Sophie Ponter

Asymptomatic enzyme raise in pre-GA bloods

It may well be covered later in the course (and I’m happy to wait to find out), but I come up against a lot of varied decision making and practice protocols (of varying formality) for pre-GA blood assessment.

I try to assess magnitude and patterns and ideally aim for diagnostics, but in first-opinion cost limited cases, is the most sensible thing in your opinion to assess repeatability? Any other tips and tricks for prioritising investigation options?

I tend to do a blood smear regardless if there are any biochemical or haematological abnormalities (especially platelets, electrolytes etc), to rule out sampling errors and issues with sample clotting

Replying to [email protected] 08/03/2023 - 10:45

Of course. I would like to note, before I take unfair credit, that I took this case on from an internal medicine specialist (I cover a duty weekend for the medicine department of a local referral hospital once a month) so she was the agent of the initial decision making.

Adult (can’t remember age) FN Springer Spaniel (18kg) with a 6 week slow-burn hx of intermittent bleeding. Initially noted blood spots around the house, suspected UTI. Hx of some skin and dental disease, nothing under notable active treatment.

Progressed through a few vague signs into sudden deterioration and severe melaena/D+.

Blood smear on admit showed no platelets. PCV pre-transfusion 25%. Torrential liquid black D+, very quiet in kennel. Imaging showed no neoplasia or other reason to suspect this was a secondary IMTP so it was deemed to be primary in nature. Ecchymoses visible on ventrum/flanks along with some worse areas secondary to self trauma (believed to be from unrelated pruritis) and petechiae on gingiva. Started on iv dexamethasone and 4ml/kg/h Hartmanns to start resolving dehydration.

The dog was typed DEA1.1 negative and initially transfused with a unit of matched packed RBCs due to the frequency and level of GI haemorrhage, and pending arrival of the platelet concentrate. The dog was then transfused without incident with two units of matched platelet concentrate (1 unit/10kg) commencing at around 9pm on Friday. Post transfusion PCV/TP was 35/62. Maintained on 2ml/kg/h Hartmanns iv overnight, with leeway to increase should fluid losses require it.

Following morning – much brighter. No further D+. Bothering us for food. Normothermic, no signs of delayed reaction. No new petechiae and ecchymoses resolving slightly.
PCV/TP 36/60. 1-2 Platelets/hpf. Scant acanthocytes on smear, otherwise RBC and WBC morphology normal.
K+ 3.8 so elected to spike next bag of crystalloids with 20mmol/l KCl
Ca2+ slightly low at 1.08mmol/l (ref 1.14-1.26) – assumed to be secondary to anticoagulant components of transfusion – added signs of hypocalcaemia onto the nurse/interns ‘call clinician if’ list regardless!

Sunday morning – bright. No further D+ in the 24h period. Still ravenous. No signs of any delayed reactions, ecchymoses marginally better again.
PCV/TP 35/62. 2-4 Platelets/hpf. RBC and WBC morphology normal; only one acanthocyte noted.
K+ 3.6 – it transpired there had been a communication failure with staff changeover regarding bag spiking and it had not been done. This was rectified and a spiked bag started
Ca2+ slightly low at 1.12mmol/l (ref 1.14-1.26) but resolving so no action taken.

I handed the case back to the specialist on Monday – the dog has gone home on oral steroids and seems to be doing well.

All things considered, a very good outcome. The platelet concentrate did its job of plugging the gaps in the GI tract while healing and generation of new platelets occurred. I would not have considered transfusing packed RBCs first, but can now see the logic; if the platelets had not held and adequate healing/coagulation had not occurred, I could have been dealing with a resurgence of the GI haemorrhage and a profound anaemia in addition to the thrombocytopenia on the Sunday.

I’m back in once a month and the specialist has been keeping me up to date, so we will wait to see how the dog gets on at home!

I’ve just used the platelet concentrate for the first time this evening (when it eventually made it all the way to Scotland!)

Will let you know how we get on with it!

Andy that’s a very good point about the painful vs pain scoring – I think sometimes the emphasis on the fact that it does actually measure a semi-quantifiable clinical parameter in the same way as temp/HR/RR/BP etc is missed and it can be seen as a box-ticking exercise. It’s a particular shame because it can be a really valuable way to teach students of vet and nursing, VCAs and recently-qualified folk the subtleties of spotting these pain parameters (and those of us who’ve been out far longer and got lazy or qualified before it was common practice!!).
Rather like the surgical checklists (I refer also here to the interesting article in the most recent (?) JSAP issue) – the actual spirit and importance of them can be lost if they are perceived as monotonous instead of essential.

I see different uptakes depending on where I Locum – A lot of places have the sheets on the walls but I rarely see them used or advocated for by vets or nurses. As a vet I’m aware I should definitely be encouraging their use more frequently. I’d be interested to learn what vets and nurses are doing in different spheres of practice (and any tips for increasing use) as a lot of my work is in under-nursed mixed practice which can be very chaotic and not always conducive to good nursing care and pain assessment!

I hadn’t considered using them for lameness cases – I love dealing with my golden oldies and all their comorbidities in particular so I will definitely be taking this forward.