scott@vtx-cpd.com
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Hello.
I hope you are both well. I totally agree. I still think we know so little about the toxicity. Jenny spoke about the values/minimal amounts reported. Regardless, I think we have to treat every ingestion seriously. I would induce emesis and start IVFT if it was my dog!
My question is… would you be happy making vomit and send home?
Scott 🙂
Hello.
Hope you are safe and well. I think clinical signs are important when it comes to making treatment decisions regarding these cases. `
The only thing I might think about doing is culturing the urine. Did the clinical signs come on again suddenly?
In a dog with this pre pill cortisol and clinical signs, you would still be justified increasing the dose by 10-20%.
Hope that helps.
Scott 🙂
Hello.
Thank you as always for your questions. Sorry for the delay in getting back to you. I have answered below your questions:
1)With regards to iv fluids, is there a rate of iv fluids (e.g 2xmaintainance, 3x maintainance etc) or a type to calculate how much should replace?
I think it is always important to address dehydration and hypovolaemia separately. Treatment of hypovolemia should be finished within 1-2 hours of presenting to the hospital. This type of resuscitation routinely requires rapid administration of large volumes of fluids intravenously. These are “shock boluses” of replacement crystalloids: 40-50 mL/kg for cats, 20-90 mL/kg for dogs (see below). Typically, I would give a portion (1/3 or 1/4 dose) of the total volume and then reassess endpoints of resuscitation to determine if more volume is truly necessary. After this initial resuscitation, I would calculate a fluid plan based on % dehydration and body weight. I would administer this volume over the next 6-12 hours.
2)With regards to dextrose, do you give like a CRI added on fluids or d you give it straight into the vein and how much?
In these cases, I would only use dextrose as a CRI if the hypoglycaemia is persistent and severe. I would normally give a bolus A dextrose bolus (0.25-0.5 g/kg, diluted 1 : 3) can be given IV.
3)In dogs with atypical HA that require only glucocorticoids p.os , what dose do you use?
Prednisolone can be administered at a relatively high dosage of 0.5 mg/kg PO q 12 h for 2-3 days. Following these first few days, the prednisolone dosage can be quickly decreased to physiologic needs (0.1-0.2 mg/kg PO q 12-24 h).
4) in dogs which require zycortal, do you give p.os prednisolone only until day 3 after diagnosis and then stop and use only in crisis or do they maintained on prednisolone on daily basis but on low dose?
They do need to be maintained on prednisolone but at the lowest possible dose (see above).
5)and last question, you mentioned about a cut off point of 55nmol/l in order to exclude hypoadrenocorticism, but then if post ACTH is between 27-55nmol/l then this not neseccarilly means hypoadrenocorticism, could you please explain this a bit further? I had a dog examined today with basal cortisol of 33.9nmol/l (so less than 55) and i am going to do an ACTH test in 2 days. What result should i expect to diagnose hypoadrenocorticism? If it is still below 55 but above 27 is this not compatible with hypoadrenocorticism?
You are looking for the lack of stimulation ultimately. Many hypoadrenocorticism cases are consistently below the detectable limit. If there are not (as in your case) you are looking for the value not to change (flatline).
Send me the result when you get it!
Scott x
Hey.
Do you have any other results from the curve of this dog? What were the other values during the day.
The duration of Caninsulin is much more variable, so 3x daily dosing would be very unpredictable and cause a lot of cross-over with dose.
Although the Glargine response is very disappointing, there are some insulins that genuinely work better in some dogs than others. It is interesting that the owner does not report PUPD. Would this owner consider a BG sensor?
Scott 🙂
Sybil,
I think you sum it up so well “We need to worry about overstretched burnt-out cynical staff more than we worry about idiot breeders”.
I LOVE THAT!
Scott x
Hello everyone.
I have heard this so much. This is definitely a real trend after the lockdown puppy boom. I could not agree more with what you have said Ashley, it puts stress on all members of the team. And the most challenging issues with these cases… MONEY!
Ultimately this comes from the top down. I think the corporate managers have to make sure we on the ground have the power to manage these cases appropriately, without worrying we will create debt and do the wrong thing. Zoe… do you remember when I did that c section for a pound!
Jokes aside… as hard as it is in the moment… I always say over and over in my head:
“none of this is the dog’s fault”
Which helps.
Scott x
Sorry.
You are absolutely right! Totally the right dose. I mean that it can be challenging at smaller doses due to the difference in concentration.
Sorry to confuse you!
Scott 🙂
Thank you so much everyone for your answers. I summarised the imaging findings below.
The cardiac comments were really interesting. My thoughts about enlargement too. We did echo this dog and found the cardiovascular structures to be normal. No heart disease noted. I obviously had the benefit of that information!:
1. Diffusely within all of the lungs there is severe poorly defined increased opacity, forming ill-defined micro-nodular/miliary-like pattern with peribronchial cuffing.
2. The cardiovascular structures are wnl.
3. The mediastinal and pleural structures are wnl.
4. The visible cranial abdomen is unremarkable.Conclusions:
1. Severe diffuse predominantly unstructured interstitial to miliary/micronodular lung pattern Ddx pulmonary haemorrhage, haemangiosarcoma metastases (no obvious splenic mass/peritoneal effusion in cranial abdomen), non-cardiogenic pulmonary oedema (neurogenic cause), less likely lymphoma/granulomatous disease with absence of regional lymphadenomegaly, less likely parasitic such as angiostrongylus/eosinophilic bronchopneumopathy/pulmonary fibrosis with absence of lower airway signs.
So the cardiac size may have been a normal variant for this dog.
Hope this all helps.
Scott xxx
Hey.
I would totally agree, I think a longer-acting insulin is the way to go in this case. I wonder whether ProZinc may be the next choice (due to licensing and ease of dosing)? If ProZinc, I would start with 0.25IU/kg BID. If considering the insulin analogs glargine (0.3IU/kg BID) or detimir (0.1IU/kg BID) the main challenges are going to be dosing (less of an issue in dogs compared to cats). Main thing is not to dilute the insulin in any way. The nadir will still vary (especially in this patient). I would monitor as you are doing with BG curves and be super aware of the possibility of hypoglycaemia in the initial stages.
Hope that helps.
Scott 🙂
Thank you Magda and Michael.
I will see if we have any more thoughts before revealing the next bit!
Scott 🙂
Really interesting case!
Could you send the timings of the most recent BG curve results. When is the dog fed?
Scott 🙂
I knew that is what you meant!
Scott 🙂
Hey.
Yes, it is the Freestyle Libre 2.
Scott x
Hello.
Using the single value to increase dose can be challenging. A single blood glucose measurement is rarely useful in monitoring DM with the exception of finding a low result, always indicative of an overdose. Single glucose measurements may be sufficient when an owner believes the dog is virtually asymptomatic, the PE is unremarkable and serum fructosamine levels are between 360 to 450 mcmol/L. In such cases, glucose concentrations between 10 and 14 mmol/l around the time of the insulin injection are consistent with good glycemic control and additional blood glucose measurements are not usually necessary.
Hope you are having a lovely weekend.
Scott 🙂
Kerida,
Thank you so much for your kind words.
We really appreciate the support.
Have a lovely weekend.
Scott 🙂
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