scott@vtx-cpd.com
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Hey Inga.
Really sorry about delay!
Really interesting question and one of my favorite drugs!
What other drugs is the dog on?
Tranexamic acid is an antifibrinolytic drug. It therefore reduces bleeding but, in certain situations, it may expose patients to a risk of thrombosis. It is used for the treatment of various types of bleeding, including menorrhagia, haematuria, certain surgical procedures and trauma. Its harm-benefit balance is favorable in certain situations associated with serious bleeding. The harm-benefit balance is different in minor bleeding: the expected benefits are smaller because the condition is not serious, and the risk of thromboembolism may be higher without the haemodilution associated with severe bleeding.
Clinical trials (human) conducted in serious haemorrhage or in patients undergoing surgery with a high risk of bleeding have not shown an increased risk of thrombosis with tranexamic acid. In practice, as of early 2013, the harm-benefit balance of tranexamic acid is favorable in severe traumatic bleeding. But when bleeding is not life-threatening, the thrombotic risk is too poorly documented to justify exposing patients to a plausible and inadequately evaluated risk.
I could find one specific human haematuria paper that overall did not represent a massive benefit (https://pubmed.ncbi.nlm.nih.gov/28916142/).
It has also been suggested that there may be a specific contraindication with bleeding in the urinary tract as tranexamic acid prolongs the dissolution of fibrin deposits already formed. Macroscopic haematuria is therefore
regarded as a contraindication for the use of tranexamic acid because this may lead to clots in the urinary tract with possible obstruction. I am not able to find any reports of this in the animal literature.So, in summary! I would probably only use it if the bleeding was severe and causing more severe side effects like a drop in PCV.
Hope that helps.
Scott 🙂
Hey.
Both pre and post results are often increased in cPSS but they do not have to be. Most of the time the post prandial is the most elevated value and is most helpful/diagnostic.
Hope that helps.
Scott x
Hey.
Really interesting question but really frustrating cases! I have seen a couple and not had any survive sadly. Anderson Moores are currently the leading centre for research and have some useful information:
https://www.andersonmoores.com/vet/CRGV.php
Anderson Moores will also offer a type of free PM service if the dog is PTS. THe main components of treatment are supportive:
1. IVFT to maintain perfusion/hydration. Be careful not to fluid overload if AKI. It is helpful to place urinary catheter and measure urine output. If anuric then furosemide could be considered but must be used with care.
2. I would administer antibiotics (amox/clav) IV is unwell and hospitalised.
3. other supportive care would include anagesia and maropitant.
4. I would be careful with doing too much topically with the skin wounds. I am a massive fan of Vetericyn spray for these sorts of situations.
5. Keep a close eye on electrolytes and obviously manage deficiencies appropriately.
6. There have been reports of the use of therapeutic plasma exchange (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6060235/). This procedure is only available in the UK at the RVC and Vets Now Glasgow.
Can you send some pictures of the skin lesions?
Hope that helps.
Scott 🙂
Thank you so much for sharing the radiographs.
I would agree with Liz’s comments.
You mentioned harsh lung sounds. Is there a crackle or a wheeze to be heard? 🙂
Scott
Great thoughts everyone!
I know the megaoesophagus was the easier one, but I wanted to share as it was a good example! I think they can sometimes be quite tricky to spot! We did manage to get this radiograph conscious. Sedation and GA can in themselves cause megaoesophagus, so I always try and get conscious when I can. We found no underlying cause, so I think idiopathic.
The pneumomediastinum was a real surprise in the other case! We really struggled to understand. The CT did not give us an answer… could it have been the blood sample!??! This dog presented with significant vitamin D toxicity. Hypercalcaemia resolved but respiration worsened. Severe interstitial pattern on CT. Sadlt we put dog to sleep, we got consent for PM, so will keep you posted. Still no explanation for the pneumomediastinum…
Pneumomediastinum is the abnormal accumulation of air within the mediastinum and it can be caused by a variety of mechanisms. Tracheal disruption can leak air into the mediastinum, and has been reported with cervical trauma, mechanical ventilation, transtracheal aspiration, tracheostomy, tracheal intubation and overinflation, or central venous catheter placement. Similar to tracheal trauma, oesophageal or pharyngeal rupture can result in pneumomediastinum. Subcutaneous emphysema from any location can eventually enter the mediastinum via the cervical soft tissues and thoracic inlet. Less commonly, air can enter the mediastinum from gas accumulation in the retroperitoneal space. In some cases, the cause of pneumomediastinum is not determined (spontaneous pneumomediastinum).
The presence of air in the mediastinum creates enhanced contrast and detail, allowing radiographic visualization of individual mediastinal structures (best seen on lateral images), including cranial vena cava, brachiocephalic trunk and left subclavian artery, oesophagus, and azygos vein. Visualization of the tracheal wall is enhanced due to the presence of both intraluminal and extraluminal air.
Scott x
Really interesting Gail.
Thank you for sharing your experience of gabapentin!
Scott 🙂
The trazodone/gabapentin in blocked cats is a brilliant idea Jack.
I am going hunting for literature now… if it is not there then this might be the first official vtx study!
Is the liquid gabapentin Bova?
Scott x
Could not agree more Emma.
Immune-mediated disease is definitely when I use it the most. I agree that clinical signs often guide us, but it is a useful marker to measure, especially when we start to wean the steroid dose. The main thing as you say is that it is really non-specific. There are a couple of interesting papers that also suggest it may be useful in the management of respiratory disease:
The Utility of Acute-Phase Proteins in the Assessment of Treatment Response in Dogs With Bacterial Pneumonia
Background: Acute-phase proteins (APPs) are sensitive markers of inflammation, and serum C-reactive protein (CRP) recently has been shown to be a useful diagnostic marker in dogs with bacterial pneumonia (BP). In humans with community-acquired pneumonia, APPs also have great utility as follow-up markers aiding in the assessment of treatment response.
Objectives: The aim of our study was to investigate the applicability of APPs as markers of treatment response in dogs with BP.
Animals: Nineteen dogs diagnosed with BP and 64 healthy dogs.
Methods: The study was conducted as a prospective longitudinal observational study. Serum CRP, serum amyloid A (SAA), and haptoglobin concentrations were followed during a natural course of BP. Normalization of serum CRP was used to guide the duration of antibiotic treatment (treatment was stopped 5-7 days after CRP normalized) in 8 of 17 dogs surviving to discharge; 9 of 17 dogs were treated according to conventional recommendations.
Results: All measured APPs initially were significantly increased, but the magnitude of increase was not correlated to disease severity. C-reactive protein and SAA concentrations decreased rapidly after initiation of antimicrobial treatment. When normalization of serum CRP was used to guide the duration of antibiotic treatment, treatment duration was significantly (P = .015) decreased without increasing the number of relapses.
Conclusions and clinical importance: Serum CRP and SAA reflected the recovery process well and therefore may be used as markers of treatment response. According to the results, the normalization of serum CRP may be used to guide the duration of antibiotic treatment in dogs with BP.
Serum C-reactive protein as a diagnostic biomarker in dogs with bacterial respiratory diseases
Background: C-reactive protein (CRP) is a major acute-phase protein in dogs. Serum concentrations are low in healthy animals, but increase rapidly after inflammatory stimuli.
Objective: The aim of the study was to investigate CRP concentrations in various respiratory diseases of dogs and to determine if CRP can be used as a biomarker in the diagnosis of bacterial respiratory diseases.
Animals: A total of 106 privately owned dogs with respiratory diseases (17 with bacterial tracheobronchitis [BTB], 20 with chronic bronchitis [CB], 20 with eosinophilic bronchopneumopathy [EBP], 12 with canine idiopathic pulmonary fibrosis [CIPF], 15 with cardiogenic pulmonary edema [CPE], and 22 with bacterial pneumonia [BP]) and 72 healthy controls.
Methods: The study was conducted as a prospective cross-sectional observational study. CRP was measured in serum samples. Diagnosis was confirmed by clinical and laboratory findings, diagnostic imaging, and selected diagnostic methods such as cytological and microbiological analysis of respiratory samples, echocardiography, and histopathology.
Results: Dogs with BP had significantly higher CRP concentrations (median, 121 mg/L; interquartile range, 68-178 mg/L) than dogs with BTB (23, 15-38, P = .0003), CB (13, 8-14, P < .0001), EBP (5, 5-15, P < .0001), CIPF (17, 10-20, P < .0001), or CPE (19, 13-32, P < .0001) and healthy controls (14, 8-20, P < .0001). Dogs with BTB had significantly higher CRP concentrations than dogs with CB (P = .001) or EBP (P < .0001) and healthy controls (P = .029). Conclusion and clinical importance: These results indicate that CRP has potential for use as an additional biomarker, especially in the diagnostics of BP. All very interesting! Have just set up a live journal club on this exact topic! Scott 🙂
Hello!
Work always has a habit of getting in the way! Yes, we are just editing now so will get the live session up ASAP!
Hope you are safe and well.
Scott 🙂
Hey.
Thanks again for your questions. Yes, in an entire male dog with urinary tract infection it would not be unreasonable to use a fluoroquinolone as a first choice. There is definitely a very good chance the prostate will be involved.
I will normally culture 5-7 days after antibiotics have been stopped.
Hope that helps.
Scott 🙂
Emma,
Thank you so much for sharing this. Really interesting.
Happy new year!
Scott x
Hello! Hello!
How lovely to hear from you! Firstly, what the heck you doing watching my DKA webinar on a Sunday night! 🙂
Good question though. I think about the transition as soon as they are re-hydrated and electrolyte/acid-base issues back to normal. It is best to start long-acting insulin when they are eating normally. The transition itself is actually very straight forward. I will stop the CRI or IM infections of neural and you can almost immediately start the long-acting. Best to do this at the time of day the insulin is likely to be given.
Does that make sense?
Scott x
Thanks Sybil.
Megaoesophagus indeed! Initially, I was a bit confused as I thought there was a problem in the cranial lung fields. Turns out this was just all the food material in the oesophagus obscuring the lung fields!
After first assessment the cat had a general anaesthetic to undergo CT and angiography. Before this procedure, a blood sample was taken for biochemistry and did not show any abnormalities. The CT revealed marked and diffuse dilation with ventral pouching (diverticulum) of the oesophagus. The diverticulum was filled with food and part of bones . No vascular ring anomaly were detected. We then attempt upper-GI endoscopy, however that was extremely difficult due to the presence of lots of food in the cervical area of the oesophagus. For this reason was not possible to assess the oesophagus entirely.
Diagnosis: Megaoesophagus and oesophageal diverticulum
Any thoughts on the cause in such a young kitten?
Scott 🙂
Thanks so much for this.
The correlation generally between WBC number and actual infection is poor.
I would culture in any situation when an infection was a possibility.
Hope that helps. Thanks again for all of your great questions.
Scott x
Areti,
So lovely to hear from you. Thank you so much for your kind words. THank yo so much as always for your questions. I have tried to answer below:
1. So in everyday practice, when we collect urine by cysto, we keep it in ptactice during the day and we send it off to the lab in the evening and they collect it in the morning. Should i place the urine into the fridge immediately after collection? As most of times is being sent off for a comprehensive screen which includes cytological analysis and culture/sensitivity.
Yes, we also send many of our urine samples off to the lab. I would keep them in the fridge until they are collected and transported to the lab.
2. When we need to repeat a urine culture, the dog in on abts, do you repeat the culture the last day of the treatment? And do you then carry on with abts until results are back or do you stop them and then restart if still infection present?
I would only do this in more complicated infections. Simple, uncomplicated infections do not require re-culture. When longer durations of treatment are being used, urine culture is reasonable to consider after 5–7 days of treatment; however, the approach to a positive or negative result should be considered in advance. Positive cultures indicate the need for evaluation of compliance and further diagnostic testing, to determine why the bacterium has not been eliminated, not simply a change in antimicrobial, particularly if clinical cure has been documented. Negative results could be used to help determine when to stop therapy if a long course of treatment is being used, but are not a guarantee of microbiological cure. Culture of urine specimens, ideally collected by cystocentesis, can be considered 5–7 days after cessation of antimicrobials in animals where clinical cure is documented. However, this
should be used as part of the diagnostic process to help differentiate relapse, re-infection and persistent infection, and to guide potential future diagnostic testing, not as an indication of a need to treat.-How long do you monitor with STT after tx with sulphonamides?
I only tend to monitor with longer courses of this drug. I would monitor on a weekly basis and after long courses, one week after the course stops.
3. What dose of amoxicillin/clavulanic acid is the most appropriate? as the dose range is 12.5-25 (quite big) and you mentioned that a reason for tx failure could be not adequate dose.
As long as you are within this range you should be fine. Often, people dose below 12.5mg/kg due to tablet size. I would make sure to go higher than this.
4. and last question: we have an automated machine for urine sediment examination which gives an exact number of RBCs and WBCs. How many per power field should we see to say that we have significant pyuria and haematuria?
Depends a little on the machine. Can you send me the details?
Hope that helps.
Scott 🙂
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