Working with protocols: anethesia

As for anesthesia in dogs and cats, and exotics and livestock for that matter, this is an area where I was constantly at odds with others, from the other technicians to the veterinarians as well. I spent many, many hours monitoring anesthesia during my training, at a nationally known facility in Las Vegas.  It's a testing and training facility not just for technicians, but also for veterinarians and human doctors as well. 

A technician is trained in anesthesia in different contexts. I was trained not only by the book but also hands on, by the doctors, including experts in anesthesia.  I was assigned to perform the blood work, assess an anesthesia risk category, calculated the drug dosages, induce the anesthesia, monitor the animal while in surgery, and recover the animal post surgery. Sometimes this entire process would last 4-5 hours.  Then, we'd do it again for the second half of the day.

We were required to know every part of the machine, how to assemble and disassemble, to read the pressure gauges, change the filters, etc.  Every part of the machine was required  knowledge and anything less than 100% was a fail.  This is one area that is critical to care of our patients. We had to know the physiological effects of everything associated with anesthesia, from the drugs, the rate we injected a drug, when to increase O2 and when to decrease it. There was no fooling around; this was probably the most serious part of our training.

Sometimes, in our training, we would monitor a dog while it was kept under anesthesia to test veterinary candidates in radiology proficiency.  In these long sessions we often saw drops in blood pressure, O2 levels, high CO2 levels, hypothermia, and other complications, simply because of the nature of the procedures.  These were not textbook cases and required thinking at all times, usually while wearing 20 pounds of lead, for 2-4 hours at a time.

During some of our sessions, we would use a CLOSED system. Medical people often think I'm nuts when I say I monitored animals on a closed system, which means that the waste gases exhaled from the animals are recycled instead of being exhausted to a filter and then into the air. It involves closing a critical valve, and on some machines, you can no longer even close this valve completely because of the potential risk to patient. But close it we did, and knowing what was involved was obviously critical to a successful outcome.

So.....when I was going to be demoted for not following protocols, I was a bit stunned hearing the doctors didn't trust me with anesthesia. WHAT?  Oh, I see, every pet no matter it's size or health status was to be started on 3% O2 and 3% Sevoflourane for 3 minutes. That is one of the dumbest protocols I've ever heard.  How can you get your patient unconscious if you are pumping that much O2 and gas at the same time?  The O2 must be LOWER than the inhalant or they all but cancel each other out. Why 3 minutes?  A Great Dane will need 5-7 minutes to reach a surgical plane, a chihuahua about 2 minutes.  And does the chihuahua that is 5 years old and healthy get the same dose as the Great Dane that is 5 years old and undergoing an emergency surgery?  No!

Incredible.  Sevoflourane is probably the safest anesthetic gas made for veterinary purposes.  it's used for human purposes as well.  Animals can remain under Sevoflourane for hours without serious risk.  Most veterinary practices use this gas above the others for this very reason. In the overwhelming majority of cases, it is used on an open system with venting to the outside. To say "average" we could say that to induce a pet you turn the Sevo to 2 or 3 %, and the O2 to 1-2%, and this varies of course.  The pet is physically monitored by a human being while it goes from a light plane, to a deeper plane (which sometimes appears lighter or deeper) and then the 3rd plane for surgery.  It involves listening to the heart, feeling for a pulse, looking at the pupils, and of course, watching the chest rise and fall. 

During this time the human usually attaches various monitors, including a capnograph to measure CO2 exhaled (the company I worked for didn't have one on either of its machines, the most important tool in IMHO to monitor patient status), a sphagnomymometer to measure blood pressure, and electric lines at the chest and hip area to monitor electrical heart activity (not a substitute for watching the chest and listening to the heart, ever).  The gums are checks for color to indicate blood flow, and the tongue is used with a light device that measures the saturated O2 in the blood. Usually one of those things or another one will act as a thermometer also.  And don't forget the fluids we talked about last week.

When the animal reaches Plane III, it is time to re-evaluate the anesthesia machine.  Usually the O2 is turned down and the gas is adjusted to maintain Plane III until the end of surgery.  It must be watched, monitored, and recorded every 5 minutes in Plane III.  Better charts in the 21st century don't simply record the number but will show trends by charting on a graph.  These trends are more important than a single number.  I prefer to mark a paper rather than leave my patient to record in a computer, but the company preferred the computer.  Save time, see more patients, record right into the computer instead of transcribing later (when we weren't busy thereby making more productive and efficient use of our time).

  

Monitoring a 45 pound dog, in a closed system, between veterinarian radiology exams.

Here is my example that made me throw in the towel.  You'll love this.

During mid-day, a large dog was prepared for a dental cleaning, a procedure done under anesthesia.  I was to do the cleaning, the vet agreed to be the anesthetist for this time. After 2-3 minutes of starting, my patient seemed to be in Plane II, starting to wake up and twitch, eyelids fluttering.  When I stopped, I turned to see the anesthesia machine at 0 on the Sevoflourane, and I forget today what the O2 was because I realized my patient was about to wake up.  I quickly pushed the Sevo to 5 or 6%, and looked around for the doctor, no where in sight.  I took over anesthesia for a moment to make sure my pet would go back to sleep and not wake up with a tube in his mouth. The doctor appeared, texting her boyfriend, so I returned to my procedure. Suddenly the doctor is aghast that the Sevo is up, accusing me of incompetence, telling me I was about to kill the dog, etc. 

Nothing was further from the truth! My anesthetist had neglected her duty to monitor the patient, I had made an emergency effort to return the patient to status.  I knew the dog was under a high level of gas, so I reached over and turned it down to 3%, putting O2 at 1%, and the deal was done.  So I thought. Those 30 seconds of 5% were important to quickly put the dog back to Plane III.  Had the dog not been intubated and covered with attachments  it's waking would have been inconvenient, but not dangerous.  Waking up under a procedure is never a good thing. 

So, I was reported as negligent and incompetent when I had made a quick emergency decision required because of the veterinarian's obsession with her new boyfriend. Texting on duty was prohibited.  Leaving your patient is active negligence.  Blaming someone else:  Priceless.

The Corporate Powers decided that 5% was a lethal dose and it was my fault (um, no, 5% Sevo is not lethal after 30 seconds on a 80 pound dog). I was not offered an opportunity to air my grievance, especially since I was lower in medical rank than the veterinarian. Another practice within the chain wanted me to join their group, as they had seen me work many times and were sure that what they saw was not an idiot.  But given the distance, and my frustration with the old technology I was working with, I decided to leave the company.

I've been contacted by them in the last couple of years probably 8 times to join their team, get a sign on bonus, etc. but I can't do it.  Go back to machines without capnographs, analog radiology, have to run back and forth between patients and doctors to discuss money and treatments - no thank you. It's a small town, this big city, and most everyone knows most everyone else in a relatively small professional community of maybe 1000 people. I prefer to go out and meet those who are looking for safe, reliable care for their pets during the holidays, and leave the drama to somebody else. 
 

Critical Thinking

I was reading the November issue of Atlanta magazine today, their technical issue.  Something hit me that I thought I needed to share.

An article identifies how we as humans have forgotten how to think.  Intrigued, I read further. It explained how some airline accidents occurred because of too much reliance on the autopilot, and in an emergency, the pilots reacted, incorrectly, instead of responding to the situation, resulting in dozens of deaths.

I was educated as a veterinary technician by a seasoned group of veterinarians, not other technicians as some quick private schools tend to use.  We learned the real-world way to nurse animals as well as the new technologies.  As an example, I will use the anesthesia and fluids drip scenarios to explain.    

In some veterinary practices, there are rigid protocols for starting animals under anesthesia or a certain amount of fluids to be given while under anesthesia.  These figures are always based on weight and species of animal.  However, a thinking person should not need the "basic" protocol to begin with.  Every patient should be treated uniquely and separately based on a number of variables including age, blood chemistry, type of operation, circumstances surrounding the operation, weight, and of course, species.

For instance, a pet undergoing anesthesia for a heart valve repair doesn't need the same level as one getting a dental cleaning.  Female cats need inhalant anesthesia for sterilization, males do not. Older pets must be monitored for additional factors that younger pets do not need.  Same with giving fluids intravenously while under inhalant anesthesia.  A dehydrated pet in an emergency situation needs an entirely different protocol than a 6 month old spaniel going for a spay.

I want to point out why I decided to leave a well known chain veterinary practice for exactly these reasons, and to remind folks to ask questions about procedures to their veterinarians, which keep doctors and technicians on their toes and accountable to clients.

My first example was regarding pre-anesthetic fluids to a dog about to undergo a spay, a straightforward operation but not exactly a simple one. The doctor asked me to set up the dog at a certain rate before she was going to go to surgery s the dog would get a certain amount of fluids in her body to offset any blood loss or low volume induced shock.  A great, precautionary measure I endorsed. The facility had two fluid machines, a stand with a hook and a box that would pinch the tube until the appropriate amount of flow was obtained in relation to how much you wanted to give over a period of time. One machine was for the pre-op and treatment room, the other was in the operating room.  The machine in the treatment room was, for whatever reason, not functioning, so instead of going into the clean operating room to get the other machine, I set up a manual drip.  This involves calculating the need of the pet, the time period to deliver, the drip rate per ml and then by per drops in a ml, then looking at your watch's second hand and setting the dial that comes on the tube. This is what the dial is for (manual setting).

The doctor came by and was upset that I hadn't used the machine from the operating room.  Did she think I couldn't do simple math?  Did she think that I would perhaps not contaminate the clean machine when it was returned to the operating room?  Did she think I would over or under dose the pet or that I couldn't count drops per second?  I wasn't sure about her reasoning, and not feeling comfortable to ask, I left my system in place knowing I was perfectly capable of doing this task. I bit my tongue over the sanitation issue of the operating room.  

Another instance came along later when setting up for a surgery of a small dog, a straightforward castration of a dog which would take less than 20 minutes.  The dog was small, and the smaller they are, the more attention they need; their body systems fail quicker for the simple reason of volume - a tablespoon of blood means more to a chihuahua than it does to a saint Bernard.  In my head I was able to quickly calculate the fluid dose, which came to about 99 drips per hour, or something of that nature (20 pound dog).  I set the machine to 100, and the doctor has a bit of a hissy fit that I had not set it at 99.  I reset her glorious machine at 99 and we continued on. I resisted telling her she was nuts to be doing my job instead of her own.

Extra fluids on a small dog that amount to perhaps 0.5 of a ml of fluids over a 20 minute procedure. This is even a difficult amount to measure, about 1/10th of a teaspoon. They don't even make measuring spoons that small. In my educated opinion, and the fact that there is more than that amount simply in the tube that delivers the fluids, over 20 minutes, even if there had been complications to cause an hour of surgery, the dog would have benefited from this extra half a milliliter rather than it cause detriment, simply because he was a small dog, all of which can benefit from 6-7 extra drops.     

The reliance on this machine was absurd.  However, the corporate office, in its attempt to create a Big Mac button its cash register, dumbed down the ability of a good technician to calculate and think and set up.  What if I'd needed to suddenly increase fluids?  Instead of simply lifting the bag or squeezing it, I would have had to touch the pad and re-enter data to reset it, then unset it a few moments later down the road, simply to be able to accurately count how many mls of fluid the dog was being pushed, not necessarily what is received, because of the difference in the tube anyway! There are markings on the bag that tell you how much fluid has been dispensed, there is no urgent need for the machine to do it.

I will continue on this vein (pun intended) in another post using anesthesia induction as an example of idiocy when it is always the same, for every pet, no matter what, and the trouble this causes for the pet (and the technician who follows blind protocols without thinking).  In an effort to make things run smoothly, I didn't want to insult the veterinarian's intelligence by stating the obvious, but these things seemed obvious to me, and I kept wondering why they didn't jump out and shout at the doctor.

Lastly, about fluids, I was trained in a theater of veterinarians, well known and accomplished, published veterinarians, and machines were the last thing we relied upon. We didn't use drip machines, and we never stepped away from our patient while it was under anesthesia.  We didn't record everything in a computer, or let a machine read all our blood smears.  Perhaps thinking isn't what this company I worked for wanted.  In that case, a robot could have been doing the work.  What have humans evolved for if not to think? 

Proteins and Lipids and Fats, Oh My!

Been pretty busy these days, so apologies for those following that I've not put anything new out lately.

Diabetic cats are becoming an epidemic in America. Are you noticing any signs?  Lots of drinking and lots of trips to the cat box to urinate? Owies that don't heal?  Weight gain? Lethargy?  You can make changes in your cat's diet to reduce these symptoms and help manage diabetes, but if you are honestly following the guidelines and your cat's health doesn't improve, it might be time to see the veterinary for more drastic measures.

Personally, I find that a diet high in protein and fat will force the liver to produce the glucose needed for brain function, and the body will start to burn the fat for energy needed by the muscles and metabolism. You hear talk of complex carbohydrates, but these food items tend to take longer to digest (of course) which happens closer to the large intestine where the bacteria count is highest. This in turn produces, well, a lot of intestinal gas.  It can be uncomfortable for the cat (and anyone within olfactory distance of the cat), so I recommend staying away from any extra carbohydrates if possible.

Start with canned cat food. Buy a premium food that is not made from ingredients that are primarily "by-products" of some sort of animal.  The canned food is to add moisture and provide the vitamins and minerals that cats need not found in the pure sources of protein and fat we can obtain (unless you want to go hunt mice and songbirds and grasshoppers).  Then we're going to add cooked chicken thighs. Not boneless skinless breasts, but thighs with the skin on.

Two weeks worth of chicken thighs can be had for about $5.  Cook them long and slow in simmering water about an hour, then cool and refrigerate until they are cool enough to handle. Remove the meat from the bone and dispose of the bones unless you want to grind them up into very small pieces - not as small as salt but smaller than peppercorns.  Don't let the cats shew on cooked bones or they could end up with a shard stuck in their esophagus.

Dice the meat into 1/4 inch cubes, fat and lean, add a little of the gelled broth, and freeze half for next week.  Put this week's half in a bowl, cover with tight lid, and then add this to your cat's canned food at about 2 parts chicken to 1 part canned food. Feed the cat a teaspoon or less of the bones or offer about a teaspoon or tablespoon of dry food for some crunch factor.  Be sure that dry food is of the utmost quality and as high in protein as you can find. Beyond One or Blue Buffalo are both good dry foods. Do not use the partially soft foods in pouches; they are usually preserved with glucose.

Fat soluble vitamins include A, D, E, and K. These can build up in fat tissue, and can be toxic, so err on the side of a little less for these four. The rest are water soluble and will wash out pretty regularly, and you need to replenish these. Talk to your veterinarian about adding vitamin supplements to your cat's homemade diet.  You can purchase over the counter vitamins at the pet shops or online made for cats' needs, but again, err on the side of less is more because there are supplements in the canned food, cats make their own vitamin C (unlike humans), and adult cats don't need the same as kittens or geriatric cats.  You do not want to deprive kittens (18 months and under) of vitamins, and your veterinarian should recommend supplements for your geriatric cats (over 10 years).

And yes, this high protein and fat, no carb diet seems extreme.  Most people are so befuddled by the combination, it going against what we've heard for so long about fats and carbohydrates, that it is hard to think about how it works.  Domestic cats are not as far removed from the wild as even dogs.  Nutritional ideas are changing.  When you consider that diabetes in humans (and cats, for that matter) has skyrocketed in the face of low fat diets and complex carbohydrates, throwing carbs, made of starch, made of sugar, at an organism not equipped to digest these compounds, is illogical and contrary.

If you are at all concerned about your cat's pancreas, kidney, and liver functions, have those checked with a urine test and chemistry blood panel test at your veterinarian.  If you don't see results within 30 days, discontinue the diet and have your pet examined for other causes of the symptoms.  If you cat is receiving insulin injections, check with your veterinarian before implementing this diet.  Insulin levels will drop substantially on this diet and then medications may be contra-indicated.

Spay and Neuter Soapbox

Just a quick reminder that the overpopulation problem with pups and kits is only one symptom of pets that have not been altered sterile.  Of course, we may think this is the top problem, and it is significant, but no one thinks about the problems for the mom and pop dogs.

I received a telephone call the other day from a person wanting to know what to do with her male dog, an intact Chihuahua-Boxer mix.  He was overly excited because their female dog, a mutt of some mysterious breeding, was in heat.  Although she'd separated them, the male continued to be ready to give the mutt his 'chioxer' DNA, which was causing him to have difficulty urinating, didn't want to drink, or eat, and, well, seemed to be running a fever.

Because I'm not a doctor I can't give a diagnosis, especially since I can't even see the animal, but I recommended she place a cold towel on his underparts and give him 80 mgs of aspirin (he was about 7 kg).   She'd given him naproxen, the day before, which is not helpful.  It's not helpful because it's not a vasodialator, it is a pain killer.  It talks to the nerve endings.  No cardiologist recommends taking naproxen for a heart attack. 

The point that we never got to was Why do you have an unneutered mix dog AND an unneutered mixed bitch?  For one, at least in Las Vegas, it is illegal to have any pets over 6 months of age that are intact without a breeder's permit, something that's not given out for mutts.  For another, it's unhealthy for your dogs (getting to that shortly).  For another, it's adding to the overpopulation problem we have putting, at last count, 10,000 dogs and 18,000 cats to death every year.  That's just in Las Vegas.

Health issues:  stop telling me you wanted to breed your dog.  It's not a valid, mature, responsible answer to "why didn't you spay her?"  Females that are allowed to breed or are left intact will almost certainly die young, as they develop a uterine infection called Pyometra.  Their uterus is not a pear, but a sausage, and their anatomy allows for easy access to bacteria.  These females usually have multiple mammary tumors, as well, often cancerous, also leading to an early death. It is much more common than people realize.  Going into heat every 6 months is no picnic, either, for owners or the dogs.

As for males, stop cringing and putting human emotions onto a sensible, intelligent animal. Dogs and cats could care less about breeding and that removing testicles is any sort of a concern.  They are perfectly happy chasing balls, squirrels, their own tail, fetching Frisbees or going for walks with YOU, their person.  I have seen not only testicular cancer (necessitating the removal of them anyway), but a condition where the penis comes out, gets trapped out, and eventually has blood supply cut off and the poor dog is thus, if caught in time, has first, an amputation, followed by a castration, followed by a new urethra opening which is much shorter than the one he was born with. The penis turns black and dies, and once that happens, it's surgery or death.

That is probably what the lady who telephoned me is facing (her dog).  I'd also suggest taking the male to a neighbor's or friend's for a few days (or the female) so the pheromones aren't floating around his poor nose 24/7.  She will probably not be able to afford the complex surgery, as she called me hoping for a cheap solution.  I suggested she take him to a vet, but she only has $50 to spare.  Well, not to sound like a heartless jerk, she ought not to take on the care of something she cannot afford to care for.

Which leads us back to puppy and kittens going to homes that might not have the resources to take care of a pet as it needs.  At the basic minimum dogs and cats need vaccines and to be neutered, with booster vaccines every 2-3 years and a dental cleaning two or three years or so. Annually is better but most pets can get away with every 2-3 years. They need quality food - not the cheapest nugget in a bag, and not assorted people foods.  The former is loaded with soy, corn, and other carbohydrates that pets don't need, the latter being unbalanced for nutrients required by pets.

If you can't do that, do everyone a favor and pass up the pet until you can.  Aren't you glad I'm not posting photos with this one ???

Are blue eyes an automatice deaf sentence?

Cats, dogs, horses, and sometimes other pets of our acquaintance, sometimes are born with one or both eyes blue.  When both eyes are the same color is it called homochromatsism, and heterochromotsism when they are different from each other or sometimes two colors in one iris.  This is not a defect, a throwback, or even any kind of a problem.  So why do people ask if my dog is blind in one eye? Sometimes they ask if he's deaf on that side. The right side of my hairy beast has a white, or low pigment 'switch' on, for lack of a better term. The eye on the right is blue.  The black side of him, his left, has dark pigment genes switched on, and hence, the common brown eye.  The flash, of course, shows you mostly a red eye and a green tapetum on the left.

 

 

Many animals have the ability to pass on blue eyed genes.  Sometimes, the gene connected with the low color pigments is related to the gene for audio processing in the brain. A pet with an all white coat, white skin, and blue eyes, although not albino (no color), may indeed be deaf.

 

Merles are often born with blue eyes, and they are not deaf, even when both eyes are blue. We often see in the Paint breed of horses a white face, called a bald, and if it includes the eye area the eye is often blue.  Again, no deafness.  Of course, a truly white horse doesn't exist as the genes for white are lethal. 

 

Many genes tag along on others, and in specific cases we may call some of these sex-link genes.  It's why females are rarely colorblind, that gene being passed on the Y chromosome in humans. In chickens, female chicks will grow adult plumage that matches the rooster, and the males will mature with the plumage of their hen momma. Alas, it doesn't work with all breeds.

 

The long answer, then, is no, blue eyes are not an automatic "deaf" sentence.  To check your pets' hearing, stand behind them when they are interested in something in front of them, and make a noise, as long as the noise doesn't make so much wind that your pet can feel the noise!  If they turn about, they heard you.  You can also snap your fingers behind their head and see if that gets you a response.  Most dogs and cats can read our body language, and will come when called even if their ears didn't hear you (and their blue eyes saw you!).

 

 

All white dog, both eyes brown.  Not deaf, and not blind!

 

When is it time to let go? Euthanasia.

Oh, the subject of euthanasia.  I get asked, often, when will I know it's time?  Did I do the right thing?  Are they suffering?  My answer is, well, each situation is different.  This not being what a person wants to hear, I thought I"d do a little research and see what I could come up with from our medical community.

I found some very good Q & A that a pet's owner should consider when trying to make the Big Decision.  Hopefully this will give you an idea from the medical standpoint.

Dr. Alice Villalobos is a well-known veterinary oncologist. Her “HHHHHMM” Quality of Life Scale is another useful tool. Hurt, Hunger, Hydration, Happiness, Hygiene (toileting), Mobility and More (good days than bad days). Dr. Villalobos recommends grading each category on a scale of 1-10 (with 1 being poorest quality of life and 10 being best). If the majority of categories are ranked as 5 or above, continuing with supportive care is acceptable.

Another thought process is that animals, bless their hearts, do not think the way we do.  They live for NOW, and are not possessed by thoughts of an afterlife, the future, or their wills, or most anything else humans have instilled into the subject of death. 

Quality is more important than quantity in this case.  Why do you want to keep your pet alive (for yourself?) or euthanize him (for yourself?).  If you pet is suffering and the joy is gone, it is time to let go.  I feel we OWE our pets, for all the things they've given to us over their lifetime, a kind passing even if we must hurt ourselves in the process. Are they facing recovery or will they simply have more days of pain, vomiting, seizures, or the like?  Are they facing $5000 in medical bills that most people cannot afford to pay?  An older pet without monetary value (unlike an animal such as a horse) may fall into this category.  Guilt is the biggest motivation here.

I have been there myself.  A young dog facing a straightforward amputation is not the same as an older cat with diabetes facing dialysis. Without insurance, we must pay the veterinarian CASH or perhaps credit.  Does this take college education or even food away from our family?  Would your unselfish pet want you to go into serious financial hardship to give them a few months of life that won't be much fun anyway?

Setting your dear friend free of a painful body is not unkind; it is the greatest kindness.  When medicine can no longer cure or ease the pain, if you pet no longer lies in the sunshine nor wags their tail to greet you, it's time to discuss the end.  Your pet would thank you for your sacrifice.

 

Excessive Heat & Animals

Just a quick note to some residents who may not know the law in Clark County.  Horses, Dogs, and Cats are required by law to be provided with supplemental cooling devices when there is an excessive heat warning advised by the NWS. 
Dogs and Cats should NOT be left outdoors without access to serious shade and cool water.  Although my silly cats will stretch out on the patio in 105F, they can come into the 78F A/C through the pet door anytime (and usually do after 10 minutes outside).  Dogs and cats do not sweat and must pant to cool off.  When the air temp is over their body temp (101.5+-), what are they going to do?
Horses are often left in the direct sun, with folks thinking they don't need shade.  Horses can sweat, but they can't take in nearly enough water to stand in the sun and 110F heat from 6 am to 8 pm without dehydration.  Lighter horses can become sunburned, leading to cancer. It is the LAW that horses must be provided 90 square feet of shade during all daylight hours, even in the winter. 
If you see a pet outdoors unable to find shade or have access to water, call Clark County Animal Control at (702) 455-7710 and tell them the address where to find the animal victim. People may have time to correct the offense, or, simply be cited on the spot.  In some cases animals may be removed from the property and taken to shelter.
As a side note, I have chickens, a goat, and a few free roaming birds that have access to cool water and many shaded places.  The chickens and goat, and horses, all have shade at all times, much more than 90 square feet, and we have installed misters in the horse corrals (under the shade) and in the chicken pen (2 feet off the ground).  All pets that can come in the house are in the house.
Rabbits and Guinea pigs are especially susceptible to heat stroke, so if it's over 100, bring them indoors, at least during the hottest part of the day.  No amount of shade will protect them and again, dehydration will kill them in a few hours.
It is a crime in Clark County to leave animals out in record breaking heat, and it is a crime of humanity to ignore such an act.  Call Clark County Animal Control at (702) 455-7710.