text:
Animal Health Technician
Author: Dr L.L. van der Merwe
With Input from Prof A. Leisewitz, Dr A. Goddard, and Dr F. Kettner
All of the Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, Onderstepoort.
This article will primarily revolve around the management of dogs with immune mediated destruction of erythrocytes secondary to babesiosis and will discuss the ideal monitoring parameters for such a case. The other causes of secondary immune mediated haemolytic anaemia (IMHA) (drugs, bacterial infections, neoplasia, etc) or primary IMHA will not be discussed in any detail. They all show very similar presenting clinical sign, the disease will progress in a similar manner, and also develop similar complications although the long term prognosis does vary.
Immune mediated haemolytic anaemia secondary to babesiosis will be self evident due to the temporal relationship with finding the parasite on a stained bloodsmear, or a history of the patient having recently being treated for babesiosis. Other secondary causes of IMHA may be much more insidious and present a greater diagnostic challenge.
The management and monitoring of a patient with haemolytic disease is a combination of both clinical and laboratory parameters.
1. Initial Patient Evaluation
1. Initial Patient Evaluation
Clinical signs are attributable to:
|The degree of anaemia
Clinical signs attributable to anaemia will depend on the acuteness of the erythrocyte destruction and whether compensatory mechanisms have been activated.
|The type of anaemia /haemolysis
Intravascular haemolysis
Hallmarks of this form of haemolysis include haemoglobinuria, haemoglobinaemia (red serum) and splenomegaly.
Extravascular haemolysis
Extravascular haemolysis
Haemoglobinaemia and haemoglobinuria are absent as the erythrocytes aer lysed within phagocytes, but splenomegally is usually present.
|Multi-systemic signs
Multi-systemic organ disease and/or failure may develop due to excessive or imbalanced cytokine secretion, the generation of free oxygen radicals, immune system dysregulation, endothelial damage, activation of the coagulation cascade, and disturbances in oxygen supply to the tissues. These complications may occur in any haemolytic disease be it babesiosis or primary IMHA.
2. Laboratory Evaluation
2. Laboratory Evaluation
There is more to the evaluation of a blood smear than simply finding Babesia parasites:
|Blood smears should always be good quality (with straight edges and well defined shoulders and a feather edge) and be properly stained for evaluation. Diagnosis may easily be missed if the quality of the smear is poor!
|Red cell regenerative capacity should be assessed. Reticulocytes and normoblasts cause anisocytosis and polychromasia with an increase in red cell distribution width (RDW). The smear may appear non-regenerative in acute severe haemolysis as the bone marrow storage pool is used and a 2-3 day lag phase exists between red cell destruction and the appearance of a bone marrow response in the peripheral circulation. Acute babesiosis also seems to suppress the red cell regenerative capacity and the degree of regeneration in the presence of an active parasitaemia is usually inappropriate. Strong red cell regenerative responses should, however, be seen soon after elimination of the Babesia parasite.
|Evaluate for concurrent Ehrlichia infection in both the monocytes as well as the neutrophils. It is important to note that phagocytosed erythrocytes and parasites may resemble Ehrlichia morulae.
|The presence of spherocytosis (small, dark staining, round erythrocytes without central pallor) indicates an immune-mediated process in red cell destruction. When more than 40-60% of red cells are spherocytes, a diagnosis of IMHA is strongly supported (although IMHA can be present with lower percentages).
|Haemolytic disease, with or without a concurrent Babesia infection is an inflammatory process. Any inflammatory process in the body may induce a neutrophila with a left shift (increased band cells). This is usually a regenerative left shift and the presence thereof does not imply bacterial infection. Babesia infection without an inflammatory leukogram may be indicative of concurrent immunosuppressive disease (such as Ehrlichia, or distemper).
- Packed cell volume (PCV):
The PCV is a percentage value obtained by centrifuging a blood sample in a micro-pipette tube. The haematocrit, on the other hand, is a haematology analyser calculated value based on red cell number and mean red cell volume.
|Determine the initial PCV at time of presentation. Whether a blood transfusion is necessary is usually not a decision based on PCV alone. Other factors such as the clinical state of the dog, the availability of blood, the chronicity of the condition, ISA positivity with ongoing erythrocyte destruction, and financial constraints will all affect this choice. The initial PCV value is also useful to assist with the evaluation of response to therapy. Dogs that have chronic disease where the anaemia evolved slowly will be better able to cope with a low PCV than dogs that have experienced a rapid decrease in the PCV.
|The buffy-coat can also be smeared to evaluate the white blood cells for the presence of Ehrlichia.
|Together with the PCV the serum component should also be assessed.
|If the sample is collected atraumatically, any red discolouration of the serum can be interpreted as intravascular haemolysis.
|Total serum proteins (TSP) can be read by a refractometer. In young animals especially, verminosis is commonly occurs concurrently with babesiosis. A low TSP is an indication for a whole blood rather than a packed red cell transfusion, or for patient support with intravenous colloids administration.
|Mild to moderate hypoalbuminaemia is common in babesiosis because of the inflammatory nature of the disease and the loss of albumin through damaged endothelium. However, the estimation of the TSP by a refractometer is a crude estimation of the albumin levels as increases in globulins (common in Babesia infection) may mask the decrease in albumin.
c) In-Saline Agglutination (ISA)/ Autoagglutination:
c) In-Saline Agglutination (ISA)/ Autoagglutination:
|Auto-agglutination is the result of the spontaneous aggregation of erythrocytes due to the presence of erythrocyte-membrane bound immunoglobulins. These antibodies may be primary or acquired auto-antibodies. Autoagglutination must be differentiated from rouleaux formation, which occurs when erythrocytes stack together due to electrostatic forces caused by the presence of serum proteins (fibrinogen and acute phase globulins).
|The ISA test is performed to check for an immune mediated reaction against the erythrocytes. Rouleaux will be dispersed by the addition of saline. False positives occur if insufficient saline is used to dilute the sample. The standard test procedure involves adding 1 drop of whole anti-coagulated blood to 6 drops of saline. This mixture should be well mixed. The slide must be evaluated under a microscope at 400 ´ magnification (no oil immersion) with low light intensity and the light condenser dropped low.
|A negative ISA test does not, however, imply that IMHA is absent as the test is relatively crude. The interpretation can be graded according to the size of the aggregates.
|It should be noted that the ISA test is useful and should be done in all cases of babesiosis at initial presentation together with the PCV. If it is not done at initial presentation, it is imperative that it be performed in all cases that respond poorly to therapy.
|It should also be noted that response to immunosuppressive treatment for IMHA should be based on a rise in PCV and not by the resolution of a positive ISA reaction. Most dogs that respond well to immunosuppression (as seen by a rising PCV) will remain ISA positive for a few days despite good recovery. This occurs because the antibodies responsible for agglutination have a long half-life and will need to be cleared from circulation before the positive ISA reaction resolves. Therefore treat the PCV and not the ISA reaction.
d) Coombs' Test
d) Coombs' Test
|Although a threshold density of erythrocyte membrane bound antibodies is required to cause auto-agglutination, the sensitized reticuloendothelial system of the body can recognize cells that are marked (opsonised) with only very few antibodies.
|The Coombs' test is more sensitive than ISA in the diagnosis of IMHA as it involves the incubation of washed patient erythrocytes with serum containing anti-immunoglobulin antibodies which increases cross-linkages and thus potentiating agglutination at lower immunoglobulin levels. This test is indicated in patients exhibiting clinical and laboratory signs of regenerative anaemia with or without spherocytosis that do not show any evidence of blood loss. There is no need to perform this test if the patient is ISA positive.
|As both the Coombs' and ISA tests are affected by foreign erythrocytes, they must be performed PRIOR to any blood transfusion.
The initial evaluation of a patient with a haemolytic disease and laboratory monitoring is a synthesis of the abovementioned simple laboratory tests, a good clinical examination and common sense.
Always remember that TRENDS are all important and one-off examinations are often misleading.
3. Patient Monitoring
3. Patient Monitoring
The complications associated with the haemolytic disease, be it babesiosis or primary or secondary IMHA, are generally due to a combination of anaemia and the systemic inflammatory reaction. The organs that are most frequently secondarily affected include the lungs (causing acute respiratory distress syndrome - ARDS), kidneys (causing acute renal failure - ARF), liver (causing icterus), erythrocytes (causing secondary IMHA), the brain (causing cerebral signs) and coagulation disorders (including pulmonary thromboembolism - PTE).
The assessment and monitoring must therefore include criteria that would evaluate these organ systems:
- Lungs:
- Kidneys:
- Secondary/acquired IMHA:
- Follow-up evaluation
Monitor for sudden increases in respiratory rate and depth, referred breath sounds and increased effort of respiration. Always remember that very anaemic Babesia infected dogs always have profound blood gas and acid-base disturbances, which should resolve with blood transfusion. If respiratory signs worsen or improve only to suddenly deteriorate again following transfusion, consider ARDS or pulmonary thromboembolism. Increases in rate and depth are signs on an early decrease in pulmonary compliance due to fluid accumulation in the interstitium. By the time rales are auscultated the fluid accumulation is severe the alveoli are flooded, which may be a very poor prognostic sign. Radiographs, although helpful in confirming pathology do not take the place of a careful clinical evaluation as clinical changes will precede radiographic changes.
The initial monitoring plan of a sick Babesia patient should include frequent (hourly) assessment of the respiratory rate for at least the first 6 hours. This parameter is a simple yet sensitive indicator of decreased pulmonary function.
Monitor for urine production, especially in haemoconcentrated babesiosis cases which very frequently present with ARF. Oliguria or anuria will precede the development of azotaemia (increases in urea and creatinine). Note that haemolysis will cause an increase in urea without a linear increase in creatinine. As such urea used alone is a poor indicator of renal function in this scenario and should always be used with creatinine or creatinine should be used alone.
The majority of clinically ill babesiosis infected dogs are Coombs' positive and it is estimated that about 20% of cases seen at Outpatients section of the Onderstepoort Veterinary Academic Hospital are ISA positive at the time of Babesia diagnosis. The decision on how to proceed with these cases is based on the PCV at the time of diagnosis, ISA positivity, the colour of the serum, and the general clinical condition of the animal Many of these patients are ISA negative within 24 – 48 hours and thus do not require a long tapering course of prednisilone as eradication of the parasite has removed the trigger or the initial test was a false positive.
Occasionally a case can develop into a severe and clinically important secondary IMHA where auto-antibodies have developed against normal erythrocyte membrane antigens. These patients are challenging to manage and require aggressive therapy often with multiple transfusions and strong immunosuppressive therapy of several months duration.
It is important to request a re-evaluation of the dog the day following initial therapy. Uncomplicated cases will show a distinct improvement in habitus and clinical signs, although the PCV may still be quite low or even the same as the previous day. The parasitized cells are removed from circulation and the PCV may fall between 1-7% six hours after injecting of the babesiacidal agent. This percentage will obviously be affected by the regenerative capacity of the patient and the initial parasite density.
The monitoring of a patient with haemolytic disease /true IMHA involves the following basic in-house laboratory tests:
|A repeat blood smear evaluation is essential to evaluate for regeneration and spherocytosis.
|Ensure that the ISA test has been performed accurately. ISA must be evaluated microscopically. If the patient is positive at a 1:6 dilution with saline, increase the ration to a 1:20. A true ISA will still be positive whereas strong rouleaux will become negative.
|Determine if the PCV is stable, decreasing or increasing. This parameter must be interpreted together with the identification of regeneration on the blood smear. IMHA cases are usually highly regenerative. Good regeneration with a stable PCV indicates ongoing erythrocyte destruction. Concomitant disease or chronic inflammation may decrease the regenerative capacity.
|Evaluate serum colour for haemolysis
A typical regimen for a mild, babesiosis induced IMHA is a tapering dose of 2mg/kg decreasing to 0.5 mg/kg over 7 days.
B. Primary IMHA
B. Primary IMHA
The diagnosis of primary IMHA is challenging as it requires the exclusion of all possible secondary causes, which are numerous.
To simplify matters an abridged version of causes follows.
Infectious: – ensure that the patient has been thoroughly examined for any chronic infections: endocarditis, osteomyelitis, discospondylitis, urinary tract infections, prostatitis, pyometra, dirofilaria, ehrlichia
Drugs: - many medications are capable inducing IMHA. Vaccinations, especially rabies are probable causes if given less than 3-4 weeks previously. Potentiated sulpha drugs are major inducers of auto-immune reactions and may cause immune mediated thrombocytopaenia, IMHA, immune mediated polyarthritis and keratoconjunctivitis sicca (KCS). Cephalosporins and penicillins are also predisposed.
Neoplastic : Neoplastic cells may express non self antigens on their cell surfaces and as such may induce a variety on immune mediated conditions e.g. Thymoma induced Myaesthenia gravis.
A thorough, logical and often costly clinical and diagnostic plan is required to eliminate secondary causes.
Primary IMHA is more resistant to therapy and will require very gradual tapering with duration of therapy up to 6 months. In large breed dogs it is often advisable to add azathioprine early in the course of therapy to allow a reduction in the prednisilone dosage and thus decrease the side effects.
These dosage regimens are not a hard and fast rule but will be modified according to regular patient and haematology re-evaluations. These parameters should be re-assessed after each dosage reduction of the immunosuppressive therapy and at regular 2-3 week intervals to ensure that the condition is resolving. Often the prednisilone is tapered too rapidly and the haemolysis starts up again. If no monitoring is performed the animal will only present when the PCV is so low that it is once again causing clinical signs.
TABLE OF DRUGS WHICH CAN BE USED TO MANAGE IMHA ( summarized)
Side effects/ comments
* Blocks macrophages
* Decreases antibody production
* 4-5 days to effect
2-4 mg.kg/ d is immunosuppressive
(> 20kg = 3mg/day, <20kg = 4mg/kg/d … BSA effect)
taper initially by decr. dose by 50% every 2-3 weeks until 1mg/kg/day.
Maintain for 4 weeks, then decrease to 0.5mg/kgoid for 4w then 0,5mg/kg alt days for 4-8 weeks.
* Large breed dogs may develop severe muscle wasting and weakness. Advise combination with azathioprine to allow dose reduction ASAP.
* Small breeds show more typical cushingoid side effects of weight gain and pu/pd
* GIT ulceration (prevent with MisoprostilÒ )
( AzapressÒ )
* Suppresses T cell function
* 2 weeks to peak effect
Initiating dose of 1-2 mg/kg / day then maintenance at 1 -2 mg/kg every alternate day
( often alternating with prednisilone)
* Contraindicated in cats
* May cause pancreatitis and bone marrow suppression
(EndoxanÒ )
* Anti-neoplastic agent
* Antibody and lymphocyte suppression
50mg/m2 first 4 days of each week for maximum of 4-6 weeks.
Not recommended by the author
* severe bone marrow suppression
* haemorrhagic sterile cystitis
(Human Intravenous Gamma globulin)
* Saturates Macrophage Fc receptors.
* Immediate effect
Indicated for erythrophagocytic IMHA.
0.5 – 1.5 g/kg iv over 4-6 hours
* Very Expensive
* Bridging therapy
* Inhibits amplification of immune reaction
5 – 15 mg/kg / day
serum levels > 200ng/ml
* Expensive
* Bridging therapy
* Decreases RBC fragility
5mg/kg tid
* For chronic management
- Jacobson LS, Reyers F et al. Changes in haematocrit after treatment of uncomplicated canine babesiosis: a comparison between diminazine and trypan blue, and an evaluation of the influence of parasitaemia. Journal of the South African Veterinary Association 1996 vol. 67 (2) pp 95 – 105
- Grundy SA, Barton C. Influence of drug treatment on survival of dogs with immune mediated haemolytic anaemia: 88 cases (1989 – 1999) Journal of the American Veterinary Medical Assosciation. 2001 vol. 218 (4)543 – 545
- Kellerman DL, Bruyette DS. Intravenous Human Immunoglobulin for the Treatment of Immune-Mediated Hemolytic Anemia in 13 Dogs. Journal of Veterinary Internal Medicine 1997 vol 11 (6) pp 327 – 332
- Reimer ME, Troy GC, Warnick LD .Immune –Mediated Hemolytic Anemia: 70 cases (1988 – 1996). Journal of the American Animal Hospital Association 1999 Vol. 35 pp 384 – 391
- Slappendal R.J. Interpretation of tests for immune mediated blood diseases. In Kirks Current Veterinary Therapeutics X (Eds) Kirk and Bonagura. pg: 498 – 50.
- Stewart A.F., Feldman B.F. Immune mediated hemolytic anemia. Part I. Clinical Entity, Diagnosis, and Treatment Theory. Compendium on Continuing Education for the Practicing Veterinarian 1993 Vol. 15 (11) pp 1479 – 1993
- Stewart A.F., Feldman B.F. Immune mediated hemolytic anemia. Part II. An Overview. Compendium on Continuing Education for the Practicing Veterinarian 1993 Vol15 (3) pp 372 – 381
- Vaughn Scott T, Jacobson L.S. et al Systemic Inflammatory Response syndrome and multiple-organ damage /dysfunction in complicated canine babesiosis. Journal of the South African Veterinary Association 2001 vol 72 (3) pp 158 – 162
What does it mean to "stabilise" a critically ill small animal patient before anaesthetic induction?
What does it mean to "stabilise" a critically ill small animal patient before anaesthetic induction?
A L Leisewitz, F Kettner, K Joubert , A Zambelli, N Keller, E Scheepers, M Bohm.
Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria, Onderstepoort.
- What is an 'unstable' patient?
A patient that presents in shock or one that is unable to adequately compensate physiologically during an intervention such as anaesthesia. Shock can be defined and suspected under the following circumstances:
|A dog or cat that is weak or collapsed. A depressed level of consciousness or sudden decrease in mentation are indicators of decompensation. These changes should be viewed in light of the nature of the trauma the patient has experienced (for example head trauma), or the possibility of a toxicity. Patients that have a sudden change in consciousness should be re-evaluated;
|Shock typically causes a low rectal temperature (although temperature may be high in cases of sepsis or blood stream infections) and cold peripheral extremities;
|Shock is associated with a tachycardia (although cats may have normal pulse and be in shock) or bradycardic; Tachycardia may be the result of pain in trauma patients and if the heart rate fails to decrease after an appropriate dose of an analgesic, hypovolaemia should be suspected. Patients that are tachycardic or normocardic where there is a suspicion of hypovolaemia or shock should be challenged with a fluid bolus equal to about 10% of their blood volume (approximately 10 ml/kg in dogs) given over 5-15 minutes. Changes in heart rate and blood pressure (the quality of the pulse) should be assessed. Before treating a patient that is bradycardic with atropine the following contraindications should be excluded: hypoxia, hypothermia and electrolyte imbalances (increased blood K+).
|Capillary refill time is typically prolonged in established shock but in hyperdynamic shock and early septic shock this may not be the case (mucous membranes are also usually pale but may be injected in hyperdynamic or septic shock);
|An attempt to feel the quality of the femoral or other peripheral arterial pulse should be made. If a peripheral pulse cannot be felt, arterial blood pressure is below 60 mmHg and this requires urgent attention.
|Respiratory rate and pattern can be good indicator of patient stability. A fast respiratory rate with shallow breathing and an irregular pattern are indicators of an unstable patient. Rapid deep breathing cannot be sustained over a prolonged period and should warn about possible respiratory muscle failure.
|Urine production is the 'poor-man's' blood pressure machine. Measuring urine production is cheap and easy, requiring minimal invasiveness and time. It provides an objective means of evaluating blood pressure over time, rather than an instantaneous assessment at the time of the examination. Production in excess of 0.5ml/kg/hour usually indicates normal blood pressure
|Blood glucose is often abnormal in unstable patients. It may both be high (as in some cases of septic shock and head trauma) and low (e.g. canine babesiosis)
Patients in compensated shock are more problematic as they may suddenly decompensate or may become unstable following the administration of anaesthesia.
|A patient that has lost a large quantity of blood and is anaemic may be unable to maintain oxygen delivery under anaesthesia. Patients with long bone fractures can loose significant quantities of blood into the haematoma surrounding the fracture. Haematocrit is a poor indicator of acute blood loss. In these cases cardiovascular signs maybe a better indicator of the need for blood pressure support.
Patients showing severe dyspnoea should be regarded as unstable even if not in shock.
- What does it mean to 'stabilise' a patient (what are the therapeutic end-points?)?
|Stabilisation is the treatment that is given in the interim period from admission until the primary problem can be, or is, addressed. The benefit of stabilisation should always be greater than the cost of delaying primary treatment.
|To restore arterial blood pressure and tissue oxygenation to as close to normal as possible. Blood pressure and tissue oxygenation cannot be directly assessed in most general practice environments in South Africa so we are forced to use markers of these indices. These have been listed above in question 1.
|These markers should be showing a consistent tendency towards normalisation. It is important to appreciate that trends in the observations are very important and the establishment of trends requires frequent monitoring during the post event period. In critically ill animals it is probably unrealistic to expect a complete normalisation of these measurements and observations. This is a very important point to remember. There is no way that leaving a shocked patient in a cage overnight on a drip only to be re-examined the next morning for the first time can be seen as ethical practice.
|Intravenous fluid and colloid infusion (at shock doses) to expand circulating volume and thus increase blood pressure.
Caution in fluid administration must be exercised in patients with brain trauma, anuric renal failure, hypoproteinemia, lung oedema and lung contusions as fluid overload may be more rapidly lethal in these cases. Fluid overloading is more rapidly a problem in cats and more caution must be exercised when fluid loading this species.
The correction of any abnormal life-threatening biochemical disorders (such as severe hypoprotienaemia, hyperkalaemia, hypoglycaemia, hyper or hypoclacaemia or ketoacidosis), the correction of anaemia due to haemolysis (to a haematocrit of at least 20%) or whole blood loss (until blood pressure is above 70 mmHg – the approximate level at which femoral pulses can be palpated).
|Ensure adequate urine production.
|The correction of any life threatening respiratory abnormality such as serious thoracic effusion or flail chest. This should be accompanied by the administration of nasal oxygen.
|The needle drainage of acute pericardial effusion that threatens cardiac output to the point of causing cardiogenic shock.
|The needle trocharisation of life threatening gastric gas distension in gastric dilatation volvulus syndrome (GDV).
|The correction (or at least an attempt to) of life threatening cardiac arrhythmias.
|The arrest of any significant bleeding that can be stopped without surgical intervention.
|The correction of acute bleeding tendencies due to clotting factor or platelet deficiencies to the point that spontaneous haemorrhage has subsided.
|The supplementation of oxygen initially has few contraindications and can be safely used in most patients. Ventilation should be assessed for adequacy in terms of respiratory rate and tidal volume. Patients with slow respiratory rates (< 8 – 10) and low tidal volume should be ventilated to maintain adequate oxygenation with 100% oxygen until a diagnosis is made. Emergencies where ventilation is a consideration are usually caused by diseases of the neuromuscular junction, brain stem trauma or pleural space occupying lesions.
|If blood pressure is still not adequately supported once adequate volume resuscitation has occurred, administer positive inotropes (dobutamine constant rate infusion) or vasoconstrictors (dopamine constant rate infusion).
|Peritoneal lavage to removed purulent septic material should exploratory celiotomy not be possible at that stage (by mean of local anaesthesia and a keyhole incision into abdomen through which a Foley's catheter can be passed to lavage the abdomen).
|Pain should be addressed. Patients will often remain unstable if left in severe pain.
|Severely hypothermic patients must have this need appropriately addressed if they are to be stabilised.
- How long should stabilisation take?
|As fast as possible. Volume resuscitation in hypovolaemic shock should not take longer than 30-60 minutes.
|This said the time required to stabilise a patient can be highly variable and will depend on the underlying condition. Some patients never reach sufficient stability to allow for interventions under anaesthetic. It must however be stressed that continuous and close monitoring of unstable patients is absolutely essential if life saving interventions that require a general anaesthetic are necessary. Only close and frequent monitoring will allow a well-timed decision as to when the best time to administer an anaesthetic might be.
|It is important to remember that stabilisation should be achieved in the shortest safe period and once a patient is showing trends towards stabilisation urgent procedures under anaesthetic should be performed. In other words medical interventions may only provide a short window of opportunity during which more permanently stabilising procedures that require general anaesthesia (GA) can be applied. Delaying invasive interventions unnecessarily will cost a life in many situations.
|Generally speaking stabilization should not take longer than a few hours. In most cases it should be achieved within the first hour or two after presentation.
|If a patient needs such an urgent intervention to save its life (like an obstructed trachea in a dog that you cannot relieve without an anaesthetic such as a puff adder bite that needs an emergency tracheostomy or a trauma patient that will die without an immediate insertion of an ET tube or a bulldog with heat stroke that has such bad laryngeal oedema or collapse that it is cyanotic and deteriorating in front of your eyes).
|If a patient is in life-threatening status epilepticus (such as with strychnine poisoning or following cranial trauma).
|A dog or cat with a flail chest or pleural effusion that will not tolerate a conscious needle drainage or drain insertion under local anaesthetic for stabilisation.
|A patient with rupture of an organ that is haemorrhaging causing haemothorax or haeomoperitoneum (such as a ruptured liver or spleen). These patients will require emergency transfusion whilst surgical intervention to stop the bleeding occurs.
|A patient in a state of collapse following a neurotoxic snakebite that requires mechanical ventilation.
|Patients with a ruptured gastro-intestinal tract, strangulation or volvulus lesion should undergo surgical correction as soon as possible. The longer contamination of the peritoneal cavity is present the poorer the outcome is.
|Intervention to correct the underlying primary problem should be performed when the risk of delaying further treatment is greater than the benefit of continuing stabilisation. Complete normalisation may not yet have been achieved.
|When further stabilisation is no longer possible due to ongoing deterioration of the patient's condition.
|When the patient is stable enough (i.e. not yet normalised) to undergo intervention to correct the primary problem.
|As an example, a patient with septic peritonitis may benefit from surgical treatment before stabilisation to "normal" levels, as it is quite likely that this cannot be achieved before the abdomen has been lavaged.
|Cats with obstructive uropathy that are hyperkalaemic. These cats should have their bladders needle drained and the hyperkalaemia should be resolved before catheterisation under general anaesthetic.
|Patients with clinically significant pulmonary contusion (usually following road traffic accidents).
|Dogs with GDV should be trocharised and urgently fluid loaded at the same time before an anaesthetic is given. Some of these patients can be stomach tubed by mouth without anaesthetic but most will require at least a short anaesthetic for this. If these dogs are in shock it is my/our opinion that the stomach should be deflated and the vascular compartment fluid and colloid loaded before surgical anaesthetic is administered.
|All patients in shock as a result of trauma that is not resulting in immediate life threatening danger (such as listed above). Fight wounds and dogs involved in motor vehicle accidents are common examples. Adequate resuscitation is normally required before radiographic examinations, wound care or complete assessments can be made. It is important to remember however that a patient that has been injured may only destabilise after admission and as such trauma patients should be closely monitored.
|All dogs with a blood loss anaemia (and MAP below 70 mmHg) or haemolytic anaemia (with haematocrits below 20%)
|Pyometra/septic peritonitis cases may need stabilisation although most cases are sufficiently stabile to intervene immediately. The general rule of thumb in any septic patient is to surgically drain or remove the source of sepsis without any or the minimum of delay. Any stabilisation without doing this can be expected to be short lived.
|Cases that are clinically dehydrated should be rehydrated in the shortest possible time before urgent anaesthetics are administered.
|Cases in low output cardiac failure that is not stable on treatment.
8. Anaesthesia
8. Anaesthesia
The appropriate use of anaesthetic agents is dependent on the clinical situation of the patient and a thorough knowledge of the clinical pharmacology of drugs used. There is little evidence to support the use of specific drugs and their influence on outcome is negligible. The most important determinate of outcome is the treatment and maintenance of stable cardiovascular and respiratory function (ensuring an adequate oxygen delivery to all cells in the body).
Essentially patients can be classified into three categories:
- those who are stable may receive a standard induction or slightly reduced induction dose;
- those who are unstable should have the anaesthetic slowly titrated to effect;
- those who are moribund or near death where minimal anaesthesia should be used.
General principles to be remembered when anaesthetising compromised patients include the optimisation of tissue perfusion and oxygen delivery to all organ systems while achieving analgesia, muscle relaxation and unconsciousness.
A. Pre-anaesthetic Management
A. Pre-anaesthetic Management
In certain cases prompt surgical treatment is life saving (uncontrolled haemorrhage, perforated intestines, ruptured pyometra or uterus, etc) but generally the accompanying shock is more dangerous than the initial trauma. In these cases the treatment of shock is the priority before surgical correction is attempted.
|Oxygen supplementation
This is almost always indicated and can be achieved with a facemask, nasal catheter, endotracheal tube or oxygen chamber. The use of an oxygen chamber is not ideal, as it does not allow access to the patient. Oxygen supplementation is especially important in cases with respiratory and cardiac compromise. In anaemic patients correcting haematocrit is more important than oxygen therapy. Remember not to stress animals attempting to administer oxygen. Free flow oxygen passed the face may be the best way of administration in cases that are overly anxious.
|Analgesics and sedatives and premedications
Useful premedications include morphine and diazepam and these are usually indicated. Acetylpromazine and alpha-2 agonists are generally contraindicated. These are required for the management of pain, fear and apprehension. Analgesia should be applied as soon as possible and be maintained post trauma or post-surgery.
These are not routinely used in trauma patients as they increase myocardial oxygen demand and reduce the threshold for arrhythmias. Atropine or glycopyrrolate may be used when vagal influence affect cardiac function or secretions need to be controlled. Trauma patients are often not starved and this increases the incidence of aspiration. Methods to reduce aspiration include position of the head lower than the abdomen, immediate intubation with a cuffed endotracheal tube and suctioning if reflux occurs.
B. Induction Agents
B. Induction Agents
It is always best to remember that the drug with which you have the most personal experience is most likely to be the safest drug in your hands. Always remember that anaesthetic drugs administered to a patient in shock in the same way as they would be used in a healthy patient will aggravate shock. This is because these drugs have potent respiratory and cardiovascular depressive effects that will exacerbate the state of shock.
Intravenous agents:
Barbiturates are known to decrease myocardial contractility, depress baroreceptor reflexes, vasodilatation, decreases venous return and depress respiration. They are poor analgesics and have no muscle relaxation. Barbiturates are arrhythmogenic when given rapidly intravenously. Propofol has less of myocardial depressant effect and fewer arrhythmias than thiopentone. The degree of myocardial depression is a function of dose and rate of injection. Barbiturates are highly protein bound and the acid-base balance; albumin content and concurrent drug administration influence their pharmacokinetics. Critically ill patients are often acidotic and hypoproteinemic and thus require lower anaesthetic doses.
Propofol causes similar haemodynamic effects as thiopentone and cannot be recommended over thiopentone unless the patient is cardiovascularly stable.
Both these agents should be given very slowly intravenously to effect to achieve a plane of anaesthesia just sufficient for intubation. Rapid administration of these agents in states of myocardial hypoxia can be fatal and it is therefore essential to supplement oxygen and ensure adequate blood pressure before induction. Propofol has a greater tendency than thiopentone to cause induction apnoea, especially if given too fast. This may prove fatal in hypoxaemic animals.
Ketamine is one of the few drugs with indirect cardiovascular stimulatory properties. It raises blood pressure secondary to a sympathetic increase in heart rate and cardiac output. It is contraindicated in any patient with myocardial disease or in a patient in maximal sympathetic stimulation (which is often the case in severe trauma or haemorrhagic shock). Ketamine is a poor muscle relaxant and spontaneous movement is possible. Ketamine increases intracranial pressure and is contra-indicated in cranial trauma. Benzodiazepines may be used with ketamine to enhance muscle relaxation.
Opioid induction
Opioid induction
This mode of induction is the preferred method for induction in compromised patients but needs to be used with caution and a complete description of the use of this modality is beyond the scope of this short review. Opioids are most commonly combined with benzodiazepines and the opioid drugs most commonly used include fentanyl, morphine and midazolam. Mixed agonist-antagonists include buprenorphine and are not preferred due to their ceiling effects and an inability to titrate the analgesia.
Because opioids (especially fentanyl) result in respiratory depression pre-oxygenation is advisable. Bradycardia may occur and is treatable with anticholinergics and in refractory cases adrenaline may be used. Morphine is associated with a dose dependent histamine release and may result in hypotension. Adequate fluid loading can minimise this negative effect and should not be a reason for withholding morphine administration. Opioid combinations (eg fentanyl and morphine) have been used successfully. Opioid induction (with for example diazepam and fentanyl) is slower than conventional methods and if rapid intubation is required it cannot be recommended. Opioids are administered to the point where tracheal intubation is possible.
Inhalation agents
These are as hypotensive as barbiturates and are only safer because the period of time from drug application to surgical anaesthesia is longer thus allowing for a longer period of time for the body to establish homeostasis for their depressant effects on blood pressure. Halothane and isoflurane both cause a dose dependent cardiovascular depression. Isoflurane is the least depressant at equipotent minimum alveolar concentration values. Isoflurane is also less arrhythmogenic and causes a quicker induction than halothane. If a traumatised patient is alert it is likely to struggle with gas induction. This struggle may result in increased circulating catecholamines which may result in arrhythmias (especially with halothane) as halothane sensitises the myocard to adrenaline. Inhalation agents have no muscle relaxing or analgesic properties.
Some dogs in severe shock require no anaesthesia and only some analgesia in order for surgery to be performed. A less depressant form of analgesia using a local anaesthetic block should be considered. Epidural anaesthesia can be useful tool for abdominal or hind limb procedures. Patients should be fluid loaded as epidural anaesthesia can result in vasodilatation. The lowest possible dose of anaesthetic should be used and all intravenous agents should be titrated to effect.
Maintenance of anaesthesia.
Some patients may require mechanical ventilation. The fact that a patient is breathing does not necessarily mean it is adequately ventilating. Remember also that an anaemic, pale patient may not show cyanosis. Close monitoring of the measures of blood pressure, perfusion and tissue oxygenation must be maintained constantly throughout the period of anaesthesia. In addition to close physical assessment of these measures of the patient's condition, additional monitoring that is very useful includes ECG, pulse oximetery, blood pressure (invasive arterial and or central venous pressure), and capnography. Haemodynamic stability is maintained with fluids, ionotropic agents (dobutamine constant rate infusion), vasoconstrictors (dopamine or adrenalin constant rate infusion) and colloids. Direct arterial blood pressure measurement and central venous pressure can be used to monitor haemodynamic stability. Urinary output is easily monitored with a catheter and is an important indicator of renal perfusion and fluid balance.
A combination of inhalation agents, opioids, benzodiazepines or ketamine can be given for maintenance.
Hypothermia kills and patients should be warmed or the body temperature maintained using hot warm bottles, warm water blankets, heating lamps or warm air heating devices during all anaesthetic procedures and post operative care should pay special attention to this aspect.
Useful references include (but are not limited to) the following texts:
Useful references include (but are not limited to) the following texts:
Manual of Canine and Feline Emergency and Critical Care
Ed: L King, R Hammond.
Published by BSAVA, United Kingdom
Emergency Medicine in Small Animal Practice
The Compendium Collection
Published by Veterinary Learning Systems, Trenton, New Jersey.
Small Animal Emergency and Critical Care. A Manual for the Veterinary Technologist.
A M Battaglia
Published by WB Saunders Co.
Emergency Procedures for the Small Animal Veterinarian.
SJ Plunkett
WB Saunders, Philadelphia
Self Assessment Colour Review of Small Animal Emergency and Critical Care Medicine.
R Kirbey
Mason Publishing Ltd, London, UK.
Fluid Therapy in Small Animal Practice. 2nd Edition.
Editor: SP DiBartola
WB Saunders Co. Philadelphia
Some useful drugs and doses are tabulated below.
Some useful drugs and doses are tabulated below.
0.02 mg/kg
0.5 mg/ml
0.04 mg/kg
0.3 mg/kg
i/m or i/v
5 mg/ml
0.2 mg/kg
5 mg/ml
10 mg/kg (with premed)
25 mg/ml
15 mg/kg (without premed)
4 - 6 mg/kg (with premed)
10 mg/ml
6-8 mg/kg (without premed)
5 - 10 mg/kg
100 mg/ml
10 - 20 mg/kg
40 microgram/kg
i/m or i/v
0.2 mg/ml
1 ml/10 kg
1 ml/10 kg
0.5 mg/ml
1 ml/10 kg
0.2-0.4 mg/kg
s/c or i/v
10 mg/ml
10 – 20 microgram/kg
i/m or i/v
0.2 mg/ml
0.02 mg/kg
0.3 mg/ml
0.1 mg/kg
10 mg/ml
1 mg/kg
7.5 mg/ml
(Published Newsletter 38, November 2004)
Refer to the new rules published on 18 January 2002. Go to the web page for veterinarians and click on Advertising. Fees and incentives shall not be the subject of any advertisement. Prices of products, merchandise and foodstuffs sold and non-professional services rendered at the facility may, however be advertised.
It would be regarded as unprofessional conduct if collusion was proved by a veterinarian to ensure that his/her advertisement appeared next to an article / advertorial by a third party if the article was considered as touting. Members may use their titles, names and surnames and qualifications inscribed into the register when an articles are published in the lay press e.g. Dr John Morgan, BVSc.
Please submit any advertisements or articles to Council for approval if you are not sure about the interpretation of the rule.
Anaesthesia: Monitoring
The following guideline should be followed for the monitoring of animals under anaesthesia: The monitoring, maintenance and recovery from anaesthesia should be effected by registered personnel and or trained non registered personnel under supervision of a registered veterinarian who must be on the premises. Surgery, monitoring and maintenance should not be done by the same person.
All animals should be monitored after surgery and not discharged unless adequately recovered from anaesthesia. All animals must be fully conscious and ambulatory before discharging them from an animal facility.
Should it be necessary for a practitioner to deviate from the aforementioned the owner should be advised of the risks involved.
(Published -December 1997)
Refer to the guideline document under Guidelines titled " Recommendations for Monitoring of Anaesthesia" below.
Anaesthesia: Starving Patients
The delay or postponement of appropriate treatment of an emergency or other condition which, if not given timeous attention, could result in unwanted complications and lead to a veterinarian being found guilty at an inquiry. Rule 4.1.2 of the Veterinary and Para-Veterinary Professions Act determines that a veterinarian is morally obliged to serve the public to the best of his/ her ability and in terms of the latest scientific knowledge. It is clear that there can be no grounds for defence on the basis of outdated information. One example is the delay of general anaesthesia for fear that complications may develop in an animal who has recently eaten.
(Published - August 2000)
Anaesthetic Gas Scavenging
Anaesthetic Gas Scavenging
KE Joubert MMedVet (Anaes), BVSc
Anaesthesiology: Department of Companion Animal Clinical Studies, Faculty of Veterinary Science, University of Pretoria
A number of practitioners have disputed the relevance and practicality of scavenging of waste anaesthetic gas from operating theatres. In a recent survey of 161 practitioners in South Africa it came to light that only 11.8% of practitioners applied any form of scavenging to prevent contamination of the operating room environment. Volatile anaesthetic agents and some carrier gases may pose a significant health risk for staff. The welfare of animals, employees, and the clients are the concern of the veterinary profession and its governing institution.
The Occupational Health and Safety Act of RSA (Act 85 of 1993 as amended by Act 181 of 1993), requires that every employer instructs employees on the hazards to their health with regard to any substance they may use, handle, store or transport (Section 8, 9 and 12). As halothane or any of the other volatile anaesthetic agents are considered a potential health risk which is augmented by the fact that the European Union and the United Sates have established maximum exposure levels, we as employers are required to take the necessary precautions as described in Act 85 of 1993. The act requires that the employer instruct the employee on the appropriate methods to handle and use hazardous substances and it also states that an employer must take appropriate measures to prevent unnecessary exposure to any hazardous substance. Failure do so, is considered under the act to be an offence. Veterinarians are advised to take cognisance of this fact as litigation may result. The council by encouraging scavenging of anaesthetic agents wishes to protect veterinarians from potential legal consequences. The Occupational Health and Safety Act is administered by the Department of Labour.
Active scavenging devices are expensive and are not mandatory for veterinary facilities. Simple passive scavenging systems can be implemented as follows:
|A pipe is connected to the pressure relief valve (pop-off valve) and another conduit through the outside wall of the room at a level below the height of the anaesthetic machine.
|Installation of an activated charcoal container on the anaesthetic machine absorbs exhaled anaesthetic gasses. Companies specialising in this kind of equipment must install this. Like the soda-lime canister, the activated charcoal must be replaced from time to time. It is also a more costly system but convenient for mobile anaesthetic machines.
|Alternative a plastic refuse bag (good quality) can also be attached to the pop-off valve and emptied outside after the procedure.
|In cases where gas masks are used (like birds) anaesthetic gases escape into the room and there is an even greater potential for risk. In these cases it is recommended that a well-ventilated room be used, the masks fits a tightly as possible and if attached to breathing circuit scavenging is possible.
This article has been based on a previous publication by the author: Joubert KE 1999 The hidden dangers of the anaesthetic machine. Journal of the South African Veterinary Association: 70: 4: 140 – 141. Prof AM Lübbe is acknowledged for his input into the article. A list of references is available on request.
(Published - April 2003)
Admissions to Veterinary Clinical Facilities
What Council expects from a veterinarian when an animal is admitted to a facility for treatment and care.
The companion animal practitioner leaves his patients not fully recovered from surgery or the rural practitioner spays a dog at 7:00 and then leaves on farm calls.
It is expected of the veterinarian to ensure that the animal is monitored by an adequately trained person and that the veterinarian or his / her colleague attends to the patient at least once a day over and above the surgery performed on the animal.
Most practitioners leave their practices at 7:00 p.m. and patients are left on their own.
An animal should not be hospitalised over night at a clinic except if full-time supervision is available ( by an adequately trained person) at the clinic / hospital concerned.
(Published -August 2000)


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Which new features do you want the most?
I'm not sure it should really be classed as a "feature" but I would really like a category for Decaffeinated when adding teas.
How about a message inbox so we can chat w/ other steepster members. I think comments on tea logs should be about the tea, I'd rather not have my convo w/ someone in public and a lot of people don't want to publicize their email address in a comment so the convo can be carried on via email.
What about searching for a steepster member by their location? Right now we can only search for people we know. This COULD be a great place to make and meet (physically, not just electronically) new tea drinking friends.
I just HAPPENED to see someone else from WI here, I'd like to activley search for them
Would love this feature! Usually I would go to meetup.com for something like this, but would definitely use this feature if provided!
I was thinking a smaller version of meetup.com could be created here just for local tea gatherings. Until then, you could consider creating a local group on meetup.com in your area for tea outings and such. I have a group on there for psychic mediumship (I'm heavily into the paranormal, and think it pairs nicely with tea) :)
Good idea. We have features along these lines already planned for later on which should help people find others geographically near them and arrange to meet in person if they want to.
Any updates on the progress of this "connect" feature? It is a fabulous idea!
On my wish list for this feature would be the ability to create and manage tea tasting clubs. I know that this mimics meetup.com - but all the tea drinkers are here on Steepster!
Unfortunately, no updates at the moment. We still have a few major features planned before we get to this on our roadmap. But those should be doozies so we hope you enjoy :)
some companies post the upcoming roadmap short term (next 1-2 features) for everyone to babble about, some don't…any chance you might let us know the next feature soon before release
AmazonV, as eager as I am for new features- I like the surprise HOLY CRAP… A NEW FEATURE! I'm normally online when Steepster goes down so I know an update is coming- so nerve wracking in a good way!=D
@AmazonV: Hmm…we'll think about that. The way we have our roadmap planned out is pretty complex – a round of significant feature development followed by a smaller round of misc. stuff so we can get the big things out of the way but also be cleaning up the smaller things too. That misc. bucket can changed pretty quickly too. The next big feature should be a fairly large technical challenge, but something we haven't really seen used the way we plan to, so we might want to keep that under wraps for now.
There's also a natural hesitation about establishing expectations in terms of what will be included and when. We have to balance all our Steepster work with other contracting gigs until Steepster can support us, so timing is always tricky to work out. Plus, we probably have different priorities than our individual users. We want to see Steepster continue to grow so it gets to a point where we can work full time on it and crank our awesome features like crazy. But if you're an individual on the site, you might not immediately see the benefit of adding more users since there are already so many great ones. So your priorities would be focused more on getting specific new features right away…does that make sense?
However, with all that said, we do like being open with our community and getting valuable feedback from you, so it could be really helpful. It's something we'll definitely discuss again.
@Jason I can understand user expectations – I am an IT employee at a large multi-national and manage three software programs servers & deployments (btw know any friends w/.Net experience, two Senior .net spots open) and totally understand how fast things change, managing expectations etc.
However I also was the business analyst before I switched sides, having a small group (opt in etc) of users to help do UAT/feedback on the one next feature that is in the works and having them know there isn't a timeline for deploy sometimes help iron some things out before they become snags or enable you to tweak them for useability
It would be lovely to able to find other local tea nerds! Right now when I type 'tea' as an interest into sites like "meetup.com" all I get are political activity. :/
I just had another thought. Beware, I intend to ramble.
As people have mentioned the Dashboard page is exploding all over the place at the moment and I haven't even dared go through what's happened on mine since I checked last. I expect it's going to even out as people get their Cupboards filled up, but at the moment it's just ridiculous. Especially for people who are following a lot of other people. Such as ahem me. And especially especially if those are really active people.
I like how the Dashboard is loaded in bits, so it moves quicker and we don't have to sit around and wait for ten thousand items of activity of some sort is being loaded all at once. On any average day, I guess I probably click view more some… I don't know, I've never counted them. Let's for the sake of the example say ten times. Nice round number and all that.
When I see that someone has commented on one of my posts or on a post that I have commented on previously, I go and look right away. Same if I want to comment on someone else's posts. I can't look through all the new updates and then go back and check because then I'd forget half of the things I wanted to see. When I'm done with that I hit the back button to go back to the Dashboard page.
I'm getting to the point now. This is the point.
The Dashboard page can't remember how far I got. If I was clicking a link on say for example page 7, I first have to scroll through pages 1-6 AGAIN to get to the place I had got to. It would be really awesome if the Dashboard page could remember where I had got to so I could skip all the scrolling through stuff I had already seen. Depending on how many things you click on while checking the newest activity you can end up with a seriously huge amount of scrolling.
I don't know if this is possible, but if it is, it would definitely save me a lot of time.
Yeah, I've tried just opening them in new tabs instead, but that's not really ideal either.
That sounds like some really complex logic that would be pretty taxing on the system (making it load slower) but the new organization of the dashboard that we're already working on should help with these concerns.
Kind of spinning off the dashboard fireworks bit, maybe the ability to tab your dashboard? So you can have a tab to see it all, a tab for entries, a tab for comments, etc.
I really like this idea.
Awesome idea, it will solve the problem of blown up dashboards and sounds easy to implement.
Dear Steeper developers, please pay attention to it.
I like this too. It would even fit in nicely with the layout of our own log pages with the tabs on it. (Actually, now that I've given it some thought, I like it much better than my own idea above.)
Speaking of Tabs on the Dashboard, I would really appreciate one that allows me to track the discussions I already participate in. I will still use the main 'Discussions' button at the top to see what everyone is dishing about, but I would like to keep closer track of the chats I'm most interested in.
As usual, thanks for asking!
JustDuckyInNE, you have the notices notifying you of new posts (and are linked directly to them) and the fact that the threads turn blue, what else are you looking for? I'm not trying to sound rude, just trying to understand.
I'd want to see tasting notes being sorted by date. I mean if you look at someone's notes for a particular tea, they are all mixed up, there is no chronological order at all. It would be interesting and useful to see how opinions change with time and more profound tasting.
I hope I'm making sense here :)
You can actually do this already if you go to the user's tealog. On their tealog, you can sort by "New" (which is the default setting). You can use this to see a person's taste develop over time and see how their tastes have changed. However, it is not setup like this on the tea page.
On the tea page (which is what I think you're referring to) a person's tasting notes for that tea are sorted by popularity. We think this is most appropriate for the location because when you are on the tea page you want to find the best/most relevant tasting notes for that tea (and we're planning to add features to help better surface the best tasting notes). But if you want to see a person's development over time, we think that is best shown on the person's tealog (which is where it is now). I hope that makes sense :)
I agree w/ Oolonga. I want to see the tasting notes for a specific tea by date, not just tasting notes by a specific person.
Jason, to make us both happy could we have the abilty to sort the tasting notes different ways? For example, by date, by user, AND by rating?
I'd like to see a "Tasting Notes Requested" section. There are a lot of teas I've seen on the shelf or on the web and wonder about them, but I haven't seen anyone taste them yet. We could post "Anyone try Murchie's Golden Jubilee?" and see if anyone responds.
Hopefully, this makes some sort of sense.
Anyway, HAS anyone tried Murchie's Golden Jubilee?
I like how this site is growing! To add my two cents' worth, I think it would be nice to have a "reply" function in our entries too, so we can respond to people individually. As some others have already mentioned, email notifications would be nice, like when someone comments on your entry/replies to your comments and when someone "likes" your stuff …
You can post a reply to a post rather than to the entire topic, but how about the ability to reply to a reply? That way people know exactly who we're talking to and what we're talking about. Also, how about a way to quote a portion of the post we're replying to. This is the very reason I posted all of my ideas separately. I figured it was a toss up between what some people may call spam and jumbling up the board. Neither are good.
I'd like to be able to somehow note or categorize my cupboard for their location. I have a set of teas at home and a set in the office, and it would be nice to be able to look up just what I have in one location and see if I need to move stuff around or purchase new stuff.
Excuse me if I'm repeating someone else here, but:
Forum organization, please. :)
It would be nice if threads could go under topics, such as
Types of Tea
Tea ware
Tea culture
It's kinda jumbled and messy in the present state.
Maybe a little search bar action, too? It is definitely becoming difficult to find things. We're a prolific bunch.
I agree. The forum needs sub-forums like JM suggested.
Under a topic, I would like to either 1) sort by several fields i.e., tea name, manufacturer, tea/teaware, posters name, date posted or 2) search on these fields within a topic.


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• Prohibited use of a rental vehicle will void Budget's Roadside SafetyNet option.
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Picture of the week
The Al-Aqsa Mosque (farthest Mosque) in Jerusalem. Built originally around 674, it was converted to a palace by the crusader kings before returning to a Mosque following Saladin's capture of Jerusalem
Highlights, September 2018
Information displayed on A&A about the Courtauld Gallery Collections does not reflect current cataloguing and photography. We're working to rectify this and will post details of an update soon.
Courtauld Insights
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Glyn Philpot: Artist at the Crossroads
In the first of a two part story Grace Brockington examines two British artists characterised by outward controversy and inner conflict: Glyn Philpot and Eric Gill
The Scent of Fashion
Nicola Harding on dress in the Courtauld's Impressionist paintings
Impressionist Dealers and Collectors
Rebecca Virag on the people who created markets for the works of Monet, Degas, Cézanne and Renoir
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A day with John Constable on Hampstead Heath
Professor Ian James, Head of Mathematics, Meteorology and Physics at the University of Reading
Jack Vettriano on Forain
A watercolour by John-Louis Forain inspires a rare interview and preview of a new work from Britain's most popular living artist
The Art of Reading
Writer and art historian Simon Ford on the enduring theme of readers and their books
Quizzes, Polls & Discussions
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Watercolours - estimate their value
Guess the detail and win a Gallery guide!
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Curators vs. Public - who's right?
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Bevin Court
Julia Barclay
08 December, 2015


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Below are the top Kalasin Franchise Opportunities. Listed below are various Franchise Opportunities currently available. Request more information on these franchises by adding them to the Shortlist.
Shown above are currently available new Kalasin franchise opportunities we have on BusinessForSale. One of the best options to start out in franchise ownership could be to buy out an existing franchise. Kalasin franchise resales will have an existing customer base and management team, have instant recognition and an established presence in the local community, and often offer start-up support and training from the current management or owner. All established and existing franchises available for sale can be found in our business for sale franchise resale section. To see the listings to buy an existing franchise; move to our homepage and select the franchise resales category.
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Parliamentary sitting calendar
Go to the full calendar of events
The Table Office is led by the Clerk Assistant (Table) and has three functional areas, as shown in figure 5. The Clerk Assistant (Table) and the Director, Legislation and Documents also perform duties as a clerk at the table in the Senate chamber.
During 2009–10, the office consolidated its staff numbers through several recruitment processes. For the fourth quarter, the full-time equivalent (FTE) staffing level for the office was 16, due to ongoing selection processes. The staff numbers were complemented in sitting weeks by employing additional staff to assist the office to maintain the high standard and output of the office.
By 30 June 2010, staff were working in their substantive positions and training for new staff was underway. The average FTE for 2009–10 remained at 17.
The cost of the office for 2009–10 was $2.5 million ($2.8 million in 2008–09).
During 2009–10, the office provided effective support for the Senate chamber by:
The Table Office provided secretariat support to three domestic committees. It also supported Senate committees generally by liaising with Senate and joint committee chairs and secretariats to facilitate interaction between the chamber and those committees.
Staff in the Table Office continued to be involved in the department's education activities.
Projects with the other parliamentary departments were initiated and progressed. The business case for the redevelopment of the document production system was prepared jointly with staff of the Department of the House of Representatives. Work was also undertaken with the other parliamentary departments on the Tabled Papers Register.
All staff in the office contributed positively to the structural review being conducted in the department. Two half-day meetings were held and attended by all in the office to put forward suggestions as to how it could continue to meet the requirements of the chamber, senators and their staff and other sections of the department. Staff in the office also contributed in other fora.
A number of the staff in the office also participated as bargaining representatives in the negotiations on the new enterprise agreement to establish the terms and conditions of employment following the expiration of the collective agreement made in 2006.
Requirements for advice, statistics and documentary support for the Senate are determined largely by the sittings of the Senate. Specific factors include:
The Table Office supported the Senate on 52 sitting days in 2009–10, a decrease compared with 56 in 2008–09. The distribution of sitting days was again skewed towards the first half of the reporting period—the Senate sat on 28 days from August to December 2009 and 24 days from February to June 2010. In the number of days represented in the first half of the reporting period, there are three hidden days (27 November and 1 and 2 December 2009) on which the Senate sat as a continuation of the sitting day of 26 November and 30 November 2009, respectively. It is not unusual for the Senate to extend a sitting day to the next day. However, two consecutive extensions are unusual. These three extended days do not account for the reduction in the number of sittings days, as the Senate sat for two hidden days in the first part of the previous year.
The Table Office provided support for the operation of the chamber, and met the needs of senators and others for accurate and timely documentation and assistance, by:
Staff also arranged for the presentation of documents by ministers, the Auditor-General and committees when the Senate was not sitting. This procedure has become an increasingly useful avenue for the timely publication of material of interest to the Parliament.
In 2009–10, 440 documents were presented this way—a 9 per cent increase on the 2008–09 total of 404. This partly reflects an increasing trend for Senate legislation committees to be required to report on bills prior to the commencement of a sitting period. It also reflects the full-year operation of the orders of the Senate requiring information on departmental and agency appointments, vacancies and grants to be provided prior to the scheduled estimates hearings.
The timely provision of advice to the Manager of Government Business and other senators assists the efficient conduct of the business of the Senate and therefore is an important aspect of the work of the Table Office. During the year, advice was provided on a range of matters, including ways to deal with bills expeditiously given the time available for debate (including the application of standing order 142, colloquially known as the guillotine), condolence motions, orders for the production of documents and motions to vary the routine of business. Staff provided this advice, both in response to requests and proactively, in a timely manner. Staff also produced accurate, high-quality documents on or ahead of time.
The office responded to the requirements of the Senate and the needs of senators and others concerning legislation and related information by:
The charts in figures 6 to 8 indicate the levels of legislative activity in recent years.
Figure 6 Senate legislative activity, 2005–06 to 2009–10
Figure 7 Amendments moved and agreed to by the Senate, 2005–06 to 2009–10
Note: The figures for amendments also include requests for amendments and proposals to omit clauses or items from bills.
Figure 8 Running sheets, 2005–06 to 2009–10
The number of amendments moved was almost identical to the number moved in the previous period. The number of amendments agreed to was also comparable. A quarter of the amendments moved (301) and agreed to (202) related to the second consideration of the carbon pollution reduction scheme bills introduced by the Government in late 2009. This number of amendments generates a demanding workload for the legislation subsection. As well as preparing running sheets to facilitate the consideration of these bills in the chamber (see below), the subsection checks and proofreads each amendment in preparation for possible inclusion in schedules of amendments. Although this work was completed in anticipation of the bills passing the Senate, the bills were finally negatived at the third reading stage in December 2009 and the schedules were not required.
Of the total number of amendments agreed to (824), 89 per cent (733) were amendments moved by the Government. This may reflect the Government's willingness to negotiate with the Opposition and the minor parties to progress its legislative program.
Running sheets facilitate the orderly and efficient consideration of all circulated amendments in committee of the whole. They are prepared when more than one set of amendments from more than one source are circulated for consideration. Running sheets are revised when further amendments are circulated after a running sheet is published. They are also revised to include outcomes and minor revisions when the consideration of a bill is complex and carries over a number of sitting days. Running sheets are provided electronically through hyperlinks in the Dynamic Red.
The number of bills for which running sheets were prepared in 2009–10 remained relatively constant with the historical average. The number of pages prepared decreased compared to the previous year (88 compared with 117). One-third of the running sheets were prepared for consideration of the Carbon Pollution Reduction Scheme Bill 2009 [No. 2] and the Carbon Pollution Reduction Scheme (Consequential Amendments) Bill 2009 [No. 2].
The office is responsible for preparing the formal 'messages' by which the two Houses communicate on legislative and other activity. In 2009–10, 205 messages were prepared (181 in 2008–09). Of those messages, 193 related to the passage of bills, and 12 were administrative in nature (for example, relating to joint committee membership).
The bills system is a document management system that enables bills and associated documents to be loaded to ParlInfo Search (to bills homepages), and metadata to be collected that reflects the progress of bills through both chambers.
The system is jointly administered by the table offices of the chamber departments and supported by the Bills System Advisory Group (BSAG). Staff from the chamber departments and the Department of Parliamentary Services are members of the group.
The group met for the first time in September 2009 and has met on two occasions since. The group's main focus is to ensure the ongoing maintenance of the system and to implement changes as required. The secretariat for the group will alternate between the chamber departments. The Department of the House of Representatives undertook that responsibility for the remainder of the 42nd Parliament.
The bills system has proven to be reliable and effective. When an unanticipated demand was placed on the system on two occasions in 2009–10—to accommodate a second identical print of certain bills—the developer was supportive in providing a short-term workaround. The advisory group has recommended that the system be changed to readily accommodate two identical prints of bills in future.
Version 12 of the system, including the homepage revision, went into production in mid-October 2009. Considerable work was undertaken by staff to revise the presentation of bills homepages. Staff are now concentrating on 'backcapturing' data for the system. This involves inputting the data for events and identifying the appropriate documents to be loaded. As a number of the documents are not available in electronic format, BSAG has been requested to implement a change to enable PDF versions to be loaded through the system. Reasonable progress has been made on the backcapture due to assistance being provided by a staff member from another subsection in the office. Further progress will be made during the upcoming election period.
The legislation subsection has continued to endeavour to meet the high expectations of users of the bills homepages. In 2009–10, 6,423,042 queries were made of the bills and legislation collection through ParlInfo Search. This represents 21 per cent of the total queries made through ParlInfo Search during that time.
Senators continued to use questions on notice—written questions to ministers on the administration of public policy—as an important accountability mechanism.
During 2009–10, staff processed 1,083 questions on notice. The Questions on Notice Summary records statistics and other information relating to these questions, including response times. Figure 9 shows the trend in the numbers of questions on notice in recent years.
Figure 9 Questions on notice, 2005–06 to 2009–10
Notices of motion (used by senators to indicate their intention to move particular motions on specified days) are drafted by senators, the Table Office and the Procedure Office. In 2009–10, Table Office staff drafted or edited and processed 486 notices of motion, which were then included in the Notice Paper and the Journals of the Senate. This is a slight decrease compared to 500 in 2008–09.
During 2009–10, senators presented 43 petitions (45 in 2008–09), collectively representing 136,083 signatories. The office continued to provide advice to senators and members of the public on whether proposed petitions, including electronic petitions, conformed to the requirements of the Senate Standing Orders. All conforming petitions were processed promptly and presented in the Senate.
The office met the needs of senators and others for accurate and timely records by:
The Table Office publishes the Senate's principal parliamentary documents online—both on the department's website and through ParlInfo Search—and in hard copy.
The Notice Paper, the formal agenda of Senate proceedings, provides essential information on the current and future business of the Senate and committees. Two versions of the Notice Paper were published before each sitting day: an abridged printed version, averaging 74 pages (51 pages in 2008–09), and a 'full' online version. The Notice Paper expands during the course of each parliament as unfinished business accumulates and the number of unanswered questions on notice increases.
The Journals of the Senate are the official record of decisions made by the Senate. During 2009–10, proof Journals were published online shortly after the end of each sitting day, and printed versions were distributed the next morning. Staff produced and published 52 proof Journals, each averaging 30 pages (27 pages in 2008–09).
The Dynamic Red, available on the department's website, provides real-time information on the progress and outcomes of business on each sitting day. Relevant bills homepages, amendments and running sheets can be accessed via the Dynamic Red. The Dynamic Red is a valuable tool to monitor the proceedings of the chamber and attracts a wide audience including senators, parliamentary staff, government departments and agencies, and the general public. It continues to receive favourable feedback from users.
Information transferred from the Dynamic Red assists with the timely production of the Senate Daily Summary, a more considered review of the previous day's proceedings. The summary contains links to primary sources such as the Journals of the Senate (which records, among other things, changes to committee memberships), Hansard and committee reports. It is an essential tool for those who work in, or observe, the Senate. The Senate Daily Summary is also produced during estimates hearings, providing links to committee programs and other information.
Statistical summaries of business conducted by the Senate were produced after each sitting week. A more comprehensive set of statistics was also maintained online, providing timely access to the most commonly sought statistics on the work of the Senate. Staff also produced biannual volumes of Business of the Senate, which has recorded statistics on the work of the Senate for more than 30 years.
The office has noticed that the number of statistical inquiries it receives is decreasing as awareness of the online statistical collection increases. However, in 2009–10, information not available on the website was still sought by senators, parliamentary staff and other clients, and these requests were dealt with promptly. The Table Office produced statistics on matters such as:
Copies of all documents presented to the Senate are made available through the inquiries and distribution services provided by the office. The office also responds to inquiries relating to the work of the Senate and acts as an information 'hub' for senators, their staff, government departments and agencies and the general public.
Statistics collected by staff answering inquiries indicate that 6,762 inquiries were responded to during 2009–10. Most of the inquiries (92 per cent) were responded to within five minutes. The remainder of the inquiries were responded to by staff in timeframes agreed on with clients.
While the majority of inquiries originate from senators, their staff and departmental officers, the services of the inquiries subsection are used extensively by other government departments and agencies (26 per cent of all inquiries), media representatives and legal organisations (21 per cent) to obtain copies of documents and advice on processes and outcomes from the Senate chamber.
The Table Office continued to use the Document Movement System or 'telelift' (an automated transportation system) to convey large quantities of documents, often simultaneously, throughout Parliament House. This system is essential to the prompt and reliable distribution by the Table Office of documents to senators, members and others in Parliament House, particularly documents required prior to the sitting of the Senate.
A pneumatic tube operates between the chamber and the Table Office. On a sitting day this device, as old-fashioned as it is, plays a vital role in transporting critical documents between the two places of work. The 'tube' and the 'telelift' are efficient means of transporting documents, saving both time and staff resources.
The Table Office processed the 6,919 documents presented to the Senate during 2009–10, and recorded them in the Journals of the Senate and the Index to the Papers Presented to Parliament. Figure 10 shows the number and type of documents tabled in the Senate in 2008–09 and 2009–10.
Three trends in relation to documents that were identified in 2008–09 continued in 2009–10:
Figure 10 Documents tabled in the Senate, 2008–09 and 2009–10
The papers database is a joint system maintained by the two chamber departments. The database facilitates the processing of documents and generates reports. One of the generated reports enables the production of the Index to the Papers Presented to Parliament. The index is published through the Senate website and is printed at the end of each parliament. In response to an approach from the Parliamentary Library, the index now has been made available through ParlInfo Search as the Tabled Papers Register. There is potential for this database to be developed further in future, including the possibility of providing the text of some documents to which the index refers. The development was acknowledged in the Joint Committee on Publications report into the development of a digital repository and electronic distribution of the Parliamentary Papers Series.
The office is using digital imaging to copy, preserve and ensure access to the collection of all documents presented to the Senate. There are two streams of work: making digital images and microfilm of the documents presented to the Senate since 2002 and creating digital images from the microfilm record of the documents from the Senate's first century. The digital images are stored in an electronic 'web repository' available through the department's website.
In 2009–10, the digital imaging team concentrated on resolving a number of technical issues that were delaying the loading of images to the web repository. This work resulted in the documents presented to the Senate in 29 of the 39 parliaments until 2001 being available online. Documents from 2001 until the current parliament are also available online. Of the 5,317,579 images loaded to the repository, 1,241,895 were loaded in 2009–10.
All the original documents presented to the Senate since its first meeting in 1901 are stored in Parliament House under archival conditions. The area available for storing these documents is limited and under increasing pressure as the collection grows. Last year's annual report mentioned a major rationalisation of stock and the acquisition of the former stationery store, which increased the document storage capability. This year the office has acquired another space in the basement, which will be dedicated to the storage of budget-related material such as portfolio budget statements. This will free up considerable space in the main basement document storage area.
During the year, the Table Office provided secretariat support for all meetings and prepared the reports of the Selection of Bills Committee, the Senate Publications Committee and the Joint Committee on Publications.
The office provided some secretariat support to the Standing Committee on Appropriations and Staffing. However, because of temporary vacancies further support was undertaken by another office in the department for six months.
The staff in the legislation subsection and the programming section also assisted committees by determining 'time critical bills'. On 13 May 2010, the Senate passed a motion referring time critical bills (those with commencement provisions that could take effect before 1 July 2010) to the relevant committee for consideration. The aim of the motion was to ensure that legislation committees had the opportunity to consider the provisions of bills introduced into the House of Representatives when the Senate was not sitting, prior to the June sittings when the legislation would be required to be passed. The motion expressed the Senate's view that a committee could consider a bill and report to the Senate that no inquiry was warranted. The bills were also considered by the Selection of Bills Committee in accordance with the provisions of the Standing Orders.
The Joint Committee on Publications held an inquiry into the development of a digital repository and electronic distribution of the Parliamentary Papers Series. The report of the committee was tabled on 24 June 2010. The committee recommended that a digital repository be developed within the Parliament, following the preparation of a business case to address issues raised in the report, mainly relating to archive and preservation concerns. The committee further recommended that the repository be ready for implementation in early 2011. Staff from the office will be involved in the development of the business case and subsequent implementation of the digital repository.
All committee meetings were convened, and documents were provided, within agreed timeframes.
Staff in the Table Office continued to contribute to the training and development of departmental staff by presenting sessions in the department's training programs and offering 'field trips'.
The field trips are half-day sessions for small groups to give departmental staff and staff from other parliamentary departments the opportunity to learn more about the work of the Table Office. Those who have attended field trips have provided positive feedback that the sessions increase awareness of the services offered by the office.
The contribution by staff in the Table Office to the seminar program administered by the Procedure Office continued throughout the year, despite staffing difficulties.
Factors influencing workload and staffing levels are set out in the 'Overviews' section.
The effectiveness of the Table Office in supporting the work of senators, the Senate and its committees is heavily dependent on the expertise of staff. The finalisation of various recruitment processes in 2009–10 means that staff are now working in their substantive positions and training for new staff is underway. On-the-job training is a fundamental component of this training and existing staff have been generous in sharing their knowledge, supporting the office to meet its objectives. The usual high standard and output of the office have been maintained.
All staff have also contributed to the initial work for the redevelopment of the document production system and the structural review being undertaken by the department. In various meetings ideas have been shared and discussed, resulting in a strong understanding of the focus the office needs to have to maintain its high standard of service to senators, the Senate and its committees.
The principal medium for evaluating the services of the Table Office is the biennial survey of senators' satisfaction with the services provided by the department. The next survey is due in 2011. As reported previously, the 2009 survey revealed high levels of satisfaction among senators with the advice, documents and services of the Table Office. Satisfaction with the work of the office has remained high across a number of surveys and the office aims to maintain the quality of its service.
To assist the office in evaluating its services, it also monitors its own performance. This monitoring in 2009–10 indicated that the high level of service was being maintained and there were no areas of major concern.
Much of the work of the Table Office involves direct contact with senators and their staff, as well as other clients. This presents an ongoing opportunity to receive feedback about the services provided by the office. Informal feedback continues to be positive and supports the office's self-evaluation.
In 2010–11, the Table Office will continue its core work relating to the sittings of the Senate. The election break will provide an opportunity for the office to focus on enhancing its operations.
Work undertaken on the redevelopment of the document production system will be furthered in cooperation with staff from the Department of the House of Representatives. It is hoped that work on this project in the next 12 months can progress to the stage of identifying priorities and establishing timeframes within which to achieve those priorities.
The development of an electronic Parliamentary Papers Series may also proceed in cooperation with the other parliamentary departments. Again, this will build on work that commenced this year.
Staff from the departments of the House of Representatives and the Senate will continue to work on the bills system, refining the system so that it continues to meet the needs of senators and their staff, parliamentary staff and persons outside the Parliament.
The office also plans to use the election period to examine the proposals made in its submission to the department's structural review. Some of these proposals related only to the Table Office, and may be implemented once the review has been completed. One such proposal is to revitalise the public interface of StatsNet.
Finally, following the election, there will be a new parliament and staff in the office will be involved in the preparations for the first sitting day of the new parliament.
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