scott@vtx-cpd.com

Replying to scott@vtx-cpd.com 07/06/2024 - 20:16

Great question!

When dealing with a haemoabdomen, stabilizing hypovolemia and hypotension is critical. While crystalloids are commonly used, there are specific situations where fresh frozen plasma (FFP) can be particularly beneficial.

Using Fresh Frozen Plasma (FFP):

Crystalloid Sparing: In cases where patients have significant protein loss, such as septic peritonitis with high protein abdominal exudates, plasma can be very helpful. These patients often develop hypoproteinemia and decreased colloid osmotic pressure (COP). In such situations, plasma can provide oncotic support, allowing for smaller fluid volumes and reducing the need for large amounts of crystalloids, which can further damage the glycocalyx and worsen TP/albumin/COP, potentially causing interstitial edema and other issues.

Glycocalyx Protection: The glycocalyx is a crucial barrier that maintains vascular integrity. Shedding of the endothelial glycocalyx occurs in response to ischemia, hypoxia, ROS, inflammation, sepsis, and trauma (including hemorrhagic shock). Research shows that resuscitation with plasma can partially restore the glycocalyx, whereas crystalloids do not. This restoration is likely due to the albumin in plasma, which helps preserve endothelial integrity, reduces glycocalyx shedding, and mitigates interstitial edema. Albumin also reduces neutrophil adhesion to the endothelium and has anti-inflammatory properties.

Coagulopathy: Another specific indication for using plasma products is in patients with coagulopathy. Fresh frozen plasma can provide necessary clotting factors to help manage bleeding disorders, which is particularly important in patients with haemoabdomen who may be experiencing coagulopathy secondary to their condition.

When to Use Plasma:

If PCV is maintained but TP is low, plasma can be useful to support oncotic pressure and provide necessary proteins.
Plasma is particularly indicated when there’s a need to avoid large volumes of crystalloids due to potential damage to the glycocalyx or worsening of interstitial edema.
Use plasma when you need to provide additional oncotic support in patients with significant protein loss or low COP.
Consider plasma products for patients with coagulopathy to provide clotting factors and manage bleeding disorders effectively.
In summary, while crystalloids are typically used for initial resuscitation, FFP has specific benefits in certain clinical scenarios, especially where maintaining oncotic pressure, protecting the glycocalyx, and addressing coagulopathy is critical. Plasma can be a valuable tool in your arsenal, particularly for patients with significant protein loss, hypoproteinemia, or coagulopathy.

If you need more detailed information or have additional questions, feel free to ask!

Best regards,

Scott

Hi Helen,

Thank you so much for sharing this information. It’s fantastic to see opportunities like the How To Thrive event being made available to us. The focus on empowering individuals and teams with the skills needed to thrive in veterinary practice is incredibly valuable. I appreciate the 20% discount offer for VTX members and course delegates—it’s a great incentive to attend.

Looking forward to the event!

Best regards,
Scott

Hi Liz,

Thanks for sharing these exciting updates from ACVIM!

And I have to say, cardiology studies always have the best names! The REPAIR study sounds like something out of a sci-fi movie. 😂

The potential use of aficamten in cats with HCM is particularly intriguing, especially given its shorter half-life and fewer drug interactions compared to mavacamten. It’s great to hear about advancements that could make a real difference in treatment options.

Looking forward to hearing more about these studies and any other interesting findings you come across.

Watch this space indeed!

Scott x

Hi there!

Great question about monitoring Cushing’s disease with pre-Vetoryl cortisol levels. There’s no perfect way to monitor the response to trilostane, and both the pre-pill (pre-Vetoryl) cortisol and ACTH stimulation tests have their roles. Here’s a breakdown based on current understanding:

Pre-Vetoryl (Pre-Pill) Cortisol:

Usefulness: Pre-pill cortisol can be useful in certain cases, but it has limitations. It’s not ideal if the dog is aggressive, very stressed, or unwell at the time of sampling. Additionally, the samples must be submitted to an external lab, as studies validating this method were not done using in-house machines.
Limitations: Cortisol secretion is episodic, so a single sample may not provide complete information. If you get a low result from a pre-pill cortisol test, it’s still advisable to run an ACTH stim test to ensure the adrenal reserve is not over-suppressed.
ACTH Stimulation Test:

Role: The ACTH stim test is the traditional method and is useful to ensure that the adrenal axis is not over-suppressed. It helps verify that the treatment is not too aggressive.
Limitations: Neither the ACTH stim test nor the pre-pill cortisol can tell you if you are giving enough trilostane. You need to consider the clinical response (i.e., resolution of clinical signs like polyuria and polydipsia).
Dosing Considerations:

Many cases do require twice-daily administration of trilostane. However, due to the cost, starting with once-daily dosing is reasonable, hoping it will be sufficient.
If ACTH stim or pre-pill cortisol levels are within the recommended range or higher and clinical signs persist, there may be scope to increase the trilostane dose.
Reference ranges for cortisol are different from therapeutic ranges; the lab should highlight these differences.
Adjust doses based on the persistence of clinical signs, not just test results. If tests suggest potential over-suppression but the dog is still showing clinical signs (like polyuria/polydipsia), consider splitting the dose to twice daily. Confirm this need with an ACTH stim at 22-24 hours post-pill if necessary.
Twice-Daily Trilostane:

Equal doses should be given morning and night to facilitate monitoring and avoid peaks and troughs in drug concentration.
Summary:

Clinical signs are the mainstay of monitoring trilostane response.
ACTH stim or pre-pill cortisol tests help avoid over-suppression of the adrenal axis.
Adjust trilostane dose primarily based on clinical signs, using these tests to guide safe dosing.
Additional Resources:
Lesley has also offered some useful resources that can provide further guidance and insights into the management of Cushing’s disease.

If you have any further questions or want to discuss this more, feel free to reach out!

Thanks,

Scott 🙂

Great Question!

Tayer also asked a similar question from lesson one which I will pop here:

“One question I have from the first lesson on Haemoabdomen – you mentioned stabilising the hypovolemia and hypotension but didn’t mention fresh frozen plasma. If you were able to maintain PCV and stop active bleeding but low TP would use it then or do you tend to just stick with colloids and wait for body to reproduce? If so when do you reach for the plasma and why…”

Scott 🙂