A combination of morphine and bupivacaine is recommended to take advantage of the synergistic effect of using analgesic agents from two different classes: 0.1 mg/kg of a 1 mg/ml preservative-free solution (e.g. DuraMorphâ) and 0.1 ml/kg of 0.5% bupivacaine. With this combination, the bupivacaine works within the first 30 minutes and lasts about 8 hours, while the morphine's peak effect occurs about 4 - 8 hours after administration and lasts 24 hours. Oxymorphone, fentanyl, butorphanol, and buprenorphine have also been proven effective when given epidurally.


Lidocaine may be given as a low dose infusion (25 - 100 ug/kg/min) to enhance the effect of other analgesic drugs. It is frequently used in combination with either morphine or fentanyl given as a CRI +/- ketamine (see below). CRIs of lidocaine should be used cautiously, if at all, in cats due to pharmacokinetics which are very different from the dog, leading to relatively high 536 peak levels even at low doses. In addition, cardiopulmonary depression may be pronounced. Bupivacaine should NEVER be given intravenously in any species.   

Recently, lidocaine transdermal patches (Lidoderm ®) have been introduced in human medicine and are being used more frequently in veterinary medicine. Lidoderm is a 5% lidocaine patch, containing a total dose of 700 mg of lidocaine suspended in gel on a felt backing. Penetration of the lidocaine into the skin produces an analgesic effect in the area of the patch, with minimal effect on normal sensation. Overall, little systemic absorption occurs (in contrast to a transdermal fentanyl patch). In human studies, the patch has been shown to be effective in treating chronic, neuropathic, or osteoarthritic pain. It has been used acutely for back pain or after cruciate repair. Care must be taken when using local anesthetics drugs by any route, due to their relatively high systemic toxicity. Toxic cardiovascular and neurologic effects (i.e. convulsions) may be seen at doses relatively close to the effective dose. Arrhythmias and myocardial depression from local anesthetics, particularly bupivacaine, can be extremely difficult to treat. The IV seizure dose for lidocaine in dogs has been reported as 11 mg/kg, while that for bupivacaine is 3 mg/kg. Cardiotoxic doses are slightly higher than the seizure dose. These agents rely on hepatic metabolism; therefore, adjustments should be made in patients with liver disease. In addition, half-lives are longer in cats and toxic doses are lower than for dogs. There are no available reversal agents.


N-Methyl-D-Aspartate (NMDA)
Antagonists While traditionally considered a dissociative anesthetic, ketamine is also recognized as an NMDA receptor antagonist. The NMDA receptor appears to play a central role in the development of central hypersensitization and "wind up" of the dorsal horn neurons. Given as a low-dose infusion at a rate of 0.1 - 0.6 mg/kg/h, ketamine may be used as an adjunct to other analgesic therapy such as continuous rate infusion morphine (at a rate of 0.1 mg/kg/hr +/- lidocaine) or fentanyl without causing anesthesia or pronounced sedation. It may help to prevent the development of opioid- induced hyperalgesia and opioid tolerance. Amantadine is an oral NMDA receptor antagonist which has been recommended to help decrease wind- up in patients ith chronic pain (e.g. 3 - 5 mg/kg PO sid for 1-2 weeks).

Non-Steroidal Antiinflammatory Drugs (NSAIDs) 

Non-steroidal antiinflammatory drugs (NSAIDs) inhibit the cyclooxygenase pathway of arachidonic acid metabolism. At least two related, but distinct, isoforms of the COX enzyme, COX-1 and COX-2, are present. COX-1 is constitutively expressed in most tissues, including the gastric mucosa, liver, kidneys and platelets, and is involved in normal "housekeeping" functions. These include gastric mucosal barrier protection, maintenance of liver and renal blood flow, particularly in low perfusion conditions such as hypovolemia and/or hypotension, and normal platelet aggregation. COX-2 is primarily an inducible enzyme found within a more limited subset of cell types, predominantly inflammatory cells, endothelial cells, articular chondrocytes and synovial fibroblasts, peripheral nerves and the central nervous system. COX-2 has also been found constitutively within the central nervous system and renal vasculature, as well as synovial chondrocytes in some species. Development of newer NSAIDs that target the COX-2 enzyme and "spare" the COX-1 enzyme, result in selective antiinflammatory effects with decreased gastric side effects and minimal effects on coagulation. However, COX-2 derived eicosanoids are increasingly recognized as physiologically important mediators of cardiovascular and renal homeostasis and play an important role in angiogenesis and wound healing ie slowing wound healing. Therefore, care must still be taken when using these newer drugs as GI and renal side effects still occur.

New information and the availability of new drugs has changed the way that NSAIDs are viewed as part of the multimodal approach to pain management. While inhibition of peripheral COX activity and the resulting anti- inflammatory effect is part of the mechanism by which NSAIDs provided analgesia, it is now recognized that much of their analgesic effect is due to inhibition of COX activity, more specifically COX-2 activity, centrally. It may take up to two hours to achieve effective inhibitory levels within the dorsal horn of the spinal cord and this should be taken into account perioperatively, when measuring the risk/benefit ratio of using these drugs at a time when anesthetic agents may adversely affect blood pressure and/or renal blood flow and oxygen delivery. Idiosyncratic side effects may also occur. Newer COX-2 drugs which have a rapid distribution to inflamed target tissues and a short plasma half-life (e.g. 1 mg/kg robenacoxib PO (Onsior) has a plasma half-life less than 2 hours) may prove to have fewer systemic side effects while still providing effective pain relief.


When selecting a NSAID for perioperative use, decisions should be made based on both safety and efficacy. In addition, thought should be given to the physical status of the patient, procedure to be performed, and anesthetic agents being used. A COX-2 preferential or selective agent is generally preferred to minimize intraoperative bleeding. Due to the potential for clinically significant changes in renal blood flow and oxygen delivery, intravenous fluid support and blood pressure monitoring during the anesthetic period are highly recommended. Reassess and reevaluate your patient regularly. Do not combine NSAIDs or NSAIDs and steroids. If preemptive analgesia is the goal, additional analgesics from other drug classes such as the opioids may be used and may be preferred in many instances. Avoid NSAIDs in patients which are hypovolemic, hypotensive or with underlying renal, hepatic or GI disease.

Veterinary patients frequently require analgesics for a period of time after acute trauma or surgery. Close attention should be paid as to whether the initial treatment provides the desired effect (i.e. analgesia!) and how long the analgesic effect lasts. Reevaluate the effectiveness of treatment regularly! Before administering any drug, carefully observe the animal and consider the underlying disease process. If any expected side effects are undesirable, alter your analgesic technique!


Click here for table of perioperative analgesics.


In This Issue
Risk Management of Anesthesia
Tech Tip
CT Scan Diagnostics
Business Tip
Continuing Education
Wellness Practice Educational Tips
Previous Tech Tips
Newsletter Archive
CT Scan Diagnostic 

CCVS CT Scan Hours: 


8:00 AM-6:00PM 7 days a week.  1-800-457-4900  

The breakdown of CT charges are as follows:

1. CT Scan, In patient $905.00 (case already hospitalized at CCVS or referred to CCVS for work up and treatment and has a CT scan)  
2. CT Scan, Additional image (if you add an additional scan site $300.00)  
3. CT Scan, Out patient $985.00 **(case sent to CCVS exclusively for a CT; this includes charges for doctor overseeing case, IV catheter, and fluids post CT).  
4. CT "Met Check" $590.00  
5. CT STAT fee, $50.00 (on top of whatever you are doing). 

These charges cover the CT, the contrast, radiologists read, rapid infuser, sevo anesthesia, and technician fee if we need to call someone in for the CT. It does not cover injectable drugs, if needed for IV anesthesia; estimated additional cost $50.00-$75.00. 



Portosystemis Shunts (PSS) (Hepatic Shunts) are relatively common. Surgical correction depends on accurate pre-operative diagnosis. The classification of PSS is an evolving process, as more and more shunt types and combinations are being identified with advanced imaging modalities. They are difficult to recognize their location in portal vasculature on occasion as they can be multiple. Extrahepatic shunts are more easily diagnosed usually via ultrasound. Knowing their size and location pre-operatively is very helpful when surgically planning and prognosing the surgical success. Both extrahepatic and intrahepatic shunts are well delineated via CT with dye enhancement. This months CT Diagnostics demonstrates two of the many variations of PSS.




Business Tip

VPG has done it's home work for us again!! DEMANDFORCE is an Intuit company (QuickBooks, Credit Card Processing ... GOPayment). Our management team recently did a Webinar with them and it appears they can help our marketing programs in both our referral and general practices ie communications with you, our RDVMs, our private practice clients, our hospitalized patient client updates, with online search engine placement, Facebook page, and more. It is all done thru your existing practice software. In our case we have three different software companies, Cornerstone, DVMax, AVImark and it is compatible with all of them.  Our rapidly expanding digital communication world via Search Engines, Email,  Facebook, Twitter etc. CHECK IT OUT!! Call Kelly Brown @ 415-296-6883 Senior Manager of the Animal/Veterinary Division. 


Read more >> 

Continuing Education Opportunities

All our lectures provide 2 hours of Continuing Education Credits. You can register online through our websites, Boston Veterinary Specialists and

Cape Cod Veterinary Specialists. A meal is provided during each lecture. Your technicians are welcome as well.

Our lecture series will begin again in the fall.

Wellness Practice Newsletters
Editors note:
Dr. Beverly Mason, Medical Director for our two general practices, writes a monthly newsletter that is emailed to our clients and printed for a handout to clients coming into the practices. They have been copied, pasted and passed around on the Internet. They are very concise, informative, and seasonally appropriate topics. Our general practice technicians find them helpful to educate their clients in the office and the email version gets very positive feedback on our Facebook and Yelp  accounts. We thought you might like to use them in your own practices and will provide them to you each month.      
This Quarter's Wellness Practice Newsletter: 
Previous Tech Tips 

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Read our March newsletter article -Oxygen Therapy in Respiratory Distress - by visiting our
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