Kerry Doolin
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Hi everyone and welcome to the course.
Neus and I have been working off and on for many years now and I am so glad we can present this topic to you all. I can’t wait for your questions! I am back doing some nights after a fair while off nights – so I think I will have my share of questions too!
Replying to Stephanie E. 06/11/2022 - 14:34
Hi Stephanie,
Im wondering for the dogs who go home after emesis with charcoal, do you recommend baseline renal bloods then bloods within 48hours on the basis the vet AKI staging etc is a more than whatever % increase from baseline but may well still be within reference range. For example like you said creatinine is 70 but then is 120 2 days later – that patient has AKI and would recommend IVFT from there –> Yes, 100% correct.
For the tiny dog or dog that has large quantities that you recommend IVFT does that not make it harder to interpret changes in creatinine from baseline – at 24 hours the creatinine is the same or lower but then off fluids may increase – do you check them again? Im sure I read/heard that the volumes of fluids to be renal protective are so high they are physiologically not appropriate for normal well dogs –> I use 2x maintenance rates, check the creatinine after 24h and if not elevated, then stop IVF and home BUT then check creatinine again in 2 days.
I fine these cases challenging to recommend treatments to the client as so much is unknown the evidence is just not there –> I really agree, it is really hard to decide what is the beast for the patient. I make sure the owner knows the risks of AKI and recommend (in most cases) 24h fluids. It is really important to make sure the client is informed so they can help in the decision making process.
Replying to Anna Deen 05/11/2022 - 14:44
Hi there Anna,
The glucose bottle you use for administering a bolus normally comes in a 50% solution. This is dosed at 0.5-1g/kg, but diluted 1:4 in 0.9% NaCl. Glucose 50% contains 25 mg glucose as monohydrate in 50 mL –> equivalent to 500 mg/mL.
If you have Glucose 30%, the drug is Dextrose monohydrate 300 mg/ml – you would need a higher high volume so probably easier to purchase the smaller 50% bottles. Due to the high osmolality of the solution, don’t use straight as a CRI.
I hope that helps.
Hi Scott,
This is a great question. The issue with grapes is the toxic dose is really unclear and a lot of the information we have is anecdotal. When I first treated grape exposure (with no evidence of AKI) over 10 years ago, the current advice (from experience information rather than research and evidence) was 72-hours of fluids at 2 time maintenance rates. We then spent the next three days sedating dogs to keep the happy healthy puppies on IVF. Since then there has been a trend away from this duration of fluid therapy in the exposed but not AKI-case.
Additionally we know the toxin is idiosyncratic.
So combining all this information, this is my personal plan for grape/raisin cases that I have been using for the last 5 or so years:
– if the dog is tiny I tend to recommend up to 24h on fluids no matter how much they eat.
– if the dog is medium-large sized and they eat only a few grapes and all/most come up with emesis – offer owner admit for fluids and discuss pros and cons and let them decide if they can afford treatment. Advising them the dog probably will be fine without from what we understand – but that AKI can be lethal. Make sure they get charcoal if they are managed as an outpatient and ensure the owners gets a blood test with RVS within 2 days.
——–> this is the only case whee I offer the option to send home. Client education is really important here.
– if the dog is medium and eats more than a few grapes; emesis, charcoal and fluids for minimum 24h, check bloods after 24h and if nor al stop IVF. Then keep in and bloods 12-24h later to ensure no rising creatinine or back to RVS in 2 days to do this.This is a tricky one to manage as often owners are hard to convince therapy due to costs and dogs look so healthy!
Replying to scott@vtx-cpd.com 02/11/2022 - 10:47
Hi Scott,
I don’t ever use Apomorphine in cats. It’s all about the Dopamine receptors, or lack thereof in cats. Cats as we know are different to dogs in this way. In the cat, their vomiting centre in the chemoreceptor trigger zone has alpha-2-receptors – that is why Xylazine and Dexmedetomidine works better. Dogs on the other hand have dopamine receptors in their CRTZ – so apomorphine is more effective.
I tend to reach most commonly for Dexmedetomidine in cats to induce emesis. I find Xylazine very hit and miss with effectiveness in cats. Xylazine does work better on a full empty stomach though.
Regarding anti-emetics after emesis. I take it on a case by case basis. So if the patient has vomited ingesta and is vomiting lots of foam and they look miserable, I treat with anti-emetics. I prefer metoclopramide because we want to be purists, but maropitant is not wrong if that is all you have. If the patient is bouncing around after emesis – save the money and send them home without!
Hope that helps.
Hi Marit,
That is a great question and shows how important it is to use the guidelines on a product advice leaflet that comes in the box.
1. For Emedog specifically (1mg/ml), the dose is –> Single subcutaneous injection at a dosage of 0.1 mg of apomorphine/kg bodyweight. This is the product licensed for use in the UK.
2. The dose in Plumbs has a small range –> 0.03-0.04mg/kg IV or 0.04-0.08mg/kg IM
3. Apomorphine Tablets 6.5mg/tablet:
a. For conjunctival or oral administration – Dose at 0.25 mg/kg (1 tablet/26 kg)
b. For subcutaneous administration – Dose at 0.08 mg/kg (0.246 mL/kg) – dissolve tablet in water for injection.
c. For intravenous administration – Dose at 0.04 mg/kg (0.123 mL/kg) – dissolve tablet in water for injection.The reason for this variable dose in Emerdog and Apomorphine ampoules is unclear. The toxic dose for Emerdog specifically has not been stated but efficacy of this drug has establish this dose and safety has been established at this dose.
So basically – if you live in the UK you must use Emedog as it is licensed and at 1mg/kg; elsewhere we use a lower dose!.
I hope that helps.
”Do we see myocardial contusion in cats or do they die before getting to us? Is it safe to administer lidocaine to a cat with suspected myocardial contusion?”
I agree with Neus that we do not tend to see this too commonly and there is certainly little evidence. Based on the potent toxicity of cats and lidocaine I rarely treat ventricular rhythms and tolerate a very high rate, over 300bpm. When you have this and cardiovascular compromise then you may need to treat. However the agents you would use would be ideally either:
Sotolol (class III anti-arrhythmic) at 1.0-2.0 mg/kg q12h or
Atenolol (class II anti-arrhythmic, beta blocker) at 6.25–12.5 mg total dose per cat q12–24Amiodarone and Mexiletine are registered as dogs only.
In those life threatening VT cases, Lidocaine (class Ib anti-arrhythmic) can be used as a slow bolus of 0.25–0.5 mg/kg, followed by 10–25 µg/kg/min CRI –> try oral though. Just be prepared with intralipid if you have a toxicity issue (wonder drug!)
Replying to Liz Bode 14/03/2022 - 20:05
Hi Liz,
Yes I have started to use CRP in my cases of suspected aspiration pneumonia. Historically – in the case of the vomiting or regurgitating dog and unclear radiographic changes not quite confirming aspiration, – ‘to be sure’ we often started the patient on antibiotics which is not good antimicrobial stewardship. Now I make sure I have checked temperature too, looked at a blood smear for inflammatory changes but really rely on CRP and find I am using antibiotics less and less without missing pneumonia in these cases.
Replying to Louise Tidley 23/03/2022 - 19:33
Hi Louise,
Great question. It is right to always be worried about a heart murmur when you hear it. I think – perhaps concerned rather than worried! At the end of the day, the most life threatening state right now is shock. So fix that and if the patient happens to have cardiac disease then a few scenarios could happen:
– they fail to respond to the fluid bolus as they have true cardiac disease or another form of cardiogenic shock (or septic) and have LV dysfunction. So here your point of care ultrasound will help with that and you may use a vasoactive agent such as dobutamine
– they do respond to the fluid bolus and the anaemia progresses – ultimately transfuse here
– they do respond to the fluid bolus and after one or a few boluses they develop respiratory signs. Here take some chest rads and look at your LA:Ao size and if there are markers for overload back off on the fluids, give frusemide if indicated and balance your fluids better. Or perhaps the LA:Ao is normal and there are pulmonary changes – think about aspiration or ARDS.These critical cases can often be improving one then and then another develops – very dynamic.
Hi Liis,
That is a really interesting article and you are right in that Ketamine has the potential to be an option for refractory status epilepticus. The reason for this is that it is reported to antagonise excitotoxic NMDA receptors). In fact, it used to be part of many human guidelines. A lot of the evidence is observation or case series so it would be great to have some adequate prospective evidence in humans and vet.
There are a few case series and studies in humans reviewing its use. A lot of the evidence is on patients that had failed to improve clinically on multiple anti-convulsants or a particular disease (immune-related encephalitis that had failed to respond to AEDs and immunotherapy therapy). Overall the findings were in refractory states of SE, ketamine as a CRI was often successful.
The study you have attached is really interesting too. Giving a Ketamine bolus on top of other AED would have the benefit of being cost effective and perhaps less monitoring if they were not anaesthetised, To prevent the need for GA and intubation that comes with the use of propofol. Also Ketamine being contraindicated in elevated ICP has been debunked.
I think as long as you consider the risks:
– animal studies could ketamine causes NMDA-mediated neurotoxicity in the developing brain so its risks in juveniles in unclear
– induces dissociative state so may make assessment of mentation and use of MGCS difficult.
– increased HR and BP
– causes laryngospasm in children
– causes nystagmus
– causes vomiting and salivationKetamine is recommended in refractory SE in humans. I am not sure I would reach for ketamine over propofol. I know that propofol has anticonvulsant effects and decreases ICP which is of benefit in these cases and the adverse effects are not relevant for SE patients. However, I am very comfortable using propofol so I suspect that is contributing to this! What we really need is some further prospective evidence to give the evidence and confidence to use in dogs.
Perhaps in the mean time in the right case I might give Ketamine a go. Thanks so much for this question!
Replying to Kerry Doolin 02/03/2022 - 09:47
Hi everyone,
This is a complicated case and I wanted to put it up so people could consider the many things we have to consider in an emergency patient but also all the different ways the same type of case can be managed.
WHAT NOW?
My problem list –>
vomiting – primary GI disease (such as acute pancreatitis or GI obstruction) vs secondary (such as pain)
hyporexia
tachycardia – pain, shock, primary cardiac, nausea
obtundation – shock, primary neurological
heart murmur – primary cardiac or septic or anaemia
abdominal pain – visceral pain or peritoneal pain
suspected peritoneal effusion – haemorrhage, chylous effusion, transudate or modified transudate or exudate
tachypnoea – pain, primary respiratory disease, anaemia
shockList of possible Differential Diagnoses –>
haemabdomen – due to ruptured abdominal lesion or coagulopathy
septic peritonitis – due to ruptured GIT from foreign body ingestion or tumour
cardiogenic shock with signs of right failure
acute pancreatitis with focal peritonitis
abdominal neoplasia causing effusion with third spacing leading to shock
The list is endless…….Plan for what next steps are most required – including treatments and tests –>
1. Place IVC and collect blood
2. treat shock with fluid bolus whilst obtaining further diagnostic information. I would use a balanced crystalloid at a dose of 10ml/kg IV over 15 minutes to target am improvement in my perfusion parameters (mentation, pulse rate, pulse quality, mm colour, CRT and extremity temperature).
3. Now to decide what tests are most useful since I am on a budget:
– PCV/TS
– lactate
– blood smear
– chemistry
I think these are a good blood test starting point to answer a lot of questions. The PCV/TS I want to know if my patient is anaemic and the total solids to clarify my hydration status (especially useful if have azotaemia). The lactate is used as an aid for response to treatment – so rather than be focussed on the admit lactate, I am more looking at the resolution of lactate (or lack thereof). The blood smear is a cheap and accurate way to evaluate the haemogram. I am not a huge fan of bench top machines as they can lack detail we need in an emergency and the wait for external pathologists can inhibit therapy. So a good blood smear allows you to quantify the type of anaemia if present, the number of white cells and whether you have bands or toxic changes. The blood smear is the most accurate way to count your platelets. Always. The chemistry allows us to further pursue a diagnosis in acute abdomen.Next some imaging:
– Point of care ultrasound is integral here. You will be able to evaluate for peritoneal effusion (make sure you recheck after fluid resuscitation as it is common to not initially have fluid and accumulate into abdomen later once fluid resuscitated). This is a great starting point. As your skills improve you can also look for gastric fluid distension (pyloric outflow or functional ileus), fluid accumulation in GIT, the elusive pancreas, liver and splenic lesions.
– collect abdominal effusion if it is present
– Point of care ultrasound of the thorax also should be performed. You will evaluate for pericardial effusion and pleural effusion. Also take the time to evaluate the heart (again as your skills progress) and looks for pseudohypertrophy in dogs (sign of hypovolaemia) and also the Left Atrium to Aorta ratio (LA:Ao) for signs of fluid overload.Other treatments I would have considered here would be the administration of analgesia. As always, avoid NSAIDs in shock and give a pure mu agonist such as methadone.
You can see that this really complicated case is approached in the same way all emergency cases are:
– treat shock if present
– run preliminary blood tests
– get some imaging as the patient is more stable
– analgesiaI will upload some further case details soon.
Hi everyone,
I thought bI would put a case up for consideration. Don’t be shy to put some answers out – don’t forget there are always more than one ways to treat cases like this.
Vicky – 30kg 5yo FN Golden retriever –
History:
Vomiting and inappetence for 3 days.
Abdominal distension for 1 day.Physical exam:
Obtunded, weakly ambulatory
HR 160bpm
Mm red, injected and dry, CRT 1 second
T=37.8 degrees Celsius
Weak synchronous femoral pulses, grade III/VI basilar heart murmur
RR 60pbm with mildly increased respiratory effort
Abdominal fluid wave with moderate abdominal effortWHAT NOW?
1. Write problem list
2. Write a list of DDx
3. Your owner has significant cost constraints, consider your problems and potential DDx – make a plan for what next steps are most required – including treatments and testsReplying to Mark Laloo 26/02/2022 - 11:47
Hi Mark,
I am glad you enjoyed the lecture. These are some good questions.
1) Regarding NSAID overdose – I use misoprostol. However, I do not tend to use sucralfate or omeprazole unless there are clinical signs to indicate them. Otherwise I worry I am wasting the clients money on a drug I may not need.
2) If I have a neurotoxin that is having a seizure – this is a perfect case where levetiracetam may be useful as it can be used as a pulse course for two or so days and stopped abruptly – if phenobarb is used, you are right, it must be weaned over a really long time.
Replying to sara marella 23/02/2022 - 09:07
Hi Sara,
Yeah this is a tricky question – I think we just know so little about some toxins in dogs and cats that we are often, like you say, going to base protocols on human medicine. I wonder if the half life is 1.5h, would a CRI be indicated in cats – this would be tricky to manage though and I suppose quite expensive.Replying to scott@vtx-cpd.com 21/02/2022 - 19:33
I haven’t actually – but that is such a great idea for epistaxis rather than squirting adrenaline up there.
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