Liz Bode
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Hi Ornella,
My pennies worth, but I would be definitely interested to know what Neus does, she probably sees more of these cases than I do.
Firstly, it sounds like you did a brilliant job and I am not sure that there are any perfect answers here. I have never had to intubate a cat or dog with severe CHF, but that is because they are often stabilised, at least a little, before I see them. I believe your approach, starting with butorphanol IM was a good one as a ‘safe’ option in such a fragile case. I guess that if the cat was so stressed and dyspnoeic even with that then going straight to induction before a POCUS examination was performed would have been OK too. These little cats are so fragile that you’re almost doomed if you do and doomed if you don’t.
LizReplying to Emma Holt 05/03/2023 - 18:35
Hi Emma,
The typical breed would be a golden retriever, they tend to get idiopathic forms but can get HSA (and the only case I have ever seen of pericardial lymphoma in a dog was a GR). Most breeds are mid-large size dogs and the smaller breeds are rarely affected by PE. That being said I have seen border terriers, this dog and Frenchies have PE too.
If collapsed we might only use butorphanol and lidocaine in the intercostal space. We might also use this if the dog is quiet. If not then we would normally choose alfaxalone IV to effect in combination with butorphanol.
Liz
Replying to Emma Holt 05/03/2023 - 18:38
Hi Emma,
Good question! I haven’t really used it in cats with significant renal disease. According to Plumb’s there is a need to reduce the dose in cats (more so than dogs as dogs metabolise 30-40% of it) but it doesn’t go into detail. I would say that using the lower end – 50mg – would probably be OK. However, if you wanted to be completely sure then you could use an alternative. I guess as it is renally excreted that it will hang around for longer.Liz
Replying to Ornella R. 01/03/2023 - 20:28
Hi Ornella,
Ooooh interesting!!!! Yes, I think the combination of the two will have most certainly pushed the cat into CHF. I see 1-2 cats a year that have had depomedrone usually that then present in CHF. They have an HCM phenotype and steroids cause fluid shifts in the body that then raise pressure in the heart. If there is diastolic dysfunction, as with HCM, the heart can’t cope with this extra pressure and CHF results. The CHF is usually reversible though, so we treat it and wait for depo to be out of the system and then careful down-titration of frusemide whilst monitoring RR. So, in your cat, I think the fact that there was severe anaemia and eccentric (dilation rather than hypertrophy) remodelling meant the cat could have been on the verge of CHF and then the steroids just tipped him over the edge. I would have hoped that if you could manage the anaemia and CHF that the CHF would resolve with time and the requirement for frusemide might disappear too.
Cats are cool! We do not see this in dogs (or at least I am not aware of dogs going into CHF after steroids).
LizHi Ornella,
Great questions!
In terms of the heart, anaemia is one of the most common ‘high-output’ states that can result in high-output failure in humans and animals. This means, as Kerry pointed out, that you have hypervolaemia and the heart has to adapt to this. It does so by eccentric dilation (think dilated chambers) and this will affect the left atrium and ventricle. An increased heart rate will also be seen. In these cases you may hear a murmur or gallop rhythm. In theory, severe anaemia can lead to pulmonary oedema which will resolve once the anaemia resolves and with management of CHF. However, this is so rare that I have never seen it. I have, however, seen plenty of cats suffer CHF through blood transfusions and intravenous fluid therapy.
LizReplying to scott@vtx-cpd.com 17/02/2023 - 14:19
Hi all,
So the clip (sorry it is so short but we only save very short clips on the echo machine!) shows severe pericardial effusion and cardiac tamponade of the right atrium. This is causing right sided heart failure and needs prompt treatment. As the dog wasn’t collapsed we did do a more complete echo examination, looking for neoplastic lesions but we didn’t find any. The dog was sedated and then we drained the effusion via a right-sided approach. We drained 300ml of haemorrhage fluid. The PCV was higher than the peripheral blood and we did drain with the help of the ultrasound so we know that this was effusion. It also did not clot. I always submit fluid for cytology and fluid analysis (culture only if it looks infectious on cytology). The diagnostic yield of cytology on pericardial effusion is low if it is haemorrhagic, but I have had pericardial lymphoma diagnosed on samples, amongst others and so I would always submit a sample or at least look at it in house. We also did a full body CT in this dog, but no neoplastic lesions were observed. The dog was hospitalised for 24 hours and then discharged. 1 month later there was no effusion, but about 10 months later the dog did re-effuse and this time neoplasia was observed on CT of the thorax. We presumed mesothelioma here.
I chose this case as it was a slightly unusual breed for a PE and there was cardiac tampoande. It is almost 50:50 in terms of neoplasia vs idiopathic causes of PE, but there are obviously other causes such as coagulopthy, infectious, inflammatory etc.
Thank you for your contributions.
LizReplying to scott@vtx-cpd.com 15/02/2023 - 13:22
Hi Emma,
Thanks for the reply, and here are my thoughts for those of you following this thread:
Problem list:
– tachycardia (HR >120bpm)
-progressive lethargy and weakness
-Hyporexia
-Suspected abdominal fluid
-Hypodynamic pulsesDDx:
-Tachycardia – likely related to underlying condition e.g. something causing reduced cardiac output but could also be fear or pain related.
– Progressive lethargy/weakness and hyporexia are probably related to the underlying disease process and won’t be considered individually.
-Fluid thrill: likely ascites, but you are correct we would need to get more info
-Hypodynamic pulses could be due to reduced cardiac output, hypovolaemia or I guess could be a partial thrombi/obstructionFurther investigations would include:
-blood pressure
-Haematology, biochemistry and electrolytes
-Abdominal and thoracic POCUS and if effusions are confirmed sampling these and sending for analysis would be helpful.
– ECGThe results were as follows:
Bloods were unremarkable
Blood pressure 120mmHg via Doppler
Abdominal POCUS demonstrated ascites and thoracic POCUS revealed this…(hopefully it works…)https://drive.google.com/file/d/1o-lUdZQxIcwzyBBfKmP34_XLuEcB8VGA/view?usp=share_link
What does the video show and what would your next steps be? What are the possible causes of this presentation?
Liz
Replying to scott@vtx-cpd.com 02/02/2023 - 18:15
These ones were hypodynamic 😉 you’re right though hyperdynamic pulses would be associated with things like anaemia, pyrexia, PDA, AR (severe) and so on…
I’ll talk about pulse quality later 😉
Hi all,
Just a reminder of the above that is happening tomorrow. All welcome to attend. It is very informal.
I also noticed that there is only one paper attached above, here is the other:
https://drive.google.com/file/d/1g7X5TyiBiFwuYGcz2mulROc-Sdhu8Igx/view?usp=share_linkLiz
Replying to mike m. 14/01/2023 - 09:32
Hi Mike,
Great question. They have looked at this and it doesn’t seem to be related. Most of the dogs have normal taurine blood levels and the diets don’t seem to be deficient in that essential amino acid.
LizReplying to Christina Frigast 01/01/2023 - 11:08
Happy New Year to both of you (and everyone else reading this post)
Brilliant!! Yes, this is a sinus tachycardia (which fits with CHF due to sympathetic drive maintaining cardiac output). There is P pulmonale as the P wave is taller than it should be, consistent with RA dilation. The QRS is splintered and this probably reduces the overall height of the R wave. The QRS is splintered like this as the electrical activity finds a different path to travel through the conduction system than normal (possibly due to ischaemia/ fibrosis etc). These findings are ‘commonly’ seen in dogs with tricuspid valve dysplasia. Here is the original report:
https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1939-1676.1997.tb00095.x
Liz 🙂Hi everyone,
Just a reminder about our Live Q and A session on 9th January at 8pm.
The zoom link can be found under the lesson for the week. The session will be recorded and uploaded to the website after editing (which can take a week or two to do). If you can’t come along but have questions about cases that you would like me to chat about then please feel free to send me those (Liz@vtx-cpd.com). If you’re there in person then bring along cases etc for us to chat about. I’ll also bring some things with me.
Hopefully see as many of you as possible next Monday 🙂
Liz
Hi Christina,
Interesting! My first thoughts (before reading your whole question) was this could have been an AIVR but not at a rate of 200bpm. In short, no I’ve not seen this following medetomidine. However, I have seen similar cases in dogs, the most recent was a Lab who was under GA and developed VT. I ran a troponin and this was very high (from memory >10) and I thought it had suffered some sort of ischaemic event under GA. Myocardial hypoxia (possibly from vasoconstriction effect of the medetomodine or reduced cardiac output) could be responsible for what you saw. In the case of my Lab – echo was normal but VT was still present on a Holter 24hours later. After discussion with the owner we didn’t treat and repeated the Holter two weeks later which was completely normal. I felt that this supported my thought of transient myocardial hypoxia (there was an issue on induction in this case though). Perhaps your dog just had mild/ more transient regional myocardial hypoxia than mine?
Liz
Hi Ursula,
I know we have chatted about this informally but thought I would answer your post too 🙂 In terms of if a cat comes to see me with an ATE I start clopidogrel at 75mg ONCE then 18.75mg/cat/day from then. I will use Fragmin (dalteparin) whilst in hospital too. The CURATIVE guidelines (2019) suggest clopidogrel and either dalteparin or a factor Xa inhibitor should be used in cats at risk of ATE but that there is no evidence to support this. So, perhaps there is some rationale to send cats home with both clopidogrel and factor Xa?
I’d be interested to hear others thoughts, especially those in ECC clinics who will see more of these cases than me.
Have a lovely Xmas.
LizHi all,
No takers yet for this case, perhaps I will bring this one to the live Q and A session? Or would you prefer me to write my thoughts on the first stage here? Happy either way.
The live Q and A session will be recorded for those who can’t attend 🙂
Liz
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