scott@vtx-cpd.com
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Replying to Holly U. 25/03/2023 - 08:14
Holly!
How wonderful to see you here! Thank you so much for joining and supporting vtx.
Let me know if you haev any questions.
Scott 🙂
Replying to Neus E. 22/03/2023 - 17:58
Thanks Neus.
This is a really interesting paper. We are chatting lots about omeprazole and the possible increase in bacterial load when dogs on omeprazole have an aspiration even due to the change in gastric pH and alteration to what swallowed bacteria survive!
I am sure you will not be surprised to hear there is omeprazole chat going on!
I will share this paper with the GI lot now!
Scott 🙂
Replying to Neus E. 22/03/2023 - 16:03
HAHAHAH!
It really is an unconforntable read!
Hope you had a lovely time on holiday… Barcelona really is my favourite place in the world!
Scott 🙂
Hello Ornella.
Great to hear from you as always. Thank you for the brilliant questions:
1. I think there could indeed be a justification for omeprazole and maropitant pre-GA in brachycephalic dogs. I would probably give it the night before and the morning of the surgery. I am not sure there is a justification for the days after when the dog has recovered. The main event we are trying to protect against is GA-related reflux oesophagitis. Some brachycephalic dogs will also need steroids, but I would not give this routinely in every case.
2- Yes, in persistent cases of haematemesis and melena, it is appropriate to prescribe a PPI while you are investigating the underlying problem. I would not prescribe a PPI immediately in more acute cases. If you fully investigated a case and would no lesions on endoscopy but there was persistent melena, there would still be an indication for a PPI. Some lesions are not detected during standard endoscopic examination:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6766531/pdf/JVIM-33-1964.pdf
3- I would often use maropitant alongside oral and injectable TXA. I would indeed use it in IMTP cases at the start of their treatment while we get the disease under control. Mainly because they are at risk of spontaneous hemorrhage. Maybe for the first 3-4 days? I would use it in the more severe cases of GI hemorrhage overall. I would not use routine with every case I am giving omeprazole.
Hope that helps.
Scott 🙂
Hello everyone!
Remember that Kerry and Felipe are available for ECC and anesthesia advice for our members!
Let me know if you have any questions.
Scott 🙂
Replying to Rosanna Vaughan 22/03/2023 - 10:46
Hello Rosanna.
Welcome to the course. Lovely to have you here. I hope you enjoy the course, please let me know if you have any questions at any time!
I agree that things change after changing nappies! 🙂
Thanks again for joining us and supporting vtx, I appreciate it.
Scott 🙂
Replying to Steph Sorrell 20/03/2023 - 10:26
Steph!
Thank you so much for being here and for delivering this really exciting course. We are so grateful that you are working with us!
Scott 🙂
Replying to Veronika Smart 19/03/2023 - 21:19
Hello Veronika.
So excited to have you here! Thank you so much for working with us on this really special course. I really look forward to getting stuck into the content.
Scott 🙂
Replying to Rosie Marshall 20/03/2023 - 17:54
Hello!
That is a good question. I think what the VPIS recommended is slightly dated. I think we have good evidence not to use in every case, especially as we have some studies that may suggest it might do more harm.
It is very case dependent. Hope that helps.
Scott 🙂
Replying to Ornella R. 20/03/2023 - 13:54
Hello.
Really interesting question! Hope you are well.
1. The decision-making when they are on NSAIDs is always really challenging. I am not sure the is a definitive right answer here! If there was an episode of haematemesis, I would stop the NSAID. I would probably not give the omeprazole if it was a one-off. However, I do not think you did the wrong thing here at all! If there was any persistence with clinical signs I would give omeprazole.
2. There is no direct link between hypoalbuminemia and ileus, but there will be many dogs that have ileus due to GI disease and PLE.
Hope that helps.
Scott 🙂
Replying to Lesley M. 05/03/2023 - 08:39
This is a really interesting presentation Lesley and a very unlucky dog!
What was the outcome in this case… did it have any problems with coagulation?
Scott 🙂
So this was actually Phosphofructokinase (PFK) deficiency!
This is the report from the genetic testing in the dog:
PFKD/ PFKD (Genetically Affected)
Interpretation:
The examined animal is homozygous for the causative mutation for PFKD in the PFKM-gene.
Trait of inheritance: autosomal-recessive
Scientific studies found correlation between the mutation and symptoms of the disease in the following breeds: American Cocker Spaniel, English Springer Spaniel, WhippetIn PFK deficiency, haemolytic crises are precipitated due to alkaemia-induced of red blood cells following excessive barking, panting, strenuous exercise and high temperatures. Therefore, the patient was kept calm, cool and rested. On subsequent testing the anaemia resolved but a reticulocytosis remained, indicating that there was ongoing increased red blood cell turnover but that the management regime allowed the dog to compensate.
So basically support care is required. I would not use immunosuppression in these cases.
Scott 🙂
Replying to Alison Lambert 18/03/2023 - 10:05
Hey Alison.
Thank you for your kind words! I am really pleased you enjoyed the course.
We really appreciate the support.
Scott 🙂
Replying to Gisela T. 11/03/2023 - 22:40
Hello Gisela.
I am so sorry for the delay in getting back to you. I am so glad you enjoyed the session and thank you for the brilliant questions:
This is a great question. Endoscopy is indeen the most definative way of diagnosing oesophagitis. It is a tricky diagnosis to make overall. I think it is reasonable to make this call in patients that are at high risk. We do have evidence that BOAS patients and some patients undergoing prolonged orthopaedic surgery can experience potentially significant gastro-oesophageal reflux (GOR). The use of omeprazole in these patients has also now been shown to help prevent the change in distal oesophageal pH that accompanies GOR, but this is probably as a result of the change in gastric pH that omeprazole mediates, not because omeprazole reduces the actual frequency of GOR. However, preventing acid damage to the distal oesophagus where there is a known risk is appropriate, so it is therefore rational to use omeprazole in some surgical patients where there is a risk of GOR, and especially in BOAS patients where GOR is a known risk.
Metoclopramide may indeed help in these cases. It may have a little effect on LOS tone, but probably not that much. The drug I am using more and more is cisapride. I think that is a good option for these cases.
2. Another PDSA vet! Love it! Which PDSA are you at?
One thing to consider is that the BOAS may be contributing to the GI signs. I realise this may not always be an option, but it might be worth looking at correcting airway in some cases:
https://onlinelibrary.wiley.com/doi/abs/10.1111/jsap.12914
I think regarless of airway issues/correction, some will also require treatment of their GI disease separately:
https://pubmed.ncbi.nlm.nih.gov/15971897/
Honestly I would consider feeding some of the severely effected ones from a height. Like the Bailey chairs we discussed in the lesson. The do not have ‘true megaoesophagus’ but will often have quite significant oesophageal diviations. Due to the possiblity of concurrent enteropathy, I would consider a hydrolysed diet in the severe ones. The best hydrolysed diet for growing dogs is Purina AH. My go-to in these cases would be cisiaptide, if that is not avaiable then I would use metoclopramide. How long to use this for is tricky to say. It depends on the severity of the signs, but in severe cases when all else is failing you can use long term.
I would try and avoid long term PPIs if possible and reserve if you can for cases that are at risk of reflux during GA. However, there are some severe cases that will need long term administration. I would try everything else first! I would also co-administer a probiotic. The key thing to remeber is that the omeprazole may reduce the oesophageal injury, but will increased the bacterail load in the regurgitated material and could make the aspiration events worse! It is so tricky… lesser of two evils and all that!
The other drug that can be helpful in some cases is steroids. This may deal with some of the residual/background inflammation in the airways and GI tract.
I hope that helps?
Scott 🙂
Hey Magda!
Honestly, such a joy to have you on the course! I am glad you enjoyed the first session. Thank you for your brilliant questions:
1. This is a great question. I think you raise a good point. In patients with megaoesophagus that are at high risk of regurgitation, it is much safer to protect the airway and do a full GA.
If you just need the radiograph and the risk is not too high, I would try butorphanol alone. This could then be ‘topped up’ with a little alfaxalone if needed.
Otherwise, If the plan is to do a full GA for other investigations I would pre-med normally (opioid and dexmedetomidine) and see if I could get the radiograph with just that.
2. This is another great question. I included a little extra in less than 3 to help cover this. There is a bit of a divided opinion on this! In any brachy dog with a history of regurgitation and GI signs, I would hive omeprazole and cisapride the day before surgery, the day of surgery, and the day after. I would also administer maropitant on the day of surgery and in an ideal world I would give them a probiotic to try and navigate the dysbiosis caused by the omeprazole.
Honestly, in brachycephalic that are ‘well’, I would probably use the same regimen. Many anesthetists would give at least one dose of omeprazole before any surgery in brachycephalic dogs. One study showed the benefit of giving it 4 hours before. There is a more recent study that suggests the benefit of omeprazole the night before and morning of GA.
Hope that helps!
Scott x
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