Bossie Boshoff, [18 Aug 2024 at 11:27:07 A discussion item: For insurance purposes, either the yohimbine at 6,25 mg/ml must be given at 1 ml/50 kg or the atipamezole must be given at 3-5 mg / 1 mg medetomidine, even if the V-tech combo used. I am not sure if there a peer reviewed paper out there which indicates you can use less than the prescribed dosage for any of the 2 reversals, even if used together. The half-life and differs between the 2 reversal drugs. I helped an insurance company as an external consultant and a couple of claims been denied because dosages for yohimbine and atipamezole was not met - this was also the comment of a pharmacological expert used by the insurance companies and this was one of the reasons some claims were denied. Hendrik Hansen, [18 Aug 2024 at 15:55:34] Bossie. It is clear that the dosages and combinations used by many vets for immobilizations do not appear in peer reviewed articles - I know that is true for me. What is also true for me is that my outcomes for certain immobilizations will certainly be worse if I only used dosages that appear in peer reviewed articles for certain species. I will defend my reason for the dosages I am using on the grounds of numbers done, data and experience. I lost more animals during my career using published peer reviewed dosages than using what is working for me in every specific situation. If the dosages that we use have to be peer reviewed, development and growth would be super slow and still not entirely risk free. Further we would never immobilized an animal at ambient temperatures of higher that 26 deg C or would we? We as Wildlife Vets are taking risks in our work on a daily basis. Using unregistered drugs for specific species, compounded drugs and concentrations because of unavailability of the optimal drug for specific situation. Working in the heat of the day, darting from a less than optimal position or distance, darting from a bakkie because the farmer can't afford the chopper etc. etc. etc. Then an insurance company that don't want to pay, wants to discredit colleagues David Pretorius, [18 Aug 2024 at 16:35:08]: It is advisable not to make absolute statements such as "the animal dies," particularly when it implies that an incorrect reversal dose is the definitive cause. This could inadvertently create a loophole for insurance companies to deny claims. The 5:1 reversal ratio is not the only option, and in some cases, certain species are not reversed at all, as the benefits of sedation may be preferred. Similarly, while the SABS standards identify the heat of the day as a primary driver of capture myopathy, recent research has shown this may not be the case. Given the advancements in scientific understanding, there is a strong argument for revisiting and updating these regulations, including those concerning atipamezole and yohimbine reversal doses. Our approach should remain neutral, both towards farmers and insurance companies. Making blanket statements such as "only a full dose is acceptable" is questionable and may lead to unintended consequences. Does this imply that animals not fully reversed or only partially reversed will not be covered by insurance? This is a critical point that needs careful consideration to avoid exclusion of coverage under certain circumstances. Similarly, if regulations state that a compromised capture occurred due to temperatures exceeding 25°C, it’s important not to rigidly adhere to this rule, especially when scientific evidence suggests otherwise. We must rely on our knowledge and experience rather than strictly following outdated standards. Hendrik Hansen, [18 Aug 2024 at 17:16:50]: Agree 👍 Andre Uys, [18 Aug 2024 at 17:23:40]: If we get hamstrung by insurance companies insisting on published doses, we would never be able to adjust doses up or down as clinical circumstances so often require and we would kill many more animals. Evidence based innovation in clinical practice is paramount to the advancement of the profession. If I were the farmers, I would contest the outcome of the repudiated claims and have their “experts” cross examined. The rate at which research would need to be conducted would have to amplified by orders of magnitude and we would spend more time in CPD’s than we would be spending trying to earn a few pennies. Ulf Tubessing, [18 Aug 2024 at 17:57:42]: I agree 100%! The insurance people always look for the back door out and that is not acceptable. This to some degree is driven by some "advising veterinary experts" who want to appear clever. I was criticised for not submitting samples for culture on a DOA sable bull that had been maturing for 2 days in the sun at 40 C. Ampie Viljoen, [18 Aug 2024 at 19:48:36]: There is a severe flaw in this argument. Just as we know there is definite species differences in the response to alpha 2’s we also know that there are species specific differences in the response to antagonists. Some species will be harmed at 5mg/ 1mg (cheetah for example). No peer reviewed articles have been published on the dosages in all species in discussion here, so a peer reviewed article can surely not be used as a blanket rule for all species and stand in a court of law. Bossie Boshoff, [18 Aug 2024 at 20:22:46]: I have read all the replies and comments. I will continue to do what I know works and do not put my clients' animals at risk and that no fingers can be shown to medication if something ever went wrong. The long and the short is the animals and my clients interest comes first. And no, except in emergencies, I do not dart insured animals when it is over 25 C. If my opinion is asked as an external consultant, I can only comment on what is published and what the specialist wrote in their report. I agree that as a vet you must know the differences in species and some species are super sensitive to certain medication. If used appropriately, this can still be in the range where insurance would not end up denying a claim for a farmer. Worst of all, if an animal dies, then as a vet, I would rather work in those ranges and with the medications that I know there are no problems with. The problem is that there is a dosage rate out there for alpha-2 antagonists and the other medications not. Insurance companies will use whatever they can to not pay out a claim, as pointed out by comments above. So, it still is every vet’s own choice what to do and use. But animal claims due to alpha-2 related complications have gone up exponentially, according to insurance companies. Leith Meyer, [18 Aug 2024 at 21:07:15]: I agree that the wildlife medicine field can’t wait for peer reviewed papers to determine all doses etc (there is simply not enough funding and capacity to do even the basics). However, it’s important that the science that is published on similar species (even if they are domesticated) is carefully considered before any innovation is done. Furthermore, evidenced based innovation needs to be done in a very careful, holistic and responsible way. If this innovation doesn’t carefully consider all the aspects of what is important for an optimal immobilization/intervention, dangerous anecdotes become normal practice, which get put into books and then it becomes really difficult to change beliefs and practices. The case in point is the 25 C ambient temperature used to determine when captures should happen or not. If this was carefully considered and researched at the time, we would not have the issues that we have today. Similarly, any new drug combination or reversal regime should be properly assessed not only for its intended purpose and cost but also from an animal welfare perspective. Importantly, for immobilizing combinations, a simple assessment of whether they cause hypoxaemia should be done - recovery without death shortly afterwards shouldn’t be a yardstick for welfare. One doesn’t need to have very fancy equipment to make a good assessment of hypoxaemia, but just assessing breathing is not good enough, proper measures need to be made. For reversal/antagonist regimes, very careful assessment of the drugs ability to prevent re-sedation/ immobilization need to be done for a long enough period after they are given, in some species/drugs this needs to as long as 24 hours, if not more. Opioids and alpha-2 agonists are potent depressors of the thermoregulatory system, so the risk of death is high if re-sedation/immobilization occurs when heat loads are high or even low. Importantly the dose of antagonist is the greatest determinant of whether re-sedation/ immobilization occurs. Apologies, if I’m highlighting basics and possibly sounding condescending (I’m not trying to be), but I think we need more care and responsibility in our innovation, with less bravado. Hendrik Hansen, [18 Aug 2024 at 22:17:56]: In 2015 we saw how Big Pharma could bring our work as Wildlife Vets and the wildlife industry to our knees - to a point where our ability to handle even emergencies was compromised by the availability of registered drugs and known protocols. It would be a sad day when that influence of big companies become even more apparent. Leith Meyer, 19 August 2024: That was almost 10 years ago when the industry was booming. The boom has gone and now there is more scrutiny on what we do as vets. The world is very focused on animal welfare and wants to see us doing things with care. There are lots of drugs options available to us and more on the way. How we innovate is important as we influence the profession and young vets going forward. It is now even more important to innovate responsibly using good science. Hendrik Hansen, 19 August 2024: Yes, that was 10 years ago - we were totally reliant on Thianil and etorphine and it became unavailable. Then we hit the fentanyl crisis and now it seems to be yohimbine. We seem to be heading for a single supplier for etorphine? Availability and cost in such a controlled business (scientific) environment remains a risk for our future work. The world is also very focused on human welfare and that could influence availability of drug groups that we became dependant on to be effective. Never say never again.
